NCLEX PREPPP

Which cerebral lobe includes the speech area that allows the client to process words into coherent thoughts? 1 Limbic lobe 2 Frontal lobe 3 Occipital lobe 4 Temporal lobe

4 Temporal lobe

When caring for a newly delivered newborn with a heart rate of 76 and gasping, which priority action would the nurse take? 1Attempt to clear the airway. 2Initiate chest compressions. 3Prepare to assist with intubation. 4Initiate positive-pressure ventilation.

4Initiate positive-pressure ventilation. Following the neonatal resuscitation algorithm, the nurse will initiate positive-pressure ventilation and monitor the newborn's SpO 2. Clearing the airway delays respiratory support. It is unnecessary to initiate chest compressions or prepare for intubation.

The client must refrain from eating or drinking (nothing-by-mouth, or NPO, status) for how many hours before a surgical procedure if general anesthesia is planned.

8 hours

Which clinical manifestations of hypokalemia will the nurse expect to note while assessing Martha? Select all that apply. A)Weak peripheral pulses B)Orthostatic hypotension C)Decreased urine output D)An absence of deep tendon reflexes E)Decreased bowel sounds and constipation

A)Weak peripheral pulses B)Orthostatic hypotension D)An absence of deep tendon reflexes E)Decreased bowel sounds and constipation

An electrocardiogram (ECG) is performed on Martha (hypokalemia). Which ECG findings would the nurse expect to note? Select all that apply. A)Flat P waves B)Peaked T waves C)Prominent U wave D)Prolonged PR interval E)Depressed ST segment F)Widened QRS complexes

C)Prominent U wave E)Depressed ST segment hypokalemia include ST-segment depression; shallow, flat, or inverted T waves; and prominent U waves. hyperkalemia include tall, peaked T waves; flat P waves; widened QRS complexes; and prolonged PR intervals.

Shortly after Ernest's admission, the hospital laboratory calls the unit to report the results of laboratory tests that were prescribed by the emergency primary health care provider. The nurse reviews the results and then plans to contact Ernest's primary health care provider. Which laboratory test results should the nurse report to the primary health care provider? Select all that apply. A)Hematocrit 48% B)Hemoglobin 15.5 g/dL (155 mmol/L) C)Triglycerides 276 mg/dL (3.11 mmol/L) D)Total cholesterol 309 mg/dL (8.0 mmol/L) E)Prothrombin time 10.0 seconds F)White blood cell (WBC) count 14,000 cells/mm3 (14 x 109/L)

C)Triglycerides 276 mg/dL (3.11 mmol/L) D)Total cholesterol 309 mg/dL (8.0 mmol/L) The normal values for the laboratory tests that have been prescribed for Ernest are as follows: hematocrit 42% to 52%, hemoglobin 14 to 16.5 g/dL, triglycerides 200 mg/dL or less; total cholesterol 140 to 199 mg/dL, prothrombin time 9.6 to 11.8 seconds, and WBC count 4500 to 11,000 cells/mm3

Rosanne is being started on intravenous trastuzumab, an antineoplastic medication. Which assessment finding indicates an adverse effect of the medication? A)Nausea B)Headache C)Tiredness D)Irregular heartbeat

D) Irregular heartbeat

The laboratory calls the ED and reports that Ernest's troponin I level is 2.0 ng/mL (2 mcg/L). Which conclusion does the nurse draw from this finding? A)The troponin I level is normal. B)The level of troponin T is needed to determine Ernest's status. C)The troponin I level is lower than normal, ruling out myocardial infarction. D)The troponin I level is higher than normal, indicating myocardial infarction.

D)The troponin I level is higher than normal, indicating myocardial infarction.

The nurse is monitoring Martha's serum potassium level while administering the IV potassium. Which serum potassium reading tells the nurse that the treatment has been effective? 3.0 mEq/L (3.0 mmol/L) 3.3 mEq/L (3.3 mmol/L) 4.0 mEq/L (4.0 mmol/L) 5.6 mEq/L (5.6 mmol/L)

4.0 mEq/L (4.0 mmol/L)

A client has primary open-angle glaucoma. Which ophthalmic preparation is indicated to manage this condition? Tetracaine Fluorescein Timolol maleate Atropine sulfate

Correct3 Timolol maleate Timolol maleate is a beta-adrenergic antagonist that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure. Tetracaine is a topical anesthetic; it will not reduce the increased intraocular pressure associated with glaucoma. Fluorescein is a dye used to identify corneal abrasions and foreign bodies. Atropine sulfate, a mydriatic, is contraindicated because it dilates the pupil, obstructing drainage and increasing intraocular pressure.

The nurse begins the physical examination by taking Sara's vital signs and her height and weight; on noting that these measurements are within the normal ranges, she proceeds with the physical examination. The nurse assesses Sara's vision and prepares to perform the confrontation test. Sara asks the nurse about the purpose of this test. What should the nurse tell Sara about the test? A. It is used to assess near vision. B. It is used to assess color vision. C. It is used to assess distant vision. D. It is used to assess peripheral vision.

D. It is used to assess peripheral vision. The confrontation test is a measure of peripheral vision in which the client's peripheral vision is compared with the nurse's under the assumption that the nurse's peripheral vision is normal. The client covers one eye and looks straight ahead, and the nurse (positioned 2 feet away) covers his or her own eye opposite the client's covered eye. The nurse advances a finger or another small object in from the periphery from several directions; the client should see the object at the same time the nurse does.

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine isethionate intravenously (IV) once daily. The nurse will monitor the client for which adverse effect? 1 Hypertension 2 Hypokalemia 3 Hypoglycemia 4 Hypercalcemia

Pentamidine isethionate can cause either hypoglycemia or hyperglycemia even after therapy is discontinued, and blood glucose levels should be monitored. Hypotension, not hypertension, occurs with pentamidine isethionate. Hyperkalemia, not hypokalemia, occurs with pentamidine isethionate. Hypocalcemia, not hypercalcemia, occurs with pentamidine isethionate.

An electrocardiogram (ECG) is performed on Martha. Which ECG findings would the nurse expect to note? Select all that apply. (HYPOKALEMIA) Flat P waves Peaked T waves Prominent U wave Prolonged PR interval Depressed ST segment Widened QRS complexes

Prominent U wave Depressed ST segment

For what additional defect should the nurse assess an infant with exstrophy of the bladder? Imperforate anus Absence of one kidney Congenital heart disease Pubic bone malformation

Pubic bone malformation D- The pubic bone and the bladder form during the same period of embryonic development. Imperforate anus, absence of a kidney, and congenital heart disease are not associated with exstrophy of the bladder.

After the admission assessment, the nurse reviews Margaret's medical record and notes that the primary health care provider has written prescriptions. Which prescription should the nurse question? A. Chest x-ray today B. Incentive spirometry every hour C. Ibuprofen 400 mg every 4 hours prn D. Out of bed to chair with assistance only

The nurse would question "Ibuprofen 400 mg q4h prn" because it does not indicate a route of administration. The components of a medication prescription, in addition to the date and time at which the prescription was written, are the name, dosage, and route and frequency of administration of any medication and the primary health care provider's signature. The other prescriptions are complete.

George's dysrhythmias and cardiac output are resistant to treatment measures, and acute kidney injury occurs. Hemodialysis is being performed to cleanse the blood temporarily, until the kidneys recover. Which access does the nurse expect the health care provider to prescribe for hemodialysis? Peritoneal Subclavian catheter Internal arteriovenous graft Internal arteriovenous fistula

The subclavian catheter is often used for temporary hemodialysis. The femoral site may also be used in this capacity. The peritoneal area is only used for peritoneal dialysis. The internal arteriovenous graft and internal arteriovenous fistula are both used for clients needing long-term hemodialysis.

The nurse calls the health care provider to report the results of the ABG studies and continues to assess Jonathan. The health care provider prescribes intravenous antibiotics and respiratory treatments, so Jonathan is admitted to the hospital and transported to the respiratory care unit. With the respiratory treatments, Jonathan's oxygen saturation increases to 95%, Jonathan becomes less dyspneic, and his skin color improves. Follow-up ABG testing has also been prescribed. Which of the following blood-gas results indicate improvement in Jonathan's condition? pH 7.29, PCO2 50 mm Hg, HCO3- 30 mEq/L (mmol/L), PO2 72 mm Hg pH 7.32, PCO2 55 mm Hg, HCO3- 22 mEq/L (mmol/L), PO2 80 mm Hg pH 7.35, PCO2 45 mm Hg, HCO3- 27 mEq/L (mmol/L), PO2 80 mm Hg pH 7.50, PCO2 30 mm Hg, HCO3- 27 mEq/L (mmol/L), PO2 76 mm Hg

pH 7.35, PCO2 45 mm Hg, HCO3- 27 mEq/L (mmol/L), PO2 80 mm Hg The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg, and the normal HCO3- reading is 22 to 27 mEq/L (mmol/L). The normal PO2 ranges from 80 to 100 mm Hg. Compensation has occurred if the pH is in the normal range of 7.35 to 7.45. Jonathan's previous ABG readings were reported as pH 7.30, PCO2 50 mm Hg, HCO3- 29 mEq/L (mmol/L), and PO2 70 mm Hg. Option 3 is the only option that indicates improvement, because all values are within the normal ranges.

Martha's serum potassium level has returned to normal. She will be discharged with a prescription for oral potassium supplementation in addition to the previously prescribed lanoxin and furosemide. Which comment indicates that Martha understands the discharge instructions? "I may get black stools." "I'll start using a salt substitute." "I can take an extra pill if I forget to take one." "I will call my doctor if I suddenly get weak."

"I will call my doctor if I suddenly get weak."

George has been discharged from the hospital but is experiencing frequent "fluttering beats" and has also lost consciousness at home. He has returned to the hospital for the insertion of an automatic implantable cardioverter-defibrillator (AICD). Which statement by George shows that he needs further preoperative teaching on this device? "I'll call the doctor if it gives me a shock." "I won't have any dysrhythmias after the AICD is implanted." "The doctor will put the device in my chest, like my friend's pacemaker." "I'll have to make follow-up visits to make sure the device is working and check the battery life."

"I won't have any dysrhythmias after the AICD is implanted." The AICD will sense ventricular fibrillation and defibrillate George's heart. It will also sense ventricular tachycardia and will defibrillate the heart if the overdrive pacing does not correct the rhythm. It will defibrillate the heart if he develops ventricular tachycardia, but it will not eliminate all dysrhythmias. The device will also provide backup pacing for bradydysrhythmias that may occur after defibrillation discharges. George could experience non-life-threatening dysrhythmias, which is another reason for him to make and keep follow-up appointments with his health care provider. It is important for George to call his health care provider to report the occurrence of shocks, get necessary follow-up care, and allow the health care provider to assess the AICD. The battery is now smaller and is inserted subcutaneously in the chest like other pacemakers. The routine follow-up visits are to assess the AICDs activity and assess the life of the battery.

A client is scheduled for radiation treatments Monday through Friday. The client asks why the treatments will not be given on Saturday and Sunday. Which is the nurse's best response? 1 "This type of schedule gives noncancerous cells time to recover." 2 "The department only operates from Monday through Friday." 3 "Your energy level will be increased greatly by a 5-day schedule." 4 "Side effects are eliminated when treatment is administered for 5 rather than 7 days."

1 "This type of schedule gives noncancerous cells time to recover."

Which nutrient causes elevated ketones in diabetic acidosis by incomplete oxidation? 1 Fats 2 Protein 3 Potassium 4 Carbohydrates

1 Fats Incomplete oxidation of fat results in fatty acids that further break down to ketones. Protein metabolism produces nitrogenous waste, causing elevated blood urea nitrogen (BUN), not ketones. Potassium is not oxidized; potassium is not directly associated with ketones. Carbohydrates do not contain fatty acids that are broken down into ketones.

A client is admitted to the hospital after taking an overdose of aspirin. A nasogastric tube is inserted for lavage. Which solution would the nurse obtain for the gastric lavage? 1 Normal saline 2 Lactated Ringer 3 Citrate magnesium 4 Sodium bicarbonate

1 Normal saline

During which period of pregnancy may drug exposure cause meromelia, cleft lip, and enamel hypoplasia? 1 Fetal period 2 Embryonic period 3 Presomite period 4 Preimplantation period

2 Embryonic period

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on? 1Administering oxygen 2Using an incentive spirometer 3Having the client breathe into a paper bag 4Administering an IV containing bicarbonate ions

3Having the client breathe into a paper bag Reassurance decreases anxiety and slows respirations; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to an acid-base balance. Administering oxygen is not necessary because there is no evidence of hypoxia. Using an incentive spirometer is used to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.

Which procedure may benefit the client who was in a traffic accident, is choking, and may have a spinal cord injury? 1Performing a vagal maneuver 2Performing a Valsalva maneuver 3Performing a jaw-thrust maneuver 4Performing a oculocephalic maneuver

3Performing a jaw-thrust maneuver Road traffic accidents and other traumas can cause an airway occlusion. It may be necessary to ensure a patent airway by opening the jaw with a jaw-thrust maneuver. This helps clear the airway. The nurse would also protect the cervical spine by manually aligning the neck in a neutral, in-line position. The vagal maneuver induces vagal nerve stimulation to slow cardiac conduction. The Valsalva maneuver involves breath holding, bearing down for bowel movements, and coughing to prevent cardiac problems. Oculocephalic maneuvers are performed to assess whether brainstem eye movement pathways are intact.

Which pH value of amniotic fluid is indicated by a Nitrazine test strip that turns deep blue? 1 4.5 2 5.5 3 6.5 4 7.5

7.5 Amniotic fluid changes the color of a nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5, or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.

This morning Nicole wakes up with an itchy, red right eye, crusted with drainage. Which interventions should the nurse anticipate? Select all that apply. Administering antibiotic drops Wearing goggles to protect the nurse's eyes Using wet compresses to ease the irritation Teaching Nicole to wash her hands to prevent infection spread Removing the crusted material from the eye with a cotton ball soaked in saline solution

Administering antibiotic drops Using wet compresses to ease the irritation Teaching Nicole to wash her hands to prevent infection spread Nicole has conjunctivitis (pinkeye). Antibiotics will need to be administered as prescribed. The pinkeye will be contagious until the eyedrops have been used for 24 hours. Nicole must wash her hands frequently, as does any person in contact with her to prevent the spread of conjunctivitis. Wearing goggles to protect the nurse's eyes is not necessary. Warm or cool compresses (depending on primary health care provider preference) may be prescribed to ease the irritation. The crusted material should be removed from the eye with cotton balls soaked in warm water, not saline solution, which could further irritate her eye.

The nurse notifies the primary health care provider of Nicole's serum glucose level. Which initial action should the nurse plan to take in treating diabetes ketoacidosis (DKA)? Inserting a Foley catheter Administering insulin intravenously (IV) Administering normal saline solution IV Informing Nicole and her mother that Nicole will need to learn how to administer insulin

Administering normal saline solution IV Rehydration is the initial step in resolving DKA. If acidosis has resulted in nausea and vomiting, IV fluids are required. In DKA, fluid losses occur mainly as a result of the osmotic diuresis that occurs with hyperglycemia. Emesis may also contribute to fluid loss. Normal saline solution is the IV rehydration fluid used first. Insulin is administered after the rehydration therapy has been started. Inserting a Foley catheter is not necessary. Although Nicole may need to learn how to administer insulin, this action is not the priority at this time.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing? A.White blood cells migrate into the wound B.Epithelial cells grow over the granulation tissue bed C.Scar tissue gradually becomes thinner and pale in colour D.Vasodilation occurs with increased capillary permeability

B.Epithelial cells grow over the granulation tissue bed During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

George remains in the hospital, and the list of assessment findings grows to include poor appetite, pale skin, hypotension and tachycardia, and fatigue. The nurse suspects decreased cardiac output. For which findings characteristic of decreased cardiac output should the nurse assess George? Select all that apply. Weight loss Lung crackles Mental status changes Increased urine output Decreased peripheral pulses

Lung crackles Mental status changes Decreased peripheral pulses

The health care provider prescribes a continuous intravenous (IV) infusion of 250 mL of normal saline solution with 40 mEq (40 mmol) of potassium chloride to be infused at a rate of 50 mL/hour by way of an infusion device. Which laboratory result is most important for the nurse to check before administering the infusion? Sodium Hematocrit Hemoglobin Blood urea nitrogen (BUN)

Blood urea nitrogen (BUN) IV potassium chloride is indicated for the prevention and treatment of hypokalemia. One complication of IV potassium chloride therapy is hyperkalemia. The serum level of potassium is regulated primarily by the kidneys. Therefore, in addition to monitoring serum the potassium level, the nurse must assess renal function before and during treatment to ensure adequate output of urine. Blood urea nitrogen is a marker of renal function, as well as of fluid volume balance. Hemoglobin and hematocrit and the sodium level are not directly associated with renal function or the administration of potassium.

Along explaining the need for weekly appointments, what other instructions related to preeclampsia should the nurse plan to give Janice so she can take care of herself and the fetus at home? Select all that apply. Reduce activity. Check weight weekly. Perform a daily fetal movement count. Check the urine for protein, using a dipstick. Perform a blood pressure check every other day.

Reduce activity. Perform a daily fetal movement count. Check the urine for protein, using a dipstick. Janice will have to reduce her level of activity to allow blood that would be circulated to skeletal muscles to be conserved for circulation to her vital organs and the placenta. When Janice is in bed, she should lie on her side to improve blood flow to the placenta. Maternal assessment of fetal activity ("kick counts") helps determine the viability of the fetus. Janice should report any decrease in movements or report it if none occurs during a 4-hour period. She should also check her urine (a first-void clean-catch specimen) for protein, using a dipstick. The weight is recorded daily (not weekly), on the same scale and in the same type of clothing and at the same time of day, to help detect any sudden weight gain, an indication of worsening preeclampsia. Because increased blood pressure may be an initial indication of a problem, blood pressure monitoring is performed two to four times per day, using the same arm and with the client in the same position.

Which genetically inherited syndromes are mostly recognized in adolescence? Select all that apply. 1 Down syndrome 2 Turner syndrome 3 Edwards syndrome 4 Angelman syndrome 5 Klinefelter syndrome

Turner, Klinefelter

On the third postoperative day after a subtotal gastrectomy, a client reports having severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. What should be the nurse's first action? 1 Assist the client to ambulate. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Encourage using the incentive spirometer

2 Obtain the client's vital signs.

Which long-term effect is associated with untreated congenital hypothyroidism? 1Myxedema 2Thyrotoxicosis 3Spastic paralysis 4Cognitive impairment

4Cognitive impairment Congenital hypothyroidism is the result of insufficient secretion by the thyroid gland because of an embryonic defect. A decreased level of thyroid hormone affects the fetus before birth during cerebral development, so it is likely that there will be some cognitive impairments at birth. Treatment before 3 months of age will prevent further damage. Congenital hypothyroidism does not become myxedema. Thyrotoxicosis is another term for hyperthyroidism. Although it is not expected, it may occur with an overdose of exogenous thyroid hormone, but it is too soon to discuss this possibility with the parents. Spastic paralysis occurs only if the infant has cerebral palsy.

Nicole has been admitted to the pediatric unit. On admission the nurse notes that Nicole had a streptococcal upper respiratory infection several weeks ago but did not finish her medication. Which findings are specifically associated with rheumatic fever? Select all that apply. Chorea Agitation Subcutaneous bruising Migratory polyarthritis "Slapped-face" appearance

Chorea, Migratory polyarthritis Rheumatic fever may occur if a group A beta-hemolytic Streptococcus infection of the throat is not adequately treated. Chorea—involuntary purposeless movement of the muscles—may occur in the presence of acute rheumatic involvement of the brain. Migratory polyarthritis is associated with rheumatic fever. In this condition the larger joints become painful and tender and are difficult to move. The signs/symptoms last for a few days and disappear without treatment but frequently return in another joint. Agitation does not specifically occur with rheumatic fever; the child is more likely to be fatigued. There is no subcutaneous bruising with rheumatic fever, but a rash, called erythema marginatum, appears and disappears with rheumatic fever. A slapped-face appearance is associated with erythema infectiosum (Fifth disease), not rheumatic fever.

Joy's cardiac status has remained stable during hospitalization, and the primary health care provider decides that the client should undergo an exercise stress test. Which instructions does the nurse give Joy while explaining the test? A)Joy will need to take a hot shower after the test. B)Joy will not be able to smoke for 1 week before the test. C)Joy will likely experience chest pain during the procedure, but this is expected. D)Joy will need to refrain from eating or drinking after midnight on the day before the test. E)Joy will need to ask her fiancé to bring her a pair of supportive shoes and loose-fitting clothing. F)Joy can ask to have the test stopped for excess fatigue, shortness of breath, leg cramps, or angina.

E&F The test may be stopped for cardiac dysrhythmias, a fall in blood pressure, or a systolic blood pressure greater than 250 mm Hg or diastolic blood pressure greater than 115 mm Hg. The client does not need to refrain from eating and drinking and may eat a light meal 2 to 3 hours before the test. The client should refrain from smoking for at least 2 hours before the test. Chest pain experienced during the test could indicate the presence of a cardiac problem, and the client is instructed to notify the primary health care provider if chest pain, dizziness, or shortness of breath occurs. After the procedure, the client is instructed to avoid taking a hot bath or shower for at least 1 to 2 hours.

A client undergoes surgical implantation of radon seeds for oral cancer. The nurse would observe the client for which side effects? 1Nausea or vomiting 2Hematuria or occult blood 3Hypotension or bradycardia 4Abdominal cramping or diarrhea

1Nausea or vomiting The mucosa of the mouth and the vomiting center in the brain stem may be affected, producing nausea and vomiting. Hematuria, occult blood, hypotension, and bradycardia are not side effects of radiation therapy related to the oral cavity. Neither abdominal cramping nor diarrhea is an expected response because of the distance between the radon seeds and the intestines.

Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? 1 Hazy 2 Yellow 3 Brown 4 Colorless

2 Yellow The yellow color of CSF can be attributed to the hemolysis of the red blood cells (RBC), which leads to increased production of bilirubin. Other causes include subarachnoid hemorrhage, jaundice, increased CSF protein, hypercarotenemia, or hemoglobinemia. Hazy or unclear CSF is indicative of an elevated white blood cell count due to infections. If the CSF has a brown color it is indicative of the presence of methemoglobin, indicating a previous meningeal hemorrhage. A colorless color indicates a normal finding. View Topics

An 8-year-old child who is experiencing a sickle cell pain episode is admitted to the child health unit. What is the most appropriate nursing care during this acute period? 1Limiting fluids until the crisis ends 2Administering prescribed analgesics 3Applying cold compresses to painful joints 4Performing range-of-motion exercises of affected joints

2Administering prescribed analgesics The priority is pain management; severe pain requires analgesics. Increased hydration is necessary to promote hemodilution, improve circulation, and prevent more sickling. Cold will constrict blood vessels, further depleting oxygenation to affected parts; warmth is preferable. There is too much swelling and pain in the joints during a crisis for the implementation of range-of-motion exercises.

The disaster management team is evaluating the damage that can happen due to a disaster. They also attempt to limit the influence of the disaster on the health community's function. Which phases of disaster management would the nurse state represents these actions? Select all that apply. One, some, or all responses may be correct. 1 Recovery 2 Response 3 Mitigation 4 Evaluation 5 Preparedness

3 Mitigation 5 Preparedness

Which type of cytokine is used to treat anemia related to chronic kidney disease? 1 α-Interferon 2 Interleukin-2 3 Interleukin-11 4 Erythropoietin

Erythropoietin Erythropoietin is used to treat anemia related to chronic kidney disease. α-Interferon is used to treat hairy cell leukemia or malignant melanoma. Interleukin-2 is used to treat metastatic renal carcinoma. Interleukin-11 is used to prevent thrombocytopenia after chemotherapy. View Topics

The clinic nurse is taking the sexual health history of an adolescent when the adolescent begins to perspire and hyperventilate. The client reports feeling dizzy and short of breath. Which condition would the nurse identify? 1Metabolic alkalosis 2Respiratory acidosis 3Pulmonary hypertension 4Hyperventilation syndrome

4Hyperventilation syndrome Hyperventilation syndrome is respiratory alkalosis that occurs with deep, rapid breathing; the clinical findings are related to an increased pH and lowered bicarbonate and oxygen levels. Metabolic alkalosis is manifested by adaptations such as hypotension, tachycardia, confusion, hyperreflexia, and dysrhythmias. Respiratory acidosis is manifested by adaptations such as tachycardia, headache, altered mental status, muscle twitching, and warm, flushed skin. Pulmonary hypertension occurs when the pulmonary arterial pressure is increased; chronic pulmonary disorders are associated with pulmonary hypertension.

Which statement reflects understanding of sepsis screening requirements by the nurse? 1Blood cultures are required to diagnosis sepsis and begin sepsis protocols. 2An oral temperature of 96.4°F (35.8°C) is not an indicator of sepsis. 3A primary health care provider's prescription is required to screen for sepsis. 4Sepsis mortality is affected greatly by treatments performed in the first 6 hours.

4Sepsis mortality is affected greatly by treatments performed in the first 6 hours. Studies have shown that if a bundle treatment is not performed in the first 6 hours, the likelihood of survival dramatically decreases. Only in about 30% to 40% of the cases are blood cultures positive in septic clients; this is because in many cases sepsis works faster than the laboratory can produce the result using the current technology. Hypothermia is as strong a sepsis indicator as hyperthermia; however, the health care team members often miss this symptom. The signs and symptoms of sepsis are not specific and may indicate many other diseases as well. If the health care team is not actively looking for sepsis, it will be missed. A sepsis screening is an assessment that the nurse can perform at any time. To perform the screening, the nurse analyzes the vital signs, client history, and laboratory reports; the nurse synthesizes the findings to evaluate if sepsis screening is negative or positive and then notifies the primary health care provider of the findings.

The nurse should include which instruction when preparing Joy for an electrocardiogram (ECG)? A)The test is painless. B)She will need to take deep breaths throughout the test. C)The test will determine whether her coronary arteries are blocked. D)She may feel some pinprick sensations from the electricity flowing through the wires.

A)The test is painless.

A 16-year-old girl arrives at the women's health center and tells the nurse that she thinks she is pregnant. The nurse obtains subjective data from the client and informs her about the laboratory procedures used to test for pregnancy. Which action should the nurse take in obtaining informed consent to treat the client? A. Asking the 16-year-old girl to sign the informed consent B. Asking the 16-year-old girl for permission to call one of her parents C. Giving the 16-year-old girl permission forms to take home for her parents to sign D. Telling the 16-year-old girl that her boyfriend will need to provide consent for her pregnancy test

A. Asking the 16-year-old girl to sign the informed consent A minor is a client under the age of legality (usually 18 years) as defined by state statute. Parental or guardian consent should be obtained before treatment is initiated for a minor except in the case of an emergency, in situations in which the consent of the minor is sufficient (e.g., treatment related to substance abuse or a sexually transmitted infection, testing for HIV and AIDS, birth control services, pregnancy, or psychiatric services, or if a court order or other legal authorization has been obtained).

The nurse goes to check on Margaret and finds her crying. Margaret says, "I don't know what to do. My doctor has just told me that I have hepatitis, and I may have given it to my family, but I don't want them to know that I have this disease! Please don't tell them; it's none of their business." Which actions by the nurse are ethically correct? Select all that apply. A. Consulting the hospital's ethics committee. B. Documenting what the client has said in the medical record. C. Telling Margaret, "If you don't tell your family, we will have to do it." D. Telling her, "Margaret, I won't tell your family, but let's discuss what could happen if you don't tell them." E. Promising not to tell Margaret's son but, when he visits, telling him what Margaret has said.

A. Consulting the hospital's ethics committee. B. Documenting what the client has said in the medical record. D. Telling her, "Margaret, I won't tell your family, but let's discuss what could happen if you don't tell them."

Shannon tells the nurse that she has never had a mammogram and asks whether she needs one. On the basis of American Cancer Society (ACS) recommendations, which instruction should the nurse provide to Shannon? A. She will need to start having a yearly mammogram at age 40 B. Her health care provider will recommend that she have a mammogram done now C. She will have a baseline mammogram now and another one every 3 years thereafter D. She will have a baseline mammogram now and then will have one every year thereafter

A. She will need to start having a yearly mammogram at age 40

The nurse calls Margaret's primary health care provider to report the fall, completes an occurrence report, and documents the occurrence in Margaret's medical record. Which statements should be included in Margaret's medical record? Select all that apply. A. The client was found lying on the floor. B. An occurrence report was placed in the medical record. C. The client's primary health care provider was notified. D. The client was not instructed in the use of the call bell. E. The client had no complaints of discomfort or pain after the fall. F. The client fell to the floor while ambulating from the bathroom back to bed.

A. The client was found lying on the floor. B. An occurrence report was placed in the medical record. D. The client was not instructed in the use of the call bell. An occurrence report is a tool used to identify risk situations and improve client care. The report form should not be copied or placed in the client's record, and no reference should be made to the report form in the client's record. The occurrence report is not a substitute for a complete entry in the client's record regarding the occurrence. The nurse documents only an objective description of what was actually observed and any follow-up care that was rendered.

The nurse assumes which responsibilities during the process of informed consent? Select all that apply. A. Witnessing the client's signing of the consent form B. Providing detailed information about the surgical procedure C. Clarifying the information that was given to the client by the primary health care provider D. Dispelling any misunderstandings that the client may have about the surgery E. Witnessing the client's understanding of the information given about the surgery

A. Witnessing the client's signing of the consent form C. Clarifying the information that was given to the client by the primary health care provider E. Witnessing the client's understanding of the information given about the surgery

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the antacids, which information would the nurse reinforce? 1 Antacids should be taken 1 hour before meals. 2 These should be scheduled at 4-hour intervals. 3 Antacid tablets are just as fast and effective as the liquid form. Correct4 Antacids commonly interfere with the absorption of other medications.

Antacids commonly interfere with the absorption of other medications. Antacids interfere with absorption of medications such as anticholinergics, barbiturates, tetracycline, and digoxin. Liquid antacids are faster acting and more effective than antacid tablets. Antacids should be taken 1 or 2 hours after meals and at bedtime. Antacid tablets may be taken more frequently than every 4 hours.

Joy experiences chest pain that radiates to her jaw during the stress test, and the test is stopped. She is given a sublingual nitroglycerin tablet, which relieves the chest pain. Joy is transported back to her hospital room and monitored closely. Joy's primary health care provider schedules cardiac catheterization, to be performed the next day, and the nurse prepares her for the test. Which information does the nurse give Joy? A)She will be able to eat a full breakfast on the morning of the test. B)The catheter insertion site will have to be shaved and be antiseptically prepared. C)She will be transferred to the coronary intensive care unit after the procedure. D)She must inform the primary health care provider of any hot feelings or palpitations during the procedure, because these are signs/symptoms of complications and the procedure will need to be stopped.

B)The catheter insertion site will have to be shaved and be antiseptically prepared.

The nurse has educated Shannon about BSE. The nurse realizes the education was effective if Shannon states that she will perform this examination how frequently? A. The first day of each month B. 7 days after the start of menstruation C. 14 days after the start of menstruation D. The 10th day of each month

B. 7 days after the start of menstruation Breast self-examination (BSE) should be performed monthly at a regular time when the breasts are not tender. In premenopausal women, the best time is 7 days after the start of menstruation. At this time, hormonal stimulation of the breasts is at its lowest point. Postmenopausal clients and clients who have undergone hysterectomy should select a specific day of the month and perform BSE each month on that day.

Radiography is performed on Charlotte's left hip and a fracture of the femoral head is diagnosed. Charlotte will require hip replacement. Because of Charlotte's history of heart disease and type 2 diabetes mellitus, the surgeon plans to ensure that these conditions are stable before performing the surgery and decides to place Charlotte in traction during the preoperative period. Which type of traction should the nurse expect the surgeon to prescribe for Charlotte in the preoperative period? Buck's traction Cervical traction Dunlop traction Pelvic belt traction

Buck's traction Buck's traction is a type of skin traction that may be prescribed in the preoperative period to ease the painful muscle spasms that accompany a hip fracture. Cervical traction is used for problems associated with the cervical vertebrae. Dunlop traction is a type of skin traction used for fractures of the humerus. Pelvic belt traction is used for the client experiencing low back pain or for a client with a ruptured or herniated disc.

The health care provider prescribes a continuous intravenous (IV) infusion of 250 mL of normal saline solution with 40 mEq (40 mmol) of potassium chloride to be infused at a rate of 50 mL/hour by way of an infusion device. Which laboratory result is most important for the nurse to check before administering the infusion? A)Sodium B)Hematocrit C)Hemoglobin D)Blood urea nitrogen (BUN)

D)Blood urea nitrogen (BUN) IV potassium chloride is indicated for the prevention and treatment of hypokalemia. One complication of IV potassium chloride therapy is hyperkalemia. The serum level of potassium is regulated primarily by the kidneys. Therefore, in addition to monitoring serum the potassium level, the nurse must assess renal function before and during treatment to ensure adequate output of urine.

The client with congestive heart failure is receiving furosemide 80 mg once daily. Which data collection assessment would be performed to evaluate medication effectiveness? Select all that apply. One, some, or all responses may be correct. Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds

Daily weight Intake and output Monitor for edema Daily pulse oximetry Auscultate breath sounds Daily weight at the same time, on the same scale, and in the same clothing is important as it is an indication of fluid gains or losses. The nurse would also record daily intake and output and report intake exceeding output. The nurse would monitor for peripheral edema and document the findings. It is important to obtain and record vital signs and daily pulse oximetry as improving results relate to effectiveness of furosemide. The nurse would also auscultate breath sounds, look for jugular venous distension, and report abnormal data.

For the client taking clopidogrel, the nurse will monitor for which adverse effect? 1 Nausea 2 Epistaxis 3 Chest pain 4 Elevated temperature

Epistaxis Clopidogrel is a platelet aggregation inhibitor; therefore bleeding can occur as an adverse effect. The high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose blowing), makes it a frequent site of hemorrhage. Nausea, chest pain, and elevated temperature are not associated with anticoagulant therapy.

One of the laboratory tests that the ED health care provider has prescribed is an arterial blood gas (ABG) determination, and the nurse prepares to obtain the specimen from the right radial artery. List the actions, in the order the nurse must perform them, involved in an Allen test, with 1 as the first action and 4 as the last. Explaining the procedure to the client Applying direct pressure over the right ulnar and right radial artery simultaneously Asking the client to open and close the hand repeatedly Releasing the right ulnar artery and assessing the rate of color return to the right hand

Explaining the procedure to the client Applying direct pressure over the right ulnar and right radial artery simultaneously Asking the client to open and close the hand repeatedly Releasing the right ulnar artery and assessing the rate of color return to the right hand

The health care provider recommends that Dianne undergo a physical examination, including laboratory studies, before she starts exercising. Which tests are appropriate for assessment of Dianne's nutritional status? Select all that apply. Hemoglobin Serum creatinine Serum transferrin Serum triglycerides Total thyroxine (T4) Serum glucose level (fasting)

Hemoglobin Serum transferrin Serum triglycerides Serum glucose level (fasting) RATIONALE: The hemoglobin blood test is used to detect iron-deficiency anemia and serum transferrin is an iron-transport protein; these laboratory result indicates a person's visceral protein status. Serum triglyceride readings are used to screen for hyperlipidemia (recall that Dianne has high cholesterol levels); the fasting serum glucose level, if increased, may indicate the presence of diabetes mellitus. The serum creatinine level reflects renal excretory function; the total thyroxine (T4) level reflects thyroid function. Although the serum creatinine and T4 levels may be checked, they are not directly related to nutritional status.

A client appears anxious, exhibiting 40 shallow respirations per minute. The client reports dizziness, light-headedness, and tingling sensations of the fingertips and around the lips. The nurse concludes that the client's symptoms are most likely related to which condition? 1Eupnea 2 Hyperventilation 3 Kussmaul respirations 4 Carbon dioxide intoxication

Hyperventilation

Which statement explains why metabolic acidosis develops with kidney failure? 1 Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate 2 Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention 3 Inability of the renal tubules to reabsorb water to dilute the acid contents of blood 4 Impaired glomerular filtration, causing retention of sodium and metabolic waste products

Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate. Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.

Which conditions are cardiovascular manifestations of alkalosis? Select all that apply. One, some, or all responses may be correct. 1 Increased heart rate 2 Decreased heart rate 3 Widened QRS complex 4 Increased digitalis toxicity 5 Prolonged PR interval

Increased heart rate Increased digitalis toxicity Increased heart rate and digitalis toxicity are cardiovascular manifestations of alkalosis. Delayed electrical conduction is a cardiovascular manifestation of acidosis, which could result in decreased heart rate, widened QRS complexes, and prolonged PR intervals.

The nurse prepares to perform an assessment of Sara's respiratory status. The nurse should perform the following actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used. Palpate Percuss Inspect Auscultate

Inspect Auscultate Palpate Percuss

When should the provider be notified for a chest tube drainage system?

Monitor the drainage in the collection chamber of a chest tube drainage system; notify the primary health care provider if drainage is greater than 100 mL/hour or if drainage becomes bright red or increases suddenly.

During labor, Janice's baby exhibits fetal distress. Which interventions should the nurse implement? Select all that apply. Placing Janice in the supine position Preparing for an emergency cesarean section Continuing to monitor maternal and fetal status Increasing the rate of the oxytocin infusion Administering oxygen at 2 L/min by way of nasal cannula

Preparing for an emergency cesarean section Continuing to monitor maternal and fetal status Preparing for an emergency cesarean section and continued monitoring of the maternal and fetal status are the correct interventions. Janice would be placed in a left lateral position, not supine; the supine position could result in vena cava syndrome and inhibit placental blood flow. If an oxytocin solution is infusing, it will be stopped to prevent further fetal distress. Oxygen would be administered at 8 to 10 L/min by way of face mask.

The blood is drawn from Jonathan's radial artery, and the laboratory calls the ED to report the results of the ABG analysis: pH 7.30, PCO2 50 mm Hg, HCO3- 29 mEq/L, and PO2 70 mm Hg. Which condition does the nurse conclude that Jonathan is experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

The nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. Which complication is the nurse trying to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.

The nurse completes Sara's physical examination and plans to assist the health care provider in performing a vaginal examination and obtaining a regular Papanicolaou test. The nurse explains the vaginal examination to Sara, informs her that all of the examination findings have been normal, and says that the health care provider will call her when the results of the Pap test are returned. Sara tells the nurse that she has never had this test and asks how frequently the Pap test must be performed. How should the nurse respond? The test should be performed yearly. The test should be performed every 6 months. The test does not need to be performed again if the results are normal. The test may be performed every 5 years because Sara has no family history of cervical cancer.

The test should be performed yearly. The Papanicolaou (Pap) smear is a painless screening test for cervical cancer. The test is simple, with no side effects. All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age; screening should be performed every year with the regular Pap test or every 2 years if the newer liquid-based test is being used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years. Women older than 30 may also be screened every 3 years with the use of either the conventional or liquid-based Pap test, plus the human papillomavirus (HPV) test.

Which clinical manifestations of hypokalemia will the nurse expect to note while assessing Martha? Select all that apply. Weak peripheral pulses Orthostatic hypotension Decreased urine output An absence of deep tendon reflexes Decreased bowel sounds and constipation

Weak peripheral pulses Orthostatic hypotension An absence of deep tendon reflexes Decreased bowel sounds and constipation