NCLEX Saunders NCLEX 8th edition pt2

Which client is at greatest risk for committing suicide?

A client with metastatic cancer. The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

The nurse is providing discharge instructions to a client who has undergone treatment of cervical cancer with a radiation (cesium) implant. Which instruction should the nurse provide to the client?

Use a vaginal dilator 3 times a week. Radiation causes scarring and fibrosis of the vagina, with a decrease in normal vaginal secretions. The client is instructed to use a vaginal dilator to prevent vaginal narrowing and stenosis. A vaginal discharge often occurs, and the woman may need to douche twice daily for as long as the discharge and odor persist. Sexual activity after internal radiation treatment can be resumed in about 3 weeks.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar in the client's room. An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply.

Remain calm. Time the seizure. Ease the child to the floor. Loosen restrictive clothing. When a child is having a seizure, the nurse should remain calm, time the seizure, ease the child to the floor if the child is standing or seated, keep the child on the side (to prevent aspiration), and loosen restrictive clothing.

The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?

Between 18 and 24 hours after the injury. The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?

"I can send my child to day care if he has a fever, as long as it is a low-grade fever." AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center.

The nurse has completed teaching a new nursing graduate on how to avoid being judgmental. Which statement by the new nursing graduate should indicate to the nurse that there is a need for further teaching?

"I don't think you need to do that."

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement?

"I will take the medication on an empty stomach." Diphenhydramine has several uses, including as an antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include taking with food or milk to decrease gastrointestinal upset and using oral rinses, sugarless gum, or hard candy to minimize dry mouth.

The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction?

"The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe." In a standing position, there should be 25 to 30 degrees of flexion at the client's elbow. A walker of incorrect height will not allow the client's line of gravity to go through his or her base of support.

The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client?

"You're wearing a new blouse." Telling the client that she looks lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations.

A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan?

A 14- to 21-day course of doxycycline. Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G.

The nurse is reviewing the plan of care for a child with a diagnosis of suspected appendicitis. The nurse would question which intervention if noted in the plan of care?

Applying a heating pad to abdomen to promote pain relief. Whenever appendicitis is suspected, the nurse should be aware of the danger of administering laxatives or enemas or applying heat to the area. The nurse can determine the most intense site of pain, located at McBurney's point, by palpation. McBurney's point is midway between the right anterior superior iliac crest and the umbilicus.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?

Contact the obstetrician (OB) and inform him or her of this finding.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

Elevate and immobilize the grafted extremity. Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit?

Fat. The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?

High-Fowlers. During insertion of a nasogastric tube, the client is placed in a sitting or high-Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Margarine. Cream cheese. Luncheon meats. Margarine, cream cheese, and luncheon meats are high-fat foods.

The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client demonstrates understanding of the instructions by stating the need to include which food item in the diet?

Milk. Milk provides the highest amount of vitamin D. Broccoli and oranges are high in vitamin C, and meat is high in vitamin B complex.

The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents. Which instruction should the nurse give to the parents?

Notify the PHCP if the child develops abdominal pain or left shoulder pain. Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the PHCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low set. Which nursing action is most appropriate?

Notify the primary health care provider. Low or oddly placed ears are associated with various congenital defects and should be reported immediately.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side and adverse effects of rifabutin? Select all that apply.

Signs of hepatitis. Signs of hepatitis. Low neutrophil count. Ocular pain or blurred vision.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

Taking medications as scheduled. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion?

The cardiac output is below the normal range.

The nurse has received the client assignment for the day. Which client should the nurse care for first?

The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination. The client is complaining of painful urination; therefore, the nurse should suspect urinary tract infection and act promptly to contact the primary health care provider because clients with neutropenia are more susceptible to bacterial infections.

The nurse is caring for an older client. Which finding should the nurse expect to note in this client while evaluating renal function?

The glomerular filtration rate (GFR) diminishes. As part of the normal aging process, the GFR decreases, along with each of the other functional abilities of the kidney. Tubular reabsorption and urine-concentrating ability also decrease. The kidneys have decreased ability to metabolize medications.

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

Withdraws the NPH insulin first. When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type.

The nurse is providing instructions to an assistive personnel (AP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the AP to place personal articles for morning care?

Within the client's reach on the left side. Hemiparesis is weakness of the face, arm, and leg on 1 side. The nurse would instruct the assistive personnel to place objects on the unaffected side and within reach of the client.

A client with a history of ovarian cysts is seen by the primary health care provider (PHCP). The client has had 2 previous surgeries related to this condition. Her PHCP recommends an exploratory laparoscopic procedure for the current ovarian cyst, which has persisted for several months. The client states that the prior ovarian cysts were benign and questions the need for this procedure. Which response is best for the nurse to provide?

"A prolonged ovarian abnormality should be evaluated thoroughly." An ovarian cyst is considered an abnormal occurrence, and it should be thoroughly evaluated.

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding?

1+ edema. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

Ask the client to extend the arms. Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?

Assigning the client to a room at the end of the hall. The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor.

The nurse working in a long-term care facility notes that several clients are taking pilocarpine hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for use if a client should develop systemic toxicity from pilocarpine hydrochloride?

Atropine sulfate. Pilocarpine hydrochloride is a cholinergic agent. Atropine sulfate must be available in the event of systemic toxicity from pilocarpine hydrochloride. Pilocarpine toxicity is manifested by vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Disulfiram is an alcohol deterrent used in the management of alcoholism in selected clients. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye. Naloxone hydrochloride is an opioid antagonist used to reverse opioid-induced respiratory depression.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item?

Bananas. Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross-reaction between the food and the latex allergen.

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin?

Crusting. The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin would indicate a potential complication.

An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine 1% to use as a topical agent. The nurse determines that the medication was effective if which finding was noted?

Decrease in urticaria. Diphenhydramine reduces the symptoms of allergic reaction, such as itching or urticaria, when used as a topical agent on the skin. The oral form also has other uses, such as to provide mild nighttime sedation. It is not used to treat burns or ecchymosis.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior?

Repetitive actions to manage anxiety. A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.

The ambulatory care nurse is preparing to assist the primary health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed?

Supine with the right hand under the head. A client undergoing liver biopsy with the use of a local anesthetic will be positioned supine with the client's right hand placed under the head. An alternative position is the left lateral side-lying position. The client also will be asked to remain as still as possible during the test. The remaining options are inappropriate positions for this procedure.

An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initialtreatment?

The administration of an emetic. Initial treatment of acetylsalicylic acid overdose includes the administration of an emetic or gastric lavage. Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium overdose.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client?

The need for sensory stimulation. A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization.

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia?

Their child will be treated for an imbalance of the chemical dopamine. The dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia. The prognosis is negatively affected when the onset of symptoms occurs during the adolescent years.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

Three sputum cultures are negative. The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point.

The home care nurse is providing safety instructions to the mother of a child with hemophilia. Which instruction should the nurse include to promote a safe environment for the child?

Eliminate any toys with sharp edges from the child's play area.

The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement?

"If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it.

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?

"I can take aspirin or my antihistamine if I need it." Aspirin and other over-the-counter medications should not be taken unless the client consults with the PHCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected; however, after the dosage is stabilized, a weight gain of 5 pounds (2.25 kg) or more weekly should be reported to the PHCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is neededwhen the client makes which statement?

"I will raise the volume of my hearing aid." To reduce or eliminate whistling from a hearing aid, it should be reinserted, making certain that no hair is caught between the ear mold and canal. The ear mold or ear can be cleansed, and lowering the volume of the aid might help.

The nurse has provided home care instructions to a client who had a subtotal gastrectomy. The nurse instructs the client on the signs and symptoms associated with dumping syndrome. Which client statement indicates that teaching was effective?

"It will cause diaphoresis and diarrhea." Dumping syndrome occurs after gastric surgery because food is not held for as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine, causing cardiovascular and gastrointestinal symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

The nurse is caring for a client with myasthenia gravis who has received edrophonium by the intravenous route to test for myasthenic crisis. The client asks the nurse how long the improvement in muscle strength will last. Which response should the nurse make to the client?

"It will last for 4 to 5 minutes." Edrophonium commonly is given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication. Within 30 to 60 seconds, most myasthenic clients show a marked improvement in muscle tone that lasts for 4 to 5 minutes.

The nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, the nurse should take which action?

Administer a dose of a prescribed antacid. The client on a mechanical ventilator who has a nasogastric tube in place should have the gastric pH monitored at the beginning of each shift or at least every 12 hours. Because of the risk of stress ulcer formation, a pH lower than 5 (acidic) should be treated with prescribed antacids. If there is no prescription for the antacid, the primary health care provider should be notified. Documentation of the findings should be done after the administration of an antacid.

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats/minute. A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin.

A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication?

Acidosis. Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis, and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply.

Administering oxygen. Inserting a Foley catheter. Administering furosemide. Administering morphine sulfate intravenously. Pulmonary edema is a life-threatening event that can result from severe heart failure.

The nurse determines that which client is at highest risk for suicide?

An 18-year-old who abuses both alcohol and drugs and who will not meet the requirements for graduation. Some risk factors associated with suicide include previous suicide attempts, mental disorders, co-occurring mental and alcohol and substance abuse disorders, family history of suicide, and impulsiveness or aggressive tendencies. The suicide rate is higher among men, although women make more attempts at suicide.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all of the doctor's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement?

An expected coping mechanism. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or another spiritual being, or caregivers.

A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result?

Blood urea nitrogen level. Succimer is a medication that is used to treat lead poisoning. Renal function (blood urea nitrogen and creatinine) is monitored closely during the administration of chelation therapy because the medication is excreted via the kidneys.

The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities?

Bone resorption and regeneration. Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning.

A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome?

Bradycardia and confusion. Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is mostunstable?

CO 3 L/min, PCWP high. The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.

The nurse takes a newly admitted client's vital signs, completes an admission assessment history on the client, and assists the client to change into a hospital gown. By completing these tasks, the nurse is demonstrating which role of the nurse?

Caregiver. The nurse is practicing basic nursing skills. Some of the tasks can be delegated, but the nurse chose to perform them, so the nurse is acting as a caregiver. A manager coordinates the care of a client, an educator teaches a client, and an advocate upholds a client's rights.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings. In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 Cs"—coughing and choking with feedings and unexplained cyanosis—should be suspected to have tracheoesophageal fistula.

The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place, activates the fire alarm, and takes which action next?

Closes the doors to the other clients' rooms. In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next priority is to activate the fire alarm and report the exact location of the fire to emergency personnel to aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels under the doorways to prevent the spread of smoke. The nurse then would obtain the fire extinguisher, pull the pin, and extinguish the fire.

Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) should be reported to the primary health care provider (PHCP)?

Cloudy yellow dialysate output. CAPD is a form of peritoneal dialysis in which exchanges are completed 4 or 5 times daily. Peritonitis is a major complication of this type of dialysis. Peritonitis can be recognized by cloudy dialysate outflow, fever, abdominal guarding (board-like abdomen), abdominal pain, pain on inflow, malaise, nausea, and vomiting. The client has the right to refuse medications, but it also is important for the nurse to explain the importance of medications to the client.

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education?

Comminuted fracture. A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 9:00 a.m. for surgery that is scheduled for 9:15 a.m. What initial action should the nurse take in relation to the characteristics of the medication action?

Consult the surgeon, as there is not sufficient time for the dilative effects to occur. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis. The nurse should consult with the surgeon about the time of administration of the eye drops, because 15 minutes is not adequate time for dilation to occur.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs. Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as heart failure (lung crackles) is an adverse effect of daunorubicin. Bone marrow depression is also an adverse effect. Fever is a frequent side effect and sores in the mouth and throat can occur occasionally.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide?

Drink 3000 mL of fluid a day. Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day, unless otherwise contraindicated. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the primary health care provider because this may indicate hypersensitivity.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action should the nurse take to eliminate the problem?

Empty excess accumulated water from the ventilatory circuit tubing. High-pressure alarms can be triggered by increased airway resistance caused by excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Excess water should be emptied from the tubing.

A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the primary health care provider to prescribe?

Fresh-frozen plasma. Fresh-frozen plasma is often used for volume expansion as a result of fluid and blood loss. It is rich in clotting factors and can be thawed quickly and transfused quickly. Platelets are used to treat thrombocytopenia and platelet dysfunction. Granulocytes may be used to treat a client with sepsis or a neutropenic client with an infection that is unresponsive to antibiotics. Packed red blood cells are a blood product used to replace erythrocytes.

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5° C (101.2° F). Which nursing action is most appropriate?

Notify the primary health care provider. A temperature of 101.2° F (38.5° C) is significantly elevated and may indicate infection. The nurse should notify the primary health care provider (PHCP). Dialysis clients cannot have fluid intake encouraged. Vital signs and the shunt site should be monitored, but the PHCP should be notified first.

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.

Hypotension. Hyperkalemia. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine.

The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this client?

Increased. The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentage of platelet aggregation. Increased platelet aggregation may occur after surgery or with acute illness, venous thrombosis, and pulmonary embolism.

The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care?

Initiate bleeding precautions. Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia).

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?

Lack of naturally occurring endorphins. Craving opiates is a result of the diminished production of endorphins that occurs with long-term abuse of the drug.

The nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter?

Limiting both movement and abduction of the right arm. In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

Provide authority, action, and participation. The person who intervenes in this situation (the nurse) "takes over" for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies.

A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 lb 2 oz (7.8 kg). The parents state that his preadmission weight was 18 lb 4 oz (8.3 kg). Based on weight alone, what type of dehydration does the nurse expect?

Moderate dehydration. Mild dehydration is a weight loss less than 5%; moderate dehydration is 5% to 10%; severe dehydration is greater than 10% weight loss. All types of dehydration are acute situations. The answer can be determined by calculating the percent of weight loss in dehydration.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome?

Numbness and tingling in the fingers. The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign.

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action?

Observing rigid rules and regulations. Clients with anorexia nervosa have the desire to please others. Rules and rituals help them manage their anxiety. Their need to be correct or perfect interferes with rational decision-making processes. These clients generally don't engage in self-mutilation.

The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse should plan to place the infant in which position?

On the left side. Following cleft lip repair, the infant should be positioned supine or on the side lateral to the repair to prevent the suture line from contacting the bed linens. Immediately after surgery, it is best to place the infant on the left side rather than supine to prevent aspiration if the infant vomits.

A client who has had a prostatectomy is complaining of pain from bladder spasms. The nurse checks the primary health care provider's prescription sheet and expects to see which medication prescribed to treat the problem?

Oxybutynin. Bladder spasms after prostatectomy are treated with antispasmodic medications, such as oxybutynin.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

Polyuria. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus.

Which interventions are appropriate for the care of an infant? Select all that apply.

Provide swaddling. Hang mobiles with black and white contrast designs. Caress the infant while bathing or during diaper changes.

The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother. Iron supplements are routinely encouraged. Calcium is critical during the third trimester but must be increased from the onset of pregnancy.

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education?

Properly glazed pottery. Paint chips, soil contaminated with lead, lead solder used in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.

Red meats. Whole-grain cereals. Carbonated beverages. When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. Low-calorie desserts should also be avoided.

Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.

Reduce exposure to environmental organisms. Use strict aseptic technique for all procedures. Ensure that anyone entering the child's room wears a mask. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room. Applying firm pressure to a needle-stick area for at least 10 minutes is a measure to prevent bleeding.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases. This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further.

The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

She will feel some pressure when the vaginal probe is moved. Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket.

A confrontation test is prescribed for a client seen in the eye and ear clinic. How should the nurse perform this test? Arrange the actions in the order that they should be performed. All options must be used.

Stand 2 to 3 ft (60 to 90 cm) in front of the client and face him or her; client covers 1 eye on request; nurse covers the eye opposite the one covered by the client; an object is gradually brought inward from the periphery; and the client reports when the object is first noted.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?

Temperature of 101.6° F (38.7° C) orally. Watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F (38.7° C) should be reported.

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion?

The cardiac output is below the normal range. The normal cardiac output for the adult can range from 4 to 7 L/min. Therefore, a cardiac output of 3.2 L/min is below normal range.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client was found lying on the floor. The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The correct option is the only one that describes the facts as observed by the nurse.

The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first?

The confused 12-year-old with bright red blood pulsing from an open fracture of the femur. Triage systems identify who should be treated first. Rankings are based on immediacy of needs, including immediate threats to life such as airway compromise or hemorrhagic shock. The 12-year-old who is demonstrating confusion is becoming hypoxic because of profound blood loss.

The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the discussion with the client?

The device is applied before getting out of bed in the morning. After spinal surgery, a brace or corset may be required temporarily to support the spine. Clients who have lumbar or thoracic spinal fusions wear a fiberglass brace, which resembles a shell. Initially, back braces or corsets may be worn constantly, whether the client is in or out of bed.

A 2-year-old with Pneumocystis jirovecipneumonia is to begin treatment with highly active antiretroviral therapy (HAART). The nurse anticipates that the primary health care provider will prescribe which combination?

Two nucleoside analogues and one protease inhibitor. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection in the client with acquired immunodeficiency syndrome. HAART consists of the combination of 2 nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase.

The nurse has determined that an unconscious client is at risk for nutritional problems. Which outcome indicates to the nurse that the goals have not yet been fully met?

Total protein concentration of 4.5 g/dL (45 g/L). The normal total protein level is 6.4 to 8.3 g/dL (64 to 83 g/L). The normal BUN is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). Expected outcomes for nutritional problems in an unconscious client include stable weight, intake equaling output, evidence of wound healing, and normal BUN, total protein, and hemoglobin levels.

A client newly diagnosed with diabetes mellitus is started on a 2-dose insulin protocol combination of short- and intermediate-acting insulin injected twice daily. What portion of the total dose is given before breakfast, and what portion is given before the evening meal?

Two thirds before breakfast and one third before the evening meal. Initially the 2-dose insulin protocol is two thirds of the dose before breakfast and one third before the evening meal. Any future changes in these ratios are based on results of blood glucose monitoring.

Phenazopyridine is prescribed for a client with a urinary tract infection. The nurse evaluates that the medication is effective based on which observation?

Urination is not painful. Phenazopyridine is a urinary analgesic. It is effective when it eliminates pain and burning with urination. It does not eliminate the bacteria causing the infection, so it would not make the urine clear amber. It does not treat urge incontinence. It will cause the client to have reddish-orange discoloration of urine, but this is a side effect of the medication, not the desired effect.

The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn?

Use of accessory muscles for breathing. Clinical indicators of respiratory injury in a burn-injured client include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing.