NCLEX Review

In this situation, it is important to present the reality to client. It helps a patient to differentiate the real world from what it's not real. If the client does not reflect reality, the nurse should acknowledge what is real.

" your wife has been dead for two months, I will serve your meal so you can eat"

Hallucinations (Schizophrenia)

Altered perception of the senses

Develops thrush

Client taking inhaled, corticosteroid

"This little light of mine will shine and blind the entire world"

Delusions of grandeur is when someone has false believe about one's own greatness or skills. Client, believing that they have the ability to what is a symptoms of schizophrenia?

Delusion

False belief altered thoughts that are not true

Universal Precautions (UP)

For diarrhea patient what kind of precaution?

Universal Precautions (UP)

For mononucleosis or Epstein-Barr virus patient what kind of precaution?

Preoperative client with INR 3.9

Fresh, frozen plasma is indicated for treatment and clotting deficiency. Which INR is abnormally high, indicates the deficiency in the blood ability to clot INR of?

Universal Precautions (UP)

Hepatitis C patient what type of precaution

Airborne precautions are for what 4 diseases?

MTV(Measles, tuberculosis, varicella) Monkey fox, SARS

Place the head of the bed flat

Nurse's action to decrease intensity of headache following epidural regional nerve block?

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? 1. I dont understand what you mean, can you give me an example 2. it is doubtful the president is out to get you 3. tell me more about the day your child died 4. why did you get so angry when she ignored you

4 explanation - For people who are anxious or overwhelmed, a "why" question asked by the nurse is often interpreted as being critical, judgmental, and intrusive. These feelings are damaging to the development of the nurse-client relationship and therapeutic communication.

Dark amber urine indicates

Presents dehydration

Second-degree type one Mobitz one or Wenckebach

RN caring for client on continuous electrical heart monitoring. Clients electrical heart rhythm displays progressively longer PR duration with non-conducted P-wave. Which type of heart block should Nurse document?

Contact precautions are used for what 4 types of diseases?

RSV, Herpatic infection, Staph infections and Enteric (bowel) infections (rotavirus)

Contact precaution

Shigellosis patient what kind of precaution

Elevated white blood cell, yellow drainage wound site is warm to touch temperature at 102°F

Signs of wound infection

Provide airway support

Systemic toxic reaction result CNS depression; important nurses action is to?

Troponin T

Will still be evident 10-14days following MI

Droplet precautions are for what 2 diseases?

meningitis, influenza, epiglottitis

Diphenhydramine (Benadryl)

Toxicity may cause adverse cardiovascular effects and is characterized by confusion, urinary retention, tachycardia, blurred vision, dry mouth, irritably, and hallucination

Standard Precautions

What isolation precaution would you use for cutaneous anthrax? Cutaneous anthrax is transmitted through animals.

Universal Precautions (UP)

What kind of precaution for aids patient?

Negative mantoux test, rules out TB

Which of the following is true concerning bacteria that causes tuberculosis?

The nurse assesses diminished lung sounds and high-pitched wheezing in a client with acute asthma exacerbation. Arterial blood gas (ABG) findings are shown in the exhibit. Which acid-base imbalance does the nurse correctly identify? pH 7.49 PaCO2 30 mm Hg (4 kPa) PaO2 79 mm Hg (10.5 kPa) HCO3- 25 mEq/L (25 mmol/L)

respiratory alkalosis

Universal Precautions (UP)

For West Nile virus, which is transmitted by mosquitoes what kind of precaution for patient?

Wash raw fruits, first if eating

Fruits can carry bacteria from improper handling. what should be performed prior to consuming it raw?

Dehydration and altered mental status

In elderly clients what are the first signs of infection due to slower immune response of a 90-year-old client diagnosed with pneumonia?

Lung crackles/Rales

Increase or elevated with blood cell in indicates infection. What may likely indicate respiratory track infections?

Infection causes

Increase respiratory rate

Aspirin reduces formation of blood clots that could cause heart attacks

Med decreases platelet aggregation that can cause MI

Paranoia

Mental condition characterized by delusions of persecution

Flumazenil

Midazolam is benzodiazepine; administer med to reverse its effect?

Illusion

Misleading image percentage to the vision

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? 1. bladder scan showing 500 mL urine 2. hemoglobin of 11g/dL 3. history of cataracts 4. reporting frequent diarrhea today

1 Explanation - Anticholinergic drugs are contraindicated when smooth muscle relaxation is already a concern. Commonly cited contraindications include narrow-angle glaucoma, urinary retention (including benign prostatic hyperplasia), and bowel ileus/obstruction.

Pinky mucus membrane is

Normal finding

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action? 1. placing the child in private room, away from nursing station 2. placing child in private room near the playroom 3. placing the child in a semi-private room near the nursing station 4. placing the child in a semi-private room with another child with ASD

1 Explanation - Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location.

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. applying counter-pressure to the clients sacrum during contractions 2. encouraging client to remain in bed during early labor 3. positioning the client on the left side with pillows for support 4. requestioning that the nurse administer epidural

1 Explanation - Fetal occiput posterior position may cause intense back pain during labor. Client comfort can be increased by applying counterpressure to the sacrum during contractions.

The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1. chest tube output of 175 mL in past hour 2. INR 1.5 3. Temp 100.3 4. total urine putput of 85 mL over past 3 hours

1 Explanation - Postoperative blood loss >100 mL/hr should be reported to the HCP immediately. The client may have a compromised suture site and can rapidly become hemodynamically unstable.

A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. deficient fluid volume relate to osmotic diuresis 2. imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. ineffective breathing pattern related to the presence of metabolic acidosis 4. ineffective health maintenance related to the inability to manage DM during illness

1 explanation - Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Deficient fluid volume related to osmotic diuresis is an appropriate ND for a client with DKA.

Nurse takes clients blood pressure, wearing a mask and gloves

Nurse Manager reports for duty and must evaluate each nurses assignment. Nurse has client with aids and a nurse manager is evaluating his care by healthcare team. She should intervene when she sees which situation?

Wear a mask specially, in crowded places

Nurse provides health teaching to client who will receive quite equestrian tablets for the first time due to latex allergy. What instruction is the highest priority?

Patient's age and weight

Nurse received patient experiencing anaphylactic correction. Provider has ordered epinephrine for immediate administration. Which of the following factors is the highest priority, when considering how much epinephrine to administer?

a. Infused iced IV fluids b. Provide 100% oxygen c. Place a cooling blanket on the client d. Administer IV dantrolene

Nurse's action caring for client who develops malignant hyperthermia?

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1. wear an eye patch on the right eye at night 2. avoid chewing 3. chew on the left side 4. maintain meticulous oral hygiene 5. use a cane on the left side

1, 3, 4 Explanation - Bell's palsy is an inflammation of cranial nerve VII (facial) that results in facial muscle weakness and inability to close the eyelids. Eye care (patch at night, artificial tears as needed) and oral care (eating on the unaffected side, oral hygiene after meals) are vital for these clients.

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply. 1. inhaled albuterol nebulizer every 20 minutes 2. inhaled ipratropium nebulizer every 20 mins 3. intravenous methylprednisolone 4. montelukast 10 mg by mouth STAT 5. salmeterol metered-dose inhaler every 20 mins

1,2,3 Explanation - Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol)

A community health nurse evaluates several clients' vaccination status. Which clients would the nurse recommend receive the influenza vaccine injection? Select all that apply. 1, 9 month old with no known medical conditions 2. 5 y.o. with congenital heart defect 3. 23 y.o. recently diagnosed with HIV 4. 45 y.o. care taker of elderly parent 5. 75 y.o. with end stage renal failure

1,2,3,4,5 explanation - Special emphasis should be placed on vaccinating the following high-risk individuals: Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected (Options 2 and 5). Immunocompromised clients (eg, HIV) have decreased ability to fight infection (Option 3). Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients (Option 4). Healthy children age 6-23 months and clients age ≥65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) (Option 1). Pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes.

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply. 1. assess the client for a carotid pulse 2. determine the clients glasgow coma score 3. miantain airway with head tilt/chin-lift maneuver 4. place a hard cervical collar on the client 5. remove the client from the car onto a backboard

1,2,4,5 Explanation - After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.

The nurse is reviewing the medication administration record of a client with atrial fibrillation. Which of the following should the nurse monitor before giving these medications? Select all that apply. Prednisone: 20 mg by mouth, daily Metoprolol: 50 mg by mouth, daily Digoxin: 0.5 mg by mouth, daily Enoxaparin: 40 mg subcutaneously, every 12 hours 1. Digoxin 2. Glucose 3. INR 4. Platelet count 5. Serum potassium

1,2,4,5 Explanation - The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4). Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity (Option 5). Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in clients receiving this medication (Option 2).

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. amenorrhea 2. fluid & electrolyte imbalances 3. heat intolerance 4. presence of lanugo 5. refusal to exercise 6. weight loss of 25% below normal weight

1,2,4,6 Explanation - - Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. - Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis - Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) - Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance - Lanugo (fine terminal hair) can be seen in extreme cases

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. fluid/electrolyte imbalances 3. heat intolerance 4. presence of lanugo 5. refusal to exercise 6. weight loss of 25% below normal weight

1,2,4,6 explanation - Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases

A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply. 1. dyspnea 2. fever 3. lightheadedness 4. skin rash 5. wheezing

1,3,4,5 Explanation-Anaphylaxis is a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).

The nurse in an outpatient clinic is caring for a client with Addison disease who has been taking hydrocortisone 20 mg daily for the last 8 years. Which client data is most important to report to the health care provider? 1. Blood pressure of 140/90 2. Low-grade fever of 100.4 3. Mild increase in fasting blood glucose 4. Weight gain of 6lb in 3 months

2 Explanation - In clients taking corticosteroids, it is imperative to notify the health care provider of signs and symptoms of infection, even a low-grade fever. The anti-inflammatory properties of corticosteroids can mask signs of infection, and their immunosuppressive effects can cause the infection to develop and spread quickly.

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? 1. Assisting the HCP in discussing a DNR order with the family 2. Obtaining equipment and cold fluids for induction of therapeutic hypothermia 3. Placing a small-bore NG feeding tube for enternal nutrition 4. Planning for passive rang-of-motion exercises to prevent contractures

2 Explanation - Following return of spontaneous circulation in an out-of-hospital cardiac arrest, therapeutic hypothermia should be implemented for 24 hours in clients who are comatose or do not follow commands. Therapeutic hypothermia has been shown to improve neurologic outcomes and decrease mortality in these clients.

A client with bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over-the-counter medications taken by the client could be contributing to increased asthma symptoms? 1. Guaifenesin 600mg orally twice daily 2. Ibprofen 400mg orally Q6 3. Loratadine 1 tab orally daily 4. Vitamin D 2,000 units orally daily

2 Explanation - Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis.

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration? 1. serum albumin level and body weight 2. serum potassium and phosphate level 3. symptoms of dumping syndrome 4. white blood cell count and neurtrophils

2 Explanation - Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. Electrolytes, especially phosphorous, potassium, and magnesium, must be monitored frequently during the first few days of nutritional replenishment.

The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that the client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate? 1. clarify vegetable consumption with client 2. decrease heparin rate 3. decrease warfarin dose 4. obtain an order for vitamin K

2 Explanation - The therapeutic effect from heparin or warfarin (Coumadin) is 1.5-2.0 times the control value. Heparin is measured with aPTT and warfarin is measured with PT/INR. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1. client has been sleeping on the floor in the den rather than the bed 2. client has refused food and water fro 4 days and has poor skin turgor 3. client repeatedly mumbles "I must kill them before they get me" 4. marijuana was found in the clients personal belongings 5. the HCP makes a diagnosis of schizophrenia

2,3 Explanation - Clients with a mental illness have the right to refuse treatment, including inpatient hospitalization. Clients can be involuntarily admitted for psychiatric treatment if they pose an imminent danger (3) to themselves or others or if they are gravely disabled and unable to meet their own basic needs(2).

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply. 1. crackles in lung bases 2. increased abdominal girth 3. jugluar vein distention 4. lower extremity edema 5. orthopnea

2,3,4 Explanation - In clients with right-sided heart failure, the heart cannot effectively pump blood to the lungs. Clinical manifestations result from systemic venous congestion and include peripheral edema, jugular venous distension, increased abdominal girth (hepatomegaly, splenomegaly), and ascites.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply. 1. discard aspirated gastric residual in a biohazard container 2. flush the nasogastric tube before and after feedings 3. place the client in the semi-fowler position 4. start the feeding after obtaining a gastric residual volume of 75mL 5. start the feeding when the gastric residual has a pH of 6

2,3,4 explanation - (Option 1) Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. (Option 5) Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational objective: When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings.

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? Select all that apply. 1. decaffeinated coffee or tea can be consumed 2. do not consume caffeine for 24 hours before the test 3. do not smoke the day of the test 4. do not take beta blockers on the day of the test 5. take diabetic medications as usual before the test

2,3,4 explanation - Pre-procedure client instructions include the following: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). Avoid caffeine products 24 hours before the test (Option 2). Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). Do not take theophylline 24-48 hours prior to the test (if tolerated). If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: Nitrates (nitroglycerine or isosorbide) Dipyridamole Beta blockers (Option 4)

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. 1. difficulty arousing from sleep 2. excessive daytime sleepiness 3. morning headaches 4. postural collapse and falling 5. snoring during sleep 6. witnessed episodes of apnea

2,3,5,6 explanation - (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder. Educational objective: At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion." What assessment findings would be a classic indication of a potential malignant skin neoplasm? Select all that apply. 1. blanches with manual pressure 2. half of the lesion is raised and half is flat 3. history of purulent drainage 4. lesion if the size of a nickel 5. various color shades are present

2,4,5 Explanation - Examination of a skin lesion for malignancy should include ABCDE: Asymmetry, Border irregularity, Color change and variation, Diameter of 6 mm or more, and Evolving in appearance.

A nurse on a pediatric unit is admitting a school-aged child with suspected Reye syndrome. Which information obtained during the history taking is most consistent with this condition? 1. no history of varicella vaccine administration 2. recent exposure to bats 3. recent influenza infection 4. recent use of acetaminophen

3 Explanation - Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function. It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever.

A client with rheumatoid arthritis (RA) tells the home health nurse, "My fatigue and stiffness are getting worse and I'm having trouble moving around, especially in the morning. What can I do?" Which intervention would be best for the client to perform first? 1. Eat a high-calorie carbohydrate breakfast immediately after awakening 2. Preform range of motion exercises before getting out of bed 3. Take a warm shower or bath immediately after getting out of bed 4. Take prescribed non-steroidal anti-inflammatory medication on awakening

3 Explanation - A nonpharmacologic intervention such as taking a warm bath/shower or applying heat can decrease morning stiffness and improve flexibility in clients with RA.

The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? 1. Heart valve injury 2. Intellectual disability 3. Joint destruction 4. recurrent pnemonia

3 Explanation - Clients with hemophilia are at risk for permanent joint destruction due to frequent bleeds into the joint spaces. Assisting clients with decreasing the incidence of bleeding episodes and prompt treatment when bleeding occurs can help minimize joint destruction.

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with intravenous (IV) albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider? 1. Albumin 2.5g/dL 2. INR 1.4 3. Potassium 3.0 mEq/L 4. Sodium 131 mEq/L

3 Explanation - Lab abnormalities common in liver failure include low albumin, elevated INR, and elevated liver function tests. A low serum potassium can increase the risk of hepatic encephalopathy and should be reported to the health care provider. Elevated serum ammonia confirms the hepatic encephalopathy diagnosis.

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. complete hourly pain assessments using a numeric scale 2. document that the client appears to be experiencing minimal pain 3. monitor for nonverbal signs of ineffective coping with labor 4. recognize that the clients' stoicism is ineffective coping with labor

3 Explanation - A client's cultural background may affect expression of pain during labor. In Japanese culture, silence and nonverbal communication may be valued over overt forms of communication. The nurse should assess the client's coping and monitor for nonverbal cues of ineffective coping (eg, writhing, screaming, panicking).

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication? 1. Aspirin 81 mg PO once a day 2. Furosemide 40 mg PO once a day 3. Glyburide 10 mg PO once a day 4. Levothyroxine 50 mg PO once a day

3 Explanation - Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin)

A mother brings a child to the emergency department with itching and the rash shown in the exhibit. The child continues to scratch the lesions. What action should the nurse take first? 1. administer antihistamine & closely crop fingernails 2. ask about the child's vaccination status 3. place a mask on the child 4. place the child in positive airflow room

3 Explanation - The priority for a child with chicken pox is isolation (airborne, contact). Supportive care includes antihistamines for itching and acetaminophen (NOT aspirin) for fever. Fingernails should be cut short to prevent excoriation and secondary bacterial infection.

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. I will call my HCP if I notice blood in my stool 2. I will not stop taking dabigatran if I get a stomach ache 3. I will place my capsules in my pill box so I will not forget to take them 4. I will swallow the capsule whole with a glass of water

3 Explanation - Thrombin inhibitors such as dabigatran reduce the risk for clots and stroke in clients with chronic atrial fibrillation. The nurse should teach the client to use bleeding precautions and monitor for symptoms of bleeding, swallow capsules whole with a full glass of water, and keep capsules in their original container until time of use.

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? 1. administering PRN antiemetic prior to infusion 2. administering via infusion pump over at least 30 min 3. drawing a trough level just prior to administration of vanco 4. starting a new IV line before administration

3 Explanation - To measure for efficacy and risk of nephrotoxicity with vancomycin, the nurse should draw periodic trough levels just prior to administration of the next IV dose.

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? 1. adenosine IV 2. dopmaine IV 3. magnesium IV 4. metoprolol IV

3 Explanation - Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.

The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1. appetite has improved 2. blood glucose is 110 mg/dL 3. urine output has decreased 4. urine specific gravity is lower

3 explanation - Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). Use of desmopressin acetate (DDAVP) in clients with diabetes insipidus will lower urinary output and cause the urine specific gravity to increase.

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply. 1. atorvastatin 2. metformin 3. metoprolol 4. olanzapine 5. omeprazole

3,4 explanation - Drugs commonly associated with orthostatic hypotension include: Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) (Option 3) Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) (Option 4) Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) Vasodilator medications (eg, nitroglycerine, hydralazine) Narcotics (eg, morphine) (Option 1) Muscle cramps and liver injury, not orthostatic hypotension, are the major adverse effects of statin medications (eg, atorvastatin). (Option 2) Major side effects of metformin are lactic acidosis and gastrointestinal disturbances (metallic taste in the mouth, nausea, and diarrhea). Unlike insulin, metformin does not usually cause hypoglycemia. Orthostatic hypotension is not a common side effect. (Option 5) Proton pump inhibitors (eg, omeprazole) are associated with increased risk of pneumonia, Clostridium difficile diarrhea, and calcium malabsorption (osteoporosis), but not orthostatic hypotension.

A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. acetaminophen 2. albuterol 3. dipenhydramine 4. enalapril 5. loratadine

3,5 explanation - Allergy skin testing involves introducing common allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Clients should avoid antihistamines as these drugs can prevent accurate results.

The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment? 1. confusion & learning disability 2. delayed physical & emotional development 3. disorientation & cognitive impairment 4. low self-esteem & impaired social skills

4 Explanation: The diagnosis of ADHD includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse.

heart failure (HF)

Can cause, shortness of breath, coughing, and wheezing, similar signs and symptoms of asthma taking decongestion is the risk please for them, and can exacerbate these issues, potentially increasing risk of heart, attack, stroke, and other life-threatening condition

Universal Precautions (UP)

Candida albicans (fungus) what kind of precautions for vaginal yeast infection?

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive? 1. Blood pressure 120/80, pulse 80/min 2. Client has no bladder spasms 3. Irrigation input 3,000mL, Foley output 3,000mL 4. Output urine is light pink in color

4 Explanation - A 3-way Foley catheter with continuous bladder irrigation allows urine to drain after a transurethral resection of the prostate. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots may occur for up to 36 hours. However, the nurse adjusts the irrigation flow to keep the urine light pink without clots.

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1. Lido 5% patch over intact skin for a client with chronic postheraputic neuralgia who reports, intolerable, persistant, burning pain 2. Hydromorphone IV for a client who has a fractured femur, is known IV heroin abuser, and rates pain 9/10 3. Tramadol for a client who is being prepared for discharge following a laprascopic cholecystomy and rates abdominal pain as 6/10 4. Transdermal fentanyl patch for a client who is 1 day postop above the knee amputation ad reports intermittent throbbing stump pain

4 Explanation - A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.

The nurse is teaching a client with insomnia techniques to improve sleep habits. Which statement by the client indicates a need for further teaching? 1. "I will avoid caffeine with dinner" 2. "I will avoid naps later in the day" 3. "I will keep my bedroom cool" 4. "I will read in bed if I can't fall asleep"

4 Explanation - Clients with insomnia should be taught good sleep hygiene - using the bed only for sleep (not reading or watching television), avoiding stimulants and exercise before bedtime, and keeping the room cool and dark.

A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? 1. "I must visit my HCP to check my drug levels" 2. "I should report to my HCP if I develop n/v" 3. "I should tell my HCP if I feel my heart skip a beat" 4. "I will need to increase my potassium intake"

4 Explanation - Drug toxicity is common with digoxin due to its narrow therapeutic range. Drug levels are frequently monitored. Nonspecific gastrointestinal symptoms similar to gastroenteritis are common and can lead to serious cardiac arrhythmias if not recognized. Potassium does not need to be monitored unless client is taking other potassium diuretics

The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching? 1. "I will call 911 if my chest pain isn't relieved by NTG" 2. "If I have chest pain, I can take up to 3 pills, 5 mins apart 3. "I will call my doctor if I start having chest pain at night 4. "I will keep one bottle in the house and one in the car"

4 Explanation - Education about sublingual NTG should include placing the tablet or spray under the tongue; repeating the dose every 5 minutes, with up to 3 total doses if angina is not relieved; notifying EMS if the first dose does not improve the symptoms; keeping the tablets in the original container away from light and heat (keeping in car does not protect from cold/heat); and replacing the bottle every 6 months once opened.

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? 1. coughing and deep breathing 2. left lateral posiiton 3. pursed lip breathing 4. sitting up and leaning forward

4 Explanation - It is an inflammation of the visceral and/or parietal pericardium. Pericarditis is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. This position reduces pressure on the inflamed parietal pericardium, especially during lung inflation. The pain is different than that experienced during myocardial infarction. Assessment shows a pericardial friction rub (scratchy or squeaking sound). Treatment includes a combination of nonsteroidal anti-inflammatory drugs (NSAIDS) or aspirin plus colchicine.

The nurse should call the primary health care provider to obtain a new prescription prior to administering which medication to a client with type 1 diabetes mellitus? 1. 10units regular insulin IV push for blood glucose >250mg/dL 2. 14units glargine insulin subcutaneous injection every night at 8pm 3. 18 units aspart insulin subcutaneous injection 15mins before breakfast 4. 20 units NPH insulin IV push administered every morning at 7am

4 Explanation - Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered IV push. Regular insulin is the only insulin that can be administered IV push.

The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first? 1. 1 day postoperative client with lower abdominal pain and no urine output for 6 hours 2. an elderly client with blood pressure 190/88 who is asymptomatic 3. Client with hep C virus who has alanine aminotranferase(ALT) values 4 times the normal value 4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign

4 Explanation - The prioritization principle is that systemic symptoms are more important than local symptoms. Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. This is a known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size.

Flash Cards4 A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1. Administer morphine to the infant 2. administer oxygen via mask 3. assess infants vital signs and pulse ox 4. place the infant in the knee-chest position

4 Explanation - This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? 1. hemoglobin 10.2 g/dL 2. hyperactive bowel sounds 3. serum sodium 152 mEq/L 4. tall, peaked T waves on ECG

4 Explanation -Hematocrit and hemoglobin values will be elevated due to hypovolemia. The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as sodium is lost via fluid shifts and insensible losses. Burn injuries cause cellular destruction, capillary leaking, and fluid shifts. Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia.

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection? 1. assist the client to the shower and provide directions to use antibacterial soap 2. delay the bath until the client has received antibiotic therapy for 24 hours 3. use a bath basin with warm water and a new wash cloth for each body area 4. use packaged pre-moistened cloths containing chlorhexidine to bathe the client

4 explanation - Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection.

E. coli bacteria

Are killed at 160°F. It is recommended to heat beef at 160°F to kill off what bacteria?

Mark the fracture and sign

Based from national client, safety standards, client should?