Nclex review: tough practice Questions 1 Archer review

The nurse is reviewing teaching with a client who has been advised to eat foods rich in phosphorus. What foods should the nurse include in dietary teaching with the client that are good sources of phosphorus? SATA Leafy greens Garlic Nuts Butter Turkey

Garlic Nuts and Turkey Garlic is a food rich in phosphorus and would be an appropriate recommendation for a client that needs to incorporate more phosphorus in their diet. Many nuts are rich in phosphorus and are an excellent way to increase the dietary intake of this important mineral. Cashews, almonds, and brazil nuts are all very high in phosphorus. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI).

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. Lab Results: Gonorrhea..Detected Chlamydia...Detected Human chorionic gonadotropin (hCG)...Positive Urine Appearance: Cloudy Urine Protein...Negative Urine Ketones...Negative Urine Bacteria...Many Urine Nitrates..Positive SATA: Pyelonephritis Chlamydia Cystitis Gonorrhea Pre-eclampsia

Chlamydia Gonorrhea Cystitis The client's urine analysis, urine gonorrhea and chlamydia screening, and serum human chorionic gonadotropin (HCG) return with several findings requiring follow-up. The findings requiring follow-up are "Detected,Cloudy, Many, Positive " Based on the findings, the client has cystitis supported by the bacteria and nitrites in the urine. The client not having any flank pain, fever, or any other systemic symptoms excludes pyelonephritis. Pyelonephritis is an ascending urinary tract infection that results when causative organism invades the kidney. Pre-eclampsia is excluded because this client has yet to have a confirmatory pregnancy screening such as an ultrasound, additionally, if pre-eclampsia were to occur, it would typically have an onset after 20 gestational weeks.

Which is a common finding when assessing cardiac status in preschool children? A. Noting a large discrepancy in arm and leg blood pressures. B. The point of maximal impulse (PMI) is at the fifth intercostal space (ICS), about 7-9 cm from the mid-sternum. C. Pulses are elevated when breathing in and decrease when breathing out. D. A systolic click best heard at the sternal border.

Choice C is correct. This finding indicates sinus arrhythmia, a commonly encountered variation of normal sinus rhythm. It is typically seen in children and young adults. During respiration, intermittent vagus nerve activation occurs, which results in beat-to-beat variations in the resting heart rate. When present, sinus arrhythmia typically indicates good cardiovascular health. Sinus arrhythmia is a commonly encountered finding when assessing preschool cardiac status.

The nurse is caring for a client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy? A. Lipid panel B. C-Reactive Protein C. Hemoglobin A1C D. International normalized ratio (INR)

A is correct. Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication may raise triglyceride levels, and thus a baseline lipid panel is necessary along with periodic monitoring. Choices B, C, and D are incorrect. A C-Reactive Protein, Hemoglobin A1C, and International normalized ratio (INR) are all laboratory data not relevant to isotretinoin. This medication is highly hepatotoxic, and the liver function tests are laboratory data that should be monitored before and during treatment.

The unit charge nurse knows which of the following are internal disasters. Select all that apply. A loss of electrical power to the facility The sudden cessation of internal communication A toxic chemical spill in the lobby of the facility A serious life-threatening medication error Train crash in a neighboring town

A loss of electrical power to the facility The sudden cessation of internal communication A toxic chemical spill in the lobby of the facility Choices A, B, and C are correct. A loss of electrical power to the facility, the sudden cessation of internal communication, and a toxic chemical spill in the lobby of the facility are all examples of domestic disasters. Other cases of civil emergencies include things like a fire, a bomb threat, a cyclone, a flood, a tornado or hurricane that affects the healthcare facility. Choice D is incorrect. A medication error is not considered an internal disaster or an external disaster. Choice E is incorrect. A train crash likely causes mass casualties and is an examples of an external disaster. Internal disasters occur within a facility and may cause harm or danger to staff, patients, and visitors. ✓ External disasters are events causing mass casualties in surrounding areas and will require significant medical care.

Your client is on complete bed rest for seven days. Which of the following is the priority nursing diagnosis for this client? A. Risk for sensory deprivation related to complete bed rest B. Risk for thrombosis related to complete bed rest C. Risk for impaired tissue integrity related to complete bed rest D. Risk for urinary stasis related to complete bed rest

B. Risk for thrombosis related to complete bed rest "Risk for thrombosis related to complete bed rest" is the priority nursing diagnosis for a client on complete bed rest for seven days, as immobile clients are at an increased risk for thrombus formation. One of the dangers of a deep vein thrombosis is the development of a pulmonary embolus. A pulmonary embolus occurs when a portion of the thrombus or clot breaks off, travels to the lungs, and subsequently obstructs the pulmonary artery, altering the blood supply to lung tissue. Pulmonary embolus has various presenting features, ranging from asymptomatic to shock or sudden cardiac arrest. Therefore, "risk for thrombosis related to complete bed rest" is the priority nursing diagnosis for this client based on Maslow's hierarchy of needs.

You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children? A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children. B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof. C. The cognitive development of young children impacts their understanding of death. D. The cognitive development of young children before 12 has no impact on their understanding of death.

C is correct. The cognitive development of young children impacts their understanding of death. Since the meaning of death and the finality of death vary according to the age of the child, the nurse should listen to and support these children according to their level of understanding. Choice A is incorrect. Nurses should openly discuss death with children as the need arises. Young children do not view death as terrifying, they do not even see death as final. Choice B is incorrect. Children before the age of 12 do have perspectives about death, its meaning, and its finality or lack thereof. Although, these perspectives are not the same as older children and adults. Choice D is incorrect. The cognitive development of young children before 12 most definitely impacts their understanding of death and its finality.

A client admitted to the medical ward for convulsions is receiving intravenous magnesium sulfate. Which of the following signs indicate an expected side effect of the drug? A. Less frequency of urination B. Frequent sleepiness C. Absence of a knee jerk reflex D. Decreased respirations

Choice B is correct. Clients taking magnesium sulfate are expected to become sleepy during the daytime as well as experience hot flashes and lethargy. Choice A is incorrect. Magnesium prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the endplate by the motor nerve impulse. Magnesium sulfate does not affect urine production. Choice C is incorrect. The absence of deep tendon reflexes indicates elevated magnesium levels. As plasma magnesium rises above 4 mEq/liter, the deep tendon reflexes are decreased. Choice D is incorrect. This indicates magnesium toxicity. As the plasma level approaches 10 mEq/liter, respiratory paralysis may occur. A decrease in respiratory rate initially manifests this.

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client A. Trendelenburg B. Side-lying C. high-Fowler's D. Reverse Trendelenburg

Choice C is correct. Hypophysectomy is generally performed via the transsphenoidal route to remove tumors from the pituitary gland. Semi-Fowler's to Fowler's position is the most appropriate as it facilitates drainage. Hypophysectomy is a surgery to remove a pituitary tumor or remove the pituitary gland ✓ The approach is most likely transnasal via endoscopy ✓ Complications of this surgical procedure include CSF leak, infection, diabetes insipidus, and hypopituitarism ✓ Postoperatively, the head of the bed should be elevated semi- to high-Fowler's ✓ The client should be instructed not to cough, sneeze, or blow their nose ✓ The client should not bend at their waist to prevent the rising of intracranial pressure ✓ The client should use mouthwash or dental floss for several days to allow the surgical incision to heal ✓ Drainage should be monitored for CSF which would be a light yellow color at the edge of the clear drainage on the dressing is called the halo sign and indicates CSF

The nurse is taking care of a client that is status-post hand arthroplasty. The nurse should not include which nursing action to prevent complications? A. Encourage the client to exercise his fingers 10 times every hour, attempting full range of flexion and extension. B. Place the client's personal items within easy reach of the non-operative arm. C. Place the client's operative arm on a pillow to rest and keep it elevated. D. Encourage the client to use the non-operative arm as much as possible.

Choice C is correct. Placing the client's operative arm on a pillow produces pressure on the ulnar nerve. This should not be included in the client's care plan. The nurse should place the hand in a sling and suspend it from the bed.

The nurse is caring for a 45-year-old client who has undergone electroconvulsive treatment (ECT) for severe depression. Which of the following nursing interventions is appropriate following the treatment?SATA Position the client supine with the head of the bed at 30 degrees. Reorient the client frequently. Remain with the client at all times. Promote bedrest for 12-24 hours. Ambulate the client as soon as possible.

Choices B and C are correct. B is correct. It will be a critical nursing intervention to frequently reorient the client who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be confused and disoriented. Due to this disorientation, they will probably be scared; the nurse must frequently reorient them to their place and situation to make them feel safe and secure. C is correct. It will be a critical nursing intervention to remain with the client who has just received electroconvulsive therapy. A side effect of electroconvulsive treatment is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them to keep them safe. The American Psychiatric Association (APA) has published guidelines for electroconvulsive therapy (ECT) as a treatment option for certain mental health conditions. ✓ECT is considered a treatment option for severe depression, bipolar disorder with a depressive or mixed episode, schizophrenia with prominent depressive or catatonic features, and certain other mental health conditions that have not responded to other treatments or where rapid response is necessary. ✓Before administering ECT, informed consent should be obtained from the client or a legally authorized representative. The consent process should include a discussion of the procedure, potential risks and benefits, alternative treatment options, and the ability to withdraw consent at any time. ✓A comprehensive psychiatric and medical evaluation should be conducted before ECT to assess the client's suitability for the procedure, evaluate potential contraindications or risks, and inform treatment planning. ✓ECT is typically performed under general anesthesia and muscle relaxation to ensure client comfort and safety. ✓The APA guidelines recommend an initial course of ECT consisting of 6-12 sessions, with maintenance treatments considered as needed.

The nurse plans care for a client immediately postoperative following a coronary artery bypass graft surgery (CABG). Which interventions are appropriate during this time? Select all that apply. obtain the client's capillary blood glucose provide tracheostomy care, as needed teach the client about the driving restrictions after this procedure ground the epicardial pacing wires to the pacemaker generator ensure patency of the mediastinal chest tubes

obtain the client's capillary blood glucose ground the epicardial pacing wires to the pacemaker generator ensure patency of the mediastinal chest tubes Choice A is correct. Tight postoperative glucose control is essential for optimal outcomes. Amongst the priorities of airway patency, ensuring appropriate hemodynamics, vital signs, and thermoregulation, the nurse will obtain frequent capillary blood glucose levels to ensure it is less than 180 mg/dL. Immediately postoperative, a continuous infusion of regular insulin is prescribed and is titrated based on the client's glucose level. The stress of this major surgery raises serum glucose levels and requires appropriate control via regular insulin. Choice D is correct. Grounding (connecting) the epicardial pacing wires to the pacemaker generator is appropriate. Epicardial pacing wires are placed on the heart to control postoperative cardiac dysrhythmias. Also, they are used to increase cardiac output by increasing the client's heart rate, if necessary. Choice E is correct. After a CABG, clients usually have two mediastinal chest tubes to drain fluid or blood around the heart. Clearing of this excess fluid and blood prevents hemodynamic compromise. These tubes are connected to a chest tube drainage system. The drainage should not exceed no more than 150 mL/hr. Choice B is incorrect. A client, after a CABG, is not given a tracheostomy. They are ventilated and oxygenated via an oral endotracheal tube (ETT). The ETT and mechanical ventilation continues 3 to 6 hours after the end of surgery. The client is extubated once they have met preset criteria, including hemodynamic stability, breathing independently, and taking appropriate tidal volumes (as indicated by the mechanical ventilator). Proving tracheostomy care would be expected after a total laryngectomy. Choice C is incorrect. Teaching the client about driving restrictions during the immediate postoperative period is inappropriate. Education is essential, but during the immediate postoperative period (1 to 4 hours after the surgery), the nurse must concentrate nursing care on ensuring the client's airway is patent, breath sounds are optimal, and vital signs are within normal limits. Once the client has stabilize

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. The nurse is teaching the client about the treatment plan. Which statement by the nurse would be appropriate? "If your HIV testing comes back positive, your baby will be infected." "Let's discuss some options for notifying your sexual partners." "You may notice dark urine and a metallic taste caused by ceftriaxone." "After you take the azithromycin, do not consume any calcium rich foods."

"Let's discuss some options for notifying your sexual partners." It is quite plausible for a client infected with HIV to deliver a baby who is HIV-negative. Robust antiretrovirals have made this possible. This statement should not be made to the client because it is not true. A client needs to notify her sexual partners of her exposure. This does not mean that she is obligated to do this herself, as public health services may assist her with contact tracing. Gonorrhea is a reportable health condition to the public health department. Dark urine and a metallic-like taste are not a finding associated with ceftriaxone; rather, this is a finding most commonly seen with metronidazole. Azithromycin does not have an interaction with calcium. This would be an appropriate teaching point if the client were discharged with doxycycline.

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. "At around the time I would normally have my period, I should abstain from intercourse." B. "I should no longer have sex during the last trimester of pregnancy." C. "My sexual desire will remain the same for the entire pregnancy." D. "The best time to enjoy sex is in the second trimester."

"The best time to enjoy sex is in the second trimester." Choice D is correct. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities. Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present. Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well-being and the presence of certain discomforts brought about by the pregnancy. It is not the same throughout pregnancy.

The nurse teaches a community health course on adult cardiopulmonary resuscitation (CPR). Which of the following statements should the nurse include? Select all that apply. "The compression rate of 100 to 120 per minute." "The compression depth should be 1.5 inches." "Allow full chest recoil between compressions." "Rotate compressor at least every 2 minutes." "Stop to check pulse every 30 seconds."

"The compression rate of 100 to 120 per minute." "Allow full chest recoil between compressions." "Rotate the compressor at least every 2 minutes." Choices A, C, and D are correct. The purpose of CPR is to move blood through the heart and to the body's cells to prevent cell death. According to the American Heart Association (AHA), high-quality CPR includes a compression rate of 100-120 per minute to 2-2.4 inches in depth. The provider must allow full chest recoil between each compressor. Full chest recoil allows the heart chambers to fill with blood between compressions. When the ventricles fill, more oxygenated blood will be available to the cells. Fatigue will result in less effective compressions, so the AHA recommends that the compressors rotate every 2 minutes or five cycles of compressions to prevent fatigue.

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. Click to specify whether the planned intervention is appropriate or not appropriate Click to specify whether the planned intervention is appropriate or not appropriate Obtain a prescription for antivirals Obtain an order to screen for additional sexually transmitted infections Obtain an order for a transvaginal ultrasound Review the client's current medications, including any over-the-counter supplements or vitamins

Appropriate: Obtain an order to screen for additional sexually transmitted infections;Obtain an order for a transvaginal ultrasound Not Appropriate: Obtain a prescription for antivirals; Review the client's current medications, including any over-the-counter supplements or vitamins

You are assigned to supervise a client care unit. Over the last several months, the nurses in the unit have told you that the unit dose dispensing of medications by the pharmacy has not been accurate at all times. Fortunately, there have been no medication errors as a result of these inaccuracies. Which of the following actions should be prioritized? A. Praise the staff for catching these inaccuracies B. Investigate and explore these near misses C. Investigate and explore these medical errors D. Report these inaccuracies to the State Department of Health

B. Investigate and explore these near misses hoice B is correct. As the supervising nurse on your client care unit, you should investigate and explore the near misses similar to how you deal with sentinel events. Near misses, such as these inaccuracies, should be reported per hospital policy to be studied and examined to circumvent future errors.

Your pregnant client has been hospitalized with hyperemesis gravidarum. She is given ondansetron to treat this illness. What serious side effects should the hospital nurses be watching for? Incorrect A. Continued nausea and vomiting B. Prolonged QT interval C. Respiratory distress D. Constipation

B. Prolonged QT interval Choice B is correct. Ondansetron is a 5HT-3 receptor antagonist that treats nausea and vomiting. It may be used in hyperemesis gravidarum when the patient loses weight or cannot cope with pregnancy-related nausea. Prolonged QT interval is a severe side effect of ondansetron. Choice A is incorrect. While the nurse should monitor for the resolution of nausea and vomiting, the continuation of emesis is not a side effect of ondansetron. Choice C is incorrect. Respiratory distress is not generally associated with ondansetron. Choice D is incorrect. Constipation can occur, but it is not a severe side effect of ondansetron. Add'L info: Push slowly can cause QT prolongation and VTach

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. Which two (2) client findings in the history and physical require further investigation? Select all that apply Nausea Breast tenderness Fatigue Burning with urination Vaginal discharge Amenorrhea

Burning with urination Vaginal discharge Based on the client's symptoms, she is presumptively pregnant. Expected presumptive pregnancy signs include nausea, vomiting, frequent urination, breast tenderness, and amenorrhea. The client also has one probable sign of pregnancy, which is the positive home pregnancy test. The two symptoms reported by the client of burning with urination and vaginal discharge are not expected signs of a presumptive pregnancy. Thus, the nurse should investigate these reported symptoms further because they are concerning.

You have an adult client who has abnormally heightened responses to minor pain like the pain from sitting on a bedpan or a small skin tear. What would you suspect that this client is affected by? A. Hyperpathia B. Drug seeking behavior C. Equianalgesia D. Dysesthesia

Choice A is correct. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with hyperpathia. Hyperpathia is synonymous with hyperalgesia and is defined as the abnormal pain processing that can lead to the appearance of neuropathic pain. Choice B is incorrect. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is most likely affected with a disorder other than drug-seeking behavior. Choice C is incorrect. Equianalgesia is the mathematically calculated relationship between different opioid medications and parenteral morphine. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with equianalgesia. Choice D is incorrect. Dysesthesia is a cutaneous symptom; i.e. pruritis, burning, stinging, tickling, crawling, cold sensation, tingling, etc. An adult client who has abnormally heightened responses to minor pain like the pain of sitting on a bedpan or a small skin tear is not affected with dysesthesia.

The nurse has provided medication instruction to a client who has been prescribed enalapril. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? "I will notify my prescriber if I develop swelling of the face." B. "I will need to weigh myself every day while taking this medication." C. "I should eat foods high in potassium while I am taking this medication." D. "I will need lab work done every so often to evaluate my liver function."

Choice A is correct. Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body, but swelling in the face, lips, and eyes can be serious. The client should notify the prescriber immediately. Angioedema may also cause airway obstruction due to swelling of the soft tissues of the upper airway. If the client has trouble breathing, then they should call 911.

A registered nurse arrives for a shift in a pediatric emergency department (ED). There are four pediatric clients in the ED. Which client would the nurse assess first? A. A one-month-old infant that is crying with retractions during inspiration B. A 5-year-old with pneumonia and a 95% pulse oxygen saturation C. A 10-year-old with diarrhea and vomiting and a potassium level of 3.6 mEq/L D. A 15-year-old diabetic with a blood glucose level of 190 mg/dL

Choice A is correct. Retractions demonstrate increased respiratory effort, meaning the pediatric client is in respiratory distress. Since retractions are a medical emergency and this pediatric client is exhibiting inspiratory retractions, thus indicating respiratory distress, this client should be the first client the nurse assesses.

The nurse observes that a fire has ignited in the client's room. After removing the client from the room, the nurse should then A. activate the fire alarm. B. extinguish the fire. C. contact the nursing supervisor. D. close the door to the client's room.

Choice A is correct. The nurse appropriately removed the client from the room where the fire was located. After removing the client, the nurse must summon help by activating a fire alarm. Activating the fire alarm is the next action because the nurse should not delay getting assistance to the area, and by obtaining aid, the nurse is promoting safety by protecting the other clients. After completing this, the nurse should contain the fire by closing the client's door. Choice B is incorrect. The nurse needs to focus on activating the fire alarm to get assistance. This is the necessary action after removing the client from the immediate area. Choice C is incorrect. Contacting the nursing supervisor is not a priority during a fire-related emergency. The nurse's focus is to obtain assistance from emergency personnel by activating the fire alarm. Choice D is incorrect. Once the fire alarm has been activated, the nurse should close any door(s) to the client's room to prevent the fire and smoke from spreading.

You have been assigned to serve on the Quality Assurance/Performance Improvement Committee. You would expect that the primary focus of this committee is which of the following? A. Outcome measures B. Process measures C. Structural measures D. Identification of individuals who have caused errors

Choice A is correct. You would expect that the primary focus of this committee is outcome measurements and outcome-oriented clinical indicators such as the rate of urinary tract infections over time. The focus of quality assurance and performance improvement activities has evolved from the structure to process outcome-oriented clinical indicators and related activities. All quality assurance and performance improvement activities are conducted in a blame-free environment that aims to identify why things have occurred, rather than on who erred.

When caring for a client new to the general practice clinic, the nurse notes that the woman is "nulliparous." The nurse knows that the term "nullipara" describes: A. A woman who had one pregnancy loss at 25 weeks and no children are live B. A woman who has never given birth to a child. C. A woman who had three prior pregnancies. D. A woman who has never been pregnant.

Choice B is correct. "Nullipara" refers to a woman who has never given birth (live birth or stillbirth). A nulliparous woman may or may not have been pregnant before. It also includes women who have been previously pregnant but have not given birth because of spontaneous miscarriage or elective abortion before 20 weeks of gestation. A woman who experiences pregnancy loss beyond 20 weeks is not included under "nullipara." Choice A is incorrect. A woman who carries a viable pregnancy beyond 20 weeks is not considered nullipara even if she had a stillbirth or pregnancy loss. Choice C is incorrect. A woman who had multiple pregnancies is considered to be multigravida. Choice D is incorrect. A woman who has never been pregnant before is referred to as "nulligravida", not nullipara.

The nurse has received a prescription for apixaban. The nurse understands that this medication is prescribed to treat which condition? Pulmonary Hypertension B. Venous Thromboembolism (VTE) C. Congestive Heart Failure D. Hypertension

Choice B is correct. Apixaban is a factor Xa inhibitor used in the treatment (and prevention) of venous thromboembolism (VTE). The advantage of apixaban is that no therapeutic monitoring is required, unlike warfarin. Choices A, C, and D are incorrect. Apixaban is a factor Xa inhibitor indicated in the treatment and prevention of VTE. It is not indicated for these conditions. Apixaban is a factor Xa inhibitor indicated in treating and preventing venous thromboembolism and stroke. This medication may be used for a client with atrial fibrillation to prevent a stroke. The medication requires no therapeutic monitoring and can be taken with or without food. The antidote for this medication is andexanet.

Which of the following would the nurse expect to be administered to treat a newborn with Respiratory Distress Syndrome (RDS) A. Theophylline B. Colfosceril C. Dexamethasone D. Albuterol

Choice B is correct. Colfosceril palmitate is a medication used as a pulmonary surfactant to treat and prevent respiratory distress syndrome (RDS). A fetus's lungs start making surfactants during the third trimester of pregnancy, or around 26 weeks gestation through labor and delivery. Surfactant coats the insides of the alveoli reducing the surface tension of fluid in the lungs, which helps make the alveoli more stable. This keeps the lungs from collapsing when the newborn exhales. Respiratory distress syndrome (RDS) is a type of neonatal respiratory disease that is most often caused by a lack of surfactant in the lungs. Prevention of RDS is generally desired in babies born at a gestational age less than 32 weeks. In an infant with RDS, colfosceril palmitate may be given via endotracheal tube in two to four doses during the first 24-48 hours after birth. Research shows that these surfactant medications improve respiratory status and decrease the incidence of pneumothorax. Choice A is incorrect. Theophylline is used to treat the symptoms of asthma or other lung conditions that block the airways, such as emphysema or chronic bronchitis. Choice C is incorrect. Corticosteroids are typically given to pregnant women below 34 weeks gestation who are at high risk for preterm delivery. Corticosteroids promote the development of type 1 and type 2 pneumocytes. As the infant approaches "term" gestation, the surfactant is secreted by type 2 pneumocytes. Given antenatally to those women at risk of pre-term delivery, dexamethasone reduces the incidence and severity of RDS in the infants. Postnatally, surfactant administration is the mainstay of treating RDS. Using steroids as frontline treatment in RDS may have growth and neurodevelopmental adverse effects. However, dexamethasone may be considered in infants who require mechanical ventilation between 7 and 21 days of age, who are receiving supplemental oxygen, and are at high risk of neonatal chronic lung disease (CLD)

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN? A. admitted with acute compartment syndrome awaiting emergency surgery. B. with cystic fibrosis who needs an early morning sputum sample collection. C. with acute respiratory failure receiving high-flow oxygen therapy. D. sepsis requiring multiple intravenous (IV) antibiotics and initiation of vasopressors.

Choice B is correct. Collecting a sputum sample is within the scope of practice for an LPN/LVN. Further, cystic fibrosis is a chronic condition that has an acuity level appropriate for an LPN.

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. incompatibility between maternal and fetal blood. C. an excessive amount of circulating white blood cells (WBC). D. erythrocytes become shaped like a sickle and sensitive to hypoxia.

Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. Excessive WBCs would be leukocytosis which is a non-specific indicator of possible infection or inflammation. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia. Add'L info: The use of Rho(D) immune globulin (RhoGAM) to prevent the mother from forming antibodies against Rh-positive blood has greatly decreased the incidence of erythroblastosis fetalis.

The nurse is caring for a client diagnosed with pernicious anemia. The nurse should anticipate a prescription for which medication? A. Thiamine B. Cyanocobalamin C. Iron dextran D. Folic acid

Choice B is correct. Pernicious anemia is characterized by the inability of the body to utilize Vitamin B12. This results in a decrease in hemoglobin, giving the client anemia. The nurse should anticipate a prescription for Vitamin B12, which may be administered parenterally for the greatest benefit. Choices A, C, and D are incorrect. Thiamine is a B-vitamin and is commonly administered for alcohol withdrawal to prevent permanent encephalopathy. Iron dextran is indicated for iron deficiency anemia. Finally, folic acid is administered for folic acid deficiency anemia which may be caused by alcoholism or certain medications such as methotrexate.

A patient who is 2-days postoperative from right femoral popliteal bypass surgery complains of worsening right leg pain. Upon assessment, the RN notes swelling and ecchymosis at the incision sites. Which action would be the nurse's initial priority? A. Apply pressure to sites with sandbag B. Palpate pedal pulses C. Assess for signs of claudication D. Apply warm compress to incision sites

Choice B is correct. The most significant complications this patient is at risk for after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.

The emergency department (ED) nurse triages a client experiencing a panic attack. The client reports nausea, chest discomfort, and a feeling of impending doom. The nurse should plan to take which priority action based on the client's symptoms? A. Assess the client for suicide B. Obtain a 12-lead electrocardiogram (ECG) C. Develop a therapeutic rapport with the client D. Inquire about the precipitating event

Choice B is correct. When a client is experiencing a panic attack, somatic symptoms such as hyperventilation, perspiration, chest discomfort, and nausea are likely. However, the nurse should always prioritize physical needs/reports such as chest pain. The nurse should obtain a 12-lead electrocardiogram as this is an effective way to rule out acute coronary syndrome (ACS). ACS may cause similar symptoms, such as a feeling of impending doom, and the nurse should intervene and obtain this necessary test. Choices A, C, and D are incorrect. These actions are essential. However, they do not prioritize over physical needs. The nurse should assess the client for suicide; however, the time assessing for suicide should be spent determining the physical stability of the client. Developing a therapeutic rapport would be helpful. Inquiring about the precipitating event would be unhelpful during a panic attack because clients cannot solve problems and effectively reflect.

The nurse working on the medical-surgical unit is assigned as a preceptor to work with a newly hired nurse. Which of the following, if performed first by the newly hired nurse, would indicate the ability to prioritize appropriately? A. Teaches a client scheduled for discharge how to ambulate with crutches. B. Witnesses informed consent for a client needing an emergency laparotomy. C. Irrigates a client's ostomy who reports abdominal cramping. D. Calculates the intake and output of a client with diabetes insipidus (DI).

Choice B is correct. Witnessing consent is within the scope of an RN. The client needing emergency surgery will require the RN's initial attention to avoid a delay in care. While the primary healthcare provider (PHCP) may override consent, this is usually reserved for clients who cannot communicate because of their condition. Choices A, C, and D are incorrect. Discharge teaching is a low-priority task, and the nurse should focus on client situations of immediate concern. Irrigating an ostomy for a patient with abdominal cramping is a priority but does not override the client needing emergency surgery. Calculating intake and output is a low-priority task.

A nurse is performing a visual acuity test on a myopic client. Which result would the nurse expect to find? Correct A. +1.25 B. 20/15 C. 20/80 D. 20/27

Choice C is correct. A 20/80 means the client can read at 20 feet what an average person can read at 80 feet. This means the client is myopic. Myopia is often called nearsightedness, as objects in the distance appear blurry to these clients. Visual acuity is usually measured by comparing the client's vision with an average person's vision. A 20/20 vision is normal, indicating normal visual acuity measured at 20 feet. The denominator here refers to what a normal subject can see. When a person has 20/20 vision, it means that person can see clearly at 20 feet what an average person can see at that distance. Similarly, when a person has 20/30 vision, that means the person can see at 20 feet what an average person can see at 30 feet. Choice A is incorrect. Standard vision screenings, like the ones performed in schools using a Snellen eye exam chart solely, often don't detect hyperopia (also referred to as farsightedness). However, a comprehensive eye examination will include the necessary testing to diagnose hyperopia. A +1.25 result is indicative of hyperopia or farsightedness. When a client is affected by hyperopia, objects that appear close to the client will seem out of focus visually. Choice B is incorrect. 20/15 indicates that the client can read at a distance of 20 feet what an average person can read at 15 feet or less. Such a client has better than normal vision, not myopic.

The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test? Incorrect Correct Answer(s): C A. Urine-specific gravity B. Liver function tests C. Blood glucose D. Creatinine kinase

Choice C is correct. A PET scan is primarily indicated to detect cancers and their response to treatment. Before a PET scan, the client is instructed to be nothing by mouth (NPO) four to six hours before the exam and have a glucose level below 150 mg/dL. The reasoning is that this exam primarily looks at cancerous tissue, which uses a substantial amount of glucose. If the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. Glucose greater than 150 mg/dL or less than 60 mg/dL will alter the results. Add'L Info: PET imaging is primarily used to detect cancers, assess the treatment response, and evaluate the extent of metastasis. F-18 fluorodeoxyglucose (FDG) is used during this exam and emits positrons, and the technique often produces images with higher contrast and spatial resolution. Malignant tissue uses a substantial amount of glucose, and if the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. The client is instructed to be NPO 4-6 hours before this exam. The client should be instructed to refrain from vigorous exercise 24- hours before the exam. After the injection of FDG, the client must lie in a quiet room for 60 minutes before the scan.

A client in a psychiatric clinic tells the nurse, "I want to kill my wife. The moment I see her, I am going to kill her." Which of the following should be the nurse's next action? A. Respect the client's right to privacy and confidentiality B. Document the client's statements C. Notify the client's psychiatrist of the comments D. Explore the client's feelings about his wife

Choice C is correct. Confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). This concept is referred to as the 'duty to warn' or 'duty to protect.' These types of situations most often arise when a client reports suicidal ideation (SI), homicidal ideation (HI), or when the client makes a threat against an identifiable third party, even if the threat was made during a private therapy session. Choice A is incorrect. As mentioned above, confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). Choice B is incorrect. Clear and accurate documentation of the client's statements and the context of the conversation is vital; however, the priority for the nurse is to ensure the safety of the client and the client's wife, likely best achieved by prompt reporting of the client's statements to the client's psychiatric health care provider (HCP). Choice D is incorrect. Assisting the client in exploring their feelings regarding their wife would potentially further increase the client's anger toward her. Therefore, this is not an appropriate action for the nurse to take at this time.

The patient tells his nurse that he has no one he trusts to make healthcare decisions if he becomes incapacitated. What should the nurse suggest he prepare? Combination advance medical directive B. Durable power of attorney for health care C. Living will D. Proxy for health care

Choice C is correct. The living will is a document whose precise purpose is to allow individuals to record specific instructions about the type of health care they would like to receive in particular end-of-life or incapacitated states. Choice A is incorrect. The combination advance medical directive appoints a proxy (agent) whom the client trusts to make decisions. The client has stated that he has no one he believes can make decisions for him. Choice B is incorrect. A durable power of attorney for health care appoints an agent that the person trusts to make decisions in the event of incapacity. The patient has told the nurse he has no one that he can trust. Choice D is incorrect. A proxy is an agent. The client has stated he has no one that he trusts to designate.

A nurse educates a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following? A. Ensure that the tested areas are kept moist with a mild lotion B. Keep the tested skin regions out of direct sunlight until after the test has been read C. Wash the test sites daily with mild soap and water D. To return on a specific date to have the test results read

Choice D is correct. It is essential for the nurse to teach the client to return on a specified date to have the test results read by the health care provider (HCP). For a client undergoing skin hypersensitivity testing, test outcomes are determined based on specific hypersensitivity changes (i.e., erythema, wheals, and induration). Therefore, an essential aspect of skin hypersensitivity testing is ensuring the results are read at the appropriate intervals. Although the health care provider (HCP) can analyze immediate hypersensitivity reactions soon after the test is performed, delayed hypersensitivity reactions must be interpreted at a follow-up appointment specified by the HCP (typically 48-72 hours after the initial appointment). Interpretation of the test results before or after this particular timeframe would yield inaccurate and unreliable results. Therefore, the nurse should ensure the client is aware of the date and time of the follow-up appointment and understands the importance of adhering to the appointment to ensure their test results are correctly interpreted. Choice A is incorrect. The tested skin sites should be kept dry and free of any products, including, but limited to, lotion. Each product placed on the testing site(s) increases the risk of altering the test result. Choice B is incorrect. Direct sunlight will not affect the test results. Therefore, educating the client to keep the skin test site out of direct sunlight is unnecessary and inappropriate. Choice C is incorrect. The tested skin sites should be kept dry and free of any products, including, but limited to, mild soap and water. Every product placed on the testing site(s) increases the risk of altering the test result, including mild soaps and water. Learning Objective Recognize the need for a nurse to teach a client who just underwent a skin test for hypersensitivity reactions about the need to return for a scheduled follow-up appointment to allow the health care provider (HCP) to interpret the test results.

Which of the following is a neurological complication that may occur when a vest restraint is too tight around a patient's body? A. Skin breakdown B. Strangulation C. Changes in skin pallor D. Numbness

Choice D is correct. The neurological complication can occur when a vest restraint is too tight around the client's body causing numbness and tingling that, unless corrected, can lead to neurological damage. Choices A, B, and C are incorrect. Skin breakdown, strangulation, and changes in skin pallor can occur when the restraint is too tight. These complications are usually related to the integumentary, respiratory, and circulatory systems, rather than neurological system complications.

The nurse is caring for a client who sustains a traumatic amputation of two fingers. The nurse should apply direct pressure to the severed fingers and wrap them in gauze. B. irrigate the amputated fingers with sterile saline. C. place the amputated fingers directly on ice. D. wrap the fingers in gauze, put it in a plastic bag, and then place the bag in ice water.

Choice D is correct. The nurse should wrap the amputated digits in a dry, sterile gauze or clean cloth. Put the wrapped part in a plastic bag or waterproof container. Place the plastic bag or waterproof container on ice. The nurse should not place the digit(s) directly on ice. The digit(s) should be insulated with gauze and a plastic bag to avoid nerve injury.

The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding? Select all that apply. Diplopia Butterfly rash Facial muscle weakness Shuffling gait Ptosis

Choices A, C, and E are correct. Key clinical features of myasthenia gravis (MG) include diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular.

he nurse is assessing a client with schizophrenia. Which of the following would be an expected finding? Select all that apply. Apraxia Anhedonia Avolition Delusions Bradykinesia

Choices B, C, and D are correct. Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder. Choices A and E are incorrect. Apraxia is defined as being unable to complete a purposeful movement. This is a feature associated with several neurological conditions, such as Alzheimer's disease, but is not a feature of schizophrenia. Echopraxia is common with schizophrenia, this is a positive symptom in which the individual mimics the movements of another individual. Bradykinesia is a feature associated with Parkinson's disease, which is slow motor movements. Additional information: Schizophrenia symptoms are divided into positive or negative symptoms. Positive symptoms include things that add something to the client. They include: Hallucinations: Experiences involving the apparent perception of something not present. They can include any of the five senses: touch, taste, smell, sight, or hearing. Auditory hallucinations, when the client hears something that is not present, are common in schizophrenia. Delusions: Fixed, false beliefs that conflict with reality. Types of delusions include persecution, grandeur, and jealousy Thought and speech disorganization Negative symptoms are things that take something away from the client. They include: Apathy: A lack of interest, enthusiasm, or concern. Alogia: Also known as 'poverty of speech,' alogia is difficulty with speaking or the tendency to speak little due to brain impairment. Anhedonia: The inability to feel pleasure. Avolition: A total lack of motivation that makes it hard to get anything done Flattened affect

The nurse is assigned to take care of a baby who is 31 weeks gestation in the neonatal intensive care unit. Which of the following potential complications must be monitored for in a neonate of this gestational age? Select all that apply. Hypoglycemia Hypothermia Birth injuries Fat wasting Respiratory distress syndrome (RDS)

Hypoglycemia Hypothermia Respiratory distress syndrome (RDS) Choices A, B and E are correct. Infants born before 37 weeks gestation have low stores of glucose and therefore hypoglycemia is a common complication of prematurity. Blood glucose should be monitored closely (Choice A). Preterm infants are at risk for poor thermoregulation and hypothermia due to decreased stores of muscle and fat. Their body temperatures should be regulated via incubator, radiant warming, bundling, or other methods of temperature control, as indicated (Choice B). Neonates born at 31 weeks gestational age are considered premature and are at risk for a number of complications due to their underdeveloped organ systems. Respiratory distress syndrome (Choice E) is a common complication of prematurity, caused by a lack of surfactant in the lungs. Babies with RDS may have difficulty breathing and require oxygen therapy or mechanical ventilation. Choices C and D are incorrect. Birth injuries (Choice C) are not a common complication for preterm infants as they are typically small and don't experience issues during vaginal delivery. This would be a complication to monitor for an infant that is large for gestational age. Fat and muscle wasting (Choice D) are not a common complication of preterm infants. They do not have large muscle and fat stores to begin with. This is common in a baby born post-term, who has wasted fat and muscle stores while in utero. Add'l Info: Some possible complications of prematurity include: ✓ Respiratory distress syndrome (RDS): RDS is a common respiratory complication of premature infants caused by a lack of surfactant in the lungs. ✓Intraventricular hemorrhage (IVH): IVH is bleeding in the brain's ventricles and can occur in premature infants due to the fragility of the blood vessels in the brain. ✓ Patent ductus arteriosus (PDA): PDA is a heart condition in which the ductus arteriosus, a blood vessel that connects the pulmonary artery to the aorta, remains open after birth, allowing oxygen-rich and oxygen-poor blood to mix. ✓ Retinopathy of prematurity (ROP): ROP is an eye disease that can occur in premature infants due to the incomplete development of the blood vessels in the retina.

1800: A 31-year-old primigravida at 38 gestational weeks 100% effaced and 2 cm dilated. Contractions occur every 15 minutes lasting for 20 seconds. The client reports that the contractions are becoming more painful and alternate between cramping and pressure. 1825: Informed consent was obtained by the physician for a planned epidural catheter with the administration of analgesia. Signature was witnessed by the RN. Continuous external fetal monitoring was applied. Normal variability was noted with the fetal heart rate of 110-130/minute. Temperature 98.0° F (37° C) Pulse 91/minute Respirations 16/minute Blood Pressure 138/76 mm Hg Oxygen saturation 95% on room air immediately after placing the epidural, the client is at risk for ____ and the nurse anticipates a prescription for _____?

Hypotension....0.0% Na The most common adverse maternal effect associated with epidural analgesia is the development of maternal hypotension. This effect can be mitigated by infusing 0.9% saline bolus pre-procedurally. Infection may occur with an epidural, but this would not be seen immediately following its placement. Antibiotics are not routinely given before the initiation of epidural analgesia. This type of analgesia would not cause early fetal decelerations or maternal hyperglycemia.

The nurse is caring for a client at 29 weeks gestation who is at risk for delivering preterm. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Methotrexate B. Indomethacin C. Oxytocin D. Folic acid

Indomethacin Choice B is correct. Indomethacin is a cyclooxygenase inhibitor indicated as a tocolytic in preterm labor. This medication relaxes the uterus and therefore decreases uterine contractions. Choices A, C, and D are incorrect. Methotrexate would be significantly contraindicated because of its teratogenic effects. This medication is often utilized in an ectopic pregnancy. Oxytocin would be contraindicated for preterm labor since it causes uterine contractions. Folic acid is useful during pregnancy; however, this medication does not suppress uterine contractions. Add'L Info: ✓ Indomethacin is a tocolytic agent indicated for the prevention of preterm labor. ✓ This medication is given orally and has maternal side effects such as gastritis and reflux. ✓ The adverse effects on the fetus include enterocolitis, cardiac defects, and intraventricular hemorrhage. ✓ This medication is contraindicated if the client has renal or peptic ulcer disease. ✓ Significant caution must be taken because indomethacin may cause cardiovascular defects in the fetus if given after 32 gestational weeks. ✓ If indomethacin is given to the client, it is generally used for less than 48 hours.

The nurse is assessing a 9-month-old infant in the clinic. Which of the following findings requires follow up? Infant sits up with the help of mom. Infant is rolling over from front to back. Infant holds a cube and closes fingers around it. Infant cannot bring toys to their mouth. Infant's weight has doubled since birth. Infant cries when handed to the nurse.

Infant sits up with the help of mom. Infant cannot bring toys to their mouth. Infant's weight has doubled since birth. A is correct. This finding requires follow-up. At 7 months old, the infant should be able to sit up without any support. This milestone is a gross motor skill that should be achieved around 6 to 8 months. So at 9 months old, if the infant still requires help from mom to sit up, this needs to be further evaluated. D is correct. This finding requires follow-up. At 4 months of age, the infants should have developed the fine motor skill of bringing objects to their mouths. This is an important way that infants explore the world around them, and it is not normal for a 9-month-old infant to not be able to bring toys up to their mouth. The nurse should follow up on this finding, as it is abnormal. E is correct. This finding requires follow-up. By 5-6 months, the infant should weigh approximately double their weight at birth. If the infant's weight has only doubled by 9 months, it would require further evaluation. Choice B is incorrect. This does not require any follow-up. Rolling over completely from front to back is a gross motor skill that should be achieved by 6 months of age. At 9 months of age, it is appropriate that the infant is able to do this. Choice C is incorrect. This does not require any follow-up. Holding a cube in the palm of their hand and closing fingers around it describe the palmar grasp, which is a fine motor skill that should be developed by 6 months of age. This is an appropriate developmental milestone for the 9-month-old infant, so no further follow up is needed. Choice F is incorrect. This does not require any follow-up. By 9 months of age, it would be expected that the infant would cry or be fearful of unfamiliar people ("stranger danger").

he nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home? Select all that apply. Positive gag reflex Hypoactive bowel sounds Blood pressure 90/60 mm Hg Incisional pain '2' on a scale of 0 to 10 Urinary output of 240 mL since surgery

Positive gag reflex Hypoactive bowel sounds Incisional pain '2' on a scale of 0 to 10 Urinary output of 240 mL since surgery Choices A, B, D, and E are correct. This client data reflects that the client is ready for discharge home. The client has a positive gag reflex, adequate urinary output (UOP) for the postoperative time frame (> 30 mL/hr), positive bowel sounds, and minimal pain. The client's UOP is high, but it would only be concerning if it were low. Intraoperative IV fluids may be given to explain the surgery that explains the increased UOP. Hypoactive bowel sounds immediately following anesthesia is expected because anesthesia decreases peristalsis. Absent bowel sounds would be a concerning finding. The client's pain is minimal and does not inhibit their ability to be discharged. Colonic motility is typically restored within 72 hours following surgery. Choice C is incorrect. This blood pressure is clinical hypotension and requires correction before discharge. It would be unsafe to discharge the client with this low blood pressure. The nurse should report this finding to the primary healthcare provider.

he nurse is interviewing a 25-year-old female client who recently experienced domestic violence. What is the rationale for excluding the family from the interview to ensure a safe and confidential environment? Select all that apply. Promote client autonomy Maintain family dynamics and support Maintains privacy and confidentiality Prevent potential intimidation or coercion Minimize the risk of retribution

Promote client autonomy Maintains privacy and confidentiality Prevent potential intimidation or coercion Minimize the risk of retribution A is correct. Excluding the family from the interview allows the client to freely express their feelings, concerns, and experiences without potential influence or interference from family members. It promotes client autonomy and empowers the client to share information openly. C is correct. Domestic violence is a sensitive topic, and ensuring a safe and confidential environment is crucial for the client's well-being. Excluding the family helps maintain privacy and confidentiality, fostering trust and allowing clients to feel more comfortable sharing their experiences. D is correct. In situations of domestic violence, the presence of family members during the interview may create a power dynamic that could intimidate or coerce the client. The nurse can help ensure the client's safety and emotional well-being by excluding the family. E is correct. Excluding the family from the interview reduces the risk of retaliation or harm if the client's disclosures reach the perpetrator. This measure prioritizes the client's safety and promotes their trust in the healthcare professional. Choice B is incorrect. B is incorrect. This answer is incorrect because maintaining family dynamics and support may not be appropriate or safe for the client in domestic violence. The priority should be the client's safety and well-being, which sometimes requires excluding the family from the interview to ensure a safe and confidential environment.

stages of Piaget's Stages of Cognitive Development

Sensorimotor Preoperational Concrete operational Formal operational The first stage of Piaget's Stages of Cognitive Development is the sensorimotor stage. This stage occurs between 0 and 2-years-old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their minds to explore. They start to form language and use it for demands. They also develop object permanence. The second stage of Piaget's stages is the preoperational stage. This stage occurs between 2 and 7-years-old. In this stage, the child is a symbolic thinker. They can use language with proper grammar to express their thoughts. Their imagination and intuition are developing rapidly. They are not yet able to think complex abstract thoughts. The third stage is the concrete operational stage. This stage occurs from 7 to 11-years-old. In this stage, concepts are attached to specific situations. The ideas of time, space, and quantity begin to develop. The fourth and last stage in Piaget's stages of cognitive development is the formal operational stage. This stage begins at age 11 and continues into adulthood. In this stage, children can use theoretical, hypothetical, and counterfactual thinking. They can reason and use abstract logic. Planning for future events and using strategy start to become possible. They can learn concepts in one area and apply them to another area.

The nurse is educating staff on infection control. Which of the following statements by the nurse would indicate a correct understanding of infection control guidelines for influenza? Select all that apply. Limiting visitation to 30 minutes per day. Keeping the door to the client's room closed. Wearing a surgical mask when providing care. Placing the client in a room at the end of the hall. Cleaning common surfaces with 70% isopropyl alcohol.

Wearing a surgical mask when providing care. Cleaning common surfaces with 70% isopropyl alcohol. Infected droplets primarily spread influenza. Wearing a surgical mask when providing care is essential. Finally, cleaning common surfaces with a cleaning agent of at least 70% isopropyl alcohol is important as the influenza virus may survive on these surfaces. Add'l Information: Influenza is a highly contagious respiratory infection ✓ Droplet precautions are implemented for suspected/confirmed cases. ✓ The door can remain open as negative pressure is not required. ✓ Infection control measures should include frequent hand hygiene, including alcohol-based hand sanitizers, before and after client care. If the hands become visibly soiled, they should be washed with soap and water. ✓ A surgical mask is necessary to prevent transmission of the infected droplets. The nurse should wear a surgical mask if care is provided within three feet of the client. If the client should leave the room, they will wear the surgical mask.

What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity? REM sleep B. Circadian rhythm C. Diurnal rhythm D. Nocturnal activity

hoice B is correct. Circadian rhythm is the 24-hour internal clock in our brain that regulates cycles of alertness and sleepiness by responding to light changes in our environment. This internally driven rhythm resets every day by the sun's light/dark cycle. The internal body clock sets the timing for many circadian rhythms, which regulate sleep-wake cycles, eating, digestion, body temperature rhythm, hormonal activity, and other bodily functions. Choice A is incorrect. REM sleep is a stage of the sleep cycle, not a term used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity. During REM (rapid eye movement) sleep, the respiratory rate and depth considerably, brain activity increases, and the eyes move rapidly. Most dreams occur during this phase of sleep. Choice C is incorrect. A diurnal rhythm can be either light-driven or clock-driven, as the time of these activities or rhythms can vary. Diurnal rhythms may persist when the client is placed in an environment devoid of time cues, such as constant light or constant darkness. Therefore, the term "diurnal rhythm" is not one used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity. Choice D is incorrect. Nocturnal activity generally refers to an activity occurring during nighttime hours. This term is not used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity.

The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply. pulmonary tuberculosis with multiple prescriptions. ischemic stroke who has left-sided hemiplegia. hyperthyroidism and is scheduled for a thyroidectomy. stage one Alzheimer's disease who lives with family. fractured tibia and fibula and is homeless. end-stage-renal disease who refuses dialysis.

ischemic stroke who has left-sided hemiplegia. fractured tibia and fibula and is homeless. An interdisciplinary care conference is where the nurse can get the necessary medical professionals to develop one big care plan for the client. A client with an ischemic stroke with hemiplegia will require interdisciplinary care such as occupational and physical therapy. Further, the client may require subacute rehabilitation provided by nursing. A client with a fractured tibia and fibula will require physical therapy and social services consultation to assist the client with housing. Clients requiring interdisciplinary conferences are individuals who have complex medical needs requiring multiple services such as social services, therapy, or case management. Choices A, C, D, and F are incorrect. A client with pulmonary tuberculosis requiring multiple prescriptions will require nursing care to reinforce teaching on the therapies. Additionally, a client scheduled for surgery will require nursing care until discharge. Further, a client with stage one Alzheimer's disease can still live independently even with this client is going to reside with family. Finally, a client refusing care will require counseling from nursing and not any other specialty.

The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching? A. "I should avoid getting water in the eye for 3 to 7 days after surgery." B. "It is okay for me to resume normal chores such as vacuuming." C. "It is okay for me to have green or yellow, thick drainage from the eye." D. "I may take aspirin for any pain I may experience."

Choice A is correct. This statement indicates effective teaching by the nurse. Following cataract surgery, the client should not get water in the affected eye for three to seven days. This measure will reduce the potential for infection.

A nurse is instructing a client about prescribed risperidone. Which statements, if made by the client, require follow-up? "I should report any abnormal movements that I develop." B. "I will need to have weekly tests to monitor my white blood cells." C. "If I get muscle stiffness, I should notify my physician." D. "I will need to chew sugarless gum if I develop a dry mouth."

Choice B is correct. Risperidone is a second-generation antipsychotic used in delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate for an individual receiving clozapine. Choices A, C, and D are incorrect. Risperidone is a second-generation antipsychotic which may adversely cause movement disorders such as dystonia or tardive dyskinesia. The client should report any abnormal movements to the provider. Neuroleptic Malignant Syndrome (NMS) is a potentially fatal adverse reaction manifested by muscle rigidity, fever, and tachycardia. This must be reported promptly. Finally, the client should use special mouthwashes and sugar-free gum for dry mouth because of the anticholinergic properties associated with this drug.

You work in a community clinic in a large city. There has been a recent outbreak of meningococcal meningitis at the local university and students who have been in contact with the sick students have been advised by public health officials to obtain prophylactic treatment. Which of the following would be helpful in preventing this disease?SATA Amoxicillin Ciprofloxacin Rifampin Meningococcal conjugate vaccine Vancomycin

Ciprofloxacin Rifampin Meningococcal conjugate vaccine Meningococcal meningitis is transmitted through respiratory droplets from infected individuals. After exposure, symptoms will usually appear within 3 to 4 days. The CDC does not recommend universal prophylaxis during an outbreak, but prophylactic treatment should be provided for individuals in close contact with the infected individuals. A single dose of ciprofloxacin or four doses of rifampin over two days can be useful in preventing the acquisition of the disease. Meningococcal conjugate vaccine (MCV4) is the preferred vaccine for at-risk individuals in this group. College students often receive this vaccination before attending school.

The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. Provide padding to the side rails Verify suction is at bedside and working properly. Keep bite block at bedside in case of seizure. Ensure nasal cannula is available and working at the bedside. Establish peripheral vascular access

choices A, B, and E are correct. Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your client safe. Suctioning the client should only occur once the seizure has terminated, as it is contraindicated to putting objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary.

Hypertonic fluids

draw fluid out of the cell into the blood: 10-20-50% DW 3% NaCl 10: used in the treatment of ketosis providing water and calories 20: Used as an osmotic diuretic causing fluid shift to promote diuresis 50: used in hypoglycemic issues administer rapidly through bolus

Normal sinus rhythm

heart rhythm originating in the sinoatrial node with a rate in patients at rest of 60 to 100 beats per minute

Menopause symptoms

vaginal dryness, hot flashes, irregular or amenorrhea, atrophy of breast tissue, sleep issues

The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply. Gloves being worn to pass out meal trays Sterile water used to irrigate nasogastric tubes Single-use blood pressure cuffs for clients with contact precautions Sterile gloves used to provide perineal care during bed baths New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)

Gloves being worn to pass out meal trays Sterile water used to irrigate nasogastric tubes Sterile gloves used to provide perineal care during bed baths These observations indicate an ineffective use of resources. To promote cost-effective care, the nurse manager should correct these by instructing staff that gloves are not used while passing or retrieving a meal tray. Gloves would only be used during preparing the client's food, as required for dietary staff. Warm tap water is used to irrigate an NGT. The gut is not sterile; therefore, using sterile water would waste resources. Sterile gloves used to provide perineal care during bed baths are not used. During a bed bath, regular (clean) gloves are used and changed frequently during a bed bath.

The nurse in the mental health unit is assessing a client with moderate anxiety. The nurse would anticipate which signs and symptoms to support this finding. Select all that apply.SATA increased pulse the feeling of impending doom reports of headache narrowing of the perceptual field inability to problem-solve or learn hyperventilation

Narrowing of perceptual field, headache, increased pulse Moderate anxiety is characterized by a client experiencing - Narrowing of the perceptual field The slightly scattered thought process The client can problem-solve and learn, although not at an optimal level Somatic symptoms such as headache, urinary urgency, and muscle tension Sympathetic symptoms such as an increased pulse, respiratory rate, palpitations, voice tremors, and shaking

A-Fib

No P waves Causes: Valve disease, heart failure, Pulm. HTN, COPD, and post heart surgery TX: Cardioversion after a TTE (rules out clots) -Long term TX: Digoxin always check ATP before giving A: apical pulse T: Toxicity: (max. 2.0) Visual disturbances, anorexia, and N&V, K+ lower than 3.5 Anticoagulant: Warfarin/Coumadin (INR) anecdote: Vita K eat moderate green leafy veg b/c they have lots of vita K and we don't want to block the warfarin from working

1400: Follow-up assessment after the infusion of 30 mL/kg of 0.9% saline bolus (1850 mL total) was infused. Vital signs: T 103.4° F (39.7° C), P 104, RR 22, BP 90/61, pulse oximetry reading 95% on room air. 1410: The physician was notified of the vital signs, and a verbal order for a dopamine drip was received for 5 mcg/kg/minute to titrate to a MAP of 65 mm Hg. The order was read back and verified. 1415: Dopamine infusion started in the client's right antecubital peripheral vascular access device. 1445: The client reports 'stinging' pain at the vascular access site. The site had erythema, swelling, and tenderness when touched. The infusion was stopped. The nurse reviewed all nursing note entries and notified the physician of the vascular access device assessment findings ➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress: Potential condition: Extravasation, hematoma, infiltration, or Phlebitis Actions to take: Flush the vascular access device, Aspirate any residual me

The client's blood pressure showed no improvement with the infused fluids, which is the standard treatment for sepsis (30 mL/kg). The following action is to initiate a vasopressor to promote tissue perfusion. The client is experiencing extravasation because the dopamine that was infusing is a vesicant. The nurse must act quickly to prevent any neurovascular damage to the affected extremity by stopping the infusion, aspirating any residual medication, discontinuing the vascular access device, and elevating the affected extremity. It was appropriate for the nurse to notify the physician because extravasation may lead to permanent injury. The nurse should obtain a prescription for phentolamine (or topical nitroglycerin if unavailable) and inject it into the subcutaneous tissues surrounding the device. Phentolamine is a vasodilator and aims to reverse any potential tissue damage. The nurse should continue to monitor the client's pain level and neurovascular status of the extremity (sensation, temperature), as this will help determine if the treatment is working or if the injury is worsening. Extravasation can be prevented by infusing vesicants (vancomycin, acyclovir, norepinephrine, dopamine) through central vascular access. While sometimes emergent administration of vasopressors is required by the client's clinical condition, the nurse should closely monitor the vascular access site and ensure that it is infused in a large-bore peripheral IV (18 gauge). The client is not experiencing infiltration, which produces a cold and numbing sensation at the affected extremity. Phlebitis makes a reddened cord-like appearance of the tender vein and is caused by inflammation of the vein triggered by a clot. Hematoma causes swelling in the subcutaneous space, which is often painless. While urinary output should be monitored for a client receiving dopamine, it is irrelevant to the client's extravasation. Additional Info ✓ Dopamine is a vasopressor that, at certain doses, may stimulate the alpha- and beta-receptors to increase mean arterial perfusion (MAP) ✓ The medication is titrated based on the client's MAP ✓ When caring for a client receiving dopamine, the nurse should continuously assess the client's heart rate and rhyt

what medication should be held 48 hours before cardioversion for SVT?

Digoxin

The nurse is caring for a pregnant client who has an order to be on partial bed rest with bathroom privileges. The nurse understands that the side effects of this order can include: Select all that apply. Deep vein thrombosis Fetal demise Alterations in mood Undesirable weight gain Decreased bone density

Deep vein thrombosis Alterations in mood Undesirable weight gain Decreased bone density Choices A, C, D, and E are correct. Prolonged bed rest can result in deep vein thrombosis (Choice A), alterations in mood due to stress and anxiety (Choice C), and undesirable weight gain (Choice D) due to inactivity. Although bed rest is not ordered often, the nurse must understand that compression stockings and ankle exercises might be requested to prevent DVT. The client should have an opportunity to talk about their feelings related to the bedrest. The nurse should consult the nutritionist to work with the client and obstetrician to ensure a healthy diet that takes into account the decreased activity. Prolonged bed rest can lead to decreased bone density(Choice E), which can increase the risk of osteoporosis. Add'L info: ✓ Bed rest during pregnancy is a common recommendation for various pregnancy complications. While bed rest may be beneficial in certain situations, it can also pose some risks and complications. ✓ Some potential complications of bed rest during pregnancy include: ✓ Physical complications: Prolonged bed rest can lead to physical complications such as muscle atrophy, blood clots, pressure ulcers, and bone demineralization. ✓ Psychological complications: Bed rest can also have psychological effects such as anxiety, depression, and social isolation. ✓ Financial burden: Bed rest can increase the financial burden on families due to loss of income and increased medical expenses. ✓ Pregnant women on bed rest are at an increased risk of developing blood clots, also known as venous thromboembolism (VTE), due to factors such as reduced mobility, altered blood flow, and changes in coagulation factors.

Torsades de pointes

Tornado Cause: Post Mi, Hypoxia, LOW MAG TX: MAG. sulfate

bradycardia

Treatment: Atropine only if symptomatic(low perfusion): cool clammy and pallor Caused by: Vagal maneuver (bearing down) Meds: CCB(calms the heart), Beta-blockers (blocks the beats)

Isotonic: Normal saline

Used for shock, fluid changes, metabolic Alkalosis, blood transfusions, HYPOnatremia, DKA CAUTION: Heart Failure, Hypernatremic, edema can lead to fluid overload

Nclex key term: bizarre QRS "Bizzare rhythm with wide QRS complex"

V-Tach or tachycardia

Nclex terms: Chaotic or unorganized EKG ""chaotic rhythm without QRS"

Ventricular Fib

NCLEX terms: LACK of QRS (vetricular) on EkG indicates

asystole

Nclex terms: Chaotic or unorganized EKG "Chatoic rythm with no Pwaves" indicates

atrial fibrillation

Nclex key term: SAWTOOTH

atrial flutter

The nurse is counseling a client about a metered-dose inhaler. Which of the following statements by the client indicates effective teaching? Select all that apply. "I will be careful not to shake the canister before using it." "I will inhale the medication through my nose." "After I deliver a dose, I will hold my breath for 10 seconds." "I will only inhale one spray with one breath." "While holding the mouthpiece away from my mouth, I will take a deep breath and exhale completely."

"After I deliver a dose, I will hold my breath for 10 seconds." "I will only inhale one spray with one breath." "While holding the mouthpiece away from my mouth, I will take a deep breath and exhale completely." Choices C, D, and E are correct. For clients with a metered dose inhaler (MDI), after a dose is administered, they should hold their breath for ten seconds to allow for the medication to be dispersed in their lungs. The client should only administer one dose (or press the button once) per breath. Before the client administers a dose of the medication from the inhaler, the client should hold the MDI away from their mouth, take a deep breath, and exhale completely. This is necessary to empty any residual lung volume and prepares the airway to receive medication.

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. Which statement, if made by the client, would require additional teaching? "It would be best for me not to have sexual intercourse during my pregnancy." "I should abstain from sexual intercourse until I have been fully treated." "It is important for me to increase my fluid intake while being treated." "If I develop a fever or pain in my side, I should come back right away."

"I should abstain from sexual intercourse until I have been fully treated." Rationale: Sexual intercourse is not prohibited during pregnancy. Unless a complication is evident, the client is free to have sexual intercourse. Abstaining for seven days following treatment of an STI is recommended to ensure that the treatment is efficacious. The client is receiving treatment for gonorrhea, and she should be instructed to postpone sexual activity until this time. The client should be instructed to increase her fluid intake as she has cystitis, which is a mainstay treatment for this condition. Fever and pain in her side are concerning and reportable as this is a classic manifestation of pyelonephritis, a complication of cystitis (the infection has ascended at this point).

The nurse is providing education for a diabetic client who is given a terbinafine prescription for onychomycosis. Which statements by the client demonstrate a good understanding regarding the treatment with terbinafine? "Following a successful course of treatment, my chance of getting cured is 90%." "I will have to take terbinafine for 3 to 6 months." "I will need liver function tests before starting terbinafine." "I will take this on an empty stomach to help improve its absorption." "It may cause taste or vision changes, so I will report vision changes to my doctor." "Dark urine, pale stools, and persistent nausea may indicate a serious side effect."

"I will have to take terbinafine for 3 to 6 months." "I will need liver function tests before starting terbinafine" "It may cause taste or vision changes, so I will report vision changes to my doctor." "Dark urine, pale stools, and persistent nausea may indicate a serious side effect." Choices B, C, E, and F are correct. Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). By inhibiting squalene epoxidase, terbinafine blocks the synthesis of ergosterol (Ergosterol is a crucial component of the fungal cell membranes). The nurse should be aware of the interactions and common side effects of terbinafine because it is one of the commonly prescribed antifungal drugs. Client education points include: Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure). The cure rate with terbinafine is close to 50% (Choice A is incorrect). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant (Choice B is correct). Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. To minimize gastrointestinal side effects, terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effects (Choice D is incorrect). Vision changes may also occur. These may represent changes in the retina and must be reported immediately to the provider (Choice E is correct). Rarely, terbinafine can cause severe liver toxicity. This can happen in even those without pre-existing liver disease. Yellow-colored urine, pale stools, jaundice, and persistent nausea may indicate acute liver damage

A nurse is conducting a prenatal class. Which statement, if made by a client, would require follow-up? A. "Since my body mass index is normal, I should be gaining 25-35 pounds." B. "It will be okay for me to continue using sugar substitutes, such as sucralose." C. "Since I am pregnant, I will have to abandon my vegan diet." D. "I will need to keep my caffeine intake less than 200 mg/day."

"Since I am pregnant, I will have to abandon my vegan diet." Choice C is correct. This statement is false and requires follow-up. A vegan diet may be continued during pregnancy if the woman is methodical in her food choices. The concern with vegan diets is the consumption of complete proteins. However, evidence has indicated that plant proteins can meet pregnancy needs. Choices A, B, and D are incorrect. These statements are true and do not require follow-up. For women with a normal BMI, the average weight during pregnancy should be 25-35 pounds. Sugar substitutes are permitted in moderation. The current recommendation for daily caffeine intake is not to exceed 200 mg/day. Add'l Info: Individuals who follow a vegan diet avoid all animal products and may have the most difficulty meeting their nutrient needs. Through careful consideration of foods and supplemental vitamins, it is entirely possible for a woman who follows the vegan diet to have a successful pregnancy.

hypotonic solution

0.45% NaCl For patients who are hypovolemic and hypernatremic

ISOTONIC FLUIDS

0.9% Nacl D5W Lactated Ringer's

A G1P0 client currently in the 28th week of gestation whose blood type is A negative was advised to receive a Rho(D) immune globulin intramuscular injection today. Which statement by the client indicates the need for further teaching about this therapy by the nurse? Incorrect A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" B. "I understand that if we find out my baby is Rh-positive, I'll need another one of these injections after delivery." C. "This shot should help to protect me in future pregnancies if this baby comes out Rh positive, although each future pregnancy will require a repeat dose." D. "This shot will prevent me from making Rh antibodies."

A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" Choice A is correct. Rho(D) immune globulin is administered to Rh-negative mothers to prevent them from producing antibodies against any Rh-positive fetus. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" indicates that the client needs further teaching, as the client is incorrectly summarizing what occurs during Rh incompatibility. During a pregnancy, Rh antibodies produced in the woman's body can cross the placenta and attack fetal blood cells. This can lead to serious health problems, even death, for a fetus or a newborn. Choice B is incorrect. The greatest chance that the blood of an Rh-positive fetus will enter the bloodstream of an Rh-negative client occurs during delivery. In these cases, the client will require a second Rho(D) immune globulin intramuscular injection. Choice C is incorrect. Rho(D) immune globulin intramuscular injection prevents an Rh-negative client from making antibodies that could affect future pregnancies. Each treatment is good only for the pregnancy for which it is given. Each subsequent pregnancy and delivery of an Rh-positive baby will require a repeat dose of Rho(D) immune globulin. Choice D is incorrect. Rho(D) immune globulin prevents maternal sensitization of Rh-positive blood by stopping the body from making Rh antibodies. This can prevent serious health problems, even death, for a fetus or a newborn in current or future pregnancies. Add"l Info: During pregnancy, a single dose of Rho(D) immune globulin should be given prophylactically at weeks 26 to 28 and again within 72 hours of delivery of an Rh-positive infant. Rh factor is an inherited protein (passed down from parent to child) that is attached to one's red blood cells. Health problems usually do not occur during an Rh-negative client's initial pregnancy with an Rh-positive fetus, as the client's body has not had the opportunity to develop many antibodies. An Rh-negative client can also make antibodies following a miscarriage, ectopic pregnancy, and/or an induced abortion. If an Rh-negative client becomes pregnant after one of these events and has not received Rho(D) immune glo

The nurse cares for a client in the emergency department with suspected substance intoxication A 31-year-old male client was brought to the emergency department (ED) by police after being found acting bizarrely at a local park. The client is hyper-alert and oriented. His speech is fast, and repeatedly states that 'someone is after him.' He has vomited twice approximately 100 mL of opaque fluid. Oral temperature 99.5 F (37.5° C) Pulse 110 bpm Respirations 22/minute BP 193/113 mm Hg Oxygen saturation 95% on room air. indicate if it is consistent with alcohol intoxication or amphetamine intoxication or both Paranoia Vomiting Hypertension Tachycardia

Alcohol: Vomit and tachycardia Amphetamine: Paranoia, hypertension, vomiting, and Tachycardia

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications can increase the risk for falls? Select all that apply. Naproxen Alprazolam Bumetanide Verapamil Allopurinol Thiamine

Alprazolam Bumetanide Verapamil Medications that may hasten the risk for falls and included benzodiazepines such as alprazolam. This medication causes drowsiness and may impair judgment. Bumetanide is a loop diuretic; this medication may cause a client to experience orthostatic hypotension and the urgency to use the bathroom. Both of which pose a fall hazard. Verapamil is a calcium channel blocker and is utilized in the management of migraines and hypertension. This medication causes vasodilation; therefore, it will allow the client to become orthostatic if they do not shift positions slowly. Add'L Information: Medications that may raise the risk for falls include any agents that may cause drowsiness (benzodiazepines, opioids), shifts in blood pressure (diuretics, beta-blockers), or alterations to the sensorium (melatonin). The nurse should diligently work to ensure a safe environment for the client and assess their risk for falls.

The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks should the nurse assign to the UAP? A. Obtain a tympanic temperature for a client who received naproxen one hour ago B. Record and empty a closed suction drain for a client recovering from a mastectomy C. Help a client to pick out low-sodium foods on their lunch menu D. Transport a client receiving an infusion of dopamine to the intensive care unit

Choice A is correct. UAPs may obtain vital signs under most circumstances. A tympanic temperature assessment is appropriate after a client receives an antipyretic such as naproxen. This task is appropriate to delegate.

The nurse is taking care of a 9-year-old boy undergoing testing for acute myeloid leukemia (AML). She is assisting with the client's positioning for a lumbar puncture. Which of the following positions is appropriate? .A.Prone B. Trendelenburg C. Supine D. Side lying

Choice D is correct. Side-lying (lateral recumbent) is the most appropriate position for a lumbar puncture (LP). The client's legs are flexed at the knee and pulled towards the chest, while the upper thorax is curved forward in an almost fetal position. A pillow may be placed under the client's head and/or between the legs. This position will allow the health care provider to identify the lumbar vertebrae and insert the needle into the subarachnoid space at the L3-4 or L4-5 interspace. The lateral recumbent position is preferred over the upright position because it allows for accurate measurement of the cerebrospinal fluid (CSF) opening pressure. An upright or sitting position may be used for the LP when the client's lateral position is not feasible.

V fib

EKG: looks sloppy/squiggly lines TX: D-Fib no need to synchronize (cardioversion), Lidocane (cheaper) ,Amiodarone, and procainamide Usually caused by: untreated V-tach, Post MI, electrolyte imbalance, and proarrhythmic meds

assystole

FlatLine TX: Epinephrine, atropine, and CPR DO NOT: SHOCK/ NO D-FIB because technically we need a wave of electricity to shock.

ISOTONIC D5W

For dehydration and fluid loss HYPERnatremia this fluid becomes HYPOTONIC when metabolized DO NOT use for resuscitation Be CAREFUL when using for those w/ renal issues

The nurse is providing care to a postpartum client who delivered a healthy newborn. Which of the following interventions should the nurse include in the plan of care to promote thermoregulation? Select all that apply. Encourage skin-to-skin contact Keep the room warm Swaddle the newborn Place an electric heating pad on the mother Use an incubator when needed, for a newborn that isn't clothed

Encourage skin-to-skin contact Keep the room warm Swaddle the newborn Use an incubator when needed, for a newborn that isn't clothed Encourage and facilitate skin-to-skin contact between the mother and newborn. This allows for direct warmth transfer from the mother's body to the baby, helping the newborn maintain a stable body temperature. Providing a warm environment also helps prevent heat loss and supports the newborn's ability to maintain a stable body temperature. Swaddling the newborn, when skin-to-skin contact is not taking place, helps keep the baby warm and reduces heat loss by minimizing exposure of the body to the environment. Wrapping the baby snugly in a blanket or using a hat helps preserve body heat. The healthy, full-term infant dressed and under blankets can maintain a stable temperature within a wider range of environmental temperatures. The use of an incubator is one of the three main methods for helping maintain thermoregulation in a newborn. Add'l Information In the health newborn assess the temperature shortly after birth and then according to agency policy. Generally, the temperature is assessed every half hour until it has been stable for 2 hours. ✓ Routine assessment and care can be performed while the infant is on the mother's abdomen. ✓ Dry the wet infant quickly with warm towels to prevent heat loss by evaporation. Pay particular attention to drying the hair because the head has a large surface area and hair that remains damp increases heat loss. ✓ Skin-to-skin contact should be encouraged. It provides physiological stability, promotes maternal attachment behaviors, protects from negative effects of separation, supports optimal brain development, and increases breastfeeding rates and duration

Lacted Ringers solution

Indicated for: Burns Hypovolemia GI fluid loss acute blood loss Contains: potassium can cause HYPERkalemia in renal PTs Contradicted: pts w/ liver issues CANNOT metabolize Lactate is converted into bicarb by the liver

The nurse is caring for a client two weeks postpartum with reports of flu-like symptoms, headache, and tenderness to the left breast. On examination, the nurse assesses enlarged axillary lymph nodes. The client is demonstrating manifestations of A. Endometritis B. Mastitis C. Pelvic inflammatory disease D. Cystitis

Mastitis commonly occurs 2-4 weeks postpartum. The client often experiences flu-like symptoms (fever, malaise, and axillary lymphadenopathy). The affected breast usually is tender, has erythema, and is swollen. The client's manifestation classically coincides with this infection. Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn. The organism enters through an injured area on the nipple, such as a crack or blister. The primary medical treatment is antibiotics and continued emptying of the breast. Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics.

what does Magnesium do for the heart?

Mellows out the heart muscles

Client w/ SVT has the following assessment data: HR:200 BP 78/40 RR:30

Priority: Cardioversion!!!! Remember to sync first!

A 27-year-old nulliparous female presented to the clinic stating that she took an over-the-counter urine pregnancy test, which was positive. She states that she is two weeks late for her menstrual period. Her symptoms include nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness. She is not in a committed relationship and uses no contraceptive methods. She reports having multiple sexual partners. She has a negative gynecological and medical history. or each client finding, click to specify if the finding is consistent with pregnancy, gonorrhea, or cystitis. Each client finding may support more than one (1) condition or disease process. Each row must have at least one, but may have more than one, response option selected. Malodorous vaginal discharge Increased urinary frequency Breast tenderness Burning with urination Amenorrhea

Pregnancy: Increased urination Breast tenderness Amenorrhea Gonorrhea: Malodorous vaginal discharge Increased urinary frequency Burning with urination Cystitis: Increased urinary frequency Burning The symptoms that the client is reporting (nausea, fatigue, increased urinary frequency, vaginal discharge that is malodorous, burning with urination, and breast tenderness) may be categorized as a manifestation belonging to pregnancy, gonorrhea, or cystitis. Malodorous vaginal discharge is a classic manifestation associated with gonorrhea. Increased urinary frequency is commonly seen in the first trimester of pregnancy and is also classically found with gonorrhea and cystitis. The fluctuating hormones cause the woman to experience breast tenderness and would be an expected finding with presumptive pregnancy. Burning with urination is not a manifestation associated with pregnancy (only increased urinary frequency) this manifestation of dysuria is associated with cystitis and gonorrhea. The cessation of menses is a classic presumptive pregnancy sign and not associated with cystitis or gonorrhea.

supravetricular tachycardia

SSSSuper fast heartbeat Causes: Strenuous exercise, heart disease, stimulants, hypoxia TX: use the vagal maneuver, ice cold stimulant: ice around the neck Adenosine: may cause heartbeat to stop Cardioversion (always remember to sync first)

A-Flutter

Sawtooth but same symptoms and Tx as A-fib Causes: Valve disease, heart failure, Pulm. HTN, COPD, and post heart surgery TX: Cardioversion after a TTE (rules out clots) -Long term TX: Digoxin always check ATP before giving A: apical pulse T: Toxicity: (max. 2.0) Visual disturbances, anorexia, and N&V, K+ lower than 3.5 Anticoagulant: Warfarin/Coumadin (INR) anecdote: Vita K eat moderate green leafy veg b/c they have lots of vita K and we don't want to block the warfarin from working

According to the National Council of State Boards of Nursing, which of the following are included in the five rights of delegation? Right task Right circumstance Right person Right direction and communication

all choices are correct All of these are among the five rights of delegation, according to the NCSBN. The fifth right is the right supervision and evaluation. The proper task means that the responsibility falls within the scope of practice and job description of the person delegated the responsibility. The right circumstance implies that the patient/client is stable enough to have someone other than an RN be responsible for the job. The right person implies that the person doing the job has the skill and knowledge to complete it safely. The right direction and communication mean that the RN must be very specific in what the job involves and how it should be done. This right also means that the LPN/LVN must also communicate back to the RN about the completion of the task or any problems with the completion. Finally, every job must be monitored by the RN to evaluate the outcomes of the procedure. Documentation should be completed per facility policy, but the RN should always ensure that the documentation is correct and complete.

The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action? A. Notify public health services B. Dim the lights in the assigned room C. Obtain blood cultures D. Explore the client's feelings regarding the diagnosis

choice C is correct. Bacterial meningitis is a medical emergency, and priority actions for the nurse are to assess the client's airway, breathing, and circulation; beyond the assessment of the ABCs and vital signs, the nurse should immediately establish a peripheral vascular access device and obtain blood cultures and laboratory work such as lactic acid and complete blood count. Lactic acid is a marker that may support the co-existing diagnosis of sepsis. The client will need an immediate lumbar puncture which will definitively exclude or confirm the diagnosis of bacterial meningitis. Considering this client has been diagnosed with bacterial meningitis, the nurse must collect blood cultures and then administer prescribed antibiotics that are aggressively dosed. Antibiotics commonly prescribed for bacterial meningitis include ceftriaxone and vancomycin.

3rd degree AV block

if the ps and qs don't agree then you have 3rd degree most deadly blocked at AV nodes assessment: even or extra slow heart rate <40BPM, galloping heart rate, hypoxia, Syncope (fainting) **theses causes and Treatments are the saem for 2nd degree** causes: meds: CCB, Beta-blockers, Digoxin, HX of MI treatment: reset the heart by stopping the meds if that doesnt work then we'll give Atropine (increase heart rate) Dopamine (increase BP), and epinephrine (to do both) to increase CO, if that doesn't work PACEMAKER

The nurse is observing a student collect vital signs on a client. Which action by the student requires the nurse to intervene? Select all that apply. The student: obtains the blood pressure with a cuff bladder width of at least 40% of arm circumference. places the BP cuff over the client's clothing garment. requests the client remove their hearing aid before obtaining a tympanic temperature. assesses the client's respirations after obtaining the pulse rate. obtains blood pressure by placing the client's upper extremity below their heart. places the pulse oximeter probe on the client's finger that has edema.

places the BP cuff over the client's clothing garment. obtains blood pressure by placing the client's upper extremity below their heart. places the pulse oximeter probe on the client's finger that has edema. These actions by the student are incorrect and require the nurse to intervene. The accuracy of blood pressure measurement may be skewed if the cuff is placed over clothes because it may impede blood pressure cuff fit and distort auscultatory sounds. The cuff should be snug over the client's skin. Further, BP results can be inaccurate if the client's extremity is not supported or at the level of their heart. If the arm is unsupported, it may cause a false-high reading. Further, if the arm is above the client's heart, it may cause a false-low reading. Pulse oximeter probes should be applied on an extremity that is non-edematous, has good peripheral blood flow, and is not obstructed by a blood pressure cuff (the cuff should be on the opposite side of the extremity where the pulse oximetry is being measured).

V-tach

tomb stones Causes: Post MI, Hypoxia (o2 low), Low MG and K+ (they're besties) TX: Early D-fib When: V-tach w/ no pulse -or- V-tach w/ pulse CARDIOVERSION (synchronize and sedate first)