HESI Comprehensive Exam

A client is taking gentamicin sulfate for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? "When was your last bowel movement?" "When was your last menstrual period?" "Are you having any difficulty hearing?" "Are you having any difficulty breathing?"

"Are you having any difficulty hearing?" Rationale: Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity. Gentamicin sulfate is an aminoglycoside. It inhibits bacterial protein synthesis and has a bactericidal effect. The nurse must assess the client for changes in hearing, balance, and urine output. The remaining assessment questions are not associated with the adverse effects of this medication.

A primary health care provider writes a prescription for 1,0 mL of 0.9% normal saline solution to be administered intravenously (IV)to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion? Type answer in the box provided. _______________ gtt/min

25

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa). On the basis of the ABG result, what does the nurse prepare to do? Assist in intubating the client and beginning mechanical ventilation

A client who sustains smoke inhalation is immediately treated with 100% humidified oxygen, delivered by way of face mask. An arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa) is an indication for intubation and mechanical ventilation. Normal arterial oxygenation is 80-100 mm Hg (10.6-13.33 kPa). Also, endotracheal intubation with mechanical ventilation is needed if the client exhibits respiratory stridor, crowing, or dyspnea, all of which indicate airway obstruction.

A nurse is reviewing the laboratory results of a female client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? White blood cell count of 2.5 × 103/μL (2.5 × 109/L)

A white blood cell count of 2.5×103/μL(2.5×109/L)is low and puts the client at risk for infection. The normal white blood cell count 4.0-11.0×103/μL(4.0-11.0×109/L). All of the other values are within normal limits. The normal sodium lvl is 135-145 mEq/L(135 -145 mmol/L). The normal hemoglobin lvl for a female 13.2-17.3 g/dL(132-173 g/L). The normal BUN concentration 6-20 mg/dL (2.1-7.1 mmol/L).

Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements (repetitive and rapid, jerky, involuntary movements that appear well-coordinated). Of which common side effect does the nurse warn the client? Drowsiness

Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency arent specific side effects of this medication.

A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client? Hearing loss

Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and isnt necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.

A nurse in a primary health care provider's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt what action by the nurse? Document the findings

By the 10 to 14th dy, the fundus is in the pelvic cavity and cannt be palpated abdominally. Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hrs after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per dy. Asking the primary health care provider to see the client immediately, having another nurse check for the uterine fundus, and placing the client in the supine position for 5 minutes and rechecking the abdomen are all incorrect and unnecessary actions in light of the assessment finding.

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. Fatigue Low-grade fever

Early manifestations of RA include fatigue, low-grade fever, weakness, anorexia, and paresthesias. Rheumatoid arthritis is a chronic, progressive, systemic and inflammatory autoimmune disease process that affects the synovial joints, resulting in their destruction. Anemia, weight loss, and joint deformities are some of the late manifestations.

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available? Calcium gluconate

Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium lvl becomes too high. Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures(eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.

A client undergoing therapy with carbidopa/levodopa calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. What should the nurse tell the client? That this is an occasional side effect of the medication

Carbidopa/levodopa, an antiparkinson agent, may cause darkening of the urine or sweat. The client should be reassured that this is a harmless side effect of the medication and that the medication's use should be continued. Although fluid intake is important, telling the client that he needs to drink more fluid is incorrect and unnecessary. Telling the client that the darkening of his urine may signal developing medication toxicity is incorrect and might alarm the client unnecessarily. Theres no need for the client to call the primary health care provider.

A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? Decreased fluid volume

Decreased fluid vol is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific signs/symptoms at the time. Sickle cell disease is a genetic disorder thats manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta.

The emergency room nurse is caring for a client who sustained extensive burn injuries. What are the nurse's primary goals for this client?Maintain a patent airway Preserve vital organ functioning Administer IV fluids to prevent hypovolemic shock

Rationale: The primary goals for the client with a burn injury are to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning.

A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which recommendations does the nurse include on the poster? Select all that apply.

Seek medical advice if you find a skin lesion. Wear a hat, opaque clothing, and sunglasses when out in the sun.

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions? Cheeseburger

The client with CopD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and dont promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness.

An adult client with chronic kidney disease who is oliguric and undergoing hemodialysis is under a fluid restriction. What percentage of the total amount of fluid can the client consume during the evening shift? 40%

When calculating how to distribute fluid to a client under fluid restriction, the nurse usually allows half or 50% of the allotted total oral fluids btw 7 am and 3 pm, the period during which the client is more active, consumes two meals, and takes most of oral medications. Another two fifths(40%)is allotted to the evening shift, and the balance(10%)is allowed during the night.

An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? Administering 100% oxygen

With a client with C monoxide poisoning, the priority is to treat the client with inhalation of 100% O to shorten the half-life of carbon monoxide to around an hour. Hyperbaric O may be required to reduce the half-life to minutes by forcing the C monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this isnt the priority. Suicide precautions should be instituted once emergency interventions have been completed and the client has been admitted to the hospital. The diagnosis is confirmed with a measurement of the carboxyhemoglobin lvl in the client's blood. Obtaining a blood specimen to measure the carboxyhemoglobin lvl is a priority; however, the nurse would immediately administer 100% oxygen to the client.

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the most appropriate way for the nurse to document this occurrence in the client's record? Writing that the client is very agitated Writing that the client yelled at the nurse Writing that the client is able to perform his/her own care Writing down the client's words and placing them in quotation marks

Writing down the client's words and placing them in quotation marks Rationale: Documenting the client's words verbatim and placing them in quotations ensures accurate data. An objective description is the result of direct observation and measurement. Documenting inferences without supporting factual data is not acceptable, because a client's statements may be misunderstood. The remaining options do not provide objective descriptions.

A hospitalized female client demonstrating mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don't say that. If you can't control yourself, we'll help you."

"Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The appropriate response is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client.

A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? "Tell me your plan for saving the world." "Why do you think that you can accomplish this by yourself?" "I don't think anyone can save the world from the terrorists by himself/herself." "You must be powerful. Do you really believe that you can do this by yourself?"

"I don't think anyone can save the world from the terrorists by himself/herself." Rationale: The appropriate response by the nurse is "I don't think anyone can save the world from the terrorists by himself/herself." The nurse should not go along with or reinforce the client's delusion. The nurse should respond to the client by presenting reality. "Tell me your plan for saving the world," "Why do you think that you can accomplish this by yourself?" and "You must be powerful. Do you really believe you can do this by yourself?" all reinforce the delusion and encourage further conversation about it.

A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching? "I can't drink alcohol." "I have to avoid having sex until the test for antibodies comes back negative." "I need to rest a lot during the day and get enough sleep at night." "I need to eat three meals a day with foods high in protein, fat, and carbs."

"I need to eat three meals a day with foods high in protein, fat, and carbs." Rationale: The client needs further teaching if the client states, "I need to eat three meals a day with foods high in protein, fat, and carbs." The client with viral hepatitis should consume a high-carbohydrate, low-fat diet, not a diet high in fat. The client should avoid hepatotoxic substances such as alcohol. Sexual intercourse is avoided until antibody testing results are negative. The client with hepatitis is easily fatigued and may require several weeks to reach his or her former activity level. It is important for the client to get adequate rest both during the day and at night so that the liver may heal.

A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? "It's important to rotate injection sites." "I need to store the insulin in a cool, dry place." "I need to keep any unopened bottles of insulin in the freezer." "I need to check the expiration date on the insulin before I use it."

"I need to keep any unopened bottles of insulin in the freezer." Rationale: There is a need for further instruction if the client states, "I need to keep any unopened bottles of insulin in the freezer." Insulin is stored in a cool, dry place. It should not be placed in the freezer or exposed to excess heat or agitation. Injection sites should be rotated to ensure adequate insulin absorption and to prevent complications of insulin administration. Once a bottle of insulin has been opened, it is dated and discarded as recommended. The client should check the expiration date on the insulin vial before using it.

A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? "I need to carry my nitroglycerin with me at all times." "I need to check my pulse before, during, and after exercise." "I need to avoid foods with saturated fats and foods high in cholesterol." "I need to participate in aerobic and weightlifting exercise three times a week."

"I need to participate in aerobic and weightlifting exercise three times a week." Rationale: There is a need for further instruction if the client states, "I need to participate in aerobic and weightlifting exercise three times a week." The client should avoid activities that involve straining, including weightlifting, push-ups and pull-ups, and straining during bowel movements. The client with CAD should participate in a simple exercise program on a regular basis. The client may begin a simple walking program by walking 400 feet (122 metres) twice a day at a rate of 1 mph (1.6 km/hr) the first week after discharge and increasing the distance and rate as tolerated, usually weekly, until he or she can walk 2 miles (3.2 km) at 3 to 4 mph (4.8 to 6.4 km/hr). The client should always carry nitroglycerin and must comply with dietary restrictions, including avoiding foods with saturated fats and foods high in cholesterol. The nurse instructs the client to take a pulse reading before, halfway through, and after exercise.

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information "I need to limit my intake of fluids while I'm taking this medication." "I need to stop the medication and call my doctor if I have severe diarrhea." "I can expect skin redness and a rash when I take this medication." "I may get a burning feeling in my throat, but it's normal and will go away."

"I need to stop the medication and call my doctor if I have severe diarrhea." Rationale: The client understands the information if stating, "I need to stop the medication and call my doctor if I have severe diarrhea." The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose. Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz [235 mL] glasses of fluid per day) while taking the medication.

A nurse provides information about smoking-cessation measures to a client diagnosed with coronary artery disease (CAD). Which statement by the client indicates a need for further information? "A community support group will help me quit." "I should drink a cup (235 ml) of coffee if I feel the urge to smoke." "Relaxation exercises will help control my urge to smoke." "I can try chewing gum or sucking on hard candy if I feel the urge to smoke."

"I should drink a cup (235 ml) of coffee if I feel the urge to smoke." Rationale: The nurse should reinforce education about the hazards of smoking and provide encouragement to clients who are interested in or willing to try smoking cessation. The client should avoid using coffee and other caffeine-containing products, which can cause restlessness and anxiety, increasing the urge to smoke. There are appropriate strategies to assist in smoking cessation. Among these are community support groups, relaxation exercises, and strategies such as chewing gum or sucking on hard candy if the urge to smoke arises.

A client diagnosed with post-traumatic stress disorder tells the nurse that he/she has stopped taking his/her prescribed medication because he/she didn't like how the medication was making him/her feel. Which initial response by the nurse is appropriate? "That's all right. I'd stop, too, if it made me feel funny." "Tell me more about how the medication was making you feel." "Did you let your doctor know that you stopped taking the medication?" "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that."

"Tell me more about how the medication was making you feel." Rationale: The appropriate response by the nurse acknowledges the client's feelings and opens the channel of communication between the nurse and client. "That's all right. I'd stop, too, if it made me feel funny," indicating approval, is a nontherapeutic response and is therefore inappropriate. "Did you let your doctor know that you stopped taking the medication?" may be an appropriate question at some point during the conversation, but it is not the most appropriate initial question. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that" demeans the client.

A client diagnosed with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which response by the nurse is therapeutic? "Why don't you really want to attend?" "This is what your primary health care provider has prescribed for you as part of the treatment plan." "OK, let's have you attend music therapy. You can sing there. How does that sound?" "Perhaps you could attend and talk to the other clients and see what they're drawing and painting."

"Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Rationale: The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your primary health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern.

A primary health care provider prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters(mL)must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. _____ mL

0.625

Ciprofloxacin hydrochloride is prescribed to a client with a urinary tract infection. The nurse provides instruction about the medication. What does the nurse tell the client about how best to take the medication? With milk With an antacid 2 hours after meals With aluminum hydroxide

2 hours after meals Rationale: Ciprofloxacin hydrochloride is an anti-infective in the fluoroquinolone family. It may be taken without regard to meals, but the best dosing time is 2 hours after a meal. Milk may affect absorption. Antacids (here, aluminum hydroxide) may reduce absorption and should be administered 2 hours apart from the ciprofloxacin hydrochloride.

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? Spontaneous bruising

A major complication of a missed abortion is disseminated intravascular coagulation(DiC). Bleeding at the sites of intravenous needle insertion or lab blood draws, nosebleeds, and spontaneous bruising may be early indicators of DiC; they should be reported and require further evaluation. Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early signs/symptoms of pregnancy(eg, nausea, breast tenderness, urinary frequency)disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur.

A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the primary health care provider? Dark urine

Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication.

A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. What does the nurse tell the client about when sexual intercourse can be resumed? In about 6 weeks, when the vaginal vault is satisfactorily healed

After abdominal hysterectomy, the client is instructed to avoid sexual intercourse until the vaginal vault is satisfactorily healed. This takes about 6 wks. A woman who has undergone this procedure must adjust to changes in the nature of pelvic sensations and stimuli during sexual intercourse; however, this isnt related to when sexual intercourse may be resumed. The client will not have menstrual periods after abdominal hysterectomy.

The nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, what would the nurse do? Check for the presence of a gag reflex

After an EgD, the nurse places the highest priority on assessing the client for the return of the gag reflex. In preparation for EgD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. No food or oral fluids are given to the client until the gag reflex is fully intact.Vital signs are checked frequently, but this action isnt associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test.

A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? "I need to contact my surgeon immediately if I feel any numbness in my genital area."

After radical vulvectomy, the client is instructed to wear support hose for 6 months and to elevate the legs frequently. The client should avoid straining during defecation and should be told that alteration in the direction of urine flow may occur. The client may resume sexual activity in 4 to 6 wks; the nurse should discuss the possible need for lubrication and position changes during coitus. Genital numbness may be present, but its not necessary to notify the surgeon immediately if numbness occurs.

A nurse is monitoring a client receiving terbutaline by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. What is the most appropriate action the nurse should take? Contact the primary health care provider

Although the nurse would document the findings, the most appropriate priority action in this scenario is to contact the primary health care provider. The nurse should monitor the client for adverse effects and notifiy the primary health care provider if the maternal heart rate is faster than 110 beats/min, respiration is faster than 24, systolic blood pressure is less than 90 mm Hg, the fetal heart rate is faster than 160, or the client complains of chest pain or dyspnea. Terbutaline may be used to stop preterm labor. It stimulates beta-adrenergic receptors of the sympathetic nervous system, resulting in bronchodilation and inhibition of uterine muscle activity. Increasing the rate of infusion and continuing to monitor the client are inappropriate and delay necessary interventions.

A nurse is assessing a client who has been taking amantadine hydrochloride for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? Bilateral lung wheezes

Amantadine hydrochloride is an antiparkinson agent that potentiates the action of dopamine in the central nervous system(CnS). The medication is used to treat rigidity and akinesia. Insomnia and orthostatic hypotension are side effects of the medication. Adverse effects include congestive heart failure(evidenced by bilateral lung wheezes), leukopenia, neutropenia, hyperexcitability, convulsions, and ventricular dysrhythmias.

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. What does the nurse tell the client is the reason amniocentesis is often performed during the third trimester? To assess the degree of fetal lung maturity

Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis.

A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he/she is discharged home. When the nurse tells the client that he/she will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate? "Tell me more about your concerns regarding the tube feedings."

An open statement such as "Tell me more about..." often elicits valuable information about the client and the client's concerns. Clients often have fears about leaving the secure environment of the healthcare facility, where he/she is cared for. This client fears that he/she will not be able to care for self at home by administering the tube feedings. The remaining nursing responses are incorrect because they are nontherapeutic statements that do not address the client's expressed concern.

The nurse is caring for a client who just returned to the surgical unit after having a suprapubic prostatectomy. What type of medication does the nurse expect to be ordered? Antispasmodics

Antispasmodics are prescribed for bladder spasms related to a suprapubic prostatectomy. This surgery involves removal of the prostate gland by an abdominal incision with a bladder incision. Phenothiazines are a class of antipsychotic medications. Antidyskinetics have an anticholinergic action and are used to treat Parkinson's disease and some of the acute mov disorders that may be caused by antipsychotic agents. Benzodiazepines are central nervous system(CNS)depressants and can cause sedation and psychomotor slowing. They can also intensify depression caused by other drugs. Benzodiazepines have some potential for abuse and should be used with caution in clients known to abuse alcohol or other psychoactive medications.

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? Anxiety

Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health.

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are worried about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?Anxiety

Anxiety is the priority client concern identified by the nurse. Anxiety is vague uneasiness or discomfort that warns of trouble and enables an individual to approach and deal with the threat. Fluid vol loss indicates a hypovolemic state, whereas fluid vol overload indicates a hypervolemic state. Premature grief is a state in which an individual grieves before an actual loss. Theres no info in the question to indicate that fluid vol loss, fluid volume overload, or premature grief are factors for concern.

A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? Asking the child to describe the intensity of the pain Asking the child to use a numeric rating scale of 0 to 100 Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain Asking the child to point to the face on a spectrum ranging from smiling to very sad, that best describes the pain

Asking the child to point to the face on a spectrum ranging from smiling to very sad, that best describes the pain Rationale: A client of preschool age has the cognitive ability to recognize happy and sad faces and to correlate them with the level of pain he or she is experiencing. It may be too complicated for some preschoolers to come up with words to describe varying intensities of pain. Many preschool children are not yet able to count to 100 or to understand the value of numbers in relation to other numbers. A child of preschool age is too young to control a PCA pump.

A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? "What are your feelings right now?"

Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and nontherapeutic.

A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? Assessing the client for organic causes of loss of arm movement Calling the crisis intervention team and asking them to assess the client Performing active and passive range-of-motion (ROM) exercises of the client's arms Asking the client to move his arms and documenting the loss of movement he has experienced

Assessing the client for organic causes of loss of arm movement Rationale: The priority is assessing the client for organic causes of loss of arm movement and ruling out any neurological disorders. After it has been determined that there is no physiological basis for the problem, further psychiatric evaluation can be done. Encouraging the client to move his arms and performing active and passive ROM exercises have no beneficial effect in this situation. In fact, either option could be harmful if there is a physiological basis for the client's problem.

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? Flulike pulmonary signs/symptoms

Rationale: Histoplasmosis is a fungal infection of the lungs. The client typically experiences a flulike pulmonary illness with cough, chest pain, dyspnea, headache, fever, arthralgia, anorexia, erythema nodosum, hepatomegaly, and splenomegaly. Neurological disturbances, gastrointestinal disturbances, and cardiac dysrhythmias are not associated with this infection.

An intravenous dose of adenosine is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication? Pulse oximeter Cardiac monitor Blood-pressure cuff Suction catheter and suction machine

Cardiac monitor Rationale: Obtaining a cardiac monitor is the priority. Wolff-Parkinson-White syndrome is an abnormality of cardiac rhythm that is manifested as supraventricular tachycardia. Adenosine is an antidysrhythmic medication used to treat this dysrhythmia. It is administered intravenously. A pulse oximeter and blood pressure cuff will each provide information about the client's cardiovascular status, but neither is the priority. There is no information in the question to indicate that a suction catheter and suction machine are necessary.

A nurse administers nitroglycerin sublingually to a client diagnosed with angina pectoris who reports chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? Checking the client's blood pressure Obtaining blood levels of cardiac enzymes Asking the client if experiencing headache Obtaining a 12-lead electrocardiogram (ECG)

Checking the client's blood pressure Rationale: Nitroglycerin is a nitrate that dilates the coronary arteries. One adverse effect of the medication is hypotension, and the nurse would assess the blood pressure and apical pulse before administration and periodically after the dose is given. Blood levels of cardiac enzymes are obtained if prescribed, but the priority is checking the client's blood pressure. Headache is a frequent side effect of the medication, mostly early in therapy and usually disappearing with continued treatment. It is not necessary to obtain a 12-lead ECG before administering a second dose of nitroglycerin unless this is prescribed by the primary health care provider. However, the client receiving intravenous nitroglycerin must have continuous ECG monitoring.

A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by her father.

Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment.

An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which finding does the nurse expect to note? A symmetrical smile Tightening of all facial muscles Ability to wrinkle the forehead on request Complaints of inability to close the eye on the affected side

Complaints of inability to close the eye on the affected side Rationale: The onset of Bell's palsy is acute. Maximal paralysis occurs within 5 days in almost all clients. Pain behind the ear or on the face may precede paralysis by a few hours or days. The disorder is characterized by a drawing sensation and paralysis, not tightening, of all facial muscles on the affected side. The client cannot close the eye, wrinkle the forehead, smile, whistle, or grimace. The face appears masklike and sags. Taste is usually impaired to some degree, but this symptom seldom persists beyond the second week of paralysis. Loss of peripheral vision is not associated with Bell's palsy.

A client with acute gouty arthritis is being started on medication therapy with indomethacin. The nurse provides medication instructions to the client. How does the nurse tell the client to take the medication? With food

Rationale: The client is instructed to take the medication with food. Indomethacin is a nonsteroidal antiinflammatory medication that produces analgesic and antiinflammatory effects by inhibiting prostaglandin synthesis. Adverse effects include ulceration of the esophagus, stomach, duodenum, and small intestine.

A nurse provides home care instructions to a client who has undergone fluorescein angiography. What comment by the client helps the nurse determine that the client needs further instruction? Drink fluids to eliminate the dye Contact the primary health care provider if the skin appears yellow Expect that the urine will be bright green until the dye has been excreted Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal

Contact the primary health care provider if the skin appears yellow Rationale: The client needs further instruction if the client plans to contact the primary health care provider if the skin appears yellow. The nurse also encourages rest and emphasizes that any yellow discoloration of the skin will disappear in a few hours. Fluorescein angiography provides a detailed image and permanent record of eye circulation. Photographs are taken in rapid succession after the intravenous administration of dye. After the test, the client may feel weak and nauseated, and the urine will be bright green until the dye has been excreted. Once the nausea has resolved, the client is encouraged to drink fluids to eliminate the dye, and instructed to avoid direct sunlight until pupil dilation returns to normal.

A school nurse observing a child diagnosed with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse? Contacting the child's primary health care provider to report the findings Administering acetaminophen to the child to relieve the pain Asking that the child not attend the physical education class until the neck pain has subsided Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control

Contacting the child's primary health care provider to report the findings Rationale: Children with Down syndrome who participate in sports that may involve stress on the neck should be evaluated radiologically for atlantoaxial instability. Signs/symptoms of the disorder include neck pain, weakness, and torticollis. Affected children are at risk for spinal cord compression. Signs/symptoms of spinal cord compression include persistent neck pain, loss of established motor skills and bladder or bowel control, and changes in sensation. If any of these signs/symptoms are noted, it must be reported immediately to the primary health care provider. Administering acetaminophen to relieve the pain and not allowing the child to attend physical education class until the pain has subsided are inappropriate actions that will delay necessary interventions. Teaching the child to use peripads to prevent embarrassment resulting from loss of bladder control may be appropriate in certain scenarios, but in this situation the child is exhibiting signs/symptoms of spinal cord compression, requiring immediate intervention.

A client arrives in the emergency department and tells the nurse that he/she is experiencing tingling in both hands and is unable to move his/her fingers. The client states that he/she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier his/her partner said he/she wanted a separation and that he/she would have to support self financially. What problem does the nurse conclude that this client is exhibiting signs/symptoms compatible with? Severe anxiety Conversion disorder Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder

Conversion disorder Rationale: Conversion disorder is characterized by the presence of one or more signs/symptoms suggesting a neurological problem that cannot be attributed to a medical disorder. Psychological factors such as stress and conflict are associated with the onset or exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular detail or many scattered details. The person may have difficulty noticing what is going on in the environment, even when it is pointed out by another. Learning and problem-solving are not possible at this level of anxiety, and the client may be dazed and confused. PTSD is characterized by repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others to which the individual responded with intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety.

A client diagnosed with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Avoid contact with all individuals other than immediate family members

Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's resistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client should, however, avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. Encouraging adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary.

Cyclobenzaprine is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client? Diarrhea Drowsiness Abdominal pain Increased salivation

Drowsiness Rationale: Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. Cyclobenzaprine is a centrally acting skeletal muscle relaxant used in the management of muscle spasm accompanying a variety of conditions. Rare side effects include fatigue, tiredness, blurred vision, headache, nervousness, confusion, nausea, constipation, dyspepsia, and an unpleasant taste in the mouth.

A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). What does the nurse tell the client? There is no need to fast (NPO status) before the procedure The gallbladder is easily removed during this procedure if gallstones are found The procedure is only performed to visualize the esophagus, stomach, and duodenum Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts

Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts Rationale: The nurse tells the client that dye may be injected to outline the pancreatic and biliary ducts. ERCP involves the oral insertion of an endoscope with a side-viewing tip and a cannula that can be maneuvered into the ampulla of Vater. The procedure may be combined with papillotomy to enlarge the sphincter and release gallstones. However, the gallbladder itself cannot be removed during this procedure. As with any endoscopic procedure, the client must remain NPO for 8 hours before the test.

A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, what does the nurse conclude? Pitting edema is present

Edema in the lower extremities reflects pooling of blood, which results in a shift of intravascular fluid into the interstitial spaces. Dehydration isnt likely to cause pitting edema. When pressure exerted with a finger or thumb leaves a persistent depression, the client is said to have "pitting edema." Therefore, the other options identify incorrect interpretations.

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. The nurse is assisting the primary health care provider with the procedure. What characteristics of the fluid removed during thoracentesis should the nurse expect to note?Thick and opaque

Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder.

A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply. Crossing the legs at the ankles only Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Inspecting the feet at least once a week for injuries, especially abrasions Using a heating pad on the legs to help keep the blood vessels dilated

Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Rationale: Long-term management of peripheral vascular disease consists of measures that increase peripheral circulation. The client is instructed to exercise regularly and is encouraged to walk for 20 minutes each day. The client also needs to wash the feet daily with a mild soap, to dry the feet well, and to inspect the feet daily for injuries or abrasions. Crossing the legs at any level should be avoided because it promotes vasoconstriction. Keeping the extremities warm is important; however, heating pads and hot water bottles should not be placed on the extremity. Sensitivity may be diminished in the affected extremity, increasing the risk for burns. Also, direct application of heat increases the oxygen and nutritional requirements of the tissue even further.

Ferrous sulfate is prescribed for a client. What does the nurse tell the client is best to take the medication with? Tomato juice

Ferrous sulfate is an iron product. Absorption of iron is best promoted when the supplement is taken with orange juice or tomato juice another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day doesnt guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, its best to take the iron supplement between meals with a drink high in ascorbic acid.

A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? Perform the physical assessment Tell the client about the nursing unit rules Establish a trusting nurse-client relationship Tell the client that he/she will have to participate in self-care

Establish a trusting nurse-client relationship Rationale: Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. The nurse should first develop a trusting relationship with the client. It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he/she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care.

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. What are some characteristics of this disorder? Select all that apply. Neediness Perfectionism Feelings of inadequacy Feeling extremely shy Sensitivity to rejection Preoccupation with details Hypersensitivity to negative evaluation

Feelings of inadequacy Feeling extremely shy Sensitivity to rejection Hypersensitivity to negative evaluation Rationale: Avoidant personality disorder is a psychiatric condition in which a person feels extremely shy, inadequate, and sensitive to rejection. Other characteristics of avoidant personality disorder include excessive anxiety in social situations and hypersensitivity to negative evaluation. Neediness is a characteristic of dependent personality disorder. Perfectionism and preoccupation with details are characteristics of obsessive-compulsive disorder.

A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. What one food item high in calcium does the nurse tell the client to eat? Sardines

Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Corn, cocoa, and peaches dont contain appreciable amounts of calcium.

A nurse is providing information about home care to a client with acute gout. Which measures does the nurse tell the client to take? Select all that apply. Drinking 2 to 3 L of fluid each day Resting and immobilizing the affected area

Gout is a systemic disease in which urate crystals are deposited in the joints and other tissues, resulting in inflammation. In acute gout, rest and immobilization are recommended until the acute attack and inflammation have subsided. Local application of cold may help relieve the pain. The application of heat is avoided because it may worsen the inflammatory process. Dietary instructions include reducing or eliminating alcohol intake and avoiding excessive intake of foods containing purines(eg, sweetbreads, yeast, heart, herring, herring roe, sardines). The client is encouraged to drink 2 to 3 L of fluid per day to help eliminate uric acid and to prevent the formation of renal calculi.

A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. What does the nurse tell the client about this blood test? Is a measure of the client's hematocrit level Is a measure of the client's hemoglobin level Helps predict the risk for the development of chronic complications of diabetes mellitus Provides a determination of short-term glycemic control in the client with diabetes mellitus

Helps predict the risk for the development of chronic complications of diabetes mellitus Rationale: The nurse tells the client that the blood test is used to assess long-term glycemic control, as well as to predict the risk for the development of chronic complications. Glycosylated hemoglobin is the best indicator of the average blood glucose level. Because glucose attaches itself to the hemoglobin molecule, measurement of glycosylated hemoglobin indicates the average blood glucose level during the previous 120 days, the lifespan of the red blood cell.

The client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" What does the nurse tell the client? Her hair will definitely fall out She should not be worrying about her hair at this point Her hair may fall out but will regrow after the chemotherapy is discontinued Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss

Her hair may fall out but will regrow after the chemotherapy is discontinued Rationale: Some chemotherapeutic agents cause hair loss, and the client should be informed of this possibility. The client should also be reassured that chemotherapy-related hair loss is temporary and that the hair will regrow after the chemotherapy is discontinued, perhaps in a different shade, color, or texture. Telling the client that her hair will definitely fall out is incorrect and telling her that she should not be worrying about her hair at this point ignores the client's concern. Hair dyes, permanents, and vigorous hair-brushing are avoided to minimize thinning.

A client is taking prescribed ibuprofen 200 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. What should the nurse tell the client? "Take the medication with food."

Ibuprofen is a nonsteroidal antinflamatory medication. Side effects include nausea(with or without vomiting)and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse wouldnt instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions arent within the legal scope of the role of the nurse. Contacting the primary health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food.

A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the primary health care provider, which does the nurse specify as the first action in the event of shock? Placing the client in a lateral position with the bed flat

If the client exhibits signs/symptoms of hypovolemic shock, the client would first be placed in a lateral position, with the head of the bed flat to increase cardiac return. It is necessary for the nurse to take this initial action to minimize the effects of hypovolemic shock and promote tissue oxygenation and thus increase circulation and oxygenation of the placenta and other vital organs. The nurse would also contact the primary health care provider and monitor fetal status closely. After positioning the client, the nurse would insert IV lines in accordance with the primary health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure isnt the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this isnt the first action.

After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? Replacement of the uterus through the vagina into a normal position

If uterine inversion is suspected, the immediate intervention by the nurse is to prepare the client for replacement of the uterus through the vagina. If this isnt possible or effective, laparotomy with replacement is performed. Hysterectomy may be required. Intravenous lines are established to allow rapid fluid and blood replacement. A tocolytic medication or general anesthesia is usually needed to relax the uterus enough to replace it. Once the uterus has been replaced and the placenta removed, oxytocin is given to induce uterine contraction and control blood loss. To help prevent trapping of the inverted fundus in the cervix, oxytocin isnt given until the uterus has been repositioned. An indwelling catheter is often inserted to aid monitoring of fluid balance and keep the bladder empty so that the uterus can contract fully, but this isnt the immediate action taken by the nurse.

The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, what should the nurse do? Document the laboratory result in the client's record

Imipramine is a tricyclic antidepressant thats often used to treat depression. The therapeutic blood serum lvl is btw 225 and 300 ng/mL, so the nurse would simply document the lab result in the client's record. Asking the lab to recheck the lvl and withholding the next dose of the imipramine and contacting the primary health care provider are unnecessary.

A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which finding elicited during the assessment indicates that the condition has not yet resolved? Type the option number that is the correct answer. _____1 Nursing Progress Notes

In a client with preeclampsia, deep tendon reflexes may be very brisk (hyperreflexia) and clonus (series of involuntary, rhythmic, muscular contractions and relaxations)may be present, suggesting cerebral irritability resulting from decreased brain circulation and edema. Hypertension, generalized edema, and proteinuria are the three classic signs of preeclampsia. Decreased urinary output (less than 30 mL/hr) indicates poor perfusion of the kidneys and may precede acute renal failure. Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a blood pressure of 128/78 mm Hg are all signs that preeclampsia is resolving.

A laxative has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication. What does the nurse tell the client to do? Increase fluid intake Consume low-fiber foods Consume foods that are low in potassium Contact the primary health care provider if the urine turns yellow-brown

Increase fluid intake Rationale: The nurse encourages the client to increase fluid intake, to consume a high-fiber diet, and to exercise. Hypokalemia may result from use of a laxative, so the nurse encourages the client to consume foods high in potassium. The client's urine may turn pink-red, red-violet, red-brown, or yellow-brown, but the client is told that this is a temporary, harmless effect.

client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs. What comment by the client suggests an understanding of the info?"I know I will have to increase my insulin during this time period.""My insulin needs should decrease during the first trimester."

Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.

An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. Skin tenting Flat neck veins Weak peripheral pulses

Isotonic dehydration decreases circulating blood vol (hypovolemia), leading to inadequate tissue perfusion. The nurse would expect to note tachycardia, tachypnea, and dry oral mucous membranes. The oral mucous membranes may be covered with a thick, sticky, paste like coating and may exhibit fissures. The client may also experience weight loss, lethargy or headache, sunken eyes, poor skin turgor(eg, tenting), flat neck and peripheral veins, and low blood pressure. Peripheral pulses are weak, difficult to find, and easily obstructed with light pressure.

A nurse is caring for a client with open-angle glaucoma. The nurse knows that what agents are used to treat this condition? Myotic agents Mydriatric agents Cycloplegic agents Anticholinergic agents

Myotic agents Rationale: Miotic agents are used to treat glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Besides mydriatic agents, cycloplegic and anticholinergic agents are contraindicated in clients with glaucoma.

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin. Which finding, indicating an adverse reaction to the medication, does the nurse monitor the client? Fever

Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. Its characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.

A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium at home. The nurse teaches the client about the medication. What does the nurse tell the client? Store the medication in the refrigerator Lie down to administer the subcutaneous injection Inject the medication in the upper outer aspect of the arm Discard the medication if the solution appears pale yellow

Lie down to administer the subcutaneous injection Rationale: The client is instructed to lie down to administer the injection and to introduce the entire length of the needle (½ inch [1.25 cm]) into a skin fold held between the thumb and forefinger. Enoxaparin sodium is an anticoagulant that is administered by way of subcutaneous injection. It is injected into the abdominal wall. The solution, which appears clear and colorless to pale yellow, is stored at room temperature.

A client who is taking lithium carbonate complains of mild nausea and voiding in large volumes. On assessment, the nurse notes that the client is also complaining of mild thirst. On the basis of these findings, what would the nurse do? Document the findings

Lithium carbonate is a mood stabilizer thats used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea. Therefore, the nurse should simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the primary health care provider, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of toxicity and if these occur the primary health care provider needs to be notified.

nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."

Lithium carbonate is a mood stabilizer used to treat manic-depressive illness. Equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Therefore the client should maintain a normal salt intake and drink 2 to 3 quarts(1.9 to 2.8 litres)of fluid each day. Many over-the-counter medications contain sodium and would therefore affect the lithium concentration, possibly pushing it out of the therapeutic range. For this reason, over-the-counter medications must be avoided. The blood lvl of lithium should be tested every 3 or 4 days during the initial phase of therapy and every 1 to 2 months during maintenance therapy. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of toxicity; if any of these problems occur, the primary health care provider must be notified.

A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication? Steak

Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.Test-Taking Strategy: Focus on the subject

Captopril is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? Checking the client's apical heart rate Maintaining the client on bed rest for 3 hours Monitoring the client for increased urine output Checking the client's breath sounds for decreased wheezing

Maintaining the client on bed rest for 3 hours Rationale: The client is closely monitored for hypotension at the start of therapy and is maintained on bed rest for 3 hours after the initial dose. Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Excessive hypotension (first-dose syncope) may occur in the client with heart failure or in the client who is severely salt or volume depleted. Checking the apical heart rate will provide information about the client's cardiac status but is not an intervention specifically related to this medication. Increased urine output and decreased wheezing are expected if the client has received a diuretic.

A client diagnosed with advanced chronic kidney disease (CKD) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that what is acceptable to use? Herbs and spices

Most clients with CkD retain sodium. The client with CkD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CkD is instructed to limit potassium intake. The client is also instructed to avoid salt substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium.

An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which characteristic of the disorder does the nurse expect the client to exhibit? Select all that apply. Nausea Eye pain Vomiting Headache Diminished central vision Increased light perception

Nausea Eye pain Vomiting Headache Rationale: In acute closed-angle glaucoma, the onset of signs/symptoms is acute and the client complains of sudden excruciating pain around the eyes that radiates over the sensory distribution of the fifth cranial nerve. Headache or brow ache, nausea, vomiting, and abdominal discomfort may also occur. Other signs/symptoms of glaucoma include seeing colored halos around lights, sudden blurred vision with decreased light perception, and loss of peripheral vision.

A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? Maintaining cuff pressure

Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead to the dev of an opening btw the posterior trachea and esophagus, a complication ka tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the client is adequately oxygenated, but this intervention isnt a measure for the prevention of tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the endotracheal tube wouldnt be removed and replaced on a daily basis.

A client with myasthenia gravis is taking neostigmine bromide. What does the nurse note that indicates the client is gaining a therapeutic effect from the medication? Improved swallowing function

Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs/symptoms of an adverse reaction to the medication.

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test."

No special preparation is necessary before a GI series, except that NPO (nothing by mouth) status must be maintained for 8 hours before the test. An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

Ergotamine is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the client to report to the primary health care provider if she experiences them while taking the medication? Cough Fatigue and lethargy Dizziness and fatigue Numbness and tingling of the fingers or toes

Numbness and tingling of the fingers or toes Rationale: Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these signs/symptoms to the primary health care provider if they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse effects of the medication.

A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. Which anxiety disorder does the nurse associate this client's symptoms? Agoraphobia Avoidant personality disorder Obsessive-compulsive disorder Dependent personality disorder

Obsessive-compulsive disorder Rationale: Obsessive-compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing anxiety; or by a combination of such thoughts (obsessions) and behaviors (compulsions). The client is inflexible and rigid, and is highly critical of self and others. The characteristics of dependent personality disorder include neediness and self-sacrificing and submissive behaviors. The client with avoidant personality disorder is extremely shy, feels inadequate, and is sensitive to rejection. Agoraphobia is the fear of open spaces.

A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Providing food and fluid as the client requests Offering high-calorie and high-protein foods and fluids frequently throughout the day Completing the dietary menu for the client to ensure that adequate nutrition is provided Weighing the client daily so that the client may determine whether the nutritional plan is working

Offering high-calorie and high-protein foods and fluids frequently throughout the day Rationale: The client should be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client should be offered choices of foods and fluids he/she likes, because the client is more likely to consume foods he/she has selected. The client should be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless.

A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply. Smoking High alcohol intake White or Asian ethnicity

Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Risk factors include being 65 yrs or older in women, 75 yrs or older in men, fam history of the disorder, history of fracture after age 50, white or Asian ethnicity, low body weight and slender build, chronically low calcium intake, a history of smoking, high alcohol intake, and lack of physical exercise or prolonged immobility.

A nurse in the cardiac care unit (CCU) is told that a client with a diagnosis of myocardial infarction (MI) will be admitted from the emergency department (ED). Which item does the nurse give priority to placing at the client's bedside? Bedside commode Suctioning equipment Electrocardiography machine Oxygen cannula and flowmeter

Oxygen cannula and flowmeter Rationale: The oxygen cannula and flowmeter are the priority. The client will require oxygen therapy after myocardial infarction to improve oxygen supply to the myocardium and ease the pain resulting from ischemia. Suctioning equipment is not the priority item but may be needed if a complication occurs. An electrocardiogram machine and bedside commode may be necessary but are not the priority items.

A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Soft, relaxed, nontender uterus

Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, esp with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred? A sudden gush of dark blood from the introitus

Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual.

A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? Powerlessness

Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any sig way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when theres an alteration in the way the client perceives his or her own body image.

A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? Inflexible and rigid Self-sacrificing and submissive Highly critical of self and others Projecting blame, possibly becoming hostile

Projecting blame, possibly becoming hostile Rationale: A client with paranoid personality disorder projects blame, is suspicious of others, and may become hostile or violent. The client also experiences cognitive or perceptual distortions. A client who is inflexible and rigid and is highly critical of self and others is showing signs/symptoms of obsessive-compulsive disorder. Being self-sacrificing and submissive is a characteristic of a client with dependent personality disorder.

A client diagnosed with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. What should the nurse do first? Obtain a pulse oximetry reading Raise the head of the client's bed Administer a dose of morphine sulfate Obtain a specimen for an arterial blood gas determination

Raise the head of the client's bed Rationale: The nurse would first raise the head of the client's bed and position the client to maximize chest expansion to ease the air hunger that the client is experiencing. Acute pulmonary edema is characterized by profound dyspnea, pallor, audible wheezing, and cyanosis. An arterial blood gas or pulse oximetry reading will reveal the need for supplemental oxygen. Morphine sulfate may be administered because it blunts the sympathetic response and promotes peripheral vasodilation. However, the nurse also needs to contact the primary health case provider to prescribe that medication. On the basis of the options provided, however, the initial action is placing the client in a head-elevated position.

Propylthiouracil has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which occurrence does the nurse tell the client to contact the primary health care provider? Sore throat

Rationale: "Propylthiouracil is an antithyroid medication that blocks thyroid hormone production. One adverse effect of propylthiouracil is agranulocytosis. Agranulocytosiss is a serous condition that occurs when the body does not make enough granulocytes (type of white blood cell). The immune system is affected, so a person with this condition is at risk of developing a severe or even life-threatening infection." The client is instructed to report signs/symptoms of infection such as a sore throat. Graves disease (hyperthyroidism) occurs as a result of excessive thyroid hormone secretion. Fatigue may or may not occur in this disorder; however, it is not an adverse effect of the medication. One manifestation of Graves disease is heat intolerance, and the client may experience diaphoresis even when the environmental temperature is comfortable for others. Agranulocytos is a serious that occurs when the body does not make enough granulocytes (type of white blood cell). The immune system is affected, so a person with this condition is at risk of developing a severe or even life-threatening infection.

A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information? Lack of adequate diversional activity

Rationale: A characteristic of lack of adequate diversional activity is the expression of boredom by the client. The question doesnt identify client difficulties w/coordination, range of motion, or muscle strength, which would be related to lack of physical mobility. Nor does the question address client's lack of energy to perform activities of daily living (bathing/hygiene self-care deficit) or lack of control.

A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?

Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose of gastric decompression or feeding the client. The client is placed in the Fowler position before insertion of the tube to promote comfort and easy insertion. A flat position may be used for clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted with the foot of the bed down and may be used to promote gastric emptying or prevent esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the head of the bed down and may be used for postural drainage or to facilitate venous return in clients with poor peripheral perfusion.

A nurse assessing the wound of a client with a stage 3 pressure ulcer notes that the wound bed is pale. What does the nurse interpret this finding as a possible indication of? The wound is improving

Rationale: A pale wound bed may reflect a low hemoglobin value. Healthy full-thickness wounds have a granular beefy-red appearance. The color of a wound provides information about vascular supply, infection, the presence of healthy or necrotic tissue, and nutritional status. Necrotic tissue is white, yellow, gray, or black. Pseudomonas infection can produce greenish drainage in a wound bed.

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which finding does the nurse expect to note?

Rationale: A stage I ulcer is characterized by intact skin that is red and does not blanch under external pressure. A stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage III ulcer is characterized by full-thickness skin loss, and the subcutaneous tissue may be damaged or necrotic. The damage extends down to but not through the underlying tissues. A deep crater-like appearance or eschar is present. A stage IV ulcer is characterized by full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Sinus tracts may develop.

A client arrives at the clinic for her1st prenatal assessment. The client tells the nurse that the1st dy of her last menstrual perk(LmP)was S 25 017. Usin Nagele's rule, what item of client info is needed for the nurse to accurately determine estimated date of delivery(EdD)?Client has regular 28dy menstrual cycle

Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the woman have a regular 28-day menstrual cycle.

A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? Abduction device

Rationale: After surgery to repair a fractured hip, an abduction device is the most important item used to maintain the affected extremity in good alignment and prevent dislocation. A hip abduction pillow helps prevent the hip from turning in or away from the body, and keeps the hip straight while in bed. It is placed between the thighs and attached to the legs with straps wrapped around the thighs and ankles. Some surgeons only allow the client to turn directly onto one side or the other; therefore the nurse checks the postoperative prescription. A trapeze bar may also be used, but it is not the priority item for repositioning the client. A sliding board is used to transfer a client from a bed to a stretcher or vice versa.

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which finding would be of greatest concern to the nurse? Urinary specific gravity is low

Rationale: After transsphenoidal hypophysectomy, the client is monitored for transient diabetes insipidus. In a client with diabetes insipidus, the greatest concern for the nurse is low urinary specific gravity and excessive urine output. A blood pressure of 138/80 mm Hg is not cause for concern. The client will have nasal packing and a mustache dressing and may complain of dry mouth because of the necessity for mouth breathing. The nurse would provide frequent oral rinses and apply petroleum jelly to dry lips. The client should perform frequent deep-breathing exercises (coughing is contraindicated) to help prevent pulmonary complications.

Alendronate is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? Every morning before breakfast, with a full glass of water

Rationale: Alendronate should be taken in the morning before breakfast with a full glass of water and on an empty stomach to maximize its bioavailability. It is a medication used to treat postmenopausal osteoporesis, glucocorticoid-induced osteoporosis, and Paget's disease of bone. Proper administration is necessary to maximize bioavailability and minimize the risk of esophagitis. No food, including orange juice or coffee, should be consumed for at least 30 minutes after alendronate is taken. To minimize the risk of esophagitis, the client should take the medication with a full glass of water and remain upright (seated or standing) for at least 30 minutes. Therefore taking the medication at bedtime, with orange juice to help with absorption, and every morning after breakfast, followed by a 30-minute period of lying down, are all incorrect.

Alprazolam is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of? Lightheadedness

Rationale: Alprazolam is a benzodiazepine thats used to manage anxiety disorders. Common side effects include muscle incoordination, lightheadedness, transient mild drowsiness, & slurred speech. The other options arent side effects of this medication.

A client is receiving an intravenous infusion of alteplase. For which adverse effect of the medication does the nurse monitor the client most closely? Bleeding

Rationale: Alteplase is a thrombolytic agent used to dissolve existing thrombi. The nurse needs to monitor the client most closely for bleeding. It is the most common adverse effect, & the nurse must monitor the client for obvious or occult signs of bleeding. Hearing loss & decreased urine output are not associated with the use of this medication. The medication may also cause a decrease in blood pressure & an allergic reaction, denoted by a rash or wheezing.

A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply. Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event

Rationale: An honest, nonjudgmental, & empathetic attitude helps the nurse build a trusting relationship w/the client. The nurse would assess the immediate posttraumatic reaction & later coping. Numbing & denial are common reactions after a traumatic event, & knowing the range of the client's behavior can help the nurse assess the impact & meaning of the trauma. Writing about the trauma in a journal can lessen the intensity of the client's emotions & his/her preoccupation w/the event over time. The nurse would ask the client about the use of alcohol & drugs before & since the event. Its important for the nurse to obtain this info, b/c attempts to self-medicate to reduce anxiety & induce sleep are common after a traumatic event. The client needs to understand that he/she isnt responsible for the event, but the nurse should emphasize that the client is responsible for learning to cope. This strategy will assist the client in easing feelings of powerlessness. The nurse would encourage attendance at support groups so that the client can share experiences, feel understood, and begin to heal.

A nurse is assessing a client who is experiencing chest pain. Which observation indicates to the nurse that the pain is most likely a result of angina? The pain is relieved by rest and nitroglycerin.

Rationale: Anginal pain may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated signs/symptoms, and is relieved by rest and nitroglycerin. Antacids provide relief from chest pain (squeezing heartburn pain) caused by esophageal or gastric disorders. An upright sitting position, the administration of an analgesic, or the administration of an antiinflammatory medication often relieves chest pain (sudden, sharp, and stabbing) caused by pericarditis.

A client diagnosed with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B. Which parameter does the nurse check to detect the most common adverse effect of this medication? Intake and output

Rationale: As a means of detecting renal injury, tests of kidney function should be performed weekly, and intake and output should be monitored closely. Amphotericin B, an antifungal medication, is highly toxic, and infusion reactions and renal damage occur, to varying degrees, in all clients. Other adverse effects include delirium, hypotension, hypertension, wheezing, and hypoxia. The remaining options are not associated with an adverse effect of the medication.

A nurse is assessing a client with hepatitis for signs/symptoms of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice? Mucous membranes

Rationale: Assessment of the skin, sclera, and mucous membranes provides the best data regarding the presence of jaundice. The color of the lips provides data regarding the presence of cyanosis. Although assessment of the skin provides adequate data regarding jaundice, the soles and palms are not the best areas of skin for assessment. Jaundice needs to be distinguished from yellow or green skin color resulting from carotenemia or quinacrine (drug used for treatment of giardiasis), The resultant yellow skin color is differentiated from jaundice by the absence of yellow color in mucous membranes and sclerae, the normal urine color, and the accentuation of yellow-brown carotenoid pigment in the palms, soles, and nasolabial folds.

A client with multiple sclerosis (MS) has been started on baclofen for muscle spasms. The client calls the primary health care provider's office 1 week after beginning the medication and tells the nurse that she/he feels extremely drowsy. What does the nurse most appropriately tell the client? That drowsiness usually diminishes with continued therapy

Rationale: Baclofen is a centrally acting skeletal muscle relaxant. Side effects of baclofen include drowsiness, dizziness, weakness, & nausea. The nurse most appropriately tells the client that drowsiness usually diminishes w/continued therapy. However, the client is told to avoid activities that require alertness until the response to the medication has been established. Therefore its not necessary to call the primary health care provider or discontinue or stop the medication.

A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, what should the nurse do? Document the findings

Rationale: Because the findings detailed in the question are expected, the nurse would document them. Immediately after radical neck dissection, the client will have a wound drain in the neck, attached to portable suction. The nurse places the client in the semi-Fowler position to minimize postoperative edema and monitors the neck drainage for volume and color. Sanguineous and serosanguineous drainage is expected in the 72 hours after surgery. Once drainage has stopped, the wound drains are removed.

Methylergonovine is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? Checking the client's blood pressure

Rationale: Because the medication causes arterial vasoconstriction and hypertension, the nurse checks the client's blood pressure before administering the medication. Methylergonovine is an oxytocic that stimulates contraction of the uterus and causes arterial vasoconstriction. It is used for the prevention and treatment of postpartum and postabortal hemorrhage caused by uterine atony or subinvolution. There is no information to indicate that the client has had an episiotomy. Although the nurse may palpate the client's bladder, this action is unrelated to the use of the medication.

Vasopressin is prescribed to a client with diabetes insipidus. For which sign/symptom, indicative of an adverse effect of the medication, does the nurse monitor the client? Chest pain

Rationale: Chest pain is a sign of an adverse effect of vasopressin, and if it occurs, the primary health care provider must be notified. Because of its powerful vasoconstrictive action, vasopressin can cause adverse cardiovascular effects. By constricting arteries of the heart, vasopressin can cause angina pectoris and even myocardial infarction, especially if the medication is administered to a client with existing coronary artery disease. Vasopressin may also cause gangrene by decreasing blood flow in the periphery. Decreased urine output is an expected effect. Neither constipation nor loss of appetite is associated with this medication.

A client with myasthenia gravis who has been taking pyridostigmine bromide for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. What muscles are involved first in a cholinergic crisis? Chewing and swallowing

Rationale: Cholinergic crisis is defined as an over-stimulation at a neuromuscular junction due to an excess of acetylcholine (ACh) caused by an overdose of anticholinesterase drugs. The weakness first appears in the muscles involved in chewing and swallowing and is followed by weakness of the shoulder girdle and upper extremities, respiratory muscles, and pelvic girdle and leg muscles.

A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction? "It's best to use cow's milk, as long as it's whole milk and not skim."

Rationale: Cow's milk (whole, skim, 1%, 2%) is not recommended in the first 12 months of life. It contains too little iron, its high renal solute load and unmodified derivatives can put small infants at risk for dehydration, and the tough, hard curd is difficult for infants to digest. In addition, skim milk and reduced-fat milk deprive the infant of needed calories and essential fatty acids. Breast milk or commercially prepared iron-fortified formula should be used to feed the infant and provides adequate nutrition throughout the infancy period. The remaining options are correct statements about feeding an infant.

Calcium disodium edetate and dimercaprol is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications? "Does your child have an allergy to peanuts?"

Rationale: Dimercaprol must not be used in the presence of a glucose-6-phosphate dehydrogenase deficiency (G6PD) or peanut allergy, nor should it be given in conjunction with iron. Therefore, the nurse must ask about allergy to peanuts. Dimercaprol may be used in conjunction with EDTA to treat lead poisoning. Dimercaprol is administered by way of deep intramuscular injection. Calcium disodium edetate is administered by way of the intravenous or intramuscular route. The assessment questions noted in the remaining options are unrelated to the administration of this medication.

A nurse in a primary health care provider's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?Distorted body image

Rationale: Distorted body image is characterized by negative verbalizations or feelings about a body part. This is a common response after mastectomy. The nurse supports the client and helps her work through these feelings. There is no information in the question to indicate that inability to care for self, inability to cope, or inability to maintain health is a problem.

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. Drooling Excessive oral secretions

Rationale: EA with or without TEF results in excessive oral secretions, drooling, and feeding intolerance. EA and TEF, the most life-threatening anomalies of the esophagus, often occur together, although they may occur singly. EA is a congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thereby failing to form a continuous passageway to the stomach. TEF is an abnormal connection between the esophagus and trachea. When fed, the infant may swallow but will then cough and gag and return the fluid through the nose and mouth. Bowel sounds over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccuping and spitting up after a meal are clinical manifestations of gastroesophageal reflux. Coughing, wheezing, and short periods of apnea are clinical manifestations of hiatal hernia.

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure

Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation.

A client is found to have iron-deficiency anemia, and ferrous sulfate is prescribed. What does the nurse tell the client is best to take the medication with? Orange juice

Rationale: Ferrous sulfate is an iron preparation, & the client is instructed to take the medication w/orange juice or another vitamin C-containing product to increase absorption of the iron. Milk & eggs inhibit the absorption of iron. Orange juice is higher in vitamin C than apple juice.

A nurse assigns an assistive personnel (AP) to care for a client who is hearing impaired and provides instructions to the AP about the effective methods for communicating with the client. Which statement by the AP indicates that further instruction is needed? "I should raise the volume of my voice and stand on the client's affected side when I'm talking to him."

Rationale: Further instruction is needed if the AP states, "I should raise the volume of my voice and stand on the client's affected side when I'm talking to him." When communicating with a hearing-impaired client, the nurse should position herself or himself directly in front of the client so that the client may read the nurse's lips. The room should be well lit, and the nurse should get the client's attention before speaking. The nurse should move closer to the ear with better hearing and speak slowly and clearly. The nurse should speak in a normal tone of voice and keep his or her hands and other objects away from the mouth while talking to the client.

Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? Lithium carbonate

Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid, thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral hypoglycemic.

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expect to see documented in the infant's medical record? Select all that apply. Weight loss Projectile vomiting Distended upper abdomen

Rationale: HPS occurs when the circular muscle of the pylorus becomes thickened, causing constriction of the pylorus and obstruction of the gastric outlet. Clinical manifestations include projectile vomiting, a hungry infant who eagerly accepts a second feeding after the vomiting episode, weight loss, signs/symptoms of dehydration, and a distended upper abdomen. A readily palpable olive-shaped mass in the epigastrium just to the right of the umbilicus is noted, and gastric peristaltic waves, moving from left to right across the epigastrium, are visible. Laboratory findings include metabolic alkalosis, a result of the vomiting that occurs in this disorder. Facial edema and metabolic acidosis do not occur in this disorder.

A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which measure does the nurse take in the care of the client? Teaching the client to move the head from side to side (scan) when eating

Rationale: Hemianopsia is the loss of vision in a portion of the visual field. Approaching the client from the side of nonintact vision, placing objects needed for self-care within the client's nonintact visual field, and positioning the client so that the damaged part of the visual field faces the door are incorrect because the client depends on and needs to use the intact portion of the visual field for sensory input. The client is taught to move the head from side to side (scan) to compensate for a diminished visual field. Scanning is also important when the client is eating.

While being seen by a primary health care provider, a client reports persistent fever, malaise, and night sweats. On physical examination, the primary health care provider palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? Reed-Sternberg cells on biopsy of a lymph node

Rationale: Hodgkin's lymphoma is a neoplasm of lymphatic tissue. The presence of giant multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. The presence of blast cells in the bone marrow is indicative of leukemia. Viral infections have been associated with Hodgkin's lymphoma but do not confirm the presence of the disease. An increased BUN level is indicative of a renal system disorder.

A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas (ABG) analysis? Pao2 of 49 mm Hg, Paco2 of 32 mm Hg

Rationale: Hypoxemic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and a normal or low Paco2. The normal Pao2 is 80 to 100 mm Hg and the normal Paco2 is 35 to 45 mm Hg. Respiratory failure may be classified, according to the underlying pathophysiology, as hypoxemic respiratory failure or hypoxemic-hypercapnic respiratory failure. Hypoxemic-hypercapnic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and an increased Paco2 (greater than 50 mm Hg). A Pao2 of 49 mm Hg and Paco2 of 32 mm Hg is the only option that characterizes hypoxemic respiratory failure.

A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. What would the nurse initially do? Identify the client's treatment goals

Rationale: If a client asks a nurse about complementary and alternative therapies, the nurse should initially identify the client's treatment goals, such as sign/symptom management. The nurse should respect the client's request and inquiry about these therapies. Offering options that may be beneficial to the client are appropriate but would not be the initial nursing action. Telling the client that the primary health care provider does not believe in these therapies is a violation of the client's right to be informed about treatment options.

A nurse provides dietary instructions about foods that will promote healing to a client diagnosed with osteoporosis who has sustained a fracture. The nurse tells the client to consume foods high in what nutrient? Vitamin C

Rationale: If a fracture has occurred, the nurse encourages the client to eat foods high in vitamin C, protein, & iron, b/c these nutrients will promote healing. Dietary therapy for the client with osteoporosis includes foods high in calcium. Although fats and carbohydrates should be included in the daily diet, they are not specifically related to the healing process. Foods containing concentrated sugar do not promote healing.

A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. What does the nurse tell the client to immediately do? Get into the shower and rinse the skin for at least 15 minutes

Rationale: If contact with poison ivy is suspected, signs/symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before skin penetration occurs. Persons walking or working in areas where poison ivy grows should protect the skin by wearing appropriate clothing. The client is also instructed to remove clothing carefully to avoid skin contact. Although a topical over-the-counter corticosteroid may relieve some of the discomfort of the poison ivy rash, this is not the action that needs to be taken immediately. Contacting the primary health care provider and coming to the emergency department for treatment are unnecessary.

A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. What should the nurse do first? Check the uterus and amount of lochia discharge

Rationale: If tachycardia is noted, the nurse should first assess the location & firmness of the uterus & amount of lochia. Additional assessments including blood pressure, estimated blood loss at delivery, & hemoglobin & hematocrit determinations should be carried out. After delivery, the normal heart rate ranges from 60 to 90 beats/min. Tachycardia may indicate excitement, fatigue, dehydration, hypovolemia, pain, or infection. Although the nurse would document the findings, it is most appropriate for the nurse to assess the client to determine the cause of the tachycardia. Oral fluids are important if the client is dehydrated, but further assessment of the problem is required and dehydration would first need to be confirmed. Rechecking the heart rate in 1 hour will delay necessary interventions.

A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note? Serum bicarbonate of 12 mEq/L (12 mmol/L)

Rationale: In DKA, the serum bicarbonate concentration is less than 15 mEq/L(15 mmol/L). The BUN and creatinine levels may be increased because of dehydration, and urinary ketones are present. Additionally, the serum glucose is greater than 300 mg/dL (16.6 mmol/L) and the serum pH is less than 7.35. A BUN reading of 15 mg/dL(5.325 mmol/L), a creatinine level of 1.0 mg/dL (88.3 μmol/L), and a negative results on urinary ketone testing are normal findings.

Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse provides information to the client about administration of the medication. What does the nurse tell the client about how to take the medications? Albuterol several minutes before inhaling the fluticasone propionate

Rationale: In a client receiving a bronchodilator by way of inhalation concomitantly with corticosteroid therapy, the client is instructed to use the bronchodilator several minutes before corticosteroid inhalation to enhance penetration of the corticosteroid into the bronchial tree. Albuterol is a bronchodilator, and fluticasone propionate is a corticosteroid. The other options are incorrect.

The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first? A victim with an open fracture of the arm that is bleeding profusely

Rationale: In a disaster situation, the nurse must triage victims on the basis of severity of injury and potential for recovery. Victims with life-threatening injuries that are readily corrected are classified as emergent and are the first priority (in this case, the victim with an open fracture of the arm that is bleeding profusely). Victims with injuries that do not require immediate treatment but that will need to be treated within 1 to 2 hours are classified as urgent and are the second priority (here, the victim with a twisted ankle and leg bruises). Victims with no injuries, those whose condition is noncritical, and victims who are ambulatory are classified as delayed (nonurgent) and are the third priority (in this case, the victim who is anxiously walking about among the victims, searching for her husband). The victim who is unresponsive and not breathing, with severely swollen and bruised eyes, is most likely dead after having sustained a severe head injury and, in this situation, is not the priority. The nurse does not have the resources necessary to save this client, whereas it may be possible for the nurse to save the client who is bleeding profusely by applying pressure to the bleeding site.

A nurse is monitoring a client with bronchogenic carcinoma for signs/symptoms of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? Stokes sign

Rationale: In superior vena cava syndrome, the superior vena cava is compressed or obstructed by tumor growth. Early signs/symptoms, which generally occur in the early morning, include edema of the face, especially around the eyes (periorbital edema), and complaints of tightness of a shirt or blouse collar (Stokes sign). As the compression worsens, the client experiences edema of the hands and arms, dyspnea, erythema of the upper body, and epistaxis (nosebleeds). Late (and life-threatening) signs/symptoms include hemorrhage, cyanosis, mental status changes resulting from lack of blood to the brain, decreased cardiac output, and hypotension (low blood pressure). Death may result if the compression is not relieved.

A nurse is providing information about the storage of insulin to a client who will be self-administering regular insulin. What does the nurse tell the client? That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity

Rationale: Insulin preparations are stable at room temperature for as long as 1 month without significant loss of chemical activity. Direct sunlight and extreme heat must be avoided. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Insulin stored at room temperature causes less discomfort on injection than does cold insulin.

A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? Regular (Humulin R)

Rationale: Ketoacidosis, the most severe manifestation of insulin deficiency, is a life-threatening emergency. IV insulin is a primary component of treatment. Regular insulin, which has a rapid onset and short duration of action, is the only insulin that may be given IV. Because regular insulin forms a true solution, it is safe for IV use. NPH, Lente, NPH/regular 50%/50% are intermediate-acting insulins.

A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic nonketotic syndrome (HNS). Which finding indicates to the nurse that fluid replacement is inadequate? Level of consciousness remains unchanged

Rationale: Lack of any improvement in the lvl of consciousness may indicate an inadequate rate of fluid replacement or a reduction in plasma osmolarity. The initial objective for fluid replacement in HNS is to increase circulating blood volume. Increased urine output indicates an improvement in the client's status. Potassium level of 3.6 mEq/L (3.6 mmol/L) and a blood pressure of 128/80 mm Hg are normal findings.

Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed. Over what period of time should the nurse administer this medication?3 minutes

Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period.

A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin 0.25 mg in the treatment of heart failure (HF). Which instructions should the nurse include on the list? Select all that apply. Take your pulse before taking each dose. Take the digoxin at the same time each day. Take the digoxin with a chewable antacid to prevent nausea. If you forget to take your daily dose, double the dose on the next day. Notify the primary health care provider if you experience loss of appetite, muscle weakness, or visual disturbances.

Rationale: Loss of appetite, muscle weakness, & visual disturbances are signs/symptoms of digoxin toxicity, & the primary health care provider must be notified if any of these occur. Digoxin is a cardiac glycoside that increases the force of myocardial contraction. Its used to treat HF & to control the ventricular rate in clients w/atrial fibrillation. The client is instructed to take the medication at the same time each dy & to check the pulse rate before taking the medication. If the pulse rate is slower than 60 beats/min or faster than 100, the primary health care provider is notified. The medication isnt taken w/an antacid, b/c the antacid will affect absorption of the medication. If the client forgets to take a dose, it needs to be taken as soon as remembered. The dose is never doubled. Hypokalemia predisposes a client to digoxin toxicity. A client isnt instructed to avoid foods that contain potassium unless specifically instructed to do so by the primary health care provider.

A nurse in a primary health care provider's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to see documented in the child's record? Episodes of cramping abdominal pain and excessive flatus

Rationale: Manifestations of lactose intolerance include diarrhea that is frothy (but not fatty), abdominal distention, cramping abdominal pain, and excessive flatus. The presence of fatty stools may indicate a problem with bile flow. Foul-smelling ribbon-like stool is a clinical manifestation of Hirschsprung disease. Profuse watery diarrhea and vomiting is one clinical manifestation of celiac disease.

A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin daily has been prescribed. The nurse makes a note in the client's medication record. When should the medication be administered? With the morning meal

Rationale: Metformin is an antihyperglycemic medication used as an adjunct to diet in the management of type 2 diabetes mellitus. When it is prescribed for daily use, it is administered with the morning meal. Giving the medication at noon, with supper, or with a midafternoon snack is incorrect because the medication is needed to maintain a controlled and consistent blood glucose level. If the prescribed metformin is an extended-release form, the primary health care provider may prescribe a daily dose of the medication with the evening meal, because this timing may enhance absorption as a result of slower nighttime gastrointestinal transit time.

A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? "Do you have episodes of dizziness?"

Rationale: Ménière disease or syndrome, also called idiopathic endolymphatic hydrops, occurs when the normal fluid and electrolyte balance of the inner ear is disrupted. The classic triad consists of episodic true vertigo (dizziness), sensorineural hearing loss, and tinnitus. Some clients experience vertigo associated with nausea, vomiting, and ataxia. Diarrhea, headaches, and loss of appetite are not associated with this disease.

A client diagnosed with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"

Rationale: Noncompliance with antipsychotic medication is one of the reasons clients with schizophrenia have relapses. The nurse should give a response to the schizophrenic client that will help the client identify the causes of relapse. The therapeutic response by the nurse is, "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" In asking, "Only you can help?" the nurse is employing restating, which can be therapeutic but is not useful in this client's situation. "You decided not to take your medication?" is another example of restating. In stating, "If you can make this observation, you probably don't need your medication any longer," the nurse is using an illogical, judgmental, and biased response that is not therapeutic.

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate by way of the nasal route. For which occurrence does the nurse tell the client to contact the primary health care provider? Headache and nausea

Rationale: One adverse effect of desmopressin acetate is water intoxication. Early signs/symptoms of water intoxication include headache, nausea, shortness of breath, drowsiness, and listlessness. The primary health care provider is notified if these signs/symptoms occur. Desmopressin, a synthetic form of antidiuretic hormone, causes increased resorption of water and a resultant decrease in urine output (an expected outcome). Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone (ADH). Abdominal cramping is a side effect, not an adverse effect, of the parenteral form of the medication. A runny or stuffy nose is a side effect, not an adverse effect, of the medication.

A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?

Rationale: Peau d'orange (French for "orange peel") is the term used to describe skin dimpling, resembling the skin of an orange, at the location of a breast mass. This change, along with increased vascularity, nipple retraction, or ulceration, may indicate advanced disease. Erythema, or reddening, of the breast indicates inflammation such as that resulting from cellulitis or a breast abscess. Paget's disease is a rare type of breast cancer that is manifested as a red, scaly nipple; discharge; crusting lasting more than a few weeks. In nipple retraction, the nipple is pointed or pulled in an abnormal direction. It is suggestive of malignancy.

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? A blood pressure higher than the normal range

Rationale: Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine, with associated signs/symptoms that include the "five P's": pressure (paroxysmal increases in blood pressure), palpitations, pallor, perspiration (profuse and generalized), and pain (paroxysmal pulsatile headaches, chest, and abdominal pain). Other clinical signs/symptoms include weight loss, constipation, tremors, hypertensive retinopathy, hyperglycemia, and hypercalcemia.

Prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. What does the nurse tell the client to do? Call the primary health care provider if a fever, sore throat, or muscle aches develop

Rationale: Prednisone is a glucocorticoid that prevents or diminishes tissue response to an inflammatory process. The client taking this medication should notify the primary health care provider if fever, sore throat, muscle aches, or sudden weight gain or swelling occurs. The medication is taken with food or milk because it can cause gastrointestinal irritation. The client is instructed not to change the dose and to not stop taking the medication without contacting the primary health care provider. The medication must be tapered gradually under medical supervision.

The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse knows that what type of medication is given to treat this condition? Calcium channel blockers

Rationale: Prinzmetal's, or variant, angina is prolonged and severe and occurs at the same time each day, most often at rest. The treatment of choice is usually a calcium channel blocker. Calcium channel blockers relax and dilate the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Inotropes, beta blockers, and angiotensin-converting enzyme (ACE) inhibitors are not given to treat this disorder.

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client? Paresthesia

Rationale: Sensory deficits such as paresthesia abnormal dermal sensation(eg, a tingling, pricking, chilling, burning, or numb sensation on the skin)w/no apparent physical cause generally appear as an early sign of acute compartment syndrome before changes in vascular or motor signs. Acute compartment syndrome is a serious condition in which increased pressure w/i 1 or more compartments causes massive compromise of circulation to the area. Resultant edema causes pressure on the nerve endings & subsequent pain. The client will also complain of severe diffuse pain thats not relieved by analgesics.

Laboratory studies are performed on a client diagnosed with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? Increased white blood cell (WBC) count

Rationale: Sickle cell disease is a genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infection, & early death. The WBC count is usually higher than normal in clients w/sickle cell disease. Also, the red blood cells assume a sickle shape, become rigid, & clump together. The main laboratory finding associated w/sickle cell disease is the large percentage of HbS present on electrophoresis. The reticulocyte count is increased, indicating anemia of long duration, & the total bilirubin lvl is increased. The hematocrit level is low & decreases during crisis, b/c the bone marrow fails to produce cells during stressful perks. Its believed that this increase is related to chronic inflammation resulting from tissue hypoxia and ischemia.

The nurse is reviewing the record of a client admitted w/Cushing's syndrome due to ingestion of large doses of long-term glucocorticoids used to treat nonendocrine conditions. What signs/symptoms does the nurse expect to note? Select all that apply.Moon face Dizziness Osteoporosis Edema in the feet

Rationale: Signs/symptoms of clients with Cushing's syndrome include moon face, dizziness, osteoporosis, and swelling of the feet. Other signs/symptoms include puffy eyelids, increased bruising, bleeding, and menstrual irregularities. Hyperkalemia, not hypokalemia, also occurs, as well as gaining, not losing, weight.

A client has a primary health care provider's appointment to get a prescription for sildenafil. The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? The client takes isosorbide dinitrate

Rationale: Sildenafil is used to treat male erectile dysfunction. It is contraindicated in the client who is using isosorbide dinitrate, a form of sodium nitroprusside or organic nitrates in any form, because both sildenafil and nitrates promote hypotension. When these medications are combined, life-threatening hypotension may result. Type 2 diabetes mellitus, a history of renal calculi, and the use of glargine insulin are not contraindications to the use of sildenafil.

Desmopressin is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while taking the medication? Intake and output

Rationale: The client is instructed to monitor and record daily intake and output of fluid. Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone. Desmopressin promotes renal conservation of water. The hormone accomplishes this by acting on the collecting ducts of the kidney to increase their permeability to water, resulting in increased water reabsorption. If the dose prescribed is adequate, urine volume should rapidly drop to normal. Appetite, pulse rate, and changes in bowel pattern are not associated with the use of this medication.

A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply. Use a straw to drink. Use caution when leaning forward or backward.

Rationale: Straws are used to drink, and meat and other foods are cut into small pieces to facilitate swallowing. The weight of the halo device alters balance; therefore the client should use caution when leaning forward or backward. The client is also told not to drive, because full range of vision is impaired with the device. A halo fixation (stabilization) device is used to prevent the head and neck from moving after a neck injury. The halo fixation device is not removed. Sexual activity does not have to be avoided; the client is instructed to use a position of comfort. Powders and lotions are used sparingly or not at all to prevent buildup of moisture and subsequent skin breakdown. The client is instructed to wear loose clothing with a large neck. The halo fixation device should not shift; if it does, the primary health care provider must be notified. The client is taught to sleep with the head supported with a small pillow to prevent unnecessary pressure and discomfort.

A child with growth hormone deficiency will be receiving somatropin. The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? Thyroid-stimulating hormone (TSH)

Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is assessed before treatment and periodically thereafter. Creatinine and BUN are used to evaluate renal function, and hemoglobin reflects hematologic activity.

As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse? "I can see that you're upset. Would you like to talk about it?"

Rationale: The best response is, "I can see that you're upset. Would you like to talk about it?" The nurse addresses the client's feelings. The client may not want to talk about his/her feelings, but the nurse has provided the opportunity to the client and is maintaining an open channel of communication. "Don't yell at me" is confrontational and nonfacilitative and imposes control. "These medications will help you feel much better" avoids the client's feelings. "Why do you want to be left alone? I'm here to help you" is not a facilitative response and may place the client, who may not be able to express his or her feelings, on the defensive.

A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign/symptom of this complication does the nurse monitor the client? Pleuritic chest pain

Rationale: The characteristic signs/symptoms of pulmonary embolism are dyspnea, tachypnea, tachycardia, and pleuritic chest pain (sharp, stabbing pain on inspiration). Pulmonary embolism, whch results in blockage of the main artery of the lung or one of its branches, occurs when an object, such as a clot, or substance travels from elsewhere in the body through the bloodstream (embolism). The client may become apprehensive and restless. A low-grade fever may occur. Chills and a high fever are characteristics of an infection.

A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair.

Rationale: The client is instructed to wash the external ear and canal daily in the shower or while washing his or her hair. The client should also wear sound protection around loud or continuous noises, avoid activities with a high risk for ear trauma, keep the volume of headphones at the lowest setting, and avoid environmental conditions involving rapid changes in air pressure. The client should never use a small object such as a cotton-tipped applicator to clean the external ear canal. The client should always sneeze with the mouth open (not closed), and also be instructed to blow the nose gently and not occlude a nostril when blowing the nose.

A nurse, conducting an assessment of a client being seen in the clinic for signs/symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride. On the basis of this information, the nurse determines that the client most likely has a history of what problem?Depression

Rationale: The client is most likely suffering from depression. Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication.

Iodine solution is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. What does the nurse most appropriately tell the client? To contact the primary health care provider

Rationale: The client should most appropriately be instructed to notify the primary health care provider if the client experiences burning sensation in the mouth and soreness of the gums and teeth. Iodine can produce toxicity (iodism). The client should be instructed about the signs/symptoms of iodism, which includes a brassy taste and burning sensation in the mouth, soreness of the gums and teeth, frontal headache, coryza, salivation, and skin eruptions. The client's signs/symptoms are not expected side effects of the medication and will not resolve with continued therapy; in fact, continued therapy will worsen the client's condition. Stopping the medication for 24 hours and then continuing it as prescribed will also worsen the client's condition.

A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? "I shouldn't drink coffee before the test."

Rationale: The client understands the instructions for an ENG if the client states, "I shouldn't drink coffee before the test." The client must fast for several hours (but not for 24 hours) before the test and should avoid caffeine-containing products for 24 to 48 hours before the test. An ENG is a test that is sensitive in detecting both central and peripheral disease of the vestibular system in the ear. It detects nystagmus (involuntary eye movements), which can be recorded. After electrodes are taped to the skin near the eyes, procedures are performed to stimulate nystagmus. No sedation is used for the ENG. Fluids are given to the client after the test but are introduced carefully to prevent nausea.

A client with a medical history of diabetes mellitus is found to have sarcoidosis and oral prednisone is prescribed. The nurse provides instructions to the client about the medication. What does the nurse tell the client? Closely monitor the blood glucose level

Rationale: The client with diabetes mellitus who is taking prednisone would be instructed to closely monitor the blood glucose level. When taken over an extensive period of time, prednisone may cause increased blood glucose and decreased potassium. It may also cause increased blood pressure and sodium retention. Sarcoidosis is a multisystem granulomatous disorder of unknown cause that can affect virtually any organ. Corticosteroids are the primary pharmacological therapy for sarcoidosis. The primary health care provider may prescribe an increased dose of insulin while the client is taking this medication.

The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. What should be the nurse's initial action? Check the drainage for glucose

Rationale: The initial nursing action is to check the drainage for glucose. If glucose is present in the drainage, the surgeon must be notified. After hypophysectomy, the nurse assesses the client's nasal drainage for quantity, quality, and the presence of glucose, which indicates that the fluid is cerebrospinal fluid (CSF). The nurse would not change the dressing unless a specific prescription to do so has been given. The nurse would document the findings, but this would not be the initial action.

A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which type of exercise does the nurse tell the client to avoid? High-impact exercise

Rationale: Vigorous or high-impact exercise may exacerbate signs/symptoms and may be damaging to articulating surfaces within joints. These type of exercises should be avoided by clients with osteoarthritis. Osteoarthritis is a joint disorder marked by joint pain that is worse after high-impact exercise or when the affected person puts weight on the joint and is relieved by rest. The other options are helpful activities/exercises in promoting joint mobility.

An emergency department (ED) nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. What is the most appropriate action the nurse should take? Notify the emergency department (ED) primary health care provider

Rationale: The most appropriate action by the nurse would be to notify the ED primary health care provider immediately. A client with a severe inhalation injury may sustain such progressive obstruction that within a short time he/she cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation. A client with an inhalation burn injury is at risk for respiratory complications. Upper-airway edema and inhalation injury are most notable in the trachea and main stem bronchi. Auscultation of these areas reveals wheezes, which are a sign/symptom of obstruction. Continuing to monitor the client, documenting the client's improvement in the medical record, and removing the oxygen mask and fitting the client with a nasal cannula are all incorrect and would delay necessary interventions.

A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and an assistive personnel (AP) on the team. Which client is the most appropriate choice for the AP? A client with rheumatoid arthritis who needs assistance with feeding and ambulation

Rationale: The most appropriate client for the AP is the client with rheumatoid arthritis who needs assistance with feeding and ambulation. When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. A client with hemophilia is at risk for bleeding and should be cared for by a licensed nurse. Suctioning, an invasive treatment, must be performed by a licensed nurse. Although a AP may weigh a client and monitor intake and output, this client has heart failure and should be monitored by a licensed nurse who will be able to listen to breath sounds and detect changes in the client's status. Feeding a client, turning and repositioning a client, assisting with hygiene measures, and ambulating a client are noninvasive interventions and that may be assigned to a AP.

A hospitalized client scheduled for surgery is told by the primary health care provider that he/she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, refuses the transfusion. What is the most appropriate initial nursing action? Supporting the client's decision to refuse the transfusion

Rationale: The most appropriate initial nursing action is to be supportive of a Jehovah's Witness' refusal to receive a blood transfusion. Religious beliefs can influence individual and family responses to health and illness, and religion can be a source of support and comfort for a client. Awareness of a client's religious beliefs enables the nurse to appropriately support the client's decisions regarding care. The nurse might need to instruct the client in how to increase dietary intake of iron, but this would not be the initial action. Telling the client about the importance of blood transfusions and telling her that the surgery will need to be canceled if she refuses the blood transfusion are both inappropriate.

A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as most important? Trapeze bar

Rationale: The most important item for the client in skeletal traction to use is a trapeze bar. This bar is a triangular device that hangs from a securely fastened overhead bar thats attached to the bed frame. It allows the client to pull up w/the upper extremities to raise the trunk off the bed. It is a useful device for helping increase independence, maintain upper-body strength, & reducing the shearing action that results when the client slides across or up & down in the bed. The client in traction wouldnt be allowed to get out of bed to use a bedside commode; rather, a bedpan or fracture pan would be used. Although a telephone & a tv are helpful for diversion & maintaining social contact, they are not the most important items.

A nurse reviews the results of a total serum calcium determination in a client with chronic kidney disease. The results indicate a level of 12.0 mg/dL (3 mmol/L). In light of this result, which finding does the nurse expect to note during assessment? Bounding, full peripheral pulses

Rationale: The normal total serum calcium lvl ranges 8.6-10.2 mg/dL(2.15-2.55 mmol/L). Hypercalcemia occurs when the total serum calcium lvl exceeds 10 mg/dL(2.5 mmol/L). Some of the key features of hypercalcemia are increased heart rate & blood pressure; bounding, full peripheral pulses; ineffective respiratory mov related to profound skeletal muscle weakness; disorientation; diminution or absence of deep tendon reflexes; increased urine output; and hypoactive bowel sounds.

The nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred? Protamine sulfate

Rationale: The nurse checks for protamine sulfate in the medication room in case a heparin overdose occurs. If the IV tubing is removed from an infusion pump and the tubing is not clamped, the client will receive a bolus of the solution of the medication contained in the solution. Heparin is an anticoagulant, and the client who receives a bolus dose of heparin is at risk for bleeding. The nurse would notify the primary health care provider. A blood sample for partial thromboplastin time (PTT) would be drawn and the results of testing evaluated. If the PTT is too high, the infusion may be stopped for a time, or a dose of protamine sulfate, the antidote for heparin, may be prescribed. Enoxaparin is an anticoagulant. Phytonadione is the antidote for warfarin sodium.Aminocaproic acid is an antifibrinolytic, inhibiting clot breakdown.

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the primary health care provider suspects iron-deficiency anemia. After reviewing the laboratory results, which finding indicative of this type of anemia does the nurse expect to note?. Microcytic red blood cells (RBCs)

Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In iron-deficiency anemia, laboratory testing will reveal low hemoglobin and hematocrit levels. In iron-deficiency anemia, iron stores are depleted first, followed by hemoglobin stores.

Calcium carbonate is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? Spinach

Rationale: The nurse instructs the client to avoid consuming spinach while taking calcium carbonate. Oral calcium salts are used to treat mild hypocalcemia and to supplement dietary calcium. The client is instructed to take oral calcium with a large glass of water with or after a meal to promote absorption. The client is also instructed to avoid taking calcium with foods that can suppress calcium absorption. Such foods include not only spinach, but Swiss chard, beets, bran, and whole-wheat cereals. The client does not need to avoid fish, milk, or watermelon.

A client diagnosed with tuberculosis will be taking pyrazinamide, and the nurse provides instructions about the adverse effects of the medication. For which occurrence does the nurse tell the client to contact the primary health care provider? Yellow skin

Rationale: The nurse instructs the client to contact the primary health care provider if he/she experiences jaundice (yellow skin or eyes); unusual tiredness; fever; loss of appetite; or hot, painful, or swollen joints. Adverse effects include hepatotoxicity, thrombocytopenia, and anemia. Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Headache, nasal congestion, and difficulty sleeping are not associated with the use of this medication.

A nurse reviews arterial blood gas (ABG) values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. What does the nurse interpret these values as indicative of?Respiratory alkalosis

Rationale: The nurse interprets these values as indicative of respiratory alkalosis. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory alkalosis, the pH will be higher than normal and the Pco2 will be low.

The nurse is caring for a newborn recently diagnosed with gastroschisis. What does the nurse know about this condition? Select all that apply. Care similar to that for omphalocele Surgery performed within several hours after birth Postoperatively most infants develop prolonged ileus Results from a defect in the abdominal wall

Rationale: The nurse knows that gastroschisis results from a defect in the abdominal wall in which the viscera is outside, not inside, the abdominal cavity and are also not covered by a sac. Care of the newborn is similar to that for newborns with omphalocele. The exposed bowel is covered loosely in saline-soaked pads, not directly wrapped around the bowel. Surgery needs to be performed within several hours after birth, and postoperatively most newborns develop prolonged ileus.

A nurse is monitoring a child with intussusception for signs/symptoms of peritonitis. For which finding, indicative of this complication, does the nurse notify the primary health care provider? Increased heart rate

Rationale: The nurse monitors the child closely for signs/symptoms of sepsis, peritonitis, and shock. Possible indicators of peritonitis include fever, increased heart rate, changes in the level of consciousness or in blood pressure, and respiratory distress. Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children ages 3 months to 6 years. The classic signs of intussusception are a sausage-shaped abdominal mass and the passage of bloody ("currant jelly") stool and diarrhea.

Levothyroxine is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the primary health care provider's office and tells the nurse that the medication has not helped. What does the nurse most appropriately tell the client? The full therapeutic effect may take 4 weeks

Rationale: The nurse most appropriately tells the client that full therapeutic effect may take 1 month. For this reason, changing the medication and the addition of a medication are not necessary. Levothyroxine is used in the treatment of hypothyroidism. Therapy with levothyroxine may begin with small doses that are gradually increased. Blood levels of thyroid hormones are checked during therapy with levothyroxine, obtaining these levels after 1 week of therapy will not provide useful information.

A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion? Blood pressure

Rationale: The nurse most closely checks the client's blood pressure every 15 mins during infusion of the medication. Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla & sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine. Most affected clients present w/hypertensive crises that may be treated w/ phentolamine. This medication, a short-acting alpha-adrenergic blocker is given by way of IV bolus or infusion for a hypertensive crisis.

A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? Clamping the intravenous catheter

Rationale: The nurse next clamps the intravenous catheter and notifies the primary health care provider. The signs/symptoms of air embolism include chest pain, dyspnea, and hypoxia. Tachycardia and hypotension will also be present, and the client will experience anxiety. The nurse will also hear a loud churning sound on auscultation over the pericardium. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. This position prevents air from flowing into the pulmonary veins. Although auscultating heart sounds, checking the client's blood pressure, and obtaining an arterial blood gas specimen may be appropriate interventions, none is the next action to take after positioning the client.

The nurse is caring for a newborn who was born to a mother infected with HIV. The nurse knows what manifestations of treatment are included in the care of this neonate? Select all that apply. Administer zidovudine to the newborn as prescribed for the first 6 weeks. For all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci.

Rationale: The nurse should administer zidovudine to the newborn as prescribed for the first 6 weeks of life. Also, for all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. In addition, all HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. The newborn can room with the mother. All neonates acquire maternal antibody to HIV infection, but not all acquire infection. Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after birth.

A nurse preparing to administer digoxin to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.0 ng/mL (2.6 nmol/L). On the basis of this result, what should the nurse do? Contact the primary health care provider

Rationale: The nurse should contact the primary health care provider. The optimal therapeutic serum level for digoxin is 0.5 to 0.8 ng/mL (0.6 to 1.0 nmol/L). A digoxin concentration greater than this level indicates toxicity, and requires the nurse to contact the primary health care provider. The remaining options are inappropriate because they could delay necessary and immediate intervention, resulting in harm to the client.

A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. What should the nurse plan to do first? Provide the client with 100% oxygen by mask

Rationale: The nurse should first provide the client with 100% O by mask. When smoke is inhaled, C monoxide binds with hemoglobin, displacing O. A high carboxyhemoglobin level impairs tissue oxygenation, resulting in tissue asphyxia. Providing the client with 100% oxygen by mask reverses this condition. The nurse would next ensure that the client has a patent IV line and then administer fluids as prescribed. The nurse would also maintain body temperature, provide wound care as needed, and provide comfort and emotional support.

A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis (MS). The client tells the nurse that she took baclofen for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care what should be monitored most closely in the client? Seizure activity

Rationale: The nurse should most closely monitor the client for seizure activity. Abrupt withdrawal of baclofen may produce hallucinations or seizures. Baclofen is a skeletal muscle relaxant, acting at the lvl of the spinal cord to reduce the frequency & amplitude of muscle spasms & spasticity in clients w/spinal cord injuries & diseases, as well as multiple sclerosis. Drowsiness may occur as a result of taking the medication but diminishes with continued therapy.

A client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid daily in a divided dose. At the primary health care provider's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. What should the nurse tell the client? The primary health care provider will probably withhold the aspirin until the signs/symptoms have subsided, then resume the aspirin at a lower dosage

Rationale: The nurse should tell the client that the primary health care provider will probably withhold the aspirin until the signs/symptoms have subsided, then resume the aspirin at a lower dosage. Salicylism is a syndrome that begins to develop when the aspirin level climbs just slightly above the therapeutic level. Overt signs/symptoms include tinnitus (ringing in the ears), sweating, headache, and dizziness. If salicylism develops, aspirin is withheld until the signs/symptoms have subsided; therapy should then be resumed with a small reduction in dosage. Tinnitus is not an expected finding. Drinking water will not prevent tinnitus. A nonsteroidal antiinflammatory medication will not be prescribed, because these medications' chemical properties are similar to those of aspirin.

A client diagnosed with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. What should the nurse tell the client to do? Increase intake of high-fiber foods

Rationale: The nurse should tell the client to increase intake of high-fiber foods. Calcium gluconate is a calcium supplement, and constipation is a side effect of calcium gluconate. It is not necessary for the client to contact the primary health care provider immediately if constipation occurs. Rather, the nurse would suggest interventions to alleviate and prevent constipation (e.g., increased fluid intake, high-fiber diet, exercise). Clients taking calcium supplements should be instructed to avoid the use of mineral oil as a laxative because it reduces vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. The client should not stop taking the medication.

A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which finding indicates to the nurse that the client has sustained a flail chest? Asymmetrical chest movement

Rationale: The nurse specifically notes paradoxical breathing (asymmetrical chest movement); oscillation of the mediastinum; increasing dyspnea; rapid, shallow respirations; accessory muscle breathing; restlessness; decreased breath sounds on auscultation; cyanosis; and anxiety related to difficulty breathing. The client will also complain of severe chest pain. Flail chest is a thoracic injury resulting in paradoxical motion of the chest-wall segment. This causes the mediastinal structures to swing back and forth with respiration.

A client with emphysema is receiving theophylline. While providing dietary instructions, what does the nurse tell the client is acceptable to consume? Apple juice

Rationale: The nurse tells the client that apple juice is acceptable to consume. Theophylline is a methylxanthine bronchodilator. Caffeine is a methylxanthine with pharmacologic properties like those of theophylline. For this reason, caffeine can intensify the adverse effects of theophylline on the central nervous system and heart. In addition, caffeine competes with theophylline for drug-metabolizing enzymes, thereby causing the theophylline level to increase. Because of these interactions, individuals taking theophylline should avoid caffeine-containing beverages such as cola, coffee, tea, and cocoa, as well as other caffeine-containing products.

Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse is providing information to the client about the medication. What time of day does the nurse tell the client is best to take the medication? In the morning, before 9:00 a.m.

Rationale: The nurse tells the client that it is best to take glucocorticoids before 9 a.m. This schedule helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenals each morning. Prednisone, a glucocorticoid, may be prescribed to reduce inflammation and pain in acute exacerbations of rheumatoid arthritis. The time frames in the remaining options are incorrect.

A nurse is preparing to provide information to a client who has been found to have stable angina. What does the nurse plan to tell the client about this type of angina? Is often managed medically with medications such as calcium channel blockers and beta-blocking medications

Rationale: The nurse tells the client that stable angina is often managed by medical means, such as calcium channel blockers & beta-blocking medications. Stable angina is chest discomfort that occurs w/moderate to prolonged exertion in a pattern that is familiar to the client. Its usually relieved by nitroglycerin & rest. Rarely does it require aggressive trt such as surgery. The disease can be managed but not cured.

A nurse provides instructions to a client who will be taking levothyroxine for hypothyroidism. When does the nurse tell the client that it is best to take the medication? In the morning, before breakfast

Rationale: The nurse tells the client that the best way and time to take the medication is on an empty stomach and preferably in the morning, before breakfast. Levothyroxine, a synthetic preparation of thyroxine, a naturally occurring thyroid hormone, is used to treat clients who require hormone-replacement therapy.

The wife of a client diagnosed with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL (3.3 mmol/L) and that her husband is awake but groggy. What does the nurse tell the client's wife to immediately do? Place some honey in her husband's mouth, between his gums and cheek

Rationale: The nurse tells the client's wife to immediately place some honey in her husband's mouth, between his gums and cheek. Once the sugar has been absorbed through the oral mucosa, the client can usually be aroused sufficiently to take a glass of juice, milk, or sugar-sweetened coffee or tea. The client and his spouse should be educated about the signs/symptoms of hypoglycemia (blood glucose level of 60 mg/dL [3.3 mmol/L] or lower). There is no reason at this time to call the primary health care provider or to call an ambulance to bring the client to the emergency department. Glucagon hydrochloride is used to treat hypoglycemic coma.

A nurse is providing dietary instructions to the mother of a child with celiac disease. What does the nurse tell the mother is acceptable to give the child? Boiled rice

Rationale: The nurse tells the mother that corn, rice, and millet may be substituted as grains. Celiac disease is a disorder in which the affected person has an intolerance to wheat, rye, barley, and oats. Dietary management is the mainstay of treatment for the child with celiac disease. Products containing gluten (e.g., wheat, rye, barley, oats, hydrolyzed vegetable protein) should be eliminated from the child's diet. This includes most pasta and baked products, as well as many breakfast cereals. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. What does the nurse tell the mother to immediately do? Encourage the child to drink water or milk in small amounts

Rationale: The nurse tells the mother to immediately administer water or milk to dilute the toxic effects of acid or alkali ingestion. These substances, when ingested, may cause burning of tissue along the gastrointestinal tract. Because these caustic substances continue to cause damage until they are neutralized, induction of emesis is contraindicated. Although calling the child's primary health care provider and bringing the child to the emergency department may each be necessary, they are not the actions to be taken immediately, because they would delay necessary treatment.

A nurse prepares to administer digoxin to a client with heart failure. Which vital sign must be checked before the medication is administered? Apical pulse

Rationale: The nurse would count the client's apical heart rate for 60 seconds before giving the medication. Digoxin is a cardiac glycoside used to treat heart failure and control the ventricular rate in clients with atrial fibrillation. If the heart rate is slower than 60 beats/min, the medication is withheld and the primary health care provider notified. Excessive slowing of the heart rate is one clinical sign of digoxin toxicity. Although the nurse might check other vital signs, the apical pulse is the most important in this context.

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside. What does this sign tell staff to avoid? Palpating the abdomen

Rationale: The nurse would place a sign at the kid's bedside warning against palpation of the kid's abdomen. Wilms' tumor, or nephroblastoma, is the most common renal tumor in children. Arising from the renal parenchyma of the kidney, this tumor grows very rapidly. It may be unilateral & localized or bilateral & sometimes involves metastasis to other organs. The tumor mass shouldnt be palpated b/c of the risk that the protective capsule will rupture. Excessive manipulation can result in seeding of the tumor & the spread of cancerous cells. Taking temperatures rectally, turning the kid to the right side, & measuring blood pressure in the right arm are interventions that do not need to be avoided.

A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs/symptoms of postoperative complications. Which finding would be a matter of concern for the nurse as an indication of hypocalcemia? The client complains of a tingling sensation around the mouth.

Rationale: The parathyroid glands may be damaged or their blood supply impaired during thyroid surgery. Hypocalcemia and tetany result when the level of parathyroid hormone decreases. The nurse assesses the client for signs/symptoms of tingling around the mouth or of the toes and fingers and muscle twitching, signs/symptoms of calcium deficiency. Calcium gluconate or calcium chloride for intravenous administration must be available in an emergency situation (severe hypocalcemia). Hoarseness and a weak voice may result if the laryngeal nerve is damaged during surgery; however, the client is reassured that the hoarseness is usually temporary. Tachycardia and a fever are signs/symptoms of thyroid storm or thyroid crisis, a complication of thyroid surgery. Postoperative thyroid storm is rare because clients receive antithyroid medications, beta-blockers, corticosteroids, and iodides before thyroid surgery.

A client with diabetes mellitus calls the clinic nurse and reports that he/she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? "Have you tested your blood glucose?"

Rationale: The priority is learning whether the client has tested his/her blood glucose level and what the level is. During illness, the client should follow the "sick-day rules" for diabetics. The blood glucose level should be checked every 4 hours. Urine is tested for ketones if the blood glucose level is greater than 240 mg/dL (13.3 mmol/L). The client should take the prescribed insulin or oral antidiabetic medication and should drink 8 to 12 oz (135 to 350 mL) of sugar-free liquids every hour when awake. The client should notify the primary health care provider if he/she becomes ill. The remaining options are questions that may be asked, but they are not the priority.

A client with type 1 diabetes mellitus is instructed by the primary health care provider to obtain glucagon hydrochloride for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information? "I need to give this if he has signs of low blood sugar and goes into a coma."

Rationale: The statement by the client's wife that indicates she understands the information is, "I need to give this medication if he has signs of low blood sugar and goes into a coma." Glucagon is used to treat hypoglycemia resulting from insulin overdose. If hypoglycemic coma develops, glucagon is administered promptly. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of injection. Once consciousness has been produced, oral carbohydrates should be given. Insulin should never be stored in the freezer. Glucagon is not used to treat hyperglycemia or used in place of insulin; also, the client should be instructed to have additional vials of insulin on hand at home so that he will not run out. Glucagon is stored at room temperature.

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his/her own insulin but has difficulty seeing and accurately preparing doses. How does the nurse place the medication in the client's refrigerator with the syringes? In a vertical position with the needles pointing up

Rationale: The syringes should be stored vertically, with the needles pointing up to prevent clogging of the needle with the insulin. Mixtures of insulin in prefilled syringes may be stored in a refrigerator, where they will be stable for at least 1 to 2 weeks. Before administration of the medication, the syringe should be agitated gently to resuspend the insulin.

A pediatric nurse is caring for a hospitalized toddler. Which activity does the nurse deem the most appropriate for the toddler? Large building blocks

Rationale: The toddler is developing the use of motor skills and enjoys manipulating small objects such as blocks, push-pull toys, and toy people, cars, and animals. Therefore large building blocks are appropriate for a client of this age. Singing games, simple board games, and videos are appropriate for the preschooler.

Testing of the plasma theophylline lvl in a client whos receiving a continuous intravenous infusion of theophylline reveals a toxic lvl of 24 mcg/mL (111 umol/L). What early signs of toxicity does the nurse assess for? Tremors Palpitations Nervousness

Rationale: Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/mL (111 mcmol/L). Early signs of toxicity include restlessness, not lethargy; nervousness; tremors; palpitations; and tachycardia, not bradycardia. The normal therapeutic range for theophylline is 10 to 20 mcg/mL (55.5 to 111 umol/L).

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. What statement by the nurse indicates a need for further information? "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal."

Rationale: There is a need for further information if the nurse states, "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal with lavage is done if the child is unconscious, but N-acetyl cysteine cannot be used because activated charcoal inactivates the antidote. If given orally, it can be diluted in juice or soda, and a loading dose of N-acetyl cysteine must be followed by maintenance doses.

The nurse is giving discharge instructions to a client recently diagnosed with hypothyroidism. The client was also given a prescription for levothyroxine by the primary health care provider. What comment by the client indicates a need for further instruction? "I know I have to notify the primary health care provider if I have any problems with a slow heart rate."

Rationale: There is a need for further instruction if the client says, "I know I have to notify the primary health care provider if I have any problems with a slow heart rate." The primary health care provider must be notified if the client has any problems with tachycardia or fast heart rate, not slow heart rate. Excessive doses of levothyroxine sodium can produce signs/symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, extreme heat intolerance, and sweating. The other comments are correct.

The nurse is instructing a client who has been diagnosed with myasthenia gravis. What comment by the client indicates a need for further instruction? "I must take my medications about 45 minutes before eating a meal."

Rationale: There is a need for further instruction if the client states, "I must take my medications about 45 minutes before eating a meal." The client needs to eat a meal 45 to 60 minutes after, not before, taking medications to decrease the risk for aspiration. The other client statements are correct. Myasthenia gravis is a disease that affects the myoneural junction. It is believed to result from an autoimmune response that destroys a variable number of acetylcholine receptors at the myoneural junction.

A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction? "I should eat three meals a day, and the biggest meal should be at suppertime."

Rationale: There is a need for further instruction if the client states, "I should eat three meals a day, and the biggest meal should be at suppertime." The biggest meal of the day is planned for the time when the client is hungriest and most rested. Most clients are increasingly tired at the end of the day. Four to six small meals per day are preferable to three larger ones. Pursed-lip or abdominal breathing may alleviate dyspnea.Shortness of breath is the most common problem related to eating for a client with COPD. The client can ease dyspnea by resting before meals. A bronchodilator used 30 minutes before a meal may be helpful if the meal-related dyspnea is a result of bronchospasm or secretions.

Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction? "I should put ice in my drinks to help soothe the discomfort."

Rationale: There is a need for further instruction if the client states, "I should put ice in my drinks to help soothe the discomfort." Oral candidiasis lesions make it difficult for the client to tolerate temperature extremes, so it is best for the client to consume foods and fluids that are tepid or room temperature rather than iced or hot. The other options are useful measures for alleviating the discomfort associated with this disorder.

A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction? "I should use oil-based cosmetics."

Rationale: There is a need for further instruction if the client states, "I should use oil-based cosmetics." The client with acne is instructed to use water-based cosmetics and to avoid exposure to skin products that contain oil, because products that are oily may cause flare-ups. The statements in the other options are correct.

A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction? "I should encourage him to keep his hands hanging at his side when he walks."

Rationale: There is a need for further instruction if the client's spouse states, "I should encourage him to keep his hands hanging at his side when he walks." Parkinson's disease is a chronic degenerative disorder that primarily affects the neurons of the basal ganglia. The client's muscles become stiff and rigid and require increased effort to move. The client is taught to hold the hands clasped behind the back when walking to keep the spine erect and counter the problems that may result when the arms hang stiffly at the sides. The statements in the other options indicate correct understanding of measures regarding activity and exercise for the client with Parkinson's disease.

Tolbutamide is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."

Rationale: There is a need for further instruction when the client says "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." Tolbutamide, a first-generation sulfonylurea, is used as an adjunct to calorie restriction and exercise to maintain glycemic control in clients with type 2 diabetes mellitus. When alcohol is combined with tolbutamide, a disulfiram-like reaction, including flushing, palpitations, and nausea, may occur. Alcohol also potentiates the hypoglycemic effects of tolbutamide. The client must be told about the dangers of alcohol consumption. The statements in the remaining options are correct.

A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching? "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work."

Rationale: There is a need for further teaching if the client states, "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work." The client is instructed to place 1 nitroglycerin tablet, not 3 tablets, under the tongue and allow it to dissolve. The client needs to obtain instructions from the primary health care provider about the preferred procedure for administering nitroglycerin. The remaining statements reflect accurate understanding of the nurse's teaching.

The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next? Assessing the wound

Rationale: View video. The nurse next assesses the wound for size; redness; swelling; and amount, color, odor, and type of drainage, if drainage is present. When performing a dressing change, the nurse dons clean gloves and removes the old dressing; checks the dressing for drainage, noting the amount, color, and odor if drainage is present; and discards the gloves and dressing. Next the nurse washes the hands and sets up the sterile field; dons sterile gloves; cleanses the wound with solution as prescribed, moving from the least to the most contaminated area; and redresses the wound. If a drain is present, the nurse applies additional layers of gauze as needed.

The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? Checking for gastric residual volume and assessing tube placement

Rationale: View video. When a client has a nasogastric tube, a priority concern is the risk for aspiration. The nurse wouldnt administer a feeding or flush the tube unless residual vol & tube placement had been checked. To check residual vol, the nurse would draw up 30 mL of air in a catheter-tipped syringe, attach it to the feeding tube, inject the air, & then pull back the plunger to aspirate all of the gastric contents. The gastric contents are checked for amount & appearance & then the pH is checked for acidity to ensure accurate placement. Its not necessary to scrub the port w/povidone-iodine solution; administering a tube feeding is a clean, not sterile procedure. Although intake & output may be monitored, its not necessary to check urine output for the previous 24 hours before starting a feeding.

The nurse, auscultating the breath sounds of a client, hears these sounds. What are they? Wheezes

Rationale: Wheezes are continuous squeaky, musical sounds, the result of air rushing through narrowed airways. They are associated with inflammation, bronchospasm, edema, secretions, or pulmonary vessel engorgement. Rhonchi are continuous low-pitched, coarse snoring sounds associated with thick, tenacious secretions; sputum production; or obstruction by a foreign body. Crackles are discontinuous popping sounds caused by air moving into previously deflated airways (they sound like air is being rolled between the fingers near the ear). Vesicular sounds are rustling sounds heard over the peripheral lung fields. They are a normal finding.

An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. Ensuring that direct pressure is applied to the external hemorrhage site Ensuring a patent airway and supplying oxygen to the client as prescribed Inserting an intravenous (IV) catheter and administering fluids as prescribed

Rationale: When caring for a client in hypovolemic shock, the nurse must 1st ensure a patent airway & supply O to the client. Direct pressure must be applied to the site of external bleeding. The nurse would also insert an IV catheter if 1 isnt already present & administer fluids as prescribed. The nurse would elevate the client's ft, keeping his or her head flat or elevated to a 30-degree angle. The nurse would take the client's vital signs every 5 mins until they were stable. The nurse would not leave the client alone.

The nurse is explaining the diagnosis of congenital diaphragmatic hernia (CDH) related to a left posterolateral defect (also called Bochdalek hernia) to a postpartum client. What body system does the nurse emphasize is the system most at risk for problems? Respiratory system

Rationale: With a congenital diaphragmatic hernia, abdominal contents herniate through an opening in the diaphragm. If caused by a left posterolateral defect, the respiratory system is most at risk for problems. This serious defect requires prompt recognition (usually in utero) and aggressive treatment to reduce its high mortality. Intestines and other abdominal structures, such as the liver, can enter the thoracic cavity, compressing the lung. Lung hypoplasia may occur on the affected side and to a lesser degree on the contralateral side. Ventilation is further compromised by hypoplasia and compression of the lung, including the airways and blood vessels. In addition to the anatomic defect, pulmonary hypoplasia and pulmonary hypertension have also been recently recognized as components in the pathology of CDH.

Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing primary health care provider before administering the medication? The client takes a prescribed antihypertensive.

Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin doesnt affect the administration of this medication.

A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the primary health care provider? Reddish lochia on postpartum day 8

Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the primary health care provider. Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14.

The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client? Relief of pain Relief of anxiety Decreased urine output Increased blood pressure

Relief of anxiety Rationale: Morphine sulfate reduces anxiety in the client in pulmonary edema. It blunts the sympathetic response and increases venous capacitance, thereby decreasing left atrial pressure. It also promotes peripheral vasodilation and causes blood to pool in the periphery. The client receiving morphine sulfate is monitored for signs/symptoms of respiratory depression and extreme decreases in blood pressure, especially when the medication is administered intravenously. Although morphine sulfate is an opioid analgesic and relieves pain, it is not administered to the client with pulmonary edema for its analgesic effect. Furosemide is administered to the client with pulmonary edema to increase urine output.

A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client? Epistaxis

Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism(ie, conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hrs of an AmI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea arent adverse effects of this therapy.

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? Multiple sexual partners

Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 yrs. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer.

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "Wearing the brace is really important in curing the scoliosis."

Scoliosis is a lateral curvature of the spine. Theres a need for further info when the mother says,"Wearing the brace is really important in curing the scoliosis."Bracing isnt curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hrs a dy, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown.

A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the primary health care provider who is scheduled to perform the ECT?Recent stroke

Several conditions pose risks in the client scheduled for ECT. Among them are recent myocardial infarction or stroke and cerebrovascular malformations or intracranial lesions. Hypothyroidism, glaucoma, and peripheral vascular disease are not contraindications to this treatment.

A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of signs/symptoms of hypoglycemia. Which answers by the client, on being asked to list the signs/symptoms, tells the nurse that the client understands the information?Hunger Weakness Blurred vision

Signs/symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations. The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia.

A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" How does the nurse interpret the client's initial reaction? Fear

The nurse interprets the client's initial reaction as fear. Fear is a response to a threat that is consciously recognized as a danger. In this situation, the client's reaction is one of fear, and the client verbalizes the object of fear (dying). There is no evidence of denial, acceptance, or anger in the client's statement.

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? "Have you ever worked in a mine?"

Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis.

A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.Spinach Legumes Whole grains

Some foods high in folic acid are glandular meats, yeast, dark-green leafy vegetables, legumes, and whole grains. Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acid-rich foods per day. Bananas provide potassium. Potatoes provide vitamin B6, and milk products are a source of calcium.

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. Fever Vasculitis Abdominal pain

Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern(hence the nickname"butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon(discoloration of fingers and/or toes after exposure to changes in temp, pleural effusions, joint inflammation, and myositis.

A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take? Stay with the client and observe her behavior Take the client to the bathroom and provide her with a warm bath Tell the client that it is time for sleep and that she needs to go to her room Tell the client that other clients are trying to sleep and that she is being disruptive

Take the client to the bathroom and provide her with a warm bath Rationale: At bedtime, the nurse should take the client to the bathroom and provide warm baths, soothing music, and medication when indicated. For the client with mania, the nurse needs to promote relaxation, rest, and sleep and to minimize manic behavior. The nurse should encourage frequent rest periods during the day and keep the client in areas of low stimulation. The client should not consume products containing caffeine. Staying with the client and observing her behavior, telling the client that it is time to go to sleep and to go to her room, and telling the client that other clients are trying to sleep and that she is being disruptive do not address the client's needs and are not measures that will help the client relax and sleep.

A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs his/her hands if forced to touch any object. While planning care, what does the nurse remember about compulsive behavior? Temporarily eases anxiety in the client Is an attempt on the client's part to punish self Is an attempt on the client's part to seek the attention of others Is a response by the client to voices saying that everything is contaminated and that he/she must engage in this behavior

Temporarily eases anxiety in the client Rationale: Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. The other options identify interpretations of the client's obsessive behavior.

A nurse is providing home care instructions to a client diagnosed with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. What does the nurse tell the client? To stop the aspirin if nausea occurs To take the aspirin on an empty stomach That ringing in the ears is a sign of toxicity That the aspirin is a short-term treatment and will probably be discontinued in 2 weeks

That ringing in the ears is a sign of toxicity Rationale: Ringing in the ears (tinnitus) is a sign of toxicity; if it occurs, the client should contact the primary health care provider. Aspirin, an antiplatelet agent, helps prevent blood clotting. A single low daily dose of aspirin may be a long-term component of the standard treatment regimen for the client with CAD. Gastric irritation may occur with the use of aspirin, and the client is advised to take the daily dose with food to prevent this. The client would not stop the medication if nausea occurs but would instead take the medication with food to relieve this discomfort.

Disulfiram is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication. What does the nurse tell the client? That driving is prohibited while the client is taking the medication To take the medication immediately if the desire to drink alcohol occurs That the effect of the medication ends as soon as the client stops taking the medication That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol Rationale: Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes.

A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse? Place small pieces of tape over the rough edges of the cast

The appropriate action by the nurse is to petal(place small pieces of tape over)the rough edges of the cast to minimize the irritation. Bivalving is performed if the limb swells and the cast becomes too tight. Using a nail file to smooth the rough edges could cause pieces of the cast to fall into the cast, possibly resulting in the disruption of skin integrity. Its not necessary to contact the primary health care provider, and there is no reason to reapply the cast.

A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse knows that what elements are related to the basic crutch stance? Select all that apply.Improves client's balance Hips and knees are extended Tripod position assumed before crutch walking Body alignment includes erect head and neck and straight vertebrae

The basic crutch stance is the tripod position, which the client assumes before crutch walking. It is formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. This position improves the client's balance by providing a wider, not narrower, base of support. The body alignment of the client in the tripod position includes an erect head and neck, straight vertebrae, and extended hips and knees. The axillae should not bear any weight.

A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. What does the nurse ensure? 30-degree flexion of the client's elbow is maintained when the client is holding the cane

The cane, which is placed on the unaffected side, should produce no more than 30 degrees of flexion of the elbow. A cane may be used if a client needs minimal support for an affected leg. A straight cane offers the least support. A hemi-cane or quad-cane provides a broader base for the cane & therefore more support. The top of the cane should be lvl w/ the greater trochanter of the femur

The mother of an adolescent diagnosed with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. What does the nurse tell the mother after providing information to the mother about diet, exercise, insulin, and blood glucose control? That the child should eat a carbohydrate snack about a half-hour before each soccer game

The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the primary health care provider. There is no reason for the child to avoid participating in sports.

Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the primary health care provider immediately if he/she experiences what sign/symptom? Neck stiffness or soreness

The client is taught to immediately contact the primary health care provider if the client experiences any occipital headache radiating frontally and neck stiffness or soreness, which could be the first sign of a hypertensive crisis. Phenelzine sulfate, a monoamine oxidase inhibitor(MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. Dry mouth and restlessness are common side effects of the medication.

A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Tongue protrusion

The clinical manifestations include abnormal movs(dyskinesia) and involuntary movs of the mouth, tongue ("flycatcher tongue"), and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia.

The nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, what should the nurse do? Document the findings

The scale for rating deep tendon reflexes is as follows: 0= absent; 1+=present, hypoactive; 2+=normal; 3+=hyperactive; 4+= hyperactive with clonus. Deep tendon reflexes should be 1+ or 2+. Reflexes that are brisker than average and hyperactive reflexes(3+ 4+)suggest preeclampsia and must be reported to the primary health care provider. Its not necessary to contact the primary health care provider, because the finding is normal. Likewise, rechecking the client's reflexes after ambulation and performing active and passive RoM exercises incorrect and unnecessary actions.

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Positive result on d-dimer study

The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DiC. DiC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Lab studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and lvls of fibrin degradation products(the most sensitive measurement) are increased.

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not perfusing. What is the nurse's most appropriate action? Ask the ED primary health care provider to check the client

The most appropriate action by the nurse would be to ask the ED health care provider to check the client. PvCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished w/the PvCs themselves b/c the decreased stroke vol of the premature beats may in turn decrease peripheral perfusion. B/c other rhythms also cause widened QrS complexes, its essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PvCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore, the nurse wouldnt tell the client that the PvCs are expected. Although the nurse will continue to monitor the client & document the findings, these arent the most appropriate actions of those provided.

A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the most appropriate response by the nurse? "Let's talk about the information that you need to determine your risk of contracting HIV."

The most appropriate response by the nurse is the 1 that encourages the client to talk about her condition. HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the info needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency dep or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern.

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? Count wet diapers to be sure that the infant is having at least six to 10 each day

The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life)and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this wouldnt provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother isnt usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz)each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle-feeding technique.

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. What does the nurse determine is the priority in the 24 hours after surgery? Encouraging the client to deep-breathe, cough, and use an incentive spirometer

The nurse determines that the priority in the 24 hrs after surgery is to encourage the client to deep-breathe, cough, and use an incentive spirometer. Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs/symptoms of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer.

A nurse on the evening shift checks a primary health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the primary health care provider's answering service and is told that the primary health care provider is off for the night and will be available in the morning. What should the nurse do next? Ask the answering service to contact the on-call primary health care provider

The nurse has a duty to protect the client from harm. A nurse who believes that a primary health care provider's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor.

The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take? Notify the primary health care provider immediately of the amount of drainage.

The nurse must immediately notify the primary health care provider of this excessive amount of drainage. The primary health care provider must also be immediately notified of any saturated head dressings. The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the suction from the J-P drain isnt an option and isnt done. Also, just documenting the amount in the client's record isnt correct even though the nurse would document that the primary health care provider was notified of the total drain amount. Just continuing to monitor the amount of drainage is also not an option.

A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which action should the nurse take next? Notifying the primary health care provider

The nurse realigns the client and, if this is ineffective in relieving the pain, should next notify the primary health care provider. A client in traction who complains of severe pain may require realignment or may have traction weights that are too heavy. Severe leg pain, once traction has been established, indicates a problem. Provision of pin care isnt related to the problem as described. The client should be medicated after an attempt has been made to determine and treat the cause; the cause of the severe pain should be investigated first. The nurse should never remove the weights from the traction without a specific prescription to do so.

A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation? Document the finding

The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal mov. This nurse should document the finding. Accelerations are thought to be a sign of fetal well-being and adequate o reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions.

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. What action should the nurse take? Administer the antihypertensive with a small sip of water

The nurse should administer the antihypertensive with a small sip of water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed.

A nurse has assisted a primary health care provider in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter what does the nurse immediately do? Call the radiography department to obtain a chest x-ray

The nurse should immediately make arrangements to have a chest x-ray done. One major complication associated w/central venous catheter placement is pneumothorax, which may result from accidental puncture of the lung. After the catheter has been placed but before its used for infusions, its placement must be checked w/an x-ray. Hanging the prescribed bag of PN & starting the infusion @the prescribed rate & infusing normal saline solution through the catheter @a rate of 100 mL/hr to maintain patency are all incorrect b/c they could result in the infusion of solution into a lung if a pneumothorax is present. Although the nurse may obtain a blood glucose measurement to serve as a baseline, this action is not the priority.

A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity. What does the nurse immediately do? Stop the oxytocin infusion

The nurse would immediately stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer o with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would also notify the primary health care provider. Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. Its used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion arent the immediate actions.

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, what should the nurse do? Recheck the temperature in 4 hours

The nurse would recheck the temp in 4 hrs. A temp of 100.4° F (38°C)is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temp persists for more than 24 hours or exceeds 100.4° F(38°C), infection is a possibility, and the fever is reported. Theres no reason to restrict place the client to strict bedrest or to notify the primary health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature.

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? Uteroplacental insufficiency during a contraction

The observation that the nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference btw successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which action should be the nurse's priority? Contact the primary health care provider

The priority action is for the nurse to contact the primary health care provider. FhR is assessed for at least 1 min when the membranes rupture. The nurse also checks the quantity, color, & odor of the amniotic fluid. The fluid should be clear(often w/ bits of vernix)& have a mild odor. Fluid w/a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis & warrants notifying the primary health care provider. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein isnt associated w/the data in the question. The nurse would continue to monitor the client & the FHR and would document the findings.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short

The room is kept slightly darkened, and bright lighting is avoided. The client is placed in a quiet private room without a telephone. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and sig others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. A cerebral aneurysm is a thin-walled outpouching or dilation of an artery of the brain. When an aneurysm ruptures, bleeding into the subarachnoid space usually ensues. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. Stool softeners are administered to help keep the client from straining during defecation. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intraabdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. Some primary health care providers permit bathroom privileges for selected clients. If the client is allowed out of bed, the nurse stresses the importance of not bending over.

A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, what does the nurse tell the client this technique involves? Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening

The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive-compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, its not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding.

A client who recently underwent coronary artery bypass graft surgery comes to the primary health care provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? "Tell me more about what you're feeling."

The therapeutic response by the nurse is, "Tell me more about what you're feeling." When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? "The placenta maintains the body temperature of my baby."

Theres a need for further discussion if the woman states that the placenta maintains the body temp of the baby. Many of the immunoglobulin G(IgG)class of antibodies are passed from mother to fetus through the placenta. Glucose, fatty acids, vitamins, and electrolytes pass readily across the placenta; glucose is the major source of energy for fetal growth and metabolic activities. The placenta provides an exchange of nutrients and waste products between the mother and fetus. O and c dioxide pass through the placental membrane by way of simple diffusion. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus.

A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. What initial action should the nurse take? Help the woman empty her bladder

This initial action by the nurse is to help the woman empty her bladder. In the postpartum period, the fundus should be firmly contracted and at or near the lvl of the umbilicus. If the uterus is found to be higher than the expected lvl or shifted from the midline position(usually to the right), the bladder may be distended. The location of the fundus should be rechecked after the woman has emptied her bladder. If the fundus is difficult to locate or is boggy(soft), the nurse stimulates the uterine muscle to contract by gently massaging the uterus. Encouraging the woman to walk is inappropriate at this time. The nurse would document fundal position, consistency, and height and any other interventions taken(eg, uterine massage) after the woman has emptied her bladder.

A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. What does the nurse tell the client to do? Always perform the exercises while lying down Expect an improvement in the control of urine in about 1 week Tighten the pelvic muscles for as long as 5 minutes, three or four times a day Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10

Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 Rationale: Kegel exercises strengthen the muscles of the pelvic floor. To perform the exercises, the client is taught to tighten the pelvic muscles to a slow count of 10, then relax to a slow count of 10. The client is also instructed to do this exercise 15 times while lying down, sitting up, and standing (a total of 45 repetitions). The client is told that an improvement in the control of urine will be noticed after several weeks of the exercises; some individuals report that improvement takes as long as 3 months.

A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. Beer Yogurt Pickled herring

Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI)used to treat depression. The client must follow a tyramine-restricted diet while taking the medication to help prevent hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided include meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausages(eg, salami, pepperoni, bologna). In addition, figs, bananas, aged cheeses, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented, or smoked foods must be avoided. Many over-the-counter medications contain tyramine and must be avoided as well.

A nurse provides home care instructions to a client with mild preeclampsia. What does the nurse tell the client? Urine output must be measured and the primary health care provider should be notified if output is less than 500 mL in a 24-hour period

Urine output of less than 500 mL/24 hr should prompt the client to notify the primary health care provider. Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg, proteinuria is no more than 500 mg/day (trace to 1+), and signs/symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium shouldnt be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours).

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs/symptoms of hypovolemic shock does the nurse closely monitor the client? Select all that apply. Tachycardia Diminished peripheral pulses

When hypovolemic shock develops, the body attempts to compensate for decreased blood vol and to maintain oxygenation of essential organs by increasing the rate and effort of the heart and lungs by shunting blood from less essential organs, such as the skin and extremities, to more essential ones, such as the brain and kidneys. This compensatory mechanism results in the early signs/symptoms of hypovolemic shock, which include tachycardia, diminished peripheral pulses, normal or slightly decreased blood pressure, increased respiratory rate, and cool, pale skin and mucous membranes. The compensatory mechanism fails if hypovolemic shock progresses and theres insufficient blood to perfuse the brain, heart, and kidneys. Later signs/symptoms of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr.