Nclex prep

Potassium levels

3.5-5

A licensed practical nurse reinforces information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which findings does the nurse tell the client to report to the health care provide

A licensed practical nurse reinforces information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which findings does the nurse tell the client to report to the health care provide

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An assistive personnel who has never had chickenpox Rationale:Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox

Ferrous sulfate is prescribed for a client. The nurse tells the client that it is best to take the medication with what item?

Rationale: Ferrous sulfate is an iron product. Absorption of iron is promoted when the supplement is taken with orange juice or 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 does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid.

Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.

Rationale: 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. The client is placed in a quiet private room without a telephone. The room is kept slightly darkened, and bright lighting is avoided. Stool softeners are administered to help keep the client from straining during defecation. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. 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 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

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?

Rationale: A client with carbon monoxide poisoning is treated with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this is not 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 level in the client's blood. Obtaining a blood specimen in which measure the carboxyhemoglobin level is a priority; however, the nurse would immediately administer 100% oxygen to the client.

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed in which manner?

Rationale: A lower abdominal incision is used in suprapubic or retropubic prostatectomy. An upper abdominal incision is not used to remove the prostate. An incision between the scrotum and anus is made when a perineal prostatectomy is performed. Transurethral resection is performed through the urethra; an instrument called a resectoscope is used to cut the tissue by means of a high-frequency current.Test-Taking Strategy: To answer this question accurately, you must be familiar with this surgery and how it is performed. Focusing on the data in the question and noting the word "suprapubic" will direct you to the correct option. Review the procedure for performing a suprapubic prostatectomy if you had difficulty with this question.

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.

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, the nurse would take which action?

Rationale: A temperature 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 temperature persists for more than 24 hours or exceeds 100.4°F (38°C), infection is a possibility, and the fever is reported. The nurse would recheck the temperature in 4 hours. There is no reason to restrict place the client to strict bedrest or to notify the health care provider. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature.

A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nägele's rule, the nurse determines that the estimated date of delivery (EDD) is which date?

Rationale: Accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. To calculate the EDD with the use of this rule, the nurse would subtract 3 months from the date of the first day of her LMP, add 7 days, and then adjust the year. First day of the LMP, September 25, 2012; subtract 3 months, June 25, 2012; add 7 days, July 2, 2012; add 1 year, July 2, 2013.

A licensed practical nurse is reinforcing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, indicating an adverse effect, does the nurse instruct the client to report to the health care provider?

Rationale: 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. The nurse tells the client that sexual intercourse may be resumed at what point?

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

The practical nurse reinforces 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?

Rationale: 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 weeks; the nurse should discuss the possible need for lubrication and position changes during coitus. Genital numbness may be present, but it is not necessary to notify the surgeon immediately if numbness occurs.

A nurse is collecting data from a client who has been taking amantadine hydrochloride for the treatment of Parkinson disease. Which finding would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?

Rationale: 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. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine which factor?

Rationale: 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 is scheduled to undergo an upper gastrointestinal (GI) series, and the licensed practical nurse reinforces instructions to the client about the test. Which statement by the client indicates a need for further instruction?

Rationale: 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. 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. 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.

A client with heart failure is taking furosemide and digoxin. The nurse is preparing to administer the medication and notes that the client complains of anorexia and nausea as the dietary aide brings the breakfast tray into the room. The nurse takes which action first?

Rationale: Anorexia and nausea are two of the common symptoms associated with digoxin toxicity. Digoxin toxicity is compounded by hypokalemia, which can occur with the use of furosemide. The nurse should withhold the dose and report the client's complaints to the registered nurse, who then should check the client's most recent potassium and digoxin levels. Dispensing an additional source of potassium, such as a banana, is helpful as a follow-up action if the client has hypokalemia. The nurse should not place the client on NPO status.

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?

Rationale: 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, the fetal heart rate is 140 beats/min with a reassuring pattern, and both the client and her husband are anxious 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?

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

A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?

Rationale: 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

.ID: 18630139588 A client with a diagnosis of anxiety disorder walks into the mental health clinic saying, "I just can't take the pressure at home, and I came here to get away from it for a bit." Which is a therapeutic nursing response?

Rationale: Asking the client to explain what is making the client feel pressured at home seeks to obtain further specific information from the client about stressors that led to the client's unscheduled visit. Obtaining information is an important aspect of data collection. The other options offer approval or praise, which may hinder therapeutic communication because the client may then seek to gain the nurse's approval.

client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should reinforce which client instruction?

Rationale: 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. There is no need for the client to call the health care provider.

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?

Rationale: 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 of returning peristalsis, 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 practical nurse is reviewing the 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?

Rationale: 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.

Amantadine has been prescribed to a client with Huntington disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

Rationale: Confusion is a common side effect of amantadine. Headache and photophobia are not associated with use of this medication. Urinary retention and difficulty urinating are common, rather than urinary frequency.

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?

Rationale: 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. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.

A nurse helps provide an educational session to community members about cancer of the cervix. The nurse informs the group members that which is an early sign of this type of cancer?

Rationale: Early cancer of the cervix is usually asymptomatic. The two chief symptoms are leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. The vaginal discharge increases gradually in amount and becomes watery and finally dark and foul smelling because of necrosis and infection of the tumor mass. As the disease progresses, the bleeding may become constant and increase in amount.

A nurse is monitoring 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, the nurse makes which determination?

Rationale: Edema in the lower extremities reflects pooling of blood, which results in a shift of intravascular fluid into the interstitial spaces. Dehydration is not 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. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the health care provider with the procedure, expect to note?

Rationale: 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.

Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication

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 licensed practice nurse reinforces instruction to a pregnant woman about foods containing folic acid. Which foods does the licensed practice nurse tell the client to consume as sources of folic acid? Select all that apply.

Rationale: 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. Some foods high in folic acid are glandular meats, yeast, dark-green leafy vegetables, legumes, and whole grains. Bananas provide potassium. Potatoes provide vitamin B6, and milk products are a source of calcium.

NPO (nothing by mouth) 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. The nurse should take which action?

Rationale: 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 licensed practice nurse is reinforcing information to a client with acute gout about home care. Which measures does the licensed practice nurse tell the client to take? Select all that apply.

Rationale: 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 (e.g., 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 survivor of sexual assault being treated in the emergency department says to the nurse, "I'm really worried that I've got human immunodeficiency virus (HIV) now." What is the appropriate response by the nurse?

Rationale: HIV is a concern of survivors of sexual assault. Such concern should always be addressed, and the survivor should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of sexual assault, and pregnancy prophylaxis can be offered in the emergency department 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 survivors of sexual assault" and "Every survivor of sexual assault is concerned about HIV" are generalized responses that avoid the client's concern.

A client is taking prescribed ibuprofen, 300 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. The nurse should provide the client with which information?

Rationale: Ibuprofen is a nonsteroidal antiinflammatory 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 would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the 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 licensed practical nurse following a nursing care plan developed by the registered nurse for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the health care provider, which does the nurse specify as the first action in the event of shock?

Rationale: If the client exhibits signs of hypovolemic shock, the nurse would contact the health care provider. The nurse would monitor fetal status closely and take action to minimize the effects of hypovolemic shock and promote tissue oxygenation. The client would be placed in a lateral position, with the head of the bed flat to increase cardiac return and thus increase circulation and oxygenation of the placenta and other vital organs. After positioning the client, the nurse would insert intravenous lines in accordance with the 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 is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr, but again, this is not 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?

Rationale: If uterine inversion is suspected, the nurse immediately prepares the client for replacement of the uterus through the vagina. If this is not 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 is not 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 is not the action that would be taken immediately.

A 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, the nurse should take which action?

Rationale: 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. After EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. 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 is not 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 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 should be the nurse's initial action?

Rationale: In the postpartum period, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is found to be higher than the expected level 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 (e.g., uterine massage) after the woman has emptied her bladder.

A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The licensed practical nurse reinforces information to the client about dietary and insulin needs and tells the client that during the first trimester, what occurs with insulin needs?

Rationale: 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.

nurse in a health care provider's office is preparing to assist with data collection on a client who is 2 weeks postpartum. The nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to take which action?

Rationale: Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hours after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Asking the 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

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 while assisting with data collection? Select all that apply.

Rationale: Isotonic dehydration decreases circulating blood volume (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, pastelike coating and may exhibit fissures. The client may also experience weight loss, lethargy or headache, sunken eyes, poor skin turgor (e.g., 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 community-acquired pneumonia who is being treated with levofloxacin. For which finding, indicating an adverse reaction to the medication, does the nurse monitor the client?

Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is 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 is taking lithium carbonate complains of mild nausea, voiding in large volumes, and thirst. The nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should take which action

Rationale: Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea, and therefore the nurse would simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the 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 of toxicity and if these occur the health care provider needs to be notified.

A 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.

Rationale: 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 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 level 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 of toxicity; if any of these problems occur, the health care provider must be notified.

77.ID: 18630138279 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?

Rationale: 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

A practical nurse is caring for a client with preeclampsia receiving magnesium sulphate via intravenous infusion. Which substance does the nurse ensure is available at the client's bedside?

Rationale: 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. 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 level becomes too high. Vitamin K is the antidote for warfarin sodium. Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency.

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?

Rationale: 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. Oxygen and carbon 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 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. Correct Use sunscreen with a low sun protection factor (SPF). Incorrect Avoid sun exposure before 10 a.m. and after 4 p.m. Wear a hat, opaque clothing, and sunglasses when out in the sun. Correct Examine the body every 6 months for possibly cancerous or precancerous lesions. Incorrect

Rationale: Measures to prevent skin cancer include avoiding sun exposure between 10 a.m. and 4 p.m.; using sunscreen with a high SPF; wearing a hat, opaque clothing, and sunglasses when out in the sun; and examining the body every month for possibly cancerous or precancerous lesions. The client should also seek medical advice if any changes in a skin lesion are noted.

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?

Rationale: 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 symptoms of pregnancy (e.g., 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 major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation.

A client with advanced chronic renal failure (CRF) 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 it is acceptable to use which item?

Rationale: Most clients with renal failure retain sodium. The client with renal failure 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 CRF 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.

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

Rationale: Necrosis of the tracheal wall caused by the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as 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 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 is not a measure for the prevention of tracheoesopha

A nurse, assisting with data collection for a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking fluoxetine. On the basis of this information, the nurse determines that the client most likely has a history of which disorder?

Rationale: Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hyperthyroidism, and coronary artery disease are not treated with this medication.

A client with myasthenia gravis is taking neostigmine bromide. The nurse determines that the client is gaining a therapeutic effect from the medication after noting which effect?

Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myasthenia 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 of an adverse reaction to the medication.

A licensed practice nurse (LPN) is reinforcing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The LPN tells the client that which one food item is high in calcium?

Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Corn, cocoa, and peaches do not contain appreciable amounts of calcium.

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.

Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Risk factors include being 65 years or older in women, 75 years or older in men, family 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 client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately takes which action?

Rationale: Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is 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. 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 stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. The nurse would also notify the health care provider. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions.

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 resulting in perfusion. Which is the appropriate action by the nurse?

Rationale: PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is 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 would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. The most appropriate action would be to ask the ED health care provider to check the client.Test-Taking Strategy: Use the process of elimination. Recalling the significance of PVCs after acute MI and noting the strategic words "not perfusing" will direct you to the correct option. Review the significance of PVCs after acute MI if you had difficulty with this question.

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 with this client

Rationale: 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, especially 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 uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax.

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 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

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 health care provider immediately if she experiences which adverse effect

Rationale: 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. The client is taught to be alert to any occipital headache radiating frontally and neck stiffness or soreness, which could be the first signs of a hypertensive crisis. Dry mouth and restlessness are common side effects of the medication

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?

Rationale: 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 with chronic renal failure who will require 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?

Rationale: 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 significant 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 there is an alteration in the way the client perceives his or her own body image.

A licensed practice nurse reinforces home care instructions to a client with mild preeclampsia. The licensed practice nurse provides which information to the client?

Rationale: 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 symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium should not 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). Therefore urine output of less than 500 mL/24 hr should prompt the client to notify the health care provider.

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?

Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., 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 hours 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 are not adverse effects of this therapy.

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.

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

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

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

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 health care provider before administering the medication?

Rationale: 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 does not affect the administration of this medication.

A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the licensed practice nurse reinforces information to the mother about the brace. Which statement by the mother indicates a need for further information?

Rationale: Scoliosis is a lateral curvature of the spine. Bracing is not 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 hours a day, 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 diagnoses, if noted on the client's record, would indicate a need to contact the health care provider who is scheduled to perform the ECT?

Rationale: 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.

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

Rationale: Sickle cell disease is a genetic disorder that is 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. Decreased fluid volume 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 symptoms at the time.

A nurse, assisting with data collection for 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?

Rationale: 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 is participating in a care planning conference for a client with Hodgkin disease who is neutropenic as a result of radiation and chemotherapy. Which aspect of the plan is designed to be most effective in decreasing the risk of infection?

Rationale: Specific nursing management of the client who is undergoing treatment for Hodgkin disease focuses on minimizing the risks or side effects of the therapy. Risk for infection is significant and handwashing is the most effective means of decreasing this risk. Limiting visitors to immediate family only may not help because an immediate family member may transmit an infection. Monitoring the WBC count provides information about the client's status but does not decrease the risk of infection. A diet high in protein is unrelated to infection.

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?

Rationale: Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. 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.

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. Which is the appropriate action by the nurse?

Rationale: 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. The nurse monitors the client for adverse effects and notifies the health care provider if the maternal heart rate is faster than 110 beats/min, respiration is faster than 24 breaths/min, systolic blood pressure is less than 90 mm Hg, the fetal heart rate is faster than 160 beats/min, or the client complains of chest pain or dyspnea. Increasing the rate of infusion and continuing to monitor the client and are inappropriate and delay necessary interventions. Although the nurse would document the findings, the most appropriate action in this scenario is to contact the health care provider.

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?

Rationale: The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the 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 is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the health care provider is the priority

The mother of an adolescent with type 1 diabetes mellitus tells the licensed practical nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. After reinforcing teaching regarding diet, exercise, insulin, and blood glucose, provided earlier by the registered nurse, the licensed practical nurse tells the mother which information?

Rationale: 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 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 health care provider. There is no reason for the child to avoid participating in sports.

57.ID: 18630138205 A licensed practical nurse reinforces dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Considering the client's disease process, which menu selections by the client tells the nurse that the client understands the instructions

Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not 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.

A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.

Rationale: The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. Symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations.

60.ID: 18630138949 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 determination of whether the infant is receiving an adequate amount of milk?

Rationale: 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 would not 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 is not 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 reviewing the laboratory results of a 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?

Rationale: The normal white blood cell count ranges from 5000 to 10,000/mm3. A white blood cell count of 2500/mm3 is low and puts the client at risk for infection. All of the other values are within normal limits. The normal sodium level is 135 to 145 mEq/L. The normal hemoglobin level ranges from 12 to 14 g/dL, depending on whether the client is male or female. The normal BUN concentration ranges from 10 to 20 mg/dL.

A nurse on the evening shift checks a health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the health care provider's answering service and is told that the health care provider is off for the night and will be available in the morning. The nurse should take which action?

Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a 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.Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, legal responsibilities of the nurse in regard to medication administration and health care provider's prescriptions. Eliminate the comparable or alike options in that they avoid clarification of the prescription (administering the medication and holding the medication). To select from the remaining options, note that it is premature to call the nursing supervisor. Also note that the correct option is the only one that clarifies the prescription. Review legal responsibilities in regard to medication prescriptions if you had difficulty with this question.

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

Rationale: 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 movement. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions.

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

Rationale: The observation that the has 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 between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly

A 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, the nurse would take which action?

Rationale: 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+ to 4+) suggest preeclampsia and must be reported to the health care provider. It is not necessary to contact the 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 client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves which treatment?

Rationale: 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, it is 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 licensed practice nurse is reinforcing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the licensed practice nurse tell the client to avoid while she is taking this medication? Select all that apply.

Rationale: 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 (e.g., 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 client who recently underwent coronary artery bypass graft surgery comes to the health care provider's office for a follow-up visit. During data collection, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

Rationale: 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

Which laboratory result would verify the diagnosis of bacterial meningitis?

Rationale:A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position would the nurse assist the client into for this procedure?

Rationale:An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Options 1, 3, and 4 are incorrect positions.

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching?

Rationale:Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions would the nurse institute during the care of the client?

Rationale:The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has MRSA. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. MRSA is contagious and is spread to others by direct contact with infected skin or infected articles.

fourth stage of labor. Which lochia characteristic would the nurse expect to note?

Rationale:The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish-brown and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which would the nurse explain to the client about this test?

Rationale:Ultrasound of the gallbladder is a noninvasive procedure and is frequently used for emergency diagnosis of acute cholecystitis. The client may need to lie still during the procedure for short intervals of time while visualization of the gallbladder is done. The client may or may not need to be NPO (per PHCP preference), but may be instructed to avoid carbonated beverages for 48 hours before the test to help decrease intestinal gas. It is a painless test and does not require the administration of oral tablets as preparation.

Lexothyroxine

Synthroid

aminocentesis

a process where a long needle is put into the fluid around a developing baby to see if the baby will have any genetic disorders

Fenestrated tracheostomy tube

allows the patient to speak, breathe, or clear secretions from the upper airway.

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.

ationale: SLE 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, pleural effusions, joint inflammation, and myositis

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

ationale: When hypovolemic shock develops, the body attempts to compensate for decreased blood volume 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 and 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 there is insufficient blood to perfuse the brain, heart, and kidneys. Later signs of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr.

Levothyroxine definition

hypothyroidism

Meningitis

inflammation of the meninges of the brain and spinal cord

colonoscopy position

left side--knees bent

esophagogastroduodenoscopy

visual examination of the esophagus, stomach, and duodenum

Terbutaline Sulfate

✓Trade Name: Brethine ✓Classification: adrenergics ✓Dosage/Route/Frequency: IV 2.5-10 mcg/min infusion; Increase by 5 mcg/min q 10 min. until contractions stop (do not exceed 30 mcg/min) After contractions have stopped for 30 min reduce infusion rate to lowest effective amount and maintain for 4-8 hr. ✓Action: Relaxes muscles in the uterus. Management of pre-term labor. Used to arrest labor. ✓Side Effects: angina or chest pain, irregular heartbeats or a fluttering heart, seizures, tremor, weakness, headache, nausea, and vomiting ✓Nursing Implications:(Considerations) : Monitor maternal pulse and BP, frequency and duration of contractions and FHR. Notify provider if contractions persist or increase in frequency or fetal distress occur. Assess maternal respiratory status for symptoms of pulmonary edema. Monitor mother and neonate for symptoms of hypoglycemia (chills; cold sweats; anxiety; confusion; hunger; difficulty concentrating).