NCLEX

Nicotine withdrawal

symptoms include headache, nervousness, poor concentration, anger, hunger, and restlessness.

low hemoglobin vital signs

tachycardia as a compensatory mechanism for the low blood volume. Tachycardia is the most reliable and earliest sign of hypovolemic shock.

suppression coping mechanism

the conscious decision to delay addressing a disturbing situation. The client does not exhibit this avoidance because they have taken their anxiety and manifested it as a physical ailment that cannot be explaine

ectopic pregnancy (EP) manifestation

unilateral abdominal (pelvic) pain, vaginal bleeding, and a positive pregnancy test. Rapid management is needed because life-threatening intraabdominal bleeding may occur.

You are the case manager for a client who is expected to have laboratory work done today according to their critical pathway. At the end of your shift, you see that the laboratory work was not done correctly. What would you document in the client's medical record?

variance Choice D is correct. When you see that the laboratory work was not done according to the critical pathway, you will document this as a variance in the client's medical record. When case management and critical pathways are used, all things that are not done as expected are variances.

hazardous medical gases are

• Oxygen: Green or white • Air: Yellow • A combination of oxygen and helium: Green and brown • Nitrous oxide: Blue • Ethylene: Red • A mixture of oxygen and carbon dioxide: Green and gray

The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of:

Choice A is correct. The nurse would believe that the NG tube is correctly placed if the gastric contents are below 3.5 in pH. Stomach contents should be acidic.

The nurse is discussing infection control with a group of nursing students. It would be correct to state that the contact precautions with alcohol-based hand hygiene measures should be sufficient for which of the following conditions?

A. Respiratory Syncytial Virus (RSV) E. Scabies

Artuculation

Articulation refers to the production and use of sounds.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

Acetazolamide Choice A is correct. Acetazolamide is a diuretic and is given either intravenously or orally to a client with angle-closure glaucoma. This medication causes a reduction of aqueous humor which is helpful in the management of angle-closure glaucoma that is marked by an IOP greater than 30 mmHg.

The nurse is caring for a primigravida patient with the following clinical data. The nurse should take which of the following actions based on the result?

Choice A is correct. A reactive NST is an expected finding and indicates fetal well-being.

The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client?

Choices D and E are correct. Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, altered level of consciousness, pupil constriction, and urinary retention.

Displacement

Displacement is the transference of emotions associated with a particular person, object, or situation to another non-threatening person, object, or situation. This client has not transferred their anxiety to someone (or something).

speech quality

Speech quality refers to the characteristic features of an individual's voice.

Lyme disease symptoms

The symptoms start with the classic bullseye rash progressing to lymph node enlargement, arthralgias, malaise, fatigue, and encephalopathy.

Simian crease

a single straight palmar crease; an abnormal finding that is associated with Down Syndrome.

transsphenoidal hypophysectomy

After hypophysectomy, the client should be monitored closely for increased intracranial pressure, headaches, urine output, and vital signs. The client should be instructed to avoid blowing their nose, coughing, or straining. The most serious adverse effect of this surgery is CSF leakage, increased intracranial pressure, infection, and diabetes insipidus. Perioperative and postoperative steroids are routinely prescribed to prevent diabetes insipidus.

Cocaine withdrawal

dysphoric mood, fatigue, insomnia or hypersomnia, and psychomotor agitation.

A mother in a pediatric clinic asks the nurse about the soft spots on her baby's head, and when they are going to harden. The nurse's most appropriate response would be:

"These soft spots are called fontanels. The one on the front closes at 12-18 months, and the one on the back closes at 2 months." Choice A is correct. Fontanels are soft. Anterior fontanels close at 12 - 18 months and posterior fontanels close at 2 months age. Fontanels facilitate the bony plates of the baby's skull to flex and allow the baby's head through the birth canal.

Which of the following is a physiological alteration that can occur with stress?

D. Hyperglycemia Choice D is correct. Hyperglycemia is a physiological alteration that can occur with stress among both diabetic and non-diabetic clients. This hyperglycemia occurred as the result of increased secretion of glucocorticoids and increased gluconeogenesis that is part of the general adaptation syndrome and the "fight or flight" phenomena.

The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse assess the client for hypoglycemia?

1000 Choice B is correct. Regular insulin is short-acting and will peak two to four hours after subcutaneous administration. Assessing the client at 1000 would be when the regular insulin would peak and thus, be the likely time for the client to exhibit hypoglycemia symptoms. The second peak will occur four to twelve hours after administering NPH insulin or around noon.

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?

B. Witnesses informed consent for a patient needing an emergency laparotomy. Choice B is correct. Witnessing consent is within the scope of an RN. The patient needing emergency surgery will require the RN's initial attention to avoid a delay in care.

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?

A. "You will need to lay flat immediately after this procedure." Choice A is correct. A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis. A percutaneous kidney biopsy is indicated for several reasons, including the diagnosis of idiopathic nephrotic syndrome. The client will be positioned prone for the procedure, and immediately following the procedure, the client should be supine for four to six hours to ensure hemostasis. Urine output will be monitored closely post-procedure. The nurse should immediately report any bruising to the area as well as hematuria.

After suffering an injury on the ski slope, a 16-year old boy is picked up by the paramedics. Bystanders say that he hit his head after going off of a jump and was not wearing a helmet. He opens his eyes and grabs at the paramedic's hand when pinched, but isn't making coherent sentences. What is this patient's Glasgow Coma Score?

A. 9 Choice A is correct. This patient scores a 2 for eye-opening, 2 for a verbal response, and 5 for motor response.

Hemophilia is an X-linked recessive disorder. If an unaffected man has a baby with a woman who is a carrier then what percent of their male offspring would be expected to have hemophilia?

25% Choice B is correct. If an unaffected man has a baby with a woman who is a carrier for hemophilia then their male offspring have a 50% chance of having hemophilia. To solve this problem, you should use a Punnett square. The nurse knows that the allele for hemophilia is x-linked; H is the normal allele and h is the abnormal allele. When we complete the Punnett square, we see as follows:

Which statement about patient-controlled analgesia (PCA) is accurate?

A. A client is often given a loading dose of their ordered pain medication before they are able to activate their own titrated dosage.

The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure? Select all that apply.

A. Blood pressure B. End-tidal carbon dioxide [ETCO2] level C. Respiratory rate E. Oxygen saturation

The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?

A C6-C7 spinal cord injury (SCI) can still retain some ability to extend shoulder, arms, and fingers with compromised dexterity in the hands and fingers. The client showing that she can maneuver a wheelchair indicates that she has progressed in therapy. Rehabilitation often will focus on learning to use the non-paralyzed portions of the body to regain varying levels of autonomy. Upon successful treatment, survivors of injuries at the C6/C7 level may be able to drive a modified car with hand controls. The C6 and C7 cervical vertebrae (and the C8 spinal nerve) form the lowest levels of the cervical spine and directly impact the arm and hand muscles. The C6/C7 injury has the potential to change everything below the top of the ribcage, resulting in quadriplegia or paraplegia. Physical therapy is an essential part of recovery. The patient will need to maintain any function not lost by the cord damage, as well as try to regain function. In acute rehabilitation of C6/C7 SCI patients, the focus is on strengthening the upper extremities to the maximal level in patients with complete paraplegia. Empowering exercises for shoulder rotation are proposed for using crutches, swimming, electric bicycles, and walking. At the end of the acute phase, strong upper extremities are needed for the independent transfer from the bed. For this purpose, active and resistance exercises to strengthen the muscles of the upper extremity should be initiated at the earliest possible period. The wheelchair is an essential tool for SCI patients to be mobile and participate in social life.

A nurse is conducting infection control assessments on the nursing unit. Which patient is at greatest risk for infection?

A central line is a significant risk factor for a patient to develop a central line-associated bloodstream infection (CLABSI). This occurs because of suboptimal sterile technique during insertion and/or inappropriate dressing changes. Additionally, TPN is a risk factor as the high glucose content makes the patient more likely to develop a bacterial or fungal infection. TPN increases the risk for a CLABSI compared to solutions such as 0.9% saline.

Malignant hyperthermia

A hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs. Malignant hyperthermia is a rare but potentially fatal adverse reaction to inhaled anesthesia or intravenous succinylcholine. This condition may be genetic. Dantrolene is a muscle relaxant that should be used to treat this emergency.

Which of the following integumentary assessments in the newborn are normal?

A is correct. Lanugo is fine, soft hair that covers the body and limbs. This is a common finding in newborns and is considered normal. B is correct. Milia are small white bumps typically found on the noses and cheeks of newborns. They are very common, considered normal, and usually go away on their own. C is correct. Mongolian spots are usual in newborns. They are a type of birthmark due to the extra pigment in certain parts of the skin. D is correct. Vernix caseosa is the "cheese-like" coating that covers the skin of a newborn immediately after birth. This is a normal finding and should not be removed from the baby until their first bath, as it provides moisture to their skin.

Which of the following growth milestones are expected for female adolescents?

A is correct. Menarche is defined as the first occurrence of menstruation, or the first time a female gets her period. This is one of the most important milestones of female adolescents. It typically occurs about two years after thelarche, or the beginning of breast development. B is correct. Thelarche is defined as the beginning of breast development at the onset of puberty. This is a significant milestone for female adolescents. It can occur anywhere between 8 years of age and 13-years-old, as there is significant individual variation.

Which of the following educational points should the nurse reinforce with the parents of a toddler diagnosed with an imperforate anus?

A is correct. Toilet training for a toddler diagnosed with imperforate anus will take longer than children who do not have this diagnosis. They will need to establish bowel habits and bowel management programs to achieve toilet training. B is correct. Regular bowel habits can indeed be established for toddlers diagnosed with imperforate anus over time. They will need to establish bowel habits and bowel management programs to achieve toilet training. D is correct. Bowel irrigations will help the toddler achieve normal bowel function. They may not need them every day, but bowel irrigations will likely be needed frequently to achieve regular bowel function.

Which of the following are appropriate nursing interventions to prevent aspiration after a child has vomited?

A. Position the child on their side B. Suction the mouth to remove vomitus. Choices A and B are correct. Positioning the child on their side will prevent aspiration and maintain a patent airway (Choice A). Suctioning the mouth will remove any further vomitus keeping the mouth clean and preventing aspiration (Choice B).

The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to:

A. Prevent client injuries Choice A is correct. The primary and ultimate purpose of reporting incidents, accidents, medical errors, and sentinel events is to prevent client injuries.

The nurse is taking care of a client in the fourth stage of labor. She notes that her fundus is firm but she is still bleeding profusely. What should be the nurse's first action?

C. Notify the physician. Choice C is correct. Profuse bleeding may indicate a laceration of the birth canal or cervix, which needs the attention of a doctor to initiate appropriate interventions.

A client is about to receive 1 unit of packed red blood cells. Before beginning the blood transfusion for the client, the nurse should ask which initial question?

A. "Have you experienced receiving a blood transfusion before?" Choice A is correct. Asking about the client's personal experience with transfusion therapy provides a chance for the nurse to evaluate the client's understanding and is a good starting point for the client's education about this procedure.

The nurse is talking to the client about preventing complications of polycythemia vera. Which statement by the client would warrant the nurse to augment teaching?

A. "I'll need to drink half a liter of water or less daily." Choice A is correct. The client needs to drink at least 3 L of fluid daily to prevent clot formation as clients with polycythemia vera are at a high risk of developing clots.

A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?

A. "I'm sorry, but under the law, we're not allowed to witness living wills." Choice A is correct. Nurses and other healthcare workers in the facility where the patient is receiving care are forbidden by law from becoming witnesses.

The nurse counsels a client about a newly inserted copper intrauterine device (IUD) for contraception. It would require follow-up if the client states which of the following?

A. "This device may raise my risk for breast cancer." C. "I should perform weight-bearing exercises." E. "This device may raise my risk for a stroke." Choices A, C, and E are correct. The copper intrauterine device is non-hormonal; therefore, it does not raise the risk of breast cancer. Unlike depot medroxyprogesterone, the IUD does not cause bone demineralization, so weight-bearing exercises are not a relevant teaching point for this type of contraception (where they would be for depot medroxyprogesterone). An increase in cardiovascular disease is not associated with the copper IUD as it is non-hormonal.

A G1P0 client with a blood type A negative is at her 28th-week gestation and was advised a RhoGAM injection today. Which statement by the client indicates the need for further teaching about this therapy?

A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" Choice A is correct. RhoGAM is administered to Rh-negative mothers to prevent them from producing antibodies against their 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.

Which of the following findings is not considered an expected change in the skin of an older adult?

A. Actinic keratoses B. Photoaging C. Solar lentigines Choices A, B, and C are correct. These are not expected changes but occur due to solar damage. The epidermis thins with aging. The epithelium renews itself every 30 days, compared with every 20 days, as in children and younger adults. The decreased activity of cells means that healing takes almost twice as long in older adults. Other changes that occur with aging include degeneration of the elastic fibers providing dermal support, loss of collagen, and a loss of subcutaneous fat. The number of sweat glands and sebaceous glands decreases as a result of atrophy; vascularity and capillary integrity of the skin layer are diminished. Nail beds become more rigid, thicker, and brittle with slowed growth. Hair usually turns gray as a result of decreased melanin. Men often experience hair loss/balding around the fifth decade of life.

A patient presents to the emergency department for palpitations. During the EKG, the nurse notices that the patient's heart rate is 190 bpm. What drug and dosage should the nurse prepare?

A. Adenosine 6 mg Choice A is correct. This patient is experiencing supraventricular tachycardia (SVT). Adenosine is the appropriate medication for this patient. The exact dosage for adenosine should be 6 mg the first time, 12 mg the second time, and 12 mg the third time. These administrations should be a rapid push followed by 20 mL of normal saline. The half-life of adenosine is very short, so this is why timely administration is necessary.

The nurse is caring for a patient with acute pulmonary edema. The nurse should do which of the following?

A. Administer prescribed furosemide D. Notify the Rapid Response Team (RRT) F. Administer prescribed morphine Choices A, D, and F are correct. Acute pulmonary edema is a medical emergency and requires the nurse to act immediately. The nurse should administer the prescribed treatments of morphine and furosemide. Morphine will curb the patient's anxiety as well as decrease the amount of fluid returning to the heart (preload). Further, the nurse will need to stay with the patient, call for help, and notify the rapid response team.

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time?

A. After exercise tolerance is assessed Choice A is correct. Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

The nurse is reviewing prescriptions for assigned patients. Which medication should the nurse question being incorrectly prescribed?

A. Albuterol via nebulizer for a patient with hypokalemia. Choice A is correct. Albuterol is a bronchodilator that is used for asthma exacerbations. Adversely, this medication may lower serum potassium levels. The nurse should question this order as this medication may decrease the potassium further.

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?

A. Alprazolam Choice A is correct. Benzodiazepines should be avoided for a client with hepatic encephalopathy. These medications can worsen the sensorium of a client, therefore, making the client at high risk for falls and injury

The nurse is preparing to admit a newborn diagnosed with tetralogy of Fallot to the neonatal intensive care unit. The nurse knows that to maintain a patent ductus arteriosus the provider will order __________.

A. Alprostadil Choice A is correct. Alprostadil will be administered to keep the ductus arteriosus open, or patent. This will allow more pulmonary blood flow to the child with low oxygen saturations while waiting for surgery.

The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take?

A. Apply a cooling blanket B. Insert indwelling urinary catheter E. Administer prescribed Dantrolene Malignant hyperthermia is a medical emergency and requires the nurse to intervene by applying a cooling blanket and ice to the axilla and groin. The nurse should also monitor the client's urinary output by inserting an indwelling catheter. Hydrating the client is essential because the client risks developing rhabdomyolysis and preventing kidney damage; aggressive hydration is implemented, and its efficacy can be monitored using an indwelling catheter. The nurse should be prepared to administer Dantrolene as this skeletal muscle relaxant is an effective treatment.

The nurse is caring for a one week post-operative right below-the-knee amputation client with peripheral arterial occlusive disease. The nurse cannot palpate a pedal pulse in the client's left foot. What is the nurse's next action?

A. Ask the client if he feels numbness on the left foot and ask him to move his left foot. Choice A is correct. It is common for clients with arterial occlusive disease to have absent pedal pulses. Absent or diminished pedal pulses alone would not warrant immediate action. However, if there are any other signs or symptoms of arterial occlusion or signs of impending gangrene, the nurse must notify the physician. Signs of acute occlusion include pain, pallor, paralysis (loss of function), numbness, and paresthesias. The nurses should first assess the client for numbness in his toes, and whether he can move them. If no other symptoms, there is no need for immediate intervention.

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?

A. Atonic seizure Choice A is correct. Atonic seizures are drop attacks or drop seizures that cause a sudden loss of muscle tone and result in the client collapsing. This is quite serious as this may cause a client to sustain an injury.

Which of the following nursing improvements follow the recommendations of the Institute of Medicine's Committee on Quality Healthcare in America?

A. Basing patient care on continuous healing relationships C. Using evidence-based decision making E. Using safety as a system priority Choices A, C, and E are correct. Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care: Safe: Avoiding injury Useful: Avoiding overuse and underuse Patient-centered: Responding to patient preferences, needs, and values Timely: Reducing waits and delays Efficient: Avoiding waste Equitable: Providing care that does not vary in quality to all recipients

The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client?

A. Blood pressure C. Intravenous site D. Urine output E. Blood glucose Choices A, C, D, and E are correct. An infusion of norepinephrine is indicated if the client is in shock. This medication helps restore vascular tone and is useful in treating life-threatening hypotension. This medication is a vesicant, and the preferred delivery is through a central line. If this is not possible, a large-bore intravenous catheter should be utilized. The patency of this catheter should be assessed frequently to prevent damaging extravasation. Blood pressure needs to be monitored continuously while this medication is administered to assess the desired response of increased vascular tone. This medication causes vasoconstriction, which decreases renal blood flow, thereby decreasing urine output. Norepinephrine causes an increase in blood glucose.

Which of the following hormones are secreted by the thyroid gland?

A. Calcitonin C. Triiodothyronine Choices A and C are correct. The thyroid gland secretes calcitonin. Calcitonin is essential for the regulation of calcium in the body. When released by the thyroid gland, it increases the amount of calcium that is deposited in the bones, therefore decreasing the amount in the blood (Choice A). Triiodothyronine, or T3, is secreted by the thyroid gland. T3 and T4 are the primary hormones secreted by the thyroid gland. They act upon metabolism and 'speed up' everything in the body. Their levels are low in hypothyroidism and high in hyperthyroidism (Choice C).

Which of the following foods is contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression?

A. Calves' liver Choice A is correct. Calves' liver is contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression. Other foods that are contraindicated when the client is taking a monoamine oxidase inhibitor (MAO) for depression include bananas, raisins, cheeses, sour cream, yogurt, beer, red wines, and Italian green beans.

The nurse is taking the history and physical of a woman who has just discovered that she is pregnant. This nurse knows that the purpose of asking a prenatal client about her history with rheumatic fever has the most to do with:

A. Cardiac stress related to a possible valvular lesion. Choice A is correct. Rheumatic fever can cause the formation of valvular lesions, which can lead to cardiac stress during pregnancy.

The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to:

A. Check for bladder distention Choice A is correct. A displaced fundus is an indication of a distended bladder. The nurse should assess the client for bladder distention and encourage the client to empty her bladder.

The nurse is educating staff on antipsychotics. It would be correct to identify which medication is a typical (first generation) antipsychotic?

A. Chlorpromazine D. Fluphenazine Haloperidol Choices A, D, and F are correct. Typical antipsychotics were the first generation of medications used in the treatment of schizophrenia. These medications are dopamine receptor antagonists.

You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following?

A. Complete a puzzle with 5 or more pieces B. Copy a triangle onto a piece of paper C. Dress himself D. Use a fork to eat dinner Choices A, B, C, and D are all correct. These are all fine motor skills that are expected in preschool-age children, who are 3 to 5 years old. Other fine motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, and brushing their teeth.

Which of the following are signs of brainstem involvement in a pediatric patient with a neurologic injury?

A. Dilated pupils C. Bradycardia Choices A and C are correct. Sluggish, dilated, or unequal pupils are all signs of brainstem involvement and should be reported to the healthcare provider immediately (Choice A). Bradycardia, slowing of the pulse, or wide fluctuations in the heart rate are all signs of brainstem involvement and should be reported to the healthcare provider immediately (Choice C).

Select the normal physiological changes associated with the aging process that can adversely affect the excretion and elimination of medications in the human body.

A. Diminished glomerular filtration F. Low functioning nephrons Choices A and F are correct. As people age, several physiological changes occur. Many of these changes impact the pharmacokinetics and pharmacodynamics of medications. The regular physiological changes associated with the aging process that can adversely affect the excretion and elimination of drugs in the human body are the aging population's low functioning nephrons and diminished glomerular filtration. These changes can lead to the accumulation of medications in the body because they are not properly eliminated.

The nurse is caring for an 82-year-old male in end-stage renal failure. Upon assessment, she notes dyspnea auscultates crackles and rales in his lungs. Which of the following signs and symptoms does she also expect?

A. Distended neck veins B. Weight gain C. Bounding pulses A is correct. A patient in end stage renal failure often experiences fluid volume excess due to their kidney dysfunction. The kidneys are unable to concentrate urine as they should and therefore large volumes of fluid are retained causing a fluid volume excess. The nurse has appreciated dyspnea, rales, and crackles on her assessment, which are all signs of fluid volume excess due to increased fluid in the lungs. Distended neck veins are another sign of fluid volume excess that she would expect to find. With the increased fluid volumes, veins of the neck appear distended. This can also be appreciated in the veins on the back of the hands. B is correct. Weight gain is another sign of fluid volume excess that the nurse would expect to find. Due to fluid accumulation with end stage renal failure, large amounts of weight can be gained due to fluid. C is correct. Bounding pulses are another sign of fluid volume excess that the nurse would expect to find. Due to the fluid retention that occurs in end stage renal failure, there are larger than normal quantities of fluid in the vascular system leading to bounding pulses.

The nurse is assisting with monitoring a client that has a chest tube and documents the appropriate assessments. Which of these assessments are expected findings?

A. Drainage system at a level below the patient's chest. D. Occlusive dressing over the chest tube. Choices A and D are correct. It is expected that the drainage system will be at a level below the client's chest. This is what allows gravity to help drain fluid from the pleural space. If the drainage system was above the client's chest, the chest tube would not work properly (Choice A). An occlusive dressing placed over the chest tube is appropriate. This is important to ensure that air does not enter the pleural space causing a pneumothorax. The nurse should check the dressing to ensure that it is airtight (Choice D).

Which of the following is the definition of death established in the Uniform Determination of Death Act of 1981?

A. Either irreversible cessation of circulatory and respiratory functions; or irreversible cessation of all functions of the entire brain including the brain-stem. Choice A is correct. The Uniform Determination of Death Act of 1981 defines death as either irreversible cessation of circulatory and respiratory functions OR the irreversible cessation of all functions of the entire brain, including the brainstem.

A client receiving chemotherapy (Cisplatin) for ovarian cancer suffers nausea and vomiting. The nurse's most important role in this is which of the following?

A. Evaluate onset, frequency, and severity of symptoms Choice A is correct. The nurse needs to assess the symptoms in terms of onset, frequency, and severity to point out patterns and help the nurse collaborate with the physician in scheduling round-the-clock emetic therapy.

The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by:

A. Fever E. Infection Choices A and E are correct. Delirium is an alteration in mental status that occurs abruptly. Delirium, unlike dementia, is reversible with treatment. Contributing factors for delirium include fever, hypoglycemia, and infection.

You are caring for a toddler who is experiencing pain as the result of a tonsillectomy. Which independent nursing intervention would you implement in terms of this pain?

A. Give the toddler a "magic" blanket to take the pain away. Choice A is correct. The independent nursing intervention you would implement for a toddler who is experiencing pain as the result of a tonsillectomy is to give the toddler a "magic" blanket to take the pain away. Toddlers are magical and mystical thinkers so this "magic" blanket may be an effective pain management technique for children of this age.

The nurse is educating a new nurse working on the pediatric unit about the causes of bacterial tonsillitis in children. Which of the following is the most common cause of bacterial tonsillitis?

A. Group A beta hemolytic streptococcus Choice A is correct. Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis.

Religious and cultural rituals/practices often surround death. Which of the following populations prefer cremations rather than burying the remains of the deceased person?

A. Hindus Choice A is correct. The Hindus prefer cremations rather than burying the remains of the deceased person. The ashes are then typically spread over the holy river. Cremations are viewed as discouraged or forbidden among those who practice Islam, Mormonism, and the Eastern Orthodox religion.

Lumbar puncture was performed on a client for a myelogram. After the procedure, he complains of severe headache. The most appropriate nursing intervention is:

A. Increase the client's oral fluid intake Choice A is correct. A headache following a lumbar puncture is usually caused by leakage of cerebrospinal fluid (CSF). Increasing fluid intake would facilitate the restoration of CSF volume.

You are taking care of an infant newly diagnosed with hydrocephalus. Which of the following assessment findings do you expect?

A. Increased head circumference B. Macewen's sign D. Setting sun eyes A is correct. The increased head circumference is due to an increasing amount of CSF in the cranial vault due to impaired absorption within the subarachnoid space. This is often the first and most noticeable sign of hydrocephalus. B is correct. Macewen's sign is an indication of hydrocephalus. This sign is positive when the nurse percusses the skull bones and hears a 'cracked-pot' sound. This sound is due to thin, widely separated skull bones present with hydrocephalus. D is correct. Setting sun eyes is an assessment finding found in children with hydrocephalus that has progressed so far it is causing increased ICP. The child looks as if they are always looking down with more prominent sclera in the top part of their eyes.

Your client has a stat order for a cooling or hypothermia blanket. After you call the appropriate department, the cooling blanket is delivered to your nursing care unit. What is the first thing you should do concerning this stat order?

A. Inspect and run the equipment prior to use. Choice A is correct. You must thoroughly inspect and run the equipment before use to ensure that it is appropriately functioning BEFORE it is used. This inspection should include an overall assessment for frayed electrical cords and documented evidence that the piece of equipment has had the mandated preventive maintenance and safety inspections according to the facility's policies and procedure.

A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself forming an obstruction is called what?

A. Intussusception Choice A is correct. A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself, forming an obstruction, is called intussusception.

The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned patients. Which of the following actions by the LPN would require the RN to intervene?

A. Irrigates an indwelling catheter with warm tap water. D. Clamps a chest tube while the patient ambulates. E. Repositions a patient who requires log rolling by using a gait belt Choices A, D, and E are correct. An indwelling catheter is irrigated with sterile water or sterile normal saline. Irrigating an indwelling catheter with tap water would introduce pathogens into the bladder. A chest tube should never be clamped as it will cause a rapid increase in intrathoracic pressure, which may cause a tension pneumothorax. A patient requiring log rolling should be repositioned with more than one staff member and with a transfer sheet. A gait belt is used when a patient is ambulating.

Which of the following statements regarding the infection impetigo are true?

A. It is the most common bacterial skin infection between the ages of 2 and 5. D. Impetigo is not usually a systemic infection. A is correct. This is a true statement. Impetigo is the most common bacterial skin infection amongst 2 to 5-year-olds. It is highly contagious and precautions should be taken to prevent the spread of the disease amongst families, daycare centers, and schools. D is correct. Impetigo is not usually a systemic infection. In most cases, the infection is confined only to the skin where the sores break out - most commonly the area around the nose, mouth, hands, and feet. Topical antibiotics can usually treat impetigo. The child is well appearing other than the obvious skin infection and usually remains afebrile.

While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient's injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing?

A. Keeping the pulley system tightened so that they may not move freely Choice A is correct. The nurse caring for a patient in traction should avoid keeping the pulley system tight. The pulley system should move freely uninhibited by knots or tension. Traction is used to reduce and immobilize a fracture.

A panicked mother brings her 8-year old son into the clinic after noticing that he will not eat. The patient only wants to drink water and is continuously urinating. After seeing that the patient's blood sugar level is 657 mg/dL, the nurse prepares to insert an IV. Which of the following critical assessment findings should concern the nurse?

A. Listlessness Choice A is correct. This patient is experiencing diabetic ketoacidosis (DKA). "Listlessness" refers to a decreased level of alertness, lassitude, or lethargy. If this patient is not entirely responsive or responding at all, he may be headed towards a diabetic coma. In that case, further assessments should be performed, such as airway, breathing, and circulation, along with hyperglycemia precautions.

Documenting the statement, "Normal speech is audible", would be a normal finding for which speech quality?

A. Loudness Choice A is correct. The term "audible" refers to the loudness of something. Characteristics of speech to evaluate include rate, rhythm, loudness, fluency, quantity, articulation, content, and pattern.

The nurse is assessing a client with Lyme disease. Which of the following would be an expected finding?

A. Lymphadenopathy B. Fatigue D. Arthralgias Choices A, B, and D are correct. Classic features of Lyme disease include erythema migrans which is a bullseye type appearing rash. Additional features of Lyme disease include myalgias, arthralgias, fatigue, lymphadenopathy, and conjunctivitis.

The nurse is counseling a female client newly diagnosed with herpes simplex virus in the genitals. Which symptoms should the nurse educate the client to expect before an outbreak? Select all that apply.

A. Lymphadenopathy C. Paresthesia E. Malaise Choices A, C, and E are correct. The initial outbreak of herpes simplex is often the worst (as it pertains to symptoms). Clients typically experience prodromal symptoms such as headaches, a low-grade fever, malaise, paresthesia, and itching at the site of the outbreak. Then the client will experience the eruption of the painful vesicles.

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following?

A. Maternal antibodies are present on the infant's red blood cells. C. The infant is at risk for erythroblastosis fetalis. A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C).

Which of the following are complications of acute tubular necrosis (ATN)?

A. Metabolic acidosis C. Hyponatremia Choice A is correct. The kidneys cannot excrete excess hydrogen ions or reabsorb bicarbonate with ATN. Due to the inability to excrete the excess acid (hydrogen ions) paired with the inability to hang on to the needed base (bicarbonate), acidosis ensues. This is due to the malfunction of the kidneys, not the lungs, so it is classified as metabolic acidosis. Choice C is correct. ATN can cause hyponatremia. Due to lower urinary output, there is hypervolemia. With fluid retention and high volume remaining in the blood vessels, the amount of sodium in the body is diluted. This is called relative dilutional hyponatremia.

Which of the following are functions of parathyroid hormone (PTH)?

A. Moves calcium from bones to the bloodstream B. Promotes renal tubular reabsorption of calcium C. Enhances renal production of vitamin D metabolites Choices A, B, and C are correct. All of these options are functions of parathyroid hormone. Electrolytes are present in all body fluids and fluid compartments. Just as maintaining fluid balance is vital to normal body functioning, so is maintaining electrolyte balance. Although the concentration of specific electrolytes differs between fluid compartments, a balance of cations (positively charged ions) and anions (negatively charged ions) always exists. Electrolytes are essential for maintaining fluid balance that contributes to acid-base regulation, facilitating enzyme reactions, and transmitting neuromuscular reactions. Most electrolytes enter the body through dietary intake and are excreted in the urine. Some electrolytes, such as sodium chloride and potassium, are not stored by the body and must be consumed daily to maintain healthy levels. Other electrolytes, such as calcium, are stored in the body; when serum levels drop, ions can shift out of storage into the blood to maintain adequate serum levels for normal functioning, at least in the short term.

Which of the following are classic manifestations of nephrotic syndrome?

A. Proteinuria B. Hypoalbuminemia C. Edema Choices A, B, and C are correct. Nephrotic syndrome is a kidney disorder. There is renal glomerular damage, which leads to massive proteinuria. Proteinuria is the increased amount of protein in the urine due to a loss of protein from the bloodstream. Because protein from the bloodstream is being lost in the urine, there is decreased protein in the bloodstream. This is can be referred to as hypoproteinemia, or hypoalbuminemia, as albumin is the type of protein lost in the bloodstream. This hypoalbuminemia causes decreased oncotic pressure in the vasculature, causing profound edema. Proteinuria is the first classic manifestation of nephrotic syndrome (Choice A). Hypoalbuminemia is the second classic manifestation of nephrotic syndrome (Choice B). Edema is the third classic manifestation of nephrotic syndrome (Choice C).

The LPN is assigned to take care of a patient with hemophilia. When she reviews the lab values, she would expect to find which of the following?

A. Normal PT level B. Abnormal PTT level C. Normal thrombin time A is correct. Patients with hemophilia will have an average PT level, between 11 and 13.5. The Prothrombin time test measures the time necessary to generate fibrin after activation of factor VII. This evaluates the extrinsic pathway: Factors V, X, prothrombin, and fibrinogen. Since patients with hemophilia have deficiencies in factors XIII, IX, or XI depending on their sub-type, this test result will be reasonable. B is correct. Patients with hemophilia will have an abnormal PTT level. The partial thromboplastin time measures the integrity of the intrinsic clotting cascade, evaluating factors XII, XI, VIII, and IX. Since these are the factors in which a deficiency leads to a type of hemophilia, this level will be abnormal in patients with hemophilia. It is prolonged from the regular 25 to 35 seconds, meaning that it takes the blood longer than usual to clot. C is correct. Patients with hemophilia will have a standard thrombin time. Thrombin time assesses how long it takes fibrin to form from fibrinogen in plasma. This is not part of the clotting cascade that patients with hemophilia have a deficiency in, so there is no abnormality. Their value will be reasonable, between 12 and 14 seconds.

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take?

A. Notify the rapid response team (RRT). Choice A is correct. This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider. Inflammation from pneumonia may cause a client to develop ARDS. A classic manifestation of ARDS is hypoxemia (PaO2 less than 80 mm Hg). Adventitious lung sounds are not normally auscultated initially with ARDS and are not a reliable assessment. Treatment for ARDS is correcting the underlying cause and maintaining adequate oxygenation and ventilation via invasive and non-invasive means. The normal PaO2 is 80-100 mm Hg, and the normal SpO2 is greater than 95%.

A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action?

A. Obtain a 12-lead electrocardiogram Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI.

A 9-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration tomorrow. Regarding his informed consent, which initial nursing action is most appropriate?

A. Obtain assent from the child. Choice A is correct. The child needs to have some control and input in the decision-making process regarding his care. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent.

The nurse is assessing a client for bacterial meningitis. Which of the following assessments should the nurse perform?

A. Oral temperature D. Glasgow Coma Scale Choices A and D are correct. Bacterial meningitis manifests as a stiff neck, photophobia, fever, altered mental status, and malaise. The nurse would need to perform an oral temperature and the Glasgow Coma Scale to discern the client's current mental status.

Which of the following components should the nurse know to include in handoff after their shift? Select all that apply.

A. PRN medications administered Choice A is correct. Medications administered as needed should be included in the nursing handoff. The nursing handoff should review the client's condition during the past shift accurately, but quickly. Important information about the client and what has occurred over the recent change is essential to include; therefore PRN medications would be included in the handoff report. The nursing handoff should review the client's condition during the past shift accurately but quickly. As needed, medications, changes in the client's situation, interventions, and the client's response to such interventions are part of the nursing handoff

The nurse is caring for a client that underwent a total knee arthroplasty the previous day. The nurse will include which intervention in the patient's care plan?

A. Place the client on a continuous passive motion exerciser for 6-8 hours a day. Choice A is correct. The client is placed on a continuous passive motion exerciser for a minimum of 6-8 hours a day. This ensures that the knee is having its maximal range of motion, which is the goal for rehabilitation.

While working in the ICU, you are caring for a client receiving Total Parenteral Nutrition (TPN). Which of the following complications should the nurse monitor while this client receives TPN?

A. Pneumothorax B. Infection C. Air embolism Choices A, B, and C are correct. Pneumothorax is a possible complication of TPN administration. This is usually caused by incorrect catheter placement and is a medical emergency that requires the nurse to notify the health care provider immediately. Infection is a possible complication of TPN administration due to poor aseptic technique, contamination of the catheter, or contamination of the TPN solution itself. To prevent disease, the nurse should use careful aseptic technique when dealing with the catheter, monitor the patient's temperature, and frequently assess the IV site for signs of infection. Air embolism is a possible complication of TPN administration if the catheter system is opened or disconnected, allowing air to enter the IV tubing instead of the TPN solution. It is a nursing responsibility to ensure air never enters the catheter system by clamping all connections and ensuring the pipe is connected correctly.

You are teaching a group of new graduate nurses about the long term effects of congestive heart failure. You know that they understand your teaching when they state the following expected findings.

A. Polycythemia B. Clubbing A is correct. Polycythemia is defined as an abnormally increased concentration of hemoglobin in the blood; it is a serious long term effect of congestive heart failure. It is due to the effects of chronic hypoxia on the body. The body senses the decrease in oxygen and increases its production of red blood cells in order to carry more oxygen to the body. The problem is that there is no more oxygen available, so the body continues to be hypoxic, and continues to produce red blood cells in an attempt to correct this. After a while of overproducing red blood cells, the blood becomes very thick.

The RN and the LPN are caring for a client who is in four-point restraints due to combative behavior. Which of the following tasks may the nurse assign to the LPN/LVN?

A. Re-assess the patient's skin integrity around the restraints hourly. Choice A is correct. While in restraints, combative patients should be assessed hourly and non-combative patients every two hours to ensure that skin breakdown around the restraints has not occurred. LPN/LVN is not allowed to do an initial or comprehensive assessment, but a re-assessment on a stable patient is within their scope of practice.

The nurse is planning to utilize reminiscence with an elderly client. Which of the following are not the nurse's roles in this type of intervention?

A. Remind the client when she repeats herself B. Probe for details of memories shared C. Focus on happy memories Choices A, B, and C are correct. Reminiscence allows an elderly client to share his thoughts and feelings about experiences in his life. It can be a useful assessment tool for nurses to gauge a patient's cognitive functioning. At times, especially if a client is very forgetful, it can be easy to interrupt or direct a patient's thoughts. While asking direct questions is acceptable, clients should be allowed time to think and talk for themselves. Elder clients should be allowed to repeat themselves during a discussion without having attention drawn to their repetition. Reminiscence therapy should enable clients to share both happy and sad memories. The sharing of both should be encouraged. Nurses should avoid pushing for details. The client should be allowed to share his thoughts, informally, and spontaneously.

The nurse is assessing a patient for bladder trauma after a car accident. Bladder trauma is suspected when the patient experiences referred pain to which of the following areas?

A. Shoulder Choice A is correct. The nurse would be right to suspect a bladder injury if the pain is radiating (referred) to the patient's shoulder. When there is pain sensation at a site other than the original location of the painful stimulus/injury, it is known as referred pain.

Which forms of nonverbal communication can be viewed differently among members of different and diverse cultures?

A. Silence C. Eye contact D. Touch E. Bodily posture Choices A, C, D, and E are correct. Silence, eye contact, touch, and bodily posture are all forms of nonverbal communication that can be viewed and perceived differently among members of different and diverse cultures. Some cultures can see silence to be a lack of attention, while others can perceive silence as a compassionate way that understanding is conveyed. Some view eye contact as aggressive and hostile while other cultures see eye contact as connectedness with others. Some cultures perceive touch as inappropriate and invasive while others recognize touch as a sign of caring and compassion. Lastly, many bodily postures and gestures differ significantly among various cultures. A smile is a relatively universal sign of joy and happiness.

The RN performs palpation and percussion in a head-to-toe assessment. Over what organ would he/she expect to hear tympany when percussed?

A. Stomach Choice A is correct. Tympany refers to a high, loud, drum-like tone that can be heard with percussion over air-containing organs. The stomach and intestines would produce tympany in a healthy adult.

A patient reports feeling numbness of the throat and tongue after taking Benzonatate. Which of the following should the nurse instruct the patient?

A. Swallow the medication without chewing it Choice A is correct. The patient should be instructed to swallow the capsules without chewing, as the medication in the capsules will cause numbness of the throat and tongue. Benzonatate is a popular antitussive. It does not act on the cough center. Instead, benzonatate has an anesthetic-like effect on stretch receptors in the lung, which interrupts the cough "message."

While working in an outpatient clinic, you take vital signs for a woman who expresses her interest in using herbal therapies to treat her chronic back pain. As a nurse, you know that herbal therapies can be safe when used properly, but should be closely monitored. You review the following teaching points with her to ensure her safe use of any herbal therapies.

A. Tell your health care provider about any herbal therapies you are using. B. Only take the recommended dose of the herbal therapy to avoid any toxicity. C. Continue taking your prescribed medications from your healthcare provider; never stop taking a medication without talking to your health care provider. Choices A, B, and C are correct. The nurse should teach the patient to tell her healthcare provider about any and all herbal therapies she is using. It is important for the patient to understand that these therapies should be treated as seriously as any medication and that her healthcare provider will need to know everything she is taking to prevent any side effects or adverse reactions. Herbal therapies used in doses higher than what is recommended can quickly become toxic and the client should be instructed on this. Discontinuing a prescribed medication, even if adding an herbal therapy, is never recommended and could be dangerous. The client should be educated never to do this.

You are caring for a client with chronic pain secondary to degenerative arthritis and osteoporosis. What information should you primarily consider in terms of this client's pain assessment?

A. The client's performance in terms of their basic activities of daily living. Choice A is correct. The client's performance of their necessary activities of daily living should be primarily considered and collected for this client's chronic pain assessment. Other assessment information should include a complete pain history, the location, duration, character, and intensity of the pain in addition to assessing other characteristics of chronic pain, including client withdrawal, client depression, and indications that the parasympathetic nervous system is activated.

The nurse is caring for a client with dementia who is unable to self-report pain. Which of the following would the nurse recognize as appropriate actions included in the Hierarchy of Pain Assessment?

A. The identification of underlying conditions that are associated with pain. C. The physiological indicators of pain. E. The behavioral indicators of pain. F. Attempts to get self-reports of pain. G. An analgesic trial to confirm pain. The following are included in the "Hierarchy of pain assessment" that is used when a client is unable to self-report pain: The identification of underlying conditions associated with pain The physiological indicators of pain The behavioral indicators of pain Attempts to get self-reports of pain An analgesic trial to confirm pain

A post-hemorrhoidectomy client is ready for discharge to home. The nurse should highlight which point in the discharge instructions?

A. The proper technique for sitz bath Choice A is correct. It is important that the client expose the operative site to warm, moist heat, such as a sitz bath, 3-4 times a day for several days post-hemorrhoidectomy.

A patient with a chest tube drainage system has just been admitted to the unit. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that:

A. There may be fibrin clots in the tubing Choice A is correct. Fibrin clots from the lungs sometimes become lodged in the chest tube system resulting in the cessation of fluctuations in the water seal column. This may also occur when the lung becomes fully expanded.

The nurse is caring for a client with a phosphorus level of 5.3 mg/dL. The nurse identifies which of the following as possible causes of this condition?

A. Tumor lysis syndrome B. Hypoparathyroidism D. Renal failure A is correct. This client has a phosphorus level of 5.3, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including phosphorus) are spilled out into the blood causing an increase in their serum levels. B is correct. Hypoparathyroidism is a cause of hyperphosphatemia. The client who experiences hypoparathyroidism has too little parathyroid hormone (PTH). PTH regulates the serum calcium concentration through its effects on the bones, kidneys, and intestines. When there is too little PTH, there are decreased calcium levels (hypocalcemia). Since calcium and phosphorus have an inverse relationship, when there are low levels of calcium there are high levels of phosphorus. Thus, hypoparathyroidism causes hyperphosphatemia. D is correct. Renal failure is a cause of hyperphosphatemia. Due to reduced kidney function, phosphorus is not able to be excreted as readily as it normally would, so increased levels of phosphorus build up in the blood causing hyperphosphatemia.

The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply.

A. Unilateral frontotemporal pain B. Nausea C. Photophobia Vomiting Unilateral frontotemporal pain that may be described as throbbing or dull Sensitivity to light (photophobia) and sound (phonophobia) Nausea and/or vomiting Altered mentation (drowsiness) Dizziness, numbness, and tingling sensations

The nurse is caring for an assigned client. Which prescription requires clarification based on the laboratory data?

A. Vancomycin 1-gram IVPB Daily B. Furosemide 40 mg PO Daily E. Ketorolac 15 mg IV Q 8 hours Choices A, B, and E are correct. The prescribed vancomycin, furosemide, and ketorolac are all medications that should be clarified with the PHCP based on the BUN and creatinine being elevated. These elevations represent renal insufficiency. All three of these medications are nephrotoxic. Vancomycin is an antibiotic indicated for MRSA infections. Furosemide is used for cardiovascular disorders such as congestive heart failure, and ketorolac is a non-steroidal anti-inflammatory (NSAID) indicated for mild to moderate pain.

The nurse is caring for a client who was recently admitted to the cardiac floor for angina. This client states that their chest pain occurs at the same time every day at rest. The patient does not believe there are any precipitating factors. Which of the following types of angina is this patient most likely experiencing?

A. Variant angina Choice A is correct. Variant angina, also known as Prinzmetal's angina, occurs at about the same time every day, usually at rest. Variant angina is treated with calcium channel blockers.

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene?

A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. B. Obtains orthostatic blood pressure by having the client stand first. D. Provides a hot foot soak for a client with diabetes mellitus. E. Obtains a urine culture from an indwelling urinary catheter.

Which of the following motor skills does the nurse expect to be developed during the school-age period, ages 6 to 12-years-old?

A. Writing in cursive D. Jumping rope A is correct. Writing in cursive is a fine motor skill that children develop in the school-age period, between 6 and 12-years-old. During this period of time children should have already mastered holding a pen or pencil and manipulating it so that they are able to color and draw. When they start school, they begin fine-tuning those motor skills to write in cursive, a much more specific skill. Children younger than 6 have not yet developed the fine motor skills necessary to write in cursive. D is correct. Jumping rope is a gross motor skill that should be developed in the school-age period. This period is characterized by rapid learning and development of skills as children start school. Other motor development milestones during the school-age period include: riding a bike, playing games, swimming, and roller skating.

The nurse is teaching parents of a child diagnosed with varicella. Which of the following information should the nurse include? Select all that apply.

A. Your child may return to school once the lesions have crusted. C. Acetaminophen may be used for fever. D. Warm baths with baking soda may help with the itching. E. Do not use any aspirin or ibuprofen during the illness. Choices A, C, D, and E are correct. Varicella is a highly contagious virus that may be spread by aerosolized droplets, contact with lesions, and contaminated surfaces. A child may return to school once all the lesions have crusted over. Fever is a common manifestation associated with varicella, and acetaminophen may be taken as prescribed to decrease the fever. Symptomatic care for a child with varicella includes warm baths with products such as baking soda or uncooked oatmeal added to relieve itching. Calamine lotion may also be applied to soothe the skin. Ibuprofen and aspirin should not be taken during the course of the illness because they may cause life-threatening skin infections.

The nurse is teaching a client with Addison's disease that requires dietary modifications. The nurse should encourage the client to consume a diet that is

A. low in potassium. B. high in sodium. Choices A and B are correct. Adrenal insufficiency may be a lifelong disorder that requires dietary and lifestyle modifications. A clinical feature of Addison's disease is hyponatremia and elevated potassium levels. It is appropriate for the nurse to counsel the client to consume a diet rich in sodium and low in potassium to prevent complications.

Which nursing actions are appropriate when irrigating a nasogastric tube connected to suction?

A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline (or the amount indicated on the order) into the syringe. C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution. E and F: After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container

The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include?

Ambulate the client with the device below the insertion site. E. Palpate around the insertion site for any crackles or popping. Choices D and E are correct. Ambulation with a chest tube is not contraindicated. If the nurse has an order from the primary healthcare provider (PHCP) and it is safe for the client to ambulate, the nurse should ambulate the client with the device distal to the insertion site. Palpating around the insertion site should be done and any crackles or popping should be reported to the PHCP because that indicates an air leak.

The nurse is performing medication reconciliation for a patient in the respiratory clinic recently prescribed with terbutaline. Which medication should the nurse be concerned about?

Atenolol is a beta-blocker that can interfere with the action of terbutaline due to its antagonistic effect on the beta receptor cells in the bronchi. The nurse should talk to the prescribing physician regarding shifting the atenolol to another drug class.

The nurse is caring for a patient with a T5 spinal cord injury. Which assessment information would indicate to the nurse that the patient is experiencing autonomic dysreflexia?

Autonomic dysreflexia is a severe, uncompensated cardiovascular reaction that occurs in response to visceral stimulation after spinal shock has resolved. Patients with spinal cord injuries at T6 or above are at risk of developing autonomic dysreflexia. A sudden, throbbing headache is one of the most important warning symptoms that a patient is experiencing this life-threatening condition.

NG removal

B is correct. Before the nurse begins assisting with the removal of a nasogastric tube she should help to explain the procedure, i.e. what is happening and what the patient can expect. This is important for minimizing anxiety and ensuring the procedure goes smoothly. C is correct. The nurse should instruct the patient to inhale deeply and hold their breath as the nasogastric tube is removed. This will help the patient to better tolerate the procedure, as holding their breath will close the epiglottis over the airway so that as the tube is removed it can easily withdraw through the esophagus and nose. D is correct. It is correct for the nurse to pull out the nasogastric tube in one steady and continuous motion. She should not pause at intervals or remove the nasogastric tube gradually since this would cause discomfort for the patient. E is correct. Before the nurse removes the nasogastric tube, the securement device will need to be removed. Depending on the facility this could be a special tape, Tegaderm, or securement device specifically for the nasogastric tubes.

pyloric stenosis

B is correct. Projectile vomiting, especially right after a feeding, is the characteristic sign of pyloric stenosis. Since the pylorus, the opening from the stomach into the duodenum, is hardened and stiffened, it does not allow food to pass from the stomach into the duodenum. This means that after a feeding, the food cannot pass down, so it comes up in the form of projectile vomiting. C is correct. An olive-shaped mass, specifically in the epigastric region near the umbilicus is a tell-tale sign of pyloric stenosis. This is the enlarged stiffened pylorus.

The nurse is precepting a new graduate who will be caring for a patient with bacterial cystitis. Which of the following statements by the new graduate requires follow-up?

B. "A 24-hour urine sample will be needed to confirm the diagnosis." Choice B is correct. Bacterial cystitis may be diagnosed based on urine analysis. A simple, clean-catch midstream urine sample is sufficient for diagnosing bacterial cystitis. A 24-hour urine is utilized for diagnosing conditions such as pheochromocytoma and abnormal protein quantification in multiple myeloma - not bacterial cystitis. The presence of leukocyte esterase, nitrite, red blood cells ( hematuria), an abnormal number of white blood cells ( pyuria, ≥10 wbcs/microliter), and bacteria in the urinalysis are indicative of an acute bladder infection ( cystitis).

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate?

B. "A great addition to your cup of tea would be a little lemon. It's going to help you absorb your iron pill better." Choice B is correct. Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption.

A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following?

B. "Drink at least 3000 mL of water per day." Choice B is correct. Allopurinol is prescribed to patients with gout or kidney stones and works by reducing the amount of uric acid produced by the body. Patients taking this medication should be encouraged to drink plenty of water, at least 3,000 mL per day.

The nurse is teaching a client about prescribed doxycycline. Which of the following statements, if made by the client, requires follow-up?

B. "I am glad that, unlike most antibiotics, I won't have to use a backup method of birth control." C. "If I get a white coating on my tongue, I will immediately stop the medication." D. "I should take this medication after I eat a meal." This client will have to use a backup method of birth control (Option B). Birth control pills also may not work if the client is taking Doxycycline. The mechanism underlying this is due to antibiotics' effects on reducing small intestinal bacteria. Decreased bacteria lead to decreased hydrolysis of the hormone, resulting in increased fecal loss of the hormone and lower circulating levels of ethinylestradiol. This long-held belief has been challenged in recent studies. Still, until the availability of extensive studies, it is advised that clients take a backup method (other forms of birth control) while taking this medicine. The white coating (Option C) is glossitis, a common side effect of Doxycycline, but the client should not stop the medication. This should not be confused with thrush since thrush presents more with painful whitish patches involving both the tongue and the palate. The medication needs to be taken on an empty stomach because food can interfere with its absorption and reduce efficacy. The client should not take Doxycycline after eating (Option D).

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply.

B. A patient complaining about poor care from a nurse. C. A patient leaving against medical advice (AMA). E. A patient threatening a nurse with bodily harm. Choices B, C, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. Events such as complaints from the patient regarding their care, leaving against medical advice (AMA), and threatening a nurse with bodily harm are all examples of incidents requiring factual reporting.

The parent of an 11-year-old client who is receiving chemotherapy for leukemia is concerned because the client's sibling has chickenpox. Which of these actions will you anticipate taking next in caring for this client?

B. Administer varicella-zoster immune globulin to the client.

The nurse is triaging a child with bilateral lower extremity chemical burns. The nurse suspects that the child may have been abused. The nurse should take which initial action?

B. Irrigate the affected area with saline Choice B is correct. A common mnemonic to remember is "the solution to pollution is dilution." When a client has a chemical burn, the highest priority is to copiously irrigate it (dilute it) with saline or water. Prompt irrigation of the area exposed to caustic substances ( acid, alkali) dilutes the chemical, attempts to neutralize the pH change in the skin, and decreases the extent of the dermal injury. Additionally, dilution lessens the risk of the caregiver getting burned by the chemical.

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?

B. "I will have to take terbinafine for 3 to 6 months." C. "I will need liver function tests before starting terbinafine." E. "It may cause taste or vision changes, so I will report vision changes to my doctor." F. "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 (Choice F is correct). Baseline liver function tests (LFTs) must be checked before the initiation of terbinafine (Choice C is correct). In the past, LFTs have been monitored every 4 to 6 weeks while on terbinafine, but new guidelines do not require routine monitoring of LFTs

A 74-year-old female client is on her 3rd postoperative day and has an indwelling urinary catheter attached. While the nurse was making the morning rounds, she complains, "Oh dear, I feel like peeing again!" The most appropriate response for the nurse is:

B. "Let me take a look at that urine bag and make sure it's draining properly." Choice B is correct. Bladder spasms may cause the urge to void, but the most appropriate initial action is for the nurse to check the patency of the urinary catheter, as the most frequent reason for an urge to void while an indwelling catheter is in place is blocked tubing.

The nurse is teaching a patient about a scheduled contraction stress test (CST). Which of the following statements should the nurse include?

B. "You may need to stimulate your nipples during this test." Choice B is correct. A CST is indicated for high-risk patients who are in the third trimester. CST requires the patient to have contractions either through oxytocin administration or nipple stimulation.

The nurse is teaching a patient who is scheduled for a colonoscopy. Which of the following information should the nurse include?

B. "You will not have anything to eat or drink by mouth for 4 to 6 hours prior to the test." Choice B is correct. A colonoscopy is a test used to study the lining of the large intestine. Four to six hours before the procedure. the nurse is correct to instruct the client to not intake anything by mouth (NPO).

While caring for an 8-month-old child admitted for dehydration, the nurse prepares to administer an IV fluid bolus. She knows that the appropriate amount of fluid bolus is based on the child's weight. Which of the following is appropriate?

B. 20 mL/kg Choice B is correct. A child that is admitted for dehydration usually needs IV hydration. Mild to moderate dehydration is often treated with oral rehydration therapy (ORT) solutions as an outpatient. Whereas if a child is requiring inpatient admission, it often means the child is severely dehydrated or not responding to oral rehydration. Severe dehydration should be treated with intravenous fluids until the child is stabilized (i.e. circulating blood volume is restored). Patients with severe dehydration often present with hypovolemic shock, acute renal failure, and altered mental status. Fluid resuscitation with intravenous fluid boluses should be administered followed by maintenance intravenous fluids. The bolus portion of the fluid is the one that is given over 10 to 15 minutes. In children, the bolus fluid is calculated using the formula 20 mL per kg of the child's weight. Only an isotonic crystalloid (normal saline or lactated Ringer solution) must be used in treating dehydration. Frequent reevaluation of the client's vital signs, pulse strength, capillary refill time, mental status, and urine output will guide the nurse on whether further boluses are needed. Rapid delivery is the key in fluid resuscitation. Repeat boluses are administered as necessary. Often, up to 60 mL per kg of fluid (around 3 boluses) may be needed within an hour to achieve stabilization. After initial resuscitation is completed and electrolytes are restored to normal, the child should receive 100 mL per kg of oral rehydration therapy solution over four hours, followed by maintenance fluids. However, if ORT fails following initial resuscitation in a child with severe dehydration, intravenous hydration should be reinitiated. In such cases, continuous hydration with 100 mL per kg of isotonic fluid is given over four hours, followed by maintenance fluids. This same method of fluid resuscitation is also used when ORT fails in a child with moderate dehydration

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed?

B. 30-40 degrees Choice B is correct. A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient's neck from flexing. A standard ICP is about 5 to 15 mmHg.

Which of the following statements about calcium are true?

B. 50-70% of serum calcium is ionized in the serum. C. Albumin and calcium levels can be directly correlated Choices B and C are correct. These are true statements. 50-70% of serum calcium is ionized in the serum (Choice B). Due to the protein-binding ability of calcium and albumin, calcium levels can be directly correlated (Choice C).

The nurse is working on the pediatric clinic and checks the list of clients who are lined up to see the physician for today. Which client would warrant the nurse's attention?

B. A 2-year-old who is drooling and does not want to swallow. Choice B is correct. A child who is drooling and does not want to swallow is indicative of epiglottitis, which can be a life-threatening situation. The nurse should assess this child first and inform the physician in case an emergency tracheostomy is required.

Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?

B. A 56-year-old male client with a leg amputation. Choice B is correct. The 56-year-old male client with a leg amputation would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain. Contralateral massage, or stimulation, unlike other cutaneous nonpharmacological comfort interventions, entails the stimulation of the opposite part of the body rather than the direct stimulation of the painful, affected area. For this reason, contralateral stimulation of the intact opposite leg will promote comfort and decrease phantom pain that has occurred as a result of the amputation.

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 that can increase the risk for falls?

B. Alprazolam C. Bumetanide D. Verapamil Choices B, C, and D are correct. 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, and this medication may cause a client to experience orthostatic hypotension along with 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.

The RN provides teaching to a patient with epilepsy who has just been started on carbamazepine to control seizure activity. Which information would be important for the nurse to include regarding this medication?

B. Avoid taking this medication on an empty stomach. Choice B is correct. The nurse should instruct this patient that carbamazepine should be taken with meals. The patient should avoid taking this medication on an empty stomach in order to reduce the risk of experiencing side effects.

A psychiatric client taking perphenazine per orem for 48 hours is seen by the nurse manifesting the following symptoms: head-turning to the left with his neck arched as well as stiffness and muscle spasms in the neck. Which medication would the nurse expect to give the client?

B. Biperiden Choice B is correct. An antiparkinsonian medication that helps alleviate extrapyramidal symptoms.

The patient with testicular cancer is receiving IV cisplatin. Which of the following should the nurse assess for?

B. Bone marrow suppression Choice B is correct. Bone marrow suppression is the most significant adverse reaction of the class of drugs that include cisplatin. Cisplatin is an alkylating agent. Blood cells are particularly sensitive to alkylating agents and bone marrow suppression is the most important adverse effect of this class. Within days after administration, the numbers of red blood cells, white blood cells, and platelets begin to decline.

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?

B. Ciprofloxacin C. Rifampin D. Meningococcal conjugate vaccine Choices B, C, and D are correct. 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 patients. 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.

You are monitoring an 18-month old patient who has just had surgical correction of an epispadias completed. Which of the following assessment findings would the nurse need to report to the healthcare provider?

B. Cloudy, foul smelling urine. C. Stent in the meatus appears clogged. Choices B and C are correct. Cloudy, foul-smelling urine could indicate an infection and needs to be reported to the healthcare provider. If the stent placed in the urethral meatus appears clogged, no urine will be able to exit the bladder. This needs to be corrected surgically, and the provider needs to be notified.

Which of the following educational points are appropriate for your patient being discharged with oral potassium supplements?

B. Commonly causes GI upset. D. Mix well. Choices B and D are correct. The most common side effect of oral potassium is GI upset. You should explain this to your patient and instruct them to take their supplement with food (Choice B). You should teach your patient to mix potassium supplements well before administering them (Choice D).

The nurse is performing an admission assessment on a client admitted to the behavioral health unit. The client is reporting new-onset blindness after witnessing a traumatic motor vehicle accident. The nurse suspects that this client is using which defense mechanism?

B. Conversion Choice B is correct. Converting anxiety into physical symptoms with no organic cause best explains this defense mechanism this client is experiencing. Conversion is a pathological defense that may manifest as a disorder if it continues to recur. This client was traumatized by the accident and converted his anxiety into a physical symptom (blindness). His new-onset blindness has no organic origin; thus, this exemplifies conversion.

The nurse is caring for a client with venous thromboembolism who has developed heparin-induced thrombocytopenia. After discontinuing the heparin infusion, the nurse anticipates which prescription from the primary healthcare provider (PHCP)?

B. Dabigatran Choice B is correct. Heparin-induced thrombocytopenia (HIT) may be a life-threatening complication of exposure to heparinoids. The treatment for HIT Is to discontinue exposure to the heparin product immediately and to continue the anticoagulation with a non-heparin product. Agents that may be safely used include apixaban, dabigatran, or rivaroxaban.

A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?

B. Decreased glomerular filtration rate (GFR) Choice B is correct. Metformin is an oral anti-diabetic indicated for type 2 diabetes mellitus. Metformin may cause renal impairment and a decrease in glomerular filtration rate (GFR) would be such evidence. During Metformin therapy, the client's renal function will be periodically monitored.

A patient presents to the emergency department following a motor vehicle accident. The nurse assesses that the patient is unable to move legs and has poor reflexes. What additional assessment data would support the diagnosis of spinal shock?

B. Decreased sensation Choice B is correct. The decreased sensation would support the diagnosis of spinal shock. Spinal shock is a temporary neurologic syndrome that is common in patients with an acute spinal cord injury. Symptoms of spinal trauma include decreased sensation, decreased reflexes, and flaccid paralysis below the level of the spinal cord injury.

A male client with chronic renal failure has questions regarding the effects of his kidney disease on his sexual activity. Which of the following is a sexual complication of chronic renal failure?

B. Decreased testosterone Choice B is correct. Chronic renal failure causes decreased testosterone levels. Low testosterone results in reduced sex drive. Sexuality has physical and emotional components, both of which can be affected by chronic kidney disease. Kidney disease can cause chemical changes in the body, affecting circulation, nerve function, hormones, and energy levels. Also, any underlying health conditions that contribute to CKD, like hypertension or diabetes, can affect male sexuality. Fatigue is one of the most common symptoms of men with kidney disease. Since kidney disease affects the endocrine system, changes in hormone levels may result in decreased sex drive. An estimated 20 to 30 million men in the U.S. have problems with impotence. Erectile Dysfunction can happen when blood vessels and nerves to the penis become damaged. Without proper blood flow, the penis cannot maintain an erection. Diabetes and high blood pressure affect blood flow and weaken blood vessels. Feelings of sexual attraction become sparse when the body undergoes these unexpected changes. This can affect how people interact with others and their ability to develop intimate relationships. Men may feel worried, anxious, and depressed when faced with CKD. This is normal, but these emotions may cause loss of energy and lower interest in activities, including sex.

The nurse is caring for a child with nocturnal enuresis that was not responsive to non-pharmacological modifications. The nurse anticipates the primary healthcare provider (PHCP) to provide which medication?

B. Desmopressin Choice B is correct. Desmopressin is indicated for the treatment of diabetes insipidus and nocturnal enuresis. This medication is a synthetic form of antidiuretic hormone.

Which position is the most appropriate to prevent foot drop for a patient who is on bed rest following a spinal injury?

B. Dorsiflexion Choice B is correct. Dorsiflexion is the most appropriate position to prevent foot drop in a patient on bed rest following a spinal injury.

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?

B. Frequent sleepiness Choice B is correct. Clients taking magnesium sulfate are expected to become sleepy during the daytime as well as experience hot flashes and lethargy.

The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following?

B. Have a bowel movement. Choice B is correct. Constipation is a significant problem associated with peritoneal dialysis. Constipation comes from the consumption of prescribed phosphate binders as well as chronic kidney disease itself. The client having a bowel movement allows decreased intestinal pressure, therefore resolving the outflow failure. If constipation is a significant problem causing outflow failure, the client can give themselves an enema prior to the procedure.

The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up?

B. Hydrochlorothiazide Choice B is correct. A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels.

The nurse is caring for a patient who is receiving prescribed olanzapine. Which of the following findings would indicate that the patient is having an adverse effect?

B. Hyperglycemia C. Weight gain D. Hyperlipidemia Olanzapine is a second-generation antipsychotic (SGA). SGAs such as olanzapine and clozapine have a high risk of causing a client to develop metabolic syndrome. Metabolic syndrome includes hyperglycemia, overweight or obesity, abdominal obesity, hyperlipidemia, and hypertension. Olanzapine and clozapine are implicated in causing some of the worse metabolic effects.

The nurse is developing a plan of care for a client admitted P. aeruginosa pneumonia. Which of the following should the nurse include in the client's plan of care?

B. Initiate a vascular access device and encourage by-mouth fluids. Initiating vascular access is essential for a client admitted with P. aeruginosa pneumonia because parenteral antibiotics are the mainstay of treatment. Dehydration is common in pneumonia, and encouraging non-caffeinated fluids is beneficial.

The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?

B. Instruct the client to turn their head from side to side Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. this is usually caused by a stroke, tumors, or epilepsy. Visual field loss is indicative of a lesion involving the visual pathway posterior to the chiasm. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected.

You are called to assess a 4-year-old patient who has suffered second and third-degree burns to her chest, abdomen, and legs. It is estimated that about 40% of her TBSA is burned. Upon assessment, her vital signs are as follows: HR: 140 RR: 44 BP: 90/60 SpO2: 88% on Room Air

B. Intubation and mechanical ventilation Choice B is correct. Intubation and mechanical ventilation are the priority for this patient. Intubation is the A in the ABC's mnemonic and stands for airway. The stem of the question states that this patient has burns to her chest. You know that smoke inhalation can burn the trachea and compromise the airway, and wounds to the chest are an indication that inhalation injury has likely occurred. Additionally, the patient is tachycardic, tachypneic, and desaturated. She is working hard to try to compensate by increasing her heart rate and respiratory rate. Still, it is not keeping up with her oxygenation and perfusion needs, as evidenced by her desaturation in room air. This patient needs intubation and mechanical ventilation to secure an airway and prevent rapid respiratory failure due to inhalation injury.

You are caring for a client with a terminal disease and this person has asked for a curandero. What should you do?

B. Refer the family and the client to a member of the clergy who may be able to help. Choice B is correct. You would refer the family and the client to a member of the clergy who may be able to help. A curandero is a healer who is believed to have supernatural powers that can cure the sick. These powers are derived from the fact that many believe that illnesses and diseases occur as the result of evil spirits and a curse from God.

Which of the following treatments are options for treating hyperkalemia?

B. Kayexalate C. Glucose and insulin D. Dialysis B is correct. Kayexalate is an enema that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. C is correct. Glucose and insulin are a standard and effective treatment for hyperkalemia when administered together. Insulin transports glucose into the cells for cellular metabolism and takes potassium with it. So, by administering glucose and insulin, the insulin ends up taking both the glucose-regulated and extra potassium into the cells. By transporting potassium to the intracellular space, the amount of potassium in the serum is decreased. D is correct. Dialysis is an appropriate treatment for hyperkalemia. If the kidneys are not working, the patient will become hyperkalemic. Dialysis can remove the excess potassium from the blood.

Your newly assigned client has a history of chronic obstructive pulmonary disease (COPD). When you enter his room, you find his oxygen is running at 6 L/min, his color is flushed, and his respirations are 8/min. What should you do first?

B. Lower the oxygen rate Choice B is correct. Low oxygen level stimulates respiration. A high concentration of supplemental oxygen removes the hypoxic drive to breathe. This can lead to increased hypoventilation and possibly the development of or worsening of respiratory acidosis can occur. Left untreated, this can result in a patient's death. Individuals with COPD experience lowered oxygen tension and increased carbon dioxide retention during sleep, especially during REM sleep, when neuromuscular control usually is depressed. This can result in pulmonary spasms and transient pulmonary hypertension.

The nurse is about to lift a 350-pound patient using an electric lift attached to the bed and transfer him to a stretcher. What should be the priority nursing action?

B. Make sure the client is correctly positioned in the lift prior to operating the lift. Choice B is correct. The safety of the client should take priority. The nurse must ensure that the client is safely secured and adequately attached to the lift. Incorrect positioning of the client in the lift's sleeves might put the client at risk for falls.

Which of the following are signs and symptoms of renal failure?

B. Metabolic acidosis C. Hyperkalemia Choices B and C are correct. The signs and symptoms of renal failure include metabolic acidosis and hyperkalemia, among many other signs and symptoms.

The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication?

B. Naproxen Choice B is correct. Naproxen should not be administered concomitantly with corticosteroids. These two medications taken together will increase the risk for gastrointestinal bleeding.

While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's initial priority action?

B. Notify the physician. Choice B is correct. The nurse should suspect this client is presenting with an abdominal aortic aneurysm (AAA) due to the bruit, or swooshing sound, upon auscultation. The nurse should immediately notify the patient's healthcare provider of this urgent situation. Rupture can occur spontaneously or with trauma; if the aneurysm bursts, it may cause life-threatening bleeding. The aneurysm should be assessed immediately to determine the need for surgical intervention.

Which of the following statements are true about special populations and the administration of analgesics?

B. Oncology clients do not have a dosage limitation in terms of analgesics. Choice B is correct. Oncology clients do not have a dosage limitation in terms of analgesics until effective pain management is accomplished. At times, very high dosages of analgesic medications are essential to relieve pain. However, on some occasions, the medication dosage may have to be titrated downward when the side effects of the drug outweigh its benefits in terms of pain relief.

The nurse is caring for a client receiving mechanical ventilation. Which prescription from the primary healthcare physician (PHCP) should the nurse anticipate?

B. Pantoprazole Choice B is correct. Mechanical ventilation may cause a stress ulcer. A proton pump inhibitor (PPI) or a histamine-2 receptor antagonist (H2 blocker) may be utilized to prevent this ulcer which may lead to a gastrointestinal bleed.

Which of the following statements regarding the anatomy of pediatric patients are true?

B. Pediatric patients have a larger head in proportion to their body. D. Pediatric patients have an immature blood brain barrier. B is correct. This is correct. Pediatric patients have a more massive head in proportion to their bodies than adults do. When babies are born, their head makes up about 25% of their total length. As they grow, this proportion lessens until the head is about 12% of the overall body height around ten years of age. D is correct. This is correct; pediatric patients have an immature blood-brain barrier. The blood-brain wall is a filtering mechanism built into the blood vessels that carry blood to the brain. They are meant to block out the passage of substances that could be harmful to the brain, but this mechanism is immature in pediatric patients. This means that pediatric patients are more at risk of drugs or toxins entering their circulation, as these could pass into the brain and cerebrospinal column, causing damage.

An 8-year-old client is admitted with rheumatic fever. Which clinical finding indicates to the nurse that the client needs to continue taking the salicylates he had received at home?

B. Polyarthritis Choice B is correct. Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates. Rheumatic fever is an inflammatory disease that can develop when strep throat or scarlet fever, which are caused by streptococcus bacteria, isn't adequately treated. It most often affects children who are between 5 and 15 years old, though it can develop in younger children and adults. Although strep throat is frequent, rheumatic fever is rare in the United States and other developed countries. However, rheumatic fever remains common in many developing nations. Rheumatic fever can cause permanent damage to the heart, including damaged heart valves and heart failure. Treatments can reduce inflammation, lessen pain, and prevent the recurrence of rheumatic fever.

A client with Raynaud's disease has just been prescribed ephedrine. What is the nurse's most appropriate action?

B. Question and discuss the prescription with the physician. Choice B is correct. Clients with Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction. The nurse should question the physician regarding this prescription.

Your client is a male patient who presents with knee joint pain, conjunctivitis, numbness in the extremities, and atrioventricular heart block following a tick bite that occurred two months ago. You suspect Lyme disease. Which stage of the Lyme disease does his presentation represent?

B. Second stage Choice B is correct. This reflects the second stage of Lyme disease. Neurological and cardiac involvement are hallmarks. Manifestations may include atrioventricular heart block and neuropathy. Ocular manifestations such as conjunctivitis can be seen in 10% of cases. Joint pain may also be present. The second stage occurs typically around seven weeks after the initial tick bite. It is also referred to as "early, disseminated Lyme" disease. Choice A is incorrect. The first stage of Lyme disease usually presents with a red rash the size of a pimple or as a large ring. The patient generally complains of flu-like symptoms. Choice C is incorrect. The third stage of Lyme disease is characterized by sizeable joint involvement and arthritis (chronic Lyme arthritis). Knee joints are often involved. Choice D is incorrect. There is no fourth stage in Lyme disease.

The nurse is caring for a cancer patient who is receiving chemotherapy. The patient is experiencing weight loss as a result of intermittent nausea. The nurse should implement which of the following nursing interventions to help with the patient's nausea?

B. Serve small meals every 2-3 hours. C. Provide meals that are best eaten at room temperature. D. Encourage the patient to brush their teeth in the afternoon rather than in the morning. Choices B, C, and D are correct. Serving small meals every 2-3 hours may help keep nausea at bay. Food eaten at room temperature and delaying teeth brushing till the afternoon may also improve nausea.

Which of the following would be a priority action for a nurse who has suffered a needlestick while working with a patient who is positive for AIDS?

B. Start prophylactic zidovudine Choice B is correct. Zidovudine is the most critical intervention. It is an antiretroviral medication that is used to prevent and treat HIV/AIDS by reducing the replication of the virus.

The nurse is caring for a client with angle-closure glaucoma. It would be correct to place the client in which position?

B. Supine Choice B is correct. Placing the client supine, who has angle-closure glaucoma, is effective as it will assist in the lens falling away from the iris, decreasing the pupillary block.

Which of the following opportunistic illnesses are a sign that a patient with HIV now has AIDS? Select all that apply.

B. Symptomatic tuberculosis C. Toxoplasmosis of the brain E. Pneumocystis carinii pneumonia Choices B, C, and E are correct. Generally, tuberculosis (TB) does not affect those with healthy CD4 levels. Symptomatic TB is a sign of AIDS. An infection with Toxoplasmosis of the brain indicates a serious infection directly related to the condition. Affecting the lung, pneumocystis carinii pneumonia is typical of patients with AIDS and a serious sign of low CD4 counts.

A 23-year-old college student seeks medical help at the infirmary complaining of severe fatigue. She reports exertional dyspnea, and her skin appears pale. Aplastic anemia is suspected. Laboratory values reflect anemia, and the client is advised for a bone marrow biopsy. The client refuses to sign the consent and states, "Come on, just get the doctor to give me a transfusion and let me go. Spring break begins this weekend, and I'm leaving for Florida." The nurse's most significant concern at this time would be:

B. The client does not understand the full impact of her condition. Choice B is correct. The most significant concern at this point is the fact that the client does not fully grasp the gravity of her condition. She must be educated and be allowed to verbalize her feelings about her situation.

What instructions should be given to the nursing assistant who is helping a patient on IV heparin with activities of daily living?

B. Use a soft-bristled toothbrush or tooth sponge for oral care. C. Use an electric razor when shaving the patient. D. Use a lift sheet when moving or positioning the patient in bed.

The nurse is supervising a new graduate place an intravenous catheter. Select all the nursing interventions that have been proven effective in terms of beginning and maintaining intravenous access.

B. Using the shortest length catheter as possible C. Using the smallest size catheter as possible F. Applying warm compresses to the site for 10 minutes Choices B, C, and F are correct. Using the shortest length catheter as possible, using the smallest size catheter as possible, and applying warm compresses to the site for 10 minutes for vasodilation are three effective nursing interventions for beginning and maintaining intravenous therapy.

While teaching a client who has recently begun a vegan diet, the nurse should highly recommend supplementing with which of the following vitamins?

B. Vitamin B12 Choice B is correct. Vitamin B12 is abundantly present in food products of animal origin. These include eggs, poultry, dairy products, fish, and meat. No strict vegetarian source has sufficient vitamin B12 to meet the recommended daily allowance (RDA). Vegans refrain from consuming all animal products, including eggs and dairy. Therefore, vegans are at a very high risk of developing vitamin B12 deficiency. Vegans should be counseled to consume alternative sources of vitamin B12 such as vitamin B12 supplements foods fortified with vitamin B12 ( fortified nutritional yeasts, fortified cereals) to reduce the risk of B12 deficiency significantly.

The nurse works on a medical/surgical unit and cares for a patient receiving digoxin and furosemide. Which of the following, if reported by the patient, must be assessed immediately?

B. Vomiting and halos around lights. Choice B is correct. Furosemide causes the patient to lose potassium. Digoxin, if taken when the patient has a low potassium level, can become toxic and show signs/symptoms of nausea, vomiting, and halos around lights. Furosemide and digoxin are often used together but may require more frequent evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to notify their healthcare provider if they experience any symptoms such as weakness, tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or irregular heartbeats.

The nurse should assess an Alzheimer's patient who has been started on rivastigmine for which of the following side effects?

B. Weight loss Choice B is correct. The most common side effects of rivastigmine are flu-like symptoms, dizziness, and weight loss. The FDA has approved limited drugs for Alzheimer's Disease. The most effective medications act by intensifying the effect of acetylcholine at the cholinergic receptor. Acetylcholine is naturally degraded in the synapse by the enzyme acetylcholinesterase. When acetylcholinesterase is inhibited, acetylcholine levels increase and significantly affect the receptors.

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by

B. hemolysis of fetal erythrocytes resulting from incompatibility between maternal and fetal blood Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, which is a severe anemia that results in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility.

The nurse educator and a newly registered RN are caring for a postoperative client with a chest tube. The nurse educator educates the new RN that at four hours post-op from a thoracic surgery, the drainage is expected to be:

Bloody Choice B is correct. Following the first four to six hours of thoracic surgery, the drainage from the chest tube is expected to be bloody. The purpose of the chest tube following a thoracic/cardiothoracic surgery is to drain blood and prevent clotting inside the pleural space. Indications for chest tube placement include pneumothorax/hemothorax, pleural effusion, empyema, chylothorax, and post-operative cardiac/thoracic surgery. Following heart surgery (cardiac bypass, valve replacement) or lung surgery (lobectomy, pneumonectomy, wedge resection), a chest tube is inserted prior to the patient leaving the operating room. The nurse is required to monitor the amount and color of the chest tube drainage, and report significant changes to the physician.

What is Turner's sign?

Bruising around the flank

The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?

C. "May I help you? We will need to be careful with their intestines since we do not want the swaddle to push them back inside." Choice C is correct. This is a therapeutic statement. It educates the parent about the need to swaddle the baby only very loosely and avoid any pressure on the exposed intestines so that they do not get pushed back inside of the baby. It also promotes bonding with the infant, as it encourages the parent to touch and care for their baby.

The nurse is caring for a client who is receiving prescribed mirtazapine. Which of the following statements, if made by the client, would indicate a therapeutic response?

C. "My depression has gotten better." D. "I am sleeping eight hours a night." Choices C and D are correct. Mirtazapine is a tetracyclic antidepressant that causes an increase in serotonin and norepinephrine. This medication is used for depressive and anxiety disorders. Mirtazapine is quite sedating and is often used for insomnia associated with depressive disorders.

Which of the following statements is true regarding the premature rupture of membranes (PROM)?

C. A priority nursing intervention with PROM is to monitor for infection. D. When observing the fluid after the rupture of membranes, it should be clear and without odor Choices C and D are correct. A priority nursing intervention with PROM is to monitor for infection. When the membranes are ruptured before labor begins, the baby is then exposed to bacteria and pathogens of the outside world. These germs can enter the birth canal and infect both the mother and the infant. One of the most critical observations you must make is of the color, odor, consistency, and amount of the amniotic fluid when the rupture of membranes occurs. Any discolored or malodorous fluid may indicate an infection. After the breakdown of membranes occurs, the nurse should monitor the mother's temperature, WBC count, CRP, and other markers of disease (Choice C). It is essential to assess the color, odor, consistency, and amount of fluid when the rupture of membranes occurs. If the liquid is green or yellow and rancid, it is indicative of infection. If the fluid is brown or black, it is indicative of meconium passing in utero. The expected finding of amniotic fluid is a clear fluid with no odor (Choice D).

The definition of a "nonverbal" client in the context of pain assessment can include the clients:

C. Absence of consciousness. Choice C is correct. The absence of consciousness is a part of the definition of "nonverbal" in the context of pain assessment. The description of "nonverbal" in the context of pain assessment is the inability to self-report pain, the failure to be adequately assessed using a numerical pain scale, and the inability to be adequately evaluated using a pictorial pain assessment scale; "nonverbal" clients have to be assessed by the nurse in terms of their nonverbal, behavioral indications of pain such as facial expressions. In addition to unconsiousness, other conditions that render the client "nonverbal" in the context of pain assessment include the very young, confused clients, comatose clients, and others.

The nurse is caring for a child who is lethargic and with a capillary blood glucose of 46 mg/dL. Which essential action should the nurse take?

C. Administer prescribed glucagon SubQ Choice C is correct. The client is lethargic and hypoglycemic. This is quite concerning and calls for the nurse to immediately administer a parenteral treatment (either glucagon SubQ/IM) or Dextrose 50% via intravenous push (IVP).

The nurse is caring for a client post-angiography using a contrast medium via the femoral approach. Which intervention should the nurse include in the patient's plan of care?

C. Assessment of kidney function tests the next day. Choice C is correct. The contrast media is a substance that is excreted in the kidneys. Aside from hydration, the nurse should check the client's kidney function tests to determine whether there has been any damage to his kidneys during the trial.

When assessing a patient with nausea, vomiting, and diarrhea, which of the following focused assessment techniques should the nurse use?

C. Auscultate abdomen, palpate the abdomen, evaluate for dehydration Choice C is correct. With the presence of nausea, vomiting, and diarrhea, the concern arises about fluid volume deficit and the potential for dehydration, which would be noted with poor skin turgor. The abdomen should be auscultated to evaluate for suspected hyperactive sounds due to the increased peristalsis.

When auscultating a patient's posterior lung sounds, where would the nurse place the stethoscope to assess bronchovesicular sounds?

C. Between the scapulae, especially on the right side Choice C is correct. Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae, especially on the right side.

The nurse is caring for a client diagnosed with Generalized Anxiety Disorder (GAD). The nurse should anticipate a prescription for which medication?

C. Buspirone Choice C is correct. Buspirone is a serotonergic agent that is efficacious in the treatment of anxiety. This medication takes time to work (approximately two to four weeks), and the client should be counseled accordingly.

The nurse comes into the client's room to check on her and her newborn child. The client tells the nurse that another nurse just came and took the baby back to the nursery. What would be the initial action of the nurse?

C. Call the nursery to ask if the baby was returned to the nursery. Choice C is correct. The nurse should always confirm first whether another staff member returned the baby to the nursery. The nurse should not cause a false alarm in the institution. A Code Pink notifies all hospital staff of a possible infant abduction.

Primary nutrients that are essential for optimal body function include:

C. Carbohydrates, proteins, and fats Choice C is correct. Carbohydrates, proteins, and fats provide the energy that is necessary for cellular function.

When making patient care assignments, the nurse recognizes that the following tasks are within the scope of practice for nursing assistive personnel [NAP], with which exception?

C. Changing the colostomy skin barrier. Choice C is correct. The NAP scope of practice allows the NAP to empty ostomy bags or change bags that do not adhere to the skin; the NAP could apply a new pack to a two-piece system, but not the adhesive skin barrier component.

The nurse in the medical ward just administered 6 units of regular insulin on a client subcutaneously. The nurse understands that after 3 hours, the nurse should monitor the client for which sign?

C. Cold sweats and trembling Choice C is correct. Regular insulin peaks at about 2 - 4 hours after administration. At this time, the nurse should be alert for signs and symptoms of hypoglycemia, the initial signs of which are cool, clammy skin, cold sweats, and trembling.

Which focus is the nurse most likely to teach for a client with a flaccid bladder?

C. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. Choice C is correct. Since bladder muscles will not contract to increase intrabladder pressure and promote urination, the process is initiated manually. Overflow incontinence is continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying. It can be seen in men with an enlarged prostate and clients with a neurologic disorder (e.g. Parkinson's disease, spinal cord injury). An impaired neurologic function can interfere with the standard mechanisms of urine elimination, resulting in a neurogenic bladder. The client with a neurogenic bladder does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic, with frequent involuntary urination.

The nurse is caring for a client receiving assist-control (AC) via mechanical ventilation. The nurse understands that this setting is used to do which of the following?

C. Deliver a preset tidal volume during spontaneous breaths. Choice C is correct. Assist-control (AC) is a volume mode on a mechanical ventilator that senses a client's ability for a spontaneous breath. When the client takes a spontaneous breath, it will deliver the tidal volume preset on the ventilator. This is in addition to the client receiving the ventilated breaths preset in the rate. For example, if the client is at a preset rate of 12 and taking 4 spontaneous breaths, each breath of the 16 will receive 515 mL of gas (the tidal volume preset).

The emergency department (ED) nurse is triaging a client who reports recent international travel to West Africa and has signs and symptoms of conjunctival infection, fever, rash, vomiting, and blood in their stool. The nurse is concerned that this client may have

C. Ebola virus disease. Choice C is correct. West Africa was a site of a recent Ebola virus disease (EVD) epidemic. The manifestations of ebola include conjunctival injection, fever, rash, vomiting, and blood in their stool. This information makes it reasonable to raise the suspicion that this client may have EVD.

A couple in a fertility clinic tell the nurse that they are concerned about transmitting a particular disease to their children. The nurse refers them to genetic counseling. All of the following are the purposes of genetic counseling, except:

C. Educate the couple on how to prevent their child from acquiring inherited disorders. Choice C is correct. This is an incorrect statement and therefore the correct answer to the question. Genetic counseling aims to let people understand that they have no control over inherited traits. Marriages and relationships can suffer because of this unless they are given adequate support.

A nurse is taking care of a 60-year-old lady who is on her first postoperative day after a right total hip replacement. The nurse knows that one complication from this procedure is dislocation. To prevent this, the nurse includes which nursing action in the plan of care?

C. Ensure that adduction of the legs is avoided. Choice C is correct. Following a total hip replacement, the goal is to prevent dislocation. Leg adduction should be avoided. The legs should be abducted. They may also be externally rotated, and the client may assume a sitting position at a 45-degree angle.

Morphine sulfate is contraindicated among lactating women due to which of the following?

C. Excreted in the breast milk. Choice C is correct. Morphine sulfate is contraindicated among lactating women because morphine sulfate is excreted in breast milk. Although, 90% of morphine sulfate is excreted in the urine.

The nurse is caring for a client receiving a continuous infusion of heparin and warfarin. Based on the client's laboratory data, the nurse should take which action? See the image below.

C. Hold future doses of the warfarin Choice B is incorrect. The heparin infusion should be stopped because the aPTT is too prolonged. The goal for a client receiving a continuous infusion of heparin is to prolong the control (baseline) aPTT 1.5 to 2.5 times. The normal aPTT is 30-40 seconds. Heparin has a short half-life, so even if the heparin infusion were paused for thirty minutes, this would lower the aPTT. The nurse should refer to the PHCP's order to determine the next course of action after the infusion is paused/stopped.

A patient presents with weight loss and diarrhea with frothy, fatty, foul-smelling, yellow-gray stools. Which of the following malabsorption issues would not be a possible cause?

C. Lactose intolerance Choice C is correct. Weight loss and diarrhea are general signs and symptoms of most malabsorption disorders and are not specific enough symptoms to differentiate these disorders. Therefore, the critical symptom is the frothy, fatty, foul yellow-gray stools (steatorrhea). Steatorrhea may occur in all of the other answer choices listed but is not seen in lactose intolerance.

The nurse is providing discharge instructions for a patient following cataract surgery. Which of the following guidelines should not be included in the patient teaching?

C. Lift objects only under 10 pounds Choice C is correct. This information should not be included. Patients should be warned against lifting anything about 5 lbs as the straining can be damaging to the healing eyes following cataract surgery.

A nurse is evaluating an 83-year-old client who has been hospitalized after a fall. He has not had a bowel movement for five days, and a possible fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction?

C. Liquid stool Choice C is correct. In a client with fecal impaction, the client has the urge to defecate but is unable to do so. A liquid stool is usually observed as it is the only thing that will be able to pass around the impacted site.

You are caring for a 17-year-old patient who has been taking isotretinoin (Accutane) for the past three months. The most critical assessment for this patient is:

C. Mood changes

A client suddenly develops syndrome of inappropriate antidiuretic hormone (SIADH) after undergoing cranial surgery. Which manifestations should the nurse expect to see from the patient?

C. Normal or slightly increased blood pressure Choice C is correct. SIADH is an abnormal release of the antidiuretic hormone (ADH), which causes the client to retain water abnormally. It is a euvolemic condition because only free water is retained, not sodium. Because free water is retained, the urinary output is lower, urine osmolality is higher, and specific gravity is higher. Physical exam findings often reveal normal skin turgor. Blood pressure is mostly normal (normotensive) or slightly increased.

The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action?

C. Notify the primary healthcare provider (PHCP) Choice C is correct. Notifying the PHCP is essential because this assessment indicates crepitus which is air trapped in and under the skin, known as subcutaneous emphysema. The PHCP needs to be notified because this is a complication, and measures such as increasing the suction on the chest tube need to be considered.

The nurse is on her way to the hospital for her shift when she encounters a roadside traffic accident. The nurse assists in responding to the victim and notes that the victim suffered a traumatic amputation of her fingers. Which intervention should the nurse implement when dealing with traumatic amputations?

C. Place the amputated fingers in a container with ice. Choice D is correct. The amputated fingers should be placed in a waterproof bag and placed in ice water, not directly on ice. Keeping these parts chilled prevents decomposition. Ice should not come directly in contact with the amputated part because it can cause ice burns, and the fingers may not be able to be sewn back.

The nurse is taking care of a patient in the Urology clinic who came in for cystitis. The resident physician prescribes oxybutynin to the client to relieve his bladder spasms. Upon review of the patient's history, the nurse notes that the patient is taking medications for glaucoma as well. What is the nurse's most appropriate action?

C. Question the resident physician's order. Choice C is correct. Oxybutynin is cautioned/contraindicated in clients with glaucoma as it blocks the parasympathetic nervous system and increases the risk of increased intraocular pressure.

When caring for a patient who has impaired hearing, the nurse knows that the best way to approach them is to do which of the following?

C. Speak at a normal volume Choice C is correct. The nurse should speak directly to the client and at an average volume. If this method does not work, the nurse should try to express what is being said differently.

The 6-year-old immigrant child has been diagnosed with Hepatitis A. He was brought from Mexico by his grandparents a few days ago. You would expect that treatment for this child will include:

C. Supportive care Choice C is correct. Hepatitis A is typically an infection that is self-limiting if the child receives the appropriate supportive care. The disease is usually transmitted by drinking water and food that is contaminated with fecal matter. Removing the source of the infection and providing a healthy diet will often help resolve the infection. A hepatitis A vaccine is available that should be given to all children and high-risk adults. This vaccine should be given in two doses.

The mother is concerned about a 2 cm, red rash on her two-month-old infant's back, which blanches with pressure. What teaching should the nurse discuss with the mother regarding this type of lesion?

C. This immature hemangioma requires no intervention. Choice C is correct. The description is consistent with an immature hemangioma (capillary hemangioma, superficial hemangioma). Because of their bright-red appearance, they are often referred to as "strawberry nevi." They blanch with pressure, which can help differentiate these lesions from port-wine stains. Immature hemangiomas are common, harmless tumors of blood vessels that occur within the first year of life. They do not require any treatment and typically resolve on their own by 5-7 years of age. They commonly appear on the face, scalp, chest, or back. Occasionally, some immature hemangiomas can interfere with vision or cause other symptoms based on their location. Such hemangiomas may be treated with medications or laser surgery.

Student nursing is discussing Freud's psychosexual stages of development with a pediatric nurse. The student nurse would be correct in stating that Freud's anal stage of development is associated with which psychosocial development?

C. Toilet training often occurs during this stage. Choice C is correct. According to Freud's developmental stages, toilet training usually occurs during the anal phase. This theory of development believes that children in this stage derive pleasure from the elimination of body waste.

The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question?

C. Topiramate Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the anticonvulsant topiramate, this will increase the seizure threshold and may attenuate the efficacy of ECT.

The nurse has been assigned the responsibility for all aspects of providing patient care during a 12-hour shift. How would you classify this approach to nursing care?

C. Total Patient Care Choice C is correct. In the total patient care model, the RN assumes responsibility for all aspects of care for a patient or group of patients during a shift, although care can be delegated. The RN works directly with the patient, family, and health care team members.

While working in the triage of the pediatric emergency department, you are notified that a patient is on their way and suspected of having impetigo. What actions should the nurse take to prevent the spread of this disease?

C. Use standard precautions D. Initiate contact precautions Choices C and D are correct. As with every patient, standard precautions should always be followed. This will be especially important for your patient with impetigo because handwashing will prevent the spread of the infection (Choice C). Contact precautions are appropriate to prevent the spread of impetigo. Staff should be made aware of the precautions with the proper signs, gowns, and gloves readily available outside of the room (Choice D).

The patient with appendicitis is experiencing discomfort before her appendectomy. The nurse should avoid which of the following non-pharmaceutical therapies to relieve this discomfort?

C. Using a heating pad Choice C is correct. Heat should not be applied to the abdomen of patients experiencing pain from appendicitis. Heat will cause vasodilation and increased blood flow to the appendix which may lead to rupture. A ruptured appendix puts the client at risk for a life-threatening condition known as peritonitis.

The nurse caring for a three-year-old with congestive heart failure recognizes which of the following as an early sign of digitalis toxicity?

C. Vomiting

The nurse is assessing a patient who just returned from surgery. The nurse checks preoperative vital signs at 8:30 AM to compare them with the current vital signs at 10:30 AM. What action should the nurse take?

Choice A is correct. The patient's 10:30 AM vital signs show signs of shock. Considering this patient is in the immediate post-operative period, the nurse should assess the surgical wound for signs of hemorrhage. If this is the source of the bleeding, the nurse should reinforce the dressing. The nurse should notify the primary healthcare physician (PHCP) of the patient's change in condition.

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing pulmonary tuberculosis (TB)?

Choices A, B, and C are correct. According to the Centers for Disease Control (CDC), risk factors for TB include immunosuppression, organ transplant, chronic corticosteroid use, substance use, diabetes mellitus, and residing in environments such as nursing homes, prisons, and homeless shelters.

While reviewing various pain scales, the nurse understands pictorial pain assessment scale, like the Wong-Baker scale, has some advantages compared to a numerical pain intensity assessment scale. One of these advantages of pictorial scale over logarithmic scale is that the logarithmic pain intensity assessment scale cannot be used when:

Choice A is correct. The primary advantage of a pictorial pain assessment scale, like the Wong-Baker scale, when compared and contrasted to a numerical pain intensity assessment scale is that the logarithmic pain intensity assessment scale cannot be used when a client is confused and disoriented. However, this type of client would be able to use a pictorial pain assessment scale like the Wong-Baker FACES range of pain assessment.

The nurse is implementing orders for a client undergoing a barium enema. Aside from the radiology department, which hospital department should be notified of the procedure?

Choice B is correct. As part of the preparations for a barium enema, the client needs to be on NPO for 8 - 10 hours. The dietary department needs to be informed about withholding meals within the NPO period.

A toddler is brought to the family clinic by her parents due to poor sleep within the past two weeks and intense perianal itching and scratching. The nurse in the clinic would suspect which condition?

Choice B is correct. Enterobiasis is an intestinal infestation with the nematode Enterobius vermicularis, or the common pinworm. It is manifested by intense perianal itching and perianal dermatitis and excoriation secondary to scratching due to the presence of eggs in the anal area.

The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours, which assessment would indicate to the nurse that the client needs immediate intervention?

Choice B is correct. Extension of the arms and legs indicates decerebrate posturing, an indication of increased intracranial pressure. The nurse should intervene when the client displays this.

You are caring for a pregnant client during the third trimester of gestation. She is in moderate pain related to rheumatoid arthritis. Which of the following is the least likely to be ordered by the doctor for this pain?

Choice B is correct. Meloxicam is the least likely analgesic that would be ordered by the doctor for a pregnant client during the third trimester of gestation for moderate pain related to rheumatoid arthritis. Meloxicam is a pregnancy category D medication during the third trimester. Pregnancy Category D medications, according to the Food and Drug Administration (FDA), have proven risks for the developing fetus; these pregnancy category D medications, therefore, should be restricted to only life-threatening conditions that cannot be treated with other drugs. Diflunisal, ibuprofen, and naproxen are pregnancy category C medications; these pregnancy category C medications pose risks in animal studies, but there is no data available in terms of human fetal risk.

Relaxin is a hormone that is released throughout a woman's pregnancy to help prepare her uterine ligaments for the growth of her fetus and uterus. A downside to relaxin is that it may:

Choice B is correct. Relaxin can lead to clumsiness because of increased flexibility and ligament relaxation. This clumsiness increases the risk of musculoskeletal injury. Relaxin may also cause round ligament pain, indigestion, and an increase in the frequency of urination.

What is the first assessment the nurse should make when a patient reports he hurt his knee playing baseball and the knee appears swollen?

Choice B is correct. The first step of any assessment is always inspection. The first step the nurse should take is to compare the knees for symmetry.

The patient has been experiencing inflammation of the eye and maybe experiencing a retinal detachment. Which of the following signs and symptoms are NOT associated with retinal detachment?

D. Intense pain in the affected eye Choice D is correct. Intense pain is not generally associated with retinal detachment. Retinal detachment may present with floaters in the field of visions, partial loss of sight, and increasingly blurred images. Some patients report feeling as though a curtain has been drawn over their eyes.

The nurse is in charge of a male client scheduled for a liver biopsy at 8 AM. In preparing this client for the procedure, the nurse should do which of the following?

D. Inform him that his vital signs will be monitored closely after the procedure. Choice D is correct. The client will be monitored closely for bleeding and shock after the procedure. It is appropriate to monitor vital signs. Choices A, B, and C are incorrect. The preparation for a liver biopsy does not include placing the client on NPO, nor administration of a laxative. The client will be asked to hold his breath but only for 5-10 seconds.

A pregnancy related spinal change that can alter mobility is known as?

Choice B is correct. The spinal change that is common in pregnancy is lordosis. This is the result of the increasing weight of the enlarging uterus and the effect of gravity. As a fetus grows, a variety of changes appear in a pregnant woman's body. The thoracic and lumbar spine curvature change, pain in the low back, and pelvic region can increase, and the balance and gait pattern also changes. Some studies report that the center of gravity of pregnant women moves towards the abdomen, resulting in an increase in lumbar lordosis, posterior tilt of the sacrum, and movement of the head to the back to compensate for the increased weight as the fetus grows.

While orienting to the PICU as a new nurse, your preceptor asks you regarding the position that would be appropriate for your patient with acute respiratory distress syndrome (ARDS). Which of the following is/ are the most beneficial position (s)?

Choice C is correct. Widespread inflammation in the lungs may result in acute respiratory distress syndrome (ARDS). ARDS patients are at very high risk for decreased oxygenation, mismatched lung perfusion, and infection related to ineffective drainage from the lungs. Prone positioning ( placing the clients on their abdomen) supports both drainage and oxygenation for the ARDS patient. Generally, it is used for ARDS patients that are mechanically intubated and are on the ventilator. Although challenging to achieve in some clients, this is the most appropriate choice for an ARDS patient.

The nurse is caring for a child with eczema. Which of the following findings should the nurse expect?

Choices A, B, and C are correct. Erythema is superficial reddening of the skin. This redness is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Pruritus is severe itching of the skin. Itching is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Papules are solid elevations of skin with no visible fluid less than 1 cm in diameter. Although not all patients with eczema will necessarily have papules, they are a common assessment finding.

While at the park, the nurse witnesses an elderly woman fall. Upon evaluation, the woman complains of severe pain and an inability to move her left leg. The nurse also notes that the woman's left leg appears shorter than the right, but there are no visible wounds. A femoral fracture is suspected. Which of the following is the greatest immediate risk for the client?

Choice D is correct. A femoral fracture puts the client at risk for hypovolemia due to hemorrhage, which may be covert and is fatal when undetected. Following a closed femoral fracture, patients can bleed into the thigh's closed space without any external bleeding signs. The nurse should be aware of this immediate risk to the client. Approximate blood loss expected with a closed femur fracture is about 1000-1500 mL, enough to predispose the client to hemorrhagic shock/hypovolemia.

The nurse is caring for a patient with chronic liver failure who received a live-donor transplant five days ago. She is taking anti-rejection medication and is experiencing headaches and diarrhea associated with the medication. She wants to know how long she will have to take the anti-rejection medication. The nurse tells her that she will take the medication for:

Choice A is correct. An anti-rejection medication will be taken for the rest of her life. This will help to prevent the body from rejecting the donated liver. Survival rates from a live donor seem to be better than from a deceased-donor transplant; however, both groups will receive anti-rejection medication for the rest of their lives. Common anti-rejection or immunosuppressant drugs include cyclosporine, prednisolone, azathioprine, tacrolimus, mycophenolate mofetil, and sirolimus. Unfortunately, these medications suppress the body's reaction to other infection threats, so the liver transplant patient is at high risk for infection. Typically, the dosage of drugs will be decreased over time, so the risk of disease will also decrease. However, the patient with any transplant should be cautioned about the high risk of infection and preventative measures needed.

The nurse receives hand-off about a client with ulcerative colitis and was informed that the client has experienced severe diarrhea in the past 24 hours. When assessing the client, the nurse should watch out for signs of:

Choice A is correct. The client experiences increased bicarbonate loss from severe diarrhea. Therefore, the nurse should assess the client for metabolic acidosis, not alkalosis

Which of these critical thinking and supervision skills is necessary for effective and appropriate supervision after the nurse assigns and delegates tasks to staff members?

Choice A is correct. The critical thinking and supervision skills necessary for effective and appropriate supervision after the nurse assigns and delegates tasks to staff members are the ongoing observation and determination of staff's time management skills to ensure that complete care is given to the clients before the end of the shift.

Which of the following is the nurse's priority nursing action for the infant experiencing a tetralogy of Fallot (tet) spell?

Calm the infant down Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take.

The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the following medications should the nurse be prepared to administer?

Choice A is correct. A tonic-clonic seizure requires a client to be placed on their side and have their clothing loosened. Prompt intervention with benzodiazepines. In this case, prescribed lorazepam is given to break the seizure.

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms?

Choice A is correct. Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia.

A patient is being evaluated in the clinic for pancreatitis. Besides an elevated white blood cell count and serum lipase levels, which assessment finding indicates a positive finding for pancreatitis?

Choice A is correct. The discoloration of the abdomen and periumbilical area is known as Cullen's sign and indicates pancreatitis when it occurs in conjunction with other symptoms. Other findings include elevated white blood cell count, bilirubin, and urinary amylase levels.

The nurse is evaluating the lab test results of one of her prenatal clients. She is eight weeks along and has a hematocrit level of 36% and hemoglobin of 11.7 gm/dL. These numbers are down from her pre-pregnancy H and H levels. The priority action of the nurse would be to:

Choice B is correct. These results are typical and should be recorded as such. A drop from pre-pregnancy values is an expected phenomenon if they remain within or close to the normal range. Most women see a decrease in their hemoglobin and hematocrit levels during pregnancy. This phenomenon is known as physiological anemia and occurs as a result of increased plasma volume in the maternal bloodstream. It is essential to confirm that the client is taking prenatal vitamins. Demand for iron increases during pregnancy. Folic acid supplementation is necessary to prevent fetal neural tube defects. Prenatal vitamins will serve to address those needs. Normal hemoglobin in a pregnant client is > 11 g/dL. Normal hematocrit in a pregnant client is > 33%.

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for the treatment of the lumps. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to:

Choice B is correct. You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.

The nurse is caring for a client with a diagnosis of stroke. The client has stage I dysphagia. Which food should the nurse feed the client?

Choice C is correct. A client with stage I dysphagia has severe difficulty in swallowing. They must be fed with puréed foods. These include puréed fruits and vegetables, purréed meats with gravy, egg yolks, and baby food.

A client has been prescribed alendronate (Fosamax) 5 mg daily for her osteoporosis. Which teaching would the nurse include to avoid side effects?

Choice C is correct. Alendronate is a bisphosphonate that may cause a side effect of esophagitis when the tablet is not completely swallowed. The client should take the drug early in the morning, 30 minutes before eating, and should remain upright during the 30 minutes before eating.

A 42-year-old female client reports colicky abdominal pain that worsens after eating a high-fat meal. The nurse anticipates that this client has which diagnosis?

Choice C is correct. Cholecystitis occurs most commonly in women older than age 40 who haven't gone through menopause. Its manifestations include episodic, colicky pain in the epigastric area that radiates to the back and shoulder. Pain in cholecystitis resembles indigestion or chest pain after eating fatty or fried foods.

What consideration should the nurse keep in mind regarding the use of side rails for a confused patient?

Choice C is correct. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails.

The ICU nurse is caring for a patient who is receiving intermittent bolus feeds via a PEG tube. The nurse checks gastric residual volume (GRV) and finds that it is 220 mL. Which nursing action is appropriate?

Choice C is correct. The nurse should administer the bolus feed as ordered. In critically ill clients on enteral nutrition, the safe range for gastric residual volume (GRV) is less than or equal to 500mL. GRV refers to the amount of fluid aspirated from the stomach following administration of an enteral feed. Originally, GRV monitoring at every six hourly intervals was designed to decrease the risk of aspiration pneumonia. Still, there is no evidence to support the claim that GRV is associated with aspiration or ventilator-associated pneumonia. Many institutions have incorrectly used GRV thresholds as low as 200 to 250 ml to hold enteral feeding for an extended period. The assumption was that elevated GRV above that threshold increased the risk of aspiration and predicted intolerance to feeding. However, several studies indicate that feeding intolerance is better denoted by gastrointestinal symptoms and signs ( vomiting, abdominal distension) than GRV. High GRV is a primary reason leading to the cessation of enteral nutrition, thereby exacerbating the critically ill's malnutrition problem. The REGANE study in ventilated patients found no differences in using a GRV limit of 500mL versus a GRV limit of 200mL regarding the incidence of gastrointestinal complications and ICU-acquired pneumonia. Based on all this evidence, the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) recommend not holding enteral nutrition for GRVs less than 500 mL in the absence of other signs of intolerance. When using GRV, intolerance of enteral feeding is defined as GRV > 500mls.

As you are bathing your client and providing nail care, you notice that the client's fingernails look like this:

Choice C is correct. The picture shows clubbing of the fingernails. Clubbing, which is also referred to as Hippocratic fingers, indicates that the client has a pulmonary or cardiac condition that causes significant hypoxia over time.

An infant is admitted to the medical ward to rule out cystic fibrosis. The nurse assesses his stool and concludes that the stool is symptomatic of cystic fibrosis. Which of the following would describe the stool in this patient?

Choice C is correct. There is malabsorption in cystic fibrosis; thus, the presence of bulky stools. Stools are also foul-smelling and greasy.

The nurse is giving discharge instructions regarding methods that can prevent dumping syndrome for a client that had undergone a pyloroplasty. Which statement from the client indicates a need for further teaching by the nurse?

Choice C is correct. To prevent rapid gastric emptying, the client needs to lie down after meals. Staying upright promotes gastric emptying due to gravity.

The nurse is caring for assigned patients. Which of the following actions would reflect effective care coordination?

Choices A, B, C, and D are correct. The nurse arranging for an interdisciplinary conference, consulting with case management, initiating outpatient referrals, and performing post-discharge phone calls are all relevant to effective care coordination. These actions work to improve care delivery through effective communication with other members of the healthcare team.

The nurse is caring for a 4-year-old client in respiratory distress. The nurse knows to assess for which complication that frequently occurs with respiratory distress?

Choice D is correct. Dehydration is a frequent complication of respiratory distress and the nurse must know to monitor for this. Tachypnea (rapid breathing) is often seen in children with respiratory distress. Additionally, mouth breathing is common in children due to nasal congestion, edema, and inflammation. As these children expire more and more frequently, significant insensible fluid losses occur. Since children with respiratory distress do not take enough fluids by mouth, their intake is rarely enough to keep up with their insensible losses. Therefore, dehydration frequently occurs in a child experiencing respiratory distress. If the child is receiving humidified oxygen, insensible losses from tachypnea are minimal. Otherwise, it's important that the maintenance fluids include an additional 20-50% to the respiratory replacement in a child with tachypnea.

The nurse observes a newly hired nurse caring for a client prescribed a unit of packed red blood cells. It would require immediate intervention if the nurse observes the newly hired nurse?

Choice D is correct. Observing a client at the initiation of the blood transfusion is to quickly assess a potentially fatal hemolytic / ABO incompatibility reaction - not a febrile reaction. This reaction manifests as back or chest pain, apprehension, and dyspnea. A febrile reaction would not manifest as quickly as a hemolytic reaction. Therefore, this action requires follow-up.

A nurse is caring for a client who has missed their last appointment with the primary healthcare provider (PHCP). The client states, "I missed my appointment because I overslept, but I knew it would be pointless anyway." The client is demonstrating which of the following?

Choice D is correct. Rationalization is a higher-level defense mechanism that involves an individual justifying behavior that is often offensive or abnormal through statements that they believe provide validation. However, the rationalization of the behavior is done to avoid authentic feelings such as guilt if they have done something wrong. The client missing their appointment because they overslept is rationalizing this choice because they perceived the appointment as pointless.

Wilms tumor is a cancer most commonly in children under the age of 5. These tumor cells originate from which of the following?

Choice D is correct. Wilms tumor, also known as nephroblastoma, is a cancer of the kidneys. It's tumor cells originate from renal cells.

While working in the emergency department, you are assessing a 3-month-old infant who was brought in by parents for poor feeding, irritability, and vomiting. Upon auscultating the heart sounds, you note a machine-like murmur. Which conditions does the nurse suspect?

Choices A and B are correct. The objective here is to identify that a patent ductus arteriosus can lead to congestive heart failure and must be suspected in an infant presenting with the symptoms mentioned in the question. The nurse does suspect a patent ductus arteriosus (PDA) (Choice A), due to the presence of a machine-like murmur, a hallmark sign of a PDA. The nurse also suspects congestive heart failure (CHF) due to the classic presenting symptoms in the infant: poor feeding, irritability, and vomiting. Symptoms of congestive heart failure in infants with congenital heart disease are often misdiagnosed and treated as septicemia so, one should be aware of this presentation. PDA is an acyanotic type of congenital heart disease. Ductus arteriosus is the communication between the pulmonary artery and the aorta. Soon after a term birth, functional closure of the ductus arteriosus occurs from vasoconstriction. In some cases, it remains open (patent) and is referred to as PDA. A small PDA often does not cause any problem. If the PDA is large, it results in significantly increased pulmonary blood flow. A large left to right shunt through a PDA causes left atrial and left ventricular enlargement. The left ventricular end-diastolic pressure increases and eventually the left ventricle fails to handle the increased volume overload resulting in CHF. In 80% of infants with critical acyanotic congenital heart disease, congestive heart failure is the presenting symptom. Difficulty in feeding is common. This is often associated with tachypnea, sweating, and subcostal retraction. One should suspect congenital heart disease in such an infant if the feeding takes more than 30 minutes. A history of feeding difficulty often precedes overt congestive heart failure, even if only by six to 12 hours. Signs of congestive heart failure on physical exam include an S3 gallop and pulmonary rales.

Your client is a patient with low potassium levels and accelerated hypertension. The physician has listed the cause as "hyperaldosteronism." Which of the following endocrine disorders cause an increased amount of aldosterone?

Choices A and C are correct. Cushing's disease (choice A) is caused by an increased secretion of adrenocorticotropic hormone (ACTH) from the pituitary gland. Increased ACTH causes increased stimulation and hyperplasia of the adrenal cortex. This leads to increased levels of both glucocorticoids (cortisol) and mineralocorticoids (aldosterone). The physician may order ACTH and cortisol levels to establish the diagnosis of Cushing's disease. Clinical symptoms include abdominal obesity, moon facies, neck hump, abdominal striae, increased blood glucose, secondary diabetes, hypertension, and hypokalemia. Other manifestations include osteoporosis and increased risk of fractures. Clients are prone to increased risk of infections because excess steroids (cortisol) cause immunosuppression. Cushing's disease accounts for 65 to 70 percent of all Cushing's syndrome.

The nurse is caring for a patient receiving lorazepam. Which of the following reported herbal supplements would require follow-up?

Choices A and C are correct. Lorazepam is a CNS depressant, and the patient should avoid potentiating the effects of this medication. Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a patient is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation.

Malignant hyperthermia is a serious adverse reaction that can occur after the administration of which of the following medications?

Choices A and C are correct. Malignant hyperthermia is a severe adverse medication reaction. The nurse should know to monitor for this adverse reaction when administering induction agents such as halothane and succinylcholine. These medications can cause excess calcium to build up in the cells, resulting in the patient experiencing sustained skeletal muscle contractions. These contractions cause a hypermetabolic state, fever, and can lead to death.

The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.

Choices A and E are correct. These observations require follow-up because this is inappropriate. Instructing the client to tilt their head back when eating or drinking would facilitate aspiration. The correct instruction would be to advise the client to have the client assume a chin-down position after they have chewed their food thoroughly. The client should be placed upright with their head of bed at 90 degrees to prevent aspiration.

You are caring for a young woman who is pregnant for the first time. Common possible complications you should inform her about include:

Choices A, B, and D are correct. Possible complications during pregnancy include anemia, mood changes, and nausea/vomiting. Anemia is typically caused by dilution of red blood cells as blood volume increases. Depression usually occurs after birth and is often called postpartum depression or "baby blues." However, as hormones change during pregnancy, the mother-to-be can experience mood changes. Nausea and vomiting usually occur during the first trimester as a result of increasing levels of human chorionic gonadotropin (HCG). This "morning sickness" is thought to be a sign of a healthy pregnancy during the first three months, but when the vomiting is persistent and prolonged, it can result in hyperemesis gravidarum. This condition may require intervention to prevent weight loss and dehydration.

The nurse is caring for a client with the following clinical data. Based on the vital signs, which medications would the nurse clarify with the primary healthcare provider (PHCP) prior to administration?

Choices A, B, and D are correct. The vital signs show hypotension (90/60 mm Hg). The nurse should clarify the prescriptions of atenolol, spironolactone, and fentanyl. All these medications decrease blood pressure and considering how low the client's blood pressure is, it would be highly detrimental. FENTANYL ALSO CAUSES LOW BLOOD PRESSURE DUE TO VASODILATION

complications of immobility

Choices A, C, and D are correct. A patient who has been on bedrest will begin to experience complications such as atelectasis, bedsores, and DVTs unless attended to by nursing staff.

You are on the team in the delivery room caring for a newly born infant. After completing the initial assessment of the infant, you know that positive-pressure ventilation is indicated if which of the following is evident?

Choices A, C, and D are correct. Apnea, gasping, or heart rate less than 100 bpm are clear indications that the team should begin positive pressure ventilation (PPV) within one minute after birth. The unit can also consider a trial of PPV if it cannot maintain oxygen saturation despite the use of oxygen or continuous positive airway pressure (CPAP).

You are the nurse caring for a patient with primary open-angle glaucoma (POAG). Common risk factors associated with POAG include:

Choices B, C, and D are correct. Risk factors for POAG include older age, African ancestry, type 2 diabetes, a family history of the disease, hypertension, nearsightedness, and trauma to the eye. Primary open-angle glaucoma is characterized by increased intraocular pressure, usually higher than 25 mmHg. It is the second leading preventable cause of blindness in the world and is the leading cause in African-Americans. The early diagnosis of POAG is critical since damage can be minimized with treatment; however, once the damage is done, it cannot be reversed. Unfortunately, most of the time, there are no early symptoms of the disease. Therefore, it is essential that teaching for all patients must include the importance of annual eye examinations for everyone and more frequent exams for those individuals in one of the risk groups.

Which of the following signs are indicative of respiratory distress in the newborn?

Choices C and D are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort when trying to pull air in through their nose and their nares flare out with inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice C). Head bobbing is a severe sign of respiratory distress in the newborn. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice D).

While assessing a newborn infant in the nursery, you observe bounding +3 radial pulses and faint +1 pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and pink. Which cardiac defect do you suspect this infant has?

Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus. Because of this narrowing, there is increased blood flow to the upper extremities and decreased blood flow to the lower extremities. That is what causes the symptoms described in the question: bounding upper pulses, faint lower pulses, and overall better perfusion to the upper extremities.

Manifestations of cholecystitis include:

Constant pain in the right upper abdominal quadrant. It may radiate to the right shoulder or scapula. Nausea, vomiting, and reports of indigestion.

The nurse is developing the care plan for an 86-year-old patient with a diagnosis of cor pulmonale. Which nursing intervention would be most important to include in regards to monitoring this patient's peripheral edema?

Cor pulmonale describes right ventricular enlargement due to pulmonary hypertension. The accumulation of fluid in the interstitial spaces results in dependent edema, jugular vein distension, shortness of breath, and weight gain. Measuring and recording the circumference of the extremity at the same location daily is the best way to monitor for changes in the patient's peripheral edema.

Parts of a pain assessment entail the subjective comments of the client in terms of their sensory and affective/emotional comments that can indicate the quality and intensity of their pain. Select the type of pain that can be shown with the client's emotions of "nagging and tender".

D. Aching pain Choice D is correct. Aching pain in terms of affective/emotional descriptors can include the client's subjective comments that include "nagging and tender." Other personal affective descriptors can consist of "troublesome," "annoying," and "tiring". Ache is the least intense, hurt is the next level of intensity, and pain is the most intense.

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence the way people see and behave within the world is defined as:

Culture Choice D is correct. Culture is defined as the customs, arts, social institutions, and achievements of a particular nation, people, or another social group.

Bacterial Cystitis

Cystitis refers to inflammation of the bladder. When bacteria cause inflammation, it is called bacterial cystitis. Diagnosis: Acute bacterial cystitis can easily be recognized by demonstrating pyuria in the urinalysis. In the absence of pyuria, the presence of bacteria alone does not mean an active infection and could merely represent colonization. Generally, clinically significant pyuria refers to greater than or equal to 10 leucocytes per microliter. Urine sample collection: Ideally, a clean-catch, midstream sample of the first urine of the day is the best specimen. However, this is not always feasible, and there is no clear evidence it is more accurate than the specimen collected at the time of clinical evaluation. Therefore, a clean catch and midstream urine sample is sufficient. The nurse should educate the client regarding the specimen collection - the initial portion of the urine stream should be discarded since the urethral area contaminants may potentially contaminate it. The subsequent midstream sample should be collected in a sterile container. Treatment: A patient with bacterial cystitis will be prescribed an antibiotic, to which the nurse should educate the patient on adherence. Not taking the antibiotics for the optimal duration can lead to recurrence and antibiotic resistance. Commonly used antibiotics for treating uncomplicated UTIs include trimethoprim/ sulfamethoxazole, nitrofurantoin, and ciprofloxacin. Recurrences: Recurrent bacterial cystitis may require reinforcement of teaching, such as hygiene measures and adequate fluid intake. Cranberry products are beneficial in preventing recurrences but not for treating active infection.

Human chorionic gonadotropin (HCG) levels increase very rapidly in the first few weeks of a viable pregnancy. During this time. HCG levels double every:

D. 48 hours Choice D is correct. In a normal pregnancy, hCG levels double every 48 to 72 hours until it reaches 10,000 to 20,000 mIU/mL. A gestational sac within the uterus can usually be seen with abdominal ultrasound when the hCG level is 6000-6500 mIU/mL. When using a transvaginal ultrasound, the gestational sac can be seen when the hCG level is 1500-1800 mIU/mL.

The nurse is using the therapeutic communication technique while caring for her prenatal client. Which phrase, when used by the nurse, is an example of "focusing"?

D. "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" Choice D is correct. Saying, "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" is an example of a therapeutic communication technique known as "focusing". During conversations, patients may mention certain issues that are important to them. When this happens, nurses can focus on the client's self-perceived priorities, prompting them to discuss issues further.

You are conducting a class for new graduate nurses working on the psychiatric/mental health unit. One of these nurses asks you about the term used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client's development of better coping skills. How should you respond to this new graduate nurse's question?

D. "The term that is used on psychiatric/mental health units to describe the planned and therapeutic elimination of all triggers and stressors on the unit to facilitate the client's development of better coping skills is a therapeutic milieu."

A 38-week pregnant client is prescribed by the physician to undergo an NST. The client is inquiring about the purpose of an NST. The most appropriate response by the nurse would be which of the following?

D. "The test checks the baby's condition." Choice D is correct. Non-stress test (NST) measures fetal heart rate in response to fetal movement and uterine activity in the third trimester. This test determines the fetus's condition during the third trimester of pregnancy.

The charge RN is delegating assignments on the orthopedic unit. The client is a 90-year-old woman who is two days post-operative arthroplasty. Vital signs are stable, and the patient's post-op course has been uneventful. The most appropriate nursing assignment for this patient would be:

D. An LVN/LPN with 5 years of experience in geriatric care Choice D is correct. The charge RN knows that this patient has been stable following her surgery. The client will require routine post-op care rather than specific orthopedic care. The responsibility for this patient can be handled by an LPN/LVN after the initial evaluation. However, given the client's advanced age, there are additional needs specific to the geriatric age group. Therefore, the most appropriate assignment is the LVN/LPN with five years of experience in geriatric care.

The nurse is caring for a patient diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which of the following medications?

D. Baclofen Choice D is correct. Multiple Sclerosis (MS) may produce symptoms such as muscle spasticity, optic neuritis, fatigue, heat intolerance, and symptoms that seem to intensify on occasion (relapses). Muscle spasticity is best controlled with muscle relaxers such as baclofen.

The nurse is caring for a client in premature labor receiving terbutaline infusion. All of the following manifestations would alert the nurse to stop the infusion, except:

D. Blood glucose level of 130 mg/dL Choice D is correct. Terbutaline may increase the blood glucose level. The nurse should monitor the client's blood sugar levels while on this drug. However, this client's blood sugar level is at 130 mg/dL, an acceptable value to continue Terbutaline infusion.

The nurse is about to change a dressing on an older man with a stage 3 pressure ulcer. What should be the nurse's first action?

D. Check the medication record to see if pain medications were administered. Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes. The nurse must provide adequate pain medications to the client before the dressing changes. Pressure ulcers ( pressure injuries/ decubitus ulcers/ bed sores) are caused by prolonged pressure on an area of skin that leads to ischemia ( reduced blood supply), skin breaks down, and underlying tissue injury. Usually, these occur over bony prominences. Depending upon the clinical appearance and the degree of damage, pressure-induced skin and soft tissue injuries are staged from stage 1 to stage 4 and unstageable pressure injuries. Stage 3 and stage 4 ulcers are ulcers with full-thickness tissue loss. Management of these deeper injuries involves debridement and covering with appropriate dressings. Generally, pressure ulcers are very painful, and optimal pain medications ( using the WHO analgesic ladder) should be administered to control pain. In stage 3 and 4 ulcers, there is significant tissue damage, and therefore, only a little or no pain may be experienced at the baseline. However, the pain may be worse than the baseline during dressing changes, even with stage 3 ulcers. The nurse should ensure that the client has been given pain medication at least 30 minutes before changing the dressing.

The parents of a 2-year old with Hirschsprung's disease are talking to the nurse in the family clinic. They ask the nurse about treatment options for Hirschsprung's disease; the nurse understands that the treatment of choice would be which of the following?

D. Colectomy Choice D is correct. In Hirschsprung's disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus.

Prednisone is to be given to a 4-year-old child with nephrotic syndrome. Which symptom should the nurse be alert for as a serious side effect of the medication?

D. Decreased ACTH levels; stomach, muscle weakness, muscle pains Choice D is correct. Prednisone can lead to adrenal suppression, which is a potentially life-threatening side effect of the drug.

The nurse is conducting client and family education about dietary considerations related to Parkinson's disease. One priority consideration that the nurse should highlight in teaching is to address the risk of:

D. Difficulty swallowing and constipation Choice D is correct. With Parkinson's disease, eating problems include dysphagia, aspiration, constipation, and the risk of choking.

The nurse is caring for a pregnant client with heart disease undergoing labor. All of the following are appropriate nursing interventions, except:

D. Encourage ambulation. Choice D is correct. Bed rest should be maintained to conserve energy and decrease cardiac stress.

The client had just given birth and is resting in the postpartum unit when suddenly she feels a sharp pain in the chest and is having difficulty breathing. Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate of 24. She is suspected of having a pulmonary embolism. What should be the initial action of the nurse?

D. Give oxygen via face mask at 8-10 liters per minute. Choice D is correct. During a pulmonary embolism, circulation in the pulmonary bed is altered, thus affecting the oxygenation of the patient. Oxygen should be started immediately at 8-10 liters per minute to decrease hypoxia.

Which lab value alteration is likely a result of corticosteroid treatment in a type 1 diabetic patient diagnosed with pneumonitis?

D. Glucose 200 mg/dL (11.1 mmol/L) Choice D is correct. Type 1 diabetes is characterized by hyperglycemia secondary to the body's inability to create insulin. Corticosteroids cause a rise in blood sugar even in a non-diabetic patient by increasing insulin resistance and triggering the liver to release additional glucose. Prednisone and other steroids can cause a spike in blood sugar levels by making the liver resistant to insulin. Steroids can make the liver less sensitive to insulin because they cause it to keep releasing sugar, even if the pancreas is also releasing insulin. This continued release of sugar triggers the pancreas to stop producing the hormone.

The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?

D. Hourly urine output of 125 mL Choice D is correct. Following hypophysectomy, the client is at risk of developing diabetes insipidus (DI). An hourly urine output of 125 mL would be considered polyuria because, in 24 hours, that would equate to 3000 mL. After hypophysectomy, the client should be monitored closely for increased intracranial pressure, headaches, urine output, and vital signs. The client should be instructed to avoid blowing their nose, coughing, or straining. The most serious adverse effect of this surgery is CSF leakage, increased intracranial pressure, infection, and diabetes insipidus.

A pregnant client at 16 weeks gestation developed a pulmonary embolism and was initiated on intravenous heparin therapy two days ago. She is getting ready to be discharged. Which of the following medications do you expect the physician to order at the time of discharge?

D. Low Molecular Weight Heparin (LMWH) Choice D is correct. The physician will most likely order Low Molecular Weight Heparin (LMWH) to be self-administered twice daily. The dosing schedule and monitoring of LMWH are more convenient than that of unfractionated heparin. LMWH does not cross the placenta and therefore does not cause fetal harm. LWMH and unfractionated heparin are the anticoagulants of choice during pregnancy. LMWH will provide therapeutic anticoagulation for the rest of the pregnancy. Most venous thromboembolism events (VTE) need therapeutic anticoagulation for at least 3 to 6 months. However, pregnancy is a hypercoagulable state. The client, therefore, is at risk for recurrent thromboembolism throughout her pregnancy and at least six weeks post-partum.

The nurse is assessing a client who is newly diagnosed with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis?

D. Low-grade fever Choice D is correct. Rheumatoid arthritis (RA) is an autoimmune disorder characterized by symptoms such as bilateral joint pain, joint swelling, fatigue, low-grade fever, and weight loss. Low-grade fever is a manifestation of inflammation. Rheumatoid arthritis causes inflammation of the joints. Usually, the joint involvement is symmetric and bilateral.

The nurse is performing health education to a 21-year-old male who just had a fiberglass cast fitted on his right forearm for an ulnar fracture. They are talking about the early signs of compartment syndrome. The nurse notes that the patient has a full understanding of the topic when he states which of the following signs and symptoms:

D. Pain with passive motion and loss of sensation Choice D is correct. Pain with passive motion and loss of sensation are early signs of compartment syndrome due to decreased blood flow from increased pressure of the cast.

The nurse is discharging the client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral should the nurse make?

D. Refer the client to a home health agency. Choice D is correct. The client is going home, thus the client needs to be referred to a home health agency so that there is continuity of care even at home.

The nurse is working at the triage desk in the emergency department when a client arrives and begins speaking in Spanish. The nurse asks if the client would like an interpreter, and the client says, "No." What is the most appropriate action for the nurse to take?

D. Request an interpreter from the hospital's interpreter service despite the client's refusal. This is the safest option and will lead to the best outcome for the client. Choice D is correct. It is most appropriate to request an interpreter from the hospital's interpreter service. A certified medical interpreter has the proper training to quickly and accurately translate the conversation as well as protect client confidentiality. This is the appropriate action by the nurse.

The nurse in the surgical ward is taking care of a patient that had just undergone an elbow arthroplasty. All of the following should be included in the patient's care plan, except?

D. Tell the client that he can do exercises after 2 weeks. Choice D is correct. The client is instructed not to lift more than 5 pounds for months. Telling him that he can exercise after two weeks is inaccurate and should not be included in his care plan.

The nurse is taking care of a client that just underwent a bronchoscopy to extract tissues for a lung biopsy. Which manifestation would alert the nurse to initiate further action?

D. The client complains that he cannot catch his breath. Choice D is correct. The client stating that he feels out of breath signals respiratory distress that may be caused by a pneumothorax, which is a common complication of a bronchoscopy. The nurse should immediately assess the client for other symptoms and initiate appropriate interventions.

Which of the following is least likely to influence the potential for a client to comply with lithium therapy after discharge?

D. The client's friend's opinion on his need to take medication. Choice D is correct. Although a patient's social network may influence terms of compliance, this influence is typically secondary when compared to the other factors listed. Lithium is believed to alter the activity of neurons containing dopamine, norepinephrine, and serotonin by influencing their release, synthesis, and reuptake. Therapeutic actions include stabilization of mood during periods of depression. It is neither antimanic nor antidepressant in individuals without bipolar disorder.

You have been asked by a new graduate nurse why peaks and trough levels of medications are so famous. How should you respond to this new graduate nurse's question?

D. You should state that peaks and troughs of medications are important to monitor in order to ensure that the medication is creating a concentration to achieve the desired effect. Choice D is correct. You should state that peaks and troughs of medications are important to monitor and follow up on to ensure that the medication is creating a concentration to achieve the desired effect. Peak and trough levels are most often done for the client who is taking an antimicrobial medication.

The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?

Democratic Choice B is correct. The democratic leadership style is predicated on individuals participating in decision-making. Developing a unit-based council, distributing decision-making responsibilities to individuals, and promoting problem-solving by staff are examples of this leadership style.

Which of the following signs and symptoms would you expect in a patient diagnosed with Graves Disease?

Diaphoresis Exophthalmos Increased appetite Diaphoresis, or excessive sweating, would be expected in a patient with Graves Disease. Due to their increase in thyroid hormone, they have too much energy and a metabolism that is working too fast. This can cause increased body temperature and sweating. Exophthalmos, or bulging eyeballs, is a severe sign of Graves Disease. Once the disease has progressed to this point, the exophthalmos is irreversible. Increased appetite is a symptom of Graves Disease. Due to the increase in metabolism, these patients experience an increase in taste, but a significant weight loss.

Lyme disease treatment

Doxycycline

PID Treatment

Doxycycline

Which of the following are bypasses in fetal circulation?

Ductus arteriosus Foramen ovale Choices A and B are correct. The ductus arteriosus is a bypass in fetal circulation. It connects the pulmonary artery to the aorta (Choice A). The foramen ovale is a bypass in fetal circulation. It is an opening between the right and left atriums of the heart (Choice B).

Ebola virus

EVD is highly contagious, and despite a vaccine being available, it has a high mortality rate. Standard, contact, and droplet precautions should be utilized. If aerosolized procedures should be performed (nebulizer, bronchoscopy), airborne precautions should be implemented. Bleach is the disinfectant of choice for surfaces contaminated with EVD. Manifestations have an abrupt onset, including fever, malaise, headache, and myalgias. As the illness progresses, vomiting and bloody diarrhea may develop, often leading to significant fluid loss.

The nurse is caring for a client that underwent an above-the-knee amputation more than 24 hrs ago. Which intervention by the nurse should not be included in the care of the client?

Elevating the residual limb using a pillow is an incorrect intervention, therefore the correct answer to this question. Proper positioning of the residual limb is crucial in preventing flexion contractures. For the first 24 hours, the residual limb should be elevated using a pillow to increase venous return and decrease edema. However, beyond 24 hours, the pillow must be removed and the residual limb should be placed flat on the bed. Elevation of the residual limb on a pillow beyond 24 hours makes the client with above-knee-amputation prone to hip flexion contractures. A flexion contracture refers to the shortening of muscles and tendons leading to deformity and rigidity of joints. The client should be encouraged to lay prone for at least 30 minutes several times a day to reduce the risk of contractures. Prolonged sitting in a chair and semi-Fowler's position must be discouraged. The nurse should also educate the client to avoid external rotation of the hip by using a trochanter roll in bed.

The emergency department nurse is caring for a client exposed to inhalation anthrax. It would be essential for the nurse to take which action?

Initiate continuous pulse oximetry Choice A is correct. Inhalation anthrax poses a serious threat because the progression of symptoms may be rapid and become life-threatening. Anthrax may cause hypoxia, and continuous pulse oximetry monitoring is essential. This would enable the nurse to determine if the client's condition is deteriorating and may allow the nurse to immediately apply supplemental oxygen.

What is Cullen's sign?

It is the presence of superficial edema and bruising around the umbilicus - it is suggestive of acute pancreatitis or an intraabdominal bleed.

Parenting styles are most similar to whose theory of leadership?

Kurt Lewin's theory of leadership is the most similar to the styles of parenting. Lewin describes the leadership styles as the autocratic, participative, democratic, and laissez-faire styles of leadership, which are the same as the different parenting styles. All these styles of leadership and parenting styles have their distinct advantages and disadvantages.

The nurse is taking care of an 8-hour post-operative spinal surgery client. What should be the priority nursing intervention for the client?

Logroll the client with three staff when turning the client from side to side. Logrolling the client is a priority to maintain proper body alignment and prevent injury to the spinal cord.

Schizophrenia treatment

MEDICATIONS: - Atypical Antipsychotics: Abilify, Clozaril, Zyprexa, Invega, Seroquel, Risperdal, Geodon. - Typical Antipsychotics: Thorazine, Haldol THERAPY: - Psychosocial Therapy

Airborne precautions

MTV MEASLES (RUBEOLA) TUBERCULOSIS VARICELLA VIRUS (CHICKEN POX) VARICELLA ZOSTER SARS SMALLPOX

You are assigned to take care of a client who just underwent a cholecystectomy. Which of the following would decrease the risk of developing atelectasis in this client?

Explanation Choices A, B, C, and D are correct. Atelectasis is defined as the total or partial collapse of the alveoli. This is a common complication in the immediate postoperative period, especially after abdominal surgeries. If atelectasis is not addressed, it may progress to pneumonia. Since alveoli are responsible for gas exchange, alveolar collapse can lead to impaired gas exchange/impaired oxygenation. Post-operatively, the client may not be able to take deep breaths due to pain from the movement of abdominal muscles. This impaired expansion of the alveoli leads to the accumulation of secretions/mucus plug, decreased surfactant, as well as the obstruction of airway and collapse of alveoli. Additional factors that predispose to this may include hypoventilation, sedation, and reduced mobility. When such factors are identified, the nurse should encourage the client to adopt interventions to mitigate those factors and prevent atelectasis. Such interventions include: Encouraging clients to take deep inspirations (Choice A) and use incentive spirometry. An incentive spirometer encourages the client to pursue deep breathing. Deep breathing aids in gas exchange and promotes the full expansion of the alveoli. Keeping the client in the supine position with the head end of the bed elevated (Choice B) or semi-recumbent area (head of the bed raised 30 to 45 degrees). This allows for maximum thoracic expansion by lowering the abdominal pressure on the diaphragm. Encouraging the client to change position at least every 2 hours (Choice C). This increases mobility and allows full chest expansion and increases perfusion to both lungs. Encouraging the client to cough at least ten times per hour (Choice D) when awake. This helps promote alveolar expansion. The above interventions are aimed at preventing atelectasis. However, the nurse should be aware of detecting atelectasis if it did end up happening. Physical exam findings assist in the diagnosis and include fever and decreased breath sounds on the side of atelectasis. In the case of complete atelectasis/collapse, the trachea/mediastinum may be shifted to the same side due to the pull by a collapsed lung. Atelectasis in the postoperative period is referred to as "resorption atelectasis" but the nurse should also be aware of other types in different client scenarios. Once the nurse detects atelectasis, treatment interventions from a nurse's perspective include: Use of incentive spirometry (IS) - IS mimics the natural process of sighing or yawning. It encourages the patient to take slow and deep breaths. The result of this process is decreased pleural pressure, increased lung expansion, and improved gas exchange. Regular repetition of IS can prevent or even reverse atelectasis. Supportive devices to assist with deep coughing. Chest physiotherapy includes tapping on the chest to loosen mucus Mobilizing the patient early, i.e. encouraging sitting up in bed, sitting over the edge of the bed, standing, or assisted ambulation. Postural drainage - to achieve this, the body is positioned with the head lower than the chest to promote gravitational drainage of the mucus from the bottom of the lungs. (Note this position is for treatment of atelectasis and is different from the semi-recumbent area used to prevent atelectasis) Bronchoscopy may be ordered in certain cases by the physician to remove the mucus plug if the patient is not showing improvement despite the above non-invasive measures.

Adderall Withdrawal Symptoms

Fatigue. Irritability. Attention and concentration disturbances. Psychomotor retardation or agitation. Slow movements. Insomnia or hypersomnia. Increase in appetite. Graphic, distressing dreams. Slow heart rate. Inability to feel pleasure. Feeling of unease or dissatisfaction. Suicidal ideation.

The nurse is caring for an 18-month-old toddler with a cough and fever. Which is the most appropriate play activity for the nurse to offer the toddler?

Finger painting Choice C is correct. Toddlers enjoy feeling different textures. They are sensorimotor learners at this point. Finger paints would be an appropriate choice.

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?

Garlic Nuts Turkey B is correct. 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. C is correct. 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. E is correct. One cup (140 grams) of roasted turkey contains around 300 mg of phosphorus, more than 40% of the recommended daily intake (RDI).

Heparin-induced thrombocytopenia (HIT)

HIT is an adverse response to heparinoids. This autoantibody reaction causes venous (deeper vein thrombosis, pulmonary embolism) and arterial thrombosis (thrombotic strokes, myocardial infarction, arterial thromboembolism) The priority of HIT is to recognize it and stop the heparin product. The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy. The nurse must report this type of platelet reduction immediately to the primary healthcare physician (PHCP). HIT treatment includes using an alternative anticoagulation agent such as fondaparinux, warfarin, rivaroxaban, dabigatran, and argatroban, inhibiting thrombin. Note that anticoagulation must be pursued in HIT despite thrombocytopenia.

A 14-year-old is admitted to the medical ward for status asthmaticus. He was put on IV theophylline. Which manifestation would the nurse consider as a side effect of the drug?

Headache Choice D is correct. Headache is one of the most common side effects of theophylline. It is important to understand the difference between a side effect and drug toxicity, A side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity (adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range.

What is the priority intervention when caring for an infant diagnosed with transposition of the great arteries?

Initiate alprostadil infusion Initiation of alprostadil is the priority for an infant diagnosed with transposition of the great arteries. Alprostadil will keep the ductus arteriosus from fetal circulation patent, allowing shunting of blood from left to right so that some oxygenated blood can exit the transposed aorta and be distributed to the body. Without alprostadil administration, the ductus arteriosus will begin to close, and if the infant does not have an ASD or VSD they will become profoundly hypoxic due to the lack of oxygenated blood in the systemic circulation.

The nurse is evaluating a patient with symptoms of metabolic acidosis. Which of the following is not a cause of metabolic acidosis?

Hyperventilation Choice B is correct. Hyperventilation due to asthma, anxiety, or high altitude may lead to respiratory alkalosis. Unless it is quickly corrected, acidosis and alkalosis can have severe or fatal consequences. The nurse needs to understand possible causes and identify symptoms as soon as possible. Note: Acidosis and alkalosis are not diseases, but instead signs of an underlying disorder. The primary treatment of acid-base disorders is targeted at correcting the underlying cause.

A common prerenal cause of acute kidney injury is:

Hypovolemia is a common prerenal cause of acute kidney injury (AKI). Prerenal reasons are those factors that are external to the kidney. Hypovolemia causes a decrease in blood flow to the organs. Hypovolemia can lead to intrarenal kidney disease.

The nurse is assessing a client with delirium. Which of the following would be an expected finding? Select all that apply.

Impaired insight into illness B. Difficulty with executive functioning C. Altered level of consciousness D. Emotional lability hoices A, B, C, and D are correct. Delirium has an abrupt onset of symptoms that include - Impairments with attention that fluctuate in intensity Difficulty with insight, judgment and executive functioning Memory impairments Altered level of consciousness Emotional lability Causes of delirium include fluid and electrolyte imbalances, infection, medications, sensory alterations, or substance use (intoxication/withdrawal).

metabolic syndrome

Metabolic syndrome is when the client has three out of the five abnormalities - Hypercholesterolemia (> 200 mg/dl) High triglycerides (> 150 mg/dl) High fasting blood glucose (>100 mg/dl) Abdominal obesity (> 40 inches in men; > 35 inches in females) Elevated blood pressure (> 130/85 mmHg) Low High-Density Lipoproteins (<50 mg/dl)

Myxedema coma

Myxedema coma is a severe form of hypothyroidism that causes an array of clinical manifestations, including: Decreased mental status Bradycardia Hyponatremia Hypoglycemia Hypotension Hypothermia Treatment is aimed at giving the client intravenous levothyroxine, corticosteroids, intravenous dextrose, rewarming, and mechanical ventilation, if necessary.

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect?

Nausea and vomiting B. Constipation C. Pruritus D. Urinary retention

Which assessment data should the nurse recognize as a sign of acute kidney injury (AKI)?

Oliguria Choice C is correct. Oliguria (urine output less than 400 mL/24 hours) is the most common initial sign of an AKI. It is usually seen within the first week of the injury.

The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication?

Ondansetron Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental

A patient presents to the emergency department with pinpoint pupils, poor attention, and slurred speech. Upon assessment of vitals, the patient is found to have a BP of 92/60 mmHg, HR 58, RR 14, and T 96.8 degrees F. Which substance is this patient's intoxication most likely related to?

Opiates Choice D is correct. The patient is showing signs of opiate intoxication. Opiate intoxication is characterized by pinpoint pupils, slurred speech, inattention, lethargy, psychomotor retardation, and impaired memory, judgment, and social function. Changes to vitals include hypotension, decreased heart rate, reduced temperature, and lower respiratory rate.

A client you are taking care of is 38-years-old. She has a history of rheumatoid arthritis and has recently been suffering from severe seasonal allergies. She has been self-medicating with aspirin and diphenhydramine. At her visit today, she reports that these medications no longer work. The physician prescribed loratadine and phenylephrine nasal spray. What instructions should the nurse give the client regarding the use of phenylephrine?

Phenylephrine should not be used for longer than 3-5 days, to help reduce the risk of rebound congestion. Phenylephrine is a sympathomimetic medication that is effective at relieving the nasal congestion associated with allergic rhinitis. Because of their local action, intranasal sympathomimetics produce few systemic effects. However, one side effect associated with their use is rebound congestion. Prolonged use causes hypersecretion of mucus and worsened nasal congestion once the drug effects wear off. This rebound effect sometimes leads to a cycle of increased drug use as the condition worsens. Because of the risk of rebound congestion, intranasal sympathomimetics should be used for no longer than 3-5 days.

strategies to reduce VAP

Proper positioning: elevation of the head of the bed to 30-45 degrees is a recommended VAP prevention strategy. Elevation of the head of the bed also reduces gastric reflux and reduces the subsequent risk of aspiration pneumonia. Excellent oral care: oral health can deteriorate quickly among mechanically ventilated clients. Good oral care decreases bacterial overgrowth and thereby decreases the risk for infection. Evidence shows routine oral maintenance with chlorhexidine about one to four times a day reduced VAP incidence. Subglottic suctioning: secretions accumulate around the endotracheal tube's cuff of mechanically ventilated patients. Aspiration of these contents into the lungs heralds an infection/ pneumonia. Some endotracheal tubes are equipped with a small hole in the shaft above the cuff. Subglottic suctioning of secretions through this opening is a recommended strategy to prevent VAP. The Centers for Disease Control (CDC) recommends an endotracheal tube dorsal lumen positioned above the endotracheal cuff to allow continuous or frequent suctioning of subglottic tracheal secretions. Early mobilization: early mobilization of mechanically ventilated clients is associated with more ventilator-free days. Nurses can coordinate exercise and mobilization activities with physical and occupational therapists.

The Maternal Serum Screen 4 (MMS4) of an obstetrics client shows decreased maternal serum alpha-fetoprotein and estriol, The hCG was increased. What strategy should the nurse include in the plan of care?

REFER TO PHYSICIAN AS THIS MAY BE A SIGN OF DOWN SYNDROME AND MOTHER NEEDS TO BE REFERRED

You are working in the newborn nursery taking care of a 2-day old infant with fetal alcohol spectrum disorder and preparing the family for discharge. Which of the following educational points are essential to include?

Regular therapy appointments will need to be scheduled. An individualized education plan should be formulated with the child's school when he is preparing for kindergarten. Choices A and B are correct. Therapy will be incredibly important for this infant after discharge. Physical therapy, occupational therapy, and speech therapy should all be incorporated with this infant's care plan. They will keep track of milestones and help aid in the development, motor skills, and cognitive abilities of the infant. Parents should be educated about the importance of these therapies so that they take them seriously and keep up with their appointments (Choice A). This child will require special education when starting school. The parents should be educated about this need so that they are realistic about their culture and prepared for the future needs of the child. Individualized education plans will be accommodated through the school system; the therapists and health care providers of the child can help inform them (Choice B).

A toddler has just been diagnosed with Reye's syndrome. Upon assessment of the child's medical history, which condition should the nurse expect?

Reye's syndrome is usually preceded by a bout of influenza the week prior.

Sepsis

Sepsis can be identified by an elevated temperature (above 100.4 degrees Fahrenheit, or 38 degrees Celcius), heart rate, respiration, and low blood pressure. Her heart rate is still within normal limits, however, this patient does have increased respiration, lower blood pressure, and a low-grade fever. In elderly patients, these vital signs need to be identified as soon as possible to prevent complications and ensure timely interventions.

The nurse is working in a women's health clinic. Which patient should the nurse see first?

Signs and symptoms of preeclampsia include blurred vision, hypertension, generalized edema, and proteinuria. The client is also a primigravida (first-time pregnant), which predisposes her to preeclampsia. The nurse should prioritize the client to include further assessment and intervention.

The nurse is changing a diaper for her 7-month-old patient suspected of having Celiac disease. She notes a large, pale, oily stool that is malodorous. This assessment finding is known as what?

Steatorrhea Steatorrhea refers to the excretion of abnormal quantities of fecal fat due to reduced fat absorption by the intestines. This produces pale, oily, malodorous stools and is a symptom of Celiac disease.

Which of the following is a cause of hyponatremia?

Sweating Choice A is correct. When a patient sweats excessively, sodium is lost in sweat and their serum sodium levels will decrease, leading to hyponatremia.

compartment syndrome

Swelling in a confined space that produces dangerous pressure; may cut off blood flow or damage sensitive tissue.

Malignant hyperthermia symptoms

The client will manifest tachycardia, muscle rigidity, fever, and rhabdomyolysis. Thus, the nurse must monitor the client for acute kidney injury and metabolic acidosis.

triage

The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke. The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C). Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections

While assessing your patient in active labor, you evaluate the fetal monitor and note late decelerations and significantly decreased variability. The patient is on a Pitocin infusion. Upon observing this nonreassuring fetal heart rate, the nurse should take the following actions in what order?

The first action the nurse should take is to identify the cause of the nonreassuring fetal heart rate. Is the patient lying on her back? Is the Pitocin drip inappropriately titrated? There are many causes of nonreassuring fetal heart rates, and sometimes a simple intervention can fix the problem. After the nurse tries to identify the cause, she should stop the Pitocin infusion. Remove the potential cause or contributing factor first. Even if the fetal heart rate seems to be improving, the Pitocin infusion should be stopped to prevent any further decelerations or decreased variability. Next, the nurse should change the mother's position and lay the mother in the left lateral position. If she is on her back, the fetus could be putting pressure on her descending aorta, or the fetus could be compressing the umbilical cord, and a simple change of position will resolve this. Next, the nurse should begin administering oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, if still unresolved, the nurse needs to prepare for an emergency delivery.

A client is admitted to the behavioral health unit and diagnosed with acute mania. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication?

The gold standard for treating bipolar mania is mood stabilizers. Valproic acid (VPA) is a mood stabilizer and is efficacious in treating mania because it has a fast onset.

The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. Place the priority actions in the correct order.

The priority nursing action is to stay with the client and call for help. This is a medical emergency, and the nurse must remain with the client to ensure safety. Next, the nurse needs to quickly wear gloves and apply pressure to the presenting fetal part. This will lift the fetus off the prolapsed umbilical cord and restore blood flow to the fetus. The nurse cannot let go until the health care provider arrives to deliver the fetus. Next, the nurse needs someone to place the client in Trendelenburg's position. This will assist with keeping the presenting fetal part off of the umbilical cord, so that blood flow to the fetus continues. Next, the nurse needs someone to administer oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, the nurse needs to prepare for the immediate delivery of the fetus. This is the only way to resolve this medical emergency.

Treatment of acute migraine

The treatment for an acute migraine headache aims to abort the headache and the associative symptoms such as nausea and vomiting. Commonly, a client may be prescribed an anti-emetic such as metoclopramide to assist with abating the symptoms. The below table reviews the treatment options for a migraine headache. Preventative treatment Verapamil Propranolol Topiramate Onabotilinumtoxin-A Valproic Acid Nortriptyline Galcanezumab Abortive treatment Ketorolac Acetaminophen Caffeine Magnesium Sulfate Dexamethasone Sumatriptan

You are reinforcing counseling for two parents that are preparing for the birth of their first child. They decided to undergo genetic testing and find out that they are both carriers for sickle cell anemia. You tell them that their baby has what chance of having sickle cell anemia?

Their baby has a 25% chance of having sickle cell anemia. The father and the mother are Ss because they are both carriers. The Punnett square is as follows:

contralateral stimulation

This is stimulating the skin in an area opposite to the painful site. Stimulation may be in the form of scratching, rubbing, or applying heat or cold. This intervention is especially helpful if the affected area is painful to touch, under bandages, or in a cast.

The nurse oversees an 80-year-old client with acute renal failure and severe anemia. The client's blood pressure is 110/70 mmHg. The physician orders two units of packed red blood cells (PRBCs) to be transfused. The nurse receives the first unit of PRBCs from the blood bank at 8:45 AM. When should the transfused unit be completed?

This time interval represents the standard practice of infusing a unit of packed red blood cells (PRBCs), which is between 90 minutes and 4 hours. Also, the nurse must always initiate blood within 30-minutes of receipt from the blood bank. In the question, the nurse received the blood from the blood bank at 8:45 AM. She can hook it up immediately but certainly, must start administering it at-least by 9:15 AM (within 30 mins). Blood can be consumed (adequately transfused) any time between 10:30 AM and 12:45 PM (minimum 90 minutes of transfusion time to a maximum of 4 hrs since the receipt from the blood bank). The nurse should remember two basic rules in transfusion medicine. 4-hour rule: Transfusion must be completed within 4 hours of removal of blood products from controlled temperature storage. 30-minutes rule: The nurse must initiate the transfusion within 30-minutes of receiving it from the blood bank. For some reason, if the delay is anticipated in starting a blood transfusion, the nurse must return it within 30 minutes to the blood bank. Red blood cell units left out of controlled temperature storage for more than 30 minutes should not be returned to the blood bank for reissue. Many patients can be safely transfused over 90-120 minutes per unit. Injecting it too fast may lead to circulatory overload (Fluid overload), especially in patients with renal failure and heart failure. It is essential to remember that in certain situations like hemorrhagic shock (severe bleeding causing hemodynamic compromise), whole blood/PRBCs can be transfused extremely fast. During major bleeding, very rapid transfusion (each unit over 5-10 minutes) may be required. However, the client's blood pressure is stable, and there is no indication in this question that he is bleeding. Safest minimum transfusion time for this client is at-least 90 minutes.

Tick Care

Tweezers or forceps should be used to remove the embedded tick as close to the head as possible. A smooth, steady pull upwards should be applied, ensuring not to twist the tick while lifting. After the tick is removed, the area should be cleaned well with soap and water. If the tick has transmitted the pathogen, Lyme disease's classic symptoms usually appear within days of the bite and include flu-like symptoms and a bulls-eye rash at the site

What percussion sound is heard over most of the abdomen?

Tympany Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity.

You are administering hydralazine to your patient with a blood pressure of 162/112 mmHg. Which of the following actions do you expect to occur with the administration of this medication?

Vasodilation Decreased afterload Choices B and C are correct. Administration of hydralazine will cause vasodilation; it is very effective at lowering blood pressure. By dilating the vessels of the body, the fluid in the vessels have more room and therefore the pressure they are exerting on the vessel walls decreases. Think of it like a garden hose - to decrease the pressure in the hose you can either make the hose bigger or put less water in the hose. Hydralazine makes the "hose" or blood vessels bigger by causing vasodilation (Choice B). When the patient vasodilates and their blood pressure drops, the afterload decreases; this is because the heart has less pressure to pump against (Choice C).

What is the sequence of action when you are mixing two insulins, such as NPH insulin and regular insulin, together in the same syringe? Place these steps in the correct order.

When you mix regular insulin with another type of insulin, always draw the regular insulin into the syringe first. When you combine two types of insulins other than regular insulin, it does not matter in what order you bring them into the syringe. The correct procedure for drawing up and mixing two different insulins like NPH insulin and regular insulin, in the correct sequential order, is: A. Prep the top of the vials with an alcohol pad. B. Inject an amount of air equal to the ordered dosage of the NPH insulin C. Inject an amount of air equivalent to the ordered dosage of the regular insulin. D. Withdraw the ordered dosage of the regular insulin. E. Withdraw the ordered dosage of the NPH insulin. This sequencing prevents the contamination of regular insulin with the longer-acting NPH insulin.

Your elderly female client has just begun a new medication for their impaired cardiac function. Which of the following is a high-priority nursing intervention, and what is the rationale for this client?

Your elderly female client has just begun a new medication for their impaired cardiac function. Which of the following is a high-priority nursing intervention, and what is the rationale for this client? Correct Answer is D. You should carefully monitor this client for the adverse effects of this cardiac medication because they are elderly and adverse effects most commonly occur when a new drug is begun. This is the correct reasoning for the nurse's priority action of monitoring.

erythroblastosis fetalis

a disorder that results from the incompatibility of a fetus with Rh-positive blood and a mother with Rh-negative blood, causing red blood cell destruction in the fetus; a blood transfusion is necessary to save the fetus

Dissociation

a disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself. This client has no evidence of a disruption in their consciousness, memory, or identity.

Preeclampsia

abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, and headache that starts after 20 weeks gestation

At the time of birth, the nurse should accomplish the following tasks: Assess the newborn's heart rate Provide positive pressure ventilation Assess muscle tone and presence of respiratory effort Clear secretions as needed. The correct sequence for these tasks is:

assess muscle tone and presence of respiratory effort. Clear secretions as needed. Assess the newborn's heart rate. Provide positive pressure ventilation. Correct answer: According to the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Program algorithm, the team should first assess the newborn's muscle tone and breathing. If those are abnormal, the team should provide a patent airway, including positioning and suctioning as needed. At the same time, the team should ensure that the infant is warm. The third task is to assess the newborn's heart rate to ensure that it is at least 100 beats per minute. The fourth task in this sequence is to provide positive pressure ventilation if the heart rate is less than 100 bpm.

thelarche

beginning of breast development

RA symptoms

fever, fatigue, weight loss, dysphoria, symmetric joint pain, joint swelling, and joint stiffness persistent in the morning

Manifestations of a hemolytic reaction

low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

Reye's syndrome

potentially serious or deadly disorder in children that is characterized by vomiting and confusion

Papules

raised lesions with no visible fluid less than 1 cm in diameter

ulcerative colitis

chronic inflammation of the colon with presence of ulcers

Acrocyanosis

cyanosis of the newborn's extremities. This is a regular occurrence during the first hours of the newborn's life

cor pulmonale

right ventricular hypertrophy and heart failure due to pulmonary hypertension

pruritus

severe itching

fluency

smoothness of speech

The emergency department nurse is caring for a client with an abdominal aortic aneurysm at risk of rupturing. The nurse will anticipate the primary healthcare provider (PHCP) to prescribe

esmolol Choice A is correct. For a client with a suspected ruptured (or rupturing) abdominal aortic aneurysm, tight blood pressure control is essential. Esmolol is a beta-blocker and will exert antihypertensive effects. Having tight blood pressure control decreases the pressure on the aneurysm. For a client with an unstable abdominal aortic aneurysm, the nurse should provide close monitoring of their vital signs and adequate pain control.

Myxedema coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure

FLACC pain scale

face, legs, activity, cry, consolability Pain tool for ages 2-10

RA risk factors

family history, female gender, and cigarette smoking. Medications primarily utilized in managing RA include disease-modifying antirheumatic drugs (DMARDs) and corticosteroids.