Final NUR 103

A home health nurse visits a client who's taking pilocarpine, a miotic agent, to treat glaucoma. The nurse notes that the client's pilocarpine solution is cloudy. What should the nurse do first? A. Advise the client to discard the drug because it may have undergone chemical changes or become contaminated. B. Advise the client to obtain a fresh container of pilocarpine solution to avoid omitting prescribed doses. C. Observe the client or a family member administer the drug to determine possible contamination sources. D. Advise the client to keep the container closed tightly and protected from light.

A. Advise the client to discard the drug because it may have undergone chemical changes or become contaminated.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. A. Assist the client to the floor. B. Turn the client to the side. C. Place a pillow under the client's head. D. Give the prescribed dose of oral phenytoin. E. Insert an oral suction device to remove secretions in the mouth.

A. Assist the client to the floor. B. Turn the client to the side. C. Place a pillow under the client's head.

Identifying factors that trigger seizure activity could lead to which alteration in the child's environment or activities of daily living? A. Avoid striped wallpaper and ceiling fans. B. Let the child sleep alone to prevent sleep interruption. C. Include extended periods of intense physical activity daily. D. Allow the child to drink soda only between noon and 5 p.m.

A. Avoid striped wallpaper and ceiling fans.

A client experienced a stroke that damaged the hypothalamus and was admitted to an acute unit. Which body function would the nurse anticipate that the client has problems with and assess as needed? A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning

A. Body temperature control

A client who sustained head trauma in a motor vehicle crash is determined to have an increase in intracranial pressure (ICP). Which complications related to an increase in ICP should the nurse be aware of? Select all that apply. A. Brain hypoxia B. Herniation of the brain C. Brain compression D. Paralysis of the lower extremities E. Urinary retention

A. Brain hypoxia B. Herniation of the brain C. Brain compression

A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously? A. C4 B. C5 C. C6 D. C7

A. C4

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway, attends to the client's immediate needs, and then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, the examination must be brief but will include which nursing intervention? A. Evaluation of the corneal reflex response B. Examination of the fundus of the eye C. Assessment of the client's gait D. Evaluation of bowel and bladder functions

A. Evaluation of the corneal reflex response

What is the function of cerebrospinal fluid (CSF)? A. It cushions the brain and spinal cord. B. It acts as an insulator to maintain a constant spinal fluid temperature. C. It acts as a barrier to bacteria. D. It produces cerebral neurotransmitters.

A. It cushions the brain and spinal cord.

A client is taking methotrexate (Otrexup) for the treatment of rheumatoid arthritis. What expected finding does the nurse observe when reviewing laboratory results? A. Low neutrophil count B. Low hemoglobin C. Elevated leukocyte count D. Elevated sedimentation rate

A. Low neutrophil count

An older adult client has a decrease in the number of T cells and B cells. Which nursing action is a high priority for this client? A. Monitor for signs of infection. B. Give warm blankets and keep the room warm. C. Encourage the client to eat six small meals a day. D. Obtain strict intake and output.

A. Monitor for signs of infection.

A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention? A. Position the left arm supported on a pillow. B. Provide full range of motion for all extremities. C. Gently stretch the right arm. D. Exercise the limbs every 8 hours.

A. Position the left arm supported on a pillow.

A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? A. Prepare to assist with ventilation. B. Monitor the client's heart rhythm. C. Prepare for gastric lavage. D. Obtain urine for drug screening.

A. Prepare to assist with ventilation.

A nurse is preparing a client with suspected herniated nucleus pulposus (HNP) for myelography. Which nursing intervention should the nurse perform before the test? A. Question the client about allergy to iodine. B. Mark distal pulses on the foot in ink. C. Check and document pain along the sciatic nerve. D. Tell the client to cough or pant to clear the dye.

A. Question the client about allergy to iodine.

The charge nurse is observing a new graduate providing care to a client who is HIV positive. Which action by the new graduate would require immediate intervention by the charge nurse? A. Recapping a needle after giving an injection B. Using gloves when changing a soiled dressing C. Wearing a face shield when irrigating a sacral wound D. Discarding gloves when exiting the client's room

A. Recapping a needle after giving an injection

When assisting with the education of the family of a client with C4 quadriplegia on how to perform tracheostomy suctioning, which instruction should the nurse be sure to include? A. Suction for 10 to 15 seconds at a time. B. Regulate the suction machine to 300 cm suction. C. Apply suction to the catheter during insertion only. D. Pass the suction catheter into the opening of the tracheostomy tube 2 to 3 cm.

A. Suction for 10 to 15 seconds at a time.

A client suffers a stroke located in the medulla. Which is the priority action by the nurse? A. Support the client's respiratory function. B. Assist the client with ambulation. C. Orient the client to surroundings frequently. D. Monitor the client for swallowing food and fluid.

A. Support the client's respiratory function.

The nurse is teaching a client with human immunodeficiency virus (HIV) to understand the importance of medication adherence. Which information would the nurse include when reinforcing the education? Select all that apply. A. The use of pill containers and calendars B. Interaction with foods and other drugs C. Management of medication side effects D. Obtaining refills on time E. When to discontinue medications

A. The use of pill containers and calendars B. Interaction with foods and other drugs C. Management of medication side effects D. Obtaining refills on time

The nurse is caring for a client with herpes zoster. Which priority measures to avoid cross-contamination would the nurse provide? A. Use transmission-based precautions. B. Administer antiviral medications as ordered. C. Apply antihistamine cream to the lesions. D. Instruct the client to wear gloves.

A. Use transmission-based precautions.

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy? A. a 30-year-old client with schizophrenia taking chlorpromazine B. a 50-year-old client taking nitroglycerin tablets for angina C. a 60-year-old client taking prednisone for chronic obstructive pulmonary disease (COPD) D. a 75-year-old client using naproxen for rheumatoid arthritis

A. a 30-year-old client with schizophrenia taking chlorpromazine

The nurse is caring for a child with meningitis receiving IV fluids. What condition should the nurse monitor for closely? A. cerebral edema B. renal failure C. left-sided heart failure D. cardiogenic shock

A. cerebral edema

A young child has had multiple ear infections and is brought to the clinic screaming and holding the right ear. Which most common complication related to acute otitis media does the nurse expect this client is experiencing? A. eardrum perforation B. hearing loss C. meningitis D. tympanosclerosis

A. eardrum perforation

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: A. electromyography (EMG). B. Doppler scanning. C. Doppler ultrasonography. D. quantitative spectral phonoangiography.

A. electromyography (EMG).

Which nursing intervention should be used to prevent footdrop and contractures in a client recovering from a subdural hematoma? A. high-top sneakers B. low-dose heparin therapy C. physical therapy consultation D. sequential compression device

A. high-top sneakers

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program? A. intermittent catheterization B. Kock pouch C. transurethral prostatectomy D. ureterostomy

A. intermittent catheterization

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report: A. light flashes and floaters in front of the eye. B. a recent driving accident while changing lanes. C. headaches, nausea, and redness of the eyes. D. frequent episodes of double vision.

A. light flashes and floaters in front of the eye.

A nurse working on a surgical floor observes an unlicensed assistive personnel (UAP) completing assigned tasks. Which situation requires the nurse to intervene? A. turning a client who is 24 hours post-op laminectomy B. bathing a bedridden client who has bilateral leg amputations C. assisting a client who is 16 hours post-op hemorrhoidectomy out of bed D. repositioning a client who is 12 hours post-op partial hysterectom

A. turning a client who is 24 hours post-op laminectomy

A client at the eye clinic reports difficulty seeing at night. Which nutritional deficiency should the nurse be sure the client is monitored for? A. vitamin A B. vitamin B6 C. vitamin C D. vitamin K

A. vitamin A

A client was diagnosed with having right subarachnoid hemorrhage. The nurse should plan to place the client in which position? A. with the head of the bed elevated B. on the right side C. on the left side D. flat in bed

A. with the head of the bed elevated

A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client? A. A private room down the hall from the nurses' station B. An isolation room close to the nurses' station C. A semiprivate room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis

B. An isolation room close to the nurses' station

A client arrives in the emergency department after being bitten by a raccoon that wandered into the yard. The nurse should anticipate administering a rabies vaccine to provide which type of immunity? A. Naturally acquired active immunity B. Artificially acquired passive immunity C. Antibody-mediated immunity D. Naturally acquired passive immunity

B. Artificially acquired passive immunity

A nurse is caring for a client who has sustained a closed head injury. What nursing intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)? A. Suction the airway every hour and as needed. B. Elevate the head of the bed 30 degrees. C. Turn and reposition the client every 2 hours. D. Maintain a well-lighted room.

B. Elevate the head of the bed 30 degrees.

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome? A. Restore blood pressure to the normal range. B. Ensure airway patency and optimal oxygen levels and protect from injury. C. Ensure adequate nutrition, hydration, and elimination. D. Provide psychological support and maintain skin integrity and effective thermoregulation.

B. Ensure airway patency and optimal oxygen levels and protect from injury.

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot? A. Nausea, vomiting, and profuse sweating B. Hemiplegia, seizures, and decreased level of consciousness (LOC) C. Difficulty breathing or swallowing D. Tachycardia, tachypnea, and hypotension

B. Hemiplegia, seizures, and decreased level of consciousness (LOC)

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Dressing or grooming self-care deficit

B. Ineffective breathing pattern

A nurse is prescribed postexposure prophylaxis (PEP) antiretroviral medication after a needle stick from an HIV-positive client. Which side effect would the nurse likely experience when taking this medication? A. Fatigue B. Nausea C. Swollen lymph nodes D. Constipation

B. Nausea

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? A. Encourage the client to close his eyes. B. Notify the physician. C. Turn out the lights in the room. D. Instill artificial tears.

B. Notify the physician.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis? A. Anxiety B. Powerlessness C. Ineffective denial D. Risk for disuse syndrome

B. Powerlessness

Which method should the nurse use to properly instill eardrops in an adult client with otitis externa? A. Pull the pinna down and back. B. Pull the pinna up and back. C. Pull the tragus up and back. D. Separate the palpebral fissures with a clean gauze pad.

B. Pull the pinna up and back.

A client with chronic alcoholism and late-stage cirrhosis of the liver has significant damage to Wernicke area. Which data obtained by the nurse are indicative of this damage? A. The client is unable to ambulate independently. B. The client does not comprehend written and spoken language but speaks. C. The client has speech impairment but is able to comprehend language. D. The client's left hand is experiencing paralysis.

B. The client does not comprehend written and spoken language but speaks.

A nurse is taking care of four clients. Which client should the nurse see first? A. a 17-year-old client 24 hours postappendectomy B. a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome C. a 50-year-old client 3 days post-myocardial infarction (MI) D. a 50-year-old client with diverticulitis

B. a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome

One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication? A. additional pyridostigmine B. atropine C. edrophonium D. acyclovir

B. atropine

A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when A. e-mailing information about a client to a friend at home. B. documenting medications after administration. C. documenting medications before administration. D. determining a client's identity from a computer chart.

B. documenting medications after administration.

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint? A. "Did you let them know that you needed help?" B. "When did you last have someone bathe you?" C. "I'm sorry you haven't been bathed. I'm available to bathe you now." D. "I don't understand why they didn't bathe you; they indicated during shift report that they did."

C. "I'm sorry you haven't been bathed. I'm available to bathe you now."

A client arrives at the clinic requesting testing for HIV. Which response by the nurse is best? A. "Did you have sex with multiple partners?" B. "The test results won't be back for a while." C. "You will need to sign a consent form prior to testing." D. "We will call you with the results."

C. "You will need to sign a consent form prior to testing."

A client who sustained a closed head injury in a skating accident pulls out his feeding tube, I.V. catheter, and indwelling urinary catheter. To ensure this client's safety, a physician prescribes restraints. Which action should a nurse take when using restraints? A. Make sure that the restraints fit snuggly to restrict the client from reaching his nose, arms, or perineal area. B. Apply one wrist restraint at a time. C. Fasten the restraint to the bed frame using a quick-release knot. D. Place a sign over the client's bed warning staff to avoid removing the restraints.

C. Fasten the restraint to the bed frame using a quick-release knot.

A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching? A. Report dizziness at once. B. Drive in daylight hours only. C. Get up slowly, turning the entire body. D. Use logrolling technique when moving.

C. Get up slowly, turning the entire body.

A client comes to the emergency department after hitting his or her head in a motor vehicle collision. The client is alert and oriented. Which nursing intervention should be done first? A. Perform full range of motion (ROM). B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open airway using head tilt/chin lift maneuver.

C. Immobilize the client's head and neck.

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? A. Shock B. Encephalitis C. Increased intracranial pressure (ICP) D. Status epilepticus

C. Increased intracranial pressure (ICP)

A client is admitted with myasthenia gravis. Which nursing intervention should be priority? A. Observe for bleeding. B. Promote mobility. C. Monitor respiratory status. D. Prevent dehydration.

C. Monitor respiratory status.

A home health nurse is visiting a client with Alzheimer's disease who lives with two adult children. The nurse notes bruising on the client's upper arms. The client is more withdrawn than normal and is unable to communicate effectively because of the disease. What is the priority action by the nurse? A. Ask the client's children why the client has bruises. B. Monitor the client's condition during subsequent visits. C. Report suspicion of elder abuse to the local agency on aging. D. Order diagnostic tests including blood work and X-rays.

C. Report suspicion of elder abuse to the local agency on aging.

The nurse is discussing the benefits of breastfeeding to a pregnant mother. Which statement made by the client demonstrates understanding of the benefits? A. The infant will receive artificially acquired active immunity to protect the infant from viruses. B. The infant will receive artificially acquired passive immunity to protect them from diseases such as multiple sclerosis. C. The infant will receive naturally acquired passive immunity to last approximately 6 months. D. The infant will receive antibody-mediated immunity to prevent the child from acquiring respiratory disorders for 1 year.

C. The infant will receive naturally acquired passive immunity to last approximately 6 months.

The nurse witnesses a client having a tonic-clonic seizure in the bed. Which is the priority action by the nurse? A. Insert a tongue blade between the client's teeth. B. Place the client in the prone position. C. Turn the head to the side. D. Insert an indwelling catheter.

C. Turn the head to the side.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal? A. More back pain than the first postoperative day B. Paresthesia in the dermatomes near the wounds C. Urine retention or incontinence D. Temperature of 99.2° F (37.3° C)

C. Urine retention or incontinence

A client was hit in the head with a baseball during practice. Which discharge instructions should the nurse reinforce? A. Watch client for keyhole pupil for the next 24 hours. B. Expect profuse vomiting for 24 hours after the injury. C. Wake client every hour and check orientation to person, time, and place. D. Notify health care provider immediately when experiencing headache.

C. Wake client every hour and check orientation to person, time, and place.

The nurse is discussing the purpose of an electroencephalogram with the family of a client who has massive cerebral hemorrhage and loss of consciousness. Which response by the nurse would be the most accurate in describing what the test measures? A. extent of intracranial bleeding B. sites of brain injury C. activity of the brain D. percentage of functional brain tissue

C. activity of the brain

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: A. provide instructions on eye patching. B. assess the client's visual acuity. C. demonstrate eyedrop instillation. D. teach about intraocular lens cleaning.

C. demonstrate eyedrop instillation.

The nurse is watching the health care provider check reflexes during a physical assessment. The RN elicits a positive Babinski reflex. The nurse is aware that this reflex is characterized by what? A. supination and flexion of the forearm B. extension of the elbow and contraction of the triceps tendon C. dorsiflexion of the great toe with fanning of the other toes D. flexion of the arm at the antecubital fossa and contraction of the biceps

C. dorsiflexion of the great toe with fanning of the other toes

A client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. The client's medications include heparin and isosorbide. The nurse should monitor the client for which condition? A. dehydration B. hypocarbia C. hypotension D. tube feeding

C. hypotension

A client with a T1 spinal cord injury arrives at the emergency department with a blood pressure of 82/40 mm Hg, pulse rate of 34 beats/minute, dry skin, and flaccid paralysis of the lower extremities. Which condition would most likely be suspected? A. autonomic dysreflexia B. hypervolemia C. neurogenic shock D. sepsis

C. neurogenic shock

The nurse is caring for a client post-transurethral resection of the prostate (TURP) with bladder irrigation. After surgery, what color would the nurse expect the urine to be? A. clear B. light yellow C. pink to dark red D. bright red

C. pink to dark red

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention would the nurse implement to reduce the client's risk of increased intracranial pressure (ICP)? A. Encouraging oral fluid intake B. Suctioning the client once each shift C. Elevating the head of the bed 90 degrees D. Administering a stool softener as prescribed

D. Administering a stool softener as prescribed

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? A. Putting slippers on the client's feet B. Crossing the client's ankles every 2 hours C. Placing hand rolls on the balls of each foot D. Attaching braces or splints to each foot and leg

D. Attaching braces or splints to each foot and leg

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse-manager. D. Call the physician immediately.

D. Call the physician immediately.

A nurse is caring for a client who has a history of epilepsy. After the client experiences a generalized tonic-clonic seizure, what is the priority nursing action? A. Turn the client on the client's back. B. Ask the client when prescribed medication was last taken. C. Place the client in a darkened room and check on the client in 30 minutes. D. Check the client's vital signs and remove restrictive clothing.

D. Check the client's vital signs and remove restrictive clothing.

A client is having a colonoscopy, and suddenly the client's heart rate drops from 72 beats per minute (BPM) to 52 BPM. Which cranial nerve does the nurse determine has been stimulated? A. Cranial nerve I (olfactory) B. Cranial nerve V (trigeminal) C. Cranial nerve IX (glossopharyngeal) D. Cranial nerve X (vagus)

D. Cranial nerve X (vagus)

When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize? A. Glaucoma is easily corrected with eyeglasses. B. The disorder will not lead to complete loss of vision. C. Yearly screening for people ages 20 to 40 is recommended. D. Glaucoma can be painless with loss of peripheral vision.

D. Glaucoma can be painless with loss of peripheral vision.

A client sustains a head trauma after falling from a roof. The nurse observes clear fluid leaking from the nose. What priority action should the nurse take? A. Use a Q-tip to gently clean the nasal passages. B. Pack the nose with nasal packing. C. Instruct the client to blow their nose to clear the passages. D. Have the fluid checked for glucose.

D. Have the fluid checked for glucose.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury

D. Risk for injury

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority? A. Disturbed sensory perception (visual) related to neurologic trauma B. Feeding self care deficit: related to neurologic trauma C. Impaired verbal communication related to confusion D. Risk for injury related to neurologic deficit

D. Risk for injury related to neurologic deficit

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease? A. Acute pain related to vertigo B. Imbalanced nutrition: Less than body requirements related to nausea and vomiting C. Risk for deficient fluid volume related to vomiting D. Risk for injury related to vertigo

D. Risk for injury related to vertigo

The parent of a child with a ventriculoperitoneal shunt calls the nurse saying that the child has a temperature of 101.2° F (38.4° C), a blood pressure of 108/68 mm Hg, and a pulse of 100 beats/minute. The child is lethargic and vomited the night before. Other children in the family have had similar symptoms. Which nursing intervention is most appropriate? A. Provide symptomatic treatment. B. Advise the parent that this is a viral infection. C. Consult the primary health care provider. D. Tell the parent to bring the child to the primary health care provider's office.

D. Tell the parent to bring the child to the primary health care provider's office.

The nurse is requested to place an ice pack on the eyelid for 2 min for a client suspected of having myasthenia gravis (MG) with diplopia. Which outcome does the nurse anticipate if the diagnosis is confirmed? A. The client will experience an improvement in respiratory status. B. The client will experience blindness. C. The client will have a grave prognosis. D. The client will have a temporary improvement in eye symptoms.

D. The client will have a temporary improvement in eye symptoms.

A nurse instills atropine drops in both eyes of a client undergoing an ophthalmic examination. Which instruction should the nurse reinforce after administering the medication? A. Be careful because the blink reflex is paralyzed. B. Avoid wearing regular glasses when driving. C. It is normal to expect that the pupils may be unusually small. D. Wear dark glasses in bright light because the pupils are dilated.

D. Wear dark glasses in bright light because the pupils are dilated.

A client is newly diagnosed with myasthenia gravis. When reinforcing education what should the nurse indicate as the cause of this disease? A. a postviral illness characterized by ascending paralysis B. loss of the myelin sheath surrounding peripheral nerves C. inability of basal ganglia to produce sufficient dopamine D. destruction of acetylcholine receptors, causing muscle weakness

D. destruction of acetylcholine receptors, causing muscle weakness

A nurse is collecting data on a client who sustained a head injury after a fall from the roof. What signs and symptoms should the nurse observe the client for? A. emotional instability, vertigo, diplopia, and weakness B. memory loss, poor attention span, incontinence, and wandering C. fatigue, lack of coordination, heat intolerance, and judgment defects D. restlessness, disorientation, pupil dilation, and projectile vomiting

D. restlessness, disorientation, pupil dilation, and projectile vomiting

When communicating with a client who has sensory (receptive) aphasia, the nurse should: A. allow time for the client to respond. B. speak loudly and articulate clearly. C. give the client a writing pad. D. use short, simple sentences.

D. use short, simple sentences.

A hospitalized child is to receive 75 mg of acetaminophen for fever control. How much will the nurse administer if the acetaminophen concentration is 40 mg per 0.4 ml? Record your answer using two decimal places.

0.75 mL

The nurse is reviewing the medical record for a client in a long-term care facility. The nurse notes an entry by the primary care physician indicating the client is colorblind. The nurse understands this condition results from a problem with which structure(s) of the eye? A. Rods B. Cones C. Lens D. Aqueous humor

B. Cones

The nurse is reinforcing education for a female client paralyzed from a spinal cord injury (SCI). Which statement made by the client demonstrates understanding of the education? A. "I may begin to menstruate within 3 months following my injury." B. "I should use birth control pills as a means of contraception." C. "It is just as safe for me to become pregnant without an SCI." D. "I should use a tampon instead of a feminine pad when I am menstruating."

A. "I may begin to menstruate within 3 months following my injury."

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. When reviewing the client's chart, the nurse expects to find which documentation that confirms the client has Myasthenia gravis? A. A positive edrophonium (Tensilon) test B. Kernig's sign C. A positive sweat chloride test D. Brudzinski's sign

A. A positive edrophonium (Tensilon) test

A client arrives in the emergency department reporting severe hives and wheezing after eating shrimp. The nurse observes the client experiencing symptoms of laryngeal edema. Which is the priority action by the nurse? A. Administer epinephrine. B. Administer montelukast (Singulair). C. Administer loratadine (Claritin). D. Administer pseudoephedrine (Sudafed).

A. Administer epinephrine.

The nurse is assigned to care for a child with spina bifida that requires routine urinary catheterization. Which priority action by the nurse is important to prevent complications caused by an IgE-mediated reaction? A. The use of nonlatex gloves for all procedures. B. Administer epinephrine prior to performing the procedure. C. Administer diphenhydramine (Benadryl) every 4 hour to prevent an allergic reaction. D. Ensure that the child does not receive antibiotics.

A. The use of nonlatex gloves for all procedures.

The nurse is working on a surgical floor. The nurse must logroll a client following a: A. laminectomy. B. thoracotomy. C. hemorrhoidectomy. D. cystectomy.

A. laminectomy.

A client suspects an allergy to latex. When gathering data from the client, which questions would be appropriate for the nurse to ask? Select all that apply. A. "Are you allergic to dairy products?" B. "Are you allergic to bananas?" C. "Are you allergic to kiwi?" D. "Are you allergic to chestnuts?" E. "Are you allergic to avocados?"

B. "Are you allergic to bananas?" C. "Are you allergic to kiwi?" D. "Are you allergic to chestnuts?" E. "Are you allergic to avocados?"

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? A. "Avoid taking daytime naps." B. "Avoid hot baths and showers." C. "Limit your fruit and vegetable intake." D. "Restrict fluid intake to 1,500 ml/day."

B. "Avoid hot baths and showers."

The nurse is reinforcing education prior to discharge for a client that has had a kidney transplant. Which statement made by the client indicates that education about rejection is understood? A. "I will take a laxative if I am unable to have a bowel movement." B. "I will report fever, chills, and profuse sweating to the primary care provider." C. "I will take my immunosuppressant drugs whenever I feel I am developing an infection." D. "I don't have to see my nephrologist any longer since I am cured of kidney disease."

B. "I will report fever, chills, and profuse sweating to the primary care provider."

Family members would like to bring in a birthday cake for a client with nerve damage. What cranial nerve will the nurse assess to determine if it is functioning so the client can chew? A. Cranial nerve II B. Cranial nerve V C. Cranial nerve IX D. Cranial nerve X

B. Cranial nerve V

A client with a T6 injury reports a pounding headache, blurred vision, and nasal congestion. The nurse observes profuse sweating above the level of injury. Which is the priority action by the nurse? A. Irrigate the client's indwelling catheter. B. Elevate the client's head. C. Place the client in Trendelenburg position. D. Obtain the client's temperature.

B. Elevate the client's head.

A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test? A. "Do not eat anything for 12 hours before the test." B. "Do not shampoo your hair for 24 hours before the test." C. "Avoid stimulants and alcohol for 24 to 48 hours before the test." D. "Avoid thinking about personal matters for 12 hours before the test."

C. "Avoid stimulants and alcohol for 24 to 48 hours before the test."

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? A. "My family will take care of me. I've given my daughter durable power of attorney for health care." B. "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." C. "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." D. "Signing an advance directive now will help ensure that my family and care team know what I want when I'm eventually unable to make decisions."

C. "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

The nurse administers an "allergy shot" to a client in the clinic. Which is the nurse's priority action? A. Have the client eat a small meal. B. Administer epinephrine before discharging the client. C. Have the client wait 20 min in the clinic after the injection. D. Administer ibuprofen (Motrin) 400 mg after injection for pain.

C. Have the client wait 20 min in the clinic after the injection.

The nurse is discharging a client from the hospital after a laminectomy. What statement made by the client indicates that further education should be reinforced? A. "I'll sleep on a firm mattress." B. "I won't drive for 2 to 4 weeks." C. "When I pick things up, I'll always bend my knees." D. "I can't wait to toss my granddaughter up in the air."

D. "I can't wait to toss my granddaughter up in the air."

The nurse is reinforcing education for a female client, who is HIV positive, about transmission of the virus. Which statement made by the client demonstrates that further education is required? A. "If I become pregnant, I must continue to take my antiretroviral medication." B. "I should not kiss anyone while I have an open sore in my mouth." C. "I will be able to breastfeed if my baby and I are taking antiretroviral drugs." D. "I may be able to transmit HIV if someone uses a glass after I drink from it."

D. "I may be able to transmit HIV if someone uses a glass after I drink from it."

A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response? A. "St. John's wort is an herbal remedy that can be used to treat depression." B. "If you take St. John's wort and Parkinsonian drugs, take them on alternate days." C. "St. John's wort must be taken in large doses to help reduce depression." D. "St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

D. "St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

A nurse is caring for a child with spina bifida. The child's mother asks the nurse what she did to cause the birth defect. Which statement would be the nurse's best response? A. "Older age at conception is one of the major causes of the defect." B. "It is a common complication of amniocentesis." C. "It has been linked to maternal alcohol consumption during pregnancy." D. "The cause is unknown, and there are many environmental factors that may contribute to it."

D. "The cause is unknown, and there are many environmental factors that may contribute to it."

The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation? A. Check for peripheral vision. B. Touch the cornea lightly with a wisp of cotton. C. Have the client follow an object upward, downward, obliquely, and horizontally. D. Observe for pupil constriction and convergence while focusing on an object coming toward the client.

D. Observe for pupil constriction and convergence while focusing on an object coming toward the client.

A client has a decrease in T cells and B cells. The nurse would monitor the client for which complication? A. Altered kidney function B. Blood loss C. Joint swelling and tenderness D. Signs of infection

D. Signs of infection

The nurse observes a client with a heart rate of 76 beats per minute. Where does the nurse identify the heartbeat originates? A. Sinoatrial node (SA) B. Atrioventricular node (AV) C. Bundle of His D. Purkinje fibers

A. Sinoatrial node (SA)

The nurse is caring for a client with Kaposi sarcoma with slight serous drainage. What should the nurse wear during the care of this client? Select all that apply. A. gloves B. gown C. surgical mask D. particulate mask E. shoe cover

A. gloves B. gown

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest? A. Infection B. Dehiscence C. Hemorrhage D. Evisceration

A. Infection

What are the different types of hypoxia?

- hypoxemic hypoxia - anemic hypoxia - circulatory hypoxia - histotoxic hypoxia

What is the pathophysiology of and possible causative events for central hearing loss?

refers to the brain's inability to interpret sounds after they have been transmitted, which can sometimes occur in atherosclerosis or after a stroke.

A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to? A. diplopia B. permanent vision loss C. loss of central vision D. pupillary constriction

B. permanent vision loss

The nurse is assisting a client with chest tubes to the bedside commode when the tube becomes disconnected and falls on the floor. Which is the priority action by the nurse? A. Reconnect the tubing. B. Double-clamp tube close to the chest wall. C. Allow the client to ambulate to the bathroom. D. Place the client in the supine position.

A. Reconnect the tubing.

What are signs and symptoms of heparin complications/adverse effects?

- Abdominal or stomach pain - Back pain - Bleeding from the gums - Blood in urine - Constipation - Coughing up blood - Dizziness - Headaches that are severe or continuing - Joint pain, stiffness, or swelling - Unexplained nosebleeds - Vomiting of blood - Unexplained bruising - Pain at the injection site

What are two of the main tumor markers that were focused on in lecture?

- CA-125 tumor marker - CEA tumor marker

What are the three main disorders in which a bone marrow transplant would be used?

- Leukemia - Severe aplastic anemia - Lymphomas

What is the difference between the cells affected by leukemia vs multiple myeloma cells?

- Leukemia cells have cancerous cells that are circulating in the blood and bone marrow - Multiple myeloma cells are a tumor in the bone marrow itself and it also involves the white blood cells

What are interventions that can be done to help a patient in respiratory distress?

- Maintaining an open and patent airway - Suctioning of excess secretions - Proper positioning to prevent aspiration - Limiting activity to reduce oxygen consumption - Anxiety meds to keep the patient calm when in respiratory distress

What are safety measures that need to be done with oxygen administration?

- Oxygen is prescribed as a medication and needs to be administered under controlled conditions - Oxygen is flammable, so it should not be administered near flammable objects, and patients need to be educated to not smoke while on oxygen - It should not be given in excess as oxygen toxicity can result - Increasing O2 in patients with COPD can be fatal, so if they have oxygen needs greater than 3 LPM, it's important to call RT to have them evaluated/placed on a BiPAP

What does moist heat (warm soak) do to affected areas of the body it is applied to?

- Stimulate circulation - Ease pain - Promote wound drainage - An easier time of applying medication

What are situation in which an abdominal binder might be indicated?

- Supporting the abdomen or large abdominal dressings - After a cesarean section for support

What are some teaching points for a patient with Meniere's disease?

- The client is advised to omit alcohol, coffee, tea, cola drinks, chocolate, and tobacco from the diet. - A low-sodium diet may be suggested, although the benefits of this diet remain controversial. - It is also important to avoid: jarring the bed, sudden movements, turning on bright lights, or making loud noises as it may precipitate the attack. Make sure to do everything slowly and explain actions to the client ahead of time.

What are the three different types of hearing loss?

- conduction hearing loss - sensorineural hearing loss - central hearing loss

What are five health risks for uncontrolled hypertension?

- heart attack - heart failure - kidney disease - stroke - cognitive decline.

A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication? A. "The medication will help dilate the pupils of my eyes." B. "The medication will help decrease pressure in my eyes." C. "The medication will prevent eye infection." D. "The medication will prevent eye movement."

B. "The medication will help decrease pressure in my eyes."

The nurse is caring for a client diagnosed with leukemia who is going to have a chemotherapy treatment. Which test would the nurse expect to be done to evaluate the client's ability to metabolize chemotherapeutic agents? A. lumbar puncture B. liver function studies C. complete blood count (CBC) D. peripheral blood smear

B. liver function studies

An anxious client is brought to the walk in clinic with difficulty breathing following a bee sting. Which of the following is the nurse's priority action? A. assist the client to lie down B. monitor the client's airway C. administer 100% oxygen via mask D. assess the site to remove the stinger

B. monitor the client's airway

The nurse is caring for a client receiving chemotherapy. Which should the nurse consider the priority? A. self-image B. nutrition C. family support D. mobility

B. nutrition

A sexually active 22-year-old woman client arrives in the clinic for a wellness visit. Which procedure will the nurse prepare this client for? A. A Pap smear B. A chest x-ray C. A CT scan of the abdomen D. A barium enema

A. A Pap smear

When auscultating the heart of a client with pericarditis, which finding should the nurse anticipate reporting? A. A rub B. Murmur C. Gallop D. Second heart sound

A. A rub

A client with quadriplegia is in spinal shock. What should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities

A. Absence of reflexes along with flaccid extremities

Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing change? A. Remove the soiled dressings using clean gloves. B. Dispose of the soiled dressings in the trash can. C. Put on a gown, sterile gloves, and a mask. D. Place clean dressings over the incision.

A. Remove the soiled dressings using clean gloves.

A client is diagnosed with pulmonary edema and having pink, frothy sputum and crackles in both lungs. Which nursing intervention would be provided at this time? Select all that apply. A. Administer morphine sulfate as ordered. B. Administer furosemide (Lasix) as ordered. C. Place the legs in a dependent position. D. Administer oxygen as ordered. E. Place the client in high Fowler position.

A. Administer morphine sulfate as ordered. D. Administer oxygen as ordered. E. Place the client in high Fowler position.

A nurse is caring for a client diagnosed with Alzheimer's disease who scored a 7 (high risk) on the Hendrich II Fall Risk Model. Which nursing intervention should the nurse implement? Select all that apply. A. Implement a bed alarm. B. Request a low-dose sedative. C. Instruct the client to ask for help before ambulating. D. Maintain the bed in the lowest position. E. Offer toileting every 2 to 3 hours. F. Advise family to notify staff when leaving.

A. Implement a bed alarm. D. Maintain the bed in the lowest position. E. Offer toileting every 2 to 3 hours. F. Advise family to notify staff when leaving.

The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.

45mg

What is the rationale for using a venturi mask?

A venturi mask is used when constant O2 concentration is critical.

A nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the diet? A. "I need to read food labels carefully to avoid gluten additives in foods." B. "My child needs a diet rich in all grains." C. "I should avoid feeding my child potatoes, rice, flour, and cornstarch." D. "My child can safely eat frozen and packaged foods."

A. "I need to read food labels carefully to avoid gluten additives in foods."

The nurse is reinforcing discharge instructions for a client who received a mechanical heart valve. Which statement made by the client indicates to the nurse that instructions are understood? A. "I will have to take lifelong anticoagulation therapy." B. "My valve will have to be replaced within 10 years." C. "I will not be able to exercise or participate in previous activities." D. "I will have to be on immunosuppressant therapy for the duration of my life."

A. "I will have to take lifelong anticoagulation therapy."

A client having an implantable cardioverter-defibrillator asks the nurse, "What should I do if I feel a shock and am alone?" Which is the best response by the nurse? A. "Lie down and call 911." B. "Continue previous activity." C. "Chew an aspirin tablet." D. "Take an extra dose of your antiarrhythmic medication."

A. "Lie down and call 911."

The parents of an infant report they are concerned about giving their child immunizations due to their association with autism. Which response by the nurse is appropriate? A. "Studies do not support a link between autism and immunizations." B. "There are limited risks of autism with the use of 'live' vaccines." C. "The administration of more than one immunization at a time has shown a slight relationship with the development of autism." D. "The use of inactivated vaccines has been linked to a slight increase in the development of autism in populations at risk."

A. "Studies do not support a link between autism and immunizations."

The nurse is applying a moist heat compress to a client's lower extremity. Which action by the nurse is a priority in order to prevent skin maceration? A. Apply a thin layer of petroleum jelly prior to compress application. B. Wrap the moist compress with an occlusive dressing. C. Apply the moist dressing continuously for 24 hr. D. Place a warm blanket over the dressing.

A. Apply a thin layer of petroleum jelly prior to compress application.

The nurse is caring for a client diagnosed with chronic thrombocytopenia. Before discharge, the nurse reinforces which activities to the client to decrease excessive bleeding? Select all that apply. A. Avoid alcohol. B. Avoid aspirin and ibuprofen. C. Avoid the influenza vaccine. D. Check with your health care provider about taking OTC drugs. E. Change any lupus treatments.

A. Avoid alcohol. B. Avoid aspirin and ibuprofen. D. Check with your health care provider about taking OTC drugs.

A client is undergoing photodynamic therapy. Which education would the nurse reinforce to prevent complications? A. Avoid direct sunlight and bright indoor lighting for 6 weeks. B. Maintain isolation for 6 weeks. C. Apply antibiotic cream to the area after treatment. D. Drink ten 8-oz glasses of fluids per day.

A. Avoid direct sunlight and bright indoor lighting for 6 weeks.

How can a nurse best protect herself after she experiences a minor allergic reaction to latex? A. Avoid use of all latex products. B. Use latex products on a limited basis. C. Carry an allergic reaction kit. D. Avoid using latex gloves.

A. Avoid use of all latex products.

The nurse is collecting data on a geriatric client with senile dementia. When reviewing this client's file, which neurotransmitter condition is the nurse likely to find in the client's history as a contributory factor to his or her cognitive changes? A. Decreased acetylcholine level B. Increased acetylcholine level C. Increased norepinephrine level D. Decreased norepinephrine level

A. Decreased acetylcholine level

Prior to having a guaiac test performed, which instruction(s) would the nurse provide to the client? Select all that apply. A. Do not take more than 250 mg/day of vitamin C. B. Avoid taking acetylsalicylic acid (Aspirin) or NSAIDs 3 days before the test. C. Avoid eating rare red meat prior to testing. D. Do not take antihypertensive medication prior to testing. E. Avoid dairy products prior to testing.

A. Do not take more than 250 mg/day of vitamin C. B. Avoid taking acetylsalicylic acid (Aspirin) or NSAIDs 3 days before the test. C. Avoid eating rare red meat prior to testing.

The nurse is caring for a client with left lower lobe pneumonia. Which nursing action would assist in improving oxygen delivery to the lungs and tissues? A. Encourage frequent coughing and deep breathing. B. Position the client with the head of the bed slightly elevated. C. Provide deep endotracheal suctioning. D. Use a bag valve mask to ventilate the client.

A. Encourage frequent coughing and deep breathing.

The rescue squad brings into the emergency department a client who has a blocked airway after choking on a piece of steak. The client is unresponsive, and resuscitation efforts are continued with a bag valve mask. Which action by the nurse is a priority? A. Gather equipment for an emergency tracheotomy. B. Intubate the client. C. Start an intravenous infusion. D. Perform a blind finger sweep.

A. Gather equipment for an emergency tracheotomy.

A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy? A. Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart. B. Remind the nurse director not to share the client's medical information with anyone because of his HIV status. C. Report the incident to the medical director. D. Ask the nurse director if she has permission to read the client's chart, and if not, tell her she needs to obtain it.

A. Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.

The nurse is preparing to apply an ACE bandage to a client's left ankle after the client has been walking. Which action would the nurse prioritize? A. Instruct the client to lie down for 15 min before wrapping. B. Have the client sit in a chair with the foot dangling before wrapping. C. Apply warm compresses to the ankle before wrapping. D. Begin wrapping from the knee to the toes.

A. Instruct the client to lie down for 15 min before wrapping.

Which action must a nurse take first before drawing a blood sample for human immunodeficiency virus (HIV) testing? A. Make sure that an informed consent form has been signed. B. Inform the client that the sample is being obtained for routine testing. C. Put on gloves and a mask. D. Tell the client that he'll be informed if the test results are positive.

A. Make sure that an informed consent form has been signed.

How can a nurse best ensure the safety of a client who has a latex allergy? A. Make sure that the latex allergy is properly documented. B. Inform the oncoming shift of the latex allergy during the shift report. C. Warn the client to avoid products containing latex. D. Instruct the client to take antihistamines daily.

A. Make sure that the latex allergy is properly documented.

A client is diagnosed with a conductive hearing loss. After performing the Weber's test, where will the nurse document that this client heard sounds? A. On the affected side by bone conduction B. On the unaffected side C. Longer through bone than air conduction D. By neither air nor bone conduction

A. On the affected side by bone conduction

The nurse is assisting a visually impaired client with meals. Which nursing interventions will assist the client with maintaining independence and dignity? Select all that apply. A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. C. Feed the client so food will not spill. D. Tell the client where food is located. E. Prepare finger foods so the client will not have to use utensils.

A. Place food in the same "clock position" on the plate. B. Tell the client what is being served. D. Tell the client where food is located.

The nurse is to obtain a urine specimen from a client who is suspected of having a urinary tract infection. After collecting and labeling the specimen, which action would the nurse take to prevent contamination of the specimen? A. Place the specimen in a biohazard bag. B. Take the specimen and place it in the laboratory refrigerator. C. Call the laboratory to come and get the specimen. D. Inform the client that the results will be back soon.

A. Place the specimen in a biohazard bag.

Which factor is most important when planning care for a client with a bleeding disorder? A. Prioritization B. Time management C. Delegation D. Verbal communication

A. Prioritization

The nurse is caring for a client who is intubated and mechanically ventilated. Which is a priority nursing intervention? A. Provide oral care every 2 hr. B. Suction the client every hour. C. Apply petroleum jelly to the lips to prevent dryness. D. Deflate the cuff and reposition the tube.

A. Provide oral care every 2 hr.

The nurse is determining the location of the point of maximal impulse for a client during an examination. Where will the nurse place the stethoscope? A. The mediastinum B. The apex of the heart C. The right lower sternal border D. The left upper sternal border

A. The mediastinum

The nurse is collecting data from a client with a bandage on the lower extremity. Which observations made by the nurse should be immediately reported to the charge nurse or provider? A. Toes are cold to touch. B. Toes are cyanotic. C. Toes are pink and warm. D. Edema is present in the foot and toes. E. Diminished pulses distal to the bandage.

A. Toes are cold to touch. B. Toes are cyanotic. E. Diminished pulses distal to the bandage.

A client is receiving radiation therapy for the treatment of breast cancer. Which information would the nurse provide the client to prevent skin damage during treatments? Select all that apply. A. Use only tepid water on the skin. B. Use baby shampoo to wash the skin. C. Wear cotton clothing next to the skin. D. Do not use heating or cooling devices next to the skin. E. Use at least an 8 SPF sunscreen when going outdoors.

A. Use only tepid water on the skin. C. Wear cotton clothing next to the skin. D. Do not use heating or cooling devices next to the skin.

Which information would the nurse provide to the client about prevention of cataract formation? Select all that apply. A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time. C. Instill saline drops twice daily into both eyes. D. Make sure eyeglasses fit well. E. Wear contact lenses rather than glasses.

A. Wear sunglasses when outside with amber, orange, or brown lenses. B. Do not stare at a computer screen for prolonged periods of time.

When conducting an information session for a group of clients with genital herpes which medication information should the nurse include? A. acyclovir B. penicillin C. doxycycline D. tetracycline

A. acyclovir

A client has a phenytoin level of 32 mg/dl. Which symptoms should the nurse monitor based on the result? A. ataxia and confusion B. sodium depletion C. tonic-clonic seizure D. urinary incontinence

A. ataxia and confusion

A child with sickle cell anemia is being treated for a vase-occlusive crisis and reports significant discomfort. Which actions can promote increased levels of comfort for the child? Select all that apply. A. cluster care interventions B. encourage fluid intake C. perform passive range of motion D. oxygen therapy as prescribed E. assist to knee-chest position

A. cluster care interventions B. encourage fluid intake D. oxygen therapy as prescribed

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? A. diphenhydramine hydrochloride B. pseudoephedrine hydrochloride C. guaifenesin D. loperamide

A. diphenhydramine hydrochloride

A nurse is reinforcing discharge instructions to a client after treatment for a severe allergic reaction from a bee sting. What instructions should the nurse include? Select all that apply. A. fill the prescription for injectable epinephrine to carry with you B. apply perfume liberally as a protection C. dress in sleeveless, easily removable garments D. obtain diphenhydramine to take following a bee sting E. wear bright colors to repel insects

A. fill the prescription for injectable epinephrine to carry with you D. obtain diphenhydramine to take following a bee sting

A nurse is caring for a child with juvenile arthritis (JA) who has oral prednisone prescribed. The nurse knows that the drug will be given at the lowest possible dosage and for the shortest period of time in order to avoid which adverse effects? A. growth retardation and increased risk of infection B. deafness and severe weight loss C. hypoglycemia and hypovolemia D. fibrotic skin changes and increased muscle mass

A. growth retardation and increased risk of infection

Which nursing action is most important to decrease the risk of postoperative complications in a child with sickle cell anemia? A. increasing fluids B. preparing the child psychologically C. discouraging coughing D. limiting the use of analgesics

A. increasing fluids

When caring for a child with sickle cell anemia in vaso-occlusive crisis, what does the nurse identify as the priority nursing intervention? A. manage pain B. provide a cool environment C. immobilize the affected part D. restrict fluids

A. manage pain

A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states which food to avoid? A. milk B. red licorice C. chicken soup D. broiled meat

A. milk

Which additional health care provider order should a nurse anticipate for a client who has been prescribed corticosteroids? A. perform blood glucose checks every six hours. B. restrict fluids to 1,000 ml in 24 hours. C. administer lactulose 40 g in 4 oz of water daily. D. obtain complete blood count (CBC) every 12 hours.

A. perform blood glucose checks every six hours.

A nurse is caring for a client who received 1 unit of fresh frozen platelets (FFP) for a platelet count of 20,000 mm3. Which repeat laboratory values will be of greatest concern to the nurse? A. platelet count 22,000 mm3 B. blood urea nitrogen 20 mg/dL C. white blood cell count 4.8 µL D. red blood cell count 5.2 µL

A. platelet count 22,000 mm3

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: A. raccoon eyes and Battle's sign. B. nuchal rigidity and Kernig's sign. C. motor loss in the legs that exceeds the loss in the arms. D. pupillary changes.

A. raccoon eyes and Battle's sign.

A nurse is monitoring a client who's receiving a blood transfusion for volume replacement. The client reports itching about 20 minutes after the infusion begins. What is the priority action by the nurse? A. report the symptom so that the infusion can be stopped immediately B. call the health care provider immediately C. give the client oral diphenhydramine and continue to monitor the client's symptoms D. do nothing because itching is a normal response to a blood transfusion

A. report the symptom so that the infusion can be stopped immediately

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity? A. swimming in rivers or lakes B. hiking in a forested area C. going horseback riding D. playing recreational softball

A. swimming in rivers or lakes

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with: A. thymus gland hyperplasia. B. poor nutrition. C. chemotherapy. D. a viral infection.

A. thymus gland hyperplasia.

What do ABG's measure?

ABG's shows the acidity and levels of oxygen and carbon dioxide levels in the blood from the artery.

What various problems can ABG's can show, and how can you recognize them on test results?

Abnormal ABGs can indicate that the patient has a respiratory issue such as acidosis or alkalosis. Abnormal ABG's could also indicate a metabolic problem such as acidosis or alkalosis.

What nursing care needs to be done for a client after use of femoral artery puncture for cardiac cath or angiography?

After a cardiac catheterization, it is important to assess the insertion site for bleeding or development of a hematoma.

Discuss nursing considerations after a thoracentesis.

After a thoracentesis it is important to monitor a patient's vital signs because the removal of excess fluid can result in vasodilation and hypovolemia. This can potentially result in syncope and shock. As a result, the nurse should monitor the patient's blood pressure and pulse immediately after the thoracentesis every 15 minutes until their vitals are stable or within acceptable levels. Since a thoracentesis is an invasive procedure that can sometimes lead to a serious complication such as a pneumothorax. A dramatic drop in oxygen saturation, and a patient gasping for air would be an indication of a possible pneumothorax.

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate? A. "If both sexual partners are HIV-positive, unprotected sex is permitted." B. "A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse." C. "Contraceptive methods, such as hormonal contraceptives, implants, and injections, are recommended for me to prevent HIV transmission." D. "The only safe sex my partner and I can practice is hugging, petting, and mutual masturbation."

B. "A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse."

The nurse is reinforcing education for a client with hypertension. Which statement made by the client indicates that further education is required? A. "I will apply methods to reduce stress in my life." B. "I don't have to take my antihypertensives if I am feeling well." C. "I will reduce the cholesterol and salt intake in my diet." D. "I will measure my blood pressure routinely at home."

B. "I don't have to take my antihypertensives if I am feeling well."

The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate? A. "Clonic seizure activity is usually interpreted as falling." B. "It's not unusual to develop seizures after a head injury because of brain trauma." C. "Focal discharge in the brain may lead to absence seizures that go unnoticed." D. "The brain needs multiple stimuli before it manifests as a seizure."

B. "It's not unusual to develop seizures after a head injury because of brain trauma."

A client with rheumatoid arthritis reports flatulence and heartburn after taking piroxicam. Which instruction should the nurse reinforce to address the client's concern? A. "These side effects will subside as you continue to take the medication." B. "Take an antacid at the same time that you take the medication." C. "This medication is used for short-term treatment of your arthritis." D. "Try taking a lower dose of the medication to relieve your symptoms."

B. "Take an antacid at the same time that you take the medication."

A client receiving ferrous sulfate therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide? A. "Take ferrous sulfate and the antacid together." B. "Take ferrous sulfate and the antacid at least 2 hours apart." C. "Avoid taking an antacid altogether." D. "Take ferrous sulfate and the antacid at least 1 hour apart."

B. "Take ferrous sulfate and the antacid at least 2 hours apart."

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. When asked by the newly graduated nurse, what type of hearing loss it is, how would the nurse preceptor respond? A. "It is considered a functional hearing loss." B. "This type of loss is a fluctuating hearing loss." C. "This is considered a sensorineural hearing loss." D. "This type of loss is a conductive hearing loss."

B. "This type of loss is a fluctuating hearing loss."

The nurse is caring for a client with pernicious anemia. Which question by the nurse explains the potential source of the anemia? A. "Did you have any surgery on your bladder?" B. "What type of diet do you follow?" C. "Do you have any changes in your vision?" D. "Have you added any new medications to your routine?

B. "What type of diet do you follow?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal a hematocrit of 24% (0.24). Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia? A. "Is the infant on any medications?" B. "What's the infant's usual daily diet?" C. "Did the infant receive phototherapy for jaundice?" D. "What's the pattern and appearance of bowel movements?"

B. "What's the infant's usual daily diet?"

A client undergoing chemotherapy states to the nurse, "I am ready to give up. I can't take this anymore." Which is the most therapeutic response by the nurse? A. "I will let your primary care provider know you are canceling your chemotherapy." B. "You sound discouraged. Would you like to talk about it?" C. "What is the problem with the chemotherapy?" D. "You need to ask your family what you should do."

B. "You sound discouraged. Would you like to talk about it?"

A child tests positive for the sickle cell trait, and the parents ask the nurse what this means. Which response by the nurse would be most appropriate? A. "Your child has sickle cell anemia." B. "Your child is a carrier but doesn't have the disease." C. "Your child is a carrier and will pass the disease to any offspring." D. "Your child doesn't have the disease now but may develop the disease as he gets older."

B. "Your child is a carrier but doesn't have the disease."

After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE). Which resource might be helpful for a nurse to recommend to this client? A. An occupational therapy consult B. A support group for clients with SLE C. A consult with a social worker D. A consult with a home health care nurse

B. A support group for clients with SLE

The nurse is caring for a client who was hit in the left eye with a softball. The eye is edematous and painful to touch. Which is the priority intervention by the nurse? A. Apply a cold pack. B. Apply a warm compress. C. Have the client lay flat for 12 hr to decrease swelling. D. Place drops in the eye to decrease pain.

B. Apply a warm compress.

The nurse is preparing a client with colon cancer for palliative surgery. Which outcome does the nurse expect for this client? A. Complete recovery B. Better quality of life C. Damage to cancer cells D. Remission

B. Better quality of life

A client receiving antiplatelet therapy is being monitored for adverse reactions. For which most commonly produced adverse reaction would the nurse observe this client? A. Difficulty hearing B. Bleeding C. Confusion D. Agranulocytosis

B. Bleeding

After applying a bandage to the upper right extremity, which action would the nurse take next? A. Administer medication for pain. B. Check the circulation of the client's fingers. C. Provide instructions for care. D. Document the application of the bandage.

B. Check the circulation of the client's fingers.

The nurse applies oxygen at 2 L/min via nasal cannula as prescribed for a client with dyspnea and an oxygen saturation of 90%. Which is a priority nursing action after oxygen administration for this client? A. Adjust the amount of oxygen flow every 4 hr. B. Continually monitor the client's respiratory status. C. Remove the oxygen cannula when ambulating in the room. D. Maintain the client in the supine position.

B. Continually monitor the client's respiratory status.

The nurse is providing a tepid sponge bath for a client with a fever. When the client begins to shiver, which action by the nurse is a priority? A. Pour isopropyl alcohol into the water. B. Discontinue the bath immediately and report findings. C. Increase the temperature of the water. D. Continue the bath since this is an expected reaction.

B. Discontinue the bath immediately and report findings.

The nurse is applying an oxygen cannula to a client with pneumonia. Which information would the nurse be sure to include when reinforcing education about oxygen administration? Select all that apply. A. Use an electric razor instead of a straight razor around oxygen. B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied. E. Discontinue the oxygen if there is nasal dryness.

B. Do not use oils around the oxygen, especially on hands. C. Avoid smoking around oxygen. D. Do not adjust the cannula after it is applied.

The nurse is caring for a client in the clinic who is diagnosed with the common cold. Which education would the nurse reinforce to help alleviate symptoms? A. Take antibiotics as prescribed. B. Drink plenty of fluids. C. Increase activity level. D. Avoid contact with others for 2 weeks.

B. Drink plenty of fluids.

The nurse is caring for a client who is blind. Which is the best way for the nurse to assist with ambulation? A. Have the aide push the client in a wheelchair. B. Have the client take the nurse's arm, with the nurse walking slightly ahead of the client. C. Have the client walk beside the nurse, with the nurse's hand on the client's back. D. Have the client walk down the hall with his or her hand along the wall.

B. Have the client take the nurse's arm, with the nurse walking slightly ahead of the client.

A client has a defective cranial nerve I. Which data would the nurse gather in order to determine function? A. Use a tuning fork to determine bone conduction. B. Instruct the client to smell and identify a variety of scents. C. Ask the client to open and close the eyes. D. Request the client to stick the tongue out and say "ah."

B. Instruct the client to smell and identify a variety of scents

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? A. Monitor vital signs every 4 hours. B. Monitor the appearance, size, and number of stools. C. Measure blood urea nitrogen (BUN) and serum creatinine levels. D. Measure intake and output.

B. Monitor the appearance, size, and number of stools.

A client's chronic, progressive hearing loss results from excess bone formation around the oval window, which impedes normal stapes movement and prevents sound transmission. The nursing student is researching the disorder. What is the clinical terminology for this correctable middle ear disorder that the student would utilize in her research? A. Stapes immobilization B. Otosclerosis C. Myringotomy D. Otitis media

B. Otosclerosis

A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first? A. Monitor intake and output. B. Place the child on the side opposite the shunt. C. Offer fluids because the child has a dry mouth. D. Administer pain medication by mouth as ordered.

B. Place the child on the side opposite the shunt.

A nurse administers etanercept by subcutaneous injection to a client with ankylosing spondylitis. Which action should the nurse take to prevent a needle-stick injury? A. Recap the needle using the one-handed scoop technique. B. Place the uncapped needle in the designated puncture-resistant container. C. Dispose of the needle in the receptacle designated for hazardous wastes. D. Recap the needle using two hands.

B. Place the uncapped needle in the designated puncture-resistant container.

A client states to the nurse, "I want to quit smoking. My father had a heart attack and he was a heavy smoker." Which action by the nurse is appropriate? A. Inform the client it would be best to stop immediately without aids. B. Provide information regarding counseling and smoking cessation aids. C. Encourage the client to quit because quitting is the only way to avoid a heart attack. D. Inform the client to get a prescription for anxiety before trying to stop.

B. Provide information regarding counseling and smoking cessation aids.

Which intervention provided by the nurse would assist the client with early chronic obstructive lung disease to improve efficiency of lung function? A. Administer breathing treatment with a bronchodilator. B. Provide smoking cessation information. C. Perform chest physiotherapy. D. Encourage coughing and deep breathing.

B. Provide smoking cessation information.

A client informs the nurse that he is color blind. Which colors does the nurse determine the client will likely have difficulty distinguishing? A. White and black B. Red and green C. Blue and purple D. Orange and pink

B. Red and green

A nurse is working with a support group for clients with human immunodeficiency virus (HIV). Which health promotion strategy should the nurse reinforce with the group? A. Avoid the use of recreational drugs and alcohol. B. Take antiretroviral medications as prescribed. C. Understand the importance of using safer-sex practices. D. Tell potential sex partners about the diagnosis.

B. Take antiretroviral medications as prescribed.

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. What does this evaluation determine for the client? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision sees at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20% decrease in acuity in one eye and a 40% decrease in the other eye.

B. The client can see at 20 feet what the person with normal vision sees at 40 feet.

A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs? A. Dysuria B. Tinnitus C. Leg cramps D. Constipation

B. Tinnitus

A client accidentally splashes chemicals into his eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment? A. To hasten formation of scar tissue B. To prevent vision loss C. To eliminate the need for medical care D. To serve as a stopgap measure until help arrives

B. To prevent vision loss

A client is receiving chemotherapy and is not required to be in reverse isolation. What activity will the nurse recommend to the client? A. bed rest B. activity as tolerated C. walks to bathroom only D. out of bed for brief periods

B. activity as tolerated

The nurse is reinforcing education to the parents of a child with leukemia about the three main consequences. What should the nurse inform the parents they should monitor for? A. bone deformities, spherocytosis, and infection B. anemia, infection, and bleeding tendencies C. lymphocytopoiesis, growth delays, and hirsutism D. polycythemia, decreased clotting time, and infection

B. anemia, infection, and bleeding tendencies

A nurse is reinforcing discharge instructions for a client with systemic lupus erythematosus (SLE). Which intervention is most important for the nurse to include? A. consume no more than 2 liters(L) of fluid daily B. apply sunscreens with SPF higher than 15 daily C. check blood sugar levels every morning before breakfast D. avoid foods containing peanuts

B. apply sunscreens with SPF higher than 15 daily

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of: A. beneficence. B. autonomy. C. advocacy. D. justice.

B. autonomy.

A client is placed on neutropenic precaution. Which nursing action is appropriate? A. putting flowers in the room B. avoiding yogurt for breakfast C. adding raw vegetables in the diet D. offering medium-rare cooked meat

B. avoiding yogurt for breakfast

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? A. client who is on complete bed rest B. client with a white blood cell count of 2000 µL C. client receiving brachytherapy for prostate cancer D. client who is 2 days postoperative following a hemicolectomy

B. client with a white blood cell count of 2000 µL

A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. When would this client require isolation if he or she were to remain hospitalized? A. isolation isn't required B. immediate isolation is required C. 10 days after exposure D. 12 days after exposure

B. immediate isolation is required

A child with weakness in the legs and a history of influenza is admitted with a diagnosis of Guillain-Barre syndrome. Which symptom, indicative of a possible serious complication, would the nurse report immediately to the primary health care provider? A. tingling in the hands B. increased hoarseness C. weak muscle tone in the arms D. weak muscle tone in the legs

B. increased hoarseness

During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for: A. muscle weakness. B. joint abnormalities. C. painful subcutaneous nodules. D. gait disturbances.

B. joint abnormalities.

A nurse is caring for a client with deep vein thrombosis (DVT). The client suddenly reports shortness of breath, blood-tinged sputum, and chest pain. The nurse suspects that the client has developed which complication? A. pulmonary hypertension B. pulmonary embolism C. cerebrovascular accident (CVA) D. myocardial infarction

B. pulmonary embolism

The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse instruct the client avoid? A. white bread B. raw carrot sticks C. stewed apples D. well-done steak

B. raw carrot sticks

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: A. lie supine with his neck extended. B. sit upright, leaning slightly forward. C. blow his nose and then put lateral pressure on his nose. D. hold his nose while bending forward at the waist.

B. sit upright, leaning slightly forward.

A client is admitted with hemophilia. Which sports should the nurse recommend for this client? Select all that apply. A. basketball B. swimming C. baseball D. golf E. soccer

B. swimming D. golf

How can someone prevent developing endocarditis?

By practicing good oral hygiene habits every day, you can reduce your risk of bacterial endocarditis. Good oral health is generally more effective in reducing your risk of bacterial endocarditis than taking preventive antibiotics before certain procedures.

The nurse is meeting with a 17 year-old client who has recently tested positive for human immunodeficiency virus (HIV). The client states, "What information will be disclosed to others." What information should be provided by the nurse? A. "You will need to disclose information to your teachers." B. "Your employers have a legal right to know your HIV status." C. "In some jurisdictions laws may require you share this information with future sexual partners." D. "You will be legally required to locate all past sexual contacts to inform them of your status."

C. "In some jurisdictions laws may require you share this information with future sexual partners."

A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate? A. "You have a mild concussion; acetaminophen is strong enough." B. "Aspirin is avoided because of the danger of Reye syndrome in children or young adults." C. "Opioids are avoided after a head injury because they may hide a worsening condition." D. "Stronger medications may lead to vomiting, which increases intracranial pressure (ICP)."

C. "Opioids are avoided after a head injury because they may hide a worsening condition."

A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client? A. Sickle cell anemia B. Folic acid deficiency anemia C. Aplastic anemia D. Iron deficiency anemia

C. Aplastic anemia

Which primary care provider order would the nurse question prior to implementing? A. Use of a warm sitz bath for relief of discomfort related to a client's hemorrhoids B. Application of a warm compress to the lower back to relieve soreness after back strain C. Application of a warm compress to the abdomen of a client with suspected appendicitis D. Use of a warm compress to the lower abdomen of a woman with menstrual cramps

C. Application of a warm compress to the abdomen of a client with suspected appendicitis

A client is scheduled for a surgical procedure. When assisting with implementation of the plan of care, which action can the nurse take to reduce surgical site infection? A. Administer oxygen during the preoperative phase. B. Wash the surgical site with soap and water prior to surgery. C. Apply warm blankets. D. Use antibiotic ointment before the incision is made.

C. Apply warm blankets.

A client was admitted with a platelet count of 95,000/µl (95 × 109/L). What would the nurse anticipate observing during data collection? A. Weakness and fatigue B. Dizziness and vomiting C. Bruising and petechiae D. Light-headedness and nausea

C. Bruising and petechiae

The nurse asks a client to use the eyes to follow finger movements to the left and right and then to close and open the eyes. Which cranial nerve will the nurse document as intact if the client is able to perform these movements? A. Cranial nerve I B. Cranial nerve II C. Cranial nerve III D. Cranial nerve IV

C. Cranial nerve III

The nurse is obtaining a urine specimen from a client for a drug screen. Which is the appropriate action for the nurse to take? A. Have the client go into the bathroom and close the door to void. B. Have the client void in a urinal or bedpan and place the specimen in a container. C. Directly observe the client voiding in the specimen container. D. Give the client a cup of water to drink while in the bathroom to assist with voiding.

C. Directly observe the client voiding in the specimen container.

A client arrives at the emergency department reporting chest and stomach pain and a history of black, tarry stools for the past 2 months. Which orders should the nurse anticipate? A. cardiac monitor, oxygen, creatine kinase, and lactate dehydrogenase (LD) levels B. prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin split product values C. ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel D. EEG, alkaline phosphatase and aspartate aminotransferase levels, and basic serum metabolic panel

C. ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel

The nurse is reinforcing education regarding the use of eye drops during treatment for a client who has been diagnosed with conjunctivitis. Which information will the nurse provide the client? A. Warm the solution briefly in the microwave prior to use. B. Save the unused solution for use if the infection returns. C. Ensure not to touch the eye with the dropper. D. Use the drops for the other member of the family who has conjunctivitis.

C. Ensure not to touch the eye with the dropper.

A client with hemophilia is admitted to the medical-surgical unit. When providing care for this client, which factor is most important? A. Performing effective client teaching B. Delegating tasks effectively C. Ensuring client safety D. Maintaining continuity of care

C. Ensuring client safety

The nurse is preparing to apply a large stretch-net bandage to a client's torso. Which action would the nurse perform first? A. Clean the client's skin with an alcohol-based solution to remove dead skin. B. Obtain pins or clips in order to attach the dressing. C. Explain the procedure to the client. D. Apply the bandage tightly to the torso.

C. Explain the procedure to the client.

A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he reports to a nurse that he continually feels weak. How should the nurse intervene? A. Recommend that the client exercise for 30 minutes a day to increase his strength. B. Notify the physician and request that the client's discharge be postponed. C. Explain to the client that he should schedule periods of rest throughout the day. D. Make arrangements for a wheelchair to be available for him after discharge.

C. Explain to the client that he should schedule periods of rest throughout the day.

The nurse is preparing a client for a bronchoscopy. Which nursing actions are essential prior to the procedure? Select all that apply. A. Administer an enema. B. Detail the complications that can occur. C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.

C. Give mouth care. D. Observe for any loose teeth. E. Explain the procedure.

A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? A. IgA B. IgB C. IgE D. IgG

C. IgE

A client is suspected of having tuberculosis. When would be the best time for the nurse to collect the sputum specimen? A. After the client brushes the teeth. B. Directly before the client goes to bed in the evening. C. Immediately after the client awakens in the morning. D. After the client eats a meal.

C. Immediately after the client awakens in the morning.

The nurse is presenting a lecture on vertigo at a community setting. The nurse will include that the client with vertigo may have a problem with which portion of the ear? A. External ear B. Middle ear C. Inner ear D. Tympanic membrane

C. Inner ear

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take? A. Contact the social services department to make arrangements for the client to complete a living will. B. Notify the physician so that he can place a do-not-resuscitate order on the client's medical record. C. Make arrangements for the client to receive information about advance directives. D. Explain that his condition is stable, so he doesn't need to be concerned at this time.

C. Make arrangements for the client to receive information about advance directives.

A licensed practical nurse (LPN) is coassigned with a registered nurse (RN) for the care of a client with hemophilia. The physician prescribes a blood transfusion for this client. Which task associated with blood transfusion is the responsibility of the LPN? A. Obtaining informed consent B. Making sure that the RN signs the transfusion form C. Monitoring the client during the transfusion D. Ensuring that a 20-gauge I.V. catheter is in place before obtaining the blood product

C. Monitoring the client during the transfusion

A client has a positive tuberculin skin test. Which action by the nurse is appropriate? A. Administer another tuberculin skin test. B. Administer a tine test. C. Prepare the client for a chest x-ray. D. Prepare the client for a bronchoscopy.

C. Prepare the client for a chest x-ray.

When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into the nurse's eyes. What should the nurse do next? A. Rinse their eyes with water, record the incident on the client's chart, and see Employee Health. B. Wash their hands, complete an incident report, and see a physician as soon as possible. C. Rinse their eyes with water, report the incident, and go to Employee Health. D. Rinse their eyes, contact Employee Health and document their findings.

C. Rinse their eyes with water, report the incident, and go to Employee Health.

A client is being considered as a candidate for a cochlear implant. Which data gathered by the nurse would support the client's candidacy? A. The client has mild mental retardation. B. The client has a history of schizophrenia. C. The client is unable to recognize words spoken. D. The client expects hearing will resume normally after surgery.

C. The client is unable to recognize words spoken.

A client has had heavy menstrual bleeding for 6 months. Her gynecologist diagnoses microcytic hypochromic anemia and prescribes ferrous sulfate, 300 mg by mouth daily. A review of her assessment reveals which condition that would indicate to the nurse that this medication is contraindicated in the use of ferrous sulfate? A. Pregnancy B. Asthma C. Ulcerative colitis D. Migraine headaches

C. Ulcerative colitis

The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? A. Limit visits by family members. B. Encourage the client to use a wheelchair. C. Use the smallest needle possible for injections. D. Maintain accurate fluid intake and output records.

C. Use the smallest needle possible for injections.

A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation of the disease and requires a low-level consistent oxygen concentration. Which method of oxygen delivery will the nurse apply? A. Partial-rebreathing mask B. Nonrebreather mask C. Venturi mask D. Nasal cannula

C. Venturi mask

Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with human immunodeficiency virus (HIV)? A. monthly plasmapheresis B. eating a diet of balanced, nutritious foods C. adherence with the complete therapeutic regimen D. getting adequate rest and sleep

C. adherence with the complete therapeutic regimen

The nurse is caring for a teen diagnosed with acute lymphocytic leukemia (ALL). A review of the laboratory report indicates a platelet count of 125,500/?L. When gathering data, which finding is most consistent with this laboratory result? A. abdominal swelling B. joint swelling C. bruising D. swollen axillary lymph nodes

C. bruising

A client takes prednisone, as prescribed, for rheumatoid arthritis. The nurse should tell the client to look for common adverse reactions to this drug, such as: A. tetany and tremors. B. anorexia and weight loss. C. fluid retention and weight gain. D. flatus and diarrhea.

C. fluid retention and weight gain.

A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority? A. impaired physical mobility B. decreased gastrointestinal motility C. impaired swallowing D. risk for isolation

C. impaired swallowing

A client with allergic rhinitis is prescribed loratadine. On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because: A. loratadine isn't available in 10-mg tablets. B. loratadine should be taken on an empty stomach. C. loratadine should be taken once daily for allergic rhinitis. D. loratadine isn't available in tablet form.

C. loratadine should be taken once daily for allergic rhinitis.

While in the emergency department, a client with C8 quadriplegia develops a blood pressure of 80/44 mm Hg, pulse of 48 beats/minute, and respiratory rate of 18 breaths/minute. The nurse suspects which condition? A. autonomic dysreflexia B. hemorrhagic shock C. neurogenic shock D. pulmonary embolism

C. neurogenic shock

The nurse is caring for a child who has just been diagnosed with sickle cell anemia. Which initial action will be most therapeutic? A. discuss plans for contraception to prevent pregnancies at this time B. referral for genetic counseling C. offer emotional support D. reinforce the idea that transmission is unlikely in subsequent pregnancies

C. offer emotional support

Which nursing measure is helpful when mouth ulcers develop as an adverse effect of chemotherapy? A. use lemon glycerin swabs B. administer milk of magnesia C. provide a bland, moist, soft diet D. frequently wash the mouth with alcohol-based mouthwash

C. provide a bland, moist, soft diet

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should: A. maintain strict isolation. B. keep the client in a private room, if possible. C. wear gloves when providing mouth care. D. wear a gown when delivering the client's food tray.

C. wear gloves when providing mouth care.

What does the C stand for in CMS-ET?

C: color of fingers or toes/ circulation (as in cap refill time or pulse distal to the bandage, which should be no more than three seconds.

What is a CA-125 tumor marker?

CA-125 tumor marker: is a blood test for cancer of the uterus, fallopian tubes, ovaries, and breast. Rising levels of CA-125 can indicate growth of a malignant tumor, recurrence of a previously treated tumor, or a tumor in the peritoneum. It is also a type of cancer antigen protein that is associated with a few types of cancerous tumors.

What is a CEA tumor marker?

CEA tumor marker: is a carcinoembryonic antigen, which is normally found in high levels in the fetus, but not in the adult. Commonly found with breast, colorectal, and lung cancers.

Which side effect of opiate use does not ease as the client adjusts to medication?

Constipation does not ease as a client adjusts to the medication, as a result stool softeners are often ordered in addition to opiates to help prevent this.

The nurse is reinforcing education to a client taking phenytoin for the treatment of seizures. The client asks, "Can I still have my beer every day"? What is the best response by the nurse? A. "Alcohol increases phenytoin activity." B. "Alcohol raises the seizure threshold." C. "Alcohol impairs judgment and coordination." D. "Alcohol decreases the effectiveness of phenytoin."

D. "Alcohol decreases the effectiveness of phenytoin."

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours." C. "Shampoo your hair every day for 10 days to help prevent ear infection." D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? A. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." B. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." C. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." D. "I will receive parenteral vitamin B12 therapy for the rest of my life."

D. "I will receive parenteral vitamin B12 therapy for the rest of my life."

An older adult client informs the nurse of a "terrible ringing in the ears." Which question would be a priority for the nurse to ask the client? A. "Do you irrigate your ears?" B. "When was the last time you had an ear examination?" C. "Does anyone in your family have this problem?" D. "What medications do you take?"

D. "What medications do you take?"

The nurse is gathering data for several clients. When obtaining pulse oximetry readings, the nurse determines that this method is ineffective for which client? A. A client on oxygen via nonrebreather mask B. A client with pneumonia C. A client with chronic obstructive pulmonary disease (COPD) D. A client with severe anemia

D. A client with severe anemia

The client's bandage has become soiled. Which action would the nurse take to avoid spreading microorganisms? A. Place a dressing under the bandage. B. Wash the bandage to remove the drainage. C. Reinforce the bandage with another. D. Replace the bandage with a new one.

D. Replace the bandage with a new one.

A client is preparing to have an angiocardiogram in the morning. Which data would the nurse obtain in preparation for this test? A. Ask if the client has crutches or a cane to use after the test. B. Ask if the client has a family member that had this test. C. Ask if the client has received a yearly flu shot. D. Ask if the client is allergic to shellfish or iodine.

D. Ask if the client is allergic to shellfish or iodine.

Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneumonia? A. Encouraging the client to be actively involved in his care B. Keeping the client's skin clean and dry C. Turning the client every 2 hours D. Auscultating breath sounds

D. Auscultating breath sounds

The nurse is obtaining data from an older adult client. Which finding would the nurse recognize as consistent with "stiffening" of the large arteries? A. Respiratory rate of 18 breaths per minute B. Heart rate of 64 beats per minute C. Blood pressure of 100/60 mm Hg D. Blood pressure of 160/72 mm Hg

D. Blood pressure of 160/72 mm Hg

A client states to the nurse, "I am taking a trip by plane and the last time I flew, the problems with my ears were awful!" Which suggestion would the nurse provide to alleviate discomfort? A. Use a Q-tip to remove impacted wax to decrease pressure when flying. B. Insert saline drips into both ears every hour while flying. C. Irrigate the ear prior to the trip to remove wax and decrease pressure. D. Chew gum to promote swallowing.

D. Chew gum to promote swallowing.

A client is eating supper and begins coughing. Which action should the nurse take first? A. Insert fingers into the mouth to do a blind sweep and remove object. B. Lay the client flat and perform chest thrusts. C. Pat the client on the back to assist with dislodging the foreign body. D. Do nothing. Coughing will usually dislodge the foreign body.

D. Do nothing. Coughing will usually dislodge the foreign body.

A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important? A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician. B. Slow the transfusion and monitor the client closely. C. Stop the transfusion, notify the blood bank, and administer antihistamines. D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.

D. Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.

The nurse is preparing a client for abdominal surgery. Which action by the nurse can prevent postoperative atelectasis? A. Suction the client every 2 hr. B. Administer supplemental oxygen. C. Administer an inhaled bronchodilator. D. Instruct the client about the use of incentive spirometry.

D. Instruct the client about the use of incentive spirometry.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate? A. Increased intracranial pressure (ICP) B. Cerebral edema C. Low cerebrospinal fluid (CSF) pressure D. Meningeal irritation

D. Meningeal irritation

A client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 mm Hg and heart rate of 50 beats/minute. Which nursing intervention should be done first? A. Place the client flat in bed. B. Check patency of the indwelling urinary catheter. C. Give one sublingual nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.

D. Raise the head of the bed immediately to 90 degrees.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? A. Bathing or hygiene self-care deficit B. Ineffective tissue perfusion: cerebral C. Dysfunctional grieving D. Risk for injury

D. Risk for injury

The nurse applies a cold pack to a client's wrist after a sprain. Which action by the nurse a priority when the client reports a burning pain at the site? A. Replace the compress with another cold compress. B. Place the wrist in hot water to reverse the cold. C. Administer an analgesic for the pain. D. Stop treatment and notify the primary care provider.

D. Stop treatment and notify the primary care provider.

The primary care provider orders ear irrigation for a client. Which situation requires the nurse to question this order? A. The client has a scratch on the external canal. B. The client has a foreign body in the ear. C. The ear canal has impacted cerumen. D. The eardrum may be punctured.

D. The eardrum may be punctured.

The nurse is caring for a child who is receiving steroid therapy as a part of the cancer treatment plan. The child tearfully asks the nurse," Why does my face looks so "fat?" What information should be included in the nurse's response? A. The facial tissues are retaining fluid as a result of the cancer. B. An activity plan to promote calorie use will be helpful in reducing this facial appearance. C. Drinking more fluids will help ensure toxins are flushed from the system and will reduce this appearance. D. This change is temporary and will subside once the steroid medication has been discontinued.

D. This change is temporary and will subside once the steroid medication has been discontinued.

The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately? A. Serum potassium level of 4.9 mEq/L B. Serum sodium level of 135 mEq/L C. Temperature of 99.2° F (37.3° C) D. Urine output of 20 ml/hour

D. Urine output of 20 ml/hour

A client has a dressing on a sacral wound that is saturated with drainage. How would the nurse obtain the output information from this dressing? A. Estimate the amount of liquid in the saturated dressing. B. The information cannot be obtained since it is not liquid. C. Weigh the dressing and document the results. D. Weigh the dressing and then weigh an identical dry dressing.

D. Weigh the dressing and then weigh an identical dry dressing.

A nurse is caring for several client's with human immunodeficiency virus (HIV) infection. Which client does the nurse suspect has acquired immunodeficiency syndrome (AIDS) wasting syndrome? A. a client with oral pain, dysphagia, and yellow-white plaques in his mouth and throat B. a client with recurrent vaginitis causing intense itching and white, thick vaginal discharge C. a client with impaired memory, hallucinations, loss of balance, and personality changes D. a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days

D. a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days

A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include: A. weight gain. B. fine motor tremors. C. respiratory acidosis. D. bilateral hearing loss.

D. bilateral hearing loss.

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: A. genetic dysfunction. B. upper and lower motor neuron lesions. C. decreased conduction of impulses in an upper motor neuron lesion. D. destruction of acetylcholine receptors.

D. destruction of acetylcholine receptors.

The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for: A. platelet dysfunction. B. oliguria and dysuria. C. stomatitis. D. diarrhea.

D. diarrhea.

A nurse is caring for a client who had cardiac revascularization surgery 3 days ago. Upon analysis of lab reports, the nurse notes the client's platelet count decreased from 230,000 to 5,000 μL? Which condition is suspected? A. pancytopenia B. idiopathic thrombocytopenic purpura (ITP) C. disseminated intravascular coagulation (DIC) D. heparin-associated thrombosis and thrombocytopenia (HATT)

D. heparin-associated thrombosis and thrombocytopenia (HATT)

A nurse is caring for a client with multiple myeloma. When assisting with the plan of care, which nursing intervention is most appropriate? A. monitoring respiratory status B. balancing rest and activity C. restricting fluid intake D. preventing bone injury

D. preventing bone injury

A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality? A. sharing the client's information with some of the nurses on the unit B. sharing the client's information with family members involved in the care of the client C. sharing the client's information with the nursing assistant providing care to the client D. sharing the client's information with the clergy who is visiting with the client

D. sharing the client's information with the clergy who is visiting with the client

Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)? A. increased bruising B. failure to thrive C. prolonged bleeding D. susceptibility to infection

D. susceptibility to infection

When discussing activities that are safe for the school-age child with hemophilia, which activities should the nurse encourage? Select all that apply. A. baseball B. cross-country running C. football D. swimming E. leisure walking

D. swimming E. leisure walking

What are nursing considerations (dos and don'ts) when caring for a client with a visual impairment?

DO: - To determine the severity of your patient's vision impairment, assess their visual acuity and visual fields. - Assess them for disorders such as cataracts, macular degeneration, and diabetic retinopathy. If they have partial vision, try to stay in their field of vision when you talk to them, and make sure the lighting is adequate. - Notify staff of a patient's impaired vision with a sign above bed, in report, and on their medical record. - Address patients directly in a normal tone of voice. - Use their name or touch their arm before you start talking to them. Tell them each time you enter or leave their room, and say your name. Always explain what you're going to do before you do it. - Orient the patient to their surroundings, including how the furniture is arranged, using specific directions and distances. Keep the area uncluttered and pathways clear. - Teach them how to use the call bell and keep it within easy reach. - Keep their bed in a low position. Arrange their personal and self-care items within reach, as they direct you, or orient to their placement. - Identify and explain unfamiliar sounds, such as monitor alarms. - When you help the patient walk, ask which side they prefer you on. Offer them your arm or elbow for them to grasp. DON'T: - Don't shout when you speak. - Insist on helping if the patient refuses.

What does the E stand for in CMS-ET?

E: edema should not be present anywhere where the immobilization device is applied

What are risk factors for endocarditis?

Endocarditis is usually caused by an infection. Bacteria, fungi or other germs get into the bloodstream and attach to damaged areas in the heart. Things that make you more likely to get endocarditis are artificial heart valves, damaged heart valves or other heart defects.

What type of isolation precautions needed for a client with pneumonia?

For a patient with pneumonia, it is important to perform proper handwashing and wearing gloves, as pneumonia can easily be spread.

What is the immediate management things you should do if you suspect a DVT in a patient?

Have a venous duplex ultrasound done on the suspected limb, compression stockings, and a heparin bolus infusion over a few days to help make sure adequate anticoagulation has been retrieved. They are also usually put on bedrest.

How many lobes does the left lung have?

How many lobes does the left lung have?

What are the 12 cranial nerves in order?

I. Olfactory II. Optic III. Oculomotor IV. Throchlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear (acoustic) IX. Glossopharyngeal X. Vagus XI. Accessory (spinal) XII. Hypoglossal

Would inadequate surfactant cause problems with external or internal respiration?

If a patient has inadequate surfactant, it causes the patient to have tremendous pain while breathing as the pleural cavity and lungs rub against one another on inspiration and expiration.

What is the process of and nursing considerations for performing a percutaneous transluminal angioplasty (PCTA) also known as balloon angioplasty?

In percutaneous transluminal coronary angioplasty (PTCA), a surgeon inserts a balloon-tipped catheter into a client's narrowed coronary artery. Injection of a radiopaque dye allows clear visibility of the coronary arteries by x-ray study so that the surgeon can see the vessels.

What are warning signs and treatment for tumor lysis syndrome?

Laboratory diagnosis of tumor lysis syndrome is based on having two or more abnormal lab values including hyperuricemia, hyperkalemia, hyperphosphatemia, and/or secondary hypocalcemia occurring within 3 days prior to or up to 7 days after the initiation of cytotoxic therapy for malignancy. In general, treatment of TLS consists of intensive hydration, stimulation of diuresis, and, more specifically, in the use of allopurinol and rasburicase.

What are some teaching points to give a patient that is diagnosed with hypertension?

Lifestyle changes to help manage hypertension include: losing weight, eating a healthy, low-sodium diet, exercising more, stopping smoking, and limiting alcohol.

What does the M stand for in CMS-ET?

M: motion or mobility of the fingers or toes (should be able to move slightly but not too freely otherwise it indicates the immobilization device is too loose)

What does the S stand for in CMS-ET?

S: sensitivity or sensation; no tingling or loss of sensation should be present

What lifestyle risk factor is the leading cause of cancer death in the US?

Smoking and tobacco use is the leading cause of cancer and preventable diseases in the US, including many types of cancer.

What is the function of surfactant?

Surfactant acts to break up the surface tension in the pulmonary lung fluids, thus reducing friction and preserving elasticity of the lung tissue.

What does the T stand for in CMS-ET?

T: temperature compared to proximal limb; should not be cold in any places distal to the immobilization devices' application point such as in the limb, fingers, or toes; A bandage that is too tight can cut off circulation and quickly cause tissue damage. If too loose, it will not provide support and will usually fall down

What are some important teaching points for a patient with cataracts?

Tell the patient that some of the earliest symptoms of cataract formation include seeing halos around lights, and that they may notice a decreased visual acuity and double vision.

What is the rationale for, and nursing considerations for collecting a sputum specimen?

The sputum specimen may be ordered for an examination and culture to help rule out the presence of the tubercle bacillus, which is the causative agent for tuberculosis. This test also helps determine what kind of infection that the patient may have including bacterial, fungal, or viral. Sputum specimens can also help diagnose malignancies. It's important for the nurse to know that the sputum specimen is often collected three days in a row in the morning when the patient first wakes up before they eat, drink, or brush their teeth. It is also important to let the patient know that they need to breathe deeply several times, and to cough with exhalation so the sputum (not the saliva) foes into the specimen cup.

What are the ways to differentiate between angina and MI?

There are several types of angina pain. Intractable angina does not respond to therapy and often is so persistent that the person cannot work. Unstable angina is pain that increases and decreases in frequency, duration, and intensity. Nocturnal angina occurs at night. Decubitus angina occurs when the person is lying down and is relieved when the person sits up. Angina can usually be controlled with nitroglycerin tablets. As soon as an attack begins, the client places a tablet under the tongue, allowing it to dissolve. A myocardial infarction (MI), also known as heart attack, coronary thrombosis, or coronary occlusion, is the sudden blockage of one or more coronary arteries. Typically, but not in all cases, an MI begins suddenly, with sharp, severe chest pain that sometimes radiates to the left arm, shoulder, and back. Pain is similar to angina pain but can last longer and is more severe; exertion is not always related to onset. Unlike angina, rest does not relieve the pain, and nitroglycerin does not help. Because an MI may imitate indigestion or a gallbladder attack with abdominal pain, definite diagnosis is often difficult. Other common symptoms of MI include panic, restlessness, and confusion; a sense of impending death; ashen, cold, and clammy skin; dyspnea; cyanosis; rapid, thready, and irregular pulse; and drop in blood pressure and in body temperature. Nausea and vomiting may be present, and the person is often in shock. Silent attacks involving CAD, that is, MIs that show no overt symptoms, are common, especially among people with diabetes, and they may result in greater damage to the heart muscle.

What are common symptoms of heart failure?

What are common symptoms of heart failure?

What are the effects of smoking on the ciliated cells in the airway?

What are the effects of smoking on the ciliated cells in the airway?

What are the risks of untreated strep infection?

What are the risks of untreated strep infection?

What is the rationale for using a partial rebreather mask?

What is the rationale for using a partial rebreather mask?

What is proper trach suction procedure?

When performing trach suctioning make sure to ventilate the patient before performing suctioning. Be sure to suction in a circular motion, and be down for no longer than 10-12 seconds. Also make sure to not go down more than three times as this can not only be irritating in the trachea, but can cause the patient's oxygen saturations to go further down if they haven't been given time to recover.

What are the visual affects of astigmatism?

With astigmatism, there is unequal curvature in the shape of the lens or the cornea, this causes light rays to focus on two different points in the retina.

What problems can be diagnosed with an echocardiogram?

an echocardiogram is a graphic record or tracing that represents the heart's electrical action. It provides information about the heart, rate, rhythm, and presence of certain disorders.

What problems can be diagnosed with an electrocardiography?

an electrocardiography uses sound waves to produce a 3D view of the heart and its blood flow. It assesses the heart size, detects for the presence of excess fluid in the pericardial sac, assesses valvular function, and it can show atrophy or distention of the individual heart chambers. It can be useful in diagnosing different heart murmurs, heart failure, and the amount of blood each ventricle ejects with each heartbeat.

What does the p-wave represent in the EKG ?

atrial depolarization (contraction)

What is the pathophysiology of and possible causative events for conduction hearing loss?

occurs from the sound waves that go to the organs of hearing are disrupted. It may also be caused by a disorder in the auditory canal, the eardrum, or the ossicles, with fluid in the ear being the most common cause. It can also be caused by a perforated eardrum, otosclerosis, or obstructions of the external auditory canal.

How does the medulla regulate respiration?

controls the depth and rate of respirations

What are electrolyte imbalance risks from furosemide?

furosemide induces various electrolyte imbalances including hypokalemia, hypomagnesemia, hypocalcemia, hyponatremia, and hyperuricemia.

What does the right bronchi further divide into?

further divides into three bronchioles

What does the left bronchi further divide into?

further divides into two bronchioles

How many lobes does the right lung have?

has three lobes the upper, middle, and lower lobes

What are the two types of respiration?

internal respiration and external respiration

What is the pathophysiology of and possible causative events for sensorineural hearing loss?

involves a disturbance of the organs of the inner ear, or of the transmitting nerve. It involves the organ of Corti or auditory nerve. Other causes may include excessive noise and congenital predisposition.

What causes hypoxemic hypoxia?

is a state of decreased blood oxygen level, leading to a decreased amount of oxygen in the tissues. This can be caused by a blocked airway, congested lungs, an injury to the chest or lungs, or acute or chronic lung infections that may interfere with breathing.

What is the larynx, and what is it's function?

is also known as the voice box; air passes through it from the pharynx, and it is made of cartilage

What is the trachea, and what is it's function?

is also known as the windpipe; air passes to the trachea from the larynx; has cartilaginous rings that provide rigidity and help keep it open; divides into two bronchi

What causes anemic hypoxia?

is caused by a reduction in the blood's oxygen-carrying capacity, which can be caused by a decrease in blood volume, decreased hemoglobin in the RBC's, or the inability of hemoglobin to take on oxygen.

What causes histotoxic hypoxia?

is caused by an inability of the tissues to use oxygen, which could be caused by a patient being under the influence of certain chemicals, making the cells unable to use oxygen.

What causes circulatory hypoxia?

is caused by inadequate blood circulation, which can be caused by either failure of the heart to pump or a rupture of a blood vessel.. It could also be caused by a lack of blood flow to the heart itself.

Explain the use of CMS-ET in assessing a limb with immobilization device in place, including frequency of assessment.

is the acronym used to make an assessment of a limb distal to the application site of an immobilization device. With frequency it's important to check the client's peripheral neurovascular status within 1 hr and at least every 2 hr after that. Rewrap, if necessary. This is important to make sure the bandage is applied appropriately and to ensure no circulation is being cut off as tissue damage can quickly occur.

What is internal respiration?

is the exchange of oxygen for carbon dioxide within the cells

What is external respiration?

is the exchange of oxygen within the alveoli of the lungs

What is a secondary tumor site, and what are it's implications?

is when the cancer has metastasized and moved to another area of the body. Cancer for this type of site may extend directly into nearby tissue or a body cavity. Secondary sites can also occur when cancer cells spread through the bloodstream or lymphatic system from the primary site to other parts of the body.

What is a primary tumor site, and what are it's implications?

is where the cancer originated. These tumors are either closely resemble normal cells

What are electrolyte imbalance risks from spironolactone?

spironolactone can cause hyperkalemia. The risk of hyperkalemia may be increased in patients with renal insufficiency, diabetes mellitus or with concomitant use of drugs that raise serum potassium.

What does the PR segment represent in the EKG?

the time from the onset of atrial depolarization to the onset of ventricular depolarization

What does the QRS complex represent in the EKG?

ventricular depolarization (contraction)

What does the T wave represent in the EKG?

ventricular repolarization (ventricular relaxation)

How does the pons regulate respiration?

works with the medulla to produce a regular breathing rhythm