NCLEX PREP_U
Which statement by the mother of a child who is receiving pancreatic enzymes for the treatment of cystic fibrosis indicates that the mother understands the teaching?
"I can sprinkle the enzymes on food." Explanation: One problem associated with cystic fibrosis is poor digestion and absorption of foods, especially fats. Pancreatic enzymes can help improve digestion and absorption of nutrients. Therefore, they are given with meals and can be sprinkled on food.
how to walk with a walker
"Place the walker directly in front of you and step into it as you move it forward." Explanation: When the client places the walker directly in front of them, they create a stable base for forward movement and reduces the likelihood of falls. The client shouldn't set the back leg down first because this creates an unstable base that could lead to a fall. The client should firmly grip the side bars; doing so provides a more stable base of support than gripping the front bar.
A nurse is taking a health history of a 10-year-old child and discovers that the child has difficulties in urinary control during the day. The parents are confused about the condition and ask the nurse for help. What is the most appropriate response by the nurse?
"There may be a significant stressor in your child's life that's causing this." Explanation: Diurnal enuresis is urinary incontinence that occurs during the day. It is most often caused by stress, urinary infections, or a defect of the urinary tract. However, a child with a urinary tract infection often exhibits additional signs and symptoms such as cloudy urine, pain with urination, and frequency. Nocturnal enuresis is urinary incontinence that occurs during the night. Children with primary enuresis never have a period of dryness. Children with secondary enuresis have had a 6- to 12-month period of dryness after a period of wetting.
Normal central venous pressure (CVP) ranges from
3-7 mm Hg
TB transmission education for newly diagnosed patient
A client with drug-resistant tuberculosis is not contagious when the client has had a negative acid-fast test. A client with nonresistant tuberculosis is no longer considered contagious when there is clinical evidence of decreased infection, such as significantly decreased coughing and fewer organisms on sputum smears. The medication may not produce a negative acid-fast test result for several days. The client will not have a clear chest X-ray for several months after starting treatment.
percussion of a distended bladder
A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drum-like sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.
What occurs during the working phase of the nurse-client relationship?
A nurse and a client evaluate and modify the goals of the relationship. Explanation: The therapeutic nurse-client relationship consists of three phases: introduction or orientation, working, and termination. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. During the termination phase, the nurse prepares the client for separation and explores the client's feelings about the end of the relationship.
amniotic fluid embolism
An extremely rare, life-threatening condition that occurs when amniotic fluid and fetal cells enter the pregnant woman's pulmonary and circulatory system s/s-can't breathe! My chest hurts really bad!" The client's skin begins to turn a dusky gray color medical emergency. After calling for assistance, the first action should be to administer oxygen by face mask or cannula to ensure adequate oxygenation of mother and fetus. If the client needs cardiopulmonary resuscitation, this can be started once oxygen has been administered. If the client survives, disseminated intravascular coagulation will probably develop, and the client will need intravenous fibrinogen and heparin.
Tonic neck reflex (fencer position)
BIRTH TO 3 or 4 MONTHS Turn newborn head turned to the right: Right arm/leg EXTEND Left arm/leg flex Turn newborn head to the left: Left arm/leg EXTEND Right arm/leg flex
Current guidelines recommend women at ??? to have a Pap test...
Current guidelines recommend women age 21 to 65 have a Pap test every 3 years with an option for women age 30 to 65 to lengthen their time between Pap tests to every 5 years when combined with the human papillomavirus (HPV) test
TCAs (tricyclic antidepressants)
DONT use with 14 of a MAOI -Anticholinergic effects and orthostatic hypotension may occur. Tell patient to report all adverse reactions. Black Box Warning: Advise family members and caregivers to closely observe patient for increased suicidal thinking and behavior and to report them immediately. Tell patient to report visual problems or eye pain, swelling, or redness. Warn patient to avoid hazardous activities requiring alertness and good coordination, especially during adjustment. Daytime sedation and dizziness may occur. Tell patient to avoid alcohol during drug therapy. Alert: Teach patient to recognize and immediately report symptoms of serotonin toxicity (fever, mental status changes, muscle twitching, excessive sweating, shivering or shaking, diarrhea, loss of coordination). Warn patient not to stop drug suddenly. Advise patient to use sunblock, wear protective clothing, and avoid prolonged exposure to strong sunlight to prevent oversensitivity to the sun.
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action?
Decrease the lidocaine infusion rate. Explanation: Side effects of lidocaine include lightheaded, euphoria, shaking, low blood pressure, drowsiness, confusion, weakness, blurry or double vision, and dizziness. Serious reactions such as seizures, bradycardia, and heart block are possible if lidocaine reaches toxic levels. The nurse should recognize these potential adverse effects and the lidocaine infusion should be decreased while lidocaine blood levels are checked to determine if the cause of the tiredness and blurred vision is a lidocaine toxicity.
detail or detachment
Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit).
Medroxyprogesterone Acetate
Depo-Provera a progestin injection, a follow-up appointment should be made for 3 months later. The nurse should emphasize the need to adhere to the medication schedule to prevent an unplanned pregnancy.
hepatitis A symptoms
Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder.
how to inaciate restraints
Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.
Alfuzosin (Uroxatral)
First-dose phenomenon, which is a severe and sudden drop in blood pressure after the administration of the first dose of an alpha-adrenergic blocker, can cause clients to fall or pass out. All clients must be warned about this adverse effect before they take their first dose of an alpha blocker. Orthostatic hypotension can occur with any dose of an alpha blocker, and clients must be warned to get up slowly from a supine position. The client needs to consult with the healthcare provider if the heart rate falls below 60/bpm.
A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth?
For maximum effectiveness, Rho(D) immune globulin should be administered within 72 hours postpartum. Most Rh-negative clients also receive Rho(D) immune globulin during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after pregnancy is terminated, the mother should receive the medication.
Glargine (Lantus)
Glargine should not be mixed in a syringe with any other insulin, has no peak action (onset is 3-4 hours and lasts 24 hours), given once daily, not continuously since it is LONG acting. Pumps = short/rapid acting.
The client asks the nurse if surgery is needed to correct a hiatal hernia. Which reply by the nurse would be most accurate?
Hiatal hernia symptoms can usually be successfully managed with diet modifications, medications, and lifestyle changes." Explanation: Most clients can be treated successfully with a combination of diet restrictions, medications, weight control, and lifestyle modifications. Surgery to correct a hiatal hernia, which commonly produces complications, is performed only when medical therapy fails to control the symptoms.
Retinopathy of Prematurity (ROP)
High levels of oxygen delivered to a preterm neonate can result in retinopathy of prematurity. The immature blood vessels in the eye constrict, then overgrow, resulting in edema and hemorrhage that produce scarring, retinal detachment, and eventual blindness.
intussusception
Intussusception occurs when a portion of the bowel slides into the next, like the pieces of a telescope. When this occurs it can create a blockage in the bowel, with the walls of the intestines pressing against one another. This leads to abdominal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Additional symptoms include vomiting, passing of stools mixed with blood and mucus, and grunting due to pain.
The toddler with nephrotic syndrome responds to treatment and is ready to go home. When helping the family plan for home care, the nurse should include which instruction in the teaching?
Keep the child away from others with an infection. Explanation: A child recovering from nephrotic syndrome should be protected from infection. Therefore, the nurse would teach the parents to keep the child away from others with an infection. Because pain is not associated with this disorder, pain medication typically is not needed. The HCP should be notified if urine output decreases, not increases.
magnesium sulfate in pregnancy
Magnesium sulfate is given to prevent and control seizures in clients with gestational hypertension. It is administered by IV; 4 g of a 50% solution in 250 mL D5W can be given as a bolus before the dose is titrated for continuous infusion. Magnesium sulfate is a general inhibitor of neurotransmission. As such, the two largest complications are the loss of deep tendon reflexes and the suppression of breathing. These are the priority assessments. If deep tendon reflexes decrease or the respiratory rate is 12 breaths/min or less, the medication should be discontinued and calcium gluconate administered. Magnesium sulfate is excreted entirely through the kidneys so intake and output should be evaluated hourly. The mother becomes very hot and flushed. This is a normal response. The fetal heart rate should not decrease from the drug.
An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mm Hg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority?
Medicate the client for pain as ordered. Explanation: Although all the interventions are incorporated in this client's care plan, the priority is to relieve pain and make the client comfortable. This will relax the client, decrease the respirations, and make deep breathing and coughing more comfortable. In addition, this would give the client the energy and stamina to achieve the other objectives.
prednisone
Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.
normal findings in neonate
Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).
ECG waves
P: atrial contraction/depolarization QRS: ventricular contraction (atrial repolarization hidden) T: ventricular repolarization
Acute Epiglottitis
Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation. The nurse should never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottitis are present because this maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are the priority. Only after a patent airway is secured can antibiotics be given to treat Haemophilus influenzae, a common cause of acute epiglottitis.
Which sign or symptom is related primarily to small-bowel obstruction rather than large-bowel obstruction?
Profuse vomiting is the classic sign of small-bowel obstruction and rarely occurs with large-bowel obstruction. Abdominal discomfort is present in both small- and large-bowel obstructions. Abdominal distention occurs with both small- and large-bowel obstruction but is more common in large-bowel obstruction. High-pitched bowel sounds indicate hyperperistalsis, which occurs early in obstruction.
What is the best way to decrease venous congestion?
Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs, which are all beneficial to a client with peripheral vascular disease.
What is the most important information the nurse can provide this client about the prescription for budesonide?
Rinse the mouth after using this medication. Explanation: Oral candidiasis or thrush (a fungal infection of the throat) may occur in 1 in 25 persons who use budesonide without a spacer device on the inhaler. The risk is even higher with large doses, but is less in children than in adults. The child should be instructed to rinse the mouth after use and parents should be instructed to monitor the child's mouth for this. The medication should be given after using a bronchodilator to ensure maximum effectiveness. Corticosteroids should not be used for acute asthma attacks.
despair stage
Sadness, crying stops, quiet, appears to be okay, withdraw/complaint behavior, cries when parent returns. Toddler becomes withdrawn and obviously depressed (e.g., not engaging in play activities and sleeping more than usual).
protest stage
Screaming, crying, clinging to parents, resistance to other adults.
Chlorpropamide (Diabinese)
Sulfonylureas. Increases insulin secretion. Decreases glucagon, increases celll sensitivity to insulin. SE: potentially severe hypoglycemia. Potential sulfa allergy
Leopold's maneuver
Support the client while the healthcare provider performs external cephalic version.
classic s/s of pericarditis
The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific ST-segment elevation, elevated ESR, and pericardial friction rub. Low urine output secondary to left ventricular dysfunction lethargy, anorexia, heart failure and pitting edema, result from acute renal failure.
Fundal height measurement
The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.
sign a patient is having difficulty breathing
The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
Preprocedural Care for Cardiac Catheterization
Verify the client has stopped taking anticoagulants if instructed by the health care provider. Check for iodine sensitivity. Verify that written consent has been obtained. Withhold food and oral fluids before the procedure. Explanation: For clients scheduled for a cardiac catheterization, it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. If the client is taking anticoagulant drugs, the nurse should ask the client if the health care provider has given instructions to withhold these medications. Oral medications are withheld unless specifically prescribed.
The nurse is administering an IV potassium chloride supplement to a client who has heart failure. What should the nurse consider when developing a plan of care for this client?
When administering IV potassium chloride, the administration should not exceed 10 or a concentration of 40 via a peripheral line. These limits are extremely important to prevent the development of hyperkalemia and the possibility of cardiac dysrhythmias. In some situations, with dangerously low serum potassium levels, the client may need cardiac monitoring and more than 10 mEq (mmol/L) of potassium per hour.
A nurse may use self-disclosure with a client if:
You Selected: the client asks directly about the nurse's experience. Correct response: it achieves a specific therapeutic goal. Explanation: Self-disclosure (making personal statements about oneself) can be a useful nursing tool. However, a nurse should use self-disclosure judiciously and with a specific therapeutic purpose in mind. The nurse should listen closely to the client and remember that the experiences of different people are sometimes similar but never identical. Using too many self-disclosures is unethical and can shift the focus from the client to the nurse. Self-disclosure that distracts the client from treatment issues doesn't benefit the client and may alienate the client from the nurse.
rooting reflex
a baby's tendency, when touched on the cheek, to open the mouth and search for the nipple
Flumazenil (Romazicon)
a benzodiazepine antagonist; the antidote for benzodiazepines Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.
Penrose drain
a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing
Naegele's Rule
add 7 days to LMP, subtract 3 months, add 1 year
The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and skin color changes, especially during feedings. The nurse should contact the health care provider (HCP) to further assess the baby and request which prescription?
an x-ray for gastric tube placement Explanation: The drooling and excessive mucus production is highly suggestive of a tracheoesophageal fistula (TEF). The initial diagnosis is made when a gastric tube cannot be passed to the stomach.
Clozapine (Clozaril)
antipsychotic anticholinergic Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the HCP. Giving the drug or telling the client to exercise could be detrimental to the client.
Salicylates
aspirin can cause hearing loss
A client who is scheduled for an open cholecystectomy has been smoking a pack of cigarettes a day for 20 years. For which postoperative complication is the client most at risk?
atelectasis Explanation: The client who has a significant cigarette smoking history and an operative manipulation close to the diaphragm (the gallbladder is against the liver) is at increased risk for atelectasis and pneumonia. Postoperatively, this client will be reluctant to deep breathe because of pain, in addition to having residual lung damage from smoking. Therefore, the client is at greater-than-average risk for pulmonary complications.
clozapine
atypical antipsychotic Because clozapine can cause tachycardia, the nurse should withhold the medication if the pulse rate is greater than 140 bpm and notify the HCP
Risperidone (Risperdal)
atypical antipsychotic notify the physician if the client notices an increase in bruising. Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important.
atenolol
beta blocker Decreases Bloop pressure
A client is being treated for dilated cardiomyopathy. Which medication would this client most likely receive?
beta-adrenergic blockers Explanation: By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of dilated cardiomyopathy. Anticoagulants are infrequently used to reduce the risk of emboli. Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they aren't as effective as beta-adrenergic blockers, and can cause increased hypotension. Nitrates aren't used because of their dilating effects, which would further compromise the myocardium.
The rapid response team arrives in the room of a client who has had a cardiac arrest. The nurse should first apply which piece of monitoring equipment?
electrocardiogram (ECG) electrodes Explanation: The nurse should first apply the ECG electrodes to the client's chest. If the client is found to be in ventricular fibrillation, the immediate priority is to defibrillate the client. Pulse oximetry is not an immediate priority. The client's oxygenation is evaluated in a code situation using arterial blood gas analysis. The client's blood pressure is evaluated after the ECG rhythm has been established. A portable Doppler ultrasound unit may be needed to check for the presence of a pulse or to check the blood pressure in a code situation.
Epispadias and Hypospadias
epispadias: urethral opening on the top (dorsal) aspect of the penis hypospadias: urethra openins on the underside of the penis
Babinski reflex
in response to the sole of the foot being stroked, a baby's big toe moves upward or toward the top surface of the foot and the other toes fan out
Propranolol Hydrochloride (Inderal)
is a nonselective beta-blocker of both cardiac and bronchial adrenoreceptors, which competes with epinephrine and norepinephrine for available beta-receptor sites. Propranolol blocks cardiac effects of beta-adrenergic stimulation; as a result, it reduces heart rate; a hypertensive effect is associated with decreased cardiac output. A contraindication of propranolol is bronchial asthma; propranolol can cause bronchiolar constriction even in normal clients. The nurse takes the apical pulse and BP before administering propranolol. The medication is withheld if the heart rate is <60 beats per minute or the systolic blood pressure is <90 mm Hg.
What is the initial step in discharge planning?
is collecting and organizing data about the client because this provides information on the client's healthcare needs. Establishing goals, client teaching, and providing home healthcare referrals are steps that will follow the collection and organization of data.
Deferoxamine (Desferal)
is used for the treatment of iron overload by ridding the body of the extra iron.
Myelomeningocele (spina bifida)
most severe form of spina bifida in which the spinal cord and meninges protrude through the spine Excessive cerebrospinal fluid in the cranial cavity, called hydrocephalus, is the most common anomaly associated with myelomeningocele. Microcephaly, an abnormally small head, is associated with maternal exposure to rubella or cytomegalovirus. Anencephaly, a congenital absence of the cranial vault, is a different type of neural tube defect. Overriding of the sutures, possibly a normal finding after a vaginal birth, is not associated with myelomeningocele.
Which guidelines define and regulate what the nurse may and may not do as a professional?
nurse practice act Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
A 32-year-old female client visits the family planning clinic and requests an intrauterine device for contraception. When assessing the client, a history of which problem would be most important to determine?
pelvic inflammatory disease Explanation: The nurse should assess the client for a history of pelvic inflammatory disease because intrauterine devices have been associated with an increased risk of pelvic inflammatory disease and perforation of the uterus. A history of thrombophlebitis, liver disease, or cardiovascular disease would be important to assess if the client were to receive oral contraceptives. Thrombophlebitis is a contraindication for oral contraceptives.
Good sources of dietary iron include
red meat, egg yolks, whole wheat breads, seafood, nuts, legumes, iron-fortified cereals, and green, leafy vegetables.
prone crawl
reflex is demonstrated when the infant pulls both arms but does not move the chin beyond the elbows.
A client with bacterial meningitis is admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use?
respiratory isolation Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use respiratory isolation. This type of isolation involves wearing a gown and gloves during direct client care and ensuring that everyone who enters the client's room wears a mask.
Montgomery straps
special adhesive strips that are applied when dressings must be changed frequently at the surgical site to avoid skin breakdown
Correct technique for instilling eyedrops includes...
the nurse bracing his or her hand on the client's forehead while instilling the medication. The client should be instructed to gently apply pressure over the inner canthus to prevent systemic absorption of the drug but is not told to apply pressure to the eyes. The medication should be instilled in the client's lower conjunctival sac. To protect the cornea, the nurse should instruct the client to look up while the drops are being instilled.
betamethasone 12 mg intramuscularly for two doses 24 hours apart
to accelerate fetal lung maturity Explanation: Corticosteroids, such as betamethasone, are prescribed for clients who are preterm to accelerate fetal lung maturity and reduce the incidence and severity of respiratory distress syndrome.
