Transition - NCLEX_PN - Cognitive analysing - 201 -

A client arrives at the health care clinic and tells the nurse that he has been doubling his daily dosage of bupropion hydrochloride (Wellbutrin) to help him get better faster. The nurse understands that the client is now at risk for which?

Bupropion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Bupropion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk.

The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir). The nurse should carefully monitor which laboratory result during treatment with this medication?

A common side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes. Options 1, 2, and 3 are unrelated to the use of this medication.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

A depressed, suicidal client often gives away that which is of value as a way of saying "good-bye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? Select all that apply.

A positive Chvostek's sign is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, a positive Trousseau's sign, diarrhea, seizures, hyperactive bowel sounds, and a prolonged QT interval.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L?

A serum potassium level less than 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which?

All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake.

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which?

Candidiasis is a fungal infection caused by Candida albicans. When it occurs in the mouth, it is called thrush and appears as white plaques. Although it can occur in an immunocompromised client, it is not considered to be common. Options 2 and 4 are not accurate regarding this infection.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.

Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. Some clients with COPD, especially those with a history of smoking, often have a productive cough especially on arising in the morning. The chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

The nurse is documenting information regarding a client's care into the computerized medical record. Which actions by the nurse would be most effective in ensuring client confidentiality? Select all that apply.

Computer terminals should never be left unattended after the nurse has logged on. This could allow unauthorized users to access the personal information of clients, and it represents a breach of confidentiality and security of client records. Likewise, another user should never be allowed access to one's account. Changing the password for computer entry monthly, shredding the printout of the nurse's flowchart, and using only personal user names and passwords represent actions that are acceptable ways to protect client information.

The nurse is caring for a client dying of ovarian cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing?

Denial, bargaining, anger, depression, and acceptance are recognized stages that a person experiences when facing a life-threatening illness. The client's statement is indicative of bargaining. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn. Anger may also be a first response to upsetting news, and the predominant theme is "Why me?" or the blaming of others.

Disulfiram (Antabuse) is prescribed for a client seen in the psychiatric health care clinic. The nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication

Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

Donepezil hydrochloride is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. This medication is not used to treat the disorders in options 2, 3, and 4.

The nurse should implement which in the care of a child who is having a seizure? Select all that apply.

During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option 3 is the only option that is not associated with care of the client with bulimia.

The nurse notes the appearance of skin breakdown on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure

Extravasation refers to the tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis. Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection. Phlebitis can cause the development of a clot (thrombophlebitis). Infiltration is seepage of the intravenous fluid out of the vein and into the surrounding interstitial spaces. It is a form of tissue injury, but the injury is not to the extent that occurs with extravasation

The nurse is reviewing the laboratory results of a client who has been diagnosed with multiple myeloma. Which finding should the nurse expect to note with this diagnosis?

Findings that are indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia as a result of the release of calcium from the deteriorating bone tissue, and an elevated BUN level. An increased white blood cell count may or may not be present, but this is not specifically related to multiple myeloma.

The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet. The nurse should check the latest result of which laboratory study while the client is taking this medication?

Foscarnet is toxic to the kidneys. Serum creatinine is monitored before therapy, two to three times per week during induction therapy and at least weekly during maintenance therapy. Foscarnet may also cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The client develops a temperature of 101° F. The nurse should do further monitoring of the client, knowing that this sign would most likely indicate which?

Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.

The nurse is caring for a client who has been prescribed furosemide (Lasix) and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? Select all that apply.

Furosemide is a loop diuretic; therefore, an expected effect is increased urinary frequency. Nausea is a frequent side effect, not an adverse effect. Photosensitivity is an occasional side effect. Adverse effects include tinnitus (ototoxicity), hypotension, and hypokalemia and occur as a result of sudden volume depletion.

The nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are unrelated to this medication.

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which significantly elevated result is noted?

Home History Help Calculator Study Mode Question 202 of 1306 Previous ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which significantly elevated result is noted? Rationale: Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

The nurse is caring for a postrenal transplant client taking cyclosporine (Sandimmune). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. Which is the vital sign that is most likely increased?

Hypertension can occur in a client taking cyclosporine (Sandimmune), and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which?

In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?

Increasing restlessness noted in a client is a sign that requires continuous and close monitoring, because it could be a potential indication of a complication such as hemorrhage or shock. A temperature of 98.6° F is normal. Faint bowel sounds heard in all four quadrants is a normal occurrence. A blood pressure of 120/70 mm Hg with a pulse of 90 beats per minute is a relatively normal sign.

The nurse is assisting in identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy

Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply.

Intermittent suction is applied while rotating the catheter for 10 to 15 seconds. The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter. Option 3 is incorrect because wall suction should be set to 80to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include in the plan of care regarding this medication? Select all that apply.

Ketoconazole is an antifungal medication. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic, and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

The nurse assists in developing a plan of care for the child with meningitis. Which should be the priority client problem for a child with a meningitis diagnosis?

Neurological dysfunction is the priority client care concern for the child with meningitis. Pain related to meningeal irritation may also be a concern, but it is not the priority. There are no data in the question to indicate that there are psychosocial issues.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 3 describes withdrawal from alcohol - Tachycardia, hypertension, sweating, and marked tremors Option 1 describes intoxication from hallucinogens - Dilated pupils, tachycardia, and diaphoresis Option 4 describes withdrawal from cocaine -Depressed feelings, high drug craving, fatigue, and agitation

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be assessed daily. However, options 2 and 3 are not required unless functional deficits exist. Isolating the child, option 4, is not necessary.

The client who is human immunodeficiency virus seropositive has been taking stavudine (d4t, Zerit). Which should the nurse monitor closely while the client is taking this medication?

Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to the use of this medication.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased. Hospitalization may actually lessen these symptoms in the depressed client because a feeling of hope or relief may occur once treatment begins. Dealing with pertinent issues may be traumatic, but this is not the best interpretation of the behavior. Time off the unit for this client could put the client at risk for injury.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

A client who is receiving total parenteral nutrition (TPN) complains of a headache. The nurse notes that the client has an increased blood pressure and a bounding pulse. The nurse reports the findings, knowing that these signs/symptoms are indicative of which complication of this therapy?

The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. A fever would be present in a client with sepsis. Signs and symptoms of an air embolus include confusion, pallor, lightheadedness, tachycardia, tachypnea, hypotension, anxiety, and unresponsiveness. Polyuria, polydipsia, and polyphagia are manifestations of hyperglycemia.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the data obtained, the nurse should identify which as a priority concern?

The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormones and providing measures to support the signs and symptoms related to a decreased metabolism. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. The client often has cold intolerance and requires a warm environment. The client would notify the health care provider if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. Iodine preparations are used to treat hyperthyroidism. These medications decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone.

Which finding would indicate that a child had a tonic-clonic seizure during the night?

The complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue. Seizures do not cause a high-pitched cry unless a tumor or intracranial pressure is the cause of the seizure diagnosis. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanching does not occur. Migraine headaches are not common in children with seizures.

The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply

The gentamicin, theophylline, and carbamazepine levels are within the normal therapeutic range; all other results are abnormal (too high). Therapeutic medication levels include the following: gentamicin, 5 to 10 mcg/mL; tobramycin 5 to 10 mcg/mL; digoxin (Lanoxin), 0.5 to 2 ng/mL; phenytoin (Dilantin), 10 to 20 mcg/mL; theophylline, 10 to 20 mcg/mL; and carbamazepine (Tegretol), 5 to 12 mcg/mL.

The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention?

The major elements of care for a child who has Reye's syndrome are to maintain effective cerebral perfusion and to control intracranial pressure. Decreasing stimuli in the environment should decrease the stress on the cerebral tissue and the neuron responses. Cerebral edema is a progressive part of this disease process. Checking pupillary responses and output are part of assessment but not the priority. Changing the body position every 2 hours is important but would not directly affect the cerebral edema and intracranial pressure. The child should be in a head-elevated position to decrease the progression of the cerebral edema and to promote the drainage of cerebrospinal fluid.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

The most common adverse effects related to fluoxetine include central nervous system (CNS) and gastrointestinal (GI) system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea. Options 1, 3, and 4 are not adverse effects of this medication.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level?

The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.6 mg/dL is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability and hyperactive reflexes should be noted in a client with hypomagnesemia.

An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best response if the level changes to which after medication administration?

The normal serum ammonia level is 10 to 80 mcg/dL. In the client with hepatic encephalopathy, the serum level is not likely to drop below normal. The most optimal yet realistic change from the options provided would be to 70 mcg/dL, which falls in the normal range. A level of 100 mcg/dL represents an insufficient effect of the medication. Lactulose is administered for its hyperosmotic laxative effect, thus removing ammonia from the colon. The client should also be monitored for hypokalemia resulting from the severe purging lactulose causes.

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL?

The normal serum phosphorus level is 2.7 to 4.5 mg/dL, so a value of 2.0 mg/dL is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

The nurse should teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include avoiding swimming and using caution when showering, avoiding exposure to people with infections, preventing debris from entering the stoma, and obtaining a Medic-Alert bracelet. Additional interventions include wearing a stoma guard or high-collar clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which?

The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

Diphenhydramine hydrochloride (Benadryl), 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. Which conclusion should the nurse infer?

Use the formula for calculating a safe dosage range.Safe dose parameter:5 mg/kg/day × 25 kg = 125 mg/dayDosage frequency:25 mg × 4 doses (every 6 hours) = 100 mg/dayThe dose is within the safe dosage range.

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.

Wound dehiscence is the separation of the wound edges, and wound evisceration is the protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the registered nurse is notified, and he or she then contacts the surgeon immediately. The client is placed in a low-Fowler's position, kept quiet, and instructed not to cough. Protruding organs are covered with a sterile, saline dressing. Ice packs are not applied. The treatment for evisceration is immediate wound closure under local or general anesthesia.

A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia?

β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Option 4 is the most reliable indicator of hypoglycemia.