Nursing- NCLEX Prep

About mid morning a 10 year old child reports to the school nurse complaing of nausea, dizziness, and chills. further assessment reveals that this child is sweating profusely and has a blood gucose evel of 57. Based on these assessment finding, which food is best for the nurse to encourage the child to eat?

peanut butter and crackers

A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care?

Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. The nurse may collaborate with the case manager to evaluate the need for continued IV antibiotics (D). The role of the case manager is to ensure desired client outcomes in a cost-effective manner.

After attending an inservice for bioterrorism preparedness and staff education, the nurse should identify which findings consistent with a possible anthrax exposure?

Flu-like symptoms, gastrointestinal distress, and papular lesions

A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?

I have known many clients with depression who have felt better after several weeks of treatment. Stating the observation that others have recovered can give a client hope

Which intervention is most important for the nurse to include in the plan of care for a client with ankylosing spondylitis?

initiate smoking cessation program

The nurse is providing comfort and palliative care for a terminally ill client who is experiencing nausea and vomiting. Which action is best for the nurse to take to promote the client's comfort?

offer high protein foods

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take?

record these findings as normal. These findings are normal for first day postop. and indicate that the wound is healing.

A male client gives a copy of his living will to the nurse upon admission to the hospital. What action should the nurse implement if the client is unable to express his desire about life-prolonging measures?

Allow the client to die with dignity and without life-prolonging techniques.

Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?

An adult who had a colon resection yesterday and has an IV. An OB nurse is usually experienced in caring for abdominal surgical wounds (cesarean sections) and IV infusions, so the adult who had a colon resection would be the best choice

Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)?

An older client with intestinal obstruction and septic shock. High risk clients vulnerable for MODS include older clients with decreased organ reserve, comorbidities, and massive inflammatory or immune dysfunction, such as septic shock

A client with advanced bone cancer is experiencing cachexia. The nurse reviews the nutritional components of palliative care with the client's family members. The nurse recognizes that the teaching is designed to achieve which outcome?

Enhance the clients quality of life. Nutritional interventions to decrease cachexia will not necessarily contribute to survival, but they may enhance the client's quality of life. Palliative care focuses on reducing symptoms and increasing quality; it does not focus on finding a cure. Nutritional interventions cannot prevent the occurrence of respiratory infections; this requires mobilization of respiratory secretions to prevent stasis. Malabsorption cannot be prevented with teaching; it may or may not occur depending upon the disease process and function of the client's gastrointestinal tract.

A client is admitted to the hospital with a diagnosis of liver disease, and a liver biopsy is performed. Postoperatively, how often and for how long would the nurse take the client's vital signs?

Every 15 minutes for 2 hours Every 15 minutes for 2 hours is an appropriate frequency to take the vital signs after a liver biopsy. The risk of internal bleeding is highest immediately after the biopsy; diseases of the liver result in impaired blood-clotting mechanisms. Every 30 minutes after a liver biopsy is too infrequent; 2 hours after the procedure, the vital signs can be taken every 30 minutes instead of every 15 minutes if the client is stable.

An adolescent client is admitted to the mental health unit for impulsivity and acting-out behavior at school. What intervention should the nurse implement that is most beneficial for this client?

Explain the consequences for breaking the unit rules

Which infant is at risk for Rh incompatibility?

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor.

A client with an acute episode of ulcerative colitis is admitted to the hospital. Blood studies reveal that the chloride level is low. Which would the nurse be prepared to administer to the client?

Intervenous therapy Intravenous therapy ensures a well-controlled technique for electrolyte (chloride) replacement. There is no assurance that adequate chloride will be ingested and absorbed via a low-residue diet. Total parenteral nutrition is not necessary at this point, although it may eventually be used. Oral electrolyte solution is not a well-controlled method to correct electrolyte deficiencies.

The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan?

Method used to aspirate medication from a vial. To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration

A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first?

Morphine sulfate (Roxanol) 5 to 10 mg SL as needed. Comfort and pain management using an effective analgesic-sedative such as morphine, is the most important standard of care therapy in hospice home care to ensure comfort and enhance the quality of life.

An 8 year old male client with nephrotic syndrome is in remission following treatment with prednisone. The nurse should teach the child to check his urine for which finding?

Protein- nephrotic syndrome occurs when filtering units of the kidneys are damaged. this damage causes proteinuria.

A client who begins an exercise program asks the nurse about carbohydrate loading. What concepts should the nurse include in teaching the client ways to increase glycogen store in muscles?

Rest and increased carbohydrate intake This typically involves several days of eating more carbs than usual while also decreasing exercise to reduce the amount of carbs you are using.

A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2° F, chills, pelvic pain, and uterine tenderness. What action should the nurse take?

Review the complete blood count. This client is exhibiting symptoms of endometritis, and an elevated white blood count suggests infection

Which action should the nurse implement when using the confrontation technique during a vision exam?

Sit facing the client and while look directly at the client's face, move an object inward from the periphery. Confrontation visual field testing involves having the patient looking directly at your eye or nose and testing each quadrant in the patient's visual field by having them count the number of fingers that you are showing

When administering an intramuscular (IM) injection to an adult client using the ventrogluteal site, which landmarks should the nurse identify to locate the area for injection?

The anterosuperior iliac spine and the greater trochanter

A male client who is admitted with a bleeding peptic ulcer develops sudden, severe upper abdominal pain. The client becomes diaphoretic and draws his knees over his abdomen. Which finding should the nurse report to the healthcare provider?

a rigid boardlike abdomen This is an involuntary response to prevent pain caused by pressure on your abdomen. Another term for this protective mechanism is guarding. This could indicate an abscess in the abdomen.

A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct assessment of this infant?

above average in weight but average in length. Typical babies weight is 7.5 lbs and typical length is 18-21 inches

A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct?

an antibiotic ointment is placed in the eyes to prevent infection. Antibiotic ointments, such as erythromycin ointment, are placed in the lower conjunctiva of each eye to prevent chlamydia and gonorrhea

When culturing a wound, the nurse should obtain the sample from which part of the wound?

areas containing purulent or pooled exudates. first clean the wound then obtain culture from the secretions.

The nurse instills an atropine ophthalmic solution into both eyes for a client who is having a routine eye examination. Which side effects should the nurse tell the client to anticipate?

blurred vision

Which information is most accurate for the nurse to use when calculating safe drug dosages for a child?

body surface area

The nurse is reviewing the laboratory results of an older client who is admitted to a medical unit. Which serum chemistry values should the nurse recognize as most commonly affected by the aging process? (Select all that apply.)

calcium, potassium, and sodium

Which action should the nurse implement when providing nasogastric (NG) feeding to an unresponsive client

check residual volume every 4 hours

A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client?

meeting nutritional needs. To avoid gastrointestinal pain and diarrhea, these clients often refuse to eat and become malnourished. The consumption of a high-calorie, high-protein diet is advised. Diarrhea, not constipation, is a problem with Crohn's disease.

on the second day after admission, a client with a fractured pelvis develops chest pain, tachypnea, and tachycardia. Which additional finding should the nurse identify that is most likely related to a fat embolism

petechiae of the anterior chest wall release of bone marrow fat globules into the venous circulation followed with platelet aggregation. Fat emboli lodge in the pulmonary vasculature , result in tissue hypoxia, and manifest as petechiae on the neck, anterior chest wall

Which nursing diagnosis is best to formulate for a 76-year-old client who is exhibiting an external locus of control?

powerlessness

A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding?

respirations of 10. With respirations less than 12 the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours and absent reflexes.

A mother brings her 4-week-old infant for the first well-child visit and tells the nurse that the baby is not smiling. Which information should the nurse provide?

social smiling begins around 2 months of age.

The nurse is developing the plan of care for an older client who is immobile and at risk for pressure ulcers. Which contributing factor should the nurse include in the nursing diagnosis, "Risk for altered skin integrity?

tissue ischemia

A male client has a prescription for disulfiram (Antabuse). Which adverse reaction should the nurse caution the client about while taking the medication?

vomiting

A client with chronic kidney disease (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response?

Stimulates erythropoiesis in the bone marrow to increase circulating erythrocytes. Epoetin alfa is a biological response modifier that is used to stimulate the formation of red blood cells.

A client who is taking nitroglycerin for angina is concerned about having headaches after taking more than one tablet. What information should the nurse provide?

This is a common side effect due to the vasodilatory effects of the medication.

Which client information should the nurse obtain that is indicative of the presence of cholelithiasis?

Upper right abdominal pain that occurs after meals and radiates to the back or right shoulder

the nurse is planning care for a child with Trisomy 21 who is admitted with recurrent upper respiratory infections and chronic constipation. Which intervention should the nurse include in the plan of care?

Use a bedside cool-mist vaporizer during naps and night time. Persistent nasal congestion forces the child to mouth-brather, which dries the oropharyngeal membranes and increases the susceptibility to upper respiratory tract and ear infections. using a cool-mist vaporizer moistens the nasal mucous membranes, liquefies, and drains nasal secretions to reduce this medium for infection

A primiparous client has been in labor for 15 hours. Two hours ago, vaginal exam revealed the cervix dilated to 5 cm, 100%, and the presenting part at station 0. five minutes ago, the vaginal exam revelas no change in the cervix or decent of the fetus. Which labor pattern should the nurse document to describe the client's progress

arrest of active phase indicated if there is no change in the dilation of the cervix for 2 hours or more in a primigravida. Prolonged latent phase is labor lasting plonger than 20 hours in primigravida

A male client with degenerative arthritis of the knees and hips takes an OTC NSAID for pain. During a routine clinic visit, the client tells the nurse, "For the past month I've been having a lot of trouble sleeping. I can't seem to fall asleep, and when I finally do get sleep, I find that I wake up a number of times during the night." Which info should the nurse obtain first?

how intense does the client rate his pain

the nurse is teaching an obese adolescent about lifestyle choices and ways to improve diet. which interventions should the nurse include in the teaching plan

incorporate favorite foods into the adolescent's diet the most successful diets are those that use ordinary foods in controlled portions rather than diets that require the avoidance of specific foods. to promote compliance, an adolescent should be taught how to incorporate favorite foods and to select substitutes that are satisfying and also maintain a healthy diet

A client is admitted with myasthenia gravis and comes into for a visit with one eyelid dropping down. How would the nurse document this assessment finding.

ptosis

A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement?

refer for further diagnosis testing

The nurse identifies a client's laboratory results and identifies an elevated serum ammonia level. Which pathophysiological process contributes to this finding?

Failure of the liver to convert ammonia absorbed from the bowel to urea

The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow?

Inject air until no sound is auscultated over the tracheostomy during a deep breath. To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the cuff) during inhalation

Which entry in the client's medical record provides the best documentation of client care?

0830- IV fluid rate increased to 100 ml/hour according to protocol.

Which pain description would the nurse expect a client to report when describing pain associated with a suspected duodenal peptic ulcer?

A gnawing sensation in the epigastric area pain is usually described as a gnawing sensation and is often caused by Helicobacter pylori and nonsteroidal anti-inflammatory drugs (NSAIDS)

A client is comatose upon arrival to the ER after falling from a roof. The client flexes with painful stimuli, and the nurse determines the client's Glascow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain the client's airway?

A nasopharyngeal tube head and neck injuries suspected want to insert a nasopharyngeal tube.

When making a home visit to a family with a teething 4 month old what information is most important for the nurse to provide the parents?

A slight fever is often associated with teething, but a fever lasting more than 3 days requires medical attention.

A young adult female is brought to the emergency room by family members who report that she ingested a large quality of acetaminophen. the nurse should prepare for which treatment to be implemented?

Acetylcysteine- used to prevent or lessen liver damage caused by an overdose of acetaminophen

The nurse provides education to a client who is learning how to self-administer gastrostomy tube feedings and would include which instruction?

Administering water after the feeding is completed Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.

The nurse is teaching a client with Addison's disease about this new diagnosis. What pathophysiological explanation should the nurse share with the client?

Adrenal insufficiency is an autoimmune dysfunction that results from white blood cells damaging the adrenal cortex

An adolescent female who lost fifty pounds during the past three months is hospitalized. During the admission assessment, the client complains of dry skin, poor skin turgor, hair breakage, brittle nails, and a history of menstrual cycle problems. Which finding is most important for the nurse to obtain additional assessment information?

Amenorhea (anorexia nervosa)

A client with GERD is unconscious and unresponsive to stimuli. The nurse places the client in a side-lying position. The nurse should monitor for the risk of which complication?

Aspiration pneumonia GERD can cause stomach contents to flow back into the esophagus and dysphagia can cause food and/or liquid to remain in the esophagus after swallowing.

A 38-year-old female client is admitted to the mental health unit after a recent manic episode of spending large amounts of money on new furniture, making excessive long-distance phone calls, and not sleeping for three days. During the admission process, the client is wearing a green bathing suit. What intervention should the nurse implement?

Assess the client's needs for food, liquids, and rest.

A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question?

Atrophine sulfate 0.4mg IM on call to operating room

Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement?

Avoid any intramuscular medications to prevent localized bleeding. Bleeding precautions for a client receiving anticoagulant treatment include minimizing IV punctures and avoiding IM injections

What is the largest contributing factor for the increase in the need for home care?

Clients are more acutely ill when discharged from acute care facilities

A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action?

Call for emergency assistance. Stridor upon exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema postoperatively. In life-threatening complications, such as respiratory obstruction or bleeding, a call for emergency assistance in case intubation is also required.

Which represents appropriate nursing management of a client's nasogastric (NG) tube in the immediate postoperative period after gastroduodenostomy?

Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. The presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period.

Which information to promote self-management would the nurse provide to a client being discharged with a new ileostomy? Select all that apply. One, some, or all responses may be correct.

Change the appliance every 4 to 7 days. A client with an ileostomy should be instructed to change the appliance every 4 to 7 days and cleanse the skin to prevent irritation when changing. Clients should be advised to drink at least 3000 mL of fluid in a 24-hour period and even more when the weather is hot. Clients should avoid alcohol of any kind because it can cause diarrhea. Nuts and seeds can become trapped in the bowel and should be avoided. The client's ostomy pouch should be emptied when it is one-third full.

During a home visit, the nurse notes that a female client with degenerative joint disease is taking 3 grams of aspirin PO daily. The client complains of tinnitus, and seems confused. Which intervention should the nurse implement?

Contact the client's healthcare provider to report the assessment findings. Tinnitus and confusion are both signs of aspirin toxicity, which is consistent with the high dose of aspirin that the client is taking. The healthcare provider should be notified of the symptoms

While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first?

Current hair care practices. Dry and brittle hair may be a result of hair treatments such as hair dyes, rinses, permanents, straighteners, or frequent blow-drying

The nurse is preparing a teaching plan for the parents of a 3-year-old who is newly diagnosed with Duchenne muscular dystrophy (DMD). Which implementation should the nurse include in the initial teaching plan?

Develop an active range of motion exercise schedule. DMD is a genetic degenerative muscular disease that results in muscle wasting, immobility, and eventual death. The initial plan of care should include active exercises

A client who is a laboratory technician and has a history of allergic rhinitis, asthma, and multiple food allergies is scheduled for surgery. Which action should the nurse implement?

Document a possible Type I latex allergy.

What assessment finding should the nurse identify in a client with fluid volume excess?

Elevated BP

The nurse identifies the nursing diagnosis of, Visual sensory/perceptual alterations related to increased intraocular pressure (IOP) for a client with glaucoma. Which nursing intervention should the nurse include in the plan of care?

Encourage compliance with drug therapy to prevent loss of vision

What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane?

Enzyme release from lysosomes. Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed suicide bags, leaks its protein catalytic enzymes

When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement?

Gather the supplies needed to discontinue the IV fluid. An IV infusion stops when pressure is placed on the skin above the tip of the catheter, but will continue to flow into the subcutaneous tissue if there is infiltration, which requires removal of the IV

The nurse is assessing an adult who displays stagnation, boredom, and interpersonal impoverishment. Based on Erikson's developmental model, which stage should the nurse develop interventions for this client?

Generativity versus stagnation

Which change in sleep patterns is most likely to occur in an older adult?

Has a decline in stage 4 sleep

A client returns to the unit after abdominal Nissen fundoplication for treatment of GERD. After 4 hours, the nurse determines the client has no drainage from the NGT and has absent bowel sounds. What action should the nurse implement?

Irrigate the NGT with normal saline irrigation of the NG tube should be implemented to promote gastric drainage and decompression.

A client is scheduled for a pyloroplasty and vagotomy because of strictures caused by ulcers unresponsive to medical therapy. Which information about the purpose of a vagotomy would the nurse include in the client's education?

It decreases acid in the stomach The vagus nerve stimulates the stomach to secrete hydrochloric acid. When it is severed, this neural pathway is interrupted and stomach acid is decreased.

A client returns from surgery after undergoing an abdominal-perineal resection with a sigmoid colostomy. The colostomy is dressed with petroleum jelly gauze and dry gauze dressings. The perineal incision is partially closed with two drains attached to Jackson-Pratt suction bulbs. During the early postoperative period, the nurse should give the highest priority to which nursing action?

Maintain a dry perineal dressing. During the immediate postoperative period, the perineal dressing should be assessed, reinforced, and changed freqeuntly becasue profuse drainage during the first hours after rugery macerates tissue and compromises incisional proximation and healing

The nurse is caring for a client admitted to the hospital for a rubber band ligation of internal hemorrhoids. Which action should the nurse take to reduce discomfort?

Offer a sitz bath Sitz baths are warm. A warm bath dilates the blood vessels and promotes circulation, relieving local inflammation and itching. Water-soluble jelly will not alleviate pain. An inflatable doughnut puts tension on the area, which increases discomfort and constricts circulation. Suppositories are contraindicated with rectal surgery; an oral analgesic usually is prescribed to help reduce pain.

A client at 13 weeks gestation is scheduled for an amniocentesis in one week. the nurse knows that the primary reason for conduction this procedure is to obtain what information?

Presence of genetic disorders- small amount of fluid is removed from the uterus and can check for Down's Syndrome, Spina Bifida, etc.

The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles?

QRS interval of 0.14 second. The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates an electrical anomaly in the ventricles.

Before administering timolol maleate (Timoptic) to a client with open-angled glaucoma, which finding should the nurse report to the healthcare provider?

Receives carvedilol (Coreg) for heart failure (HF).

The nurse is teaching a client who is newly diagnosed with Type 1 diabetes mellitus about diet and insulin. the client should be instructed to perform glucose self-monitoring when which symptoms occur after exercising.

Shakiness

The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider?

SpO2 is 88% with shallow, slow respirations. Bradypnea, ineffective gas exchange, and low SpO2 should be reported to the healthcare provider because a client with a C7 spinal cord injury is likely to deteriorate due to post-injury spinal cord edema that may extend to cervical innervation of the diaphragm.

After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next?

Start the first transfusion of blood. The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started

Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)?

Type 1 DM and retinopathy and mild vision loss. Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop nephropathy

What nursing intervention should the nurse include in the plan of care for a client following a bone marrow aspiration?

Use of a compression dressing for firm pressure to the site

In reviewing the medical record, the nurse notes that a client's last eye examination revealed an IOP of 28 mmHg. What information should the nurse ask the client?

Use of prescribed eye drops since last exam by ophthalmologist.

A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which vitamin should the nurse explain to the client is indicated to take for his lifetime?

Vitamin B12

The nurse is assessing a client who is receiving risperidone (Risperdal). The nurse should monitor the client for which common side effect that is most likely to occur during therapy?

Weight Gain

A female client who is diagnosed with an eating disorder has difficulty translating her pain into words. Which approach should the nurse implement to allow this client greater self-disclosure?

dance therapy

what does a sunken fontanel and high heart rate indicate?

dehydration

A client who had a severe weight loss is told the importance of eating more protein to provide the essential amino acids. The client asks the nurse why these substances in protein foods are essential. How should the nurse respond?

"They must come from your food because your body cannot make them." All amino acids are needed for the synthesis of various proteins, but the term "essential" refers to those amino acids that the body cannot make and that are indispensable in the diet. All amino acids in a protein contribute the same number of calories for energy. All amino acids, not just essential amino acids, contain nitrogen. All amino acids, not just essential amino acids, are necessary for rebuilding body tissue.

An elderly client is admitted with suspected bacterial pneumonia and lethargy. Ten minutes after the nurse initiates low-flow oxygen per nasal cannula and a peripheral IV with a secondary infusion of ticarcillin (Ticar), the client becomes disoriented, restless, and tachypneic. Which nursing action has the highest priority?

Stop the IV piggyback infusion and increase the oxygen flow to 3 L/minute. The client's symptoms depict the onset of an anaphylactic reaction to ticarcillin, an extended-spectrum penicillin, so the priority nursing actions include halting the client's exposure to the medication and supporting breathing efforts

A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first?

Stop the irrigation flow. The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped to prevent severe bladder distention.

While auscultating the lungs of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take?

Suction the client's endotracheal tube and auscultate following suctioning. Coarse, snoring sounds (rhonchi) heard over large upper airways are frequently produced by secretions partially blocking air passages and usually disappear after suctioning

The nurse is assessing a postpartum client who delivered in the car. Which finding should the nurse identify as the earliest manifestation of a puerperal infection?

Temperature of 100.8° F 24 hours after delivery The common risk factors for puerperal infection includes mode of delivery, Postpartum Haemorrhage, prolonged labour, and anaemia.

During history-taking, the nurse discovers that a client takes megadoses of vitamin A. How would the nurse interpret this finding?

The body stores excess vitamin A, even in toxic amounts. Vitamin A is a fat-soluble vitamin that accumulates in the body and is not significantly excreted, even if extremely large amounts are ingested. After prolonged ingestion of extremely large doses, toxic effects can occur.

An older adult is hospitalized for weight loss and dehydration due to nutritional deficit. Which factor would the nurse consider when planning care for this client?

The nutritional needs of an older adult are unchanged except for a decreased need for calories. A well-balanced diet with fewer calories because of decreased metabolism is suggested for older adults. Limited financial resources are one cause of malnutrition in the older adult. Fluid needs do not increase.

What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.)

border irregularity, lesions with asymmetry, and lesions with color variation ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion; B for irregular border; C for color, usually dark; D for diameter equal to or greater than 6 mm; and E for elevation.

The nurse is suctioning the trach for a child who is experiencing rhonchi and unable to expel mucus. Which action should the nurse implement to provide effective pulmonary toileting?

each pass of the suction catheter should take no longer than five seconds To ensure the child's 02 sat returns to normal, suctioning of the trach should last no more than 5 seconds per aspiration and rest periods provided after each aspiration.

The nurse is providing tracheostomy care for a client who has encrusted secretions inside the inner cannula. Which solution should the nurse use to remove the debris?

hydrogen peroxide when the mucus in your mouth comes into contact with hydrogen peroxide, it creates a foam. The foam makes the mucus less sticky, which makes it easier to drain

After a transurethral resection of the prostate, the retention catheter is pulled taut and secured to the client's leg. The client reports a feeling of pressure and asks why this is necessary. Which rationale would the nurse include in a response to this question?

prevents bleeding. Pressure of the balloon against small blood vessels of the prostatic fossa causes them to constrict, thereby preventing bleeding. The taut catheter may cause discomfort or bladder spasms. The tautness of the catheter does not promote urinary drainage.

The nurse is providing dietary teaching to a client receiving a high-protein diet while recovering from an acute episode of colitis. Which would the nurse include in the rationale for this diet?

repairs tissue Protein is required for the building and repair of intestinal tissues. Increased protein will not affect peristalsis significantly. Anemia may result from chronic bleeding; usually, it is corrected with increased iron intake. Muscle tone is affected by exercise or lack of exercise.

A client is receiving an opioid analgesic every 2 hours for intractable pain. Which pathophysiological consequence should the nurse identify if the client receives the medication at regular intervals?

respiratory acidosis Hypoventilatory effect of opioid drugs and other drugs (e.g. barbiturates) that depress respiration and cause respiratory acidosis.