NCLEX-RN Passpoint - Basic Care and Comfort, Pharmacological and Parenteral Therapies, Reduction of Risk Potential, Physiological Adaptation

Which finding is an early indicator of bladder cancer?

painless hematuria

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy." The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate.

A client with peripheral vascular disease has poor circulation. The nurse should assess the client for changes in: (Select all that apply.)

1. nail bed color. 2. skin temperature. 3. pain in extremity.

The nurse is providing dietary teaching for a client with diabetes. Which statement about the diet would be accurate?

It is planned around a wide variety of commonly available foods

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine?

It's a centrally-acting antitussive and can cause dependence.

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

Observe the puncture site for swelling and bleeding

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?

Offer the client frequent oral hygiene care

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

In evaluating a client's response to nutrition therapy which laboratory test would be of highest priority to examine?

albumin level

Which assessment finding puts a client at increased risk for epistaxis?

cocaine use; Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages.

Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)?

high-calorie, high-protein diet; The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:

maintain adequate nutrition through oral or parenteral feedings.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures; The concern with this infant is sepsis based on prolonged rupture of membranes before birth. Blood cultures would provide an accurate diagnosis of sepsis but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results. Continuing with vital signs, voiding, stooling, and eating every 4 hours is the standard of care for a normal newborn, but a respiratory rate greater than 60, grunting, and occasional flaring are not normal. Although not normal, the need for the intensive care unit is not warranted as newborns with sepsis can be treated with antibiotics at the maternal bedside. The CBC does not establish the diagnosis of sepsis, but the changes in the white blood cell levels can identify an infant at risk. Many experts suggest that waiting until an infant is 6 to 12 hours old to draw a CBC will give the most accurate results.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

Measure the client's legs

The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue?

"I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

A nurse is instructing a client with asthma on the use of an inhaler with a spacer. The client asks what the purpose of the spacer is. The nurse's best response is

"The spacer traps medicine from the inhaler, then breaks up and slows down the medication particles, so you get more medication."

A client has been involved in a shooting and is brought to the emergency department with profuse bleeding from the abdomen. Place each intervention in order of priority. All options must be used

1. Assess all vital signs, including oxygen saturation 2. Infuse intravenous fluids to prevent shock 3. Assess the chest for evidence of other injuries 4. Control the pain from the gunshot wound 5. Maintain NPO in anticipation of surgery

The nurse is caring for a client with an I.V. line. During care of the I.V. line, the nurse would be required to wear protective gloves in which situations? Select all that apply.

1. When inserting the IV, 2. When discontinuing the IV, 3. When changing the IV site

For which client(s) does the nurse anticipate the healthcare provider's orders for pneumatic compression devices? Select all that apply.

1. client who had extended low anterior resection for colonic mass 2. client in the intensive care unit on a ventilator with sepsis 3. client with four vessel coronary artery bypass graft with bilateral chest tubes

The nurse is caring for a client on a patient-controlled analgesia (PCA) pump. What additional interventions by the nurse would be effective for pain relief? Select all that apply.

1. gentle massage of the area with positioning 2. encouraging relaxing of inflamed muscles and performing distraction exercises

A client, with new onset of atrial fibrillation, is receiving warfarin to help prevent thromboemboli. The client will be discharged when the warfarin reaches therapeutic levels, and when the international normalized ratio (INR) ranges from

2 to 3 INR

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care?

An increased need for insulin and blood glucose monitoring

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she makes which statement?

Antibodies are not usually formed until after exposure to an antigen.

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Assess respiratory status.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown. At 1030, the client has sharp midchest pain after having a bowel movement. What should the nurse do first?

Assess the client's vital signs.

The nurse is caring for a client with type 1 diabetes mellitus. At 0300, the nurse finds the client disoriented to time and place, diaphoretic, and reports palpitations. What is the nurse's priority intervention?

Check blood glucose level; Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose.

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating ordered antibiotic therapy, the nurse should prepare the client for:

Delivery

The wife of a client admitted for treatment of newly diagnosed paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, "Why isn't he eating? He's still talking about his food being poisoned." Which appraisal by the nurse is most accurate?

Education about her husband's medications is needed.

A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first?

Elevate the affected arm and apply ice to the injury site

What actions should the nurse take for a 4-year-old girl who has just had a lumbar puncture?

Encourage the parents to hold the child.

A nurse is caring for an infant who is in critical condition. The nurse notes that the child weighs 11 lb (5 kg) and has had a blood loss of 100 mL. Assessment reveals a decreased urine output, mild tachycardia, and restlessness. Which of the following should be the priority action for the nurse to take?

IV Administration of lactated Ringer's; The loss of small volumes of blood in children is significant and can lead to hypovolemic shock. In this situation, the blood loss represents approximately 10% of the child's total blood volume. Because the child is exhibiting signs of early hypovolemic shock, the priority action should be the administration of Ringer's lactate for fluid resuscitation. The remaining options may need to be implemented, but the priority is to correct the fluid deficit.

A 12-year-old child is scheduled for surgery to repair a fractured tibia. One hour prior to surgery, the nurse assesses that the child is febrile. What is the best action for the nurse to take?

Inform the surgeon; The surgeon must be informed immediately so the decision can be made whether to proceed with the surgery. A child scheduled for surgery in 1 hour would be NPO, so oral antipyretics would not be an option. Although cool compresses might relieve some discomfort, the priority is to notify the physician.

Which statement indicates that the parents understand the need for their child to receive long-term antibiotic therapy after an episode of rheumatic fever?

It will prevent further streptococcal infections

What is the most important information for the nurse to include when teaching a client about metronidazol?

Mixing this drug with alcohol causes severe nausea and vomiting; When mixed with alcohol, metronidazole causes a disulfiram-like effect involving nausea, vomiting, and other unpleasant symptoms. Urine may turn reddish brown, not greenish, from the drug. Cardiovascular or respiratory effects are not associated with this drug.

What should the nurse do to prevent pressure ulcers in an older adult?

Perform a systematic skin assessment at least once a day; Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided.

The client is taking 50 mg of lamotrigine daily for bipolar depression. The client shows the nurse a rash on his arm. What should the nurse do?

Report the rash to the health care provider (HCP).

A client with deep vein thrombosis has been receiving warfarin for 2 months. The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do?

Return to laboratory for analysis of prothrombin times

The nurse is assisting a client diagnosed with dementia during meal time. Which nursing would best prevent complications?

Serve one course at a time with the appropriate utensil

A deceased client had dentures and an artificial eye. What should the nurse do with these items?

Tag them for the mortician

A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need something else." What should the nurse should tell the client to do?

Take the medication at mealtime; Nausea is a common adverse effect of venlafaxine; it should be taken at mealtime to minimize gastrointestinal discomfort.Venlafaxine, unless prescribed in the extended release form, is given in divided doses throughout the day. The amount should not be taken in one dose because of the drug's 3- to 7-hour half-life in adults. The dosage should not be halved unless warranted by the client's psychological condition.

A client with hyperglycemia who weighs 210 lb (95 kg) tells the nurse that their spouse sleeps in another room because the client's snoring keeps the spouse awake. The nurse notices that the client has large hands and a hoarse voice. Which disorder would the nurse suspect as a possible cause of the client's hyperglycemia?

acromegaly; Acromegaly, which is caused by a pituitary tumor that releases excessive growth hormone, is associated with hyperglycemia, hypertension, diaphoresis, peripheral neuropathy, and joint pain. Enlarged hands and feet are related to lateral bone growth, which is seen in adults with this disorder. The accompanying soft tissue swelling causes hoarseness and, commonly, sleep apnea. Type 1 diabetes is usually seen in children, and newly diagnosed persons are usually very ill and thin. Hypothyroidism and growth hormone deficiency aren't associated with hyperglycemia.

When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is appropriate?

administering fluids to the client

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to

drink liquids only between meals

The nurse assesses a child with suspected juvenile hypothyroidism. Which signs or symptoms should the nurse expect this child to manifest?

dry skin and constipation; Clinical manifestations of juvenile hypothyroidism include dry skin, constipation, sparse hair, and sleepiness. Short attention span, weight loss, moist flushed skin, rapid pulse, and heat intolerance suggest hyperthyroidism.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report

light flashes and floaters in front of the eye; The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment

Which night clothes would the nurse recommend for an infant with atopic dermatitis?

one-piece cotton pajamas with long sleeves; Atopic dermatitis results in pruritus. The infant's skin should be covered as completely as possible to keep him from scratching himself. Cotton is the preferred material because it allows the skin to breathe and moisture to evaporate.

A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately?

Place the child in a bathtub of cool water; The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water.

The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. Which comment by the client indicates the client needs further education?

"I know I shouldn't drive after taking my furosemide."

A client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is a 7 out of 10." What action by the nurse would be most appropriate?

Administer pain medication as ordered; A pain rating of 7 out of 10 indicates significant pain. Therefore, the most appropriate action would be to administer pain medication as ordered.

Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement?

daily weight

A client is diagnosed with iron deficiency anemia. When teaching the caregivers about using supplemental iron elixir, the nurse should provide which instruction?

"Give the elixir with water or juice;" Because iron preparations may stain the teeth, the nurse should instruct the caregivers to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption. Giving it with fruit juice may be preferable because vitamin C enhances iron solubility and absorption.

A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the client understands how to take the prednisone when the client says:

"It is best if I take this medication with some food.

A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger cookies to help control the nausea. What should the nurse tell the parents?

"You can try them and see how he does;" Some clients find ginger cookies or "snaps" help relieve nausea. Ginger, in small doses such as would be found in the cookies, has few side effects. There is no reason that the parent should not try this dietary intervention; however, the nurse must monitor the client's response. If the child has a diet as tolerated prescription, there is no need for an additional prescription.

The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH at 1700 each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?

0100, while sleeping; The client with diabetes mellitus who is taking NPH insulin in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply.

1. Assisting the client into Sims' position. 2. Washing hands and putting on gloves. 3. Encouraging the client to retain the solution for 5 to 15 minutes

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply.

1. Bring up the suspected physical abuse with a trusted authority figure. 2. Report the suspicion to the local Adult Protective Services Agency within 24 hours.

There are a limited number of capnography monitors available on the unit. The nurse priorizes which clients as requiring ongoing capnography? Select all that apply.

1. Client being treated for an uncontrolled seizure disorder 2. Client scheduled for a procedure using moderate sedation 3. Client with increased intracranial pressure due to trauma 4. Client with acute exacerbation of chronic obstructive pulmonary disease

When administering flumazenil intravenously for reversal of sedation, what should the nurse do? Select all that apply.

1. Give the medication undiluted in incremental doses. 2. Be alert for shivering and hypotension. 3. Use only a free-flowing IV line in a large vein. 4. Monitor the client's level of consciousness; Flumazenil should be administered in small quantities such as 0.2 mg over 15 to 30 seconds but never as a bolus. Flumazenil may be given undiluted in incremental doses. Adverse effects of flumazenil may include shivering and hypotension. The nurse should monitor the client's level of consciousness while recovering from sedation. Flumazenil should be administered through a free-flowing IV line in a large vein because extravasation causes local irritation.

A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body?

27%; According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice; Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?

Decrease cardiac demands by promoting rest

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?

Deficient knowledge related to lack of exposure to apnea monitor.

During a visit to the clinic, a pregnant 25-year-old woman who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily; Dietary measures such as increasing dietary intake of bulk and roughage (e.g., eating at least four pieces of fruit each day) help to relieve constipation and should be suggested initially. Other nonpharmacologic measures include drinking a glass of hot fluid in the morning, increasing fluid intake, and exercising regularly.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess; In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. These changes put the client at risk for marked nutrient and calorie deficiency

The nurse should inform a client taking carbamazepine that it can affect other medications in which way?

It decreases the effects of oral anticoagulants; The nurse should inform the client that carbamazepine can decrease the effects of oral anticoagulants. Carbamazepine can increase the serum concentration of verapamil and can decrease the serum concentration of other anticonvulsants and the effects of oral contraceptives.

A multiparous client at 14 weeks' gestation has such severe morning sickness that she has "not been able to keep anything down for a week." The nurse should review the results of the urinalysis for which value?

Keytones; When a client is not able to eat, the intake of carbohydrates is dramatically reduced, causing fat to be burned for energy. Improper fat metabolism results in ketones in the urine from the starvation this client is experiencing.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet; A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?

Milk; A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first?

Raise the head of the bed

A client has been hospitalized with a diagnosis of myasthenia gravis. The client has been talking on the phone. The nurse enters the room right after the client has recovered from choking on a sandwich. What should the nurse do next?

Tell the client to swallow when the chin is tipped down on the chest

A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made after the procedure would indicate the development of a potential complication?

The client experiences a sudden increase in temperature

A pediatric client has just had a plaster cast placed on his lower left leg. Which action should the nurse take to provide safe cast care?

Use only the palms of the hand when handling the cast.

A client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation in the anteroseptal leads and T-wave inversion in leads V3 to V5. Which medication should the nurse prepare to administer?

nitroglycerin; The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to order an infusion of nitroglycerin to dilate the coronary arteries. Lidocaine and procainamide are cardiac drugs, which may be indicated for this client at some point but aren't used for coronary artery dilation. If a cocaine user experiences ventricular fibrillation or asystole, a physician may order epinephrine. However, this drug must be used with caution because cocaine may potentiate its adrenergic effects.

A 3-year-old boy has arrived in the emergency department. The nurse documents the following assessment findings in the client's chart, knowing that they are consistent with which disease process?

pneumonia; The elevated fever, shallow respirations, decreased breath sounds, rales, harsh cough, and productive mucus are findings associated with pneumonia. Typically, there is no fever with asthma and cystic fibrosis, and bronchiolitis presents with a low-grade fever. Wheezing is associated with asthma and bronchiolitis; however, this was not found upon physical examination of this client. Bronchiolitis produces a dry cough, and pneumonia causes a productive, harsh cough. The client with cystic fibrosis typically presents with wheezing, rhonchi, and thick, tenacious mucus.

A nurse is interviewing the parent of a 7-year-old child. Which symptom reported by the parent leads the nurse to suspect that the child has type 1 diabetes?

recent bed-wetting; Polyuria, recognized by parents as bed-wetting in a child recently toilet-trained, is a hallmark of type 1 diabetes mellitus. Polyphagia is also a hallmark of type 1 diabetes mellitus.

he nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they:

strengthen the muscles while keeping the joints stationary.

A primipara who is Rho(D) negative has just given birth to a Rh-positive baby. The nurse is developing a plan of care. How should Rho(D) immune globulin be administered?

to the client within 3 days; Administering Rho(D) immune globulin to the client within 72 hours of birth prevents antibodies from forming that can destroy fetal blood cells in the next pregnancy. Rho(D) immune globulin isn't given to the baby. The client should not wait 6 weeks to receive Rho(D) immune globulin as antibodies will already have formed.

The nurse is assessing the primitive reflexes of a 1-month-old infant. Of the reflexes shown in the photos, which one would the nurse expect to remain the longest?

Plantar grasp reflex; noted to disappear by 8 months.

When developing the plan of care for a toddler who has taken an acetaminophen overdose, which intervention should the nurse expect to include as part of the initial treatment?

gastric lavage; Initial management of a child who has ingested a large amount of acetaminophen would include inducing vomiting or performing gastric lavage with or without activated charcoal to aid in the removal of the substance.

A client is admitted to the emergency department with a history of abdominal aortic aneurysm. The nurse assesses the client for which sign or symptom that suggests the client's abdominal aortic aneurysm is extending?

increased abdominal and back pain; Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

The nurse should assess the client with severe diarrhea for which acid-base imbalance?

metabolic acidosis; A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.

The nurse is assessing the ankle-brachial index (ABI) for a client with peripheral vascular disease. The highest systolic pressure for each ankle is 80 mm Hg and the highest brachial pressure is 160 mm Hg. What does this client's ABI indicate?

mild to moderate insufficiency; ABI is calculated by dividing the highest systolic pressure for each ankle by the highest brachial pressure. For this client it would be 80/160 mm Hg = 0.50 ABI. This indicates that the client has mild to moderate insufficiency. Clients with ABI of about 1.0 have no arterial insufficiency; clients with ABI of less than 0.50 have ischemic rest pain; and clients with an ABI of 0.40 or less indicates severe ischemia or tissue loss.

Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client's:

electrocardiogram (ECG); Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Lidocaine level will be monitored but it is not the primary focus; troponin level monitors myocardial damage. Blood pressure, which can drop on lidocaine, does need to be monitored but the focus should be the ECG to evaluate the effectiveness of the medication.

Liquid oral iron supplements have been prescribed for a child. What is the most important information for the nurse to provide to this child's parents?

give the medicine via a dropper or through a straw

The nurse is caring for a neonate 4 hours after birth who has not passed meconium. When the nurse is assessing the neonate, the "wink reflex" cannot be elicited, and a membrane filled with meconium is observed bulging through the anus. Which of the following defects does the nurse suspect has occurred in utero?

imperforate anus; An imperforate anus is discovered at birth when inspection of a newborn's anal region reveals no anus or a membrane filled with black meconium that protrudes from the anus. The condition is also suspected if it is impossible to insert a rubber catheter into the rectum. A "wink" reflex (touching the skin near the rectum should make the anus contract) cannot be elicited if sensory nerve endings in the rectum are not intact. Intussusception is a telescoping of a portion of bowel into another portion causing obstruction. A meconium plug is a hard portion of meconium that completely blocks the intestinal lumen. Coanal atresia is a congenital defect where the nasal passages are blocked.

An incoherent client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, the nurse prepares to take emergency action to prevent the potential complication of

myxedema coma; Severe hypothyroidism may result in myxedema coma, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema. Thyroid storm is an acute complication of hyperthyroidism. Cretinism is a form of hypothyroidism that occurs in infants. Hashimoto's thyroiditis is a common chronic inflammatory disease of the thyroid gland in which autoimmune factors play a prominent role.

The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider?

protamine sulfate; The aPTT is at a critical value, and the client should receive protamine sulfate as the antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered to increase the hematocrit.

When caring for a client with preeclampsia during labor, the nurse should:

restrict the amount of fluid administered; The volume of fluids administered during labor to a client with preeclampsia should be restricted. Clients usually receive between 60 and 150 ml/hour.

The nurse is caring for a client with type 1 diabetes. The nurse finds the client unconscious and administers glucagon, 1 mg intramuscularly. What is the next action by the nurse when the client regains consciousness?

offer orange juice and crackers

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway; If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed.

A nurse is assessing a 6-month-old infant at a well-baby check. The parent says that the infant has been having diarrhea for the last 2 days. Which is the nurse's priority action?

Collect more data from parent about the diarrhea

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test?

total protein; The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

A client who has been experiencing depression for 3 months was recently placed on sertraline. The client calls a nurse and reports that significantly improved mood and optimism about the future. Which piece of additional information would require a rapid nursing intervention?

The client is sleeping only 3 hours per night and does not feel fatigued in the morning; Some individuals who start on antidepressant medications, including selective serotonin reuptake inhibitors (SSRIs), may develop hypomania or mania. The client's limited sleep and lack of fatigue despite limited sleep are indications that the client may be having a hypomanic or a manic episode, which requires rapid nursing intervention and contacting the physician.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

by supplying a magic slate or similar device

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to

rest in an air-conditioned room. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided.