NCLEX varios
A client with depression receiving phenelzine sulfate (Nardil) suddenly complains of a severe headache and neck stiffness and soreness, and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart?
Phentolamine Rationale: The antidote for hypertensive crisis is phentolamine. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present.
A nurse is preparing to administer ticarcillin. An abnormal elevation in which laboratory value should prompt the nurse to withhold the medication and notify the health care provider before administering the medication?
Blood urea nitrogen and creatinine Rationale: Ticarcillin is a penicillin-type antibiotic and can cause nephrotoxicity.
The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client?
Breathe rapidly.
Isoniazid is prescribed for a child with human immunodeficiency virus infection who has a positive Mantoux tuberculin skin test result. The mother of the child asks the nurse how long the child will need to take the medication. For how long should the nurse tell the mother the medication will need to be taken?
12 months
A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). The nurse reviews the laboratory findings and determines that the test result is positive if which value is noted?
1:20 Rationale: The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and cause tissue death. When the fluorescent method is used, the test sometimes is referred to as FANA. If this test is positive, a value greater than 1:8 will be present. Therefore, the other options are incorrect.
A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents the following pressure. Which readings are within normal limits (WNL) for the client? Select all that apply.
6 mm Hg 8 mm Hg Rationale: The normal LAP is 1 to 10 mm Hg
A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply
Avoid contact sports. Wash hands frequently. Avoid crowded places such as shopping malls. Avoid people who have received live attenuated vaccines.
A nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed?
Chlorpromazine (Thorazine) Rationale: Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.
An older client has been receiving cimetidine (Tagamet). The nurse should report to the health care provider (HCP) that the client is experiencing a side effect of the medication if which finding is noted during the assessment?
Confusion Rationale: Older clients are especially susceptible to central nervous system (CNS) side effects of cimetidine; the most frequent of these is confusion. Additionally, renal impairment in this population further increases this risk for confusion. Less common CNS side effects include headache, dizziness, drowsiness, and hallucinations. Options 1, 3, and 4 are not associated with this medication.
Capecitabine (Xeloda) has been prescribed for a client, and the client asks the nurse about the side effects of the medication. The nurse responds that a frequent side effect of this medication is which finding?
Diarrhea Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Frequent side effects include diarrhea, nausea, vomiting, stomatitis, hand and foot syndrome (painful palmar-plantar erythema and swelling with paresthesias, tingling, and blistering), fatigue, anorexia, and dermatitis. Weakness, irritability, and increased appetite are not side effects of this medication.
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
Observing rigid rules and regulations Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.
The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action?
Place the fetal heart monitor on the client in order to do a nonstress test (NST). Rationale: The BPP includes five components, one of which is an NST. Each of these components allows the practitioners to assess if the central nervous system is fully functional and that the fetus is not hypoxemic. Four components are included in the ultrasound portion of the profile in addition to an NST: fetal breathing movements, fetal movements, fetal tone, and amniotic fluid index. Each of the five components is given a score of either 2 or 0. Zero indicates an abnormal result and a 2 indicates a normal result. After the ultrasound components, the client's BPP was an 8 out of 8 possible points. This indicates fetal well-being, but there is a need to complete the BPP by obtaining an NST.
The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What should the nurse monitor to detect the most common complication of TPN?
Temperature Rationale: The most common complication associated with total parenteral nutrition is infection. Monitoring the temperature would provide data that would indicate infection in the client.
A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What is the best position for the nurse to place the client in for the procedure?
Upright and leaning forward with the arms on an over-the-bed table
The nurse develops a plan of care for a Native-American client. The nurse identifies which practices and preferences as characteristic of this ethnic group? Select all that apply.
Use of religion Avoiding eye contact Use of spiritual practices Use of healing practices
The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.
Viruses Nutrients Medications Antibodies
Diclofenac (Voltaren) is prescribed for a client with osteoarthritis. Which medication, if noted on the client's record, would alert the nurse to consult with the health care provider?
Warfarin sodium (Coumadin) Rationale: Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Interactions may occur with the use of anticoagulants, and the nurse should consult with the HCP about a potential medication interaction if an anticoagulant is prescribed.
Aluminum hydroxide (Amphojel) is prescribed for a client with chronic kidney disease (CKD). The nurse should instruct the client to take this medication at what time?
With meals Rationale: The client who is receiving aluminum hydroxide should take the medication with meals. The phosphate-binding effect of this medication is most effective when it is taken with food. If tablets are used, they should be chewed well before swallowing