nclex saunders pt. 8

The nurse is providing client and family instructions for a client who has been recently diagnosed with glaucoma. Which statement indicates that the client's family member needs further teaching regarding the eye drop application of pilocarpine hydrochloride (Isopto Carpine)? Select all that apply. 1. "I should apply the eye drops directly over my family member's pupil." 2. "I will apply the eye drops into a sac made by pulling down on his lower eyelid." 3."I have to contact the prescriber if my family member develops a small pupil." 4."I should count the drops as I'm applying them to ensure the accurate number is given." 5."I need to wipe off the tip of the eye drop bottle with a tissue between administrations."

1. "I should apply the eye drops directly over my family member's pupil." 3. "I have to contact the prescriber if my family member develops a small pupil." 5. "I need to wipe off the tip of the eye drop bottle with a tissue between administrations." Option 1 indicates incorrect understanding: The eye drops should not be given directly over the pupil. Option 3 indicates incorrect understanding: The intended effect of the medication is pupil constriction, and it is not necessary to notify the prescriber. Option 5 indicates incorrect understanding: Wiping off the eye drop bottle with a tissue would easily transmit infection. Option 2 indicates understanding of using the conjunctival sac as the correct administration site. Option 4 indicates correct understanding that the correct number of drops should be applied.

The nurse is preparing to administer ribavirin (Virazole) to a child with respiratory syncytial virus (RSV). The pharmacy dispenses the medication as a powder. Which action does the nurse perform to prepare to administer the medication? 1. Mixing the medication as prescribed and administering by inhalation 2. Mixing the medication in formula and administering it orally to the child 3. Mixing the medication in sterile saline and administering it by subcutaneous injection 4. Mixing the medication in sterile water and administering it by intramuscular injection

1. Mixing the medication as prescribed and administering by inhalation Ribavirin is active against RSV, influenza virus types A and B, and herpes simplex virus. It is administered by inhalation, and the medication is absorbed from the lungs and achieves high concentrations in respiratory tract secretions and erythrocytes. It is not administered orally, subcutaneously, or intramuscularly.

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique should the nurse anticipate being used to check for evidence of birth trauma? 1. Palpating the clavicles for a fracture 2.Listening to the heart for a cardiac defect 3.Blanching the skin for the evidence of jaundice 4.Performing Ortolani's maneuver for hip dislocation

1. Palpating the clavicles for a fracture Because of the neonate's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles and/or brachial plexus palsy. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. Option 2 is not related to birth trauma. Option 3 would not be present initially. Hip dislocation is congenital and is not caused by birth trauma.

The nurse is preparing a client for surgery. Which would be a component of the plan of care? 1. Review the results of the preoperative laboratory studies. 2.Report any increases in blood pressure on the day of surgery. 3.Instruct the client to avoid oral hygiene on the morning of surgery. 4.Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery.

1. Review the results of the preoperative laboratory studies. The nurse needs to review the results of the preoperative laboratory studies and notify the health care provider of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours. Oral hygiene is allowed, but the client should not swallow any water.

The nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate (Cyclogyl) eye drops are prescribed to be administered preoperatively. The nursing instructor asks the student about the action of the eye drops. The student appropriately responds when communicating which action of the medication? 1. Initiate miosis in the operative eye. 2. Dilate the pupil of the operative eye. 3. Constrict the pupil of the operative eye. 4. Provide the necessary lubrication to the nonoperative eye.

2. Dilate the pupil of the operative eye. Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. It is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis to dilate the eye. Options 1, 3, and 4 are incorrect actions of this medication.

Letrozole (Femara) is prescribed for a postmenopausal client with advanced breast cancer. Which side effect of this medication should the nurse reinforce in the instructions to the client regarding this medication? 1. Diarrhea 2. Leg pain 3. Insomnia 4. Nervousness

2. Leg pain Letrozole is an aromatase inhibitor used to treat advanced breast cancer in postmenopausal women whose disease progressed after antiestrogen therapy. The most frequent side effects include skeletal, back, arm, and leg pain. Less frequent side effects include nausea, headache, fatigue, constipation, vomiting, and dyspnea.

The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values should the nurse expect to note in this client? 1. Sodium of 145 mEq/L 2. Potassium 5.4 mEq/L 3.Magnesium 2 mEq/L 4.Phosphorus 2.3 mEq/L

2. Potassium 5.4 mEq/L Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering. In acidosis, extracellular hydrogen ion content increases and hydrogen ions then begin to move into intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions must leave the cell, creating a relative hyperkalemia. Sodium, magnesium, and phosphorus would remain within normal range.

A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous tests to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, which condition should the nurse suspect the client may be experiencing? 1. Psychosis 2. Repression 3. A conversion disorder 4. A dissociative disorder

3. A conversion disorder A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed a murder that was so psychologically painful, the client became deaf. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

The nurse is caring for a client with heart failure. The client suddenly becomes anxious and restless, has a sudden onset of breathlessness, and becomes cyanotic. The nurse suspects pulmonary edema and immediately places the client in which bestposition? 1. Lithotomy 2.Low-Fowler's 3.High-Fowler's 4.Trendelenburg's

3. High-Fowler's Positioning the client upright (high-Fowler's position), with the legs dangling over the side of the bed, has an immediate effect of decreasing venous return and decreasing lung congestion. Low-Fowler's position will not achieve this effect. The supine position is a flat position, and when in Trendelenburg's position, the client is flat with the head lower than the rest of the body. These positions would worsen the client's condition.

Docetaxel (Taxotere) is prescribed for a client with metastatic breast cancer. In addition, dexamethasone is prescribed to be administered before initiation of the docetaxel. What is the rationale for the addition of dexamethasone to the treatment plan that the nurse should explain to the client? 1. Prevents neutropenia 2. Prevents thromboembolic disorders 3. Reduces the severity of fluid retention 4. Enhances the effects of the docetaxel

3. Reduces the severity of fluid retention Docetaxel is an antineoplastic medication. Frequent side effects include alopecia, hypersensitivity reaction, fluid retention, nausea, vomiting, diarrhea, fever, myalgia, and nail changes. Before receiving docetaxel, the client is premedicated with an oral corticosteroid to reduce the severity of fluid retention and prevent a hypersensitivity reaction. Options 1, 2, and 4 are not actions of dexamethasone. In addition, dexamethasone is used with caution in the client with thromboembolic disorders.

The nurse hangs a 1000-mL bag of intravenous (IV) fluid on an assigned client. Forty-five minutes later, the nurse notes that the client is complaining of a pounding headache, is dyspneic, is apprehensive, and has an increased pulse rate. The IV bag has 500 mL remaining. The nurse should take which action? 1. Remove the IV. 2. Sit the client up in bed. 3. Shut off the IV infusion. 4. Slow the rate of infusion.

3. Shut off the IV infusion. The client's symptoms are compatible with speed shock. This may be verified by noting that 500 mL has infused in the course of 45 minutes. The first action of the nurse is to shut off the IV infusion. Other actions may follow in rapid sequence. The nurse may elevate the head of the bed to aid the client's breathing. The health care provider is notified immediately. Slowing the infusion rate is inappropriate because the client will continue receiving fluid. The IV does not have to be removed; it may be needed to manage the complication.

A client with human immunodeficiency virus (HIV) who is taking an oral solution of ritonavir (Norvir) complains about the taste of the solution. Which response by the nurse is accurate? 1. "Try refrigerating the solution." 2."Take the medication at bedtime." 3."Mix the oral solution with chocolate milk." 4."You need to notify the health care provider."

3."Mix the oral solution with chocolate milk." Ritonavir oral solution is preferably administered with a food substance. It may be mixed with chocolate milk or a dietary supplement to improve the taste. The client also is instructed to consume the dose within 1 hour of mixing. It is not necessary to notify the health care provider. Taking the medication at bedtime or refrigeration of the medication will not have an effect on the taste of the oral solution.

The nurse reinforces instructions to a client who has been prescribed betaxolol eye drops for the treatment of glaucoma. The nurse instructs the client regarding the administration of the medication and about the importance of returning to the clinic for which assessment? 1. Temperature 2. Pupil dilation 3 .Presence of Trousseau's sign 4. Blood pressure and apical pulse

4. Blood pressure and apical pulse Betaxolol is an antiglaucoma medication and a beta-adrenergic blocker. Hypotension manifested as dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. For the client taking this medication, the nurse also monitors bowel activity and monitors for the evidence of heart failure (HF) as manifested by dizziness, night cough, peripheral edema, and distended neck veins. An increase in weight and a decrease in urine output may also be indicative of HF, so intake and output should also be monitored. Pupil dilation and monitoring temperature are unrelated to the use of this medication. A positive Trousseau's sign indicates a calcium imbalance. Test-Taking Strategy: Focus on the subject, the name of the medication, and recall that medication names that end with the letters, -lol, are beta blockers and that these types of medications are frequently used to treat hypertension. Also use the ABCs—airway, breathing, and circulation—to direct you to the correct option.

A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. Which should the nurse do immediately? 1. Gently push the cord into the vagina and place the client on her side. 2.Transport the client to the delivery room and call the health care provider. 3.Summon for help from other staff members and place the client supine and flat. 4.Place a gloved hand into the vagina and hold the presenting part off of the umbilical cord.

4. Place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should also place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. The nurse should summon for help, and other staff members should contact the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is also administered to the mother to increase fetal oxygenation.

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives in the unit, which action should the nurse do first? 1. Weigh the child. 2. Take the child's temperature. 3. Ask the parents about the child. 4. Place the child on a pulse oximeter.

4. Place the child on a pulse oximeter. To adequately determine whether the child is getting enough oxygen, the child is placed on a pulse oximeter. The pulse oximeter will then provide ongoing information on the child's oxygen level. The child is also immediately placed on a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse would then gather data including taking the child's temperature and weight and asking the parents about the child.

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication? 1. "I should apply the medication to my entire body, washing it off after 2 hours." 2. "I will apply the application to my entire body and leave it on for 24 hours, followed by a cleansing bath." 3."I should apply the medication to my entire body, avoiding the skin folds and creases and wash it off in 12 hours." 4."I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

4."I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application." The client is instructed to massage the medication into the skin of the entire body, starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skin folds and creases. Contact with eyes, mucous membranes, and any region of inflammation should be avoided. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application, and, if needed, treatment can be repeated in 7 days.

The nurse responds to an external disaster (a mass casualty event) that occurred in a large city when a building collapsed. There are numerous victims that require treatment. Which victim should the nurse attend to first? 1. An alert victim who has numerous bruises on the arms and legs 2.A victim who received a head injury and is crying hysterically 3.A victim who sustained multiple serious injuries and is deceased 4.A victim with a partial amputation of a leg who is bleeding profusely

4.A victim with a partial amputation of a leg who is bleeding profusely The nurse determines which victim will be attended to first based on the acuity level of the victims involved in the disaster. The victim who must be treated immediately or life, limb, or vision will be threatened is categorized as emergent and is the priority (option 4). The victim who requires treatment, but life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority (option 2). If the victim requires evaluation and possible treatment, but time is not a critical factor, then that person is categorized as nonurgent and is the third priority (option 1). In such a disaster, the victim who sustained multiple serious injuries and is deceased is not the priority.

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change? 1. Advancing the drain by ¼ inch 2. Wearing clean gloves during the procedure 3.Securing the drain by taping it firmly to body 4.Checking the wound site for drainage from the drain

4.Checking the wound site for drainage from the drain The wound site needs to be checked for drainage from the drain; the drainage can excoriate the skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action would be immediate? 1. Clamp the chest tube. 2. Instruct the client to inhale. 3.Call the health care provider. 4.Reattach the chest tube to the drainage system.

4.Reattach the chest tube to the drainage system. In most situations, clamping chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. The nurse would also notify the registered nurse of the occurrence. The health care provider will need to be notified, but this is not the immediate action. The client would not be instructed to inhale.

what is conization?

A procedure in which a cone-shaped piece of abnormal tissue is removed from the cervix. A scalpel, a laser knife, or a thin wire loop heated by an electric current may be used to remove the tissue

The nurse is collecting data from a client suspected of having ovarian cancer. Which question should the nurse ask the client to elicit information specifically related to this disorder? 1. "Have you been having diarrhea?" 2. "Have you had any abnormal vaginal bleeding?" 3. "Are you having any excessive vaginal bleeding?" 4. "Does your abdomen feel as though it is swollen?"

"Does your abdomen feel as though it is swollen?" Signs/symptoms of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, and constipation. Ascites with dyspnea and ultimately general severe pain will occur as the disease progresses. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

what is enucleation?

Enucleation is the removal of the eye that leaves the eye muscles and remaining orbital contents intact. This type of ocular surgery is indicated for a number of ocular tumors, in eyes that have suffered severe trauma, and in eyes that are otherwise blind and painful

The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. Based on these findings, the initial nursing action is which? 1. Remove the IV. 2. Slow the rate of infusion. 3. Notify the health care provider. 4. Check for loose catheter connections.

1. Remove the IV. Phlebitis at an IV site can be determined by client discomfort at the site, as well as by redness, warmth, and swelling proximal to the catheter. The line should be removed, and a new line should be inserted at a different site. Options 2 and 4 are incorrect. The health care provider should be notified if phlebitis occurred, but this is not the initial action.

The nurse has reinforced discharge instructions to a mother of a child who is taking tetracycline (Sumycin) to treat Rocky Mountain spotted fever (RMSF). Which statement by the mother indicates an understanding regarding the administration of the medication? 1. "I need to give the medication with milk." 2. "I need to give the medication with a sip of water." 3. "I need to use a straw when I give the medication." 4. "I need to mix the medication in a Styrofoam cup with water."

3. "I need to use a straw when I give the medication." Because tetracycline hydrochloride can cause staining of the teeth, straws should be used, and the mouth should be rinsed after administration. Option 4 is not necessary. The medication should be administered 1 hour before or 2 hours after the administration of milk. A full glass of water rather than a sip should be taken with the medication.

A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note which uterine fundus position? 1. To the left of the abdomen 2. To the right of the abdomen 3.At the level of the umbilicus 4.Two fingerbreadths above the symphysis pubis

3.At the level of the umbilicus Immediately after delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is more than 1 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure? 1. Pelvic exam 2. Amniocentesis 3.Contraction stress test 4.Chorionic villus sampling

3.Contraction stress test A client with painless vaginal bleeding is at risk for going into labor, and a contraction stress test is indicated. The concern is that if fetal oxygenation is only marginally adequate when the uterus is at rest, it may be decreased further during uterine contractions. Options 2 and 4 are not appropriate at this time. A pelvic examination is contraindicated when there is vaginal bleeding

The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should the nurse expect to note at this time? 1. Pink lochia 2. White lochia 3.Dark red lochia 4.Serosanguineous lochia

3.Dark red lochia In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red. Options 1, 2, and 4 are not the expected characteristics of lochia at this time.

The nurse who is assisting in caring for a client with a tracheostomy tube notes heavy bleeding from the stoma. The nurse also notes that the tracheostomy tube pulsates with the client's heartbeat. The nurse immediately performs which action? 1. Transports the client to surgery. 2. Administers supplemental oxygen. 3. Initiates an intravenous (IV) line. 4. Applies pressure to the artery at the stoma site.

4. Applies pressure to the artery at the stoma site. Heavy bleeding from a tracheostomy site is a life-threatening complication. Direct pressure is applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action.

A client who experienced ventricular fibrillation has just been defibrillated. Following the defibrillation, which action should the nurse take immediately? 1. Increase the intravenous flow rate. 2.Check the client's neurological status. 3.Take the client's blood pressure and pulse. 4.Resume cardiopulmonary resuscitation (CPR)

4.Resume cardiopulmonary resuscitation (CPR) Following defibrillation, the nurse immediately resumes CPR for 2 minutes. Even if a normal rhythm has been restored, the heart pump needs to be re-primed to provide improved cerebral blood flow to improve neurological outcome. Options 1, 2, and 3 are not immediate actions following defibrillation.

what is renal colic?

Renal colic is a type of abdominal pain commonly caused by obstruction of ureter from dislodged kidney stones. The most frequent site of obstruction is the vesico-ureteric junction (VUJ), the narrowest point of the upper urinary tract.

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which should the nurse assigned to care for the client do first? 1. Take the client to a quiet room. 2. Teach the client how to take deep breaths. 3. Ask the client to describe the events of the accident. 4. Ask the client to talk to the police about what she witnessed.

Take the client to a quiet room. If a client with severe anxiety is left alone, he or she may feel abandoned and become overwhelmed. Placing the client in a quiet room is a priority intervention, but the nurse must stay with the client. It is not possible to teach the client deep breathing or relaxation exercises until the anxiety decreases. Asking the client to describe the events of the accident or to talk to the police should not be implemented until the anxiety has decreased.

Efavirenz (Sustiva), an antiviral medication, is prescribed for a client with human immunodeficiency virus (HIV) infection. Which time should the nurse tell the client is best to take this medication? 1. At bedtime 2.With lunch 3.With dinner 4.Before breakfast

1. At bedtime Because the medication causes temporary nervous system side effects during the first 2 to 4 weeks of therapy, the client is instructed to take the medication at bedtime. Because of the nervous system effects, options 2, 3, and 4 are not recommended administration times

Capecitabine (Xeloda) is prescribed for a client with metastatic breast cancer. The nurse reinforces information to the client about the medication including what frequent side effect? 1. Diarrhea 2. Headache 3.Myalgia 4.Dyspepsia

1. Diarrhea Capecitabine is an antineoplastic medication. Diarrhea is a frequent side effect associated with the medication. Headache, myalgia, and dyspepsia can occur with the use of this medication, but these are not frequent side effects.

The nurse is collecting data from a client and is observing the client ambulate with the use of a cane. For which client action, when observed, should the nurse intervene and suggest a physical therapy referral? 1. The client holds the cane close to the body. 2. The client holds the cane on the unaffected side. 3. The client moves the cane and the unaffected side together. 4.The cane handle was parallel to the greater trochanter of the femur.

3. The client moves the cane and the unaffected side together. The client should move the cane and the affected side together. The cane helps support the affected side as it moves forward. It also helps the client maintain balance. The client holds the cane on the unaffected side to shift the client's weight away from the affected side. The client holds the cane close to the body to prevent the client from leaning. The cane's handle should reach the level of the greater trochanter of the client's femur with a 25- to 30-degree flexion at the client's elbow.

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, which is important for the nurse to understand? 1. The client is allowed to set the goals for the plan of care. 2. Letting the client act out and using the quiet room and restraints will be required initially. 3. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition. 4. Refraining from pointing out the inconsistencies of the client's communication is essential to initial treatment.

3. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition. As the nurse plans care for the schizophrenic client, it is important to understand the client's developmental stage and ability to accept the disease. Because of the severe decompensation in thinking, the client lacks insight and may not even acknowledge illness. In the acute phase, the nurse will take the lead in planning for the client's basic human needs such as nutrition, hygiene, sleep, and activities of daily living (ADLs). Options 1, 2, and 4 are incorrect.

A client with heart failure who is taking furosemide (Lasix) and digoxin (Lanoxin) calls the nurse and complains of anorexia and nausea. The nurse should take which action? 1. Administer an antiemetic. 2. Hold the morning dose of furosemide. 3. Administer the daily dose of digoxin. 4. Check the result of the potassium level drawn 3 hours ago.

4. Check the result of the potassium level drawn 3 hours ago. Anorexia and nausea are two of the common symptoms associated with digoxin toxicity, which is compounded by hypokalemia. The nurse should first check the results of the potassium level. This would provide additional data to report to the health care provider, which is a key follow-up nursing action. The nurse would not hold the furosemide without a prescription to do so, given the information provided. The nurse would withhold the digoxin and notify the registered nurse, who would contact the health care provider because digoxin toxicity is suspected. The nurse would not administer an antiemetic without further investigating the client's problem. The digoxin blood level should also be checked. Test-Taking Strategy: Focus on the data in the question. Use the steps of the nursing process to answer the question. Option 4 is the only option that addresses data collection.

The nurse is collecting data from a client who is experiencing the typical signs/symptoms of tuberculosis (TB). The nurse should expect the client to report having symptoms of fatigue and cough that have been present for how long? 1. A day or two 2. Almost a week 3. One to 2 weeks 4. Several weeks to months

4. Several weeks to months The client with tuberculosis may report symptoms that have been present for weeks or even months. The symptoms may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.

The nurse is caring for a hospitalized client following cystoscopy and is monitoring for signs of complications associated with the procedure. Which result noted in the first few hours following the procedure indicates the need to notify the registered nurse? 1. Yellow urine 2. Pink-tinged urine 3.Pale yellow urine 4.Bloody urine with clots

4.Bloody urine with clots The client may have clear, yellow, or pink-tinged urine after cystoscopy. Bloody urine with clots is always an abnormal finding and should be reported immediately

A client with acute nonlymphocytic anemia receives treatment with cytarabine (ARA-C). The nurse reinforces medication instructions to the client and tells the client that it is important to report which adverse effect to the health care provider? 1. Nausea 2. Anorexia 3.Headache 4.Sore throat

4.Sore throat The major adverse effect of cytarabine is bone marrow depression resulting in hematological toxicity. Signs of hematological toxicity include fever, sore throat, signs of local infection, easy bruising, or unusual bleeding from any site. If these signs occur, the health care provider (HCP) is notified. Anorexia, nausea, and a transient headache can occur as side effects of the medication but do not necessarily warrant HCP notification unless they are persistent.

what is keratoplasty?

Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty.

The nurse collects data from a client with a diagnosis of macular degeneration of the eye. The nurse should expect the client to report which symptom? 1. Blurred central vision 2. Loss of peripheral vision 3.Clear vision when reading 4.Increased clarity when looking at objects

1. Blurred central vision The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients may complain of visual distortion usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk.

The nurse is reinforcing client education regarding symptoms of testicular cancer. The nurse encourages the client to report which symptoms as being associated with testicular cancer? Select all that apply. 1. Difficulty attaining an erection 2. Purulent discharge from the penis 3. A grainy mass palpated in a testicle 4. Difficulty initiating the urine stream 5. An enlargement of one of the testes

3. A grainy mass palpated in a testicle 5. An enlargement of one of the testes A grainy mass palpated in a testicle and enlargement of the testes are symptoms of testicular cancer and should be reported. The other symptoms are not associated with testicular cancer.

The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? 1. Check the hourly urine output. 2. Check the client's pulse oximetry. 3. Check the intravenous (IV) site for infiltration. 4. Place the client in modified Trendelenburg's position.

4. Place the client in modified Trendelenburg's position. The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's blood volume status by assessing the urine output and ensuring that the IV is infusing without complications. The nurse should also check the client's pulse oximetry and notify the registered nurse.

The nurse is caring for a client following enucleation. On data collection, the nurse notes staining and bleeding on the dressing. The nurse should take which action? 1. Document the findings. 2.Reinforce the dressing. 3.Notify the registered nurse. 4.Mark the amount of staining with a black pen.

3.Notify the registered nurse. Postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon. Options 1, 2, and 4 are inaccurate nursing actions if staining or bleeding is present on the dressing following enucleation. The nurse should notify the registered nurse, who would then notify the health care provider immediately.

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply. 1. Bowel sounds are absent. 2. The client's abdomen is distended. 3. Respiratory excursion is diminished. 4.The blood pressure rises when the client sits up. 5.Accessory muscles of respiration are areflexic.

1. Bowel sounds are absent. 2. The client's abdomen is distended. 3. Respiratory excursion is diminished. 5.Accessory muscles of respiration are areflexic. During the period of areflexia (a condition in which your muscles don't respond to stimuli) that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.

The nurse is assisting in caring for a client who is receiving amphotericin B intravenously (IV) to treat disseminated candidiasis. The nurse reviews the plan of care and implements which action during the administration of the medication? 1. Monitors urinary output 2.Monitors blood pressure 3.Monitors for hypothermia 4.Monitors for hyperglycemia

1. Monitors urinary output Amphotericin B is a toxic medication that can produce symptoms during administration such as chills, fever, headache, vomiting, and impaired renal function. The medication is also very irritating to the IV site, commonly causing thrombophlebitis. The nurse administering this medication watches for all of these problems. Options 2, 3, and 4 are not specifically related to the administration of this medication.

Psyllium (Metamucil) is prescribed for a client with a cardiac disorder to facilitate defecation and prevent straining with bowel movements. The nurse reinforces instructions to a client regarding administration of the medication. Which statement by the client indicates an understanding of the use of the medication? 1. "I need to mix the medication with custard." 2. "I should mix the medication with a full glass of water." 3."I should decrease the amount of fiber in my diet when I take this medication." 4."I need to decrease my fluid intake following administration of the medication."

2. "I should mix the medication with a full glass of water." Metamucil is a bulk-forming laxative. It should be taken with a full glass of water or juice (not custard), followed by another glass of liquid. This will help prevent impaction of the medication in the stomach or small intestine. Both fiber in the diet and fluid intake should not be decreased unless specifically prescribed by the health care provider.

The nurse is reviewing the plan of care developed by a nursing student for a client scheduled for keratoplasty. The nurse discusses the plan with the student if which incorrect intervention is listed in the plan? 1. Cutting the client's eyelashes 2. Administering medications that will dilate the pupil 3. Instilling antibiotic ophthalmic medication as prescribed 4. Obtaining a culture and sensitivity with conjunctival swabs

2. Administering medications that will dilate the pupil Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient's eye may include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists prescribe a medication such as 2% pilocarpine to constrict the pupil before surgery.

A client with carcinoma is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. The plan of care mentions observing for interstitial pneumonitis as the priority of care. Which finding most closely correlates to symptoms of interstitial pneumonitis, requires reporting? 1. Barking cough upon exertion 2. Lung wheezing and shortness of breath 3. Productive cough with thick, yellow sputum 4. Distended neck veins with pink, frothy sputum

2. Lung wheezing and shortness of breath Bleomycin sulfate is an antineoplastic medication that can cause interstitial pneumonitis that can progress to pulmonary fibrosis. Pulmonary function studies along with hematologic, hepatic, and renal function tests need to be monitored. The nurse needs to monitor the respiratory status for dyspnea and wheezes that indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Productive cough is symptomatic of bacterial pneumonia. Distended neck veins and pink, frothy sputum are symptoms of heart failure. A barking cough is not a symptom of interstitial pneumonitis.

Zidovudine (AZT) is prescribed for an adult client with human immunodeficiency virus (HIV). Which statement by the nurse provides the best instruction to the client about the medication? 1. "This medication must be taken with milk." 2. "Discontinue the medication if nausea occurs." 3."Space the medication doses evenly around the clock." 4."Aspirin can be taken to treat a headache if one occurs."

3."Space the medication doses evenly around the clock." Zidovudine interferes with HIV replication, slowing the progression of HIV infection. The client is instructed to space the doses of the medication evenly around the clock. Food or milk does not affect the gastrointestinal absorption of the medication. The client is instructed to continue therapy for the full length of treatment. The client also is instructed not to take any medication, including aspirin, without the health care provider's approval.

The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication? 1. Neomycin 2.Penicillin 3.Silver nitrate 4.Erythromycin

4.Erythromycin Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the baby's passage through the birth canal. Ophthalmia neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria.

The nurse discusses emergency nursing measures that are implemented at the site of an injury with a nursing student. Which initial action does the nurse tell the student to perform in the event of carbon monoxide poisoning? 1. Carry the client to fresh air. 2. Wrap the client in blankets. 3. Keep the client as quiet as possible. 4. Initiate cardiopulmonary resuscitation (CPR).

1. Carry the client to fresh air. Whenever a victim inhales a poison, the victim is carried immediately to fresh air. Any tight clothing is then loosened and CPR is initiated if necessary. Oxygen is administered as soon as possible. Chilling is prevented, and the victim is wrapped in blankets and kept as quiet as possible.

The nurse on the day shift receives client assignments for the day. Which assigned client should the nurse check first? 1. A client with a diagnosis of ulcerative colitis who is scheduled to be discharged today 2. A client who was admitted during the night because of a severe exacerbation of asthma 3.A client scheduled for a kidney, ureter, and bladder (KUB) x-ray to determine the location of a kidney stone 4.A client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system

2. A client who was admitted during the night because of a severe exacerbation of asthma The nurse would first check the client who was admitted during the night because of a severe exacerbation of asthma. This client's problem directly relates to airway, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next check the client who had a pulmonary wedge resection 2 days ago and is attached to a closed chest tube drainage system. This client's problem also relates to airway; however, there is no indication that this client is experiencing any severe problems. The nurse would next assess the client scheduled for a KUB. The nurse would want to ensure that this client understands the reason for the x-ray. Additionally, the nurse needs to determine whether the client is experiencing any pain as a result of the kidney stone. The nurse would next assess the client preparing for discharge to determine the need for reinforcement of home care instructions. Note the strategic word, first. Use the ABCs—airway, breathing, and circulation.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action? 1. Call a code. 2. Assess the client. 3. Confirm the rhythm. 4. Check the cardiac leads and wires.

2. Assess the client. If a monitor alarms sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. Asystole should not be mistaken for an unattached electrocardiogram wire. The other options would be appropriate once the nurse has assessed the client. Note the strategic word, immediate. Use the steps of the nursing process, remembering that data collection is the first step. This will assist you in eliminating options 1 and 4. From the remaining options, select option 2 because it is client-focused. Remember to assess the client first.

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client? 1. Stop nursing until the nipples heal. 2. Begin feeding on the less sore nipple. 3. Avoid rotating breast-feeding positions. 4. Substitute a bottle-feeding until the nipples heal.

2. Begin feeding on the less sore nipple. The nurse would instruct the mother to begin feeding on the less sore nipple. The infant sucks with greater force at the beginning of feeding. Rotating breast-feeding positions, breaking suction with the little finger, nursing frequently, not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness. The mother should be encouraged to continue breast-feeding to maintain adequate milk supply while nipples toughen and adapt to feedings.

The nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which would be the priority action in the plan of care for this child on return from the procedure? 1. Elevate the head of the bed. 2. Check circulation in the feet. 3.Abduct the hips using pillows. 4.Turn the child onto the right side.

2. Check circulation in the feet. During the first few hours after a cast is applied, the primary concern is swelling that may cause the cast to produce a tourniquet-like effect and restrict circulation. Therefore, circulatory assessment is a priority. Elevating the head of the bed of a child in a hip spica cast would cause discomfort. Using pillows to abduct the hips is not necessary because a hip spica cast immobilizes the hip and the knee. Turning the child side to side at least every 2 hours is important because it allows the body cast to dry evenly and prevents complications related to immobility; however, it is not as important as checking circulation. Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to answer this question. Option 2 addresses circulatory status.

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action? 1. Document the finding. 2. Encourage oral fluid intake. 3. Notify the health care provider. 4. Administer acetaminophen (Tylenol).

2. Encourage oral fluid intake. During the first 24 hours following delivery, the mother's temperature may rise to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore, the initial nursing action is to encourage fluid intake. The nurse would document the temperature, but this is not the initial action. Options 3 and 4 are not necessary at this time.

A health care provider places a Miller-Abbott tube in a client who has a bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next? 1. Initiate a tube feeding. 2. Notify the health care provider. 3.Document the finding in the client's record. 4.Pull the tube out 6 cm, and secure the tube to the nose with tape.

3. Document the finding in the client's record. The Miller-Abbott tube is a nasoenteric tube, which is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a health care provider's responsibility. The tube is weighted by a special substance and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. Options 1, 2, and 4 are incorrect nursing actions. The nurse would, however, keep the registered nurse informed about the progress of the tube advancement.

Lamivudine (Epivir) is prescribed for a client with human immunodeficiency virus (HIV) who is presently taking zidovudine (Retrovir). Which should the nurse reinforce in the medication instructions to the client? 1. That the medication must be taken with food 2.That numbness of the hands and feet is expected 3.To report vomiting or abdominal pain to the health care provider 4.To discontinue the zidovudine during the course of therapy with lamivudine

3.To report vomiting or abdominal pain to the health care provider Lamivudine is an antiretroviral agent administered in combination with zidovudine to delay the appearance of zidovudine resistance. Lamivudine is well absorbed orally with or without food. Peripheral neuropathy can occur with its use, and the client is instructed to notify the health care provider if burning, numbness, or tingling of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by nausea, vomiting, and abdominal pain, is also an adverse effect of the medication and requires health care provider notification.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? 1, Prepare for reintubation. 2. Call the health care provider. 3. Call the rapid response team. 4. Check the client for spontaneous breathing.

4. Check the client for spontaneous breathing. If unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance from the registered nurse, and prepare for reintubation. There are no data in the question to indicate that a code needs to be called.

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? 1. Check the blood pressure. 2. Check the oxygen saturation level. 3. Have the client take some deep breaths. 4. Lower the head of the bed slowly until the dizziness is relieved.

4. Lower the head of the bed slowly until the dizziness is relieved. Dizziness or feeling faint is not uncommon when a postoperative client is positioned upright for the first time after surgery. If this occurs, the nurse relieves the feeling by lowering the head of bed slowly until the dizziness subsides. The nurse would then check the pulse and blood pressure. Because the problem is circulatory, not respiratory, options 2 and 3 are not the first actions to take.

A client with chronic obstructive pulmonary disease (COPD) asks the nurse for assistance with preparing a living will. The client tells the nurse that she has not discussed the living will with the family and wanted to make some decisions before discussing the will with the family. Which initial step in preparing this document should the nurse inform the client to do? 1. Talk to the family. 2.Contact a lawyer. 3.Consult with the American Lung Association. 4.Discuss the request with the health care provider.

4.Discuss the request with the health care provider. The client should discuss the request for a living will with the health care provider. The client should also discuss this desire with the family, although in this situation, based on the client's feelings, talking to the family would be the second step. Wills should be prepared with legal counsel and should identify the executor of the estate, address distribution and use of property, and specific plans for burial. Although option 1 may be helpful, this contact would not be the initial step. The lawyer would be contacted following discussion with the health care provider and family.

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions? 1. "I cannot drink or eat anything after midnight on the night before surgery." 2. "I need to discontinue my prescribed knee exercises at least 1 week before surgery." 3."I need to stop taking my prescribed prednisone 48 hours before the scheduled surgery." 4."My last dose of prescribed aspirin (acetylsalicylic acid [ASA]) should be taken the evening before surgery."

1. "I cannot drink or eat anything after midnight on the night before surgery." Antiplatelet medications such as aspirin alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be discontinued abruptly. In fact, additional dosages of the corticosteroid may be necessary before stressful situations, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful. The client should be instructed to maintain a nothing-by-mouth (NPO) status in preparation for surgery.

A client with acquired immunodeficiency syndrome (AIDS) is taking zidovudine (Retrovir) 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results of the blood studies indicate severe neutropenia. Which should the nurse anticipate to be prescribed for the client? 1. Discontinuation of the medication 2. Reduction in the medication dosage 3. Administration of epoetin alfa (Epogen) 4. The administration of prednisone concurrent with the therapy

1. Discontinuation of the medication Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

The nurse is caring for a client diagnosed with Bell's palsy 1 week ago. Which data would indicate a potential complication associated with Bell's palsy? 1. Excessive tearing 2. Partial facial paralysis 3. The ability to taste food 4. Negative outcomes on the electromyography

1. Excessive tearing Complications of Bell's palsy include abnormal return of nerve function; "crocodile tears" (autonomic fibers reconnect to the lacrimal duct instead of the salivary glands, so the client develops excessive tearing while eating); abnormal facial movements because of reinnervation of inappropriate muscles; and spasms, atrophy, and contractures caused by incomplete motor fiber reinnervation. Partial facial paralysis is a factor indicating recovery. Negative outcomes on the electromyography performed 1 week after symptom onset indicate that nerve function is present (a negative test indicates a positive prognostic outcome). Tasting food 1 week after symptom onset indicates a good prognosis for recovery.

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. Which is the most appropriate nursing intervention? 1. Monitor the client for dysrhythmias. 2. Instruct the client to consume low-calcium foods. 3.Instruct the client to include a banana in the daily diet. 4.Instruct the client to consume foods low in magnesium.

1. Monitor the client for dysrhythmias. Hypomagnesemia is defined as a plasma magnesium level less than 1.6 mg/dL. The client should be monitored for dysrhythmias because the client is predisposed particularly to ventricular dysrhythmias. The client also should consume foods high in magnesium. Bananas are high in potassium, not magnesium. Because hypocalcemia frequently accompanies hypomagnesemia, high-calcium foods should be consumed.

The nurse is inserting soft contact lenses into the eyes of a client. Which direction does the nurse tell the client to look? 1. Straight ahead 2.Upward and outward 3.Downward and inward 4.Downward and outward

1. Straight ahead When inserting contact lenses for a client, the nurse tells the client to look straight ahead. This applies to both rigid and soft contact lenses. The other options do not allow the correct eye positioning for inserting the lenses.

A client with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The client calls the nurse at the health care provider's office and reports nausea, vomiting, and abdominal pain. Which instruction should the nurse provide to the client? 1. This is an expected side effect of the medication. 2. Come to the office to be seen by the health care provider. 3. Take crackers and milk with the administration of the medication. 4. Decrease the dose of the medication until the next health care provider's visit.

2. Come to the office to be seen by the health care provider. Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides; decreased serum calcium; and nausea, vomiting, or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. The client should be seen by the health care provider.

Isotretinoin (Accutane) is prescribed for a client to treat severe cystic acne. The nurse tells the client that the length of the usual prescribed course of treatment is which? 1. 1 month 2. 4 to 8 weeks 3. 15 to 20 weeks 4. 1 year

3. 15 to 20 weeks Isotretinoin is usually administered 2 times daily for a period of 15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If needed, a second course may be administered, but not until 2 months have elapsed after completing the first course.

Indinavir (Crixivan) is prescribed for a client with a diagnosis of human immunodeficiency virus (HIV). Which medication instruction should the nurse reinforce to the client? 1. Expect the urine to turn red. 2. Take the medication with a large meal. 3. Increase fluid intake to at least 1.5 L/day. 4. Expect a significant amount of unexplained weight loss.

3. Increase fluid intake to at least 1.5 L/day. Indinavir is an antiretroviral agent. This medication can cause kidney stones; therefore, the client is instructed to increase fluid intake to at least 1.5 L/day. The client is also instructed to report sharp back pain or the presence of blood in the urine. The client is instructed to take the medication 1 hour before or 2 hours after a large meal. If the medication needs to be taken with food, the client should consume a light meal, such as dry toast, juice, or a bowl of cereal with milk. Unexplained weight loss must be reported to the health care provider.

The nurse is reinforcing preoperative instructions to a client scheduled for cataract surgery and prepares a written list of instructions for the client. Which statement by the client indicates a need for further teaching? 1. "My eyelashes may be cut before surgery." 2. "Eye medications will be placed in my eye before the surgery." 3."I can drink any liquids that I want to on the morning of the surgery." 4."Medication may be given to me on the day of surgery to produce relaxation."

3."I can drink any liquids that I want to on the morning of the surgery The client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered, and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back but will grow slowly. Eye medications such as mydriatics, cycloplegics, or beta blockers may be administered before the surgical procedure.

A client has a prescription to receive purified protein derivative (PPD) 0.1 mL intradermally (tuberculin skin test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, 5/8-inch needle. Which technique should the nurse use to insert the needle? 1. At a 45-degree angle with bevel side down 2. At a 30-degree angle with bevel side down 3.Almost parallel to the skin with bevel side up 4.Almost parallel to the skin with bevel side down

3.Almost parallel to the skin with bevel side up A tuberculin skin test is administered by giving 0.1 mL of PPD intradermally. This involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, 5/8-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal, when administered correctly.

A client is admitted to the hospital because of complaints of vomiting and abdominal pain. During data collection, the client tells the nurse that he is taking entacapone (Comtan). Based on this finding, the nurse elicits information from the client regarding the presence of which condition? 1. Hypertension 2 .Hyperlipidemia 3.Parkinson's disease 4.Peripheral vascular disease

3.Parkinson's disease Entacapone is an antiparkinsonian agent used in conjunction with levodopa to improve the quality of life in clients with Parkinson's disease. It is not used to treat cardiovascular disorders. Test-Taking Strategy: Note that options 1, 2, and 4 are comparable or alike in that they all are cardiovascular disorders.

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action? 1. Obtain a set of vital signs. 2.Administer oxygen at 21%. 3.Place the client in high-Fowler's position. 4.Obtain equipment for starting an intravenous line.

3.Place the client in high-Fowler's position. The first nursing action is to place the client in a position that aids in respiration, which would be sitting bolt upright or in high-Fowler's. Other nursing actions follow in rapid sequence and include monitoring vital signs and administering bronchodilators and oxygen (but at levels of 2 to 5 L/min or 24% to 28% by Ventimask). Insertion of an intravenous line and ongoing monitoring of respiratory status are also indicated.

When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client? 1. Don a mask and gloves. 2 Put on a pair of gloves. 3.Put on a gown and gloves. 4.Don a mask and a gown.

3.Put on a gown and gloves. The Centers for Disease Control and Prevention recommend the wearing of gowns and gloves for close contact with a person infested with scabies. Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Scabies is usually transmitted from person to person by direct skin contact. All contacts that the client has had should be treated at the same time.

The nurse is assisting in preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate in an extended format by mouth. The nurse should include which priority nursing action in the plan of care for this client? 1. Monitor the urine output. 2. Encourage increased fluids. 3. Monitor the client's temperature. 4. Encourage the client to cough and deep breathe.

4. Encourage the client to cough and deep breathe. Morphine sulfate suppresses the cough reflex. Clients need to be encouraged to cough and deep breathe to prevent complications related to the use of this medication. Although options 1, 2, and 3 may be components of the plan of care for this client, option 4 identifies the priority nursing action. Test-Taking Strategy: Note the strategic word, priority. Recalling that morphine sulfate suppresses the cough reflex and the respiratory reflex will direct you to the correct option. Additionally, using the ABCs—airway, breathing, and circulation—will easily direct you to the correct option.

The nurse is reinforcing instructions to a client scheduled for conization in 1 week for the treatment of microinvasive cervical cancer. The procedure has been explained by the health care provider, and the nurse is reviewing the complications associated with the procedure. The nurse determines that the client needs further teaching if the client states that which is a complication of this procedure? 1. Infertility 2 .Infection 3. Incompetent cervix 4.Ovarian perforation

4. Ovarian perforation(a hole or piercing in) Conization generally is not performed on women who desire to bear children because it can lead to incompetence of the cervix or infertility. Complications of the procedure include hemorrhage; infection; and less frequently, cervical stenosis.

The nurse is assigned to care for a client with herpes simplex virus (HSV) who is receiving acyclovir (Zovirax). The nurse is monitoring for adverse effects of the medication. Which laboratory result should the nurse specifically monitor to identify an adverse effect associated with the use of this medication? 1. Platelet count 2. Red blood cell count 3.White blood cell count 4.Blood urea nitrogen (BUN)

4.Blood urea nitrogen (BUN) The most common reaction related to the administration of this medication is phlebitis and inflammation at the intravenous site of infusion. Reversible nephrotoxicity manifested as elevations in serum creatinine and blood urea nitrogen also occurs in some clients. The cause of nephrotoxicity is the deposition of acyclovir in the renal tubules. The risk of renal injury is increased by dehydration and by the use of other nephrotoxic medications.

A child is to be admitted to the orthopedic unit following a Harrington rod insertion for the treatment of scoliosis. The nurse is assisting in preparing a plan of care for the child. The nurse plans to monitor which priority item in the immediate postoperative period? 1. Pain level 2. Ability to turn using the logroll technique 3. Ability to flex and extend the lower extremities 4.Capillary refill, sensation, and motion in all extremities

4.Capillary refill, sensation, and motion in all extremities When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular assessments including circulation, sensation, and motion should be done every 2 hours. Level of pain and ability to flex and extend the lower extremities are important postoperative assessments but not the priorities of the options provided. Logrolling would be performed by nurses. Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to answer this question. Option 4 addresses circulatory status.

The nurse is reinforcing medication instructions to a client with human immunodeficiency virus (HIV) who will be taking saquinavir (Invirase). What instruction does the nurse provide the client in regard to taking the medication? 1. At bedtime 2. On an empty stomach 3. Two hours before breakfast 4. Within 2 hours after a full meal

4. Within 2 hours after a full meal Saquinavir is an antiviral medication. It is administered within 2 hours after a full meal. If the medication is taken without food in the stomach, it may result in no antiviral activity.

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site? 1. The gluteal muscle 2. The lower aspect of the rectus femoris muscle 3. The medial aspect of the upper third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle

4. The lateral (a side part of something) aspect of the middle third of the vastus lateralis muscle The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. Options 1, 2, and 3 are incorrect injection sites.

The nurse is reviewing the postoperative prescriptions for a client who has just returned from surgery and notes that the surgeon has prescribed lepirudin (Refludan). Which is this medication prescribed to prevent? 1. Pain 2. Nausea 3. Respiratory complications 4. Thromboembolic complications

4. Thromboembolic complications Lepirudin is an anticoagulant used in clients with heparin-induced thrombocytopenia and associated thromboembolic disease to prevent further thromboembolic complications. In the postoperative client, the initial dose is administered as soon as possible after surgery but not more than 24 hours after surgery.

A client had a Miller-Abbott tube inserted 24 hours ago. The nurse is asked to check the client to determine whether the tube is in the appropriate location at this time. Which finding would indicate adequate location of the tube? 1. Bowel sounds are absent. 2. The aspirate from the tube has a pH of 7.45. 3. The aspirate from the tube has a pH of 6.5. 4.The tube can be palpated to the right of the umbilicus.

2. The aspirate from the tube has a pH of 7.45. The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine (to correct a bowel obstruction). The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic, and the pH of the intestinal fluid is 7 or higher if the tube is adequately located. Location of the tube can also be determined by x-ray, not palpation. Options 1 and 3 are incorrect and would not determine adequate location of the tube

The nurse is reinforcing instructions to a client with a diagnosis of hordeolum regarding the treatment plan. Which instruction should the nurse include in the teaching plan for the client? 1. Avoid the use of antibiotic ointment. 2. Apply a cool compress to the eye twice daily. 3.Apply a warm compress for 15 minutes four times daily. 4.Press on the hordeolum after the warm compress to induce rupture.

3.Apply a warm compress for 15 minutes four times daily. Hordeolum is commonly known as a sty. Therapeutic management includes the application of a warm compress for 15 minutes 4 times daily and installation of an ophthalmic antibiotic ointment to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in bringing purulent contents to a head, causing rupture with drainage. If a sty does not rupture spontaneously, it can be incised with a small sterile instrument by the health care provider. The client should be told not to press on or squeeze the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain.

The licensed practical nurse employed in the ambulatory clinic is assisting a registered nurse with preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse ensures that which medication is readily available before the medication is administered? 1. Protamine sulfate 2.Phytonadione (vitamin K) 3.Epinephrine (Adrenalin) 4.Acetylcysteine (Mucomyst)

Epinephrine (Adrenalin) IVIG is an immune serum that increases antibody titer and antigen-antibody reaction, providing passive immunity against infection. Anaphylactic reactions, although rare, can occur, and the nurse ensures that epinephrine is readily available when administering this medication. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for oral anticoagulants. Acetylcysteine is used to treat acetaminophen overdose.

The nurse is assisting in caring for a client with a respiratory tract infection who is receiving intravenous tobramycin sulfate (Tobrex). The nurse is instructed to monitor for adverse effects of the medication. The nurse understands that which finding is indicative of an adverse effect of this medication? 1. Nausea 2. Vertigo 3. Vomiting 4. Hypotension

2. Vertigo Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of cranial nerve VIII. Ototoxicity is a frequent adverse effect of therapy with aminoglycosides and could result in permanent hearing loss. If this occurs, the health care provider should be notified. Nausea, vomiting, and hypotension are rare side effects of the medication. Test-Taking Strategy: Focus on the subject, tobramycin sulfate, and note the words adverse effect. Answer this question by recognizing that tobramycin is an aminoglycoside and that ototoxicity is a frequent adverse effect of therapy with aminoglycosides.