New

What problem in the client with chronic renal failure would be prevented by receiving epoetin alfa? You answered this question Correctly 1. Anemia 2. Halitosis 3. Edema 4. Pain

Anemia

A postpartum client is receiving methylergonovine maleate 0.2 mg by mouth three times a day. What is most important for the nurse to monitor with this client? You answered this question Correctly 1. Dizziness 2. Hypertension 3. Nausea and vomiting 4. Headache

Hypertension

Finasteride (Proscar)

Prostate Anti-inflammatory

Amikacin (Amikin)

aminoglycoside antibiotic

Metronidazole (Flagyl)

antibiotic , a synthetic drug used to treat trichomoniasis and some similar infections.

Dyspnea

difficult or labored breathing

Beta blockers (Atenolol) block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in

hyperthyroidism

Sunburn is a painful inflammatory skin reaction that results from overexposure to ultraviolet radiation (eg, sunlight). Care for minor sunburn is symptomatic and involves protecting the burn from further sun exposure

increasing fluid intake, taking mild oral analgesics (eg, acetaminophen), and applying cool compresses and soothing lotions. Corticosteroid creams exacerbate symptoms of sunburn.

parietal lobe function

integrates somatic and sensory input.

pallor

paleness

Creatinine lab values

0.6-1.3

Credé maneuver

act of bending forward and applying hand pressure over the bladder to stimulate urination (bearing down)

C3 spinal cord injury causes...

airway issues

Clients who follow a vegan diet should be taught about vitamin B12 deficiency and the importance of supplementation. Vitamin B12 deficiency affects the

entire nervous system, from peripheral nerves to the spinal cord and brain.

Magnesium lab value

1.5-2.5

Regular insulin is a short-acting insulin that reaches the peak effect within

2-5 hours after subcutaneous administration. Therefore, clients who receive regular insulin subcutaneously at 11:30 AM are at highest risk for hypoglycemia between 1:30 PM and 4:30 PM

serum albumin

3.5-5.5 g/dL

Normal urine output

30 mL/hr

Rapid-acting insulins (eg, lispro, aspart) take peak effect in

30 minutes to 3 hours

NPH (Humulin N) peak

4-12 hr

Serum lactate levels in septic shock

4mmol/L

When auscultating for a murmur associated with mitral valve stenosis, the nurse should place the stethoscope at the

5th intercostal space, midclavicular line

regular heart rate

60-100 bpm

Normal CSF pressure

60-150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases.

Chloride lab value

95-105

Bell's Palsy

A localized facial nerve dysfunction that causes facial droop and numbness

Phenytoin (Dilantin)

Anticonvulsant 10-20

Paroxetine (Paxil)

Antidepressant

Nystatin (oral suspension)

Antifungal

characteristic of emphysema

Barrel chest , diminished breath sounds , deceased activity tolerance

A client is taking methylphenidate to treat attention deficit disorder. Which changes are likely to be observed by the nurse when working with this client? You answered this question Incorrectly 1. Decreased intake of food 2. Calmer demeanor 3. Increased attention span 4. Increased activity level 5. Insomnia

Decreased intake of food 2. Calmer demeanor 3. Increased attention span 5. Insomnia

Serotonin syndrome symptoms

Delirium, tachycardia, hyperreflexia, shivering, agitation, sweating, muscle spasms, coarse tremors

transsphenoidal hypophysectomy This care includes the following:

Frequent mouth care with a soft sponge to prevent infection; this includes no use of a toothbrush for at least 10 days to prevent suture line disruption. The nurse should teach the client to avoid coughing, sneezing, or straining. These actions can cause CSF leakage. Any clear nasal drainage should be tested for the presence of CSF, indicated by a glucose level >30 mg/dL in the fluid The nurse should perform frequent neurological checks and report signs of increased intracranial pressure or bleeding to the health care provider. The head of bed should be maintained at a 30-degree angle to decrease intracranial pressure

Sulfamethoxazole/trimethoprim (Bactrim, sulfa)

Identifying and treating a potential rash are the priority over management of expected symptoms for a known diagnosis.

Hydroxychloroquine (Plaquenil)

It can treat and prevent malaria. It can also treat lupus and arthritis.

Fluid bolus

Large amount of fluid in short amount of time

Phenelzine (Nardil)

MAOI antidepressant

Hematocrit lab values

Male: 42%-52% Female: 37%-47%

lacto-ovo-vegetarian

Person who consumes all vegan items plus dairy products and eggs.

Bell's Palsy tx

R/O stroke, TIA, mastoid infection, bone fx, lyme's disease and tumors. Corticosteroids high doses X 10 days. Acyclovir if herpes simplex is suspected. Drops to protect cornea from drying. Patch to cover eye while sleeping.

Erythropoiesis-stimulating agents (eg, epoetin alfa) are medications used to stimulate the production of

RBCs (eg, hemoglobin, hematocrit)

Educational objective: brain

The frontal lobe controls executive function and personality. The temporal lobe receives auditory input. The parietal lobe receives sensory input. The occipital lobe receives visual images

Orthopnea means

a breathing difficulty that is relieved by sitting upright

macrobiotic diet

a diet thought to help people live longer because it focuses on natural foods

Chronic Venous Insufficiency (CVI)

condition of poor venous blood return to the heart

Coarse crackles occur with

fluid overload

Clients prescribed sulfa antibiotics (eg, trimethoprim-sulfamethoxazole [Bactrim]) should be assessed for allergies to sulfa drugs and sulfonylurea medications, such as

glyburide, due to potential cross-sensitivity reactions.

Hydroxychloroquine Common side effects may include:

headache, dizziness, ringing in your ears; nausea, vomiting, stomach pain; loss of appetite, weight loss; mood changes, feeling nervous or irritable; skin rash or itching; or. hair loss.

BNP lab value

less than 100 is normal, good indicator of CHF, edema, if elevated assess s/s of CHF

Aural phase

sensory warning that is similar each time a seizure occurs

prodromal phase

short period of vague symptoms and malaise; can serve as a warning of more symptoms to come but may not be noticed

primary risk factor for bladder cancer

smoking

phenelzine (Nardil), which is a monoamine oxidase inhibitor. Foods high in tyramine (eg, aged cheese, yogurt, cured meats, fermented foods, broad beans, beer, red wine, chocolate, avocados) need to be restricted to reduce

the risk of hypertensive crisis

Ictal phase

the seizure itself

Creatinine levels should be closely monitored for signs of nephrotoxicity in the client receiving IV

vancomycin

The nurse is working with a client who is experiencing urinary incontinence. What alterations in diet could improve urinary function? You answered this question Incorrectly 1. Encourage the client to drink cranberry juice to acidify the urine. 2. Encourage the client to drink caffeine containing beverages in the evening. 3. Ask the client to limit or eliminate artificial sweeteners in the diet. 4. Ask the client to limit intake of caffeine to no more than 2 cups of coffee per day. 5. Suggest that the client limit or eliminate alcoholic drinks in the diet.

1. Encourage the client to drink cranberry juice to acidify the urine.. 3. Ask the client to limit or eliminate artificial sweeteners in the diet. 4. Ask the client to limit intake of caffeine to no more than 2 cups of coffee per day. 5. Suggest that the client limit or eliminate alcoholic drinks in the diet.

A client diagnosed with rheumatoid arthritis has been prescribed dexamethasone orally as part of treatment therapy. What side effects should the nurse inform the client are expected? You answered this question Incorrectly 1. Fatigue 2. Insomnia 3. Hypoglycemia 4. Truncal obesity 5. Increased appetite 6. Low blood pressure

1. Fatigue 2. Insomnia 4. Truncal obesity 5. Increased appetite

Which prescriptions would necessitate the nurse to seek clarification from the primary healthcare provider? You answered this question Correctly 1. Furosemide 20.0 mg p.o. daily. 2. Chlordiazepoxide 50 mg p.o. q4h p.r.n. for agitation. 3. Diphenhydramine 25 mg p.o. hour of sleep for three nights. 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily.

1. Furosemide 20.0 mg p.o. daily.. 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily. / It is inappropriate to have a trailing zero after a decimal point for doses expressed in whole numbers. It can be mistaken as 200 if the decimal point is not seen and read appropriately. The Folic acid order lacks a route, thus needs clarification. This order should be written as Heparin 1,000 units subcutaneously daily. Use commas for dosing units at or above 1,000 or use words such as one thousand to improve readability. Use units rather than IU (International units) as it can be mistaken as IV or 10

The nurse is discussing the ability of a client to leave the long-term care facility. The family is concerned that the client may not be able to handle elimination needs. What questions should the nurse ask? You answered this question Incorrectly 1. How easy is it to maneuver about in your bathroom? 2. Are you able to change your clothing and perform hygiene measures? 3. Do you experience episodes of not being able to control your bladder? 4. Do you have anyone at home to help you if needed? 5. Do you want to return home to live?

1. How easy is it to maneuver about in your bathroom? 2. Are you able to change your clothing and perform hygiene measures? 3. Do you experience episodes of not being able to control your bladder? 4. Do you have anyone at home to help you if needed?

The nurse is providing foot care to the client who has diabetes. The nurse reinforces teaching with the client about proper care of the feet. What should the nurse include in the discussion? You answered this question Correctly 1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes. 5. Cut toenails rather than file them. 6. Cut nails in a rounded fashion.

1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes.

What actions should the nurse include when providing care for a client admitted with Guillain-Barre' Syndrome? You answered this question Correctly 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Reinforce teaching for range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Reinforce teaching for range of motion exercises. 6. Refer to physical therapist. With this disease we know that there is progressive muscle weakness, cramping and paralysis. So interventions should focus on the hazards of immobility, pain, and maintaining the airway.

A client diagnosed with heart failure has been prescribed a 2 gm sodium diet. Which food choices selected by the client would indicate to the nurse that the client understands this diet? You answered this question Incorrectly 1. Pork loin 2. Frozen cheese ravioli dinner 3. Instant vanilla pudding 4. Thin crust pepperoni and ham pizza 5. Fresh salad with fresh citrus juice dressing 6. Bottled tomato juice

1. Pork loin 5. Fresh salad with fresh citrus juice dressing

What actions should the nurse take when administering fentanyl? You answered this question Incorrectly 1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 3. Shave hair where fentanyl patch will be applied. 4. Place fentanyl patch over dry skin. 5. Apply adhesive dressing over the fentanyl patch. 6. Dispose of fentanyl patch in trash.

1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. 4. Place fentanyl patch over dry skin.

The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Which foods should the nurse reinforce that are appropriate for the client? You answered this question Incorrectly 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries

Avocados and apricots / Avocados, apricots, milk, fruit juices, bananas and cantaloupe are good sources of potassium. Loop diuretics deplete the electrolyte potassium

Bactrim

antibiotic

peripheral arterial disease (PAD)

blockage of arteries carrying blood to the legs, arms, kidneys and other organs

Epitaxis

nosebleed

Vitamin E function

antioxidant that protects erythrocytes and membranes from damage (E for Erythrocytes)

Aerobic exercise typically lowers blood glucose levels

as glucose production in the liver fails to keep up with elevated glucose uptake by the muscles at work.

Clients who undergo a partial laryngectomy are at increased risk for

aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.

Hemoglobin lab values

*Male:* 14-18 g/dl *Female:* 12.0-16.0 g/dl

MODS (multiple organ dysfunction syndrome)

-complication of an form of shock due to inadequate tissue perfusion -failure of 2 or more organ systems -end result if shock isn't stopped

Pathophysiology of emphysema

-hyperinflation of alveoli -destruction of alveolar walls by proteolytic enzymes from inflammatory cells -loss of airway elasticity -destruction of alveolar capillaries -airway narrowing and collapse

BUN lab values

10-20 mg/dL

High-risk clients on isoniazid therapy for treatment of tuberculosis may experience neurological side effects due to a decrease in the body's ability to utilize vitamin

B6 (pyridoxine). A vitamin B supplement will prevent these effects.

sulfamethoxazole/trimethoprim

Bactrim

Which nursing intervention should the nurse implement when administering a medication through a nasogastric (NG) tube? You answered this question Incorrectly 1. Place the client in a high-Fowler's position for medication administration. 2. Flush the tubing between administering medications 3. Turn the client onto their left side after medication administration. 4. Mix the medication directly into the tube feeding

Flush the tubing between administering medications

Ulnar Fracture

Fracture of the ulnar bone (distal, proximal, mid-shaft)

Serum Iron (Lab Values)

Male: 80-180 mcg/dL Female: 60-160 mcg/dL

diplopia (double vision)

May be caused by trauma to cranial nerves, resulting in paralysis of extraocular muscles May occur in stroke Loss of depth perception occurs.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agent? You answered this question Correctly 1. Proton pump inhibitor 2. Mitotic inhibitor 3. Serotonin antagonist 4. Acetylsalicyclic acid

Proton pump inhibitor

Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are given to relieve some of the symptoms of thyrotoxicosis.

They block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism.

Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs movement, swallowing, speech, and cognitive abilities. Death typically occurs within 20 years. Clients who have a parent with this disease should receive genetic counseling,

When planning a family

diabetes insipidus

a disease in which the secretion of or response to the pituitary hormone vasopressin is impaired, resulting in the production of very large quantities of dilute urine, often with dehydration and insatiable thirst / occurs either when the pituitary gland cannot secrete enough antidiuretic hormone (ADH) (ie, neurogenic DI) or when the kidneys do not respond to ADH (ie, nephrogenic DI). Neurogenic DI typically occurs after injury to or removal of the pituitary gland. Clinical manifestations include polydipsia (increased thirst), profound polyuria (increased urine output), and low urine osmolality and specific gravity (dilute urine). Clients with DI can become seriously dehydrated, so oral or IV rehydration must be given to replace lost fluids.

macular degeneration (MD)

a gradually progressive condition in which the macula at the center of the retina is damaged, resulting in the loss of central vision

thyrotoxicosis (thyroid storm)

an acute and potentially deadly condition caused by an overactive thyroid

Amoxicillin/clavulanate in liquid form should be shaken well prior to administration; the correct dose is administered using a

calibrated measuring device. The medication is taken with or without food, at evenly spaced intervals, and until the prescribed dose is consumed. If nausea or diarrhea develops, the medication may be administered with food.

macrocytic anemia

due to folate or vitamin B12(cobalamin) deficiency (megaloblastic anemia), THF-M --> VitB12-M --> Methionine, (transfer of methyl groups)

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

Oxybutynin (Ditropan)

incontinence dry mouth

Hematocrit (Hct)

percentage of red blood cells in the blood

Modafinil (Provigil)

narcolepsy

Linezolid (Zyvox)

oxazolidinone antibiotic

Complete heart block

results in the ventricles depolarizing independently from the atria

dysphagia

difficulty swallowing

Trichomoniasis

an STD caused by a microscopic protozoan that results in infections of the vagina, urethra, and bladder

To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, wear protective clothing, use sunscreen properly (daily application; minimum SPF of 15-30; 15-30 minutes before going outside; reapplication after getting wet

and every 2 hours), and avoid non-solar exposure to ultraviolet radiation (eg, tanning beds, sunlamps).

Thiamine (Vitamin B1)

1. Wernicke-Korsakoff 2. Deficiency

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? You answered this question Incorrectly 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

1. White grape juice 2. Gelatin 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey

Sulfamethoxazole/trimethoprim (Bactrim, sulfa) is a common cause of allergic reactions that often present as delayed cutaneous reactions. Allergic reactions frequently begin with fever, followed by a

flat, red rash (looks like measles) and itching. The priority is to identify the allergy and take appropriate measures.

Clients must be awakened for a prescribed, necessary

neurologic assessment. A neurologic assessment consists of the Glasgow Coma Scale, pupillary checks, movement and strength of the extremities, and vital signs.

Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired surgically. The nurse caring for a client in Buck traction should frequently assess the

neurovascular status and skin integrity of the affected limb and maintain it in a straight, neutral position

When caring for clients with overflow incontinence

nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed

occipital lobe function

of the brain registers visual images. Injury to the occipital lobe could result in a deficit with vision. The nurse should notify the health care provider immediately and document the finding

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include

ototoxicity and nephrotoxicity and are affected by age, renal function, and drug dose. Careful dosing is especially important for older clients. Tinnitus and vertigo are early signs of ototoxicity.

After transurethral resection of the prostate, the rate of continuous bladder irrigation is adjusted to keep urinary

output light pink in color. Bladder spasms (treated with belladonna-opium suppositories) are expected after the procedure.

Hemoglobin is a component of red blood cells that carries

oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

Gastroparesis

partial paralysis of the stomach

partial laryngectomy/hemilaryngectomy

partial removal of the larynx

A client with a penicillin allergy may be allergic to cephalosporin antibiotics. Cephalosporins may be safely administered to clients with a history of mild allergic reaction, such as rash, but they are contraindicated in clients with a history of

penicillin anaphylaxis

Postical phase of the seizure

period directly after the seizure is over. It is especially important to describe the seizure episode including behavior after the seizure and document drug therapy.

Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with

peripheral arterial disease

Diabetes insipidus (DI) can occur when the pituitary gland is injured or removed and not enough antidiuretic hormone is secreted. DI causes

polydipsia and profound polyuria with dilute urine. Clients with DI following a hypophysectomy should receive desmopressin and be positioned with the head of the bed at 15-30 degrees.

Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of systemic lupus erythematosus. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include

retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required

Lumbar puncture can be performed with clients in the

sitting position or positioned on the left side with the knees drawn up (fetal position)

Caregivers of clients with Alzheimer disease should be taught safety modifications for the home

such as placing frequently used items within reach, arranging furniture to allow for free movement, labeling doors to commonly used rooms, providing a night light, and locking stairwell and outside doors.

paracentesis (abdominocentesis)

surgical puncture to remove fluid from the abdomen

Use of fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin), especially ciprofloxacin, places clients at increased risk for

tendinitis and tendon rupture that most often occur in the Achilles tendon. This class of antibiotics carries a black box warning about this risk.

The nurse is reinforcing client education on zolpidem. Which statement by the client indicates to the nurse that the client understands important points about zolpidem? You answered this question Incorrectly 1. "There is a high potential for tolerance with this medication." 2. "I may do things in my sleep that I will not remember the next day." 3. "Daytime drowsiness is rare when taking this medication." 4. "The most common side effects of this medication are confusion and a bitter aftertaste."

"I may do things in my sleep that I will not remember the next day."

A client has a diagnosis of major depression and began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working. Which reply by the nurse indicates adequate understanding of treatment? You answered this question Correctly 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach desired effect in 1-3 weeks."

"You should reach desired effect in 1-3 weeks."

The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, "I am just not feeling well. My medicine is not working." Which reply by the nurse indicates adequate understanding of treatment? You answered this question Correctly 1. "I agree, your medication is not working." 2. "Your treatment may have to be changed." 3. "Most SSRIs take about 5 days to work." 4. "You should reach the desired effect in 1-3 weeks."

"You should reach the desired effect in 1-3 weeks."

Diabetic neuropathy treatment

- Strict monitoring of blood glucose levels - PT for: pain, foot care, overall fitness - Drugs

Seizure precautions (most important)

1) Do not put anything in a client's mouth (except for status epilepticus, where an airway is needed) in the event of a seizure 2) Do not restrain a client in an event of a seizure. Lower him to the floor or bed. Protect head, remove nearby furniture, provide privacy, put client on his side with head flexed slightly forward, loose clothing to prevent injury 3) Stay with the client and call for help 4) Administer medication as ordered 5) After seizure, explained what happened to client. Provide comfort. 6) Document thoroughly: duration, behavior, description, length, injury, aura, postictal state, and report to provider

The nurse is caring for an elderly client status post total hip replacement and a history of cirrhosis. the nurse reinforces teaching about pain management. Which statements by the client's spouse shows understanding of pain management? You answered this question Correctly 1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 3. "This narcotic causes very deep sleep, which is what my spouse needs." 4. "If constipation is a problem, increased fluids will help." 5. "My spouse can have one glass of wine to help promote pain relief."

1. "If the pain increases, I must let the nurse know immediately." 2. "I should have my spouse try the breathing exercises to help control pain." 4. "If constipation is a problem, increased fluids will help."

Rapid acting insulin peak

1-2 hours

The nurse has been teaching the client about warfarin for prevention of pulmonary emboli. Which comments by the client indicate understanding of the medication? You answered this question Incorrectly 1. "I must get my blood levels checked regularly." 2. "I shouldn't change my diet to include a lot of foods containing vitamin K without supervision." 3. "I should eat lots of foods containing vitamin K." 4. "I should report this medication to any primary healthcare provider that I see." 5. "I should not change the dosage without talking with my primary healthcare provider."

1. "I must get my blood levels checked regularly." 2. "I shouldn't change my diet to include a lot of foods containing vitamin K without supervision." 3. "I should eat lots of foods containing vitamin K." 4. "I should report this medication to any primary 1. "I must get my blood levels checked regularly." 2. "I shouldn't change my diet to include a lot of foods containing vitamin K without supervision." 4. "I should report this medication to any primary healthcare provider that I see." 5. "I should not change the dosage without talking with my primary healthcare provider." healthcare provider that I see."

A nurse is performing eye care for an unconscious client. Which actions should the nurse include? You answered this question Incorrectly 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

1. Administer moist compresses to cover eyes every 2 hours. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate. Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.

A pediatric nurse is reinforcing instructions to a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? You answered this question Incorrectly 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

1. At 4 weeks of age, the infant should be able to gaze at objects. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age. Infants do not have tears until about 3 months of age.

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? You answered this question Incorrectly 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Chronic fatigue syndrome who has had no relief of fatigue. Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health

The nurse is caring for a client receiving digoxin. What information should be reinforced by the nurse to the client about this medication? You answered this question Incorrectly 1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels. 4. Report pulse rate of 64 or more. 5. Report symptoms of nausea, loss of appetite, or visual disturbances.

1. Check your pulse daily before taking the medication. 2. Report a marked decline in pulse rate. 3. Consume foods high in potassium to maintain adequate serum potassium levels 5. Report symptoms of nausea, loss of appetite, or visual disturbances.

The nurse is caring for a client on the surgical unit. Which prescriptions could the nurse safely administer to the client? You answered this question Incorrectly 1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 2. Regular insulin 10 U stat 3. MS 2 mg IM every 2 hours as needed for pain 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights

1. Chlordiazepoxide 10 mg p.o. q 4h p.r.n. for agitation 4. Cefepime 1 gram IVPB every 8 hours 5. Diphenhydramine 25 mg p.o. hour of sleep for three nights

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further education? You answered this question Incorrectly 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus

Diabetes insipidus (DI) is a metabolic disorder of decreased antidiuretic hormone, which is responsible for water retention in the kidneys. DI is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include

polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity

Hyperglycemia is also a side effect of

prednisone , Clients with an acute illness (eg, influenza, cellulitis)

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? You answered this question Incorrectly 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1. Dark, yellow urine 2. Lethargic 4. Tachypnea 5. Decreased urine output. The fontanels will be sunken rather than bulging. Bulging fontanels indicate brain swelling or fluid build up in the brain. Sunken fontanels are related to dehydration

A nurse is planning to participating in educating students about oral health. Which points should the nurse reinforce? You answered this question Incorrectly 1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 3. Brush teeth twice a day with toothpaste that does not have fluoride. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

1. Do not drink soft drinks between meals. 2. Eat raw vegetables to help keep teeth clean. 4. Use a pea size amount of toothpaste. 5. Floss teeth daily.

The nurse plans to reinforce teaching with a client on how to manage the use of a behind the ear hearing aid. What strategies should the nurse include? You answered this question Incorrectly 1. Hairspray should not be used while wearing the hearing aid. 2. A whistling sound when the hearing aid is inserted indicates proper placement. 3. Submerse hearing aid in cool water daily to clean. 4. Illustrate where damage commonly occurs on a hearing aid. 5. Batteries last 6 months with daily wearing of 10-12 hours.

1. Hairspray should not be used while wearing the hearing aid. 4. Illustrate where damage commonly occurs on a hearing aid.

A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever. You answered this question Correctly 1. Keep water by the bedside 2. Place a plastic cover over the pillow 3. Administer an antipyretic every 4 hours 4. Keep a change of linen in the room 5. Position the client in a semi-fowlers position

1. Keep water by the bedside 2. Place a plastic cover over the pillow 4. Keep a change of linen in the room A clue is the use of a word or phrase that leads you to the correct answer. First let's identify the key words or phrases in the stem. The key words are pneumonia, night sweats, and fever. The question is asking for nursing interventions. 1. Correct: Think about if the client is losing fluids then the nurse must have an intervention to replace the fluids if possible. Keeping water by the bedside will promote the client consuming the water and the nurse to promote the client drinking the water. 2. Correct: During and after the fever episode interventions to promote client comfort should be initiated. Plastic cover will protect the pillow. The damp pillowcase can also be changed without changing the pillow. 3. Incorrect: Antipyretics are usually prescribed as needed not every 4 hours to reduce the fever. The antipyretics are also prescribed when the client's temperature is greater than a specific reading. 4. Correct: A time management technique for caring for a client with frequent fever episodes is to keep a change of linen in the room. The bed is to be kept dry as possible. 5. Incorrect: This client has been diagnosed with pneumonia. Positioning the client in a semi-fowlers position relaxes the abdominal muscles which improves breathing, but will not affect the client's temperature

The client has been prescribed promethazine for reports of nausea. The nurse makes rounds to the client's room approximately one hour after the medication was administered. What can the nurse expect to find when seeing the client? You answered this question Correctly 1. Reports feeling sleeping 2. Reports dry mouth 3. Reports that the drug has already stopped working 4. Reports blurred vision 5. Reports feeling calm

1. Reports feeling sleeping 2. Reports dry mouth 4. Reports blurred vision 5. Reports feeling calm. / Promethazine causes sedation in most people. The medication has anticholinergic effects. Blurred vision is one of the anticholinergic side effects that the client may have. The medication works also as an antianxiety agent.

A nurse is discussing with the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? You answered this question Incorrectly 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1. Serve meal in a quiet environment 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? You answered this question Incorrectly 1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva 5. Heart rate 60/min

1. Skin rash 2. Reports fatigue 3. Dyspnea on exertion 4. Pale conjunctiva An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBC's is fatigue and dyspnea upon exertion because RBC's are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication.

Which actions are appropriate for the nurse to reinforce in the nutritional teaching plan to accomplish the goal of a diet lower in fat? You answered this question Incorrectly 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.

1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 4. Incorporate plant sources of protein. Two percent milk can reduce the amount of fat consumed daily, not only in milk that the client drinks, but also in foods that contain milk as an ingredient. Air-popped corn contains no fat unless butter is added after popping. The client still is able to have a crunchy snack without the fat. Plant proteins such as kidney, black, or lima beans are good sources of protein without the fat from a meat source.

The nurse is reinforcing teaching with a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that instructions have been successful? You answered this question Incorrectly 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."

2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 5. "There is no restriction on egg white consumption."

What dietary information should the nurse provide to a client diagnosed with Celiac disease? You answered this question Incorrectly 1. "The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables." 2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta."

2. "Creamed based canned soups are a source of hidden wheat." 3. "You can eat foods containing fax, corn, or rice." 4. "Avoid foods and beverages that contain malt." 5. "Do not eat traditional wheat products such as pasta." Gluten is a general name for the proteins found in wheat, rye, barley and triticale - a cross between wheat and rye. Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. The most cost effective and healthy way to follow the gluten-free diet is to seek out these naturally gluten-free food groups, which include: Fruits; Vegetables; Meat and poultry; Fish and seafood; Dairy; Beans, legumes, and nuts

In which situations should the nurse notify the primary healthcare provider of a medication incident? You answered this question Correctly 1. Every occurrence. 2. Client is harmed or dies. 3. Medication incident is a near miss. 4. Nurse administers an incorrect dosage. 5. Client questions the medication color.

2. Client is harmed or dies 4. Nurse administers an incorrect dosage

The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? You answered this question Incorrectly 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs

2. Fish 5. Scrambled eggs. Fish and scrambled eggs are both high in protein and low in fiber. Foods high in fiber are irritating to the GI tract and should be avoided. A food diary is needed to determine triggers for flare-ups. 1. Incorrect: Fiber in the beans will increase motility. 3. Incorrect: Fiber in apple will increase motility. 4. Incorrect: Dairy products should be avoided in times of flare-ups as dairy is often a cause of flare ups.

The nurse is caring for a client who has aphasia. What actions should the nurse include in providing care to improve communication with this client? You answered this question Correctly 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

Unexpected and projectile vomiting without nausea can be a sign of increased intracranial pressure (ICP), especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. It can be associated with headache and gets worse with a lowered head position. The most appropriate action is to

immediately obtain a full set of vital signs and report the findings to the supervising registered nurse.

aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

Psoriasis is a chronic, autoimmune condition characterized by exacerbations of silver plaques on reddened skin. Although there is no cure, management includes

includes topical and systemic medications, phototherapy, and avoidance of triggers

Sulfasalazine (Azulfidine)

is a 5-aminosalicylate used to decrease inflammation in the intestines. To prevent relapse, the medication should be continued even when symptoms subside. Because sulfasalazine hinders the absorption of folate, folic acid supplements are encouraged

Phosphorus lab value

2.5-4.5 mg/dL

The nurse is caring for a client admitted to rule out myocardial infarction. The nurse has administered sublingual nitroglycerin. What time frame should the nurse expect the earliest onset of effectiveness? You answered this question Incorrectly 1. 15 seconds 2. 3 minutes 3. 5 minutes 4. 15 minutes

3 minutes

cerebral arteriovenous malformation

is a congenital deformity of tangled blood vessels often occurring in the brain. These vessels may weaken and rupture, causing an intracranial hemorrhage. Any neurologic changes and severe headache need to be addressed immediately as these may indicate hemorrhage.

The nurse is caring for a client admitted with an episode of bleeding esophogeal varices. What should the nurse monitor for after administering propranolol to this client? You answered this question Incorrectly 1. Increased systolic BP 2. Hypokalemia 3. Bradycardia 4. Wheezing 5. Decreased hematemesis

3. Bradycardia 4. Wheezing 5. Decreased hematemesis / Propranolol is a beta blocker that affects the heart and circulation. It is used in the treatment of high blood pressure, irregular heartbeats and in the prevention of angina and headaches. This medication works by blocking epinephrine and reduces heart rate, blood pressure and strain on the heart. Decreasing the heart rate should decrease bleeding. Wheezing is an adverse reaction from propranolol and should be monitored for after administration. A decreased in heart rate and blood pressure will help to decrease bleeding. Hematemesis is vomiting blood.

Measures for reducing the risk of aspiration for clients with dysphagia include diet modification

pureed, mechanically altered, soft), thickened liquids, positioning the client in an upright position, placing food on the stronger side of the mouth, and flexing the chin slightly downward. A client with visual impairment should be reminded to turn the head from time to time while eating.

parietal lobe

receives sensory input for touch and body position

occipital lobe

registers visual images

thoracentesis is performed to

remove fluid from the pleural space.

Oral nystatin suspension is an antifungal medication used to treat oral thrush caused by candidal infections. Nurses administering nystatin should assist the client

removing and soaking dentures, if present; assess the affected area frequently; educate the client to swish the medication in the mouth before swallowing; and ensure that the suspension is well shaken before dosing.

What should the nurse know when caring for a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine? You answered this question Incorrectly 1. Stay 6 feet from people for 2 weeks. 2. This medication is given intravenously as a one-time dose. 3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant. 5. Radioactive iodine is absorbed by the parathyroid glands.

3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant

Cast care instructions include

reporting foul odors or hot areas in the cast; preventing the cast from getting wet; elevating the affected extremity above heart level for the first 48 hours; regularly exercising the affected extremity; and reporting symptoms of impaired circulation (eg, numbness, tingling, pallor, coolness). Clients should never insert objects inside the cast.

Aortic Stenosis (AS)

is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest.

The nurse is reinforcing client education about timolol maleate. What should the client know about the newly prescribed timolol maleate eyedrops for glaucoma? You answered this question Correctly 1. The medication works by causing the pupils to constrict. 2. The medication will dilate the canals of Schlemm. 3. This medication decreases the production of aqueous humor. 4. The medication improves ciliary muscle contraction.

This medication decreases the production of aqueous humor.

A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this?

Vitamin B6

A client with a history of adrenal insufficiency is placed on fludrocortisone. Which value is most important for the nurse to monitor? You answered this question Incorrectly 1. Magnesium 2. Weight 3. Pain 4. Glucose

Weight / Weight is monitored daily to check for sudden increases which would indicate fluid retention

Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12 deficiency and the

resulting macrocytic anemia

A weak or absent pedal pulse and a cool or mottled extremity in a client who is post abdominal aortic aneurysm repair can indicate an arterial or graft occlusion,

leading to possible life- or limb-threatening ischemia.

Retinal detachment can result from trauma and aging. Classic symptoms include

lightning flashes, floaters, a curtain across the vision, and "gnats/cobweb/hairnet" throughout the vision. Retinal detachment requires emergent consultation and treatment to prevent loss of vision.

Management of urge incontinence includes

loss of excess weight, anticholinergic medications (eg, oxybutynin), avoidance of bladder irritants, pelvic floor exercises, and bladder training. Dry mouth is a common adverse effect of anticholinergic medications.

Overflow Urinary Incontinence (OUI)

loss of urine when the intra-bladder pressure exceeds the urethra's capacity to remain closed due to urinary retention

What is the priority nursing action to take when reinforcing teaching of a client about warfarin? You answered this question Incorrectly 1. Advise the client to call the prescribing primary healthcare provider before taking any new medications or supplements. 2. Advise the client to notify a healthcare provider if experiencing dizziness or lightheadedness. 3. Advise the client of the need to have the International Normalized Ratio (INR) checked frequently. 4. Advise the client that warfarin is used to prevent thrombosis.

Advise the client to notify a healthcare provider if experiencing dizziness or lightheadedness. / Dizziness and lightheadedness could be a symptom of bleeding, which is a very common and very serious side effect of warfarin.

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test? You answered this question Correctly 1. Alanine aminotransferase (ALT) 2. Serum glucose 3. Serum creatinine 4. Serum electrolytes

Alanine aminotransferase (ALT) / ALT levels will increase primarily in liver damage/disorders. A side effect of administering divalproex is drug-induced hepatitis.

The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? You answered this question Incorrectly 1. Fluticasone 2. Salmeterol 3. Theophylline 4. Albuterol 5. Levalbuterol

Albuterol Levalbuterol / Albuterol and levalbuterol are both rapid acting bronchodilators, that will quickly relieve shortness of breath, chest tightness and wheezing. This client is in distress now. Either medication would be indicated.

Common asthma triggers to avoid include the following:

Allergen inhalation (eg, mold, pollen, dust mites, animal dander) Air pollutants (eg, tobacco smoke) Infections - viral upper respiratory infections are the most common Pharmacological agents (eg, beta blockers, aspirin, nonsteroidal anti-inflammatory drugs)

Donepezil (Aricept)

Alzheimer's

Glasgow Coma Scale (GCS) score

An evaluation tool used to determine LOC, which evaluates and assigns point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes

Leukocytes (White Blood Cells)

Any of the blood cells that are colorless, lack hemoglobin, contain a nucleus, and include the lymphocytes, monocytes, neutrophils, eosinophils, and basophils.

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? You answered this question Correctly 1. Aromatherapy 2. Biofeedback 3. Guided Imagery 4. Acupuncture

Aromatherapy /

Normal adult ABG values at sea level pH 7.35-7.45 PaO2 80-100 mm Hg PaCO2 35-45 mm Hg HCO3 22-26 mEq/L Saturation (SaO2) 95%-99%

Arterial blood gas analysis provides objective data about the efficiency of gas exchange in the lungs.

Aerobic exercise typically lowers blood glucose levels.

As muscles use up glucose, the liver is unable to produce enough glucose to keep up with the demand.

Nystatin is an antifungal medication commonly used to treat mucocutaneous candidal infections (ie, oral, intestinal, vaginal, skin). When caring for a client prescribed nystatin, the nurse should:

Assist clients with oral candida who wear dentures in removing them and soaking them in nystatin suspension because dentures often become a reservoir for reinfection Assess the appearance of the affected area (eg, oral cavity, skin lesions) frequently throughout nystatin therapy (eg, before administration, during routine assessments) to monitor treatment efficacy and identify potential side effects (eg, mucous membrane irritation) Instruct clients prescribed nystatin liquid suspension for oral thrush to swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of any esophageal candida Ensure that liquid suspension forms of nystatin are shaken well before being measured for dosing because medication precipitates and causes unequal concentrations within the liquid

used to determine structural abnormality (eg, enlarged heart, fractured ribs), presence of air, fluid, infiltrates, lesions, and response to treatment.

Chest x-ray

darkening of the skin, discolored and thick skin on legs, swollen blood vessels in the skin, or varicose veins

Chronic Venous Insufficiency

The nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? You answered this question Correctly 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.

Clean the face and hair at the end of the bath.

Metronidazole side effects

Common side effects may include: nausea, vomiting, loss of appetite, stomach pain; diarrhea, constipation; unpleasant metallic taste; rash, itching; vaginal itching or discharge; mouth sores; or. swollen, red, or "hairy" tongue. Can also sometimes cause urine to turn dark brown, but this is not dangerous and it goes away after the drug is stopped. May cause Stevens-Johnson syndrome (SJS), a life-threatening complication characterized by necrosis and sloughing of the skin and mucous membranes. Clients should be educated to immediately report signs of SJS (eg, rash, skin peeling).

Brain natriuretic peptide (BNP) is a marker for which one of the following? (check one) A. Renal failure B. Acute adrenal insufficiency C. Cerebrovascular accident D. Heart failure E. Ureteral obstruction

D. Heart failure. Brain-type natriuretic peptide (BNP) is synthesized, stored, and released by the ventricular myocardium in response to volume expansion and pressure overload. It is a marker for heart failure. This hormone is highly accurate for identifying or excluding heart failure, as it has both high sensitivity and high specificity. BNP is particularly valuable in differentiating cardiac causes of dyspnea from pulmonary causes. In addition, the availability of a bedside assay makes BNP useful for evaluating patients in the emergency department.

A client prescribed oral iron medication is reporting nausea after administration. What should the nurse tell the client to do about this symptom? You answered this question Correctly 1. Take the iron with a class of milk. 2. Eat bran cereal immediately after ingesting iron. 3. Drink orange juice with the iron medication. 4. Take docusate sodium at bedtime.

Drink orange juice with the iron medication. / Iron is best absorbed on an empty stomach, however, if nausea and vomiting occur, drink orange juice with the iron. It will help decrease nausea and vomiting, and will enhance absorption of the iron

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? Exhibit You answered this question Correctly 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel. T - 98 ° (36.7°) P - 74 R - 20 BP - 88/50

Enalapril / Enalapril is an angiotensin converting enzyme (ACE) inhibitor. An ACE inhibitor will lower the client's blood pressure. The blood pressure in the stem's exhibit is low. Lowering the client's blood pressure more could have a negative effect on the client's condition

To promote rapid diuresis in a client in acute pulmonary edema, which prescription would the LPN/VN expect the nurse to administer first? You answered this question Correctly 1. Furosemide 40 mg IVP 2. Dopamine 15 mcg/kg/min 3. Hydrochlorothiazide 25 mg PO 4. Captopril 25 mg PO

Furosemide 40 mg IVP / Yes, there is a good bit of fluid overload with acute pulmonary edema, so the furosemide should be started first. Furosemine is a loop diuretic that prompts rapid loss of excess fluid.

The nurse enters the client's room to administer the morning dose of digoxin. Before administration, the nurse checks the client's apical pulse to find the rate to be 70. What should the nurse do? You answered this question Correctly 1. Hold the medication as the pulse rate is too low. 2. Wait 30 minutes and attempt to give the medication again. 3. Contact the primary healthcare provider. 4. Give the medication as prescribed

Give the medication as prescribed

Tetany symptom is linked to what?

Hypocalcemia

Donepezil has been prescribed to a client with cognitive impairment. The nurse is reinforcing teaching of the family members. Which statement by the family member indicates understanding of this medication? You answered this question Incorrectly 1. This medicine will control agitation and aggression. 2. This medication should be given at bedtime since it is for insomnia. 3. Notify the primary healthcare provider if the client is vomiting coffee ground material. 4. This drug is given as needed for confusion.

Notify the primary healthcare provider if the client is vomiting coffee ground material / A rare but very serious side effect that can occur: black stools, vomit that looks like coffee grounds, severe stomach/abdominal pain. Notify the primary healthcare provider immediately.

Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke

Noxious stimuli may include: Bladder distention (eg, obstructed urinary catheter, neurogenic bladder) Fecal impaction Tight clothing (eg, shoelaces, waistbands)

assisting with a colorectal cancer screening using the guaiac fecal occult blood test

Obtain supplies, wash hands, and apply non-sterile gloves 4. Open the slide flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide 3. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide 5. Wait 30-60 seconds 1. Document the results in the electronic medical record

The nurse should closely monitor renal function and assess for any changes in hearing or balance in a client receiving aminoglycoside antibiotics

Ototoxicity and nephrotoxicity are serious adverse reactions related to this type of medication.

Asthma avoid

Pharmacological agents (eg, beta blockers, aspirin, nonsteroidal anti-inflammatory drugs)

A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? You answered this question Correctly 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.

Protein must be limited because of elevated ammonia levels. Normally, protein is broken down into ammonia, which the liver converts into urea, and the kidneys then easily excrete. However, in a diseased liver, this conversion is not possible, and ammonia continues to build up in the body, ultimately affecting the brain. The nurse would be aware that additional protein would be harmful for this client.

SIRS (systemic inflammatory response syndrome)

SIRS is widespread inflammation that can occur in infection, trauma, shock, ect. May result from or lead to MODS. Most frequently associated with sepsis.

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse reinforce to the client about how to take these medications? You answered this question Correctly 1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate. / When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate

After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take? You answered this question Correctly 1. Administer the insulin dose to the client. 2. Consult with the charge nurse about administering the insulin dose to the client. 3. Tell the nurse that whoever draws up the medication has to administer that medication. 4. Offer to take the call from the primary healthcare provider so the nurse can administer the insulin.

Tell the nurse that whoever draws up the medication has to administer that medication

transsphenoidal hypophysectomy

endoscopic procedure to surgically remove a pituitary tumor through an incision in the sphenoid sinus without disturbing brain tissue

benign prostatic hyperplasia (BPH)

enlargement of the prostate gland

Which medication should the nurse administer first after receiving the morning shift report? You answered this question Incorrectly 1. Levothyroxine to the client with hypothyroidism and a thyroid stimulating hormone (TSH) level of 2.8 mU/L 2. Amlodipine to the client with hypertension and a blood pressure of 150/86 3. Regular insulin sliding scale dose to the client with diabetes and a 210 blood glucose level. 4. Cefotaxime intravenous piggyback to the newly admitted client with a diagnosis of pneumonia and a white blood cell count (WBC) of 12,000mm3

The first dose of an intravenous antibiotic medication is the priority and should be administered within 1 to 2 hours from when the prescription was placed. This is the priority medication to administer first. The WBC count is elevated

After discontinuing a peripheral IV line, it is most important for the nurse to record which information? You answered this question Incorrectly 1. How the client tolerated the procedure. 2. The length and intactness of the catheter tip. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.

The length and intactness of the catheter tip.

Amoxicillin/clavulanate belongs to the aminopenicillin group and is often used to treat respiratory infections. Instructions for parents about amoxicillin use include the following:

The medication may be taken with or without food as food does not affect absorption. The most common side effects of this medication are nausea, vomiting, and diarrhea. If nausea or diarrhea develops, the medicine may be administered with food to decrease the gastrointestinal side effects Shake the liquid well prior to administration. Administer at evenly spaced intervals throughout the day to maintain therapeutic blood levels Ensure that the child receives the full course of therapy; do not discontinue the medication if the child is feeling better or symptoms have resolved

Normal serum calcium is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy

The nurse should check for Trousseau's and Chevostek's signs as early indications of hypocalcemia.

A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg, enoxaparin [Lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin-based anticoagulants that causes a drastic decrease in platelet count (ie, ≤50% of pretreatment levels and/or platelet count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial and venous thrombosis (eg, deep venous thrombosis, pulmonary embolism).

The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping enoxaparin therapy and initiating a nonheparin anticoagulant (eg, rivaroxaban, argatroban)

The nurse is observing crutch walking of a client with a fractured lower leg with a non weight bearing cast. Which crutch gait would be most appropriate for the nurse to reinforce teaching? You answered this question Incorrectly 1. Swing through 2. Two point 3. Three point 4. Four point alternating

Three point / All of the weight bearing is done by the unaffected leg and the crutches. The injured leg does not touch the ground during the performance of this gait. This is most appropriate for the client with a lower leg cast.

The nurse is discussing with a client information about herbal therapy. What is the main goal of herbal therapy? You answered this question Incorrectly 1. To treat a specific disease or symptom by taking prescription medications. 2. To restore balance within the body by supporting the client's self-healing ability. 3. To avoid the use of toxic chemicals within the body. 4. To incorporate Eastern healing practices into Western medicine.

To restore balance within the body by supporting the client's self-healing ability

How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? You answered this question Incorrectly 1. 3 mL syringe with 23 gauge, 1" needle for IM injection 2. Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection. 3. Prime intranasal spray for administration. 4. Tuberculin (TB) syringe with 28 gauge, 3/8" needle for intradermal injection.

Use a 25 gauge, ¾" needle for subcutaneous (Sub-Q) injection

Clients with increased ICP should be encouraged not to

cough, strain, or increase abdominal or thoracic pressure. The head of the bed should be maintained at 30 degrees, and stimulation in the room should be minimized.

Clients with severe aortic stenosis are at risk for

developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis.

The nurse should find out more about this client's allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross-sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules. If this client's reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However if

the client had an anaphylactic reaction to penicillin, the health care provider (HCP) will need to prescribe a different antibiotic.

Prompt potassium replacement is the priority action for hypokalemic clients with myocardial infarction because

they are at increased risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) and cardiac arrest

Affected skin is highly prone to breakdown and ulcerations

venous leg ulcers), commonly on the inside of the ankle

temporal lobe

visual and auditory input / clients cannot understand verbal or written language.

Paracentesis removes fluid from the abdominal cavity to improve symptoms or provide a specimen for testing. The client should be instructed to

void prior to the procedure and be placed in high Fowler's position. Abdominal girth, weight, and vital signs should be recorded before and monitored after paracentesis

Serum lactate level

which measures the level of lactic acid in the blood, is a fairly reliable and accurate indication of tissue hypoperfusion and hypoxia

Ethambutol (Myambutol)

☐ Obtain baseline visual acuity tests. ☐ Determine color discrimination ability. ☐ This medication should not be given to children younger than 13 years of age. ☐ Instruct the client to report changes in vision immediately. / is an antibiotic and works by stopping the growth of bacteria.This antibiotic treats only bacterial infections. It will not work for viral infections (such as common cold, flu) used to treat TB

Autonomic Dysreflexia S/S

♠♠Signs & Symptoms •Pounding headache(caused by the elevation in blood pressure) •Goose Pimples •Sweating above the level of injury •Nasal Congestion •Slow Pulse •Blotching of the Skin •Restlessness •Hypertension (blood pressure greater than 200/100) •Flushed (reddened) face •Red blotches on the skin above level of spinal injury •Sweating above level of spinal injury •Nausea •Slow pulse (< 60 beats per minute) •Cold, clammy skin below level of spinal injury

A nurse is reinforcing teaching with a client who has frequent urinary tract infections on how to prevent future infections. What statement by the client would indicate to the nurse that this has been successful? You answered this question Incorrectly 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe." Holding urine can lead to stasis of urine and increasing the risk for infection. Foods such as eggs, cheese, meat and poultry, whole grains, cranberries, plums and prunes, and tomatoes tend to increase the acidity of urine. Acidic urine is less likely to allow for bacterial growth. Discarding toilet paper after each swipe will decrease exposure and accidental introduction of bacteria into the urinary meatus.

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. The nurse is reinforcing client education on the medication. Which client statements indicate an understanding of isoniazid? You answered this question Incorrectly 1. "I will notify my primary healthcare provider if my urine turns dark." 2. "My primary healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "I should avoid eating aged cheeses and smoked fish." 4. "I will eat foods such as tuna twice a week." 5. "I will rise slowly from lying to sitting, or sitting to standing."

1. "I will notify my primary healthcare provider if my urine turns dark." 2. "My primary healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "I should avoid eating aged cheeses and smoked fish." 5. "I will rise slowly from lying to sitting, or sitting to standing." / Signs of hepatotoxicity from this medication include dark urine, jaundice, and clay-colored stool. Isoniazid- induced pyridoxine (Vitamin B6) depletion causes neurotoxic effects. Vitamin B6 supplementation of 10-50 mg usually accompanies isoniazid use. Aged cheeses and smoked fish are high in tyramine which may cause palpitations, flushing, and blood pressure elevation while taking isoniazid. Avoid these foods during treatment. Isoniazid should be taken on an empty stomach, one hour before or two hours after food. Some clients experience orthostatic hypotension while taking isoniazid, so caution against rapid positional changes

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? You answered this question Incorrectly 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

"I need to see my eye doctor at least once every year." / Though there are relatively few side effects, the most serious is retinal toxicity which requires treatment by an ophthalmologist

Which statement by a client would indicate to the nurse that the client understands important points about alendronate? You answered this question Correctly 1. "It is recommended that I recline for 15 minutes after taking my medication." 2. "Food should be eaten immediately after taking alendronate." 3. "My medication tablet should be chewed for rapid absorption." 4. "I should drink a full 8 ounce glass of water with my medication."

"I should drink a full 8 ounce glass of water with my medication." / Alendronate is a biophosphonate drug used in the treatment of osteoporosis and other bone diseases. The client should take each tablet in the morning with a full glass of water (6-8 ounces or 180-240 ml) at least 30 to 60 minutes before the first food, beverage or medication of the day, to increase absorption.

A female client with a history of frequent exacerbations of asthma asks the nurse why she is at greater risk for fractures than other women her age. What is the nurse's best response? You answered this question Correctly 1. "The steroids you are taking decrease calcium in the bone by sending it to the blood." 2. "Taking steroids causes bone calcium to increase, thus causing osteoporosis." 3. "Clients who have asthma are not able to exercise enough to prevent fractures from occurring." 4. "Asthma should not put you at increased risk for fractures but you are at risk for decreased blood glucose levels."

"The steroids you are taking decrease calcium in the bone by sending it to the blood." / Long term use of steroids decreases serum calcium, so the body takes calcium from the bone and puts it in the blood in order to bring the serum calcium back to a normal level. Every time a steroid is given, calcium is removed from the bone, thus leading to a greater risk for osteoporosis and fractures.

The son of a client diagnosed with Alzheimer's Disease who is listed as a person who has access to the client's health information asks the nurse why his father has been prescribed donepezil. What response should the nurse make? Exhibit You answered this question Correctly 1. "Depression is often treated with this medication." 2. "This medication is used to treat confusion." 3. "Behavioral problems are diminished when the client receives this medication." 4. "This medication will address sleep disturbances.

"This medication is used to treat confusion."

Cardiac Glycosides Action

- Drug increases the force of ventricular contraction (+ inotropic) and thereby can increase CO - Increase in CO leads to more effective filling of the ventricle and increases the perfusion to the kidneys - Increases Ca+ in cardiac myocardial cells due to electrolyte movement - Dysrhythmia pts., digoxin slows the conduction from SA to AV node to regulate heart rhythm without increasing HR slows rate

Pathophysiology of congestive heart failure

-Cardiac output or stroke volume decreases -Backup and congestion develop as coronary demands for oxygen and glucose are not met -Output from ventricle is less than the inflow of blood -Congestion in venous circulation draining into the affected side of the heart

The nurse is reinforcing discharge teaching for a client with thrombocytopenia. Which should the nurse include? You answered this question Incorrectly 1. Floss between teeth daily. 2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitting shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.

. 2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitting shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma. Thrombocytopenia is a deficiency of platelets, and platelets help your blood clot which stops bleeding. Hard food can cause bleeding as it passes through the esophagus and can cause gums to bleed. A stool softener should be taken daily to prevent a hard stool. Straining and hard stools can lead to tissue trauma and bleeding from the rectum. Well fitting shoes can prevent injury while ambulating. Cool compress will prevent hematoma formation and stop bleeding.

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which actions should be included when caring for this client? You answered this question Incorrectly 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Use alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.

. 2. Instituting contact precautions for all who enter the clients room. 4. Dedicating equipment for use only in the client's room.

What instruction should a client know about a newly prescribed salmeterol inhaler? You answered this question Correctly 1. "Use the inhaler immediately if wheezing and shortness of breath occur during exercise." 2. "Use the inhaler when you experience a stuffy nose due to seasonal allergies." 3. "Carry the inhaler with you at all times and take 2 puffs anytime you experience an exacerbation." 4. "This inhaler should be used routinely as prescribed even when free of symptoms."

. "This inhaler should be used routinely as prescribed even when free of symptoms."

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? You answered this question Correctly 1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1. Reports a scratchy throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong."

A client diagnosed Alzheimer's disease has been prescribed memantine. The nurse is reinforcing education about this medication. What points should the client know about this medication? You answered this question Incorrectly 1. When beginning this medication provide ambulatory assistance. 2. This medication is prescribed to help improve mild dementia. 3. This medication must be taken without food. 4. If a dose is missed, double the next dose. 5. If the client cannot swallow the capsule you sprinkle on applesauce.

1. When beginning this medication provide ambulatory assistance. 5. If the client cannot swallow the capsule you sprinkle on applesauce. Memantine is used for moderate to severe dementia associated with Alzheimer's disease.

A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse knows that the insulin should start to lower the blood sugar within how many minutes? You answered this question Correctly 1. 15 2. 30 3. 45 4. 90

15 / Insulin aspart mixture is a rapid-acting insulin and starts to work within 15 minutes after given subcutaneously

The nurse has determined that a client is at risk for experiencing dumping syndrome after having had a partial gastrectomy. Which teachings about this condition should the nurse reinforce with this client? You answered this question Incorrectly 1. "After eating you should assume a right side lying position for 30 minutes." 2. "Drink liquids an hour after consuming meals." 3. "Eat three meals rather than six smaller meals." 4. "Carbohydrates should be decreased in the diet." 5. "The primary healthcare provider may prescribe a multivitamin with iron."

2. "Drink liquids an hour after consuming meals." 4. "Carbohydrates should be decreased in the diet." 5. "The primary healthcare provider may prescribe a multivitamin with iron. Fluid intake with meals is discouraged: instead, fluids may be consumed up to one hour before or one hour after mealtime. Carbohydrates increase gastric motility which this client does not need. Therefore the diet should be low in carbs. Supplementary vitamins and iron may be recommended when the client has dumping syndrome.

A client who has Parkinson's disease has a new prescription for benztropine. What does the nurse reinforce to the client about this medication? You answered this question Incorrectly 1. This medication blocks dopamine in the brain to decrease tremors and muscle stiffness. 2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. 4. No lab tests are needed while taking this medication. 5. Sit up or stand up slowly to prevent lightheadedness.

2. The client should notify their primary healthcare provider if urinary retention develops. 3. Benztropine can reduce the ability to sweat, so do not become overheated. . 5. Sit up or stand up slowly to prevent lightheadedness.

A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation? You answered this question Incorrectly 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling.

3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling. Compression stockings put gentle pressure on the leg muscles. Studies in healthy people have shown that wearing compression stockings minimizes the risk for developing DVTs after long flights. It is important for passengers to keep moving their legs to help the blood flow, even when waiting in the airport terminal. Alcohol and coffee contribute to dehydration, which can lead to thickened blood and increased risk for DVT.

A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include:

A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognizes which clients to be at greatest risk for ineffective oral hygiene? You answered this question Incorrectly 1. A client who has just had knee surgery taking opioids for pain. 2. A right handed client who had a stroke affecting the right hemisphere of the brain. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An elderly client experiencing loss of appetite. 5. A client who takes phenytoin for partial seizures.

A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. . 5. A client who takes phenytoin for partial seizures. / Phenytoin causes gingival overgrowth, swelling and bleeding of the gums. This can make oral hygiene more difficult.

Which client is at the greatest risk for ineffective oral hygiene? You answered this question Correctly 1. A client who has just had knee surgery after a skiing accident. 2. A right-handed client who has had a stroke causing mild weakness on the left side of the body. 3. A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. 4. An independent, elderly client having elective surgery.

A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy. A client with severe nausea and vomiting after chemotherapy is at an increased risk for ineffective oral hygiene problems due to vomiting, decreased oral intake, and the effects of the chemotherapy on the normal bacterial flora of the mouth

Wernicke encephalopathy and Korsakoff syndrome

A condition that occurs in alcoholics due to a thiamine deficiency, in which the mammillary bodies and dorsomedial nuclei of the thalamus are damaged (contains 2 parts, 1st: opthalmoplegia, ataxia, confusion; 2nd: amnesia, confabulation, personality change)

The adequacy of oxygenation and ventilation in a client with respiratory failure is best evaluated through

ABG analysis

Asthma is an obstructive lung disease characterized by hyperreactive airways and chronic inflammation. Asthma exacerbations occur due to various triggers (eg, allergens, respiratory infection, exercise, cold air), resulting in edema, hypersecretion of mucus, and bronchospasm. Narrowing of the airways culminates in air trapping, lung hyperinflation, and increased airway resistance. In severe asthma, breath sounds may be diminished due to closure of bronchioles. Absent breath sounds in a client with asthma are a medical emergency. Clinical manifestations of an asthma exacerbation include:

Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue Chest tightness related to air trapping Cough from airway inflammation and increased mucus production Diminished breath sounds related to hyperinflation High-pitched expiratory wheezing caused by narrowing airways .As asthma worsens, wheezing may be heard on both inspiration and expiration. Tachypnea related to inability to take a full, deep breath

A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action? You answered this question Incorrectly 1. Keep client NPO until the gag reflex returns. 2. Perform an immediate cleansing enema. 3. Administer 30 mLs milk of magnesia orally. 4. Monitor vital signs every ten minutes until stable.

Administer 30 mLs milk of magnesia orally. 3. CORRECT. An Upper GI involves the ingestion of a barium based contrast under fluoroscopy to view the esophagus, stomach, and small intestine. Following such a procedure, it is vital for the client to pass all the barium before a blockage occurs. The client is encouraged to drink large amounts of fluid and is administered an over the counter laxative, such as milk of magnesia, to remove barium. 1. INCORRECT. The client's gag reflex was not inactivated. The reflex must remain intact in order for the client to drink the barium based contrast during the test. 2. INCORRECT. The barium would not yet have reached the colon following the Upper GI and therefore a cleansing enema would not be effective. If the client had received a lower GI, an enema may have been ordered. 4. INCORRECT. The client is fully awake and conscious during the entire procedure. No medications were administered that would alter the vital signs; therefore, every 10 minute vital signs are not necessary.

Two days after being prescribed enoxaparin the nurse notes hematemesis. Lab work has been obtained. Based on this data what action is most important for the nurse to take? Exhibit You answered this question Correctly 1. Administer protamine sulfate. 2. Administer the next dose of enoxaparin. 3. Obtain vital signs. 4. Insert a nasogastric tube. Hemaglobin: 10.0 g/dL Hematocrit: 40% RBCs: 4.5 Platelets: 90,000

Administer protamine sulfate / This client has a low hgb, hct, and platelet count and is actively bleeding. Protamine sulfate is the antidote for enoxaparin.

What nursing intervention takes priority for the client one day postoperative bowel resection reporting pain of a 6 on a 0 to 10 pain scale? You answered this question Incorrectly 1. Assist the client in changing positions. 2. Use a distraction technique. 3. Administer the prescribed analgesic. 4. Encourage the client to walk

Administer the prescribed analgesic.

A client with an ischemic stroke was prescribed warfarin 5 mg daily by mouth 48 hours ago. At 0830 the international normalized ratio (INR) reading was 2.0. What action should the nurse take? You answered this question Correctly 1. Administer warfarin. 2. Administer phytonadione. 3. Request the lab to run another INR. 4. Notify the primary healthcare provider about the INR level.

Administer warfarin / The nurse should continue to monitor the client, and administer the warfarin. The normal range for INR is 0.8 - 1.1 for a client not prescribed an anticoagulant. The optimal therapeutic INR range for a client on warfarin should be 2.0 - 3.0

Retinal detachment Postoperative teaching should include:

Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining) (Options 1 and 2) Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health care provider (Option 4) Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for detachment (Option 5). Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds the retina in a specific position to allow healing

Which medication does the nurse expect will help decrease tremors in a client diagnosed with hyperthyroidism? You answered this question Correctly 1. Steroids 2. Anticonvulsants 3. Beta blockers 4. Iodine compounds

Beta blockers

The nurse is participating in providing a community education class on alternative therapies. Which alternative therapy that uses substances found in nature should the nurse include? You answered this question Correctly 1. Energy therapies. 2. Mind-body interventions. 3. Body-based methods. 4. Biologically-based therapies.

Biologically-based therapies

To do purse-lips breathing:

Breathe in through your nose (as if you are smelling something) for about 2 seconds. Pucker your lips like you're getting ready to blow out candles on a birthday cake. Breathe out very slowly through pursed-lips, two to three times as long as you breathed in. Repeat.

Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION:

Change in bowel or bladder habits (Option 5) A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere (Option 3) Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole (Option 4) Nagging cough or hoarseness

What is the best information the nurse can provide when administering acetylsalicylic acid 81 mg to a client experiencing severe, crushing chest pain radiating up the left jaw? You answered this question Incorrectly 1. Chew the acetylsalicylic acid prior to swallowing. 2. Place the acetylsalicylic acid under the tongue so that it can dissolve. 3. Swallow the acetylsalicylic acid tablet. 4. Insert the acetylsalicylic acid between the cheek and gum for greater absorption.

Chew the acetylsalicylic acid prior to swallowing / Acetylsalicylic acid has been shown to decrease mortality and re-infarction rates after MI. The fastest way to get the aspirin into the circulatory system is to have the client chew the acetylsalicylic acid prior to swallowing.

While in the emergency department, a 68 year old client being treated for flu symptoms, became symptomatic with an episode of atrial tachycardia which was successfully treated with cardioversion. After stabilization, the client was admitted to the telemetry unit with a diagnosis of the flu, and a history of angina. Primary healthcare provider prescriptions were received. What is most important for the nurse to ensure prior to administering Peramivir? Exhibit You answered this question Incorrectly 1. Creatinine clearance is greater than 50 mL/min. 2. Pulse greater than 70 beats/min. 3. Cardiac rhythm showing normal sinus rhythm. 4. Oral temperature less than 101° F (38.3° C)

Creatinine clearance is greater than 50 mL/min.

Tyramine foods

Fruits and Veggies are okay except remember salad BAR, avoid Banannas, Avacados, Raisins, Grains are okay except for active yeast, no organ meats, no preserved meats, no dairy, no alcohol, tinctures, caffiene, chocolate, licorice, soy sauce

Ninth cranial nerve

Glossopharyngeal, mixed taste

A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of the client's treatment regimen? You answered this question Correctly 1. Mitotic inhibitors 2. Systemic glucocorticoids 3. Antifungals 4. Anticoagulants

Glucocorticoids (steroids) are an appropriate pharmacologic treatment for rheumatoid arthritis. Other treatment options include the use of NSAIDs, biologic and nonbiologic DMARDs (methotrexate and others). Remember, all the other problems associated with the use of steroids.

infections are leading causes of pelvic inflammatory disease and infertility?

Gonorrhea and chlamydia are the most common causes of pelvic inflammatory disease, which can lead to infertility.

Heart failure with reduced ejection fraction

HFrEF; heart failure associated with systolic dysfunction and reduced myocardial contractility; ejection fraction is ≤ 40%.

What action should the nurse take when collecting data about a client's near vision? You answered this question Incorrectly 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

Have client read a newspaper at 14 inches (36 cm).

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? You answered this question Incorrectly 1. Blood pressure 102/68 2. Glucose 118 3. Urinary output (UOP) 440 mL over previous 8 hour shift. 4. Heart rate 56/min

Heart rate 56/min

The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern? You answered this question Correctly 1. Hypokalemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypocalcemia

Hypokalemia

A client was prescribed a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse is reinforcing client education on MAOI medication. Which comment by the client indicates adequate understanding of the tyramine restrictions that apply? You answered this question Correctly 1. I cannot eat avocados or smoked ham. 2. I can eat sausage for breakfast, but not bacon. 3. At least I can still have my beer. 4. I can have blue cheese on my salad but not ranch dressing

I cannot eat avocados or smoked ham / Clients taking MAOIs cannot consume foods containing large amounts of tyramine. MAOIs block monoamine oxidase which breakdown tyramine. Having a MAOI prescribed and eating a diet high in tyramine can cause a severe increase in blood pressure. Smoked ham and avocados are high in tyramine.

A client receiving palliative care is reporting constipation. What action should the palliative care nurse provide first? You answered this question Correctly 1. Increase foods high in fiber. 2. Administer an enema 3. Increase fluid intake 4. Administer docusate sodium. Increase fluid intake is correct. Dehydration is one of the most common causes of constipation. Fluids keep your stool soft and easy to pass.

Increase fluid intake. Increase fluid intake is correct. Dehydration is one of the most common causes of constipation. Fluids keep your stool soft and easy to pass.

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? You answered this question Correctly 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity

Increased specific gravity / Specific gravity is an indicator of hydration status and urine osmolality. In a dehydrated client, specific gravity is increased, indicating highly concentrated urine

The nurse is caring for a Puerto Rican client. The client has several injuries from a car accident and is experiencing pain. Which behavior is likely to be noted? You answered this question Incorrectly 1. Loud crying with pain. 2. Enduring the pain in order to bring honor. 3. Quiet and stoic responses to pain. 4. Refusing pain medication because it is God's will

Loud crying with pain / Puerto Rican clients tend to cope with pain by loud and outspoken reports of pain. This is consistent with Puerto Rican culture and their response to pain

A client with heart failure and pulmonary edema is given furosemide IM. Which data indicates the furosemide has achieved the desired effect? You answered this question Correctly 1. Weight has decreased 2 pounds 2. Systolic blood pressure has decreased 3. Urinary output has increased 4. Lungs have fewer rales on auscultation.

Lungs have fewer rales on auscultation / The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life threatening sequelae with heart failure (HF). The number one thing to "worry" about in clients with HF is pulmonary edema because this is what can kill the client

What is the most important goal of care for a client who is receiving warfarin? You answered this question Incorrectly 1. Be compliant with dietary restrictions. 2. Maintain a therapeutic prothrombin time. 3. Be compliant with medication dosage daily. 4. Avoid other anticoagulant medications.

Maintain a therapeutic prothrombin time.

How does the nurse identify the correct size of crutches for a client? You answered this question Incorrectly 1. Turn the crutches upside down and measure from the heel to the shoulder. 2. Obtain a set of crutches and adjust the height until the client can stand comfortably while resting the axilla on the crutch pad. 3. Measure the client while standing upright from the axilla to the heel then adjust the crutches so that the elbow flexion is a 30-degree angle. 4. Measure the client from 2 inches below the axilla to 6 inches lateral to the client's hee

Measure the client from 2 inches below the axilla to 6 inches lateral to the client's heel. Measuring the client from 2 inches below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches. This is the correct size while a client is standing.

Risk factors for PUD include gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg, aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors:

NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing (Option 1). Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion (Option 2). Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing (Option 3). Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing (Option 4). Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion.

A nurse is to administer a time release capsule to a client who has difficulty swallowing. Which intervention would be the best course of action for the nurse to take? You answered this question Correctly 1. Open the capsule and sprinkle it on applesauce. 2. Melt the capsule in juice or water. 3. Notify the charge nurse. 4. Break the capsule in half using a pill splitter.

Notify the charge nurse / If the client has difficulty swallowing a capsule or tablet, the charge nurse ask the primary healthcare provider to substitute a liquid medication if possible

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? You answered this question Correctly 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

Notify the primary healthcare provider

When preparing to administer the client a dose of intravenous piggyback (IVP) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take? You answered this question Correctly 1. Notify maintenance to come and check the pump immediately. 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

Obtain a replacement pump

A female client has used Depo-Provera injections for birth control for several years. For the past 6 months, attempts to become pregnant have been unsuccessful. What information should the nurse provide the client? You answered this question Correctly 1. A primary healthcare provider who specializes in this problem should be seen. 2. Have a sperm count performed on the client's partner. 3. Ovulation may not occur for many months after using Depo-Provera. 4. Ensure proper nutrition, rest, and establish an exercise program.

Ovulation may not occur for many months after using Depo-Provera.

The nurse is caring for a client on the post surgical unit. What should the nurse know about short term treatment of post op pain? You answered this question Incorrectly 1. There are no concerns about addiction from pain medications following surgery. 2. Pain control following surgery rarely results in addiction. 3. The opioid medications typically result in addiction. 4. The primary healthcare provider will not prescribe an addictive medication.

Pain control following surgery rarely results in addiction.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? You answered this question Correctly 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

Palliative care prevents and treats symptoms and side effects of disease and treatments.

The nurse reinforces teaching with a client taking isoniazid for the treatment of tuberculosis (TB) regarding appropriate food choices. Which food choice indicates to the nurse that reinforcement has been successful? You answered this question Correctly 1. Salad with bleu cheese dressing. 2. Smothered liver with onions. 3. Smoked salmon with crackers. 4. Pear salad with lettuce.

Pear salad with lettuce / Pears are acceptable fruit. Foods high in tyramine can cause headaches, fast or irregular heartbeats, nausea and vomiting and sensitivity to light. Foods high in tyramine such as aged cheeses, certain meats, liver, smoked fish, sour cream, raisins, bananas and avocados should not be eaten when taking isoniazid

The primary healthcare provider prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse implement? You answered this question Incorrectly 1. Offer the client frequent high calorie snacks. 2. Check the apical pulse before each dose. 3. Perform or assist with oral hygiene every shift. 4. Give the medication 30 minutes prior to meal.

Perform or assist with oral hygiene every shift./ Phenytoin is an anticonvulsant. It works by slowing down impulses in the brain that cause seizures. A major side effect is gingival hyperplasia. Oral hygiene is important for decreasing this complication while the client is on phenytoin.

The nurse is reinforcing teaching to a client about the use of a cane. Which is the correct cane technique? You answered this question Incorrectly 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on stronger side of body. Place cane forward 6 to 10 inches while client stands with body weight divided between both legs. The weaker leg is advanced to cane, with body weight divided between strong leg and the cane. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client stands with body weight divided between both legs. The weaker leg is advanced to the cane, with the body weight divided between the strong leg and the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

Place the cane on stronger side of body. Place cane forward 6 to 10 inches while client stands with body weight divided between both legs. The weaker leg is advanced to cane, with body weight divided between strong leg and the cane.

The nurse is caring for a preoperative client who received intramuscular lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? You answered this question Correctly 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom

Place the client on a bedpan

The nurse is caring for a preoperative client who received intramuscular lorazepam 5 minutes ago and is now requesting to void. What is the appropriate nursing action? You answered this question Incorrectly 1. Ask the unlicensed assistive personnel to assist the client to the bathroom. 2. Insert a indwelling urinary catheter since the client is going to surgery. 3. Place the client on a bedpan. 4. Allow the client to go to the bathroom.

Place the client on a bedpan

Which prescription should the nurse question when a client is receiving spironolactone 25 mg by mouth daily? You answered this question Correctly 1. Digoxin 0.125 mg by PO daily 2. Potassium chloride 40 mEq orally t.i.d. 3. Cimetadine 300 mg PO q6h 4. Metoprolol 100 mg p.o. daily

Potassium chloride 40 mEq orally t.i.d. / Do not give potassium supplements, salt substitutes, or angiotensin-converting enzyme inhibitors to clients taking potassium sparing diuretics because these drugs can increase the risk of developing high to extremely high blood potassium levels.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? You answered this question Incorrectly 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

Potassium level of 3.1 mEq/L (3.1 mmol/L) / Torsemide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmoL/L) is hypokalemia, and a common sign and symptom includes muscle cramps.

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? You answered this question Incorrectly 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

Prior to onset of intense pain.

The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? You answered this question Incorrectly 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.

Promotes the return of venous blood to the heart and assists in preventing blood clots. The anti-embolic stockings promote return of venous blood to the heart and assist in preventing the stasis of blood that can lead to blood clots

The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered

RMS is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest.

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?

Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis.

Pursed lip breathing technique

Relax the neck and shoulders. Inhale deeply for 2 seconds through the nose with the mouth closed. Exhale for 4 seconds through pursed lips, as if blowing through a straw. If unable to exhale for this long, practice regularly until you can exhale for twice as long as you inhale

Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include:

Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy.

The nurse is caring for a client who is taking an antipsychotic medication for the treatment of schizophrenia. The nurse is told in report that the client has akathisia, as a side effect of their antipsychotic medication. What symptom should the nurse expect this client to have? You answered this question Incorrectly 1. Upward gaze of the eyes. 2. Involuntary movement of the tongue. 3. Reports of restlessness. 4. Lack of movement or slowed movement.

Reports of restlessness.

A post-operative client has received morphine for pain. The nurse checks the client 10 minutes later. Which data warrants further action by the nurse? You answered this question Correctly 1. Blood pressure 94/60 2. Pulse rate 72/min 3. Pain level 3/10 4. Respiratory rate at 8/min

Respiratory rate at 8/min / Normal respiratory rate is 12-20 per minute. The respiratory rate indicates respiratory depression following administration of an opioid. Care should be taken to titrate the dose so that the client's pain is controlled without depressing the respiratory function.

The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause

Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates.

A teaching plan for a client prescribed rifampin includes these additional instructions:

Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives.

A client with asthma uses a corticoid inhaler. What teaching should the nurse reinforce to decrease the risk of an oral fungal infection? You answered this question Correctly 1. Lessen the exposure of the oral mucosa to the corticoid inhaler by exhaling rapidly. 2. Rinse the mouth completely and brush teeth following the use of the corticoid inhaler. 3. Use alcohol based mouth rinses with corticoid inhaler. 4. Drink water prior to using the corticoid inhaler.

Rinse the mouth completely and brush teeth following the use of the corticoid inhaler

asthma attack such as difficulty breathing, wheezing, coughing, shortness of breath, and difficulty performing normal daily activities. Other symptoms of an asthma attack may include:

Severe wheezing when breathing both in and out Coughing that won't stop Very rapid breathing Chest tightness or pressure Tightened neck and chest muscles, called retractions Difficulty talking Feelings of anxiety or panic Pale, sweaty face Blue lips or fingernails

Placing a client with a decreased level of consciousness in a position that uses gravity

Side lying / to help drain oropharyngeal and gastric secretions can be effective in preventing aspiration and reducing the risk for aspiration pneumonia.

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? You answered this question Correctly 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

Side-lying / 3. Correct: We want to position for comfort with the knees flexed and on the side for airway. 1. Incorrect: Avoided to prevent pooling and edema in pelvis 2. Incorrect: Partial lying on stomach is going to be painful 4. Incorrect: Stretching out straight puts pressure on the abdomen and should be avoided

Serotonin Syndrome

Similar to NMS but caused by serotonin medications, and has HYPERreflexive muscle activity

salpingo-oophorectomy

Surgical removal of the fallopian tubes and ovaries

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which data should be reported to the primary healthcare provider? You answered this question Incorrectly 1. Hemoglobin level of 10 g/dL (1.6 mmol/L) 2. Blood pressure of 120/84 3. Constipation 4. Swelling of feet and ankles

Swelling of feet and ankles / Erythropoietin is generally well tolerated. Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots.

Desmopressin (DDAVP)

Synthetic analog of ADH hormone used for diabetes insipidus and nocturnal enuresis

TBSA = [anterior torso] + [anterior arms] + [anterior legs] + [perineum]

TBSA = [18] + [4.5 + 4.5] + [9 + 9] + [1] TBSA = 18 + 9 + 18 + 1 = 46%

The nurse is caring for a client on the skilled nursing unit. The client has lost 8 pounds (3.6 kg) since admission 3 months ago. Which strategy may help to improve the client's caloric intake? You answered this question Correctly 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the nursing tech to feed the client at each meal.

Take the client to the dining room for meals.

Labetalol has been prescribed for a client. Which nursing intervention is important for the nurse to perform prior to administering the medication? You answered this question Correctly 1. Listen to the client's breath sounds. 2. Check the client's temperature. 3. Monitor for peripheral edema. 4. Take the client's blood pressure.

Take the client's blood pressure./ The therapeutic effect of labetalol, which is a beta blocker, is to lower the blood pressure. The clue is that this drug ends in lol

A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?

The nurse should assess the lung sounds for crackles and report to the supervising registered nurse (RN) and the health care provider (HCP), who can prescribe loop diuretics.

Seizure manifestations generally are classified into 4 phases:

The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

The nurse is reinforcing the medication prescriptions with a client for which English is a second language (ESL). Which nursing intervention most likely will prevent a medication error with this client? You answered this question Correctly 1. Use the teach-back method so that client is repeating the instructions back to the nurse. 2. Give printed information to the client. 3. Ask the client if they have questions before the client leaves the healthcare setting. 4. Refer medication questions to the pharmacist.

The teach-back method of asking the client to repeat the teaching instructions to the nurse will most likely reveal any misunderstanding. This allows the nurse to reinforce any areas where clarification is needed.

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the outpatient psychiatric clinic and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? You answered this question Correctly 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow.

Transport the client to the emergency room. / The client may be experiencing neuroleptic malignant syndrome, a potentially life threatening adverse reaction. Symptoms include high fever, unstable blood pressure and myoglobinemia. The client should be taken to the ER.

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration?

Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis

Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions for OSA include:

Using a continuous positive airway pressure (CPAP) device at night to keep the tongue from collapsing backward Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax, leading to airway obstruction (Option 2) Weight loss and exercise may reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA (Option 3). Avoiding sedating medications (eg, benzodiazepines, certain antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness

Lifestyle and dietary measures that may prevent GERD and associated symptoms include:

Weight loss, as excessive abdominal fat may increase gastric pressure Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated Refraining from eating at bedtime and/or lying down immediately after eating Dairy is okay

Pursed lip breathing technique

While sitting upright, the patient inhales through the nose while counting to three, then exhales slowly and evenly against pursed lips while tightening the abdominal muscles

flat affect

a lack of emotional responsiveness

vegan

a person who does not eat food from any animal source

Neuroleptic Malignant Syndrome (NMS)

a potentially fatal, idiosyncratic reaction to an antipsychotic (or neuroleptic) drug

Vancomycin Resistant Enterococcus (VRE)

a strain of enterococcus that cannot be controlled with antibiotics; it is spread through direct and indirect contact

arteriovenous fistula (AVF)

a surgically created connection of an artery and vein to provide circulatory access for hemodialysis

arterial blood gases

a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present

pleural effusion

abnormal accumulation of fluid in the pleural space

paresthesia

abnormal sensation of numbness and tingling without objective cause

Loop diuretics are diuretics that

act at the ascending limb of the loop of Henle in the kidney. They are primarily used in medicine to treat hypertension and edema often due to congestive heart failure or renal insufficiency.

Decreased urine output of <30 mL/hr could be due to low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). The nurse should

always assess the client first and then report to the supervising registered nurse and health care provider

Cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of

anemia

Oxazolidinones (Linezolid)

antibiotic that works by inhibiting protein synthesis: binds the 23S rRNA and prevents formation of the 70S initiation complex

Radiation therapy to the head and neck can cause mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth), leading to decreased nutrition. Care includes

avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene.

frontal lobe function

behavioral changes

Platlets (thrombocytes)

blood clotting

Due to the possibility of nephrotoxicity, monitoring of vancomycin trough level to maintain optimal drug level

blood urea nitrogen and creatinine to assess renal function is indicated, especially in clients with impaired renal function and who are age >60.

Clients with benign prostatic hyperplasia (BPH) have increased risk for urinary tract infections (UTI) due to incomplete bladder emptying and urine retention. Symptoms of UTI that differ from those of BPH include

burning sensation with urination and cloudy/foul-smelling urine.

The live-attenuated, intranasal influenza vaccine is a safe and effective choice for many healthy clients age 2-49 years

but should not be given to clients who are immunocompromised, pregnant, or age <2 years.

Warning signs of cancer for nurses to monitor include

change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION).

systemic lupus erythematosus (SLE)

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs is the form of the disease that most people are referring to when they say "lupus." The word "systemic" means the disease can affect many parts of the body. ... Discoid lupus erythematosus is a chronic skin disorder in which a red, raised rash appears on the face, scalp, or elsewhere, is the form of the disease that most people are referring to when they say "lupus." An inflammatory disease caused when the immune system attacks its own tissues.

Monoamine Oxidase Inhibitors (MAOIs)

class of antidepressant drugs sometimes used for treating depression

Urge incontinence (overactive bladder)

condition caused by uncontrolled contraction or over activity of the detrusor muscle

Linezolid is an antibiotic with monoamine oxidase inhibitor-type properties that is prescribed to treat vancomycin- and methicillin-resistant bacterial infections. Selective serotonin reuptake inhibitors are

contraindicated during therapy due to the increased risk of serotonin syndrome.

frontal lobe function

controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes.

Clients with cystic fibrosis should adhere to a

diet high in fat and calories to combat nutrient malabsorption. Liberal fluid intake is encouraged to thin the thick secretions. Spiritual support should be offered to cope with the impact of a shortened life span.

Dysarthria definition

difficult poorly articulated speech that usually results from interference in control over the muscles of speech. General cause is damage to the central or peripheral nerve.

Dietary management of ulcerative colitis includes

eating small, frequent meals; following a low-residue, high-protein, high-calorie diet; taking supplemental vitamins and minerals; avoiding caffeine, alcohol, and tobacco; and drinking at least 2000-3000 mL/day of fluid. Continued use of sulfasalazine prevents relapse and prolongs symptom remission

lacto-vegetarian

excludes animal flesh and eggs but does include dairy products

What are the possible side effects of sulfamethoxazole and trimethoprim?

fever, sore throat, and headache with a severe blistering, peeling, and red skin rash; the first sign of any skin rash, no matter how mild; pale skin, easy bruising or bleeding; cough, feeling short of breath; diarrhea that is watery or bloody;

Dark-colored urine and yellow skin can indicate the presence of

hepatotoxicity which is associated with many drugs used to treat tuberculosis (eg, isoniazid, pyrazinamide, rifampin). However, hepatotoxicity is not common with ethambutol.

temporal lobe function

integrates visual and auditory input and past experiences.

Absence seizures (petit mal)

may appear to stare into space for a few seconds. Other symptoms include lip smacking, eyelid fluttering, and chewing motions

Macrocytic anemia causes

megaloblastic (B12/folate def, impaired DNA synth) non-megaloblastic (hypothyroid, liver dz, alcoholism, drugs)

MAOIs

monoamine oxidase inhibitors

Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a

narcotic or during oversedation

The normal therapeutic level of vancomycin is 10-20 mg/L (6.9-13.8 µmol/L). Elevated vancomycin trough levels (>20 mg/L [>13.8 µmol/L]), creatinine (>1.3 mg/dL [>115 µmol/L]), and blood urea nitrogen (>20 mg/dL [>7.1 mmol/L]) are associated with

nephrotoxicity and should be reported to the health care provider.

Neuritis is an inflammation of what?

nerve

Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a

ruptured cerebral aneurysm and should be treated as an emergency.

Peptic ulcer disease (PUD) is a gastrointestinal illness caused by breaks in the gastrointestinal mucosa, leading to ulcer formation. To reduce ulcer formation risk, clients with PUD should be instructed to stop

smoking; avoid chronic NSAID use; avoid meals or snacks before sleeping; and limit alcohol and caffeine consumption.

retinal detachment s/s

specks floating before the eye; flashes of light; blurred vision

Difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to

streptomycin

Aminoglycoside antibiotics

tetracycline, erythromycin, streptomycin, chloramphenicol

The Valsalva maneuver

the action of attempting to exhale with the nostrils and mouth, or the glottis, closed. This increases pressure in the middle ear and the chest, as when bracing to lift heavy objects, and is used as a means of equalizing pressure in the ears.