nclex reviw

10

Leg cramps often occur when the pregnant woman stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect.

Which information should the nurse provide to the client who will be receiving chemotherapy with doxorubicin? Select all that apply.

1.) Alopecia can occur. 2.) Cardiotoxicity can occur. 3.) Urine and sweat may turn red. 4.)The medication is administered by the intravenous route. 5.) Promptly report any signs of bleeding to the primary health care provider.

A client received a dose of regular insulin this morning at 7:00 am. At which time should the nurse likely anticipate the potential for a hypoglycemic reaction to occur?

10:00 am

13

Antiviral medications may be used in specific client populations. If a person is known to be at high risk for influenza and has been exposed to type A influenza, the provider may choose to provide prophylaxis with an antiviral agent such as amantadine. Amantadine would not be prescribed to prevent bronchitis, pneumonia or tuberculosis.

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

6

Diabetic clients should take in approximately 15 g of carbohydrate every 1 to 2 hours when unable to tolerate food because of illness. Each of the beverages listed in options 1, 2, and 3 provides approximately 13 to 15 g of carbohydrate in a half-cup serving. Mineral water is incorrect for two reasons. First, it contains sodium and should not be used by the client with hypertension. Second, it is not a source of carbohydrates.

8

Many newborns exhibit jaundice in the newborn period. Total bilirubin levels tend to peak on the second and third days after birth. These levels are between 5 and 10 mg/dL in the healthy newborn. Option 2 is not correct because the range given is not elevated for a 2-day-old newborn, and there are no data to support an Rh incompatibility. Term newborns are not treated with phototherapy until their bilirubin is above 12 mg/dL.

A client diagnosed with acute lymphocytic leukemia has been prescribed asparaginase. Which finding represents possible medication toxicity?

Prolonged blood clotting times

7

Propylthiouracil inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

12

Saquinavir is an antiviral medication. It is administered within 2 hours after a full meal. If the medication is taken without food in the stomach, it may result in no antiviral activity.

9

The client with Addison's disease being treated with fludrocortisone needs to notify the primary health care provider of muscle cramps, weight gain, edema, nausea, infection, trauma, stress, or chest pain.

The client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented?

The medication will be temporarily discontinued.

rational 4

The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

rational 1

The signs and symptoms of right-sided heart failure include fatigue; edema in the sacrum, legs, feet, and ankles; hepatomegaly; abdominal distention as a result of ascites; weight gain; and dyspnea. Left-sided signs and symptoms include fatigue, dyspnea, wheezing, orthopnea, sleep apnea, pulmonary edema (pink, frothy sputum), pallor, and clammy skin

The nurse is newly employed in a health agency. The nurse is told that the decision-making process of the organization is based on a centralized structure. The nurse determines that this means that the authority to make decisions is vested in whom?

few individuals such as the board of directors

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse determines to include which essential elements in the discharge teaching guide? Select all that apply

1.) Avoid potentially hepatotoxic over-the-counter drugs. 2.) Teach symptoms of complications and when to seek prompt medical attention. 3.) Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. 4.) Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting.

Fludrocortisone is prescribed for a client with Addison's disease. The primary health care provider needs to be notified if the client experiences which conditions? Select all that apply.

1.) Edema 2.) Chest pain 3.) Muscle cramps

A client with right-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.

1.) Weight gain 2.) Pitting edema

rational 3

Asparaginase can cause severe adverse effects; however, they are often different from those of other anticancer medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. In contrast to most anticancer medications, asparaginase does not depress the bone marrow or cause alopecia, oral ulceration, or intestinal ulceration

14

Because the liver is unable to metabolize many over-the-counter drugs it is important for the client to avoid these. The client and family must also know that cirrhosis of the liver is a chronic condition, and there are many associated complications that require immediate medical intervention. Because of the risk of hemorrhage, spicy food and activities that increase pressure within the portal system must be avoided.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

15

Doxorubicin causes cardiotoxicity, and the client should be monitored for this adverse effect. It also causes alopecia and the urine and sweat to turn red. It is administered by the intravenous route. Because of its vesicant properties, doxorubicin can cause severe local injury if extravasation occurs. Bone marrow suppression can occur, and the client should report signs of this adverse effect to the primary health care provider or caregiver Stool turns white in disorders that block bile secretion, such as cholelithiasis; this does not occur with chemotherapeutic agents.

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which disorder?

Graves' disease

16

Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

5

Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

The nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which beverage does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally?

Mineral water

11

Regular insulin is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. During the peak action of insulin is when hypoglycemic reactions are most likely to occur. This makes option 2 correct.

The primary health care provider has prescribed amantadine for a client admitted to the hospital for hip replacement surgery. The nurse recognizes that this medication was prescribed because the client's history showed recent exposure to which?

Type A influenza

rational 2

With regard to the decision-making process, organizations may be described as having a centralized or decentralized structure. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decision-making involves a number of individuals and filters down to the individual employee, the organization is said to operate in a decentralized fashion.

The nurse is reinforcing medication instructions to the client with a diagnosis of human immunodeficiency virus (HIV) who is prescribed saquinavir. Which instruction should the nurse most appropriately provide the client in regard to taking this medication?

Within 2 hours after a full meal

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges