NCLEX

A nurse is planning to administer a nicotine transdermal patch (Nicoderm) to a female client who is trying to stop smoking. Which of the following actions should the nurse plan to include? Remove the old patch after applying the new one. Wear sterile gloves when applying the patch. Date, time, and initial the patch before applying it. Apply the patch to the client's breast.

Always date, time, and initial the transdermal medication patch prior to application on the client. Pressure of the writing pen can cause discomfort and increase release of the medication. The nurse should not ever apply a patch with estrogen or nicotine to the breasts of a female client. It is not neccesary to wear sterile gloves, but clean gloves are important to protect nurse from exposure to the medication. Always remove the existing patch BEFORE applying a new one to prevent medication overdose.

A nurse in a community clinic is assessing a client who reports uncontrolled vomiting and diarrhea for the past three days. Which of the following findings should the nurse expect? (SATA) Pale yellow urine hypotension poor skin turgor furrowed tongue bradycardia

Hypotension is correct. This seems to be dehydration, which manifests as hypotesnsion, particularly postural hypotension. Poor skin turgor is correct, in dehydration skin turgor lacks elasticity. Furrowed tongue is correct. Dehydration manifests as longitudinal tongue furrows Bradycardia is incorrect. Patient would have tachycardia. Pale yellow urine is incorrect. Patient would have dark, concentrated urine.

A nurse is reinforcing teaching for a client who is about to start therapy with alendronate (Fosamax) to treat osteoporosis. Which of the following adverse effects should the nurse remind the client to report? (SATA) Jaw Pain Tinnitus Dysphagia Drowsiness Blurred Vision

Jaw pain is correct. Alendronate can cause osteonecrosis of the jaw. Blurred vision is correct. Alendronate can cause ocular inflammation. Dysphagia is correct. It can cause esophagitis. Tinnitus is incorrect. Salicylate toxiticty is a common cause of tinnitus. Drowsiness is incorrect. It is unlikely to cause drowsiness, but can cause headache.

A nurse is caring for a client who received morphine sulfate 30 min ago. Which of the following best determines therapeutic client response to this medication? Improved output with decreased peripheral edema No nausea with good appetite0 rating on pain scale Stable vital signs

Morphine is an opioid anagesic used to treat moderate ot severe pain. Most reduce pain by centrally blocking neurotransmitters in the spinal cord, altering response to pain. Nurses should monitor the effectiveness of analgesic medications 30-60 min after administration. The best indicator that the analgesic is effective is the client's interpretation of pain relief and verbalization that pain is at an acceptable level. Improve output with decreased peripheral edema is expected of diuretics. No nausea with good appetite is for antiemetics.

A 46 year old African American man is in an outpatient clinic for a physical exam. He has a BP of 124/82, a BMI of 24, and reports no previous medical problems. Which of the following should the nurse anticipate doing for this client? Schedule the next client appt for one year from now. Provide information on ways to reduce the risk factors of HTN. Provide information for a weight loss plan that includes physical activity. Schedule an appointment for a prostate-specific antigen test.

Provide info on ways to reduce HTN risks. African americans in the US have some of the highest rates of HTN in the world. The client is considered to have prehypertension, which is any systolic of 120-139 and a diastolic of 80-89. A BMI of 24 is considered to be of normal weight. 25-29.9 is considered overweight. Anything 30 and higher is obese. The PSA is recommended to start at age 50 for men.

On auscultation of a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following is the appropriate nursing intervention? Repeat auscultation after asking the client to breathe deeply and cough Place the client on bedrest in semi-Fowlers position. Instruct the client to limit fluid intake to less than 2,000 ml/day. Prepare to administer antibiotics

Repeat after asking client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also develop from hypoventilation. They sometimes clear after a deep breath or a cough. Although semi-Fowler's position can help ease breathing, it wont resolve crackles. It is premature to impose fluid restrictions. It is premature to assume that infection is the cause yet.

A nurse is reinforcing teaching for a client who is about to start therapy with methotrexate (Rheumatrex) to treat rheumatoid arthritis. Which of the following instructions should the nurse review with the client? (SATA) Avoid people who have infections. Report unexplained bruising to the provider. Take ascorbic acid to help minimize side effects. Expect to feel the effects immediately. Do not drink alcoholic beverages.

Report unexplained bruising is correct. Methotrexate can cause thrombocytopenia, and bruising or petichiae can indicate a low platelet count. Avoid people who have infections is correct, methotrexate causes bone marrow suppresion and increases risk for infection. No alcoholic beverages is correct. Alcohol ingestion can increase the risk of liver damage. Ascorbic acid is incorrect. If anything, providers can prescribe folic acid to help minimize side effects. It may take 4-6 weeks to achieve the drugs therapeutic effects.

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (SATA) Urinary incontinence Diarrhea Bradypnea Orthostatic hypotension Nausea

Respiratory depression, which causes respiratory rates to drop dangerously low, is a common adverse effect of opioid analgesics. Dizziness or lightheadedness when changing positions is a common adverse effect. Nausea and vomiting are common adverse effects. Constipation, not diarrhea, is a common adverse effect of opioid analgesia. Urinary retention, not urinary incontinence, is a common adverse effect.

The nurse is caring for a group of clients. What nursing infection control intervention must be implemented? Protective isolation techniques. Contact precautions Needle precautions only Standard precautions

Standard precautions should be used when caring for all clients, including those with AIDS.Contact precautions are only required for specific clients, such as clients with conditions that can be transmitted on contact. Protective isolation is only for immunocompromised clients.

A nurse is contributing to the plan of care for a client who has meningitis and is at risk for increased ICP. Which of the following should the nurse recommend? (SATA) Implement seizure precautions Perform neurological checks 4x a day Administer morphine for the report of neck and generalized pain Turn off room lights and TV Monitor for impaired extraocular movements Encourage the client to cough frequently

The client is at risk for seizures due to possible increased ICP. The nurse should turn off the room lights and TV because they can cause a seizure when a client is at risk for increased ICP. The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP. The nurse should perform neurological checks more frequently due to the risk of increased ICP. The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in a clients LOC. The nurse should instruct the client to avoid coughing, this can increase ICP.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the LEAST likely risk of the development of third-spacing? The client with sepsis The client with cirrhosis The client with kidney failure The client with diabetes mellitus

The client with DM. Fluid that shifts into interstitial space and remains is called third-spacing. Common sites for third-spacing are the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsoprtion syndrome, malnutrition, alcoholism, and older age.

The nurse is reading the primary health care provider's progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? The client with a draining wound. The client with a urinary catheter. The client with a fast respiratory rate. The client with a NG tube to low suction.

The client with a fast RR. Sensible losses are those that the person is aware of, such as wound drainage, GI trach losses, and urinatino. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

A nurse is caring for a client who is postprocedure following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse apply? (SATA) Use the Glasgow Coma Scale to evaluate the client Assist the client to a supine position Administer an opioid medication Encourage the client to increase fluid intake Remove the bandage on the client's puncture site.

The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. The nurse should administer an opioid medication for a client's report of headache pain. The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. The GCS is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. Leaking CSF can cause a headache following a lumbar puncture. The client will have a patch to seal the puncture site if the headache doesn't resolve.

A nurse is preparing to administer heparin to a client via the deep subcutaneous route. Which of the following is an appropriate action for administering this medication? Inject the medication into the abdomen above the level of the iliac crest. Use a 220gauge needle to inject the medication. Massage the injection site after administration. Use a 1-inch needle to inject the medication

The nurse should inject the medication into the abdomen above the level of the iliac crest. The nurse should use a small needle, 25 or 26-gauge, when adminsitering a deep subcutaneous injection. The nurse should apply firm presssure without msassage to the site for 1-2 min after administration. Massaging the area after injecting heparin can cause bleeding. The nurse should use a short needle, 1/2 to 5/8-inh when administering a deep subcutaneous injection.

A nurse is reinforcing teaching with a client who is to undergo an EEG the next day. Which of the following information should the nurse include in the teaching? "Do not wash your hair the morning of the procedure." "Try to stay awake most of the night prior to the procedure." "The procedure will take approximately 15 minutes" "You will need to lie flat for 4 hours after the procedure."

The nurse should instruct the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. The client should wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the readings. The procedure will take 45 minutes to two hours. The client can resume normal activity immediately after the procedure.

A nurse is checking for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take? (SATA) Place client in supine position Flex client's hip and knee. Place hands behind the client's neck Bend client's head toward chest Straighten the client's flexed leg at the knee

The nurse should place the client in supine position. She should place her hands behind the client's neck when checking for Brudzinski's sign to flex the neck. She should bend the client's head toward the chest. The nurse should flex the hip and knee and straighten it for Kernig's sign.

A nurse is reviewing the plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (SATA) "I think I might be pregnant." "I take warfarin." "I take antihypertensive medication." "I am allergic to shrimp." "I ate a light breakfast this morning."

The nurse should report the possible pregnancy because the contrast dye can place the fetus at risk. She should report the client is taking warfarin due to the potential for bleeding following the angiography. She should report an allergy to shrimp, which is shellfish, because of a potential allergic reaction to the contrast dye. She should report the intake of food because the client should remain NPO for 8-12 hours prior. There is no contraindication related to contrast dye for a client taking antihypertensive medication.

The nurse is preparing a medication and observes the date of expiration on the vial occurred two months ago. Which action should the nurse perform? Return the medication to the pharmacy Notify the provider Discard the medication Give the medication

The nurse should return the medication to the pharmacy.

A nurse is preparing to administer lisinopril (Prinivil). Which of the following findings should be reported to the provider immediately? Rash and impaired sense of taste Low urine output and WBC count Swelling of the tongue and oral pharynx Decreased BP and pulse rate

The nurse should withhold the medication and notify provider immediately if the client reports swelling of the tongue or threat. Known as angioedema, ACE inhibitors can cause this potentially fatal reaction that develops in 1% of aptients. Symptoms include giant wheals and edema of the tongue, glottis, and pharynx. Severe reactions should be treated with subcutaneous epinephrine. ACE inhibitor should be discontinued and never used again. The nurse should withhold the ACE inhibitor if the client's BP is too low and instruct the client to change positions slowly. Lisinopril will not affect the client's pulse rate; beta-blockers lower the pulse rate. It is common for the client to experience orthostatic hypotension after recieving the first dose.

A nurse is talking to an older adult client's caregiver who is interested in respite care. The nurse explains that the purpose of a respite care program is to provide restorative care palliative care temporary care pain management

The purpose of respite care is to give family members temporary relief from the stress they may experience while providing care for a family members.

A provider prescribes fluoxetine (Prozac) for a client who reports frequent periods of extreme sadness. The nurse reinforcing teaching with the client knows he understands how to take this medication when he says what? "I should not take this medicine with grapefruit juice." "I'll take this medicine first thing in the morning." "I'll take this medicine at bedtime." "I'll take this medicine with food."

The usual recommendation is to take fluoxetine as a single dose in the morning. If taken at night it can cause insomnia. The drug can be taken with or without food. Grapefruit juice can interfere with metabolism of many drugs, but not fluoxetine.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5. The nurse understand that a potassium value at this level would be noted with which condition? Diarrhea Traumatic burn Cushing's syndrome Overuse of laxatives

Traumatic burn. A serum potassium level that exceeds 5.0 is hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (truma, burns, sepsis, or metabolic/respiratory acidosis) are at risk for hyperkalemia. All of the other choices are at risk for hypokalemia.

A nurse is caring for a client. The client states, "I don't want to take my medication." Which of the following actions should the nurse take? Tell the client the physician wants the client to take the medicine. Ask the client why he refuses to take the medicine. Document that the client refuses the medication. Explain the purpose for the medication.

Document that the client refuses. It is appropriate for the nurse to document the client's wishes.

A nurse is caring for a client who has thrombophlebitis and has been placed on IV heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses by the nurse is appropriate? "The time it takes for heparin to dissolve the clot depends on the size of the clot." "It usually takes at least two to three days." "The time it takes heparin to dissolve clots varies between clients." "Heparin prevents new clots from forming rather than dissolving established clots."

Heparin is given to prevent the formation of enw clots by blocking the conversion of prothrombin to thrombin and fibrinogen tofibrin. It does not dissolve established clots.

A nurse is evaluating the pain level of a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is determining which of the following components of pain assessment? Presence of associated manifestations Location of the pain Pain Quality Aggravating and relieving factors

Nausea and vomiting are common manifestations clients have when in pain. The location of the pain is where the client feels the pain. Pain quality is what the pain feels like, such as throbbing or dull. Aggravating and relieving factors are what might make the pain better or worse.

A provider prescribes cyclobenzaprine (Flexeril) for a client who has a fractured ulna. When the client asks the nurse what this medication is supposed to do, the nurse should explain that cyclobenzaprine will relieve muscle spasms relieve pain reduce itching kill microorganisms

Nurse should explain that the provider prescribed cyclobenzaprine to relieve muscle spasms that can accompany pain of fractures. Cyclobenzaprine is not an analgesic nor an antimicrobial. Cyclobenzaprine does not relieve itching; in fact, it can cause pruritus.

A nurse who is reinforcing teaching for a client who is about to start taking docusate (Colace) should make sure that the client understands that this medication should result in less diarrhea. regular bowel movements. relief from nausea. fewer bowel movements.

Regular bowerl movements. The intended outcome of docusate therapy is to produce stool that is softer in consistency and easier for the client to pass. That should improve the regularity of the clients BMs. The medication does not treat diarrhea and nausea; in fact, it can cause it.

A nurse is receiving shift report about assigned clients. Which of the following activities should the nurse plan to attend to first? Notify the provider about a medication error. Check the lab findings of a preop client scheduled for surgery later in the shift. Suction the tracheostomy of a client who has copious secretions. Reinsert an IV catheter that was removed due to infiltration.

Suction the tracheostomy. Use the ABC approach to client care.

A nurse is caring for a client who is one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as a personal protection equipment? Administering an IM injection Administering an IV piggyback medication Talking to the client at the bedside Completing a dressing change

While performing a dressing change on a client who is HIV positive, the nurse should wear appropriate personal protective equipment, which inculdes a gown.

A nurse is reinforcing teaching to a client with a history of falls about home safety. Which of the following statements by the client indicates an understanding of the teaching? "I will place a bath seat in my shower to use when I bathe." "I will keep my walker at the end of my bed." "I will keep the fluorescent ceiling light on in my room at night." "I will place an area rug at the entry of my bathroom."

A bath seat indicates understanding. An increased incidence of falls is caused by inappropriate use of assistive devices. The client should keep her walker at the side of the bed. Fluorescent lighting increases eye strain and glare, and should not be left on at night as it can interfere with the 24-hr dark-light cycle. Area rugs result in increased incidence of falls.

While auscultating a client's breath sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? An expected heart sound. A cardiac murmur. A third heart sound A fourth heart sound.

Cardiac murmurs are relatively loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. Turbulence between heart sounds is not an expected finding. S3 is an extra heart sound, is low pitched, ends in early diastole, and is similar to the sound of a gallop. S4 is an extra heart sound, is low pitched, ends in late diastole, and is similar to the sound of a gallop.

A nurse is caring for a client on bedrest. Which of the following is the priority action to include in the client's plan of care? Apply antiembolic stockings Change client's position every 2 hr Perform ROM exercises 2-3 times daily Encourage client to consume 2000 mL of fluids per day.

Change client's position every 2 hr. Relieves pressure on the skin and prevents pressure ulcer formation. Application of antiembolic stockings prevents venous stasis, but it is not priority. Encouraging 2000 mL of fluid promotes circulation and skin hydration, but it is not priority. Performing ROM reduces muscle atrphy and joint contractures, but is not priority.

A nurse is administering morning medications and realizes that nifedipine (Procardia) was administered to the wrong client. Which of the following is the priority nursing action? Fill out an occurrence form according to policy. Check the client's vital signs. Administer the medication to the correct client. Notify the client's charge nurse.

Check vitals. Nifedipine is an antihypertensive medication. The nurse should immediately check the client's vitals for any significant alterations and then notify the HCP. Completing an occurence form is an action the nurse should take but is not priority. Administering the med to the correct client is an action that should be taken but is not priority.

A client provides a nurse with a list of home medications. Which of the following should the nurse recognize as incompatible? Furosemide (Lasix) and digoxin (Lanoxin) Alprazolam (Xanax) and zolpidem (Ambien) Gentamicin sulfate (Garamycin) and fluconazole (Diflucan) Warfarin sodium (Coumadin) and multivitamins

Coumadin and multivitamins are considered incompatible. Warfarin sodium is classified as an anticoagulant used for prophylaxsis and treatment of DVT, PE, and atril fibrillation. Multivitamins contain fat-soluble vitamins A, D, E, and K. Vitamin K is the antidote for overdosage of warfarin sodium. Lasix and Lanoxin are compatible. Lasix is a loop diuretic used in treatment of edema with CHF, cirrhosis of the liver, kidney disease, and HTN. Lanoxin increases contractility of the heart and has antiarrhythmic properties. It is important to monitor potassium level in a client on these two medications because Lasix is not potassium sparing, so if potassium is out of normal range, the cardiac muscle can become irritable.

A nursing unit is notified that IV pumps available for use are limited due to a high census in the hospital. The nurse should use one of the available pumps for which of the following clients receiving IV therapy? A client who has a fractured left femur who is receiving lactated Ringer's solution IV. A client who has DKA who is receiving insulin. A client who has bronchial pneumonia who is receiving Ceftin IV. A client who has acute alcohol withdrawal and is receiving thiamine IV.

DKA receiving insuling. It needs a pump because insulin must be closely monitored during administration. None of the rest need an IV pump.

A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4. What should the nurse look on the cardiac monitor as a result of this laboratory value? ST elevation Peaked P waves Prominent U waves Narrow, peaked T waves

A serum potassium level of 5.4 is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? Check the pedal pulses and feet for edema. Ask the client to push their feet against the nurse's palms. Ask the client If they have been up today. Ask the client how strong they feel today.

Asking the client to push with the feet against the nurses hands is appropriate to determine the client's level of strength. Checking pedal pulses and feet for edema is appropriate for ealuation of the CV system. Even if the client has been up today, it does not guarantee the ability to get out of bed on his own again. Asking the client how strong he feels is not a reliable method for assessing strength.

An older adult client's provider prescribes aspirin 650 mg/q6h PO to treat rheumatoid arthritis. The nurse should reinforce with the client that a possible adverse effect of aspirin therapy is insomnia blurred vision constipation bleeding

Aspirin can cause bleeding, tinnitus, gastric ulceration, nausea, and heartburn. Aspirin is more likely to cause diarrhea than constipation. Aspirin is more likely to cause hearing loss than blurred vision. Aspirin is more likely to cause drowsiness than insomnia.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? Position the client in left lateral Trendelenburg. Request an order for ABGs. Initiate oxygen therapy. Clamp the catheter.

Clamp the catheter is the first action the nurse should take to prevent additional air from entering the central venous system. Initiating oxygen therapy is an important actionl however, to prevent further injury to the client, clamping should come first. Requesting ABGs is important, but clamping is priority. Placing the client in left lateral trendelenburg is important but not priority.

A nurse is caring for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse recommend for inclusion in the plan of care? Massage reddened areas with dressing changes. Cleanse with povidone-iodine solution. Apply a heat lamp twice a day. Cleanse with saline solution.

Isotonic saline solution, a nonionic agent, is used to prevent disruption of tissue healing. Moisture promotes improved healing so heat lamp therapy is not appropriate. Povidone-iodine solution is a drying agent and does not promote healing of fragile skin. Massage is avoided because it damages fragile capillaries and increases tissue necrosis.

A nurse is reinforcing discharge instructions for a client who has asthma and is about to start taking theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse reactions? Constipation Oliguria Tachycardia Drowsiness

Tachycardia. Theophylline can increase cardiac stimulation. Theophylline is more likely to cause urinary frequency than oliguria. Theophylline is more likely to cause diarrhea than constipation. Theophylline is more likely to cause insomnia than drowsiness.

A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following clinical manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect? Tachypnea Constipation Hypothermia Seizures

Constipation. Mydriatic eye drops can cause systemic anticholinergic effects, such as constipationm dry mouth, photophobia, and tachycardia. These eye drops are more likely to causer respiratory depression than tachypnea. Mydriatic eye drops are more likely to cause fever than hypothermia. They are unlikely to cause seizures, although they can cause delirium and coma.

A nurse is reinforcing teaching with a client who is scheduled for a CT scan with contrast. Which of the following statements by the client indicates understanding of the teaching? "I should not have caffeine 48 hr before my procedure" "I will have my kidney function checked before the test" "I should tape my wedding band in place before the procedure" "I will have my brain activity monitored during the test"

Contrast media used for the CT is excreted by the kidneys. The nurse should check kidney function prior to the CT to prevent harm. Stimulants like caffeine should be withheld 24-48 hours before an EEG. The client should be NPO 3-4 hours prior to a CT scan. The client should remove all forms of metal before the procedure. An EEG monitors brain activity.

A nurse is preparing to administer IV therapy to a client who is compromised. Which of the following are clinical manifestations of left-sided heart failure? (SATA) Dyspnea Orthopnea GI bloating Jugular vein distention Paroxysmal nocturnal dyspnea

Dyspnea is correct. Orthopnea is correct. Paroxysmal nocturnal dyspnea is correct. GI bloating is a manifestation of right-sided heart failure, and same with jugular vein distention.

A nurse is talking with a client who is about to receive a one-time dose of diazepam (Valium). Which of the following information should the nurse be sure to give the client? Grapefruit juice inactivates this medication. A single dose of diazepam is unlikely to cause side effects. It is important to avoid foods that contain tyramine. Diazepam can cause drowsiness.

It can cause drowsiness. Valium has sedative properties, so the client should not engage in potentially hazardous activities after recieving diazepam. Clients who take MAOIs must avoid foods that contain tyramine. Virtually every medication can cause side effects, even after only one dose. Althoughgrapefruit juice can affect the metabolism of many medications, generally raising their blood levels, diazepam is not among them.

A nurse is contributing to the plan of care for a client who has bacterial meningitis. Which of the following interventions should be included? (SATA) Monitor for hypotension. Provide an emesis basin at bedside. Administer antipyretics. Perform a skin assessment, Keep head of bed flat.

The nurse should provide an emesis basin at bedside, meningitis causes nausea and vomiting. The nurse should plan to administer antipyretics for fever. The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis. The nurse should elevate the head of the bed to 30* to promote venous drainage from the head and prevent increased ICP. The nurse should plan to monitor for hypertension when a client has meningitis.

A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse incorporate? Collect urine from the catheter port Instruct the client to clean from front to back with an antiseptic solution Ensure only sterile water is used to inflate the balloon Use a sterile specimen container

Use a sterile specimen container. A culture attempts to identify micro-organisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against them. A catheter urine specimen for culture and sensitivity requires a sterile specimen from a stright ir indwelling catheter using sterile technique.A minimum of 3 mL of urine is neccesary. A straight catheter has a single lumen for draining urine directly from the bladder into a sterile collection container. It does not remain in the bladder and would not have a second lumer for sterile water to be inserted into a balloon. A client would clean front to back while obtaining a clean-catch midstream specimen.

A nurse is caring for a client who reports daily use of acetaminophen (Tylenol) to manage mild knee pain. Which of the following statements by the client should be of most concern? "I have a glass of wine before bedtime each evening." "I take two regular-strength tablets in the morning and two in the evening." "I have my blood checked often due to the heparin I am taking." "I take three to four Vicodin ES tablets a day for severe knee and joint pain."

Vicodin ES is a combination analgesic that contains 650 mg of acetaminophen in each tablet. If the client took three of these tablets, that would be 1950 mg of Tylenol and four tablets would be 2600 mg. Clients shoud check the amount of acetaminophen in OTC products to be sure not to exceed the damily maximum dose if they are taking other acetaminophen products. This option creates the highest potential for acetaminophen overdose. In the event of an overdose, administer the antidote for acetaminophen, which is acetylcysteine (Mucomyst). Clients taking heparin should not take other medications that depress platelet aggregation such as aspirin. One glass of wine each night is not considered to be excessive, but any alicent who consumes alcohol regularly should avoid high doses of acetaminophen.

A nurse is caring for a client who receives digoxin (Lanoxin). Before administering this medication, which of the following actions should the nurse take? Offer the client a light snack. Measure the client's BP. Measure the client's apical pulse. Weight the client.

Digoxin decreases heart rate, so the nurse should count the apical puse for at least 1 min before administering it. The nuse should withhold the medication if the client's heart rate is below 60/min. It is not neccesary to measure the BP immediately before dosing, although the nurse should monitor the client's blood pressure routinely. Same with BP. The client can take the medication with or without food, although giving it immediately after food can slight delay absorption.

A nurse is reinforcing teaching for a client who takes pain medication and was recently prescribed docusate sodium (Colace). Which of the following statements indicates the client understands the information? "I am to have 1-2 soft stools each day." "I will take the medication for diarrhea." "I drink 4 ounces of water when I take the medication." "I may occasionally take with mineral oil.

Docusate sodium is a stool softener and therapeutic effect is achieved when having 1-2 soft stools each day. It is not used to treat diarrhea. The client should drink 8 ounces of water when the medication is administered. If taken with mineral oil, the patient will have increased systemic absorptions.

A nurse is collecting data from a client who reports sever headache and a stiff neck. Data collection reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? Administer antibiotics Implement droplet precautions Obtain IV access Decrease bright lights

Droplet precautions. The client is exhibiting manifestations of possible meningitis. When using the urgent vs nonurgent approach, the nurse determines the priority action is to initiate droplet precautions to prevent the spread of the disease. All other answer choices should be implemented, but they are not priority.

A nurse is assisting a client who is postoperative with ambulation. While ambulating with the nurse, the client feels faint and starts to fall. Which of the following is an appropriate action by the nurse? Push the client up against the wall to prevent a fall. Ease the client gently to the floor. Hold the client upright until another nurse can provide a wheelchair. Grasp the client around the waist to prevent a fall.

Ease the client to the floor. It protects the nurse and client from injury. Pushing the client against the wall may cause injury to the client. Attempting to hold a client upright who is fainting places the nurse at risk for injury. Grasping the client around the waist may result in both the client and nurse falling.

A nurse is caring for an older client who has several medications prescribed and expresses reluctance to take them because of difficulty swallowing. Which strategy should the nurse use for this client? Disguise the meds by placing them in meat. Crush the meds and mix them with soft foods. Place the client in semi-Fowler's position. Request that injectable meds be prescribed.

Crush the medications and mix them with soft foods. This makes them easier to swallow. Ice cream, pudding, and applesauce mask the taste. Meats are often the most difficult food to ingest, this action could be dangerous as the client could aspirate. Sitting upright is recommended for clients with difficulty swallowing. Requesting injections is not a realistic long term solution.

A nurse is reinforcing teaching with a client whose medication was changed from metoprolol (Lopressor) to metoprolol/hydrochlorothiazide. (Lopressor HCT). Which of the following statements by the client indicates understanding of the teaching? "Now I will not have to diet to lose weight." "With the new medication, I should experience fewer side effects." "I will not have to do anything different because it is the same medication." "The extra letters after the name of medication means it is a stronger dose."

Fewer side effects. When used in combination with thiazide diuretics, a lower dose of the beta-blocker can be used, because beta-blockers have fewer side effects in lower dosages. This diuretic requires an increase in potassium in the diet. HCTZ is a diuretic, and the loos of fluid will reuslt in weight loss. But, the client should weigh daily and watch for weight loss. IT is a change in fluid rather than a loss of fat. Continuation of the recommended diet for control of BP is neccessary.

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? "I'll wait to use the device until it's absolutely necessary." "I'll be careful about pushing the button so I don't get an overdose." "I should tell the nurse if the pain doesn't stop after I use the device." "I will ask my son to push the dose button when I am sleeping."

He should tell the nurse if the pain doesn't stop. If the client is not achieving adequate pain control, the nurse will reevaluate the pain management plan. The client is the only one who should operate the PCA pump. The client may use the device when he begins to feel pain. It will help prevent unnecessary worsening of the pain and more doses of analgesia to provide pain relief. A feature of PCA devices is the timing control or lockout mechanism, which enforces a preset minimum interval between medication doses. This feature prevents overdose.

A nurse is talking with a group of young women about the use of oral contraceptives. The nurse should point out that taking which of the following herbal preparations reduces the effectiveness of this birth control method? Gingko biloba St. John's wort Black cohosh Ginseng

St. John's wort, which can help depression, decreases the effectiveness of oral contraceptives. Black cohosh can interfere with medications that promote fertility, but not with oral contraceptives. Ginseng can incease the hypoglycemic effects of some antidiabetes medications. Gingko biloba can interact with proton pump inhibitors.

A nurse provides enteral tube feeding teaching to a client. Which of the following statements indicates a need for further teaching? "The residual will be checked before each feeding." "The placement of the tube will be verified before each use." "The feedings can be easily given in the home setting." "The formula will be kept cold until each use."

Tube feeding formula should be administered at room temperature. If the formula is cold, it can cause gastric cramping, nausea, and vomiting. A serious complication associated with enteral feedings is aspiration. To reduce the risk of aspiration, the gastric residual volume should be checked prior to every bolus feeding. The residual should be less than 200 mL. The initial placement of the tube should be verified by x-ray before the client recieves the first feeding. The most reliable method for verification of placement is x-ray confirmation. The tube is observed for any change in length, changes in volume of aspirate, and the pH of the aspirate.

A provider prescribes a transfusion of one unit packed RBC for a client who has a low hemoglobin level. The provider also prescribes diphenhydramine (Benadryl) for administration before the transfusion to prevent hemolysis fluid overload fever urticaria

Urticaria. For clients who have previously had allergic reactions to blood transfusions, administering an antihistamine such as Benadryl before transfusion may prevent future reactions. An antihistamine will not prevent a febrile reaction to a blood transfusion. A possible preventative measure is transfusing leucocyte-poor blood products to avoid sensitization to the donor's wbc. To prevent fluid overload, transufuse the blood product slowly and not exceed the volue neccesary. An antihistamine will not prevent hemolysis, which results from an incompatibility between the donor and the recipient.