Level of Cognitive Ability
3.4-5
Normal Albumin Level
Providing a quiet atmosphere with dimmed lights (Decrease stimuli to control ICP)
The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention?
Tachycardia
The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?
-Chamomile -Peppermint oil
The nurse determines that which herbal therapies can be prescribed for its use as an antispasmodic?
Low and Intermittent
The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings will the health care provider prescribe?
Neurologic Conditions
The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?
Acetazolamide (Diamox)
Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase
Bleeding
After a renal biopsy, the client complains of pain at the biopsy site, which radiates to the front of the abdomen. Which would this indicate?
Elevated BUN and/or Creatinine Levels
After kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?
-The development of audible expiratory wheezes (Beta Blockers may induce bronchospasms, particularly in clients with chronic obstructive pulmonary disease or asthma)
The nurse is monitoring a client who is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol?
Confusion
The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of the infection. Which sign/symptom should occur first?
Gastrointestinal dysfunctions
The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). Which information should be important for the nurse to gather regarding the adverse effects related to the medication?
Hypokalemia, hyperglycemia, sulfa allergy
The nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. Which are concerns related to the administration of this medication?
-Client with a fast respiratory rate (Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.)
The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?
To inhibit thrombus formation
The nurse is reviewing the health care provider's (HCP) prescriptions for a client scheduled for a cardiac catheterization and notes that the HCP has prescribed tirofiban (Aggrastat). The nurse understands that this medication has been prescribed for which purpose?
Liver function tests
The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which laboratory test(s) would identify an adverse effect associated with the administration of this medication?
Rigid extension and pronation of the arms and legs
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?
-Seizure disorders (Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered.)
The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the health care provider?
-Tonometry -Visual field check
The nurse is reviewing the results of an eye examination on a client. Which tests can detect glaucoma?
Graves' disease
The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which disorder?
-"I need to obtain a yearly influenza vaccine." (Cyclosporine is an immunosuppressant medication. Because of the medication's effects, the client should not receive any vaccinations without first consulting the HCP.)
The nurse reinforces medication instructions to a client who had a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client indicates a need for further teaching?
-Sulfisoxazole
The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?
Thiazide Diuretics
Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.
-Alcohol Use -Smoking -Wt. Loss
What are some risk factors for a gastric ulcer?
An antiparkinsonian agent used in conjunction with levodopa to improve the quality of life in clients with Parkinson's disease
What is Entacapone (Comtan) for?
Hypoglycemia
What is a severe side effect of pentamidine isethionate (Pentam) that may be fatal?
-Use nonlatex gloves. -Use medications from glass ampules. -Do not puncture rubber stoppers with needles. -Keep a latex-safe supply cart available in the client's area.
Which interventions would apply in the care of a client at high risk for an allergic response to a latex allergy?
Cloudy cerebrospinal fluid with high protein and low glucose levels
Which laboratory result would verify the diagnosis of bacterial meningitis?
A restful environment
Which measure should the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease?
A β2 agonist
A child is brought to the emergency department for treatment of an acute asthma attack. The nurse prepares to administer which medication first?
Dimercaprol (BAL in oil) (Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine.)
A child is hospitalized with a diagnosis of lead poisoning. The nurse caring for the child should prepare to assist in administering which medication?
Reticulocyte count
A child suspected of having sickle cell disease (SCD) is seen in a clinic, and laboratory studies are performed. Which laboratory value is likely to be increased in sickle cell disease?
Hearing acuity (This medication can cause ototoxicity and nephrotoxicity; therefore, hearing acuity tests and kidney function studies should be performed before the initiation of therapy.)
A client has been prescribed amikacin (Amikin). Which priority baseline function should be monitored?
CBC
A client is receiving anticonvulsant therapy with phenytoin (Dilantin). The nurse plans to monitor the results of which laboratory test closely?
Slurred speech
A client is receiving baclofen (Lioresal) for muscle spasms caused by a spinal cord injury. The nurse monitors the client, knowing that which is a side effect of this medication?
Bloody
A client is returned to the nursing unit following thoracic surgery with chest tubes in place. During the first few hours postoperatively, the nurse assisting in caring for the client checks for drainage. Which type of drainage is expected?
An increase in muscle strength
A client is suspected of having myasthenia gravis, and the health care provider administers edrophonium (Enlon) to determine the diagnosis. After administration of this medication, which sign/symptom would indicate the presence of myasthenia gravis?
-Hypoxia (After a burn injury, clients are normally alert. If a client becomes confused or combative, hypoxia may be the cause. Hypoxia occurs after inhalation injury and may occur after an electrical injury.)
A client who sustained an inhalation injury arrives in the emergency department. On data collection, the nurse notes that the client is very confused and combative. The nurse determines that the client is experiencing which?
Muscle spasm in the area of the herniated disk
A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which?
Nasal Obstruction
A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?
-Rash -Stevens-Johnson syndrome -Hepatitis -Increased transaminase levels -Hepatotoxicity
A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which side/adverse effects of the medication?
Cool, numb fingers and toes
A client with vascular headaches is taking ergotamine (Ergomar). Which client complaint should the nurse monitor?
Elevated vanillylmandelic acid (VMA) levels in the urine
A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor would the nurse expect to find documented in the child's record?
Baclofen (Lioresal)
A health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route?
p24 antigen assay
A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?
Bounding radial pulses and absent or weak femoral and pedal pulses
A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant?
Laser therapy
A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?
Opisthotonos
A prolonged arching of the back with the head and heels bent backward that indicates meningeal irritation.
The child's cervical spine
A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?
4 yoa
An induration that measures 10 mm or more is considered to be a positive result for children who are younger than _______.
Decreased lean body mass and glomerular filtration rate
An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?
Thromboembolism
Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast cancer. The nurse assists in developing a plan of care for the client and suggests monitoring the client closely for which adverse effect of this medication?
Placental Abruption
Maternal hypertension put the pregnant pet at risk for what?
..................
Baclofen is a central nervous system (CNS) depressant and frequently causes drowsiness, dizziness, weakness, and fatigue. It can also cause nausea, constipation, and urinary retention.
Urinary retention
Meperidine hydrochloride (Demerol) is prescribed for the client with pain. Which should the nurse monitor as a side effect of this medication?
Peripheral vascular disease
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should question administration of the medication if which condition is documented in the client's medical history?
BP
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item?
Liver disease
Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history knowing that this medication is contraindicated if which disorder is present?
............
Children with Down syndrome frequently have instability of the space between the first two cervical vertebrae. They require diagnostic studies (an x-ray of the cervical spine) to determine if this is present before participating in activities that put pressure on the head and neck, which could cause spinal cord compression.
Renal failure
Colcrys (colchicine) is prescribed for a client with a diagnosis of gout. The nurse reviews the client's medical history in the health record, knowing that the medication would be contraindicated in which disorder?
............
Crystals form in mannitol if the solution is cooled, but quickly dissolve if the container is placed in warm water, then cooled to body temperature before administration.
Those with a peanut allergy bc it contains peanut oil
Dimercaprol should be avoided in what type of patients?
-When the last alcoholic drink was consumed (Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered.)
Disulfiram (Antabuse) is prescribed for a client seen in the psychiatric health care clinic. The nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?
Brown pigmentation of the iris
Latanoprost (Xalatan) drops are prescribed for the client with glaucoma. The client returns to the health care clinic for evaluation. Which finding noted in the client indicates a side effect associated with the use of these eye drops?
Autism
Risk for injury related to an inability to anticipate danger, a tendency for self-mutilation, and sensory perceptual deficits are the priority concerns. Inability to interact socially, troubling thought processes, and inability to verbally communicate are also appropriate problems for the child with autism, but the priority is the risk for injury.
-Chest Pain -Coughing -Hypotension -Cyanosis -Hypoxia -"Windmill" sound over the right ventricle
S/S of an Air Embolism
-Tachycardia -Drowsiness -Blurred Vision -Dry Mouth -Constipation -Urinary Retention
Side effects of Atropine Sulfate (anticholinergic)
Baclofen
Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence.
-Positive Kernig's sign -Tachycardia -A red macular type rash -Photophobia
Signs of Meningitis
-Decongestants (Episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants)
The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?
-Gait
The client who is human immunodeficiency virus seropositive has been taking stavudine (d4t, Zerit). Which should the nurse monitor closely while the client is taking this medication?
A temporary worsening of the condition
The client with myasthenia gravis becomes increasingly weak. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Enlon) is administered. Which indicates that the client is in cholinergic crisis?
Hemoptysis
The coughing up of blood
SOB
The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax?
10-80 mcg/dL
The normal serum ammonia level
-Skin disruption (In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is skin disruption related to the exposed bladder mucosa.)
The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant?
-Administration of a subcutaneous rubella virus vaccine (A postpartum woman with a titer of 1:8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II).)
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which should the nurse anticipate to be prescribed by the health care provider?
Numbness in the legs
The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client?
Furosemide (Lasix)
The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?
Allogenic liver transplant
The nurse is admitting a client to the nursing unit who is scheduled for several diagnostic tests. When obtaining a medication history, the nurse discovers that the client is taking tacrolimus (Prograf) daily. On further data collection, which should the nurse expect to note in the client history?
Red-Brown Urine
The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which finding is associated with the diagnosis of glomerulonephritis?
Complaints of a burst of black spots or floaters
The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?
-Serum creatinine (Foscarnet is toxic to the kidneys)
The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet. The nurse should check the latest result of which laboratory study while the client is taking this medication?
Intratracheal
The nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route?
Tachycardia
The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?
Edema of the face and eyes
The nurse is assisting in caring for a client with an inoperable lung tumor and helps develop a plan of care by addressing complications related to the disorder. The nurse includes monitoring for the early signs of vena cava syndrome in the plan. Which early sign of this oncological emergency should the nurse include monitoring for in the plan of care?
Leakage of clear fluid from the nose (Could be CSF)
The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?
-Wearing gloves when emptying the client's bedpan -Keeping all linens in the room until the implant is removed -Wearing a film (dosimeter) badge when in the client's room -Wearing a lead apron when providing direct care to the client
The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care?
Cranial nerve VII, facial nerve
The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. The nurse understands that assessment of which cranial nerve should identify a complication specifically associated with this surgery?
Hyperinflated lungs on chest x-ray
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect the client to experience?
Respiratory Acidosis
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?
Metabolic Alkalosis
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
-Increasing Temp. and BP -Decreasing Pulse and Respirations
The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?
Metabolic Acidosis
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
Maintain moisture of the normal saline dressing on the gibbus area.
The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?
BP
The nurse is caring for a postrenal transplant client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. Which is the vital sign that is most likely increased?
-Notify RN -Prepare to administer morphine sulfate. -Prepare to administer intravenous fluids. -Prepare to administer 100% oxygen by face mask.
The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Which interventions should the nurse perform?
-Bed Rest -Elevation of Scrotum -Ice Packs -Sitz Bath -Analgesics -ABX
The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented?
Decreased force in the stream of urine
The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine if the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom?
-Serous drainage (A small amount of serous drainage is expected at pin insertion sites)
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?
