summer fyi questions

pt has been dx with uremic syndrome and has the potential to develop complications. which of these complications can the nurse anticipate? 1. flapping hand tremors 2. an elevated hematocrit level 3. hypotension 4. hypokalemia

1. flapping hand tremors; elevation of uremic waste products causes irritation of nerves and results in flapping hand tremors

a patient with thyroid disease has exophthalmos. (aka proptosis). what is the cause of this? 1. fluid edema in the retro-orbital tissues which force the eyes to protrude 2. impaired vision which causes the patient to squint 3. increased eye lubrication which makes the patient blink less 4. decrease in extraocular eye movements which results in the "thyroid stare".

1. fluid edema in the retro-orbital tissues which force the eyes to protrude

a patient has had diarrhea for 4 days. which of the following findings is likely? SATA 1. bradycardia 2. hypotension 3. fever 4. poor skin turgor 5. peripheral edema

2. hypotension 3. fever 4. poor skin turgor; prolonged diarrhea leads to dehydration which causes a decrease in blood pressure. dehydration leads to fever; tachycardia is more likely than bradycardia; peripheral edema is a sign of fluid overload, not a fluid a deficit

of freud's developmental stages, which one occurs from ages 7-11 years old in which the child continues his/her development but sexual urges are relatively quiet? 1. genital 2. latency 3. phallic 4. oral

2. latency

a routine urinalysis is ordered for a client. what should the nurse do if the specimen cannot be sent immediately to lab? 1. to no action 2. refrigerate 3. store and send later 4. discard specimen and collect another one later

2. refrigerate; refrigeration can preserve specimen for several hours

a 6 month old infant can usually: 1. sit up 2. roll over 3. crawl short distances 4. stand while holding on to furniture

2. roll over

the nurse is caring for a patient who abruptly withdrew from barbiturate use. the. nurse should expect the patient to experience: 1. ataxia (inability to coordinate voluntary muscle movements) 2. seizures 3. diarrhea 4. urticaria (a rash of red round welts that itch)

2. seizures

which term refers to pelvic pain that occurs midway between menstrual cycles coinciding with ovulation? 1. amenorrhea 2. dysmenorrhea 3. Mittelschmerz 4. Billroth procedure

3. Mittelschmerz; German for "middle pain". is one sided lower abdominal pain that effects some women during ovulation; it is a sign that the woman has released an egg from the ovary

good dental care reduces the risk of endocarditis. to promote good dental care for a patient with mitral stenosis, the teaching plan should include the use of: 1. dental floss 2. electric toothbrush 3. manual toothbrush 4. irrigation device

3. manual toothbrush; the other options may cause bleeding of the gums allowing bacteria to enter and increase the risk of endocarditis

which of these is a sign of pemphigus vulgaris? 1. turner's sign 2. chvostek's sign 3. nikolsky's sign 4. trousseau's sign

3. nikolsky's sign; occurs when the epidermis can be rubbed off by slight friction, there are flaccid bullae (a large blister containing serous fluid), foul smelling; lesions typically on face, back, chest, umbilicus; turner's sign - grayish discoloration of flanks and seen in acute pancreatitis; chvostek's sign - seen in tetany (involuntary contraction of muscles that is usually the result of low calcium), is a spasm of facial muscles elicited by tapping the facial nerve in parotid region; trousseau's sign - seen in tetany in which carpal spasm can be elicited by compressing the upper arm with a BP cuff.

when caring for a patient with benign prostatic hyperplasia (BPH) the nurse should understand that: 1. this is a congenital abnormality 2. usually becomes malignant 3. predisposes to hydronephrosis 4. causes an elevated acid phosphatase level

3. predisposes to hydronephrosis; excess urine accumulation in kidney; due to back up of urine into ureters and then into kidneys.

the nurse is assessing the apical heart rates of several different newborns. which rate is normal? 1. 90 bpm 2. 140 bpm 3. 180 bpm 4. 190 bpm

2. 140 bpm; normal heart in an infant is approximately 100-160 bpm.

while the nurse is palpating for the pulse rate, she notices that the pulse is increased and requires moderate pressure for obliteration. which grade would be given based on the 4-point scale? 1. 1+ 2. 0 3. 3+ 4. 2+

3. 3+; 0 - absent; 1+ - palpable, but thready weak, easily obliterated; 2+ - normal, easily identified, not easily obliterated; 4+ - full, bounding, cannot obliterate

when the peak is drawn is based on the route. when should the peak be drawn after an intramuscular medication has been given? 1. 5-10 minutes 2. 15-30 minutes 3. 30-60 minutes 4. not necessary for this route

3. 30-60 minutes

which stage of growth and development is concerned with the role of identification? 1. oral stage 2. genital stage 3. oedipal stage 4. latency stage

3. oedipal stage; the child learns to resolve oedipal conflicts by learning to identify with the parent of the same sex and accomplishes this by mimicking the role of this parent

which condition are these symptoms of: develops between 4 and 6 weeks of age, includes a palpable bulge below the right costal margin, projectile vomiting during or shortly after feeding, poor weight gain, malnutrition, and dehydration. 1. tracheoesophageal fistula 2. intestinal obstruction 3. pyloric stenosis 4. intussusception

3. pyloric stenosis

the nurse is interviewing a client with a hx of BPH. which of the following chronic effects of this renal d/o would the nurse assess for? *number times patient urinates in 24 hours *what meds pt is currently taking for the condition *the results of his latest prostate specific antigen (PSA) test *whether he usually experiences a complete emptying of the bladder

*whether he usually experiences a complete emptying of the bladder

when calculating dosages: 15gr equals...

1 gram

tissue plasminogen activator (tPA) is to be administered to a patient in the ED. which is the priority nursing assessment? 1. apical pulse rate 2. electrolyte levels 3. signs of bleeding 4. tissue compatibility

3. signs of bleeding; assessing for bleeding is a priority when administering a thrombolytic agent b/c it could lead to hemorrhage

how many gtts are in 1 ml?

15 gtts (medical drops)

what is the incubation time for syphilis? 1. 1 week 2. 4 months 3. 2-6 weeks 4. 48-72 hours

3. 2-6 weeks; although the usual incubation period is about 3 weeks for syphilis, clinical symptoms may appear as early as 9 days or as long as 3 months after exposure

which is not a sign of thromboembolism? 1. edema 2. swelling 3. redness 4. coolness

4. coolness

a nurse is teaching a patient with hypertension about items that contain sodium. which of these is the lowest in sodium? 1. antacids 2. laxatives 3. toothpaste 4. demineralized water

4. demineralized water

which of the following conditions is the predominant cause of angina? increased preload decreased afterload coronary artery spasm inadequate oxygen supply to the myocardium

inadequate oxygen supply to the myocardium

this is when the skin and underlying tissues swell giving it a waxy appearance/consistency. typical in patients with an under active thyroid.

myxedema; "myxo" - slime, mucus

which of the following types of angina is most closely related to an impending MI? angina decubitus chronic stable angina nocturnal angina stable angina

unstable angina; unpredictable, long lasting, severe, progressive

the nurse is aware that clients with chronic alterations in kidney function suffer from insufficient amounts of: vitamin A vitamin D vitamin E vitamin K

vitamin D; kidneys are responsible for converting vitamin D into active form

a 1 year old boy's length is assessed by the nurse and is below what is expected. his current height is 28 inches and his birth length was 20 inches. what should the current length be? 1. 27 inches 2. 30 inches 3. 32 inches 4. 35 inches

2. 30 inches. the child is 2 inches shorter than he should be; at 1 year the child should have increased length by 50% of birth length.

when teaching the parents of school age children about communicable diseases, which of these has a complication of encephalitis? 1. pertussis 2. varicella 3. scarlet fever 4. poliomyelitis

2. varicella; aka chickenpox; is caused by a virus and may be followed by encephalitis. characterized by skin lesions

which organism causes a trichomonal infection? 1. yeast 2. fungus 3. protozoan 4. spirochete

3. protozoan

a patient with acute poststreptococcal glomerulonephritis requests a snack. the most therapeutic food selection would be: 1. peanuts 2. pretzels 3. bananas 4. applesauce

4. applesauce; provides nutrition without large additional amounts of sodium and potassium

a patient is admitted for an acute myocardial infarction. if the patient asks to see his chart, what should the nurse do/say? 1. allow the patient to view his chart 2. contact the supervisor for approval 3. ask the patient if he has concerns about his care 4. tell the patient that he isn't permitted to view his chart

3. ask the patient if he has concerns about his care

a 2 year old child with a congenital cardiac malformation that has right to left shunting of blood through the heart would likely have? 1. proteinuria 2. peripheral edema 3. elevated hematocrit 4. absence of pedal pulses

3. elevated hematocrit; polycythemia (increase in number of red blood cells in the body - makes blood thicker and increases risk for clots), reflected in an elevated hematocrit, is a direct attempt of the body to compensate for the decrease in oxygen due to the mixing of oxygenated and unoxygenated blood.

a patient has an external shunt for hemodialysis (aka arteriovenous shunt) . the nurse understands that the most serious complication associated with hemodialysis is? 1. septicemia 2. clot formation 3. exsanguination 4. sclerosis of vessels

3. exsanguination; exsanguinate - to drain the blood from; b/c an external shunt provides circulatory access to a major artery and vein, special precautions must be taken to prevent disconnection of the cannula. disconnection can cause excessive blood loss and death. clamps should be carried at all times by the patient for this reason

which of these are characteristic of decerebrate posturing? 1. upper extremity flexion with lower extremity flexion 2. upper extremity flexion with lower extremity extension 3. extension of the extremities after a stimulus 4. flexion of the extremities after stimulus

3. extension of the extremities after a stimulus; may occur with upper brain stem injury

after a child undergoes surgery to repair defects associated with tetralogy of fallot, it is essential that the nurse prevent: 1. crying 2. coughing 3. hard stools 4. unnecessary movement

3. hard stools; the vasalva maneuver requires taking a deep breath, holding it, and then straining. this increases the intrathoracic pressure which puts excessive strain on the heart sutures

what are the priorities of care for a patient in sickle cell crisis? 1. nutrition, hydration, electrolyte imbalance 2. hydration, pain mgmt, electrolyte balance 3. hydration, oxygenation, pain mgmt 4. hydration, oxygenation, electrolyte balance

3. hydration, oxygenation, pain mgmt

superego is the part of self that says: 1. i like what i want 2. i want what i want 3. i should not want that 4. i can't wait for what i want

3. i should not want that; conscience and sense of right or wrong are expressed in the superego which acts to counterbalance the id's desire for immediate gratification

a child with a cardiac malformation associated with left to right shunting will likely have which major characteristic? 1. severe growth retardation 2. clubbing of the fingers and toes 3. increased blood flow to the lungs 4. polycythemia and elevated hematocrit

3. increased blood flow to the lungs; with left to right shunting, blood flows from the higher pressure left side to the lower pressure right side. the increased blood flow to the right ventricle results in increased blood flow to the lungs

when a patient experiences a brain attack, which position should the nurse initially place the patient in? 1. prone 2. supine 3. lateral 4. trendelenberg

3. lateral; absence of a gag reflex is common after a brain attack. to prevent aspiration, lateral is used

after closure of an infant's meningomyelocele, what essential nursing intervention must be included in the plan of care? 1. strict limitation of leg movement 2. decrease of environmental stimuli 3. measurement of head circumference daily 4. observation of serous drainage from nares

3. measurement of head circumference daily

after an abdominal cholecystectomy (surgical removal of gallbladder), a pt has a t-tube attached to a collection advice. on the day of surgery, 300ml of bile is emptied from the collection bag. the next day, the bag contains 60ml of bile. the nurse's intervention is guided by the knowledge that: 1. the t-tube may have to be irrigated 2. the bile is now draining into the duodenum 3. mechanical problems may develop with the t-tube 4. suction must be reestablished in the portable drainage system

3. mechanical problems may develop with the t-tube; this amount of drainage is inadequate. 1000ml of bile is expected in 24 hours via the implanted tube; the presence of a mechanical obstruction (compression or kinking) should be determined

a postterm infant delivered vaginally is exhibiting tachypnea, grunting, retractions, and nasal flaring. these assessment findings are indicative of which condition? 1. hypoglycemia 2. respiratory distress syndrome 3. meconium aspiration syndrome 4. transient tachypnea of the newborn

3. meconium aspiration syndrome; MAS occurs often in postterm infants and develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth; respiratory distress syndrome is a complication of preterm infants not postterm; transient tachypnea is typically seen in infants delivered via c section

a patient experiences a seizure and exhibits uncontrollable jerking movements. which type of seizure did the patient experience? 1. tonic seizure 2. absence seizure 3. myoclonic seizure 4. clonic seizure

3. myoclonic seizure; characterized by sudden jerking movements of a single or multiple muscle group

the patient had 20mg of lasix (furosemide) at 10am. which would be essential for the nurse to include at the change of shift report? 1. patient lost 2lbs in 24 hours 2. patient's potassium level is 4 mEq/L 3. patient's urine output is 1500mL in 5 hours 4. patient is due for another lasix dose at 10pm.

3. patient's urine output is 1500mL in 5 hours; 30ml per hour is the minimum; 2000ml w/in 24 hour is maximum;

what is the most serious complication of meningitis in young children? 1. epilepsy 2. blindness 3. peripheral circulatory collapse 4. communicating hydrocephalus

3. peripheral circulatory collapse (aka Waterhouse-Friderichsen syndrome); caused by bilateral adrenal hemorrhage

a patient has underdone a lumbar puncture to obtain CSF for analysis. the nurse recognizes that the CSF is normal when it is negative for? 1. protein 2. glucose 3. red blood cells 4. white blood cells

3. red blood cells

a patient is scheduled for a craniotomy due to a brain tumor. to prevent cerebral edema after surgery, the nurse should expect the use of: 1. diuretics 2. antihypertensives 3. steroids 4. anticonvulsants

3. steroids; glucocorticoids (steroids) are used for their anti-inflammatory action, which decreases the development of edema

the nurse is assessing a client admitted with complaints related to chronic kidney dysfunction. the nurse recognizes that this client is most likely to present with which of the resulting symptoms? *anemia *hypotension *diabetes mellitus *clinical depression

*anemia; kidneys are responsible for erythropoietin (in addition to converting vitamin d into a usable form). erythropoietin causes bone marrow to produce rbc's.

which of these nursing interventions are needed when caring for a patient on aminoglycosides? SATA 1. monitor intake and output 2. assess for tetany 3. obtain hx of allergies 4. monitor vital signs during infusion 5. maintain a patent IV site 6. monitor peak and trough

1. monitor intake and output 3. obtain hx of allergies 4. monitor vital signs during infusion 5. maintain a patent IV site 6. monitor peak and trough

what is the goal of a myringotomy? 1. promote drainage from the ear 2. irrigate the eustachian tube 3. correct a malformation in the inner ear 4. equalize pressure on the tympanic membrane

1. promote drainage from the ear; surgical incision is made to ear drum to relieve pressure or drain fluid.

a patient is admitted to the hospital due to metabolic acidosis caused by DKA. which of these does the nurse prepare as the initial tx for this problem? 1. regular insulin 2. potassium 3. sodium bicarbonate 4. calcium gluconate

1. regular insulin; metabolic acidosis is anaerobic metabolism caused by the body's inability to use circulating glucose. administration of insulin corrects this problem

which of these are early signs of hypoxemia? 1. restlessness 2. tachypnea 3. bradycardia 4. confusion 5. pallor

1. restlessness 2. tachypnea 5. pallor; other early signs include: tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds; late signs include: bradycardia, confusion, stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, cardiac dysrhythmias

antipsychotic drugs can cause extrapyramidal side effects. which responses may indicate pseudoparkinsonism? SATA 1. rigidity 2. tremors 3. mydriasis (when the pupil remains dilated and does not respond to light changes) 4. photophobia 5. bradykinesia

1. rigidity, 2. tremors, 5. bradykinesia (impairment of voluntary motor control and slow movements or freezing); antipsychotics can cause this due to their effect on postsynaptic dopamine receptors

when a patient with a cervical injury complains of a severe headache and nasal congestion, the. nurse should assess for? 1. suprapubic distention 2. increased spinal reflexes 3. adventitious breath sounds 4. imminent development of shock

1. suprapubic distention; suprapubic (above the pubic bone); these are symptoms of autonomic dysreflexia, which are commonly precipitated by a distended bladder

a patient has 15% blood loss. which of the following assessment findings indicate hypovolemic shock? 1. systolic blood pressure less than 90 mm Hg 2. pupils unequally dilated 3. respiratory rate of 4 breaths/minute 4. pulse rate less than 60bpm

1. systolic blood pressure less than 90 mm Hg; typical signs and symptoms of hypovolemic shock includes systolic blood pressure of less than 90 mm Hg

which statement is most appropriate for the nurse to use when interviewing a newly admitted depressed patient focus on feelings of unworthiness and failure? 1. tell me how you feel about yourself 2. tell me what has been bothering you 3. why do you feel so bad about yourself? 4. what can we do to help you during you stay with us?

1. tell me how you feel about yourself

a patient is recovering from a thyroidectomy. while monitoring the patient's initial post operative condition, which of these should the nurse report immediately? 1. tetany and paresthesia 2. mild stridor and hoarseness 3. irritability and insomnia 4. headache and nausea

1. tetany and paresthesia; 4 nodules on thyroid gland are the parathyroid (responsible for calcium) - when thyroid is removed, patient may experience hypocalcemia; patient could also experience seizures

a 5 y/o patient admitted for repair of tetralogy of fallot has an elevated RBC count. the polycythemia is a compensatory mechanism for: 1. tissue oxygen need 2. low blood pressure 3. diminished iron level 4. hypertrophic cardiac muscle

1. tissue oxygen need; decreased tissue oxygenation stimulates erythropoiesis resulting in excessive production of RBC's

which condition are these symptoms of: causes coughing, choking, and intermittent cyanosis during feeding, and also causes abdominal distention. 1. tracheoesophageal fistula 2. intestinal obstruction 3. pyloric stenosis 4. intussusception

1. tracheoesophageal fistula

a nurse is sending an ABG specimen. which info should the nurse include on the lab requisition? SATA 1. ventilator settings 2. a list of client allergies 3. client's temperature 4. date and time specimen was drawn 5. any supplemental oxygen the client is receiving 6. extremity from which the specimen was obtained

1. ventilator settings, 3. the client's temperature, 4. the date and time the specimen was drawn, 5. any supplemental oxygen the client is receiving

what is the expected hematocrit range for a 1 year old infant? 1. 19-32% 2. 29-41% 3. 37-47% 4. 42-69%

2. 29-41%

several patients are prescribed rifampin (Rifaden) for tuberculosis treatment. which patient presents a specific concern for the nurse? 1. a 45 year old taking a loop diuretic 2. a 26 year old taking oral contraceptives 3. a 32 year old taking a proton pump inhibitor 4. a 72 year old taking intermediate acting insulin

2. a 26 year old taking oral contraceptives; rifampin (Rifadin) increases the metabolism of oral contraceptives which could result in an unplanned pregnancy

after gastroscopy, an adaptation that indicates a major complication would be: 1. nausea and vomiting 2. abdominal distention 3. increased GI motility 4. difficulty in swallowing

2. abdominal distention; may indicate perforation, a complication that could lead to peritonitis

a patient has glaucoma and edema of the lower extremities. the nurse understands that this systemic drug may be prescribed to produce diuresis and inhibit formation of the aqueous humor: 1. chlorothiazide (Diuril) 2. acetazolamide (Diamox) 3. bendroflumethiazide (Naturetin) 4. demecarium bromide (Humorsol)

2. acetazolamide (Diamox)

a patient has been dx with disseminated intravascular coagulation (DIC). which of the following is contraindicated for this patient? 1. administering heparin 2. administering coumadin 3. treating the underlying cause 4. replacing depleted blood products

2. administering coumadin; DIC has not been found to respond to oral anticoagulants such as coumadin

in preparing a patient on oral narcotic analgesics for d/c after a mastectomy, the nurse should include which of the following in postoperative teaching? 1. use oral narcotics sparingly 2. bowel-training program 3. high, protein low carb diet 4. upper extremity weight training

2. bowel-training program; fluids, fiber, mobility are all included in bowel training program due to patient being prescribed opiates

when using an incentive spirometer, which would lead a nurse to determine the need for further teaching? 1. inhales slowly 2. breathes through the nose 3. removes mouthpiece to exhale 4. forms a tight seal around mouthpiece with lips

2. breathes through the nose; the incentive spirometer is ineffective if the patient breathes through the nose; the patient firsts exhales, forms a tight seal with lips, inhales slowly, holds to the count of 5, removes mouthpiece to exhale; should be done 10 times every hour for best results

a patient has undergone thoracic surgery and has a chest tube connected to a water seal drainage system. presence of excessive bubbling is identified in the water seal chamber. the nurse should: 1. strip the chest tube catheter 2. check the system for air leaks 3. recognize the system is working correctly 4. decrease the amount of suction pressure

2. check the system for air leaks; bubbling indicates an air leak which must be eliminated to permit lung expansion

which one of these would interfere with an ordered urine specimen for vanillymandelic acid (VMA) levels? 1. whole grain bread and cereals 2. chocolate pudding and gelatin 3. spinach and kale 4. beef and beef products.

2. chocolate pudding and gelatin; VMA is a test done to detect pheochromocytoma, an adrenal tumor that often leads to malignant hypertension. patients should avoid coffee, tea, bananas, cocoa products, vanilla, and aspirin for 2 days before the test

a patient is dx with thromboangiitis obliterans (Buerger's disease). the nurse places priority on teaching pt about modifications of which risk factor? 1. exposure to heat 2. cigarette smoking 3. diet low in vitamin c 4. excessive water intake

2. cigarette smoking; buerger's disease is an occlusive disease of the median small veins and arteries. more common in men over 40 that smoke.

what common adaptation of children with tetralogy of fallot should the nurse expect? 1. slow respirations 2. clubbing of fingers 3. subcutaneous hemorrhages 4. decreased RBC counts

2. clubbing of fingers; hypoxia leads to poor peripheral circulation; clubbing develops over time as a result of tissue hypertrophy and additional capillary development in the fingers

a patient with cholecystitis (inflammation of the gallbladder - Greek khole "gall") is taking propantheline bromide. what should the nurse tell the patient to expect as a result of the this drug? 1. increased bile production 2. decreased biliary spasm 3. absence of infection 4. relief from nausea

2. decreased biliary spasm at the common bile duct; propantheline bromide is an anticholinergic (blocks the action of acetylcholine - side effects "can't see, can't spit, can't pee, s**t)

which of these could contribute to an exacerbation of COPD? 1. decreased fat intake 2. decreased fluid intake 3. sleeping soundly during the night 4. anxiety about the upcoming pulmonologist visit

2. decreased fluid intake

when is the surgical repair of a cleft palate (staphylorrhaphy - "staphylo": uvula + Greek "raphe" - ) performed on an infant? 1. delayed until child is 6 months old 2. delayed until child is 18 months old 3. between birth and 3 months of age 4. as soon as arrangements can be mad

2. delayed until child is 18 months old; it is done at this time to allow for growth of the palate and also before the infant develops speech patterns; repair of a cleft lip takes place between birth and 3 months of age

after a bioterrorism attack which adaptations can the nurse expect in survivors during the immediate period after the attack? SATA 1. guilt 2. denial 3. altruism 4. confusion 5. helplessness

2. denial, 4. confusion, 5. helplessness; shock and belief are the initial responses to a traumatic experience

after a renal transplantation, the patient is started on oral doses of cyclosporine. which of these instructions are correct? 1. the diet should be supplemented with iron 2. dilute the solution in chocolate milk and drink it immediately 3. store the medication in the refridgerator 4. the medication will be tapered over the next 3 months

2. dilute the solution in chocolate milk and drink it immediately; this should be diluted in milk or orange juice and drank immediately b/c this helps with absorption and masks the taste. glass should be rinsed and residual drank so no medication is missed. this medication is taken for life.

a nurse is monitoring a patient for brachial plexus compromise after shoulder arthroplasty. the nurse assesses the ulnar nerve by: 1. asking the patient to raise their forearm above the head 2. having the patient spread all of the fingers wide and resisting pressure 3. asking the patient to move the thumb toward the palm and then back to neutral position 4. having the patient grasp the nurse's hand and noting the strength of the first and second fingers

2. having the patient spread all of the fingers wide and resisting pressure; raising forearm above the head assesses flexion of the biceps and determines status of the cutaneous nerve; moving the thumb towards the palm assesses the radial nerve; having the patient grasp nurse's hand assesses the medial nerve

which of these is the primary cause of tonic clonic seizures in adults over 20 years old? 1. electrolyte imbalance 2. head trauma 3. epilepsy 4. congenital defect

2. head trauma; trauma is one of the primary causes of brain damage and seizure activity in adult. other common causes include: neoplasms, withdrawal from drugs and alcohol, and vascular disease

a nurse is working on a psychiatric unit. which of these can the RN legally be permitted to perform? SATA 1. psychotherapy 2. health promotion 3. case management 4. prescribing medication 5. treating human responses

2. health promotion, 3. case management, 5. treating human responses; all of these are in the nurse's scope of practice

pursed lip breathing is used to: 1. precipitate coughing 2. help maintain open airways 3. decrease intrathoracic pressure 4. facilitate expectoration of mucus

2. help maintain open airways; pursed lips prolong expiration against the slightly closed lips. this prolongs exhalation and maintains positive airway pressure which maintains an open airway and prevents airway collapse; pursed lips increase intrathoracic pressure (not decreases); huff coughing stimulates the natural cough reflex (used to mobilize sputum and stimulate cough)

a patient has been dx with bell's palsy. which statement made by the patient indicates the need for further teaching? 1. i wear an eye patch at night 2. i am staying on a liquid diet 3. i wear dark glasses when i go out 4. i have been gently massaging my face

2. i am staying on a liquid diet; bell's palsy is caused by a lower motor neuron lesion of the 7th cranial nerve that may result from infection, trauma, hemorrhage. meningitis, or tumor. it is not necessary that the patient remain on a liquid diet.

what should the primary goal of therapy for a patient with pulmonary edema and heart failure be? 1. enhance comfort 2. increase cardiac output 3. improve respiratory status 4. peripheral edema decreased

2. increase cardiac output; peripheral edema is a medical emergency and would require immediate intervention, not therapy

a patient is admitted with the dx of pneumocystis jiroveci pneumonia and is prescribed IV pentamidine. which intervention should the nurse plan to implement to safely administer the medication? 1. infuse over 1 hour and allow pt to ambulate 2. infuse over 1 hour with pt in supine position 3. administer over 30 minutes with pt in reclining position 4. administer IV push over 15 minutes with pt in supine

2. infuse over 1 hour with pt in supine position; IV pentamidine is an antifungal medication infused over 1 hour with the pt in supine to minimize severe hypotension and dysrhythmias; pneumocystis jiroveci pneumonia is a fungal infection of the lungs; pneumocystis jiroveci is the name of the fungus

what patient outcome support the conclusion that the use of an incentive spirometer was effective? 1. supplemental oxygen use will be reduced 2. inspiratory volume will be increased 3. sputum will be expectorated 4. coughing will be stimulated n

2. inspiratory volume will be increased; the incentive spirometer encourages the pt to execute and maintain a sustained inspiration; patients who use an incentive spirometer may or may not be receiving supplemental oxygen

which condition are these symptoms of: presents with constipation, colicky abdominal pain, nausea, and dramatic abdominal distention. 1. tracheoesophageal fistula 2. intestinal obstruction 3. pyloric stenosis 4. intussusception

2. intestinal obstruction

which symptom would a patient newly diagnosed with hodgkin's lymphoma likely be experiencing? 1. weight gain 2. night sweats 3. severe lymph node pain 4. headache with minor visual changes

2. night sweats; assessment of a patient with hodgkin's disease often reveals night sweats, enlarged painless lymph nodes, fever, and malaise.

the nurse is caring for a toddler after surgical repair of a cleft palate. the nurse should position the child: 1. on the back 2. on the stomach 3. on the back with head slightly elevated. 4. for comfort

2. on the stomach; the patient is placed on their stomach to prevent pooling of secretions in the oropharynx.

a patient is prescribed sotalol 80mg BID. which assessment finding indicates that pt is experiencing an adverse effect? 1. dry mouth 2. palpitations 3. diaphoresis 4. difficulty swallowing

2. palpitations; this is a beta-adrenergic blocking agent that may be prescribed to treat chronic angina pectoris. adverse effects include: palpitations, bradycardia, irregular heartbeat, difficulty breathing, signs of heart failure, cold hands and feet. pt can also experience GI issues, anxiety, unusual tiredness

the nurse explains to the parents of an infant with colic that the typical bx is caused by: 1. inadequate peristalsis 2. paroxysmal abdominal pain 3. an allergic response to certain proteins in milk 4. a protective mechanism designed to eliminate foreign proteins

2. paroxysmal abdominal pain

play during infancy is important because it enhances: 1. cognitive development 2. physical development 3. emotional development 4. social development

2. physical development; solitary play; mobiles strengthen eye movement, rattles promote fine finger movement, and soft toys encourage tactile sense

an infant had corrective surgery for hypertrophic pyloric stenosis. to reduce vomiting, the nurse should teach the mother that immediately after feeding the infant, she should: 1. rock the infant 2. place the infant in an infant seat 3. place the infant flat on the right side 4. keep the infant awake with sensory stimulation

2. place the infant in an infant seat; an elevated position allows gravity to aid in preventing vomiting.

a patient with myocardial infarction asks the nurse why he is taking morphine. the nurse explains that morphine: 1. decreases anxiety and restlessness 2. prevents shock and relieves pain 3. dilates coronary blood vessels 4. helps prevent fibrillation of the heart

2. prevents shock and relieves pain; morphine is used to relieve the pain associated with MI. it also decreases apprehension and prevents cardiogenic shock (life threatening condition where the heart cannot sufficiently pump enough blood to meet the body's needs

a patient has a tonic-clonic seizure. which of these is the priority nursing intervention during the seizure? 1. turn her on her side 2. protect her from injury 3. call for additional help 4. establish a patent airway

2. protect her from injury

while a patient with chest tubes is ambulating, the connection between the tube and water seal dislodges. which action by the nurse is most appropriate? 1. assist the patient back to bed 2. reconnect the tube to the water seal 3. assess the patient's lung sounds with a stethoscope 4. have the patient cough forcibly several times

2. reconnect the tube to the water seal; the tube should be reconnected as quickly as possible.

a patient is admitted with a dx of tetanus. it is most important for the nurse to observe for which clinical indicator? 1. muscular rigidity 2. respiratory tract spasms 3. restlessness and irritability 4. spastic voluntary muscle contractions

2. respiratory tract spasms

which elevated laboratory test would most likely indicate acute pancreatitis? 1. serum bilirubin level 2. serum amylase level 3. potassium level 4. sodium level

2. serum amylase level; amylase concentration is high in the pancreas and is elevated in the serum when the pancreas becomes acutely inflamed. also, it distinguishes pancreatitis from other acute abdominal issues

the nurse is preparing to administer digoxin (Lanoxin) intravenously to a patient with a-fib. in relation to the infusion of the medication, the nurse: 1. may administer the dose over 1 minute 2. should monitor serum potassium 3. may give the drug with other infusing medications 4. should withhold the drug if the blood pressure is 115/60 mm Hg

2. should monitor serum potassium; low serum potassium can contribute to toxicity; digoxin inhibits sodium potassium ATPase

an arab patient is terminally ill and death is imminent. the nurse should position the bed facing? 1. northeast 2. southeast 3. west 4. south

2. southeast; this will face patient towards mecca which is to the southeast of the united states.

a patient is prescribed haloperidol (Haldol). the nurse should teach the patient to avoid: 1. driving at night 2. staying in the sun 3. ingesting aged cheeses 4. taking medications containing aspirin

2. staying in the sun; Haldol causes photosensitivity

the nurse should recommend the chickenpox vaccine for children at risk for contracting it and who are about to receive? 1. insulin 2. steroids 3. antibiotics 4. anticonvulsants

2. steroids; steroids have an immunosuppressant effect

why are patients advised to take dexamethasone (decadron) with food or milk? 1. retards pepsin production 2. stimulates hydrochloric acid production 3. slows stomach emptying time 4. decreases production of hydrochloric acid

2. stimulates hydrochloric acid production; the food/milk stimulates the stomach to produce hydrochloric acid

a patient has been exhibiting decorticate (flexor) posturing and then suddenly exhibits decerebrate (extensor) posturing. the nurse interprets that the change is indicate of? 1. an insignificant finding 2. an improvement in condition 3. decreasing intracranial pressure 4. deteriorating neurological function

4. deteriorating neurological function; decorticate - Latin - "remove the bark from". this is a flexor posture in which the patient has bent arms, clenched fists, and legs out straight. hands, wrists, and arms are bent in towards the body on chest. this is a sign of severe brain damage. decerebrate - extensor position; arms and legs are held straight out, toes are pointed downward, head and neck are arched backward, hands are curled; decerebrate is indicative of damage to the deeper brain structures (including midbrain, pons, diencephalon).

a patient is given leucovorin calcium to a patient before the ordered methotrexate (chemotherapeutic drug). the patient asks the reason for this. the nurse explains that leucovorin calcium is being given to: 1. potentiate the metabolite required for destruction of cancer cells 2. supply levels of folic acid required by blood forming organs 3. act synergistically with antineoplastic drugs to destroy cancer cells 4. increase production of phagocytic cells required to remove debris liberated by disintegrating cancer cells

2. supply levels of folic acid required by blood forming organs; methotrexate is a folic acid antagonist that can cause depression of the bone marrow. this can sometimes be prevented by giving folic acid beforehand. some physicians advocate for giving it after a course of methotrexate therapy; leucovorin calcium (aka folinic acid) is a chemotherapy protective drug; it can treat anemia

which of these eye drops would the nurse question if prescribed for a patient with increased ICP? 1. artificial tears 2. betaxolol (betoptic) 3. acetazolamide (diamox) 4. epinephrine hcl (epirate)

4. epinephrine hcl (epirate)

the trough is always drawn how many minutes before administration of next dose? 1. 15 minutes 2. 45 minutes 3. 30 minutes 4. 60 minutes

3. 30 minutes

a patient has burgher's disease and is being told about the importance of smoking cessation. the nurse anticipates that the patient will go home with a prescription for? 1. paracetamol 2. ibuprofen 3. nitroglycerin 4. nicotine (nicotrol)

4. nicotine (nicotrol); is given in controlled and decreasing doses for the mgmt of nicotine withdrawal

a child with lead poisoning is prescribed chelation therapy. which medication will the child receive? 1. ipecac syrup 2. activated charcoal 3. sodium bicarbonate 4. calcium disodium edetate (EDTA)

4. calcium disodium edetate (EDTA)

which of these is the most common complaint for a patient with colorectal cancer? 1. abdominal pain 2. hemorrhoids 3. change in caliber of stools 4. change in bowel habits

4. change in bowel habits; constipation, diarrhea, and/or constipation alternating with diarrhea are the most common signs

when a continuous intravenous nitroglycerin infusion is ordered for a patient suffering from MI, which of the following is the most essential nursing action? 1. monitoring urine output 2. monitoring blood pressure every 4 hours 3. obtaining serum potassium levels daily 4. obtaining infusion pump for the medication

4. obtaining infusion pump for the medication; pump is required for accurate control of medication

which types of medications end in -pril and are used for primary and secondary hypertension?

ACE inhibitors (angiotensin-converting enzyme inhibitors).

which medications end in -cin or -mycin? these interfere with the protein synthesis of bacteria and are effective against most gram negative bacteria and some gram positive bacteria

aminoglycosides (anti-infectives).

what medications end in -olol and are used to lower pulse rate, blood pressure, and cardiac output. these drugs can be used to treat migraines, vascular headaches, and certain preparations are used to treat glaucoma. the meds work by blocking the sympathetic vasomotor response.

beta adrenergic blockers

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1.Stable angina 2.Variant angina 3.Unstable angina 4.Nonanginal pain

variant angina (aka prinzmetal angina)

in regards to medication, what does "TAP" stand for?

a method to remember what is done before or after when dealing with troughs and peaks; trough then administer then peak; trough before drug administration, peak after administration

the nurse teaches that the signs of autism initially may be evident when the child is about: 1. 2 years of age 2. 6 years of age 3. 6 months of age 4. 1 to 3 months of age

1. 2 years of age; by 2 years old, the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment.

which crutch gait should the nurse teach the client wearing a prosthesis after a single leg amputation? 1. 4 point gait 2. 3 point gait 3. tripod crutch gait 4. swing-through crutch gait

1. 4 point gait; provides for weight bearing on all points that touch the floor and maximum support during ambulation

when the peak is drawn is based on the route. when should the peak be drawn after a sublingual medication has been given/dissolved? 1. 5-10 minutes 2. 15-30 minutes 3. 30-60 minutes 4. not necessary for this route

1. 5-10 minutes after drug is dissolved

which findings documented in the hx of an older patient would require the nurse to implement accident prevention protocol? SATA 1. ROM is limited 2. peripheral vision is decreased 3. transmission of hot impulses is delayed 4. patient reports incidences of nocturia 5. high frequency hearing tones are perceptible 6. voluntary and autonomic reflexes are slowed

1. ROM is limited 2. peripheral vision is decreased 3. transmission of hot impulses is delayed 4. patient reports incidences of nocturia 6. voluntary and autonomic reflexes are slowed

an infant with a cleft lip and palate is at an increased risk for: 1. URI and otitis media 2. otitis media and diarrhea 3. URI and diarrhea 4. diarrhea and vomiting

1. URI and otitis media; the open space decreases natural defenses against bacteria

which of these patients would not be a candidate to take imipramine (tofranil)? 1. a patient with a hx of myocardial infarction 2. a patient with a hx of hepatitis 3. a patient with a hx of enuresis 4. a patient with a hx of gastric ulcers

1. a patient with a hx of myocardial infarction; imipramine and other tricyclic antidepressants can cause cardiac dysrhythmias and should not be used in those with cardiac problems.

which of these patients have an increased risk for developing puerperal infection? 1. a patient with a hx of previous infections 2. a patient who has given birth to a set of twins 3. a patient who has had numerous vaginal examinations 4. a patient who has experienced 3 previous miscarriages 5. a patient who underwent a vaginal delivery 6. a patient who experienced a prolonged rupture of the membranes

1. a patient with a hx of previous infections, 3. a patient who has had numerous vaginal examinations, 6. a patient who experienced a prolonged rupture of the membranes; puerperal - Latin - "bringing forth children"; occurring at the time of childbirth or shortly after; in addition to selected answers, cesarean births, prolonged labor, trauma, and retained placental fragments.

during second day of hospitalization following a MI, which of these would be an expected outcome? 1. able to perform self care without pain 2. severe chest pain 3. can recognize risk factors of MI 4. can participate in cardiac rehab walking program

1. able to perform self care without pain

a patient who is receiving phenytoin (Dilantin) asks why folic acid is prescribed. What is the nurse's best response? 1. absorption of foods is inhibited 2. potentiates the action of phenytoin 3. improves absorption of iron from foods 4. prevents the neuropathy caused by phenytoin

1. absorption of foods is inhibited. phenytoin inhibits folic acid absorption and potentiates effects of folic acid antagonists. dosage must be carefully adjusted b/c folic acid diminishes effects of phenytoin

which guidelines are appropriate for the nurse to follow when performing endotracheal suctioning? SATA 1. apply suction while withdrawing the catheter 2. perform suctioning on a routine basis (every 2-3 hours) 3. maintain medical asepsis during suctioning 4. use a new catheter for each suctioning attempt 5. limit suctioning to 2-3 attempts

1. apply suction while withdrawing the catheter, 4. use a new catheter for each suctioning attempt, 5. limit suctioning to 2-3 attempts; nurse applies suction only when withdrawing (not while inserting it); to prevent hypoxemia, the nurse should limit each session to 2-3 attempts and allow one minute between passes for ventilation and oxygenation; endotracheal suctioning requires surgical asepsis not medical asepsis

when does spermatogenesis occur? 1. at time of puberty 2. any time after birth 3. immediately following birth 4. during embryonic development

1. at time of puberty

a patient is prescribed ketoconazole. which instruction should the nurse teach the patient? 1. avoid exposure to sunlight 2. limit alcohol use 3. take this medication with an antacid 4. take medication on an empty stomach

1. avoid exposure to sunlight; this medication is an antifungal medication and increases photosensitivity. the patient should have no alcohol while taking this b/c it can be hepatotoxic. this medication should be taken with food or milk

a patient with copd is being discharged home on continuous oxygen. what info does the nurse provide to the patient and his wife regarding use of oxygen? 1. because of his need for oxygen, the patient will need to limit activity at home 2. the use of oxygen will eliminate the patient's shortness of breath. 3. precautions are necessary b/c oxygen can spontaneously ignite and explode 4. use oxygen during activity to relieve strain on the patient's heart

1. because of his need for oxygen, the patient will need to limit activity at home

for a patient that has been experiencing persistent vomiting, which serum electrolytes should the nurse be most concerned with? 1. chloride and sodium levels 2. phosphate and calcium levels 3. protein and magnesium levels 4. sulfate and bicarbonate levels

1. chloride and sodium levels; sodium is concerned with the regulation of extracellular fluid volume and is lost with vomiting. chloride, which balances cations in the extracellular compartments, is also lost with vomiting. b/c sodium and chloride are parallel electrolytes and hyponatremia will occur

what are miotics used for? 1. constricting the pupil 2. relaxing the ciliary muscle 3. constricting intraocular vessel 4. paralyzing ciliary muscle

1. constricting the pupil; these constrict the pupil and contract the ciliary muscle. these effects widen the filtration angle and permit increased out flow of aqueous humor

which of these has the best supply of b12? 1. dairy products 2. vegetables 3. grains 4. broccoli

1. dairy products; dairy products and meats are good sources

which of these is true regarding a diabetic patient and exercise? 1. during exercise the body will use carbs for energy production, which in turn will decrease the need for insulin 2. with an increase in activity the body will utilize more carbs; therefore more insulin will be required 3. the increase in activity results in an increase in the utilization of insulin; therefore the patient should decrease their carb intake 4. exercise will improve pancreatic circulation and stimulate the islet of langerhans to increase the production of intrinsic insulin

1. during exercise the body will use carbs for energy production, which in turn will decrease the need for insulin

which of these assessment findings would be expected for a patient dx with end stage renal disease (ESRD)? SATA 1. edema 2. anemia 3. polyuria 4. bradycardia 5. hypotension 6. osteoporosis

1. edema, 2. anemia; two functions of the kidneys are maintenance of water balance in the body and secretion of erythropoietin (which stimulates red blood cell formation in bone marrow). these impairments result in edema and anemia. kidney failure results in decreased urine production and increased blood pressure. tachycardia is a result of the increased fluid load on the heart.

during the convalescent stage, a patient with RA should be encouraged to: 1. engage in active joint flexion and extension 2. continued immobility until pain subsides 3. engage in range of motion twice daily 4. flexion exercises 3 times per day

1. engage in active joint flexion and extension; this mobilizes exudates in the joints which relieves stiffness and pain

what is the primary action of insulin in the body? 1. enhances the transport of glucose across cell walls 2. aids in the process of gluconeogenesis 3. stimulates the pancreatic beta cells 4. decreases the intestinal absorption of glucose

1. enhances the transport of glucose across cell walls

when caring for a neonate, which intervention is routinely performed for all newborns to r/o tracheoesophageal fistula and esophageal atresia? 1. feeding the newborn a few sips of sterile water before introducing breast milk or formula 2. feeding the newborn a few sips of formula before introducing breast milk 3. feeding the infant a few sips of formula in an upright position 4. feeding the newborn sterile water for the first 2 feedings

1. feeding the newborn a few sips of sterile water before introducing breast milk or formula; this prevents aspiration of formula into the lungs

which adaptations indicate an increase in intracranial pressure? SATA 1. fever 2. stupor 3. orthopnea 4. rapid pulse 5. hypotension

1. fever 2. stupor; increased intracranial pressure affects the hypothalamic temperature regulating center in the brain, resulting in fever; increased intracranial pressure disrupts neurons and neurotransmitters, which results in faulty impulse transmission and an altered level of consciousness

which of these are signs of croup? SATA 1. fever 2. crackles 3. bronchospasm 4. barking cough 5. inspiratory stridor

1. fever, 4. barking cough, 5. inspiratory stridor; fever is a common finding in croup; the cough is tight, with a barking, metallic sound due to laryngeal edema

when a patient is prescribed tranylcypromine, which foods should be avoided? SATA 1. figs 2. apples 3. bananas 4. broccoli 5. sauerkraut 6. baked chicken

1. figs, 2. bananas, 5. sauerkraut; tranylcypromine is a MAOI. foods that contain tyramine need to be avoided b/c they put the pt at risk for a hypertensive crisis; foods with tyramine include - figs, bananas, sauerkraut, avocados, soy, fermented or aged fish and meats, some cheeses, yeast extract, and some beer and wine

of freud's developmental stages, which one occurs from ages 11-adult and involves leaving old dependencies and learning to deal maturely with the opposite sex? 1. genital 2. latency 3. anal 4. oral

1. genital

a patient with cerebral palsy, athetoid type, should have frequent rest periods because: 1. grimacing and writhing movements decrease with relaxation and rest 2. hypoactive deep tendon reflexes become more active with rest 3. stretch reflexes are increased with rest 4. fine motor movements are improved with rest

1. grimacing and writhing movements decrease with relaxation and rest; patients with athetoid cerebral palsy (aka dyskinetic cerebral palsy) experience contraction of the muscles and muscle rigidity; athetosis = a continuous succession of slow, writhing, involuntary movements of the hands and feet and other body parts

which clinical manifestations should alert the nurse to a hemolytic transfusion reaction? select all that apply: 1. headache 2. tachycardia 3. hypertension 4. apprehension 5. distended neck veins 6. a sense of impending doom

1. headache, 2. tachycardia, 4. apprehension, 6. sense of impending doom; when blood with different antigens other than the patient's are infused, antigen antibody complexes are formed. these complexes destroy the transfused cells and start an inflammatory response in the patient's blood vessel walls and organs. the reaction may include fever, chills, disseminated intravascular coagulation, circulatory collapse. other manifestations include answers 1,2,4,6 in addition to chest pain, low back pain, tachypnea, hypotension, hemoglobinuria; reaction can be immediate or after units have been infused

the nurse plans care for a patient requiring IV fluids and electrolytes. which of these findings correlate with the need for this type of therapy? 1. hyponatremia 2. bounding pulse rate 3. chronic kidney disease 4. isolated syncope episodes 5. rapid, weak, thready pulse 6. abnormal serum and urine osmolality levels

1. hyponatremia, 5. rapid,weak, thready pulse, 6. abnormal serum and urine osmolality levels; rapid, weak, thready pulse is found with fluid and electrolyte imbalances like hyponatremia; a bounding pulse rate is a manifestation of fluid volume excess; patients with chronic kidney disease experience inability of kidneys to regulate the body's water balance so fluid restrictions may be used and patient would not be given more fluids; "thready pulse" - a scarcely perceptible and commonly rapid pulse that feels like a fine mobile thread under a palpating finger

which of these are side effects of ACE inhibitors? SATA 1. hypotension 2. hacking cough 3. nausea/vomiting 4. dry mouth 5. angioedema 6. rashes

1. hypotension 2. hacking cough 3. nausea/vomiting 5. angioedema 6. rashes; angio (relating to blood or lymph vessels); angioedema is swelling in the deep layers of the skin often seen as urticaria hives); ACE inhibitors cause a cough due to causing an increase in bradykinin (molecule involved in inflammation response, vasodilation, and pain) this can irritate the airways and trigger a cough

a patient is prescribed carbamazepine for trigeminal neuralgia. which statement indicates that patient understands nurse's teaching? 1. i will report a fever or sore throat to my dr. 2. some joint pain is expected and nothing to worry about 3. i must brush my teeth to avoid damage to my gums 4. my urine may turn red in color

1. i will report a fever or sore throat to my dr; carbamazepine (Tegretol) is an anticonvulsant medication but it is also used to alleviate pain associated with trigeminal neuralgia. agranulocytosis (condition where there is a low level of granulocytes - a type of WBC) is an adverse effect of this medication and puts patient at risk for infection. unusual bruising and bleeding are also adverse effects of this med.

a patient who has been dx with type 1 diabetes mellitus and a hx of DKA is receiving home care instructions. which statement made by the spouse requires further teaching? 1. if he is vomiting, i shouldn't give him any insulin 2. i should bring him to the dr if he develops a fever 3. if our grandchildren are sick they shouldn't come to visit 4. i should call the dr if nausea or abdominal pain lasts more than 1-2 days

1. if he is vomiting, i shouldn't give him any insulin; DKA is life threatening and develops when a severe insulin deficiency occurs. infection and the stopping of insulin are precipitating factors of DKA; nausea and abdominal pain that lasts more than 1-2 days should be reported b/c this could be indicative of DKA

halfway through the administration of blood, a patient complains of lumbar pain. after stopping the infusion, the nurse should? 1. increase normal saline 2. assess pain further 3. notify blood bank 4. obtain vital signs

1. increase normal saline; this is infused to keep the line patent and to maintain blood volume

a patient has been dx with hypertension. the priority nursing dx would be: 1. ineffective health maintenance 2. impaired skin integrity 3. deficient fluid volume 4. pain

1. ineffective health maintenance; managing hypertension is the priority for this pt.

a patient is resuming eating after a Billroth II procedure. to minimize complications associated with eating, which actions should the nurse teach the patient? SATA: 1. lay down after eating 2. eat a diet high in protein 3. drink liquids with meals 4. eat 6 small meals per day 5. eat concentrated sweets only between meals

1. lay down after eating, 2. eat a diet high in protein, 4. eat 6 small meals per day; this patient is at risk for dumping syndrome. to keep this from happening, the patient should lay down after eating and avoid drinking liquids with meals. the patient should be placed on a dry diet that is high in protein, moderate in fat, low in carbs. this patient should avoid concentrated sweets; Billroth II is constructed by sewing a loop of jejunum to the gastric remnant; Billroth 1 is constructed by creation of an anastomosis of the duodenum and gastric remnant.

a patient is on lithium for management of bipolar disorder. which signs/symptoms indicates toxicity? 1. lethargy and motor weakness 2. hand tremors 3. tardive dyskinesia 4. pruritis (itching)

1. lethargy and motor weakness; early signs of lithium toxicity; normal levels are 0.6-1.2; hand tremors may be a side effect but is not a sign of toxicity

a 4 y/o patient who recently moved to the U.S. from columbia presents with 102 degree temp, runny nose, rash, small red irregularly shaped spots with blue-white centers in his mouth. the child likely has: 1. measles 2. chickenpox 3. fifth disease 4. scarlet fever

1. measles; aka rubeola; the blue white spots in the mouth are called Koplik spots which appear before the rash and subside about 2 days after the rash is visible.

what should the nurse include in the teaching plan for the parents of an infant dx with PKU? 1. mental retardation occurs if PKU is untreated 2. testing for pku is done immediately after birth 3. treatment for pku includes lifelong medications 4. pku is transmitted by an autosomal dominant gene

1. mental retardation occurs if PKU is untreated

a patient with cystic fibrosis is receiving gentamicin. which nursing action is most important? 1. monitor intake and output 2. obtain daily weights 3. monitor for constipation 4. obtain stool samples to test for occult blood

1. monitor intake and output; gentamicin belongs to the aminoglycosides antibiotic class; these are hard on the kidneys. BUN and creatinine should be monitored to ensure they do not increase. also, urine output needs to be monitored to ensure that this does not decrease

a patient is dx with heart failure who has a magnesium level of 0.75 Eq/L. which action should the nurse take? 1. monitor the patient for irregular heart rhythms 2. encourage intake of antacids with phosphate 3. teach the pt to avoid foods high in magnesium 4. provide a diet of ground beef, eggs, chicken breast

1. monitor the patient for irregular heart rhythms; normal mag levels are 1.3-2.1. magnesium plays an important role in myocardial nerve impulse conduction thus hypomagnesemia increases patient's risk of ventricular dysrhythmias; a nurse should avoid administering phosphate in the presence of low mag b/c it can aggravate the condition.

a patient with pernicious anemia will need to take/do which of these after he goes home? 1. monthly vit b12 injections will be necessary 2. ferrous sulfate PO daily 3. coagulation studies to evaluate medications 4. decrease intake of leafy green vegetables b/c of increased vit k

1. monthly vit b12 injections will be necessary; the body needs b12 to make RBC's. instrinsic factor (a special protein) binds to b12 so it can be absorbed in the intestines; pernicious (meaning harmful) anemia is caused by a b12 deficiency

what clinical manifestations may indicate that a patient is experiencing orthostatic hypotension? SATA: 1. nausea 2. dizziness 3. bradycardia 4. lightheadeness 5. flushing of the face 6. reports of seeing spots

1. nausea, 2. dizziness, 4. lightheadedness, 6. reports of seeing spots; other symptoms include tachycardia and pallor (paleness); a drop in systolic BP of 15 mm Hg and 10 mm Hg in diastolic also occurs.

an infant is hospitalized and being monitored for increased intracranial pressure. the anterior fontanel bulges when the infant cries. based on this assessment, which conclusion should the nurse draw? 1. no action is required 2. head of bed needs to be lowered 3. infant needs to be placed on NPO status 4. primary healthcare provider should be notified immediately

1. no action is required; the anterior fontanel is diamond shaped and located on the top of the head. this normally closes by 12-18 months of age. the posterior fontanel closes by 2-3 months of age; a bulging or tense fontanel is seen when the child is crying or when there is increased ICP.

for which clinical indication should the nurse observe the child suspected of being autistic? 1. not wanting to eat 2. crying for attention 3. catatonic like rigidity 4. enjoying being with people

1. not wanting to eat

which of these are side effects of beta adrenergic blockers? SATA 1. orthostatic hypotension 2. tremors 3. bradycardia 4. nausea/vomiting 5. diarrhea 6. potential to mask signs of hypoglycemia

1. orthostatic hypotension 3. bradycardia 4. nausea/vomiting 5. diarrhea 6. potential to mask signs of hypoglycemia; beta blockers can block signs of hypoglycemia b/c they block norepinephrine thereby slowing the heart rate and reducing shakiness/trembling. hunger, irritability, and confusion can also be concealed

which of these are potential side effects of aminoglycosides? SATA 1. ototoxicity 2. dilated pupils 3. nephrotoxicity 4. seizures 5. hypotension 6. blood dyscrasias 7. rash

1. ototoxicity 3. nephrotoxicity 4. seizures 5. hypotension 6. blood dyscrasias 7. rash; dycrasia means "bad mixture" - describes imbalance of constituents in blood

when changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened blanchable area approximately 2 cm in diameter on her left buttock. the nurse's initial skin breakdown intervention is to: 1. position the client on right side 2. finish providing fresh dry linens to bed 3. include a 2 hour turning schedule in care plan 4. measure the area in order to describe it in nurse's notes.

1. position the patient on the right side

the nurse is reviewing the blood chemistry profile for a patient experiencing late stage salicylate (aspirin) poisoning and metabolic acidosis. which serum study should the nurse review for info about the acid-base balance? 1. potassium 2. magnesium 3. sodium 4. phosphorus

1. potassium; a patient with late stage salicylate (aspirin) poisoning is at risk for metabolic acidosis b/c acetylsalicylic acid increases the H+ concentration and decreases the pH and creates a bicarbonate deficit. hyperkalemia develops as the body attempts to compensate for the H+ by moving H+ into the cell and potassium out of the cell. potassium accumulates in the extracellular space; clinical manifestations of metabolic acidosis include the clinical indicators of: hyperkalemia, hyperpnea (rapid or deep breathing), CNS depression, twitching, and seizures

a patient with a partial occlusion of the left carotid artery is being discharged on warfarin (Coumadin). which clinical indicator should the nurse tell the patient to seek medical consultation: 1. presence of blood in the urine 2. increased swelling of the ankles 3. diminished ability to concentrate 4. occurrence of transient ischemic attacks

1. presence of blood in the urine; warfarin derivatives increase INR and prothrombin time leading to an increased risk of bleeding; any abnormal or excessive bleeding should be reported b/c it could indicate toxicity.

a patient with a hx of cirrhosis and alcoholism is admitted with severe dyspnea related to ascites. the nurse knows that ascites is most likely the result of increased: 1. pressure in the portal vein 2. production of serum albumin 3. secretion of bile salts 4. interstitial osmotic pressure

1. pressure in the portal vein; the enlarged cirrhotic liver impinges the portal system causing increased hydrostatic pressure resulting in ascites

what should nursing care for an infant after surgical repair of a cleft lip include? 1. preventing the infant from crying 2. place infant in semi-sitting position 3. keep infant NPO 1 day after surgery 4. feed the infant with a spoon for the first 2 days after surgery

1. preventing the infant from crying; crying places tension on the suture line. frequently an appliance called a Logan bow is taped to the cheeks to relax the operative site and this reduces the chance of trauma

a patient has undergone mitral valve replacement and suddenly experiences continuous bleeding from the surgical incision during post op period. which of the following pharmaceutical agents should the nurse prepare to administer? 1. protamine sulfate 2. quinidine sulfate 3. vitamin c 4. coumadin

1. protamine sulfate; used to prevent continuous bleeding after open heart surgery; used to reverse the effects of heparin

why is a patient in chronic renal failure on a low protein diet? 1. protein breaks down into waste products that increase the workload of the kidneys 2. protein increases the amount of sodium and potassium to be regulated by the kidneys 3. protein decreases the amount of serum albumin and promotes edema formation 4. protein decreases serum calcium and phosphorus levels

1. protein breaks down into waste products that increase the workload of the kidneys; protein breaks down into nitrogenous wastes that increase the workload of the kidneys.

a patient with myasthenia gravis continues to become weaker despite tx with neostigmine. the nurse understands that edrophonium HCl (Tensilon) is ordered to: 1. r/o out cholinergic crisis 2. promote a synergistic effect 3. overcome a neostigmine resistance 4. confirm the dx of myasthenia

1. r/o out cholinergic crisis; Tensilon increases muscle strength; weakness persists if symptoms are caused by a cholinergic crisis, which can result from toxic levels of neostigmine

which of these should not be in CSF? 1. rbc's 2. wbc's 3. insulin 4. protein

1. rbc's

at a well-baby clinic visit for a 2 month old infant, which vaccines would likely be administered? SATA 1. rotavirus (RV) 2. pneumococcal (PCV) 3. inactivated poliovirus (IPV) 4. varicella; measles, mumps, and rubella (MMR) 5. haemophilus influenzae type b con jugate (Hib) 6. diphtheria and tetanus toxoids and acellular pertussis (DTaP)

1. rotavirus (RV) 2. pneumococcal (PCV) 3. inactivated poliovirus (IPV) 5. haemophilus influenzae type b con jugate (Hib) 6. diphtheria and tetanus toxoids and acellular pertussis (DTaP)

a patient dx with borderline personality disorder has negative feelings toward the other patients on the unit and considers them all to be "bad". which defense was being used by the patient when this statement was made? 1. splitting 2. ambivalence 3. passive aggression 4. reaction formation

1. splitting; aka all or nothing thinking; common ego defense mechanism; person fails to bring together the dichotomy of both perceived positive and negative qualities

which of these are typical findings in regards to a patient with acute pancreatitis? 1. steatorrhea, abdominal pain, fever 2. fever, hypoglycemia 3. melena, persistent vomiting, hyperactive bowel sounds 4. hypoactive bowel sounds, decreased amylase and lipase levels

1. steatorrhea, abdominal pain, fever

a patient is prescribed inhalation vasopressin therapy. what will the nurse evaluate to determine the therapeutic response to this medication? 1. urine specific gravity 2. blood glucose 3. vital signs 4. oxygen saturation levels

1. urine specific gravity; vasopressin (aka ADH)

a patient is being assessed for abruptio placentae. which manifestation of this condition should the nurse expect to note? SATA 1. uterine irritability 2. uterine tenderness 3. painless vaginal bleeding 4. abdominal and low back pain 5. strong and frequent contractions 6. nonreassuring fetal heart rate patterns

1. uterine irritability, 2. uterine tenderness, 4. abdominal and low back pain, 6. nonreassuring fetal heart rate patterns; placental abruption, aka abruptio placentae, is the separation of a normally implanted placenta before the fetus is born. this occurs when there is bleeding and a formation of a hematoma on the maternal side of the placenta. painful vaginal bleeding is also a sign; painless vaginal bleeding is a sign of placenta previa

a colostomy pouch should be emptied: 1. when it is 1/3 to 1/2 full 2. prior to meals 3. after each fecal elimination 4. at the same time each day

1. when it is 1/3 to 1/2 full

which patient is most likely to have iron deficiency anemia? 1. a patient with cancer receiving radiation twice a week 2. a toddler whose primary nutritional intake is milk 3. a patient with peptic ulcer who had surgery 6 weeks ago 4. a 15 year old in sickle cell crisis

2. a toddler whose primary nutritional intake is milk

a patient is prescribed anticoagulant therapy for a pulmonary embolism. which drug should the nurse advise the patient not to take until talking with her physician? 1. ferrous sulfate 2. acetylsalicylic acid 3. isoxsuprine (Vasodilan) 4. chlorpromazine (Thorazine)

2. acetylsalicylic acid; aspirin can caused decreased platelet aggregation

a priority nursing diagnosis for a patient admitted to the hospital with a dx of diabetes insipidus would be: 1. sleep pattern deprivation related to nocturia 2. activity intolerance r/t muscle weakness 3. fluid volume excess r/t intake greater than output 4. risk for impaired skin integrity r/t generalized edema

2. activity intolerance r/t muscle weakness; diabetes insipidus is a rare condition in which the kidneys are unable to retain water and the body makes too much urine, blood glucose is normal. the body doesn't make enough ADH. diabetes insipidus causes thirst due to dehydration from constant urination. the loss of fluids cause muscle weakness, dry skin, constipation.

which action is specific to the plan of care for a patient with trigeminal neuralgia (aka tic douloureux)? 1. apply ice compresses to the affected area 2. be alert to prevent dehydration or starvation 3. initiate exercises of the jaw 4. emphasize the importance of brushing the teeth

2. be alert to prevent dehydration or starvation

a patient with myasthenia gravis has been receiving neostigmine (Prostigmin). what is the action of this drug? 1. stimulates the cerebral cortex 2. blocks the action of cholinesterase 3. replaces deficient neurotransmitters 4. accelerates transmission along neural sheaths

2. blocks the action of cholinesterase; neostigmine is an anticholinesterase and inhibits the breakdown of ACh and this prolongs neurotransmission

the nurse is reviewing this set of ABGS: pH 7.43, PCO2 31 mm Hg, and HCO3 21 meq/L. which acid balance is present? 1. compensated metabolic acidosis 2. compensated respiratory alkalosis 3. uncompensated respiratory acidosis 4. uncompensated metabolic alkalosis

2. compensated respiratory alkalosis

a female patient whose ECG exhibits multiple premature ventricular complexes is going to begin taking oral disopyramide (Norpace). when the nurse is teaching the patient about side effects, what should be mentioned? 1. rhinnorhea 2. constipation 3. hyperglycemia 4. stress incontinence

2. constipation; this medication is a non-nitrate antidysrhythmic and causes constipation due to its anticholinergic properties

neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. what are the signs and symptoms? SATA 1. jaundice 2. diaphoresis 3. hyperrigidity 4. hyperthermia 5. photosensitivity

2. diaphoresis, 3. hyperrigidity, 4. hyperthermia; these symptoms occur due to a dopamine blockade in hypothalamus

the nurse finds a patient sitting on the floor. the nurse ensures patient's safety, completes an incident report, and notifies the HCP of the incident. which action should the nurse implement next? 1. staple the incident report in patient's medical record 2. document the patient events and follow up nursing actions 3. provide a copy of the incident report to the provider and the family 4. document that a copy of the report was sent to risk mgmt

2. document the patient events and follow up nursing actions; the incident report is a confidential internal document used to improve quality of care. it should not be copied, stapled, or placed in chart. the nurse avoids referring to the incident report in the record and should not document that the incident report has been sent to another dept.

a nurse discourages a patient from straining excessively when attempting to have a bowel movement. what physiological response primarily may be prevented by avoiding straining? 1. incontinence 2. dysrhthmias 3. fecal impaction 4. rectal hemorrhoids

2. dysrythmias; straining causes the person to hold their breath which can precipitate dysrhythmias. this maneuver increases the intrathoracic and intracranial pressures which can precipitate dysrhythmias, brain attack, and respiratory difficulties (all of which can be life threatening); although straining can contribute to hemorrhoids, these are not life threatening.

a patient dx with borderline personality d/o with antisocial bx would likely be: 1. retiring and devious 2. engaging and rejecting 3. suspicious and withdrawn 4. indecisive and perfectionistic

2. engaging and rejecting; pts with bpd tend to be engaging and establish intense relationships, which they then test for signs of rejection. they tend to make others feel that they are not helpful and never could be

which of these should a patient prescribed phenelazine avoid eating? 1. peanuts, dates, and raisins 2. figs, chocolate, and eggplant 3. cracked wheat, peas, and beef 4. milk, cottage cheese, and ice cream

2. figs, chocolate, and eggplant; phenelazine (nardil) is an maoi. foods high in tyramine should be avoided.

which of these will the nurse anticipate administering for a patient dx with DIC (disseminated intravascular coagulation)? 1. packed rbc 2. fresh frozen plasma (ffp) 3. volume expanders (such as D10W) 4. whole blood

2. fresh frozen plasma (ffp)

a patient with cushing's syndrome is discharging from the hospital. which of these statements indicates understanding of discharge instructions? 1. i need to eat foods low in potassium 2. i need to check the color of my stools 3. i need to check the temperature of my legs twice per day 4. i need to take aspirin rather than acetaminophen for a headache

2. i need to check the color of my stools; cushing's results in an increased secretion of cortisol. cortisol stimulates the secretion of gastric acid which can result in peptic ulcers and GI bleeding. the patient should be encouraged to eat potassium rich foods to correct hypokalemia which occurs with this disorder.

which statement below demonstrates a patient's understanding following a thyroidectomy? 1. i will definitely continue taking antithyroid medication after the surgery 2. i need to place my hands behind my neck when i have to cough or change positions 3. i need to turn my head and neck front, back, and side to side every hour for the first 12 hours after surgery 4. i may experience tingling in my toes, fingers, and lips after surgery

2. i need to place my hands behind my neck when i have to cough or change positions; this will reduce incisional tension; tingling in the finger, toes, and lips after surgery could indicate an injury to the parathyroid gland during surgery resulting in hypocalcemia

isoniazid (INH) is prescribed as a prophylactic measure for a patient whose spouse has active TB. which of these statements indicate the need for further teaching? SATA 1. i will be taking this drug 6 months from now 2. i will sometimes allow our children to sleep in bed with us at night 3. i plan to start taking pyridoxine supplements with breakfast 4. i know i have TB b/c the skin test was positive 5. i be skipping wine at my neighbor's party, but i can have cheese

2. i will sometimes allow our children to sleep in bed with us at night, 4. i know i have TB b/c the skin test was positive 5. i be skipping wine at my neighbor's party, but i can have cheese; the children are at increased risk for TB and should also be screened, the positive test indicates that the patient has been exposed to the bacilli and developed antibodies not necessarily the disease itself, both wine and cheese contain tyramine and histamine which can cause headache, flushing, and drop in BP and should be avoided when taking INH

strict toilet training before a child is ready will cause problems in personality development b/c at this age, the child is learning to: 1. satisfy own needs 2. identify own needs 3. satisfy parents' needs 4. live up to society's expectations

2. identify own needs; toddlers struggle to identify their own needs. too early and too strict toilet training results in ambivalence b/c toddler's needs and physical abilities are in conflict with parental demand. toddlers are faced with giving up these needs or risking parental approval

when caring for a child with meningococcal meningitis, the nurse should observe for the: 1. presence of severe glossitis 2. identifying purpuric skin rash 3. low grade nature of the fever 4. constant tremors of the extremities

2. identifying purpuric skin rash; meningococcal meningitis is identified by its epidemic nature and purpuric (purple) skin rash

the nurse is assessing a child with meningitis. which of the following assessments will the nurse look for? 1. flat fontanel 2. irritability, fever, and vomiting 3. jaundice, drowsiness, refusal to eat 4. negative kernig's sign

2. irritability, fever, and vomiting; symptoms may also include seizure activity; fontanel would be bulging as pressure rises. kernig's sign would be present due to meningeal irritation; kernig sign is is one of the physical signs of meningitis. severe stiffness of the hamstrings causes issues with straightening the legs when the hip is flexed to 90 degrees. this occurs due to meningeal inflammation caused by movement of the spinal cord or nerves against the meninges.

which preoperative diet is most appropriate for a patient scheduled for a hemorrhoidectomy? 1. high fiber 2. low residue 3. bland 4. clear liquid

2. low residue; this is good before surgery. however, postoperatively high fiber is best b/c it will decrease the possibility of constipation

which medication will the nurse anticipate to be prescribed for a patient with anxiety and apprehension in a patient with pulmonary edema? 1. chloral hydrate 2. morphine sulfate 3. sodium phenobarbital 4. hydroxyzine hydrochloride

2. morphine sulfate; this binds with the same receptors as natural opioids. has rapid onset, lowers BP, decreases pulmonary reflexes, and produces sedation

the nurse is caring for an infant with tetralogy of fallot. which of the following drugs should the nurse anticipate administering during a tet spell? 1. propranolol (inderal) 2. morphine 3. meperidine (demerol) 4. furosemide (lasix)

2. morphine; this decreases the infundibular (funnel-shaped organs or parts) spasm; propanolol may be administered as a preventative measure but not during a tet spell; tet spell - when a patient with tetralogy of fallot suddenly develops deep blue skin, nails, and lips after crying, feeding, or when agitated.

a patient is prescribed pyridostigmine. when assessing the patient for side effects of the medication, the nurse should ask the patient about the presence of which occurrence? 1. mouth ulcers 2. muscle cramps 3. feelings of depression 4. unexplained weight gain

2. muscle cramps; this medication is an acetylcholinesterase inhibitor used to tx myasthenia gravis. muscle cramps can happen as a result of overstimulation of neuromuscular receptors.

the nurse is administering 40mg of furosemide (Lasix). the nurse identifies that this is being administered too fast when the patient says: 1. my bladder feels full 2. my ears are plugged up 3. my heart is beating fast 4. my left arm feels numb

2. my ears are plugged up; rapid administration of Lasix can cause tinnitus, ear pain, loss of hearing

a nurse is teaching an expectant parent. which of these is the best way to prevent cognitive impairment caused by congenital hypothyroidism? 1. vitamin intake 2. neonatal screening 3. adequate protein intake 4. limiting alcohol consumption

2. neonatal screening; congenital hypothyroidism is a common preventable cause of cognitive impairment. newborn infants are screened for congenital hypothyroidism before d/c from the newborn nursery and before 7 days of life.

a patient is advised to gradually decrease his dosage of dexamethasone (Decadron) and to continue a lower maintenance dosage. the nurse explains that the gradual decrease provides which effect? 1. production of antibodies by the immune system 2. return of cortisone production by the adrenal glands 3. building of glycogen and protein stores in the liver and muscle 4. time to observe for return of increased intracranial pressure

2. return of cortisone production by the adrenal glands; hormone therapy must be withdrawn slowly to allow the appropriate organ to adjust and resume production of the hormone; dexamethasone (Decadron) is used to treat a wide variety of chronic diseases - mgmt of cerebral edema, diagnostic agent in adrenal disorders, endocrine issues, dermatologic issues, used to tx inflammation and more

a patient with moderate hypertension is prescribed a beta blocker, timolol (Blocadren). the nurse identifies that the patient needs further instruction when the patient says: 1. change positions slowly 2. take the medication before going to bed 3. expect to feel drowsy when taking this medication 4. count the pulse before taking this medication

2. take the medication before going to bed; this medication should not be taken before bed b/c the BP usually drops during sleep. this medication blocks beta-adrenergic receptors in the heart, which lowers BP. the drug should be taken in the morning to maximize the therapeutic effect

syphilis is not considered contagious during this stage: 1. primary stage 2. tertiary stage 3. incubation stage 4. secondary stage

2. tertiary stage; the tertiary stage is noncontagious; tertiary lesions contain only small numbers of treponemes (parasitic or pathogenic bacterium in warm blooded animals - causal agent of syphilis and yaws). yaws - contagious disease of tropical countries

nitroglycerin sublingual tablets have lost their potency when: 1. sublingual tingling is experienced 2. the tablets are more than 3 months old 3. the pain is unrelieved but facial flushing is increased 4. onset of relief is delayed, but the duration of relief is unchanged

2. the tablets are more than 3 months old

after an ileal conduit surgery, which of the following complications should the patient be closely monitored for? 1. ascites 2. thrombophlebitis 3. inguinal hernia 4. peritonitis

2. thrombophlebitis; after a pelvic surgery, there is an increased chance of thrombophlebitis due to the pelvic manipulation that can interfere with circulation and promote venous stasis; thrombophlebitis = inflammation of a vein associated with formation of a thrombus (clot)

when is a patient most likely to experience FES (fat embolism syndrome)? 1. 1-2 hours after injury 2. 48 hours after injury 3. 18-24 hours after injury 4. 72 hours after injury

3. 18-24 hours after injury; the average onset of FES is 18-24 hours after injury to long bones or crushing injury. fat globules and tissue thromboplastin exit from the bone marrow and local tissue as a result from the injury. fat molecules then enter the venous circulation, move to the lungs, and embolize small capillaries. petechial rash on the neck, chest, conjunctivae, or axillae are classic signs of FES. elevated temperature, pulse rate, and respirations are associated with FES. 75% of patients also exhibit neurological signs (altered mental state, restlessness, lethargy, coma, confusion.

which of these is the incubation time for syphilis? 1. 1 week 2. 4 months 3. 2-6 weeks 4. 48-72 hours

3. 2-6 weeks; although the usual incubation period of syphilis is about 3 weeks, clinical symptoms may appear as early as 9 days or as long as 3 months after exposure

a patient weighed 210 lbs on admission. After 2 days of diuretic therapy, the patient weighs 205.5 lbs. the nurse could estimate the amount of fluid lost is: 1. 0.3 L 2. 1.5 L 3. 2.0 L 4. 3.5 L

3. 2.0 L; 1 liter of fluid approximately weighs 2.2 lbs. a 4.5 pound weight loss equals approximately 2 liters

a nurse is teaching a patient newly dx with diabetes mellitus about blood glucose monitoring. which of these glucose levels should the patient report if it is consistently exceeded? 1. 150 mg/dL 2. 200 mg/dL 3. 250 mg/dL 4. 350 mg/dL

3. 250 mg/dL; normal blood glucose levels range from 70-110. a patient with diabetes mellitus should be taught to report blood glucose levels that exceed 250 mg/dL.

an isotonic enema is ordered for a 2 year old child. what is the maximum amount of fluid the nurse should give w/out a practitioner's specific order? 1. 100-150 mL 2. 155-250 mL 3. 255-360 mL 4. 365-500 mL

3. 255-360 mL; no more than 360 mL of solution should be administered to a young child unless ordered due to possible disturbance of fluid and electrolyte balance

the problem of separation anxiety becomes more problematic for children being hospitalized during the ages of? 1. 5 to 11 years 2. 12 to 18 years 3. 6 to 30 months 4. 36 to 59 months

3. 6 to 30 months

a nurse mgr is reviewing critical care pathways of the patients on the nursing unit. the nurse mgr collaborates with each nurse assigned to the patients and performs a variance analysis. which finding should indicate the need for further assessment and analysis? 1. a patient is performing his own colostomy care 2. a 1 day post op patient has a temp of 98.8 3. a 2 day post abdominal hysterectomy patient has drainage noted from the incision 4. a patient newly dx with diabetes is preparing his own insulin for injection

3. a 2 day post abdominal hysterectomy patient has drainage noted from the incision; variances are actual deviations from the critical paths. option 3 is the only option that identifies the need for further action; variances can be positive or negative; positive variance occurs when the pt achieves the maximum benefit and is d/c'd earlier than anticipated. negative variance occurs when events occur that prevent a timely d/c.

an infant has patent ductus arteriosus (PDA). the nurse explains that this is: 1. an enlarged diameter of the aorta 2. a narrowing of the entrance to the pulmonary artery 3. a connection between the pulmonary artery and the aorta 4. an opening in the wall between the right and left ventricles

3. a connection between the pulmonary artery and the aorta; before birth oxygenated blood is shunted directly into the systemic circulation via the ductus arteriosus. after birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. occasionally, this remains open especially in preterm infant

atropine sulfate (atropine) is contraindicated in all but one of these patients: 1. a patient with high blood pressure 2. a patient with bowel obstruction 3. a patient with glaucoma 4. a patient with UTI

3. a patient with glaucoma; this increases intraocular pressure

which of these are a potential side effect of cascara sagrada? 1. GI bleeding 2. peptic ulcer disease 3. abdominal cramps 4. partial bowel obstruction

3. abdominal cramps; this is a laxative and frequent side effects are abdominal cramps and nausea

an infant with hypertrophic pyloric stenosis (HPS) is admitted to the unit. when palpating the infant's abdomen, the nurse expects: 1. a distended colon 2. marked tenderness around the umbilicus 3. an olive-sized mass in the right upper quadrant 4. rhythmic peristaltic waves in lower abdomen

3. an olive-sized mass in the right upper quadrant; due to thickened muscle (hypertrophy) of the pyloric sphincter

of freud's developmental stages, which one occurs at ages 2-3 when the child learns to respond to the demands of society (such as bladder and bowel control)? 1. genital 2. latency 3. anal 4. oral

3. anal

immediate nursing care for an infant with a myelomeningocele should include: 1. changing the diaper immediately when moist 2. positioning the infant prone with legs adducted 3. applying a sterile, moist nonadherent dressing to the sac 4. placing the infant in reverse trendelenburg position

3. applying a sterile, moist nonadherent dressing to the sac; this is done to prevent drying and breakage of the sac, b/c any opening increases the risk for infection to CNS

antineoplastic drugs are used to treat: 1. hypothyroidism 2. pancreatitis 3. cancer 4. paralytic ileus

3. cancer; antineoplastics (aka chemotherapy drugs) are used to treat cancer; they work by blocking the formation of neoplasms (abnormal growth of cells in the body)

a patient is dx with gonorrhea. which medication should the nurse anticipate being ordered? 1. acyclovir (Zovirax) 2. colistin (Cortisporin) 3. ceftriasone (Rocephin) 4. dactinomycin (Actinomycin)

3. ceftriasone (Rocephin); inhibits the synthesis of bacterial cell walls. effective against neisseria gonorrhoeae (a gram negative diplococcus)

during a nap, a hospitalized 3 year old boy "wets the bed". the nurse should? 1. ask him to help remake the bed 2. put clean sheets on the bed over a rubber sheet 3. chance his clothes without discussing the incident 4. explain that big boys should call the nurse when they need to void

3. chance his clothes without discussing the incident; bed-wetting accidents are not uncommon at this age, especially during hospitalization when regression may occur. the best approach is to ignore the event

sublimation is a defense mechanism that helps the individual? 1. act-out in reverse something already done or thought 2. return to an earlier, less mature, stage of development 3. channel unacceptable impulses into socially approved behavior 4. exclude from consciousness things that are psychologically disturbing

3. channel unacceptable impulses into socially approved behavior; sublimation is an unconscious defense that reduces the anxiety that may result from unacceptable urges or harmful stimuli; an example would be someone that gets in an argument with a neighbor and instead of acting out in a violent way, goes for a jog instead.

a patient is prescribed allopurinol (Aloprim) for gout. the object of this therapy is to: 1. increase bone density 2. decrease synovial swelling 3. decrease uric acid production 4. prevent crystallization of uric acid

3. decrease uric acid production; Allopurinol interferes with the final steps in uric acid formation

a female patient who is sexually active and prescribed isoniazid (INH) should be cautioned about which side effect? 1. prevents ovulation 2. has a mutagenic effect on ova 3. decreases effectiveness of oral contraceptives 4. increases the risk of vaginal infection

3. decreases effectiveness of oral contraceptives

which of these medications will be prescribed for the dx of Rocky Mountain spotted fever? 1. ganciclovir 2. amantadine 3. doxyclycine 4. amphortericin b

3. doxyclycine; an alternative medication is chloramphenicol.

a client with an excessive alcohol intake has a reduced amount of ADH. the nurse anticipates that the patient will exhibit: 1. hematuria 2. an increased blood pressure 3. dry mucous membranes 4. a low serum sodium

3. dry mucous membranes due to excessive urination (dehydration)

a patient with multiple sclerosis is to receive every other day injections of interferon beta-la (Avonex). which adverse effect should the nurse explain the patient may experience? 1. anhidrosis 2. hypercalcemia 3. flulike symptoms 4. decreased heart rate

3. flulike symptoms

which of these would a patient with polycythemia vera have? 1. increased fatigue and bleeding tendencies 2. hemoglobin below 13 3. headaches, dyspnea, claudication (pain in legs or arms while walking or using arms related to not having enough blood flow to arms and legs) 4. back pain, ecchymosis, joint tenderness

3. headaches, dyspnea, claudication (pain in legs or arms while walking or using arms related to not having enough blood flow to arms and legs); polycythemia vera (poly-many; cyt- cells) is a type of blood cancer that causes the bone marrow to make too many RBC's and this causes the blood to thicken; can result in clots

which of these is an early manifestation of laryngeal cancer? 1. stomatitis 2. airway obstruction 3. hoarseness 4. dysphagia

3. hoarseness; hoarseness lasting 2 weeks should be evaluated b/c it is one of the most common warning signs

to prevent postoperative complications, the nurse assists the patient with coughing and deep breathing exercises. this is best accomplished by implementing: 1. coughing exercises one hour before meals and deep breathing one hour after meals 2. forceful coughing as many times as tolerated 3. huff coughing every 2 hours or as needed 4. diaphragmatic and pursed lip breathing 5-10 times 4 times per day

3. huff coughing every 2 hours or as needed; huff coughing helps keep the airways open and secretions mobilized; huff coughing is an alternative for patients who are unable to perform a normal forceful cough (such as postop patients) . deep breathing and coughing should be performed at the same time; extended forceful coughing fatigues the patient; diaphragmatic and pursed lip breathing are techniques used for patients with obstructive airway disease

a patient is receiving benazepril to treat hypertension. which statement indicates the need for further teaching? 1. i need to change positions slowly 2. i need to monitor my blood pressure every week 3. i need to use salt moderately on foods 4. i need to report signs and symptoms of infection to my dr.

3. i need to use salt moderately on foods; benazepril is an ace (angio-tensin converting enzyme) inhibitor. the patient is instructed not to use salt. the patient should report fever, mouth sores, and sore throat to the HCP b/c it could be neutropenia.

which of these blood laboratory findings confirm the likelihood of rheumatic fever in a child patient? 1. increase leukocyte count 2. decreased hemoglobin count 3. increased antistreptolysin-O (ASO titer) 4. decreased erythrocyte sedimentation rate

3. increased antistreptolysin-O (ASO titer); a child suspected of having rheumatic fever is tested for streptococcal antibodies; an elevated level indicates rheumatic fever; the increased leukocyte count does indicate the presence of infection but is not specific to confirming this particular dx.

what is the most serious complication for a patient with acute renal failure? 1. constipation 2. anemia 3. infection 4. platelet dysfunction

3. infection

when a patient asks what is the best way to prevent gonorrhea, which of these would be correct answers? 1. douche after intercourse 2. avoid engaging in sexual bx 3. insist that my partner use a condom 4. use a spermicidal cream with intercourse

3. insist that my partner use a condom; although not 100% effective, the best protection against gonorrhea is a condom

parents of a newborn are being given d/c instructions following the child's myelomeningocele repair. which teaching should the nurse include? 1. demonstrate restrictive positions to keep infant from turning 2. discussion about the need to limit the infant's fluid intake to formula only 3. instructions on how to do passive ROM exercises to the infant's lower extremities 4. explanation of the need to provide the infant with a quiet environment

3. instructions on how to do passive ROM exercises to the infant's lower extremities; this promotes circulation and prevents atrophy

a low dose of ondansetron (Zofran ODT) is prescribed for a patient receiving chemotherapy. this medication will be prescribed by which route? 1. oral 2. intranasal 3. intravenous 4. subcutaneous

3. intravenous

which of the following puts a patient at risk for breast cancer? 1. menopause at an early age and excessive caffeine use 2. slender build and first birth before 20 years old 3. menarche at an early age and nulliparous 4. asian descent and lower socioeconomic status

3. menarche at an early age and nulliparous

mafenide (Sulfamylon) cream is applied to a patient's burn areas. the nurse understands that a serious side effect of this medication is? 1. curling's ulcer 2. renal shutdown 3. metabolic acidosis 4. hemolysis of red blood cells

3. metabolic acidosis; mafenide (Sulfamylon) interferes with the kidneys' role in hydrogen ion excretion which results in metabolic acidosis

what is the most serious complication of meningitis in young children? 1. epilepsy 2. blindness 3. peripheral circulatory collapse 4. communicating hydrocephalus

3. peripheral circulatory collapse (aka waterhouse friderichsen syndrome) is caused by bilateral adrenal hemorrhage. this results in acute adrenocortical insufficiency which causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration (extreme physical weakness), hypotension

which principle should the nurse base patient teaching to reestablish a regular pattern of defecation? 1. sedentary activities produce muscle atonia 2. increased fluid promotes ease of evacuation 3. peristalsis is initiated by gastrocolic reflex 4. increased potassium is needed for neuromuscular irritability

3. peristalsis is initiated by gastrocolic reflex; stomach distention after eating results in contractions of the colon (gastrocolic reflex) which promotes defecation. establishing regularity of meals that include fiber/bulk will establish routine patterns of defecation

of freud's developmental stages, which one occurs from 3-7 years old in which the child learns to realize the difference between males and females and becomes aware of sexuality? 1. genital 2. latency 3. phallic 4. oral

3. phallic

a patient is receiving torsemide 5mg daily. what value should indicate to the nurse that pt may be experiencing an adverse effect? 1. chloride level of 98 2. sodium level 135 3. potassium level 3.1 4. BUN level of 15

3. potassium level 3.1

what should the nurse include in the nursing plan for a patient with obsessive-compulsive bx of hand and body washing? 1. denying the patient time for ritualistic bx 2. determining the purpose of the ritualistic bx 3. providing the patient with a routine schedule of activities 4. suggesting a symptom substitution technique to refocus the bx

3. providing the patient with a routine schedule of activities; routines decrease anxiety and the need for the ritual

a patient with schizophrenia, who has type II (negative) symptoms is prescribed Risperdal. the medication has minimized the type II symptoms when the patient: 1. is less agitated 2. has fewer delusions 3. shows interest in unit activities 4. reports that the hallucinations have stopped

3. shows interest in unit activities; apathy is a common type II (negative) symptom; flat affect and lack of socialization are also common

a patient has been hospitalized on a psychiatric unit for one week due to bipolar d/o, depressive episode. when scheduling activities for this pt what would be appropriate? 1. complete a jigsaw puzzle by herself 2. play a game of cards with several other patients 3. talk with the nurse several times during the day 4. engage in a game of ping-pong with another patient

3. talk with the nurse several times during the day; one on one conversation provides the patient with low anxiety and individualized attention

a 4 year old was admitted to PICU after a ventral septal defect. several hours after surgery, he is noted to be restless and irritable. in the past hour, the pulse has increased from 106 to 110, BP remains unchanged, and respirations are rapid and shallow. which of these is likely the situation? 1. the child is developing a fluid volume deficit 2. the child is developing symptoms of impending shock 3. the child is in pain 4. the child is developing heart failure

3. the child is in pain; restlessness, irritability, a slight increase in pulse rate, and rapid shallow respirations are indicative of pain

a patient is taking dipyridamole after a valve replacement. which statement indicates that patient understands the medication instructions? 1. the medication will prevent a stroke 2. the medication will prevent a heart attack 3. the medication will protect my heart valve 4. this medication will help keep my blood pressure down

3. the medication will protect my heart valve; dipyridamole is an antiplatelet medication. it may be given along with warfarin sodium to protect patient's artificial heart valves.

why does the nurse expect a cancer patient to have soreness of the mouth and anus during chemotherapy? 1. the tissues are poorly nourished b/c patient is anorectic. 2. the entire GI tract is involved due to the direct irritating effects of chemotherapy 3. the tissues that normally divide rapidly are damaged by the chemotherapeutic agent 4. the side effects of the chemotherapeutic agent tend to concentrate in these areas

3. the tissues that normally divide rapidly are damaged by the chemotherapeutic agent; many chemo drugs function by interfering with DNA replication associated with cellular replication (mitosis). the rapid mitosis of the stratified squamous epithelium of the mouth and anus results in these areas being powerfully affected by the drugs

a patient with TB asks the nurse why vitamin b6 (pyridoxine) is given with isoniazid (INH). the nurse should explain: 1. the tuberculostatic effect of isoniazid is enhanced 2. immunologic defenses of the pt are improved 3. the vitamin is extrinsically needed b/c with isoniazid natural vitamin synthesis is decreased 4. destruction of remaining organisms is accelerated after their reproduction by isoniazid is inhibited

3. the vitamin is extrinsically needed b/c with isoniazid natural vitamin synthesis is decreased; INH (isoniazed) often leads to pyridoxine (vitamin b6) deficiency b/c it competes with the vitamin for the same enzyme.

a patient with RA is receiving aurothioglucose, a gold compound. it is most important that the nurse monitor for? 1. hypertension 2. cutaneous lesions 3. thrombocytopenia 4. elevate blood glucose

3. thrombocytopenia; adverse reactions include blood dyscrasias (dyscrasias = Greek for bad mixture" - an abnormal condition or disease of the blood), - can include eosinophilia, thrombocytopenia, aplastic anemia, and leukopenia

problems with dependence vs. independence develop during which stage of growth? 1. infancy 2. school age 3. toddlerhood 4. preschool age

3. toddlerhood; the toddler is learning autonomy however there is still emotional and physical dependence on parents.

an assessment specific to safe administration of mannitol is? 1. vital signs every 4 hours 2. weighing daily 3. urine output hourly 4. level of consciousness every 4 hours

3. urine output hourly; mannitol is an osmotic diuretic and is contraindicated in the presence of inadequate renal function and heart failure b/c it increases the intravascular volume that must be filtered and excreted by the kidney

the term condylomata acuminata refers to which of these: 1. scabies 2. herpes zoster 3. venereal warts 4. cancer of the epididymis

3. venereal warts; are variably sized cauliflower like warts

the nurse is caring for a child with a complete intestinal obstruction. which is a key finding in this patient? 1. vomiting 2. intense thirst 3. visible peristaltic waves 4. nausea

3. visible peristaltic waves; the visible waves propel bowel contents towards the mouth instead of the rectum; vomiting, intense thirst, and nausea are symptoms of a small bowel obstruction, not a complete obstruction

which newborn infant would warrant immediate intervention by the nursery nurse? 1. 1 hour old who has abundant lanugo 2. 6 hour old who respirations are 52 3. 12 hour old who is turning red and crying 4. 24 hour old who has not passed meconium

4. 24 hour old who has not passed meconium; newborns are expected to pass meconium w/in 24 hours otherwise concerns of obstruction; newborn respirations are 30-60

a patient has burns to both entire legs and the perineal area. what percentage of the patient's body has been burned? 1. 36% 2. 46% 3. 18% 4. 37%

4. 37%; the rule of 9's divides the body into areas that are multiples of 9 except the perineum. each entire leg is 18%, head is 9%, trunk is 36%, perineal area is 1%

two days after a sprain accompanied by edema, the practitioner orders the application of warm compresses. what is the appropriate temperature range for the compresses? 1. 65 to 79 F 2. 80 to 92 F 3. 93 to 97 F 4. 98 to 105 F

4. 98 to 105 F; warm compresses (slightly above body temp) dilate blood vessels and decrease edema

when caring for a patient in a thyroid crisis, the nurse would question an order for: 1. IV fluid 2. propanolol (inderal) 3. prophylthioruacil 4. a hyperthermia blanket

4. a hyperthermia blanket; patient would be experiencing high temp and would not need a hyperthermia blanket

a 7 year old girl develops a UTI. the practitioner orders a sulfonamide preparation. what is a major nursing responsibility when administering this drug? 1. weigh the child daily 2. give milk with the medication 3. monitor the child's temperature frequently 4. administer the drug at prescribed times

4. administer the drug at prescribed times; to maintain the desired drug level in the blood, it has to be given at prescribed times. if the blood level falls, the organism has an opportunity to build resistance to the drug

a young child has coarctation of the aorta. what should the nurse expect when taking vitals? 1. a weak radial pulse 2. an irregular heartbeat 3. a bounding femoral pulse 4. an elevated blood pressure in the arm

4. an elevated blood pressure in the arm; coarctation (Latin - coartare - meaning to press together) - the aorta is pinched or narrowed, usually in the thoracic segment. this causes decreased blood flow below the constriction and increased blood volume above it

a patient has an AV fistula in the RUE for hemodialysis treatments. when planning care for this patient, which measure should the nurse implement to ensure patient safety? 1. use the right arm for blood pressure measurement 2. use the fistula for all venipunctures and intravenous infusions 3. ensure that small clamps are attached to the AV fistula dressing 4. assess the fistula for presence of a bruit and thrill every 4 hours

4. assess the fistula for presence of a bruit and thrill every 4 hours; AV fistulas are created by anastomosis (Greek "outlet, opening" - union or intercommunication of the vessels of one system with those of another) of an artery and a vein within the subcutaneous tissues to create access for hemodialysis. blood pressures, intravenous infusions, and venipunctures are not done on the extremity with the fistula b/c of the risk of clotting, infection, or damage to the fistula.

the client is 1 day postpartum and the nurse notes the fundus is displaced laterally to the right. which nursing intervention should be implemented first? 1. prepare to perform in and out catheterization 2. assess bladder using scanner 3. massage fundus for 2 minutes 4. assist client to bathroom

4. assist client to bathroom; #1 reason for displaced fundus is full bladder; if bladder still displaced after urinating, then massage fundus

a patient has a prescription for valproic acid (Depakote) 205mg once daily. to maximize patient's safety, which time is best to administer medication? 1. with lunch 2. with breakfast 3. before breakfast 4. at bedtime with a snack

4. at bedtime with a snack; valproic acid is an anticonvulsant that causes CNS depression. b/c of this effect on the CNS, side effects can include sedation, ataxia (poor muscle control), and confusion. administering at bedtime enhances pt safety by reducing risk of injury from sedation.

which of these is a manifestation of stage II lyme disease? 1. lethargy 2. headache 3. erythematous rash 4. cardiac dysrhythmias

4. cardiac dysrhythmias; stage II lyme disease develops within 1-3 months in most untreated individuals. the most serious problems in this stage include cardia dysrhythmias, dyspnea, neurological disorders like bell's palsy and paralysis; flulike symptoms (headache and lethargy), muscle pain, stiffness, and rash appear in stage 1.

which statement is true about cocaine? 1. cocaine is sometimes prescribed for weight control 2. cocaine can only be injected or inhaled 3. effects of cocaine lasts 1 to 8 hours 4. cocaine is occasionally used as a local anesthetic

4. cocaine is occasionally used as a local anesthetic; cocaine hydrochloride solution is sometimes used as an anesthetic before nasal surgery; cocaine's duration of action is 15 minutes to 2 hours

the nurse is caring for an infant with meningitis. by which route does the nurse understand that the bacteria responsible for the meningitis may have entered the infant's CNS? 1. genitourinary tract 2. gastrointestinal tract 3. skin or mucous membranes 4. cranial apertures or sinuses

4. cranial apertures or sinuses; infections of cranial structures can cause meningitis because bacteria travel by direct anatomic route to the meninges and CSF

which route does bacteria that causes meningitis enter the CNS? 1. genitourinary tract 2. GI tract 3. skin or mucous membranes 4. cranial apertures or sinuses

4. cranial apertures or sinuses; this route allows bacteria to directly enter the meninges and CSF

a patient with COPD has a bluish tinge around the lips. what term does the nurse chart to accurately describe this condition? 1. hypoxia 2. hypoxemia 3. dyspnea 4. cyanosis

4. cyanosis; a bluish tinge to the mucous membranes is called cyanosis; this is the most accurate b/c it is what the nurse observes; the nurse can only observe signs/symptoms of hypoxia; more info is needed to validate this conclusion

a patient is prescribed tacrolimus daily. which finding indicates that the patient may be experiencing an adverse effect of the medication? 1. hypotension 2. photophobia 3. profuse sweating 4. decrease in urine output

4. decrease in urine output; tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in patients with allogenic (Greek "allos" meaning other and "gen" meaning born) liver transplants. nephrotoxicity is indicated by increased serum creatinine level and decrease in urine output.

a patient is taking OTC glucosamine for joint stiffness and pain. when teaching, the nurse should include that the patient should reconsider taking this if the patient has: 1. osteoarthritis 2. heart disease 3. hyperthyroidism 4. diabetes mellitus

4. diabetes mellitus; the glucosamine molecule is glucose based and may be unsafe for a patient with glucose intolerance. it may also increase resistance to insulin and interfere with anti-diabetic medications

a patient is scheduled for a 6 week ECT treatment program. what intervention by the nurse is important to maintain safety of the patient during the 6 week program? 1. tyramine-free meals 2. avoidance of exposure to sun 3. maintenance of steady sodium intake 4. elimination of benzos for nighttime sedation

4. elimination of benzos for nighttime sedation; the use of these drugs can raise the seizure threshold which is counterproductive

the etiology of raynaud's disease is unknown. however, it is characterized by: 1. episodic vasospastic disorder of capillaries 2. episodic vasospastic disorder of small veins 3. episodic vasospastic disorder of aorta 4. episodic vasospastic disorder of small arteries

4. episodic vasospastic disorder of small arteries; vasospasms of the small cutaneous arteries that involve fingers and toes

which medication is instilled into the eyes of a newborn infant as a preventative measure against ophthalmia neonatorum? 1. penicillen 2. neomycin 3. vitamin k 4. erythromycin

4. erythromycin ; ophthalmia neonatorum is an eye infection acquired from passing through the birth canal. infection from these organisms can cause blindness or serious eye damage; erythromycin is effective against neisseria gonorrhoeae and chlamydia trachomatis; vitamin k is administered in an injectable form to newborn to prevent abnormal bleeding and it promotes liver formation of the clotting factors II, VII, IX, and X.

the nurse should maintain isolation of a child with the dx of bacterial meningitis: 1. for 12 hours after admission 2. until cultures are negative 3. until antibiotic therapy is completed 4. for 48 hours after antibiotic therapy begins

4. for 48 hours after antibiotic therapy begins; most children are no longer contagious after 24-48 hours of IV antibiotics

a patient with a fractured left tibia has a long leg cast and is using crutches to ambulate. which sign and symptom indicates a complication associated with crutch walking? 1. left leg discomfort 2. weak biceps brachii 3. triceps muscle spasm 4. forearm weakness

4. forearm weakness; is a probable sign of radial nerve injury caused by crutch pressure on the axillae

the nurse is caring for a patient who had clostridium welchii (c. perfringens) cultured from a wound. which disease is produced when this organism enters a wound causing crepitus? 1. tetanus 2. anthrax 3. botulism 4. gangrene

4. gangrene; clostridium welchii (c. perfringens) is a spore forming bacterium that produces a toxin that decays muscle, releasing a gas; it is one of the major causative agents for gas gangrene

what nursing action is appropriate if a patient has a potassium of 8 mEq? 1. no change is required 2. restrict intake of potassium and give sodium polystyrene sulfonate (Kayexalate) 3. restrict fluids to reduce potassium 4. give insulin, glucose, calcium, and/or bicarbonate STAT, as ordered

4. give insulin, glucose, calcium, and/or bicarbonate STAT, as ordered; option 2 would not be a fast enough option

which of these drugs would NOT be used to control teh symptoms of meniere's disease? 1. antiemetics 2. diuretics 3. antihistamines 4. glucocorticoids

4. glucocorticoids; these play no significant role in disease treatment

a thirsty patient with glomerulonephritis should be offered? 1. juice 2. ginger ale 3. milk shake 4. hard candy

4. hard candy; this will relieve thirst and increase carbs w/out supplying extra fluid

a patient is prescribed imipramine (Tofranil) 75mg TID. what nursing action is appropriate when administering this drug to a patient? 1. avoid administration of barbiturates and steroids with this drug 2. warn pt not to eat cheese or fermented products 3. observe for increased tolerance so therapeutic dose is maintained 4. have patient check for intraocular pressure and provide instructions to be alert for symptoms of glaucoma

4. have patient check for intraocular pressure and provide instructions to be alert for symptoms of glaucoma

an 18 month old is dx with intussusception. which observation indicates that pt is adequately hydrated? 1. the drainage from his ng tube is gradually decreasing 2. his iv is infusing at a prescribed rate 3. wets a diaper every 4 hours 4. his urine specific gravity is 1.012

4. his urine specific gravity is 1.012; 1 and 2 do not indicate hydration status; #3 does not indicate the amount of each voiding or hydration status

what medication would the nurse anticipate giving a patient for meniere's disease? 1. nifedipine 2. amoxicillin 3. propanolol 4. hydrochloride (hydro diuril)

4. hydrochloride (hydro diuril); this is a diuretic and helps reduce the amount of fluid that builds in the ear

a patient has a dx of chronic kidney failure and needs hemodialysis. the nurse understands that the reason hemodialysis is necessary b/c the patient now has: 1. ascites 2. acidosis 3. hypertension 4. hyperkalemia

4. hyperkalemia; protein breakdown liberates cellular potassium ions, leading to hyperkalemia, which can cause cardiac dysrhythmia. the failure of the kidneys to maintain a balance of potassium is one of the main indications for dialysis

a patient with a head injury shows signs of increasing intracranial pressure when they exhibit: 1. intermitten tachycardia 2. polydipsia 3. tachypnea 4. increased restlessness

4. increased restlessness; restlessness indicates a lack of oxygen to the brain stem which impairs the reticular activating system

which medication might be given to an infant with patent ductus arteriosus in hopes of achieving a pharmacologic closure of the defect? 1. digoxin (lanoxin) 2. prednisone 3. furosemide (lasix) 4. indomethacin (indocin)

4. indomethacin (indocin); is a "ductus arteriosus patency adjunct"; inhibits prostaglandin synthesis, decreased prostaglandin production allows the ductus to close

the nurse explains to the parents of an infant with a congenital heart defect why gavage feedings have been instituted. it is b/c: 1. vomiting is prevented 2. gavage feedings can be given quickly 3. the amount of food can be regulated 4. it conserves energy that would be expended on sucking

4. it conserves energy that would be expended on sucking; gavage feeding is preferred for weak infants (those with respiratory distress or ineffective sucking/swallowing and those that are easily fatigued; gavage - French - "to stuff" - introduction of material into the stomach via a tube

which statement said by a COPD patient at discharge indicates a need for further teaching? 1. i will rest a few minutes before i eat 2. i will not eat as much cabbage as i once did 3. i will try to drink 3 liters of fluid every day 4. it's best to eat 3 large meals a day so that i get all my nutrients

4. it's best to eat 3 large meals a day so that i get all my nutrients; large meals distend the abdomen and elevate the diaphragm which may interfere with a COPD patient's breathing; gas forming foods (ie cabbage) may cause bloating which interferes with normal diaphragmatic breathing. adequate fluid intake helps liquify pulmonary secretions

which of these is likely for a patient with acute pancreatitis? 1. constipation 2. hypertension 3. ascites 4. jaundice

4. jaundice; may be present with acute pancreatitis due to obstruction of the biliary duct

a patient has a fractured right ankle and has a short leg cast. during discharge teaching, which info should the nurse include to prevent complications? 1. trim the rough edges of the cast after it is dry 2. weight bearing on the right leg is allowed once the cast feels dry 3. expect burning and tingling sensations under the cast for 3-4 days 4. keep the right ankle elevated above the heart level with pillows for 24 hours

4. keep the right ankle elevated above the heart level with pillows for 24 hours; leg elevation reduces edema and increases venous return. edema can cause compartment syndrome; family may be taught to "petal" the cast to prevent skin irritation. if edges are not petaled and instead trimmed, pieces can fall into cast and cause skin breakdown.

a patient with parkinson's exhibits bradykinesia when they present with: 1. intentional tremor 2. paralysis of limbs 3. muscle spasm 4. lack of spontaneous movement

4. lack of spontaneous movement; this term describes the slowing down from initiation and execution of movement; kinesis means "motion"

a patient is prescribed lovastatin. the nurse determines that the patient understands the effects of the medication if the patient states the need to adhere to the periodic evaluation of which lab test? 1. bleeding times 2. creatinine levels 3. blood glucose levels 4. liver function studies

4. liver function studies; this is a HMG-CoA reductase inhibitor used to tx hyperlipidemia; the medication is converted by the liver to active metabolites and therefore is not used in patients with active hepatic disease or elevated transaminase levels

dietary tx of children with PKU includes: 1. protein free diet 2. protein enriched diet 3. phenylalanine free diet 4. low phenylalanine diet

4. low phenylalanine diet; because phenylalanine is an essential amino acid, it must be provided in quantities sufficient for promoting growth while maintaining safe blood levels; Phenylalanine occurs naturally in many protein-rich foods, such as milk, eggs and meat.

a patient is taking Levodopa for parkinson's. what should the nurse know about this drug? 1. is inadequately absorbed with meals 2. must be monitored by weekly lab tests 3. causes an initial euphoria followed by depression 4. may cause the side effect of orthostatic hypotension

4. may cause the side effect of orthostatic hypotension; Levodopa is the metabolic precursor of dopamine. it reduces sympathetic outflow by limiting vasoconstriction, which may result in orthostatic hypotension.

a patient with type 2 diabetes mellitus develops gout and is prescribed allopurinal (Zyloprim). the patient is also taking metformin (Glucophage) and an OTC NSAID. What should the nurse advise the patient to do? 1. decrease daily dose of NSAIDS 2. limit fluid intake to 1 quart per day 3. take the medication on an empty stomach 4. monitor blood glucose levels more frequently

4. monitor blood glucose levels more frequently; Zyloprim can potentiate the effect or oral hypoglycemics, causing hypoglycemia.

after a cholecystectomy, which statement would indicate that the patient understands the dietary teaching? 1. i need to eat a high protein diet for 12 months after surgery 2. i should not eat foods that upset my stomach before surgery 3. i should avoid fatty foods as long as i live 4. most people can tolerate a regular diet after this surgery

4. most people can tolerate a regular diet after this surgery; it may take 4-6 months but most people can eat anything they want

a patient that is admitted to the ED due to chest pain has serum cardiac enzyme levels drawn. the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. the nurse concludes that these results are compatible with what dx? 1. stable angina 2. unstable angina 3. prinzmetal's angina 4. new-onset myocardial infarction (MI)

4. new-onset myocardial infarction (MI); creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. levels begin to rise 3-6 hours after the onset of chest pain, peak at 24 hours, and then returns to normal in about 3 days; troponin is a regulatory protein found in striated muscle (skeletal and myocardial). troponin 1 is particularly sensitive to mycardial muscle injury; these levels would not be elevated in the case of angina

when the peak is drawn is based on the route. when should the peak be drawn after a PO medication has been given? 1. 5-10 minutes 2. 15-30 minutes 3. 30-60 minutes 4. not necessary for this route

4. not necessary for this route

of freud's developmental stages, which one occurs from 0-2 years old and involves achieving gratification through oral activities such as feeding, thumb sucking, and babbling? 1. genital 2. latency 3. anal 4. oral

4. oral

the dr orders valsartin (Diovan), an angiotensin II receptor antagonist. for which possible side effect should the nurse monitor the patient for? 1. constipation 2. hypokalemia 3. change in visual acuity 4. orthostatic hypotension

4. orthostatic hypotension; angiotensin II receptor antagonists block vasoconstrictor and aldosterone producing effects of angiotensin II at receptor sites, including vascular smooth muscle, thus reducing the blood pressure; excessive hypotension can occur

a nurse is caring for a 3 month old infant whose abdomen is distended and whose vomitus is bile stained. the nurse suspects an intestinal obstruction and should observe for? 1. high pitched cry and weak pulse 2. constant pain and absence of stools 3. irregular heart rate and hypotonicity 4. paroxysmal pain and grunting respirations

4. paroxysmal pain and grunting respirations; paroxysmal - a fit, attack or sudden increase in symptoms; paroxysmal pain is related to peristaltic action associated with intestinal obstruction; abdominal distention pushes the diaphragm upward, causing respiratory distress characterized by grunting respirations

after a vaginal delivery, what should the nurse do to prevent heat loss via conduction in the newborn? 1. wrap the newborn in a blanket 2. close the doors to the delivery room 3. dry the newborn with a warm blanket 4. place the newborn on a warm crib pad

4. place the newborn on a warm crib pad; hypothermia caused by conduction occurs when the newborn is on a cold surface like a cold pad or mattress.

which of the following complications should the nurse monitor a patient for that has acute pancreatitis? 1. myocardial infarction 2. cirrhosis 3. peptic ulcer 4. pneumonia

4. pneumonia; this patient is prone to complications associated with the respiratory system; inflammatory chemicals are released into the bloodstream and lungs can be effected; can result in ARDS

which of the following test results is a key finding in the child with cystic fibrosis? 1. chest x-ray that reveals interstitial fibrosis 2. neck x-ray showing areas of upper airway narrowing 3. lateral neck x-ray revealing an enlarged epiglottis 4. positive pilocarpine iontophoresis sweat test

4. positive pilocarpine iontophoresis sweat test; the child sweats normally but the sweat contains 2-5 times the normal levels of sodium and chloride; cystic fibrosis is caused by mutations in the CFTR gene which encodes a chloride channel located on the surface of certain epithelial cells. because the chloride channel is defective, chloride is not reabsorbed into sweat duct cells

the nurse is providing care for a patient recovering from an acute inferior myocardial infarction with recurrent angina. what instruction should the nurse provide? 1. avoid sexual intercourse for at least 4 months 2. replace sublingual nitroglycerin tablets yearly 3. participate in an exercise program that includes overhead lifting and reaching 4. recognize the adverse effects of acetylsalicylic acid (aspirin) which include tinnitus and hearing loss

4. recognize the adverse effects of acetylsalicylic acid (aspirin) which include tinnitus and hearing loss; after an acute MI many patients are instructed to take an aspirin daily. adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea; sexual intercourse usually can be resumed in 4-8 weeks if the HCP agrees and patient is able to achieve traditional parameters such as climbing two flights of steps w/out chest pain or dyspnea; new nitroglycerin tablets should be purchased every 6 months; activities that include lifting overhead should be avoided b/c they reduce cardiac output

what therapeutic effect does levodopa (L-dopa) have for a patient with parkinson's? 1. increase in acetylcholine production 2. regeneration of injured thalamic cells 3. improvement of myelination of neurons 4. replacement of the neurotransmitter in the brain

4. replacement of the neurotransmitter in the brain; Levodopa is the precursor of dopamine. it is converted to dopamine in the brain cells where it is stored until needed by axon terminals.

which nursing dx takes the highest priority postoperatively after receiving general anesthesia? 1. pain related to the surgery 2. fluid volume deficit related to fluid and blood loss from surgery 3. impaired physical mobility related to surgery 4. risk for aspiration related to anesthesia

4. risk for aspiration related to anesthesia

for a patient that is prescribed clozapine, which aspect of follow up care is important? 1. a monthly EEG 2. a cardiology consult 3. an echocardiogram 4. routine complete blood count with differential

4. routine complete blood count with differential; clozapine (Clozaril) can cause a potentially fatal blood dyscrasia (an abnormal or disordered state of the body - Greek "bad mixture") characterized by decreased white blood cells and severe neutropenia.

a patient is admitted to the BH unit after a suicide attempt. the patient is tearful and silent. which is the nurse's best initial response? 1. note the bx, record it, notify the attending physician 2. sit quietly next to the patient and wait until pt speaks 3. say, "you are crying, that means you feel badly about what you did" 4. say, "i notice you are tearful and seem sad. tell me what it's like for you and perhaps we can begin to work it out together"

4. say, "i notice you are tearful and seem sad. tell me what it's like for you and perhaps we can begin to work it out together"

a patient has a herniated lumbar intervertebral disk and is experiencing low back pain. which position is the best to minimize pain? 1. supine with knees slightly raised 2. high fowler's position with foot of the bed flat 3. semi fowler's position with foot of the bed flat 4. semi fowler's position with knees slightly raised

4. semi fowler's position with knees slightly raised; this position is also called the William's position.; keeping the foot of the bed flat will further extend the spine

which of these are excellent food sources of vitamin E and beta carotene? 1. fish and fruit jam 2. oranges and grapefruit 3. carrots and potatoes 4. spinach and mangoes

4. spinach and mangoes; sources of vitamin e include wheat germ, nuts, corn, seeds, olives, spinach, asparagus, and other green leafy vegetables; sources of beta-carotene include dark green vegetables, carrots, mangoes. and tomatoes

how should the new mother care for her baby's umbilical cord stump? 1. expect a moderate amount of drainage 2. keep the area moist with normal saline 3. apply a small sterile dressing twice per day 4. sponge-bathe the baby until the cord stump falls off

4. sponge-bathe the baby until the cord stump falls off; this is done instead of immersing the baby in a tub of water b/c the moisture will retard drying of the cord stump and will delay its falling off

which of the following antituberculosis drugs can damage the 8th cranial nerve? 1. isoniazid (INH) 2. paraoaminosalicylic acid (PAS) 3. ethambutol hydrochloride (myambutol) 4. streptomycin

4. streptomycin; is the most effective antibacterial agent for TB; can damage 8th cranial nerve due to causing ototoxicity (common side effect of aminoglycosides)

a patient with type 1 diabetes mellitus has blood work that reveals a glycosylated hemoglobin of 10%. the results indicate which finding? 1. this is a normal value that indicates pt is managing the blood glucose well 2. this is a value that doesn't offer info regarding the patient's management of the disease 3. this is a low value that indicates that patient is not managing blood glucose very well 4. this is a high value that indicates that the patient is not managing blood glucose well

4. this is a high value that indicates that the patient is not managing blood glucose well; glycosylated hemoglobin (aka a1c) is a measure of glucose control during the 6-8 weeks before the test. it is not influenced by the dietary mgmt 1-2 days before the test is done. this test should be 6% or less for a patient with diabetes mellitus.

the nurse encourages a patient with a spinal cord injury to drink fluids. this is primarily to prevent? 1. dehydration 2. skin breakdown 3. electrolyte imbalances 4. urinary tract infections

4. urinary tract infections; patients in the early stages of spinal cord damage experience an atonic bladder (characterized by absence of muscle tone, an enlarged capacity, and overflow with a large residual. this leads to urinary stasis and infection.

when calculating dosages: 1gr equals how many mg?

60mg

a patient with acute kidney failure complains of nausea, pain in the abdomen, diarrhea, weakness, and irregular pulse. the nurse concludes that the patient most likely has? 1. hyperkalemia 2. hyponatremia 3. hypouricemia 4. hypercalcemia

1. hyperkalemia; hyperkalemia occurs in kidney failure because the kidneys are damaged and cannot excrete potassium

the nurse suspects that the client has a bladder infection based on the client's exhibiting an early sign or symptom such as: chills hematuria flank pain incontinence

hematuria; chills is a later sign, flank pain is a sign of pylenophritis (infection moved to kidney) and is a later sign; incontinence is not a sign of bladder infection

a patient with arthritis asks the nurse if acetaminophen can be substituted for aspirin. the nurse explains that acetaminophen (Tylenol): 1. lacks anticoagulant action 2. has the same action as aspirin 3. lacks an antiinflammatory action 4. has more severe side effects than aspirin

3. lacks an antiinflammatory action; acetaminophen is not an NSAID; it does however decrease pain and fever

a patient is taking nitrofurantoin (Macrobid) 50mg orally every evening at home for recurrent UTI's. what instructions should the nurse give to the patient? 1. increase intake of fluids 2. strain urine for crystals and stones 3. stop the drug if urinary output increases 4. maintain the exact time schedule for taking the drug

1. increase intake of fluids; to prevent crystal formation, the patient should have sufficient fluid intake to produce a urine output of 1000-1500ml while taking this drug.

the top 3 nursing concerns after a patient has had any type of surgery?

1. infection 2. formation of thrombus/DVT/pulmonary embolism 3. hemorrhage

based on developmental norms for a 5 y/o, the nurse should hold a scheduled dose for digoxin (Lanoxin) elixir and contact the practitioner if the child's apical pulse falls below: 1. 60 bpm 2. 70 bpm 3. 90 bpm 4. 100 bpm

2. 70 bpm; the purpose of digoxin is to slow and strengthen the apical rate. the normal rate for a 5 y/o child is 70 - 110. if the rate is 10-20 below normal, administering the drug could drop the heart rate to an unsafe level

a client is suspected of having a fat soluble vitamin deficiency. to assist the client with this deficiency, the nurse informs the client that: 1. more exposure to sunlight and drinking milk could solve your nutritional problem 2. eating more pork, fish, eggs, and poultry will increase your b complex intake 3. increasing your protein intake will increase your negative nitrogen balance 4. decreasing your triglyceride levels by eating less saturated fats would be a good health intervention for you

1. more exposure to sunlight and drinking milk could solve your nutritional problem

the nurse understands which principle is associated with reabsorption of water from glomerular filtrate in the kidney tubules? 1. osmosis 2. diffusion 3. active dialysis 4. active transport

1. osmosis; osmosis occurs in the kidney tubules and all capillary beds

the labor and delivery nurse is performing a vaginal examination and assesses a prolapsed cord. which intervention should be implemented first? 1. place pt in trendelenburg position 2. ask father to leave room 3. request that the patient not push during contractions 4. prepare the patient for an emergency c section

1. place patient in trendelenburg position; nurse priority is to get pressure off the cord; gravity will assist you; pushes the fetus back into the uterus which takes pressure off the cord; a nurse will NEVER use hands to push cord back in

a 6 year old is admitted to the hospital with pneumonia. what is the priority need that must be included in the nursing plan? 1. rest 2. nutrition 3. exercise 4. elimination

1. rest; rest reduces the need for oxygen and minimizes metabolic needs during the acute febrile stage

following a head injury, the client has thin drainage coming from the left ear. the nurse describes the drainage as: 1. serous 2. purulent 3. cerebrospinal fluid 4. serosanguineous

1. serous; it is not CSF because drainage must be tested before making that assumption. if drainage tested positive for glucose or seemed to have a yellow ring that formed around it, this would be CSF

which of the following clients will most benefit from client (or parent) education regarding the prevention of renal infections via proper hygiene habits? * males ages 35-65 *males ages 3 - 16 *females ages 3-12 *females ages 20-50

*females ages 3-12; due to shorter urethra than adult female and inadequate knowledge of cleaning perineal area

what should the nurse include in a teaching plan for a patient taking calcium channel blockers like nifedipine (Procardia)? check all that apply: 1. reduce calcium intake 2. change positions slowly 3. report peripheral edema 4. expect temporary hair loss 5. avoid drinking grapefruit juice

1. change positions slowly, 2. report peripheral edema, 3. avoid drinking grapefruit juice; changing positions slowly help with orthostatic hypotension, peripheral edema can be indicative of heart failure and this should be reported, grapefruit juice affects the metabolism of calcium channel blockers

a client is admitted with acute gouty arthritis. which medication does the nurse anticipate the physician may prescribe to prevent and treat and acute attack of gout? 1. colchicine 2. hydrocortisone 3. ibuprofen (motrin) 4. probenecid (benemid)

1. colchicine; colchicine decreases the formation of lactic acid, which may promote the deposition of uric acid in the joints; is an antimitotic medication (disrupts mitosis)

which of the following would the nurse expect to see offered on a full liquid diet? 1. custard 2. pureed meats 3. soft fresh fruit 4. canned soup

1. custard

a patient who is receiving multiple medications for a myocardial infarction complains of severe nausea and has a slow and irregular heartbeat. the nurse determines that these are signs and symptoms of which medication toxicity? 1. digoxin 2. furosemide 3. lidocaine 4. morphine

1. digoxin; other signs and symptoms of toxicity include anorexia and visual disturbances.

what nursing intervention best meets a major developmental need of a newborn in the immediate postoperative behavior? 1. give a pacifier to the infant 2. put a mobile over the crib 3. provide the infant with a soft toy 4. warm the infant's formula before feeding.

1. give a pacifier to the infant; sucking meets oral needs which are primary during infancy

the nurse is evaluating a patient with osteoarthritis. which joints will likely be effected first? 1. hips and knees 2. ankles and metatarsals 3. fingers and metacarpals 4. cervical spine and shoulders

1. hips and knees; they are the joints that experience most weight bearing.

parents of an infant ask why their child is scheduled for an IM polio vaccine rather than oral. which response is best? 1. the american academy of pediatrics recommends the IM vaccine b/c it is safer 2. the consensus is that either can be used since both produce the same results 3. the oral vaccine is more expensive so IM is preferred unless it is contraindicated 4. the center for infectious disease recommends the IM vaccine unless the infant for a family member is immunocompromised

1. the american academy of pediatrics recommends the IM vaccine b/c it is safer; IM polio vaccine is recommended b/c of the danger of acquiring vaccine associated polio paralysis

a 2 year old is admitted with a tentative diagnosis of bacterial meningitis. a lumbar puncture is performed to confirm the dx. the dx is confirmed because the spinal fluid has: 1. a decreased cell count 2. an elevated protein level 3. an increased glucose level 4. a low spinal fluid pressure

2. an elevated protein level; the blood brain barrier is affected which permits the passage of protein into the CSF

which of the following tests is used most often to diagnose angina? chest x-ray echocardiogram cardiac catheterization 12 lead electrocardiogram (ECG)

12 lead electrocardiogram

the nurse working in a women's health clinic is returning phone calls. which patient should the nurse call first? 1. 16 year old patient who is complaining of severe lower abdominal cramping. 2. 23 year old primigravida patient who is complaining of blurred vision 3. 48 year old perimenopausal patient who is expelling dark red blood clots 4. 68 year old who think her uterus is falling out of her vagina

2. 27 year old primigravida experiencing blurred vision; the concern would be that this patient may be experiencing preeclampsia; usually happens after 20 weeks, more common in first pregnancy or pregnancy with twins, symptoms include high blood pressure (headache, blurred vision etc) and protein in urine.

the client is experiencing urinary retention and the healthcare provider is contacted. the nurse anticipates a medication that will be ordered to promote emptying of the bladder is: 1. oxybutynin chloride (ditropan) 2. bethanechol (urecholine) 3. propantheline (pro-banthine) 4. nystatin (mycostatin)

2. bethanechol (urecholine); this med increases the contraction of the bladder; ditropan and propantheline are anticholinergics (dry everything up) - can't see, can't pee, can't spit, can't sh*t.

the female UAP informs the nurse she has helped the 1 day postpartum pt change her peri-pad three times in the last 4 hours. which action should the nurse implement? 1. ask UAP why she was not notified earlier. 2. go to room and check patient immediately 3. instruct UAP to massage pt's uterus 4. document the finding in the patient's chart

2. go to the room and check pt immediately

when preparing a teaching plan for a patient with RA, which information should not be included? 1. ulnar drift 2. heberden's nodes 3. swan neck deformity 4. boutonniere deformity

2. heberden's nodes; these are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis

a patient with cancer is taking the plant alkaloid vincristine (Oncovin). in contrast to the usual side effects of chemotherapeutic agents, what is the most common side effect of vincristine? 1. nausea 2. alopecia 3. constipation 4. hyperuricemia

3. constipation; most chemotherapy causes diarrhea. vincristine can cause severe constipation, impaction, or paralytic ileus

as a result of a transfusion reaction, a patient develops kidney damage. what is the most significant clinical response that the nurse should assess when determining kidney damage? 1. glycosuria 2. blood in the urine 3. decreased urinary output 4. acute pain over kidney

3. decreased urinary output; diminished renal function can be evidenced by a decrease in output to less than 400ml in 24 hours.

what should the nurse do before administering a tube feeding to an infant? 1. irrigate the tube with water 2. slowly instill 10ml of formula 3. give the infant a pacifier 4. place the infant in trendelenberg position

3. give the infant a pacifier; should be given to infant during tube feeding so child associates sucking with feeding and meeting oral needs

a child is taking vincristine. what should the nurse expect the dietary plan to include to minimize side effects? 1. low in fat 2. high in iron 3. high in fluids 4. low in residue

3. high in fluids; a common side effect of vincristine is a paralytic ileus that results in constipation; preventative measures include high fiber foods and fluids that exceed minimum requirements; these will keep the stool bulky thereby promoting evacuation; used for cancer tx

a patient with adrenal insufficiency complains of weakness and dizziness, especially in the morning. the nurse understands that probably this is caused by: 1. lack of potassium 2. postural hypertension 3. a hypoglycemic reaction 4. increased extracellular fluid volume

3. a hypoglycemic reaction; deficiency of the glucocorticoids causes hypoglycemia in the patient with addison's disease; signs of hypoglycemia include nervousness, weakness, dizziness, cool moist skin, hunger, tremors

for an infant born with a unilateral cleft lip and palate, feeding will probably be: 1. limited to IV fluids 2. accomplished with a cross cut nipple 3. achieved with a rubber tipped syringe or medicine dropper 4. different from feeding an infant with a bilateral cleft lip and palate

3. achieved with a rubber tipped syringe or medicine dropper; because the infant with this condition is unable to form a vacuum for sucking, a rubber tipped syringe allows formula to flow along the side and back of mouth, minimizing danger of aspiration

the nurse is caring for a postpartum client in the "taking in" phase. which intervention is most appropriate for the nurse to implement? 1. ask the client to demonstrate how to change infant's diaper 2. determine if the client's blood is Rh-negative or Rh-positive 3. allow the client to ventilate feelings about the birth of her infant 4. discuss advantages of breastfeeding over bottle feeding

3. allow client to ventilate feelings about the birth of infant; this stage is "about the mother"; during taking in allow client to talk about her expectations/worries and herself.

the nurse is caring for a patient receiving packed RBC's. which finding leads the nurse to believe there is a transfusion reaction caused by incompatible blood? 1. dyspnea 2. cyanosis 3. backache 4. bradycardia

3. backache; mismatched blood cells are attacked by antibodies and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules resulting in backache

which action by the nurse would warrant immediate intervention by the charge nurse? 1. nurse allows volunteer to rock infant 2. nurse puts gloved finger in newborn's mouth 3. nurse performs the Ortoloni maneuver on newborn 4. nurse requests LPN to bathe newborn

3. nurse performs the Ortoloni maneuver; this can only be done by physician or nurse practitioner; procedure for checking for hip dysplasia

a mother brings in her 9 month old child to discuss the introduction of new foods. what should the nurse suggest? 1. introduce a new food after he has had his regular feeding 2. offer a new food everyday until he likes one and then offer it again 3. offer a new food after he has had some formula when he is still hungry 4. mix the pureed food with formula and have him drink it from a bottle

3. offer a new food after he has had some formula when he is still hungry; child associates this act with eating and takes advantage of the child's unsatisfied hunger

the nurse is caring for the clients in a women's clinic. which client warrants intervention by the nurse? 1. pregnant client with hematocrit and hemoglobin of 11/33 2. pregnant client with fasting blood glucose of 110 3. pregnant client with 3+ protein in urine 4. pregnant client with white blood cell count of 11,500

3. pregnant client with 3+ protein in urine (due to potential preclampsia) hematocrit and hemoglobin numbers are expected due to fluid shift in mother (hemodilutional anemia - normal in pregnancy); fasting glucose should be 70-110; if high WBC's in urine would be an issue but blood stick is okay. WBC's can go up to 25,000 right after giving birth

a major indication of illness in an infant is? 1. profuse perspiration 2. longer periods of sleep 3. rapid grunting respirations 4. crying immediately after feedings

3. rapid grunting respirations; these are signs of respiratory distress in an infant; grunting is a compensatory mechanism whereby the infant attempts to keep air in the alveoli to increase arterial oxygenation

what should the nurse do to control edema of the residual limb 1 week after a client has had an above the knee amputation? 1. administer diuretic 2. restrict oral fluids 3. rewrap the elastic bandage as necessary 4. keep the residual limb elevated on a pillow

3. rewrap the elastic bandage as necessary; elastic bandages compress the residual limb which prevents edema and promotes shrinking/molding.

a child with cystic fibrosis has been hospitalized for bacterial pneumonia. selection of the antibiotic used to tx the pneumonia is based on: 1. tolerance of the child 2. selectivity of the bacteria 3. sensitivity of the bacteria 4. preference of the practitioner

3. sensitivity of the bacteria; when the causative organism is isolated, it is tested for antimicrobial susceptibility (sensitivity) to various microbial agents; when an organism is sensitive to a medication, the medication is capable of destroying the organism

the nurse should maintain isolation of a child with bacterial meningitis: 1. for 12 hours after admission 2. until cultures are negative 3. until antibiotic therapy is completed 4. for 48 hours after antibiotic therapy begins

4. for 48 hours after antibiotic therapy begins

a child with HIV is admitted for pneumocystis jiroveci pneumonia. the provider orders trimethoprim/sulfamethoxazole (Bactrim) and pentamidine (Pentam). when administering bactrim to a child with aids, for which common side effect should the nurse monitor? 1. jaundice 2. headache 3. toxic nephrosis 4. hypersensitivity reactions

4. hypersensitivity reactions; can include skin rashes, erythema, fever, pruritis occur in much greater frequency in adults and children with aids

a patient with diabetes describes the metabolic process in diabetes in great detail while eating chocolate cake. which defense mechanism does the nurse identify that the patient is displaying? 1. projection 2. dissociation 3. displacement 4. intellectualization

4. intellectualization; when a painful emotion is avoided by means of rational explanation that removes the event from any personal significance

the charge nurse has received lab reports for patients on the postpartum unit. which patient would warrant intervention by the nurse? 1. patient with WBC count of 18,000 2. patient with serum creatinine of 0.8 3 patient with platelet count of 410,000 4. the patient whose serum glucose level is 280

4. patient with serum glucose level of 280; should be 70-110; in maternity, an increase in WBC's is expected (can go up to 25, 000 but will come down in 24-48 hours); creatinine is 0.8-1.3; platelets should be 150-450,000

a 10 year old is diagnosed with lymphocytic thyroiditis (hashimoto's disease). the nurse should explain to the parents that this condition is: 1. chronic 2. inherited 3. difficult to treat 4. probably temporary

4. probably temporary; the goiter associated with hashimoto's disease is usually transient and regresses spontaneously in 1-2 years.

a nurse is assessing an infant who had a revision of a ventriculoperitoneal shunt. what observation alerts the nurse that the intracranial pressure has increased? 1. hypoactive reflexes 2. a lower blood pressure 3. rapid pulse rate 4. tension of the anterior fontanel

4. tension of the anterior fontanel; the anterior fontanel would be widened and tense b/c of the increased volume of CSF

a nurse is preparing to ambulate a patient on the 3rd day after cardiac surgery. the nurse would plan to do this to better tolerate walking? encourage patient to cough and deep breathe premedicate the patient with an analgesic provide the patient with a walker remove telemetry equipment b/c it weighs down hospital gown

premedicate patient with analgesic; decreases the demand on heart; often morphine is used

the nurse is assessing a 78 year old female African American patient with dark skin. When assessing the skin, which source of light would be avoided due to casting a bluish hue on the skin? * natural sunlight *halogen light *fluorescent light *incandescent light

*fluorescent light

a client with degenerative arthritis needs a hip replacement. what should the nurse understand about the surgery? 1. takes place in a laminar airflow room 2. requires 3 separate stages 3. is done early in the disease process 4. is done with patient in lithotomy position

1. takes place in a laminar airflow room; reduces risk for bone infection b/c potentially contaminated air flows away from sterile field.

which medication should the nurse anticipate will be recommended for a patient with RA? 1. xanax 2. aspirin 3. codeine 4. meperidine

2. aspirin; due to its anti inflammatory effect

when caring for a patient with meningococcal meningitis, the nurse should observe for the: 1. presence of severe glossitis 2. identifying purpuric skin rash 3. low grade nature of the fever 4. constant tremors of the extremities

2. identifying purpuric rash; "purpura" = characterized by eruptions of purple patches on the skin

the incoming teeth that bud first in a 6 month old infant are the: 1. canines 2. incisors 3. upper molars 4. lower molars

2. incisors; the bottom incisors are the first to appear and this occurs at 6-8 months of age

a 3 month old infant is having difficulty breathing. which of these would alert the nurse to suspect shaken baby syndrome (SBS)? 1. birth occurred before 32 weeks gestation 2. lack of stridor and adventitious breath sounds 3. previous episodes of apnea that last 10-15 seconds 4. retractions and use of accessory muscles

2. lack of stridor and adventitious breath sounds; common sign of shaken baby syndrome is apnea without stridor or adventitious breath sounds resulting from CNS trauma

a 3 month old has been diagnosed with congenital hypothyroidism. what is the probable effect on the child's future if treatment is not begun in early infancy? 1. lifelong myxedema 2. more severe mental retardation 3. development of spastic paralysis 4. repeated episodes of thyrotoxicosis

2. more severe mental retardation; decreased thyroid hormone affects the fetus before birth during cerebral development so it is likely there will be some cognitive impairments at birth. tx before 3 months will prevent further damage.

a newborn is admitted with the dx of choanal atresia. the nurse is aware that this is an anomaly located in the: 1. anal area 2. nasopharynx 3. intestinal tract 4. laryngopharynx

2. nasopharynx; this is a lack of an opening between one or both of the nasal passages and the nasopharynx; choanal - Greek choane = meaning funnel; atresia - Greek atretos = not perforated, absence of a natural passage

which client should the postpartum nurse assess first after receiving the am shift report? 1. patient who is complaining of perineal pain when urinating 2. patient who saturated multiple peri-pads during the night 3. patient who is refusing to have infant in room 4. patient who is crying because the baby will not nurse

2. patient who saturated multiple peri-pads during the night

the nurse is caring for a client with continuous bladder irrigation. which is the most important nursing action? 1. monitor urine specific gravity 2. subtract irrigant from output to determine urine volume 3. record urine output every hour 4. include irrigating solution in a 24 hour specimen

2. subtract irrigant from output to determine urine volume

the client who delivered twins 3 days ago calls the women's clinic and tells the nurse, "i am having hip pain that makes it difficult to walk". which statement is the nurse's best response? 1. i will make you an appointment today with the HCP 2. this often occurs a few days after delivery and will go away with time 3. are you performing kegel exercises regularly? 4. the pain may decrease if you empty your bladder every 2 hours

2. this often occurs a few days after delivery and will go away with time; can takes weeks or months for ligaments and bones to shift back into pre-pregnancy stage; explain to mother that this is normal

a 3 month old infant with severe developmental dysplasia of the hip has a hip spica cast applied. to prevent a serious complication that can occur with a spica cast, the nurse should teach the parents to: 1. change diapers frequently 2. decrease the number of feedings per day 3. call the practitioner if a foul smell develops 4. avoid turning from prone to supine

3. call the provider if a foul smell develops; indicates development of infection

a viral disease that begins with malaise and a highly pruritic rash that begins on the abdomen, spreads to the face, and proximal extremities and possibly results in grave complications is: 1. rubella 2. rubeolla 3. chickenpox 4. yellow fever

3. chickenpox; secondary bacterial complications - encephalitis, pneumonia, and hemorrhagic varicella

the patient in labor is showing late decelerations on the fetal monitor. which intervention should the nurse implement first? 1. notify HCP 2. instruct pt to take slow deep breaths 3. place pt in left lateral position 4. prepare for an immediate delivery

3. place pt in left lateral position; heart rate should increase when mom is having contractions not decelerate; laying on left side increases perfusion and oxygenation.

the maintenance of fluid and electrolyte imbalance is more critical in infants and toddlers than in adults because: 1. cellular metabolism is less than in adults 2. the proportion of water in the body is less than in adults 3. renal function is immature in children until they reach school age 4. the extracellular fluid requirement per unit of body weight is greater than in adults

4. the extracellular fluid requirement per unit of body weight is greater than in adults; the extracellular body fluid represents 45% at birth, 25% at 2 years of age, and 20% at maturity.

what is the first intervention for a patient experiencing a myocardial infarction? administer morphine administer oxygen administer sublingual nitroglycerin obtain an ECG

administer oxygen

a home care nurse is making a routine visit to a patient receiving digoxin (lanoxin) in the tx of heart failure. the nurse would particularly assess the client for? thrombocytopenia and weight gain anorexia, nausea, and visual disturbances diarrhea and hypotension fatigue and muscle twitching

anorexia, nausea, visual disturbances; digoxin increases contractility of the heart causing it to pump more efficiently but it slows the heart rate; before giving digoxin apical heart rate must be taken for a full minute ; digoxin has a narrow therapeutic range 0.5 - 2. if patient reaches 2.4 or higher, patient is toxic

this is another term for the LES (lower esophageal sphincter) located at the bottom of the esophagus where it meets the stomach (esophagogastric junction)

cardiac sphincter; named due to the adjacent gastric cardia (part of stomach closest to the esophagus)

this term is used to describe an incompetent or relaxed cardiac sphincter that permits reflux of the contents of the stomach into the esophagus; mostly seen in children and infants

chalasia; achalasia is the condition where it is difficult for foods and liquid to pass from esophagus into the stomach due to nerve damage in esophagus

which of the following conditions is associated with a predictable level of pain that occurs as a result of physical or emotional stress? anxiety stable angina unstable angina variant angina

stable angina; patient knows that the chest pain is going to happen. ex. every time i garden i have chest. pain and i will have my nitroglycerin handy