(Pharmacology + Parenteral Therapy I/II + Management of Care ASSIGNMENT RN SEM 4)

A child who has been undergoing prolonged steroid therapy takes on a cushingoid appearance. What will the nursing assessment probably reveal? Select all that apply. 1. Truncal obesity 2. Thin extremities 3. Increased linear growth 4. Loss of hair on the body 5. Decreased blood pressure

1). An increase in appetite results in deposition of fat on the abdomen and trunk. 2). Muscle wasting results in thin extremities. > Increased excretion of calcium causes retardation of linear growth and a resulting short stature. > Because of the excess production of androgens, virilization and hirsutism occur. > Increased salt and water retention cause hypertension and hypernatremia.

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? 1. International normalized ratio (INR) 2. Accelerated partial thromboplastin time (APTT) 3. Bleeding time 4. Sedimentation rate

1). Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. > APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. > Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. > Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.

A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response? 1. Orange feces 2. Yellow sclera 3. Temperature of 96.8° F (36° C) 4. Weight gain of 5 pounds (2.3 kilograms)

2). An adverse reaction to isoniazid (INH) is hepatitis, resulting in jaundice. > Rifampin, an antitubercular medication, can color excretions orange, which is not harmful. > A temperature of 96.8° F (36° C) is within expected limits. > Weight gain indicates improvement in the client's health status.

A nurse is administering erythropoietin three times a week to a client receiving chemotherapy for cancer. Which client response is considered most significant? 1. Elevated liver enzymes 2. Elevated hematocrit level 3. Increase in Kaposi sarcoma lesions 4. Increase in the white blood cell (WBC) count

2). Erythropoietin stimulates red blood cell production, thereby increasing the hematocrit and hemoglobin level. > An elevated liver panel is not related to erythropoietin because erythropoietin is not hepatotoxic. > Erythropoietin increases red blood cells (RBCs), not WBCs. > Increased Kaposi sarcoma lesions are a sign of acquired immunodeficiency syndrome (AIDS) progression and are not affected by erythropoietin.

Which parts of the nephron are the sites of action for furosemide? Select all that apply. 1. Glomerulus 2. Loop of Henle 3 . Distal tubule 4 . Proximal tubule 5. Bowman capsule

2, 3, and 4). Furosemide, known as a 'loop diuretic', inhibits sodium and chloride reabsorption from the ascending loop of Henle and proximal and distal tubules. > The glomerulus is a site of glomerular filtration. > The Bowman capsule (BC) is a site of the collection of glomerular filtrate.

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action? 1. Authority 2. Autonomy 3. Accountability 4. Responsibility

3). Accountability means being answerable for one's actions. The nurse's action of admitting the mistake and seeking instructions to correct it indicates accountability. > Authority is the legitimate power to give instructions and make final decisions in a situation. > Autonomy is freedom of choice and responsibility for the choices. > Responsibility indicates the duties and activities that an individual is employed to perform.

A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse? 1. Nurse practitioner 2. Nurse administrator 3. Certified nurse-midwife 4. Clinical nurse specialist

4). The hospital will most likely hire a clinical nurse specialist. A clinical nurse specialist is an expert in a specific area of practice and in a particular setting such as an intensive care unit. > A nurse practitioner has expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. > A nurse administrator looks after the management of the care provided to clients within a health-care agency. > A certified nurse-midwife provides care to women during their pregnancy, labor or delivery.

A nurse is helping a client determine and articulate personal values about health problems. The nurse also explains the effect of these problems on lifestyle adjustments. Which Gardner's task of leadership is the nurse leader applying? 1. Explaining 2. Managing 3. Motivating 4. Affirming values

4). Values are the connecting thoughts and inner driving forces that give purpose, direction, and precedence to life priorities. According to the Gardner's tasks of leadership, helping the client sort out and articulate personal values that are related to health problems is affirming values. It also involves explaining the effect of these problems on lifestyle adjustments. > Explaining includes teaching and interpreting information to promote well-being in the client. > Managing involves assisting the client with planning, priority setting, and decision making. ***This also includes ensuring that organizational systems work on behalf of the client. > Motivating includes inspiring clients or family members to achieve their vision.

A client is receiving clonidine for hypertension. What side effect of clonidine will the nurse include when providing drug education? 1. Xerostomia 2. Diarrhea 3. Euphoria 4. Photosensitivity

> Xerostomia (dry mouth) is one of the common side effects of this drug. The reaction usually diminishes over the first 2 to 4 weeks of therapy. > This drug causes constipation, not diarrhea. > This drug may cause depression, anxiety, fatigue, and drowsiness, not euphoria. > Photosensitivity is not a side effect of this medication.

Pyridoxine (vitamin B6) and isoniazid (INH) are prescribed as part of the chemotherapy protocol for a client with tuberculosis. Which response indicates to the nurse that vitamin B6 is effective? 1. Weight gain 2. Absence of stomatitis 3. Absence of numbness and tingling in extremities 4. Acceleration of dormant tubercular bacilli destruction

3). One of the most common side effects of INH is peripheral neuritis, and vitamin B6 will counteract this problem. > Although it does help nutrition, this may not result in weight gain. > B6 does not affect stomatitis. > It does not speed the destruction of the causative organism.

How are profits used in a for-profit health care organization? 1. Profits are paid out to shareholders. 2. Profits are used to buy new equipment. 3. Profits are used to build additional facilities. 4. Profits are invested in improving health care services.

1). Health care organizations can be classified as for-profit and not-for-profit based on how the profits are distributed. In a for-profit organization, the profits are generated for the shareholders. > In a not-for-profit organization, the profits are used to buy new equipment, build additional facilities, and improve health care services.

While caring for a client receiving hydrocortisone therapy, the nurse anticipates a dose adjustment in the client's prescription. Which observation in the client supports this anticipation? 1. Three episodes of vomiting 2. Passage of loose stools 3. Body temperature of 37.2°C (99°F) 4. Sudden weight gain of 8 kg

4) Excessive hydrocortisone therapy causes rapid weight gain, fluid retention, and a round face. Thus a sudden weight gain of 8 kg (17.637 lbs.) indicates excessive hydrocortisone levels and indicates the need for dose adjustment. > Vomiting, diarrhea, and fever are seen in excessive prednisone therapy.

A client has an order for a sublingual nitroglycerin tablet. The nurse should teach the client to use what technique when self-administering this medication? 1. Place the pill inside the cheek and let it dissolve. 2. Place the pill under the tongue and let it dissolve. 3. Chew the pill thoroughly and then swallow it. 4. Swallow the pill with a full glass of water.

> Sublingual medication is placed under the tongue and is quickly absorbed through the mucous membranes into blood. > The buccal route requires placing medication between the cheek and gums. > Chewing the pill and then swallowing it may be done for oral administration of some large size pills, but not with the sublingual route of administration. > Taking the pill with water is required with the PO route of administration of medication, but not with sublingual. In addition, a full glass of water may be an excessive amount of fluid to swallow one pill.

A broad-spectrum oral antibiotic is prescribed for an adolescent with a bacterial infection. The prescription reads, "Take three times a day." At which times should the nurse recommend that the medication be taken to maintain a therapeutic blood level? 1. 8:00 AM, 2:00 PM, 8:00 PM 2. 6:00 AM, 2:00 PM, 10:00 PM 3. 6:00 AM, 12:00 PM, 8:00 PM 4. 10:00 AM, 4:00 PM, 10:00 PM

2). Antibiotics should be administered with the doses equally spaced to ensure maintenance of the blood level of the medication within the therapeutic range. > The 12 hours between the 8:00 PM and the 8:00 AM doses and between the 10:00 PM and 10:00 AM doses is too long; the blood level of the drug will become subtherapeutic during this interval. > The 10 hours between the 8:00 PM and 6:00 AM doses is also too long.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1. Lactated Ringer solution 2. 5% dextrose and water 3. 0.9% normal saline 4. 0.45% normal saline

3). Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. ***Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.

A nurse is assessing several clients. Which client will require parenteral nutrition? 1. A client with brain neoplasm 2. A client with anorexia nervosa 3. A client with inflammatory bowel disease 4. A client with severe malabsorption disorder

4). A client with severe malabsorption disorder requires parenteral nutrition. > Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

A client is receiving dexamethasone to treat acute exacerbation of asthma. For what side effect should the nurse monitor the client? 1. Hyperkalemia 2. Liver dysfunction 3. Orthostatic hypotension 4. Increased blood glucose

4). Dexamethasone increases gluconeogenesis, which may cause hyperglycemia. > Hypokalemia, not hyperkalemia, is a side effect. > Liver dysfunction is not a side effect. > Hypertension, not hypotension, is a side effect.

After taking spironolactone, the client inquires about foods and fluids that contain potassium. Which juice should the nurse recommend? 1. Prune juice 2. Orange juice 3. Tomato juice 4. Cranberry juice

> Spironolactone is a potassium-sparing diuretic, and foods high in potassium should be avoided. > Cranberry juice should be recommended because it contains the least amount of potassium. > Prune, orange, and tomato juice are all high in potassium.

A nurse is caring for a female client who is receiving rifampin for tuberculosis. Which statements indicate that the client understands the teaching about rifampin? Select all that apply. 1. "This drug may be hard on my liver so I must avoid alcoholic drinks while taking it." 2. "This drug may reduce the effectiveness of the oral contraceptive I am taking." 3. "I cannot take an antacid within 2 hours before taking my medicine." 4. "My healthcare provider must be called immediately if my eyes and skin become yellow."

1). Alcohol may increase the risk of hepatotoxicity. 2). Rifampin has teratogenic properties and may reduce the effectiveness of oral contraceptives. 4). Yellowing of the eyes and skin are signs of hepatitis and should be reported immediately. > An antacid may be taken 1 hour before taking the medication. ***The capsule may be opened and the powder mixed with applesauce.

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C & S) are prescribed. Place these interventions in the order in which they should be implemented. 1. Promote bed rest with raised head of bed. 2. Provide oxygen via nasal cannula. 3. Obtain blood specimens for C & S. 4. Administer prescribed antibiotic.

1). The client's respiratory status is the priority. Promoting bed rest with raised head of bed reduces oxygen demand 2). Administering oxygen via nasal cannula increases the supply of oxygen to the alveolar capillaries. 3). Obtaining specimens for culture and sensitivity must be performed before administering antibiotics, which prevents false microbiologic interpretation caused by the effect of the antibiotic. 4). Administer Prescribed Antibiotic

A nurse determines that the teaching about the side effects of azithromycin has been understood when the adolescent client identifies which problem as the most common side effect of this medication? 1. Tinnitus 2. Diarrhea 3. Dizziness 4. Headache

2). Diarrhea initially is related to gastrointestinal irritation; later it is related to loss of intestinal flora, which may lead to overgrowth of drug-resistant microbes, resulting in superinfection. ***This also causes diarrhea. > Tinnitus, dizziness (vertigo), and headache all may occur, but none is the most common side effect.

A client develops a maculopapular rash on the upper extremities and audible wheezing during the administration of intravenous vancomycin. To ensure the client's safety, which action would the nurse carry out first? 1. Notify healthcare provider 2. Stop infusion 3. Decrease flow rate 4. Reassess in 15 minutes

2). The first action the nurse should take is to stop the infusion immediately. The client may be experiencing an allergic reaction. > The nurse should stop the medication infusion and then notify the healthcare provider. > Decreasing the flow rate is not an appropriate action. ***Infusions must be stopped if allergic reaction is suspected. > This could be an emergent situation, so reassessing in 15 minutes is not the most appropriate action.

What client response must the nurse monitor to determine the effectiveness of amiodarone? 1. Absence of ischemic chest pain 2. Decrease in cardiac dysrhythmias 3. Improvement in fasting lipid profile 4. Maintenance of blood pressure control

> Amiodarone is a class III antidysrhythmic used for treating ventricular and supraventricular tachycardia and for conversion of atrial fibrillation. > Results of fasting lipid profile are expected with antilipidemics. > Degree of blood pressure control is expected with antihypertensives. > Incidence of ischemic chest pain is expected with antianginal agents, such as nitrates.

A client is prescribed albuterol to relieve severe asthma. What adverse effect will the nurse instruct the client to anticipate? Select all that apply. 1. Tremors 2. Lethargy 3. Palpitations 4. Visual disturbances 5. Decreased pulse rate

1). Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. 3). Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. > Albuterol may cause restlessness, irritability, and tremors, not lethargy. > Albuterol may cause dizziness, not visual disturbances. > Albuterol will cause tachycardia, not bradycardia.

A nurse administers beclomethasone by inhalation to a client with asthma, and the client asks why this medication is necessary. What should the nurse explain is the purpose of this pharmacologic therapy? 1. Promotes comfort 2. Decreases inflammation 3. Stimulates smooth muscle relaxation 4. Reduces bacteria in the respiratory tract

2). Beclomethasone reduces the inflammatory response in bronchial walls by suppression of polymorphonuclear leukocytes and fibroblasts and the reversal of capillary permeability. > Beclomethasone does not directly promote comfort. > Beclomethasone does not stimulate smooth muscle relaxation. > Beclomethasone is not an antibiotic.

The primary healthcare provider prescribes 80 mg of furosemide by mouth daily. Before administering the furosemide, which action is the priority? 1. Weigh the client. 2. Assess skin turgor. 3. Check the potassium lab results. 4. Check the total intake and output for the last 24 hours.

> Although assessing skin turgor, weighing the client, and checking the intake and output are all a part of assessing for hydration, the potassium level should always be checked before administering furosemide (SEE Table(s): 33-7/Hypertension & Table 68-6/ Chronic Kidney Disease for a complete list of medications. >>> Administering furosemide in the presence of hypokalemia could cause cardiac arrhythmias.

Which behavior does the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge, and the delegator does not expect the relationship to be ongoing? 1. Telling 2. Selling 3. Delegating 4. Participating

1). According to Hersey's Situational Leadership Model, if the relationship between a delegator and a delegatee with limited knowledge is new and is not going to be ongoing, the delegator's behavior is characterized as "telling." > Delegator's behavior is characterized as "selling" if the delegatee and delegator have an ongoing relationship and a new task is being delegated. > The delegator's behavior is characterized as "delegating" when the delegatee has expertise and an established relationship with the delegator. > If the delegatee has willingness and ability, but the relationship with the delegator is new, then the delegator's behavior is characterized as "participating."

A nurse on the pediatric unit receives a change-of-shift report. In which order should the nurse assess the children? Begin with the child whose status is most critical and end with the child whose status is most stable. 1. 8-month-old with vomiting and diarrhea lasting 1 day 2. 5-year-old with diarrhea lasting 2 days 3. 11-year-old with abdominal cramps lasting 4 hours 4. 6-year-old with low-grade fever lasting 3 days 5. 3-year-old with celiac disease who is to be discharged within 2 hours

1). An infant, whose body consists of a larger percentage of water than that of an older child or adult can become dehydrated and experience severe electrolyte imbalances within several hours of becoming ill. This is a life-threatening situation that requires immediate intervention. 2). A 5-year-old can become dehydrated after a prolonged session of diarrhea; therefore reassessment of the degree of dehydration should be performed as soon as possible. 3). Although appendicitis may be the cause of the 11-year-old child's abdominal cramps, there is no apparent emergency because the child has been tolerating the abdominal cramps for several hours. 4). Although the 6-year-old child should be assessed further to determine the cause of the fever, it has been tolerated for 3 days. 5). The 3-year-old with celiac disease who is to be discharged within 2 hours is stable and ready for discharge.

A nurse notes gentamycin in the prescription of an older adult with osteomyelitis. Which nursing interventions should be conducted before starting therapy? Select all that apply. 1 Assessing renal function 2. Assessing hydration status 3. Checking the erythrocyte count 4. Checking the blood platelet count 5. Assessing serum thyroxin levels

1). Because gentamycin can increase the risk of nephrotoxicity, the nurse should assess a client's renal function before starting therapy. 2). Dehydration can further increase the risk of nephrotoxicity; therefore the client's hydration status should also be checked before starting therapy. > Gentamycin generally does not impact erythrocyte and blood platelet counts nor does it affect serum thyroxin levels.

The nursing student accompanies a group of registered nurses in a campaign that promotes the participation of parents to get their children immunized. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it to last year's report. Which type of research does the nursing student think that the group is doing? 1. Evaluation research 2. Descriptive research 3. Experimental research 4. Correlational research

1). Evaluation research tests the effectiveness of a program, practice, or policy. It measures the outcomes of a campaign. > Descriptive research measures the characteristics of persons, situations, or groups. For example, this study would measure the frequency of an occurrence of an event. > Experimental research is a study where the investigator controls the study variable and randomly assigns the subjects to different conditions for the variable test. > Correlational research explores the interrelationships among variables of interest; this study does not include any active intervention by the researcher.

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. 1. Obtain the client's vital signs. 2. Monitor hemoglobin and hematocrit levels. 3. Allow the blood to reach room temperature. 4. Determine typing and crossmatching of blood. 5. Use a Y-type infusion set to initiate 0.9% normal saline.

1). Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. 4). Prior to beginning the transfusion, the nurse and another hospital-approved personnel should double-check client identification and blood product identification (blood unit number, blood type and crossmatch data like Rh factor along with expiration date) with another licensed nurse. 5). Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. > The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. > Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within four hours.

A nursing student is evaluating statements regarding the five levels of proficiency set forth by Benner. Which statement indicates that a nurse is in the advanced beginner stage? 1. The nurse is learning about the profession through a specific set of rules and procedures. 2. The nurse is able to identify the basic principles of nursing care through careful observation. 3. The nurse is able to understand the organization and specific care required by certain clients. 4. The nurse is able to assess the entire situation and transfer knowledge gained from multiple previous experiences.

2). According to the levels of proficiency set forth by Benner, a nurse in the advanced beginner stage is able to identify basic principles of nursing care through careful observation. > A nurse in the novice stage learns about the profession through a specific set of rules and procedures. > After reaching the competent stage, a nurse will be able to understand the organization and specific care required by certain clients. > A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple previous experiences.

What should a nurse teach the client to do to avoid lipodystrophy when self-administering insulin therapy? 1. Exercise regularly. 2. Rotate injection sites. 3. Use the Z-track technique. 4. Avoid massaging the injection site.

2). Fibrous scar tissue can result from the trauma of repeated injections at the same site. > Exercise is unrelated to lipodystrophy, but it reduces blood glucose, which decreases insulin requirements. > Insulin is given subcutaneously; the Z-track technique is used with some intramuscular injections. > Gentle pressure over the injection site after insulin administration promotes absorption.

A registered nurse assesses clients with dark skin. Which statement made by the registered nurse indicates the need for further teaching? 1. "I should touch the skin to feel its consistency." 2. "I should use a fluorescent light source to assess the skin color." 3. "I should place my hand on the skin to assess the temperature." 4. "I should look for any changes in skin color darker than surrounding skin."

2). The nurse should use natural light or a halogen light source to assess accurately the skin color. ***Fluorescent light casts a blue color, which can make skin assessment difficult. > The nurse should touch the client's skin to feel its consistency. > The nurse should assess the area for the skin temperature using his or her hand. > The nurse should look for any changes in skin color that are darker than surrounding skin.

A nurse administers albuterol to a child with asthma. For what common side effect will the nurse monitor the child? 1. Flushing 2. Dyspnea 3. Tachycardia 4. Hypotension

3). Albuterol produces sympathetic nervous system side effects such as tachycardia and hypertension. > Pallor, not flushing, is a common side effect. > Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. > Hypertension, not hypotension, is a common side effect.

Which statement regarding erythropoietin is true? 1. Erythropoietin is released by the pancreas. 2. An erythropoietin deficiency causes diabetes. 3. An erythropoietin deficiency is associated with renal failure. 4. Erythropoietin is released only when there is adequate blood flow.

3). Erythropoietin is produced by the kidneys; its deficiency occurs in renal failure. *** Erythropoietin deficiency causes anemia. > Erythropoietin is released by the kidneys, not the pancreas. > Erythropoietin is secreted in response to hypoxia, which results in decreased oxygenated blood flow to the tissues.

A client receiving intravenous vancomycin reports ringing in both ears. Which initial action should the nurse take? 1. Notify the primary healthcare provider. 2. Consult an audiologist. 3. Stop the infusion. 4. Document the finding and continue to monitor the client.

3). The first action the nurse should take is to stop the infusion immediately. Vancomycin can cause temporary or permanent hearing loss. > The nurse should stop the medication infusion and then notify the healthcare provider at once if a client reports any hearing problems or ringing in the ears. > An audiologist may need to be consulted at a later date, but this is not the best first action. > The nurse should document the findings; however, it is not the initial action.

A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats per minute. Following treatment with diltiazem hydrochloride, what assessment indicates to the nurse that the diltiazem hydrochloride is effective? 1. Increased urine output 2. Blood pressure of 90/60 mm Hg 3. Heart rate of 110 beats per minute 4. No longer complaining of heart palpations

> Diltiazem hydrochloride's purpose is to slow down the heart rate. > SVT has a heart rate of 150 to 250 beats per minute. >>> A heart rate of 110 indicates that the diltiazem hydrochloride is having the desired effect. > Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. > Heart palpations are experienced by some with various dysrhythmias. > A decreased sensation of heart palpations is a positive finding but is not present in all clients. > Increased urine output may occur over a period of time because of the increased ventricular filling time but would not occur until after the heart rate had stabilized.

A client with malabsorption syndrome is admitted to the hospital for medical intervention. A subclavian catheter is inserted, and the client is started on total parenteral nutrition (TPN). What should the nurse teach the client in order to prevent the most common complication of TPN? 1. Avoid disturbing the dressing or getting it wet. 2. Keep the head as still as possible whenever moving. 3. Regulate the flow rate on the infusion pump as necessary. 4. Monitor daily weights at the same time while wearing the same clothing.

> Disturbing the dressing may expose the area to pathogens. Infection is the most common complication; sterile technique at the catheter insertion site must be maintained. > Keeping the head still is not necessary; the catheter is sutured in place, and reasonable movement is permitted. > The client should be taught to leave the infusion pump set at the rate prescribed by the healthcare provider and to call the nurse if the alarm rings. > Excessive weight gain or loss is not a complication of total parenteral nutrition.

A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. Which potential complication should the nurse monitor this client for? 1. Dehydration 2. Hypoglycemia 3. Allergic reaction 4. Diabetes insipidus

> TPN is a hypertonic solution that pulls fluid from the interstitial compartment into the intravascular compartment, resulting in diuresis and dehydration. > Because of its high glucose content, TPN may cause hyperglycemia, not hypoglycemia. > Allergic reaction is unlikely; the administration of lipids is associated more commonly with allergic reactions. > TPN may precipitate hyperglycemia (pseudo diabetes mellitus), not diabetes insipidus.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in phytonadione and that should be avoided. What should the nurse include on the list? Select all that apply. 1. Spinach 2. Oranges 3. Broccoli 4. Chicken breast 5. Sweet potatoes

1 and 3). The amount of phytonadione (vitamin K) in 1 cup of raw spinach is 181%, and a half cup of chopped and boiled broccoli is 138% of the Daily Value (DV) recommended by the U.S. Food and Drug Administration, according to the U.S. National Institutes of Health. > Fruit, including oranges, contains minimal phytonadione. > Chicken breast is high in protein, not phytonadione. > Sweet potatoes are high in vitamin A but not phytonadione.

The registered nurse is assigning a task to an unlicensed nursing personnel (UNP). Which key elements are considered while assessing the UNP's ability to perform work? Select all that apply. 1. Safety 2. Attitude 3. Stability 4. Ethnicity 5. Critical thinking

1, 3, and 5). The registered nurse should consider the elements of safety, stability, and critical thinking. ***While assessing the work to be assigned to an unlicensed nursing personnel (UNPs), the registered nurse should consider the elements of safety, stability, and critical thinking. > Attitude is one of the multiple factors that influences the effectiveness of the leader. > Ethnicity is not a factor that plays a role in the process of delegation.

A 4-year-old child is receiving prednisone. Which immunizations are safe for the child to receive? Select all that apply. 1. Rubeola 2. Pertussis 3. Varicella 4. Inactivated poliovirus 5. Tetanus immune globulin

2, 4, and 5). Pertussis (whooping cough) vaccine is made from inactivated toxins. ***It is safe to give the child the inactivated poliovirus vaccine; it is not a live attenuated virus vaccine. *** Tetanus immune globulin is an antitoxin that provides transient passive immunity; ****tetanus toxoid is contraindicated. > Rubeola (measles) vaccine is made from a live attenuated virus. > Varicella (chickenpox) vaccine is made from a live attenuated virus.

A healthcare provider prescribes losartan for a client. Which is the most important nursing action? 1. Assess the client for hypokalemia. 2. Ensure that the medication is ingested with food. 3. Monitor the client's blood pressure during therapy. 4. Teach that a missed dose can be doubled at the next scheduled time.

3). A lowering of the client's blood pressure reflects a therapeutic response and should be monitored frequently. ***Losartan is an antihypertensive. It blocks vasoconstrictor and aldosterone-producing effects of angiotensin II at receptor sites. >>> The client may be at risk for hyperkalemia, not hypokalemia. >>> Losartan may be taken without regard to meals. >>> Doubling a dose is unsafe. A missed dose can be taken as long as it is not close to the next scheduled dose.

A client with a diagnosis of uncontrolled diabetes began receiving furosemide 2 days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L (Canada: 2.8 mmol/L). What is the most appropriate action for the nurse to take? 1. Hold the morning dose of the diuretic and have the lab repeat the test. 2. Continue to monitor the level to ensure that it stays within the normal limits. 3. Notify the primary healthcare provider of the critically low result. 4. Anticipate a prescription for an increase in the dosage of the furosemide.

3). The healthcare provider should be notified because a potassium level of 2.8 mEq/L (2.8 mmol/L) is low. ***Normal range for serum potassium is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). > The client's serum potassium level is critically below the normal limit and the healthcare provider should be notified. ***Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. > The nurse should not hold the diuretic or repeat the lab test unless advised by the healthcare provider. > An increase in furosemide would cause an increased loss of potassium.

Twenty minutes after the start of an intravenous (IV) vancomycin infusion, the client appears flushed and complains of palpitations. What action should the nurse take? 1. Stop the infusion; the client is having an allergic reaction. 2. Continue to monitor the client; this is an expected reaction. 3. Contact the primary healthcare provider to obtain a prescription to decrease the infusion rate. 4. Contact the primary healthcare provider to obtain a prescription for an antianxiety medication.

3). The rate of the infusion should be decreased. Administering vancomycin too rapidly can produce "red man syndrome," characterized by flushing, an increased heart rate, and a decrease in blood pressure; these clinical findings should disappear when the rate of the infusion is decreased. ***Red man syndrome is expected only if the IV flow rate is too rapid; the rate must be decreased. > It is not necessary to stop the infusion because slowing its rate will alleviate the problem. > The client does not need an antianxiety agent. > Red man syndrome is expected only if the IV flow rate is too rapid; the rate must be decreased.

The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? 1. Antibiotic 2. Antihistamine 3. Bronchodilator 4. Expectorant

3). Theophylline is a bronchodilator. It relaxes the smooth muscles in the bronchial airway and relieves bronchospasms. This in turn improves air exchange. > An antibiotic is used to treat a bacterial infection. > An antihistamine blocks the action of histamine. > An expectorant is used to loosen mucus in the lungs. ***An antibiotic, an antihistamine, or an expectorant will not relax the smooth muscles in the bronchial airway for clients experiencing an acute episode.

The nursing student is learning about triage during mass casualty incidents (MCIs). Which statement made by the nursing student indicates effective knowledge regarding MCIs? 1. "Two-thirds of victims are generally tagged red or black." 2. "The triage of victims of an MCI must be conducted in one minute." 3. "Victims who arrive at the hospital on their own are not considered during triage." 4. "The total number of victims can be estimated by doubling the number of victims who arrive in the first hour."

4). The total number of victims a hospital can expect is estimated by doubling the number of victims who arrive in the first hour. > In general, two thirds of victims are tagged green or yellow, and the rest of them are tagged red or black. > Triage of victims of an MCI must be conducted in less than 15 seconds. > Victims who arrive at the hospital on their own are known as walking wounded and are considered during triage.

A client with congestive heart failure is receiving intravenous digoxin (Cardoxin) therapy. The registered nurse identifies which items on the client's care plan that are appropriate for a licensed practical nurse (LPN) to perform? Select all that apply. 1. Help the client ambulate when required. 2. Monitor the client's vitals every 30 minutes. 3. Administer adequate oral fluids to the client. 4. Prepare the nursing diagnosis after assessing the client. 5. Administer the digoxin (Cardoxin) if the client has chest pain.

> To provide safe care, the nurse should act within the scope of practice and certification. > The licensed practice nurse (LPN) can monitor the vitals, ambulate the client, and administer oral fluids to prevent dehydration. > The LPN cannot administer medications intravenously and cannot formulate nursing diagnosis; therefore, these two actions do not fall within the scope of the LPN's practice.

What is the most appropriate play activity for a preschooler whose hand is immobilized during IV therapy? 1. Watching television 2. Reading a comic book 3. Cutting out paper dolls 4. Manipulating jigsaw puzzles

>>> Manipulating jigsaw pieces is intellectually stimulating and can be done with an IV line in place. > Watching television is a passive activity that is not especially stimulating for a preschooler. > The preschool-age child is not old enough to read comic books. > Both hands are needed to hold and cut paper.

What information is a nurse likely to find in the clinical implications section of an article?

Explanation regarding the method of applying findings in a practice setting

Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction? 1. At breakfast 2. Before lunch 3. Before dinner 4. In the early afternoon

2). Regular insulin is short acting and peaks in 2 to 4 hours, which in this case will be at or before lunch. > Breakfast is too soon; regular insulin peaks in 2 to 4 hours. > Before dinner is too late; regular insulin peaks in 2 to 4 hours. > The early afternoon is too late; regular insulin peaks in 2 to 4 hours.

A transfusion of packed red blood cells is prescribed for a client with anemia. List the following actions in the order in which they should be performed by the nurse. 1. Ensure that the client signed a consent for the transfusion. 2. Determine the client's vital signs. 3. Compare the number on the blood product and laboratory record. 4. Don a pair of clean gloves. 5. Run the transfusion slowly.

1). A client must sign a consent for the transfusion before the procedure; clients have the right to refuse. 2). Vital signs should be obtained immediately before the transfusion to serve as a baseline for comparison if a reaction is suspected. 3). Two nurses must verify that the numbers, ABO type, and Rh type on the blood label and laboratory record match before hanging the transfusion to minimize risk of transfusion reactions. 4). Clean gloves must be worn before inserting the spike of the blood administration set. 5). The transfusion is run slowly for the first 15 to 20 minutes, but only after other steps have been completed.

A 4-year-old child is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). A blood transfusion is ordered, and an intravenous line is started. What will the nurse do in regard to administering the transfusion? 1. Infuse the blood over no more than 4 hours. 2. Take the vital signs 3 hours after the transfusion. 3. Check the vital signs 15 minutes after starting the transfusion. 4. Have the blood warm at room temperature for 1 hour before administration.

1). Blood should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature. > Taking the vital signs 3 hours after the transfusion is too long to wait; ***the vital signs should be checked every 5 minutes during the absorption of the first 50 mL of blood and then routinely thereafter (every 15 minutes to 1 hour, depending on hospital policy). > Vital signs must be checked every 5 minutes during the administration of the first 50 mL of blood to detect a transfusion reaction. > Blood should be used within 30 minutes after its arrival from the blood bank; the risk for bacterial proliferation increases over time and exposure to room temperature.

Which nursing interventions may promote safe drug administration in a child diagnosed with heart failure who is receiving digoxin? Select all that apply. 1. Checking for compliance with the client's drug regimen 2. Monitoring the client's serum potassium and magnesium levels regularly 3. Administering digoxin only through the intramuscular route 4. Calculating the correct dosage form, prescribed amounts, and the prescriber's order 5. Monitoring and recording the client's intake and output, heart rate, blood pressure, daily weight, and respiration rate regularly

1). Checking for compliance with the client's drug regimen is important so that the child does not have drug to drug interactions. 2). Digoxin may alter the serum potassium and serum magnesium levels, which affects heart function. 4). Calculating the correct dose according to the healthcare provider's orders helps to prevent drug toxicity. 5). Monitoring and recording drug intake and output, heart rate, blood pressure, daily weight, and respiration rate is a part of general nursing care. > Administering digoxin through the intramuscular route is not advised because this method is very painful.

While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? 1. Stop the blood transfusion immediately. 2. Report to the primary healthcare provider. 3. Recheck identifying tags and numbers on the client. 4. Maintain a patent intravenous (IV) line with saline solution.

1). During acute hemolytic reactions, the nurse should stop a blood transfusion as a priority nursing intervention. *** An incompatible blood transfusion can result in an acute hemolytic reaction in the client. > After stopping the blood transfusion, the nurse should report it to the primary healthcare provider. > The nurse can then recheck the client's identifying tags and numbers and maintain a patent IV line with saline solution.

A client has been taking levothyroxine for hypothyroidism for 3 months. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. 1. Tremors 2. Bradycardia 3. Somnolence 4. Heat intolerance 5. Decreased blood pressure

1). Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, tachycardia, hypertension, heat intolerance, and insomnia. ***These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. > Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. > Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. > Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.

A client with diabetes asks how exercise will affect insulin and dietary needs. What information does the nurse share about insulin and exercise? 1. "Exercise increases the need for carbohydrates and decreases the need for insulin." 2. "Exercise increases the need for insulin and increases the need for carbohydrates." 3. "Regular physical activity decreases the need for insulin and decreases the need for carbohydrates." 4. "Intensive physical activity decreases the need for carbohydrates but does not affect the need for insulin."

1). Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. ***The need for insulin is decreased.

A client with tuberculosis is to begin combination therapy with isoniazid, rifampin, pyrazinamide, and streptomycin. The client says, "I've never had to take so much medication for an infection before." How will the nurse respond? 1. "This type of organism is difficult to destroy." 2. "Streptomycin prevents side effects of the other drugs." 3. "You'll only need to take the medications for a couple of weeks." 4. "Aggressive therapy is needed because the infection is well advanced."

1). Multiple drugs are administered because of the concern regarding drug resistance. > Streptomycin sulfate is an antibiotic; it does not prevent the side effects of other drugs used in therapy. > Multiple antitubercular drugs are necessary for an extended period, approximately 6 to 8 months depending on the individual. > Aggressive therapy may increase anxiety and may not be needed even when the infection is well advanced.

What is the priority nursing action when caring for a client receiving nitroglycerin for the treatment of angina? 1. Asking the client to sit or stand slowly 2. Monitoring the client's urine output frequently 3. Advising the client to report when experiencing a headache 4. Reporting to the healthcare provider if pain does not subside after 5 minutes

1). Nitroglycerin is a potent antihypertensive and antianginal medication. The nurse should instruct the client to sit and stand slowly after taking the medication to prevent orthostatic hypotension. > After ensuring the client's safety, the nurse should monitor the urine output. > A headache is a common side effect of nitroglycerin. > The client should have a tingling sensation after taking the nitroglycerin, which ensures that the medication is potent.

A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. What will the nurse do first? 1. Administer the platelets rapidly through the intravenous (IV) line 2. Set the IV pump to run for 8 hours 3. Flush the IV line with a dextrose solution 4. Check the vital signs every 2 hours during the transfusion

1). Platelets must be infused within 1 hour. They may be infused as rapidly as the child's cardiovascular status will tolerate. > Platelets are fragile and should be administered as quickly as possible, >>> within 1 hour, or as fast as the child can tolerate the infusion. <<< ***There are minimal numbers of red blood cells (RBCs) and white blood cells contained within the infusion, which reduces the risk of a severe reaction. > A dextrose solution is not appropriate for flushing a blood derivative line because it may cause hemolysis of RBCs. > Two hours is too long an interval between checks of the child's vital signs. *******Vital signs should be obtained before the infusion, 15 minutes after initiation of the infusion, and at the end of the infusion.

A registered nurse is evaluating the statements of a client after teaching the client measures to decrease the risk for antibiotic-resistant infections. Which statements made by the client indicate a need for more education? Select all that apply. 1 "I should wash my hands frequently." Correct2 "I should skip doses when I am completely well." 3 "I should avoid taking antibiotics to treat the common cold." Correct4 "I should save unfinished antibiotics for later emergency use." 5 "I should avoid taking antibiotics without asking the physician."

2). Antibiotics should not be stopped even if the client is feeling better. Skipping doses may allow antibiotic-resistant bacteria to develop. 4). Antibiotics should not be saved for later emergency use because old antibiotics can lose their effectiveness and in some cases can even be fatal if taken. > Hand washing is necessary to prevent infections. > Antibiotics are effective against bacterial infections but not viruses, which cause the common cold. > Antibiotics should be taken only after asking the physician.

A health care provider prescribes vancomycin peak and trough levels for a client who is receiving vancomycin intravenous piggyback (IVPB). When should the nurse have the laboratory obtain a blood sample to determine a peak level of the antibiotic? 1. Halfway between two doses of the drug 2. Between 30 and 60 minutes after a dose 3. Immediately before the medication is administered 4. Anytime it is convenient for the client and the laboratory

2). Because the drug was administered IV, the blood level of the drug will be at its highest shortly after administration. > A drug blood level measured halfway between two doses will not obtain the peak level. > Immediately before the medication is administered is done for a trough level, when the drug level is at its lowest. > Anytime it is convenient for the client and the laboratory will produce inaccurate results; ***peak and trough levels are measured in relation to the time a drug is administered.

A client is receiving total parenteral nutrition (TPN) through a central venous access device. The nurse discovers that the TPN bag is empty and the next bag has not been received yet from the pharmacy. What is the most appropriate action for the nurse to take? 1. Perform a finger stick glucose test and call the primary healthcare provider with the results. 2. Hang a bag of 10% dextrose at the ordered TPN rate and place an urgent request for the next TPN bag. 3. Discontinue the infusion and flush the IV line with saline solution until the next TPN bag is ready. 4. Hang a bag of 5% dextrose at a keep-open rate and notify the nurse manager of the occurrence.

2). Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. > After beginning an infusion of 10% dextrose, the nurse may perform a finger stick glucose test and notify the healthcare provider if the results are abnormal. > Discontinuing the infusion and flushing the line until the next TPN bag is ready is not recommended. > Starting an infusion of 5% dextrose at keep vein open (KVO) until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless there is a negative client outcome that results.

A client with arthritis is to begin long-term steroid therapy. Which statement indicates to the nurse that the client understands the instructions about this medication? 1. "My urine may become discolored." 2. "I should avoid crowds in enclosed areas." 3. "Weight loss can occur with this medication." 4. "The medication should be taken between meals."

2). Crowds, especially in enclosed areas, can lead to infections when on steroids. ***Steroid therapy decreases lymphocytes, resulting in depressed immunity and a greater risk for infection. > Steroids have no effect on urine color. > Sodium is retained, resulting in fluid retention and weight gain. > Steroids increase production of hydrochloric acid and should be taken with food or an antacid to prevent ulcer formation.

A nurse is teaching the parents of an 8-year-old child who is taking a high dose of oral prednisone for asthma. What critical information about prednisone will be included? 1. It protects against infection. 2. It should be stopped gradually. 3. An early growth spurt may occur. 4. A moon-shaped face will develop.

2). Gradual weaning from prednisone is necessary to prevent adrenal insufficiency or adrenal crisis. > Prednisone depresses the immune system, thereby increasing susceptibility to infection. > The drug usually suppresses growth. > A moon face may occur, but it is not a critical, life-threatening side effect.

A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy? 1. Bleeding at the infusion site 2. Shortness of breath with crackles 3. Feeling of warmth throughout the body 4. Infiltration at the catheter insertion site

2). Hypervolemia may precipitate pulmonary edema, which produces shortness of breath, crackles, cough, apprehension, and frothy sputum. > Although bleeding at the infusion site may occur, it is not the most serious complication; an altered respiratory status is the priority. > Feeling of warmth throughout the body occurs with the IV administration of dye for diagnostic procedures; it does not occur with IV fluids, such as 0.9% sodium chloride (NaCl) or D5W without an additive. > Although infiltration at the catheter insertion site may occur, it is not the most serious complication; an altered respiratory status is the priority

A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. What will the nurse identify as an indicator that the nitroglycerin sublingual tablets have lost their potency? 1. Sublingual tingling is experienced. 2. The tablets are more than 3 months old. 3. The pain is unrelieved, but facial flushing is increased. 4. Onset of relief is delayed, but the duration of relief is unchanged.

2). Loss of potency can occur after 3 months, reducing the drug's effectiveness in relieving pain. ***Nitroglycerin tablets are affected by light, heat, and moisture. ***A new supply should be obtained routinely. > Experiencing sublingual tingling indicates the tablets have retained their potency. > Unrelieved pain with an increase of facial flushing and delayed relief with the duration of relief remaining the same do not necessarily indicate loss of potency.

A healthcare provider prescribes inhaled corticosteroids for a 6-year-old child with asthma. The nurse concludes that the mother understands the teaching about the side effects of this medication when the mother makes which statement? 1. "I'll watch for frequent urination." 2. "I'll check for white patches in the mouth." 3. "I'll be alert for short episodes of not breathing." 4. "I'll monitor for an increased blood glucose level."

2). Oral candidiasis is a potential side effect of inhaled steroids because of steroids' antiinflammatory effect; the child should be taught to rinse the mouth after each inhalation. > Frequent urination is not a side effect of steroid therapy. > Apneic episodes are not a side effect of steroid therapy. > Hyperglycemia is not a side effect of inhaled steroid therapy; ***it may occur when steroids are administered for a systemic effect.

A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions should the nurse implement to protect the infant under the oxygen hood? 1. Offer fluid every 15 minutes to prevent dehydration 2. Put a hat on the infant's head to prevent hypothermia 3. Keep the oxygen concentration consistent to limit respiratory distress 4. Remove the infant from the hood every 15 minutes to provide stimulation

2). Oxygen has a cooling effect, and the infant should be kept warm so metabolic activity and oxygen demands are not increased. > Offering fluid every 15 minutes may produce fluid overload, which could in turn result in increased cardiac output; this is an undesirable outcome, especially for an infant with respiratory distress. > Oxygen concentration is determined from blood gas levels and is changed accordingly. > Removing the infant from the hood every 15 minutes will tire the infant and increase the need for oxygen.

A nurse is administering 40 mg of furosemide (Lasix) intravenously. Which sensation reported by the client does the nurse consider when determining that it is being administered too quickly? 1. "Bladder feels full." 2. "Ears are buzzing." 3. "Heart is beating fast." 4. "Left arm feels numb."

2). Rapid administration of furosemide can cause tinnitus (a perceived ringing or buzzing in the ears), loss of hearing, and ear pain. > Lasix has a diuretic effect; urinary retention does not occur. > Lasix does not affect the heart rate. > Lasix does not cause peripheral neuropathy.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse advise the client? Select all that apply. 1. Avoid solid food. 2. Take the oral medication. 3. Drink fluids throughout the day. 4. Monitor capillary glucose levels. 5. Do not take medication until tolerating food.

2). Skipping the oral hypoglycemic agent may precipitate hyperglycemia. ***Delaying an oral hypoglycemic agent may precipitate hyperglycemia. 3). Fluids prevent dehydration; 4). Monitoring of glucose levels permits early intervention if necessary. > Skipping the oral hypoglycemic agent may precipitate hyperglycemia. Food intake should be attempted to prevent acidosis. > Food intake should be attempted to prevent acidosis.

After stabilization of an acute adrenal insufficiency (addisonian crisis), intravenous medications are decreased gradually, and the client now is receiving hydrocortisone by mouth. What instruction should the nurse include when performing discharge teaching? 1. Eat a diet high in sodium. 2. Take the medication with food. 3. Maintain the same dose indefinitely. 4. Eliminate a dose if side effects occur.

2). Taking the medication with food minimizes the side effect of gastrointestinal irritation; the health care provider should be notified immediately if abdominal pain or tarry stools occur. > The diet should be low in sodium because cortisone can cause fluid retention. > The dose may have to be adjusted with health care provider supervision when the client is under physical or emotional stress. > Cortisone levels must be maintained; changes in dosage must be supervised by the health care provider.

A client who recently started receiving oral corticosteroids for a severe allergic reaction is instructed that the dosage will be reduced gradually until all medication is stopped at the end of two weeks. What reason does the nurse provide for this gradual reduction in dosage? 1. Discontinuing the drug too fast will cause the allergic reaction to reappear. 2. Slow reduction of the drug will prevent a physiologic crisis because the adrenal glands are suppressed. 3. The healthcare provider is attempting to determine the minimal dose that will be effective for the allergy. 4. Sudden cessation of the drug will cause development of serious side effects, such as moon face and fluid retention.

2). The body's natural corticosteroid production has been suppressed during treatment; avoiding abrupt cessation of the drug will give the body time to adjust to less and less of the exogenous source and to resume secretion of endogenous corticosteroid. > Not completing the course of therapy, rather than stopping it quickly, may cause signs and symptoms of the allergy to recur. > The healthcare provider has already determined the correct dosage, and it has been prescribed. > Moon face and fluid retention are associated with long-term steroid use, not with the cessation of therapy.

A nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which statement made by the client indicates the need for further teaching? 1. "I will wait for at least 1 minute between puffs." 2. "I will shake the whole unit vigorously one or two times." 3. "I will hold my breath for at least 10 seconds after removing the mouthpiece." 4. "I will insert the mouthpiece of the inhaler into the non-mouthpiece end of the spacer."

2). The metered-dose inhaler should be shaken vigorously for a minimum of three or four times for proper mixing of the content inside the inhaler. > A minimum of a 1-minute gap should be given in between the puffs to ensure proper movement of the medications into the lungs. > After removing the mouthpiece, the client should hold his/her breath for at least 10 seconds so that the drug does not escape with exhalation. > Inserting the mouthpiece of the inhaler into the non-mouthpiece end of the spacer is the correct way of closing the inhaler.

To begin the administration of total parenteral nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action? 1. Obtain a chest x-ray to determine placement. 2. Auscultate the lungs to evaluate breath sounds. 3. Draw a blood sample to assess blood glucose level. 4. Assess the right upper extremity for neurologic deficits.

2). The most significant and life-threatening complication of insertion of a subclavian catheter is a pneumothorax because of the proximity of the subclavian vein and the apex of the upper lobe of the lung; a client's respiratory status always is the priority. > Although a chest x-ray may be done before TPN is begun, it is not the priority immediately after insertion of the catheter. > A baseline blood glucose level should be obtained before insertion of the catheter. ***After TPN is started, routine monitoring of blood glucose levels is important. > Although assessing for a neurologic deficit should be done eventually, it is not the priority at this time.

The team leader is making client assignments. Which team member should be assigned a client with a tracheostomy, chest tube, and blood transfusion? 1. Charge nurse 2. Registered nurse (RN) 3. Unlicensed assistive personnel (UAP) 4. Licensed practical nurse/licensed vocational nurse (LPN/LVN)

2). The registered nurse (RN) is qualified to meet all of the client's needs. ***The team leader assigns the professional, technical, and ancillary personnel to the type of client care they are prepared to deliver and must be knowledgeable about the legal and organizational limits of each role. > The charge nurse does not receive a client assignment in team nursing. > The client assignment is beyond the scope of unlicensed assistive personnel (UAP). > ***The licensed practical nurse/licensed vocational nurse (LPN/LVN) may be qualified to address the client's tracheostomy and chest tube but is not able to support the blood transfusion.

The client with emphysema complains of increased shortness of breath and becomes anxious. The healthcare provider prescribes oxygen at 1 L/min via nasal cannula. The nurse understands that this prescription is appropriate for what reason? 1. High concentrations of oxygen cause alveoli to rupture. 2. High concentrations of oxygen eliminate the respiratory drive. 3. The client does not need any more than 1 L/min. 4. The oxygen at 1 L/min should be enough to diminish the anxiety.

2). Too much oxygen will knock out the stimulus to breathe. Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. ***Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. > High concentrations of oxygen will not cause a rupture. > The client actually could need more oxygen; however, if a higher concentration is given, it will knock out the respiratory drive. > The oxygen is being given because of the shortness of breath.

A client with a diagnosis of anemia is receiving packed red blood cells. What is the most important action by the nurse when administering the transfusion? 1. Warning the client about the possibility of fluid overload 2. Monitoring the client's response, particularly within the first 10 minutes 3. Adjusting the client's transfusion flow rate so that it infuses at a consistent rate during the procedure 4. Having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion

2). Transfusion reactions usually occur early during the administration of a blood transfusion (first 30 mL of blood); early detection of a transfusion reaction will permit a quick termination of the infusion. > The risk of fluid overload is unlikely, and this information can be frightening. > The donor's, not the recipient's, blood is tested for HIV. > The flow rate should be slower during the first 10 to 15 minutes of the infusion to limit the amount of blood infused; this allows time to assess the client's response for signs and symptoms of a transfusion reaction before too much of the blood is infused.

A client is started on tetracycline antibiotic therapy. What should the nurse do when administering this drug? 1. Administer the medication with meals or a snack. 2. Provide orange or other citrus fruit juice with the medication. 3. Give the medication an hour before milk products are ingested. 4. Offer antacids 30 minutes after administration if gastrointestinal side effects occur.

3). Any product (Milk & Dairy etc...) containing aluminum, magnesium, or calcium ions should not be taken in the hour before or after an oral dose of tetracyclines (with the exception of doxycycline) because it decreases absorption by as much as 25% to 50%. > Food interferes with absorption; it should be given one hour before or two hours after meals. > Citrus juice has no influence on this drug. > Antacids will interfere with absorption.

A client with a cardiac dysrhythmia is receiving digoxin and verapamil. Because of the combined effect of these two medications, what adverse effect does the nurse anticipate? 1. Physical agitation 2. Reflex stimulation 3. Myocardial depression 4. Respiratory stimulation

3). Both digoxin and verapamil decrease cardiac impulse conduction, with resultant depression of the myocardium; verapamil decreases conduction at the sinoatrial (SA) and atrioventricular (AV) nodes, which may cause bradycardia, AV block, and cardiac arrest. > Digoxin and verapamil together do not cause agitation. ***Side effects of verapamil include fatigue and depression, not agitation. > Digoxin and verapamil do not influence the reflexes of the body. > Digoxin and verapamil do not influence respirations.

The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the healthcare provider has prescribed theophylline 300 mg orally to be taken daily at 9:00 AM. The nurse will teach the client to take the medication on which schedule? 1. With a meal 2. Only at bedtime 3. At a specific time prescribed 4. Until symptoms are gone

3). For theophylline to be effective, therapeutic serum levels must be maintained by taking the medication at the prescribed time. ***If the medication is not taken at the prescribed time, the level may drop below the therapeutic range. The medication will not be effective if it drops below the therapeutic range. > Theophylline should be given after a meal and with a full glass of water to decrease gastric irritability. > It should not be taken at night, as it can cause central nervous system stimulation resulting in insomnia, restlessness, irritability, etc. > Theophylline is used for long-term medication therapy.

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg, and she is admitted to the hospital for bed rest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? 1. Clopidogrel 2. Warfarin 3. Heparin 4. Enoxaparin

3). Heparin is the medication of choice during the acute phase of a deep vein thrombosis; it prevents conversion of fibrinogen to fibrin and of prothrombin to thrombin. > Clopidogrel is a platelet aggregate inhibitor and is used to reduce the risk of a brain attack. > Warfarin, a long-acting oral anticoagulant, is started after the acute stage has subsided; it is continued for 2 to 3 months. > A low-molecular-weight heparin (e.g., enoxaparin) is not administered during the acute stage; it may be administered later to prevent future deep vein thromboses.

The health care provider prescribes an oral hypoglycemic for the client with type 2 diabetes. What will the nurse need to consider when developing the teaching plan? 1. Oral hypoglycemics work by decreasing absorption of carbohydrates. 2. Oral hypoglycemics work by stimulating the pancreas to produce insulin. 3. Clients taking oral hypoglycemics may subconsciously relax dietary rules to gain a sense of control. 4. Clients with type 2 diabetes do not need to be concerned about serious adverse effects from oral hypoglycemics.

3). Taking a tablet may give the client a false sense that the disease is under control, and this can lead to dietary indiscretions. > Some oral hypoglycemics work by stimulating the pancreas to produce insulin, others work by decreasing carbohydrate absorption, and others work in a variety of other ways; ***therefore teaching should be specific to the drug prescribed. > Oral hypoglycemic drugs can have serious adverse effects.

A male client who is receiving prolonged steroid therapy complains of always being thirsty and urinating frequently. What is the nurse's best initial action? 1. Have the client assessed for an enlarged prostate. 2. Obtain a urine specimen from the client to test for ketonuria. 3. Perform a finger stick to test the client's blood glucose level. 4. Assess the client's lower extremities for the presence of pitting edema.

3). The client has signs of an increased serum glucose level, which may result from steroid therapy; testing the blood glucose level is a method of gathering more data. > The symptoms are not those of benign prostatic hyperplasia. > The blood glucose level, not the amount of ketones in the urine, should be assessed. > The symptoms presented are not those of fluid retention, but of hyperglycemia.

During the administration of total parenteral nutrition (TPN), an assessment of the client reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1. Restart the client's infusion at another site. 2. Slow the rate of the client's infusion of the TPN. 3. Interrupt the client's infusion and notify the healthcare provider. 4. Obtain the vital signs and continue monitoring the client's status.

3). The client is experiencing pulmonary edema because of a fluid volume excess. The high concentration of TPN precipitates a fluid shift from the interstitial compartment into the intravascular compartment. Fluid will continue to be infused, which will continue to increase the intravascular volume.

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications? 1. Thiazide diuretics 2. Calcium channel blockers 3. Angiotensin receptor blockers 4. Angiotensin-converting enzyme (ACE) inhibitors

4). ACE increases the sensitivity of the cough reflex, leading to the common adverse effect sometimes referred to as an ACE cough. > A cough is not a side effect of thiazide diuretics, calcium channel blockers, or angiotensin receptor blockers.

A healthcare provider has prescribed isoniazid for a client. Which instruction should be a priority for the nurse to give the client about this medication? 1. Prolonged use can cause dark, concentrated urine. 2. The medication is best absorbed when taken on an empty stomach. 3. Take the medication with aluminum hydroxide to minimize gastrointestinal (GI) upset. 4. Drinking alcohol daily can cause drug-induced hepatitis.

4). Alcohol may increase hepatotoxicity of the drug, so the nurse should instruct the client to avoid drinking alcohol during treatment and monitor for signs of hepatitis before and while taking drug. > Prolonged use does not cause dark, concentrated urine. > The client should take isoniazid with meals to decrease GI upset. > Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.

A nurse is caring for a first-grader receiving prednisone. What outcome does the nurse expect with adrenocorticosteroid therapy? 1. Accelerated wound healing 2. Development of hyperkalemia 3. Increased antibody production 4. Suppressed inflammatory process

4). Because of the suppression of the inflammatory process, the nurse must be alert to the subtle symptoms of infection, such as changes in appetite, sleep patterns, and behavior. > Adrenocorticosteroid therapy delays, not accelerates, wound healing. > Adrenocorticosteroid therapy may cause hypokalemia, not hyperkalemia, because of the accompanying retention of sodium and fluid. > Adrenocorticosteroid therapy decreases, not increases, the production of antibodies.

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? 1. Weight loss 2. Hypoglycemia 3. Decreased blood pressure 4. Inadequate wound healing

4). Because the anti-inflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. > A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism. > Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. > Hypertension, not hypotension, occurs as a result of sodium and fluid retention.

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? 1. A reduction of confusion 2. An absence of ecchymotic areas 3. A decreased viscosity of the blood 4. An activated partial thromboplastin twice the usual value

4). Desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5 to 2 times normal. > While anticoagulants help prevent thrombi that could block cerebral circulation, they do not increase cerebral perfusion, and so will not affect existing confusion. > Although absence of bleeding suggests that the drug has not reached toxic levels, it does not indicate its effectiveness. > This medication does not affect the viscosity of blood.

A client receiving steroid therapy states, "I have difficulty controlling my temper, which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1. Tell the client it is nothing to worry about. 2. Reassure that everyone does this at times. 3. Instruct the client to attempt to avoid situations that cause irritation. 4. Interview the client to determine whether other mood swings are being experienced.

4). Steroids increase the excitability of the central nervous system, which can cause labile (UNSTABLE) emotions manifested as euphoria and excitability or depression. > Telling the client it is nothing to worry about or that it is normal denies the value of the client's statement and offers false reassurance. > The client has already stated the problem and does not know why this is happening. > Instructing the client to attempt to avoid situations that cause irritation is difficult to do because the mood swings may occur without an overt cause.

After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client reports feeling dizzy and having some hearing loss. The nurse withholds the drug and promptly reports the problem to the healthcare provider. Which part of the body does the nurse determine is being affected as indicated by the symptom reported by the client? 1. Pyramidal tracts 2. Cerebellar tissue 3. Peripheral motor end-plates 4. Eighth cranial nerve's vestibular branch

4). Streptomycin sulfate is ototoxic and may cause damage to auditory and vestibular portions of the eighth cranial nerve. > Pyramidal tracts, cerebellar tissue, and peripheral motor end-plates are not affected by streptomycin.

A nurse is providing postoperative care for a client who has begun taking levothyroxine after undergoing a thyroidectomy. Which findings in the client may indicate potential thyrotoxic crisis? 1. Elevated serum calcium 2. Sudden drop in pulse rate 3. Hypothermia and dry skin 4. Rapid heartbeat and tremors

4). Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. > Hypercalcemia is not related to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands. > Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. > Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.

A nurse has administered sublingual nitroglycerin. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin? 1. Relief of anginal pain 2. Improved cardiac output 3. Decreased blood pressure 4. Dilation of superficial blood vessels

> Cardiac nitrates relax smooth muscles of the coronary arteries; they dilate and deliver more blood to heart muscle, relieving ischemic pain. > Although cardiac output may improve because of improved oxygenation of the myocardium, improved cardiac output is not a basis for evaluating the effectiveness of sublingual nitroglycerin. > Although dilation of blood vessels and a subsequent drop in blood pressure is a reason why IV nitroglycerin may be administered, decreased blood pressure is not the basis for evaluating the effectiveness of sublingual nitroglycerin, which is indicated for pain relief. > Although superficial vessels dilate, lowering the blood pressure and creating a flushed appearance, dilation of superficial blood vessels is not the basis for evaluating the drug's effectiveness.

A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply. 1 . Heparin 2. Clopidogrel 3. Warfarin 4. Enoxaparin 5. Acetylsalicylic acid

> Heparin may be used during pregnancy because it does not cross the placental barrier and will not cause hemorrhage in the fetus. > Enoxaparin does not cross the placental barrier; its classification for pregnancy is B. > Clopidogrel is a platelet aggregation inhibitor. It is not used for thrombophlebitis; it is used to reduce the risk of brain attack, transient ischemic attack, unstable angina, and myocardial infarction. > Warfarin crosses the placental barrier, causing hemorrhage in the fetus. > Acetylsalicylic acid is a platelet aggregation inhibitor and is not recommended during pregnancy (D category).

A primary healthcare provider prescribes verapamil to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil? 1. Monitor the electrocardiogram for a prolonged PR interval on initial administration. 2. Keep the client in the recumbent position for 1 hour after administration. 3. Instill the dose in 50 mL of normal saline and administer it over 15 minutes. 4. Assess the client's respiratory rate and rhythm before administering the drug.

> Hypotension is a common side effect of intravenously administered verapamil. Keeping the client in the recumbent position for 1 hour after administration provides for the safety of the client. > A prolonged PR interval may occur during extended therapy, not on initial administration of verapamil. > Verapamil should be administered undiluted when given intravenously. ***It is administered over 2 minutes for adults and over 3 minutes for older adults. > The client's heart rate and blood pressure should be assessed before administration to provide a baseline for comparison. ***Verapamil will decrease the blood pressure and dysrhythmias.

A nurse is caring for a client who is receiving a unit of packed red blood cells. Which findings lead the nurse to suspect a transfusion reaction caused by incompatible blood? Select all that apply. 1. Cyanosis 2. Backache 3. Shivering 4. Bradycardia 5. Hypertension

> Mismatched blood cells are attacked by antibodies, and the hemoglobin released from ruptured erythrocytes plugs the kidney tubules; this kidney involvement results in backache. > Shivering occurs as part of the inflammatory response associated with a transfusion reaction. > Cyanosis is not commonly associated with a transfusion reaction. > Tachycardia, not bradycardia, is associated with a transfusion reaction. > Hypotension, not hypertension, is associated with a transfusion reaction.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. The health care provider's prescriptions include nothing by mouth and total parenteral nutrition (TPN). The nurse explains that the TPN therapy provides what benefit? 1. Is the easiest method for administering needed nutrition 2. Is the safest method for meeting the client's nutritional requirements 3. Will satisfy the client's hunger without the discomfort associated with eating 4. Will meet the client's nutritional needs without causing the discomfort precipitated by eating

> Providing nutrients by the intravenous route eliminates pancreatic stimulation, therefore reducing the pain experienced with pancreatitis. > TPN is used to meet the client's needs, not the nurse's needs. > TPN creates many safety risks for the client. > Hunger can be experienced with TPN therapy.

A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? 1. Omeprazole 2. Acetaminophen 3.Docusate sodium 4. Pseudoephedrine

> Pseudoephedrine has a pressor effect that may counteract antihypertensive medications, causing an increase in blood pressure. > Omeprazole does not interact with antihypertensives. However, it can increase the action of phenytoin, digoxin, clopidogrel, and cyclosporine. > Acetaminophen does not have to be avoided when receiving an antihypertensive. > Docusate sodium does not have to be avoided when receiving an antihypertensive.

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1. Wear support hose continuously. 2. Lie down for 30 minutes after taking medication. 3. Avoid tasks that require high-energy expenditure. 4. Sit on the edge of the bed for 5 minutes before standing.

> Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. > Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. > Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. > Energetic tasks, once standing and acclimated, do not increase hypotension.

A school-aged child is to receive a blood transfusion. What should the nurse do first if an allergic reaction to the blood occurs? 1. Shut off the infusion. 2. Slow the rate of flow. 3. Administer an antihistamine. 4. Call the healthcare provider.

> The child is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. > Slowing the rate of infusion will not halt the allergic reaction to the transfused blood. > Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires a healthcare provider's prescription. > The healthcare provider should be notified after the infusion has been stopped.

A client with a hemoglobin level of 6.2 g/dL (62 mmol/L) is receiving packed red blood cells. Twenty minutes after the infusion starts, the client complains of chest pain, difficulty breathing, and feeling cold. What is the first action the nurse should take? 1. Stop the transfusion. 2. Notify the healthcare provider. 3. Provide several warm blankets. 4. Slow down the rate of infusion.

> The client is experiencing an anaphylactic reaction, and the infusion should be stopped to prevent further problems. > The healthcare provider should be notified after the transfusion is stopped. > The blood transfusion should be stopped before implementing actions that address the client's anaphylactic reaction. > Slowing the infusion will permit more of the incompatible blood to infuse, worsening the response.

An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? 1 The nurse should wait for the court's order to give blood to the client. 2 The nurse should proceed with the transfusion in order to save the client's life. Correct3 The nurse should inform the primary healthcare provider and not give blood to the client. 4 The nurse should explain to the family member that the client needs this transfusion.

> The client or the client's family member has the right to refuse treatment and the nurse should value their beliefs and traditions. Therefore, the nurse should inform the primary healthcare provider and not perform the blood transfusion. > The nurse should not proceed with the treatment because this may cause severe legal implications. > The nurse should not wait for a court's order or explain or convince the family member to change his or her mind.

What should the nurse include in the discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home? 1. Changing the TPN access device daily 2. Contacting and scheduling professionals to administer the TPN 3. Listing the schedule of the days the client is to receive the TPN 4. Administering the TPN while working around the client's normal activities

> The less disruptive the procedure, the greater the acceptance by the client. > Most often, total parenteral nutrition is set up to run daily during sleeping hours. > Depending on the type of circulatory access used, it may not need to be changed for weeks. > The client or a significant other can be taught the principles of administration.

A client is admitted to the cardiac care unit with an anterior lateral myocardial infarction. The healthcare provider prescribes 500 mL of D5W with 50 mg of nitroglycerin to be administered intravenously to relieve pain. The nurse should assess for which most common side effect of this medication? 1. Nausea 2. Syncope 3. Bradycardia 4. Hypotension

> The major action of intravenous nitroglycerin is venous and then arterial dilation, leading to a decrease in blood pressure. > Nausea is not a common side effect of intravenous nitroglycerin. > Syncope is an infrequent effect when nitroglycerin is given intravenously. > Reflex tachycardia may occur with the decrease in blood pressure.

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply. 1. Observe for chest wall trauma 2. Establish a patent airway by positioning 3. Evaluate the client's level of consciousness 4. Assess breath sounds and respiratory effort 5. Remove all clothing for a complete physical assessment

1 and 4). The priorities to check for breathing include observation of the chest wall for trauma and assessment of breath sounds and respiratory effort. > Establishment of a patent airway by positioning occurs during the assessment of the airway and cervical spine. > Level of consciousness is evaluated to determine mental status of the client. > Clothing is removed to perform a complete physical assessment of the client.

The nurse is preparing to administer a subcutaneous dose of 15 units of lispro insulin to a client. Choose the proper syringe for this injection. 1 2 3 4

2). An insulin syringe, marked in units, is the only appropriate syringe for administering an insulin injection. > The 1-mL syringe is a tuberculin syringe. Tuberculin syringes, the 3-mL, and 5-mL syringes, are not appropriate for insulin injections because they are not measured in units.

A nurse is monitoring a 6-year-old child for toxicity precipitated by digoxin. For what sign of digoxin toxicity will the nurse assess the child? 1. Oliguria 2. Vomiting 3. Tachypnea 4. Splenomegaly

2). Vomiting is a sign of digoxin toxicity in children. > Oliguria is associated with renal failure, not toxicity. > Tachypnea is associated with heart failure, not toxicity. > Splenomegaly is associated with heart failure, specifically right ventricular failure.

Which intravenous fluid should the nurse classify as hypertonic? 1. Ringer solution 2. 5% dextrose in water 3. Lactated Ringer solution 4. 5% dextrose in normal saline

4). 5% Dextrose in Normal Saline. > An isotonic solution has the same osmolarity as body fluids. > A hypertonic solution has a higher osmolarity than body fluids; it pulls fluid from cells, causing them to shrink and the extracellular space to expand. > This hypertonic solution provides 586 mOsm/kg. > This isotonic solution provides 309 mOsm/kg. *** The other isotonic solutions provide 278 mOsm/kg.

Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the client with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1. Once the tablet is dissolved, spit out the saliva. 2. Take tablets 3 minutes apart up to a maximum of five tablets. 3. Common side effects include headache and low blood pressure. 4. Once opened, the tablets should be refrigerated to prevent deterioration.

> The primary side effects of nitroglycerin are headache and hypotension. > It is not necessary to spit out saliva into which nitroglycerin has dissolved. > For pain that is not relieved, additional tablets may be taken every 5 minutes up to a total of three tablets. > It should be stored at room temperature.