ARCHER - CAT EXAM #2

The nurse is caring for a child who is lactose intolerant. The nurse anticipates that the child is at risk for a deficiency in Select all that apply. Vitamin A. sodium. magnesium. Vitamin D. calcium.

Choices D and E are correct. Vitamin D and calcium are most frequently found in lactose-containing products like milk and cheese. Very few foods contain high amounts of vitamin D (milk, cheese, fatty fish like salmon and tuna, egg yolks, fortified cereals, and orange juice). Milk is fortified with vitamin D and is one of the primary sources of vitamin D for most people. Milk is also one of the significant sources of daily calcium. A child with lactose intolerance is at the most important risk of developing vitamin D and calciumdeficiencies. Choice A is incorrect. Milk and other dairy products contain vitamin A but do not contain a significant amount to cause a deficiency if the client is lactose intolerant. Choice B is incorrect. Lactose intolerance would not trigger a sodium deficiency. Choice C is incorrect. Milk and other dairy products contain magnesium but do not contain a significant amount to cause a deficiency if the client is lactose intolerant.

The nurse is counseling a female client interested in starting contraception. The client tells the nurse a preference for contraception that does not involve pills or any device. Based on the client's preferences, the nurse may recommend which contraceptive product to the primary healthcare provider (PHCP)? A. Depot medroxyprogesterone B. Intrauterine device (IUD) C. Hormonal vaginal ring D. Combined estrogen-progestin pill

Choice A is correct. Depot medroxyprogesterone acetate is an intramuscular (IM) injection that provides contraception for 13 weeks. Considering that the client prefers no pills or anything invasive, this would be an appropriate recommendation to the PHCP. Choices B, C, and D are incorrect. An IUD and vaginal ring are invasive and would not be recommended for this client based on their stated preference. The combined estrogen-progestin pill is given orally and is not preferred by the client.

The client taking lithium for bipolar disorder is experiencing vomiting, diarrhea, and blurred vision and their lithium level is 2.5 mEq/L (mmol/L) [0.6 - 1.2 mEq/L, mmol/L]. The nurse suspects which finding is occurring? A. Lithium toxicity B. An allergic reaction to the medication C. A normal reaction to lithium D. This lithium level is too low

Choice A is correct. The average lithium level is 0.6 mEq to 1.2 mEq/L (mmol/L). Any level over 1.5 mEq/L (mmol/L) indicates a toxic serum lithium level. Vomiting, diarrhea, blurred vision, abdominal pain, tremors, and tinnitus are symptoms of lithium toxicity. Choice B is incorrect. These symptoms do not describe an allergic reaction to lithium. Choice C is incorrect. Vomiting, diarrhea, and blurred vision are not normal findings in a client taking lithium. Choice D is incorrect. Evidence suggests that the lithium level is too high, at 2.5 mEq/L (mmol/L), not too low

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated? A. Apply TED hose to bilateral legs B. Assess the need for smoking cessation C. Physical therapy consult D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler

Choice A is correct. The client is presenting with signs of arterial insufficiency and an arterial ulcer. The application of compression (TED hose) to the extremities is contraindicated in cases of severe arterial insufficiency because the compression may further aggravate the ischemia. TED hose should not be applied until cleared by the primary healthcare provider (PHCP). The PHCP may want to ensure that the perfusion is adequate before clearance is given to apply a compression device.

The nurse in the emergency department is caring for a child with nuchal rigidity, fever, photophobia, and rash. The nurse should initially A. provide the client a tepid sponge bath. B. initiate droplet precautions. C. prepare the client for a lumbar puncture. D. prepare the client for a computed tomography scan of the brain.

Choice B is correct. Meningitis should be suspected based on this client's symptoms of fever, photophobia, and nuchal rigidity. Until the etiology is clear, the client must be placed in respiratory isolation using droplet precautions to prevent the spread of the disease to other individuals. Suspected bacterial meningitis cases warrant placing the client on droplet isolation. All transmission-based precautions must be implemented based on clinical suspicion and immediately on presentation of the client to a health care facility.

The nurse cares for a 14-year-old client brought to the clinic by his parents A 14-year-old male presents to the clinic with his parents after experiencing a fever, fatigue, and a sore throat for the past week. The parents note that the client has been too tired to participate in after-school activities and has experienced a decreased appetite. On exam, the client has cervical lymphadenopathy, exudate in the pharynx and on the tonsils, and petechiae. All other physical exam findings were normal except for increased spleen size noted during palpation. The client has no medical history and is current on all scheduled vaccinations The client is demonstrating signs and symptoms of mononucleosis pertussis bronchitis influenza

Mononucleosis (Mono) is an acute infectious disease caused by a virus. This client has classic mono symptoms. Additionally, influenza is excluded as it does not cause splenomegaly. The client not having a cough excludes the diagnosis of bronchitis and pertussis. Additional Info Mononucleosis (Mono) is an acute infectious disease common for individuals younger than 25. Mono may produce symptoms such as - Fever Significant fatigue Pharyngitis that has exudate and petechiae Enlarged tonsils Lymphadenopathy Splenomegaly This condition is usually self-limiting and treated with supportive measures such as cool fluids and acetaminophen. This condition is caused Epstein-Barr virus spread by oral secretions. Antibiotics are not effective for this condition. The splenomegaly is concerning because if the individual plays contact sports, they are at high risk of splenic injury, which could lead to life-threatening hemorrhage. Thus, contact sports should be restricted until the spleen returns to its normal size, which may take several weeks.

The nurse is caring for an infant who is experiencing a tetralogy of Fallot (tet) spell. Which of the following is the nurse's priority action? A. Administer propranolol B. Administer sodium bicarbonate C. Calm the infant D. Notify the healthcare provider

Choice C is correct. Immediately calming the infant is the nursing priority during a tet spell. While the infant is crying, their pulmonary vascular resistance is increasing leading to decreased oxygenated blood and more cyanosis. By calming them down you will immediately be decreasing their pulmonary vascular resistance so that blood can flow to the lungs and provide oxygen to the body. This is the first action that the nurse should take. Choice A is incorrect. While propranolol may be used in children with tetralogy of Fallot, it will not be the priority nursing action for the infant experiencing a tet spell. It will be given much later if necessary. Choice B is incorrect. Sodium bicarbonate may be needed at some point during a tet spell if it is not resolving, but would not be indicated as soon as it starts and would not be the priority nursing action.

The nurse understands that which of the following benefits can be attributed to delayed cord clamping in a newborn? Select all that apply. Increased blood volume Decreased brain hemorrhages Decreased risk of polycythemia Decreased jaundice Increased iron stores

Additional Info ✓ Delayed cord clamping refers to the practice of delaying the clamping of the umbilical cord for at least 30-60 seconds after birth or until the cord stops pulsating. This practice has been associated with several benefits for the newborn. ✓ Improved iron status: Delayed cord clamping allows for a greater transfer of iron-rich blood from the placenta to the newborn, which can help to prevent iron deficiency anemia in the first year of life. ✓Better cardiovascular stability: Delayed cord clamping has been associated with higher blood pressure and better circulatory stability in the newborn immediately after birth. ✓ Reduced risk of intraventricular hemorrhage: Delayed cord clamping has been linked to a decreased risk of intraventricular hemorrhage, a serious condition that can occur in premature infants. ✓ Decreased risk of respiratory distress syndrome: Delayed cord clamping has also been associated with a reduced risk of respiratory distress syndrome in premature infants. ✓ Improved neurodevelopmental outcomes: A 2019 systematic review and meta-analysis found that delayed cord clamping was associated with better neurodevelopmental outcomes in infants at 2 years of age.

The nurse is caring for a newborn with neonatal abstinence syndrome (NAS). Which of the following actions would be appropriate for the nurse to take? Keep the room fairly dark. Swaddle the infant in the flexed position. Provide the infant with a pacifier during crying spells. Plan to feed the infant less frequently Increase the lighting in the room to keep the infant awake.

Additional Info ✓ Neonatal abstinence syndrome (NAS) is a disorder in which infants exposed to maternal drugs before birth demonstrate signs of drug withdrawal. ✓ NAS occurs in infants who have suffered prenatal opiate exposure sufficient to cause withdrawal signs after birth. ✓ Infants with NAS may be irritable and have hyperactive muscle tone and a high-pitched cry. Although they have tremors, their blood glucose level is normal. ✓ Infants appear hungry and suck vigorously on their fists but have poor coordination in sucking and swallowing. Frequent regurgitation, vomiting, and diarrhea are common. Infants are restless, and their excessive activity and poor feeding ability fail to gain weight. ✓ Seizures may occur, which may be life-threatening. ✓ Interventions for NAS include Obtain a urine specimen from the infant to determine the substance. A meconium analysis may also be performed. More frequent feedings are necessary with a higher calorie content. Feeding may be difficult, so gavage feeding may be necessary. Maintain a quiet environment with low stimulus. Swaddle the infant in a flexed position. Use a calm approach when caring for an infant.

A nurse is reviewing discharge instructions for a client nearing discharge after undergoing a dilation and curettage (D&C) procedure for an elective abortion at 14 weeks gestation. As part of the discharge instructions, the nurse instructs the client on complications that would warrant the client to seek medical attention. Which statement, if made by the client, would indicate a need for additional education on this topic? A. "If I have stomach pain, tenderness, and a low-grade fever, I can just take a tablet of acetaminophen, and I will be fine." B. "There will be instances where I will feel a sense of loss." C. "I should anticipate minimal vaginal bleeding for 10 to 14 days." D. "I need to see a doctor if my temperature reaches 100°F or higher."

Choice A is correct. Abdominal tenderness, pain, and a "low-grade fever" may be indicative of a uterine infection. The client should report this to their health care provider (HCP) immediately. Choice B is incorrect. The client may likely experience intermittent feelings of loss following an elective abortion. This is often a common occurrence following this type of procedure. If the client finds these feelings occurring frequently or becoming difficult to deal with, instruct the client to contact the clinic to arrange a referral with an appropriate mental health provider. Choice C is incorrect. The client should anticipate some vaginal bleeding due to uterine changes and surgical trauma. Bleeding may last from two weeks to a month, with the average duration ranging from 10 to 14 days. Choice D is incorrect. Instruct any client who has undergone an abortion to seek medical attention in the event they develop a temperature of 100°F or higher or foul-smelling vaginal drainage, as the main concern is infection and/or sepsis.

The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning? A. Pulmonary edema B. Tinnitus C. Nausea and vomiting D. Tachycardia

Choice A is correct. All of these manifestations are associated with an aspirin overdose. Pulmonary edema is the most concerning and is caused by a lung injury induced by aspirin. A treatment for aspirin overdose is an infusion of sodium bicarbonate to correct metabolic acidosis. During the infusion, the nurse must be sensitive to the potential lung injury caused by aspirin; thus, auscultating lung sounds and assessing for pulmonary edema will be essential. Manifestations of pulmonary edema include tachypnea, tachycardia, and crackles in the lung fields. Choice B is incorrect. Tinnitus (humming, buzzing, or ringing in the ear) may be transient and is not life-threatening. Choice C is incorrect. Nausea and vomiting are expected and are concerning because they may lead to hypovolemia. Treatment is parenteral fluids and prescribed anti-emetics. Choice D is incorrect. Tachycardia is likely with ASA poisoning because of the electrolyte shift and fluid volume depletion. Cardiac monitoring is the standard of care for this diagnosis.

The nurse is caring for a client who has been prescribed depot medroxyprogesterone acetate. Which of the following statements, if made by the client, requires follow-up? A. "I will need another injection in 8 weeks." B. "I may gain weight while on this medication." C. "I can expect increased vaginal bleeding." D. "I should increase my weight-bearing exercises."

Choice A is correct. Depot medroxyprogesterone acetate is an injection that provides contraception for 13 weeks. The client should return for another injection at 13-week intervals - not 8 weeks. Choices B, C, and D are incorrect. Weight gain, acne, increased vaginal bleeding, and decreased bone density are common effects associated with this contraception. Additional Info ✓ Depot medroxyprogesterone acetate is an effective contraceptive given intramuscularly or subcutaneously every 13 weeks. ✓ While a client takes depot medroxyprogesterone acetate, calcium and vitamin D supplementation are recommended, coupled with weight-bearing exercises. ✓ Women with a high risk for cardiovascular disease and a stroke should not take depot medroxyprogesterone acetate. This medication may increase the risk for major adverse cardiovascular events (MACE).

The nurse in the postanesthesia care unit (PACU) cares for a client who had an appendectomy. Which of the following client assessments warrants immediate follow-up? The client A. has breath sounds that are high-pitched and crowing. B. reports incisional pain at a level of '5' on a scale of 0 (no pain) to 10 (severe pain). C. has a capillary blood glucose of 115 mg/dL [70-110 mg/dL]. D. reports persistent nausea following the administration of an anti-emetic.

Choice A is correct. High-pitched crowing sounds are consistent with a client having stridor. Stridor is a concerning adventitious breath sound because it indicates upper airway narrowing. The nurse needs to immediately respond to this client and determine if they have anaphylaxis to an intraoperative medication or a mechanical obstruction. Choice B is incorrect. Incisional pain after an appendectomy is expected. Compared to adventitious breath sounds, this does not require the nurses' immediate attention. Choice C is incorrect. The glucose being marginally elevated may be expected after surgery. Following stressful events, such as the appendectomy, the adrenal glands secrete more steroids causing the blood glucose to increase. This is not a priority concern.

The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as A. a non-vesicant drug entering subcutaneous tissue. B. a vesicant drug entering into subcutaneous tissue. C. a vesicant drug entering the muscle by injection. D. a vesicant drug entering into intradermal tissue.

Choice A is correct. Infiltration is a complication that can occur when a non-vesicant drug intended for intravenous administration, unintentionally enters the surrounding subcutaneous tissue. This may happen due to issues like catheter displacement or improper needle placement. Choice B is incorrect. This is not a typical description of infiltration. Vesicant drugs are known to cause tissue damage and are more closely associated with extravasation, a different complication. Choice C is incorrect. Infiltration is a complication that can occur when a non-vesicant drug intended for intravenous administration, unintentionally enters the surrounding subcutaneous tissue. This has nothing to do with the muscle, as the medication does not go this deep. Choice D is incorrect. This is not a common description of infiltration. Intradermal injections are typically shallow and intentional, such as for tuberculosis testing. Vesicant drugs causing tissue damage would be more closely associated with extravasation.

A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN? A. Collect data on the client's skin integrity. B. Educate the client on the need for restraints. C. Initiate peripheral vascular access. D. Continually assess the client to determine if restraint use is necessary.

Choice A is correct. It is appropriate for the RN to delegate to the LPN/VN to collect data on the client's neurovascular status (pulse, skin condition, capillary refill) every two hours while the client is restrained. Data collection does not require analysis, and the PN can collect data such as auscultating lung sounds, data collecting on a client's skin integrity, collecting vital signs, and collecting a client's health history. Choices B, C, and D are incorrect. The RN is responsible for educating the client on the use of restraints. Additionally, the initiation of peripheral vascular access (intravenous line) is within the scope of the RN. Assessing the client to determine the continued need for the restraint will be necessary and appropriate for the RN.

The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's A. hard palate of the mouth. B. lower back and sacrum. C. lower legs right below the knee. D. nail beds.

Choice A is correct. Jaundice is a yellow color of skin and sclerae caused by bilirubin buildup in the baby's blood. In dark-skinned babies, jaundice may not be visible upon skin assessment, even with high blood bilirubin levels. The correct technique when assessing an infant (or an adult) with dark skin for jaundice would be to examine the mucous membranes in the mouth, the hard palate, or the sclera. Choices B, C, and D are incorrect. Lower back and sacrum, lower legs, and nail beds are not appropriate physical landmarks to assess for jaundice. Additional Info In infants with dark skin, the nurse should assess the color of the palate and mucous membranes of the mouth and the conjunctivae. Jaundice begins at the head and moves down the body as the bilirubin level rises. The nurse must determine the areas of the body affected by jaundice and document carefully to use for comparison during future assessments.

The nurse is caring for a client who arrives with an intentional overdose of nortriptyline. Which information is essential to obtain? A. The number of pills that were consumed. B. The indication for the medication. C. Previous suicide attempts and methods. D. Circumstances leading up to the overdose.

Choice A is correct. Nortriptyline is a tricyclic antidepressant (TCA) used to manage depressive and obsessive-compulsive disorders. Overdoses of tricyclics can be fatal because of their cardiotoxicity. Discerning how many pills were consumed would be very helpful. The priority for this client is to complete a 12-lead electrocardiogram followed by continuous cardiac monitoring. Choices B, C, and D are incorrect. The indication for the medication, previous suicide attempts, and circumstances leading up to the overdose are not priority questions to obtain. The immediate care of this client would not change based on these questions. However, knowing that a client took three pills versus thirty would be quite helpful in determining the severity of the overdose.

Which of the following best describes a newborn reflex that includes a hand opening with abducted and extended extremities following a jarring motion? A. Moro reflex B. Grasp reflex C. Babinski reflex D. Rooting reflex

Choice A is correct. The Moro reflex occurs in response to a slight drop, sudden movement of the crib, or a loud noise; the newborn quickly makes a symmetrical abduction of the extremities and places the index fingers and thumbs into a "C" shape. Choice B is incorrect. The grasp reflex occurs when the newborn wraps the fingers around the examiner's finger when placed in the newborn's palm. Choice C is incorrect. When the sole is stroked, the newborn's big toe moves upward toward the top surface of the foot, and the other toes fan out. This is known as the Babinski reflex. Choice D is incorrect. The rooting reflex occurs as the newborn turns their head to the side on which the cheek is stroked.

The nurse is precepting a newly hired nurse administer an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up? A. Prepares to administer the medication in the dorsogluteal. B. Prepares to insert the needle at a 90-degree angle. C. Uses isopropyl alcohol to clean the area prior to injection. D. Washes their hands before and after the procedure.

Choice A is correct. This action requires follow-up as the dorsogluteal site is not recommended. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels.

A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following? A. "Facial swelling is expected in the first few days of therapy." B. "Drink at least 3000 mL of water per day." C. "Do not eat while taking this medication." D. "This medication begins working immediately."

Choice B is correct. Allopurinol is prescribed to patients with gout or kidney stones and works by reducing the amount of uric acid produced by the body. Patients taking this medication should be encouraged to drink plenty of water, at least 3,000 mL per day. Choice A is incorrect. Facial swelling is not normal and may indicate an emergency reaction. Patients who experience swelling should seek medical attention as soon as possible. Choice C is incorrect. Eating with this medication is appropriate. Choice D is incorrect. This medication does not work immediately and may take a few months to reach full effectiveness.

The nurse is assessing a client receiving treatment for cancer. Which of the following findings should alert the nurse to the possibility that the client is developing disseminated intravascular coagulation (DIC)? A. Bradycardia B. Petechiae C. Urinary incontinence D. Fever

Choice B is correct. DIC is a complicated and potentially fatal event that may be triggered by cancer, gram-negative sepsis, and eclampsia. Classic manifestations of DIC include vital signs reflecting bleeding (tachycardia, hypotension), petechiae and ecchymoses, and blood oozing from wound sites, intravenous lines, catheters, and mucosal surfaces. Choice A is incorrect. DIC would cause tachycardia as the client hemorrhages. Tachycardia is a sign of hemorrhagic shock requiring immediate treatment with packed red blood cell transfusions. Choice C is incorrect. Urinary incontinence is not a manifestation associated with DIC. However, DIC can lead to organ dysfunction, such as acute renal and liver failure. Choice D is incorrect. Fever is not a clinical manifestation associated with DIC.

The nurse is caring for a client who is receiving prescribed doxorubicin. Which of the following findings would warrant immediate follow-up? Correct A. Anorexia B. Fever C. Alopecia D. Malaise

Choice B is correct. Doxorubicin is an antineoplastic that may cause pancytopenia. Pancytopenia is when the client has low WBCs, RBCs, and platelets. The significant leukopenia caused by this medication makes the client quite susceptible to infection. A fever for a client receiving an antineoplastic is highly concerning because it could indicate infection. Choices A, C, and D are incorrect. Common effects of antineoplastics, including doxorubicin, are anorexia, alopecia, and malaise. These are expected findings and are not life-threatening compared to a fever which may be a warning sign of a systemic bacterial, viral, or fungal infection.

The nurse is caring for a client who is receiving clozapine. Which of the following findings would warrant immediate follow-up? A. Total cholesterol 206 mg/dL B. WBC 3,000 mm3 C. Weight gain 1 kilogram D. Blood glucose 255 mg/dL

Choice B is correct. Follow-up laboratory work is essential for a client taking clozapine. The medication may adversely cause neutropenia. The client will be instructed to obtain this necessary laboratory work to ensure they are not experiencing agranulocytosis, which enhances the risk of infection. This WBC count is quite low and requires follow-up. Choices A, C, and D are incorrect. Clozapine may cause considerable weight gain, hyperglycemia, and hyperlipidemia. These findings are concerning but are not a priority over leukopenia.

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

Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. Excessive WBCs would be leukocytosis which is a non-specific indicator of possible infection or inflammation. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia.

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. hemolysis of fetal erythrocytes resulting from incompatibility between maternal and fetal blood C. inability to metabolize amino acid phenylalanine, causing high levels of phenylalanine. D. erythrocytes become shaped like a sickle and sensitive to hypoxia.

Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, which is a severe anemia that results in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. The inability to metabolize amino acid phenylalanine, causing high levels of phenylalanine characterizes phenylketonuria. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia.

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg? A. By palpating the skin over the tibia and fibula B. By documenting daily calf circumference measurements C. By recording vital signs obtained four times a day D. By noting difficulty with ambulati

Choice B is correct. Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs. Choices A, C, and D are incorrect. These options are not the correct way to assess for the presence of thrombophlebitis.

The nurse is caring for a client with the following clinical data. The nurse should expect the primary healthcare provider (PHCP) to prescribe what medication? See the exhibit. View Exhibit A. Enalapril B. Labetalol C. Amiodarone D. Nitroglycerin

Choice B is correct. Labetalol is an alpha- and beta-adrenergic blocking agent used to treat a hypertensive emergency. Considering that this client is both hypertensive and tachycardic, labetalol would be a good choice. Choices A, C, and D are incorrect. Enalapril is an ACE inhibitor that may be given intravenously. However, this medication would have no effect on the client's tachycardia. Thus, this would be an inappropriate recommendation. Amiodarone is an umbrella drug used to manage atrial and ventricular dysrhythmias. This medication is not indicated for a hypertensive emergency. While utilized in treating a hypertensive emergency, nitroglycerin would not be efficacious for the client's tachycardia. It would make the tachycardia worse as this drug causes reflex tachycardia as the blood pressure is decreased.

The nurse performs a physical assessment on a newborn and observes fine, downy hair on the cheeks and forehead. The nurse analyzes this finding as A. milia. B. lanugo. C. vernix caseosa. D. mongolian spot.

Choice B is correct. Lanugo is the soft, down hairs present on newborns' shoulders, back, and forehead. It is theorized that this assists in keeping the newborn warm. Choice A is incorrect. Milia are tiny white bumps that commonly appear on newborns' foreheads. These dermal cysts of keratin disappear during the first month of life. Choice C is incorrect. Vernix caseosa is a white, creamy, naturally occurring biofilm covering the fetus's skin during the last trimester of pregnancy. This is often washed off during the first bath. Choice D is incorrect. Mongolian spots are a type of gray-blue birthmark in appearance and are commonly found on the lumbar and sacral-gluteal region. Black and Asian babies are widely affected by these benign spots that disappear by six years of age.

The nurse is caring for a client who has been newly prescribed naproxen. Which condition in the client's medical history would require clarification with the primary healthcare provider (PHCP)? A. Rheumatoid arthritis (RA) B. Congestive heart failure (CHF) C. Osteoarthritis D. Psoriatic arthritis

Choice B is correct. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) indicated in treating musculoskeletal disorders such as rheumatoid arthritis, osteoarthritis, strains, and sprains. NSAIDs carry several adverse effects, including edema, renal failure, gastrointestinal irritation leading to an ulcer, myocardial infarction, and stroke. If the client has congestive heart failure, this would be contraindicated because naproxen would lead to further fluid accumulation.

The primary healthcare provider (PHCP) prescribes the insertion of a nasogastric tube for a client with paralytic ileus. The nurse understands that the primary purpose of placing this tube is to A. feed the client. B. decompress the stomach. C. irrigate the stomach. D. administer medications.

Choice B is correct. Paralytic ileus is characterized by an interruption of peristalsis, which causes a client to have abdominal distention, persistent nausea and vomiting, hiccups, and decreased bowel sounds. An NGT is placed to decompress the stomach and relieve the pressure from the ileus. Choices A, C, and D are incorrect. Feeding the client, irrigating the stomach, and administering medications may be accomplished by inserting an NGT. However, the purpose of an NGd in the context of paralytic ileus is gastric decompression. A paralytic ileus may occur after surgery as the anesthesia impedes the restoration of peristalsis.

The nurse just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first? A. A 3-hour old newborn weighing 6 pounds B. A 4-hour old newborn delivered at 42 weeks C. A 6-hour old newborn that is 21 inches long D. An 8-hour old newborn delivered at 40 weeks

Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother's last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemia and hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. In this case (Choice B), a 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first. Choice A is incorrect. According to the World Health Organization (WHO), the average birth weight for a full-term baby is around 7.5 lb. However, a birth weight range between5.5 lb. (2.5 kg) and 8.2 lb. (4.0 kg) is considered normal. Small for gestational age (SGA) is defined as a birth weight of less than 10th percentile for gestational age. Large for gestational age (LGA) refers to a birth weight equal to or more than the 90th percentile for a given gestational age. Macrosomia refers to a birth weight greater than 4000 to 4500 grams ( 4 to 4.5 kg), regardless of gestational age. The infant weighing 6 pounds (Choice A) is within the normal weight range for a newborn; the nurse does not need to see this infant first.

The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position? A. Trendelenburg B. Supine C. Right lateral decubitus with head end elevated D. Prone

Choice B is correct. The client with acute angle-closure glaucoma should be placed supine, which will assist in the lens falling away from the iris, mechanically helping to relieve angle closure and decreasing the pupillary block. Clients with open-angle glaucoma (OAG) are advised to sleep with their heads elevated to about 30 degrees. However, there is insufficient evidence to recommend the same for angle closure glaucoma. The supine position is widely accepted for angle-closure glaucoma. Choices A, C, and D are incorrect. Lateral decubitus, prone, and trendeleburg are all positions that can significantly increase the IOP. Therefore, they are unhelpful in the management of angle-closure glaucoma. Placing the client supine will enable the treatment (mannitol, acetazolamide) to achieve its objective of reducing the pupillary block by separating the lens from the iris. Trendelenburg position can significantly increase the IOP. Surgeons should be aware of this effect in glaucoma clients that are placed in the Trendelenburg position during surgery (choice A) The lateral decubitus position increases the IOP in the dependent eye. In this case, the right eye is affected, and lying in the right lateral position will exacerbate the angle closure of glaucoma (choice C). In a prone position, the lens-iris diaphragm moves forward, tending to occlude an anatomically predisposed angle and further increasing intra-ocular pressure (choice D).

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. B. A neonate with cyanotic hands and feet that has not passed meconium. C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. D. A neonate with abdominal respirations and intermittent tremors of the extremities.

Choice C is correct. A neonate is expected to be pinkish in appearance. Saliva should be minimal and the normal temperature for a newborn is from 36.5 °C to 37 °C. These symptoms could indicate potential respiratory distress or other health issues that require immediate assessment and intervention. Choice A is incorrect. Molding and overriding sutures in a neonate are normal and may persist for a few days. Choice B is incorrect. Acrocyanosis in the newborn may be present for 2 to 6 hours. A neonate with cyanotic hands and feet that has not passed meconium may have transient cyanosis, which can be a normal response in newborns. The absence of meconium passage in the first 24 hours is not unusual. Choice D is incorrect. There is no need to worry about this sign. A neonate with abdominal respirations and intermittent tremors of the extremities may exhibit these behaviors as part of the normal adjustment to extrauterine life

The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected? A. Stools that contain blood and mucus B. Pain with urination C. Episodic upper abdominal pain D. Hypoactive bowel sounds

Choice C is correct. Episodic abdominal pain originating in the right upper quadrant or epigastric area is commonly associated with cholecystitis. The pain may be induced by a meal high in fat. Choices A, B, and D are incorrect. Stools containing blood and mucous would be a clinical finding in a patient with ulcerative colitis. Pain with urination (dysuria) would be a manifestation associated with sexually transmitted infections or cystitis. Hypoactive bowel sound is not an expected finding with acute cholecystitis.

A nurse is assessing a client on bed rest for 48 hours. When the nurse asks the client to point his toes upward, he reports pain in his right calf. Which of the following actions should the nurse prioritize next? A. Based on the positive Homan's sign, contact the provider to obtain an order for an ultrasound to assess the client for deep vein thrombosis (DVT) B. Instruct the client not to ambulate C. Assess the calf for pain, swelling, and warmness D. Attach an intermittent pneumatic compression device

Choice C is correct. Homan's sign yields a low predictive value for the presence or absence of deep vein thrombosis (DVT) and, therefore, should not be relied upon. The nurse should assess the client's right lower leg for reliable signs and symptoms of deep vein thrombosis, including pain, swelling, and warmth. If these indicate a DVT, the nurse should contact the provider and request an order for an ultrasound (with Doppler) to evaluate venous blood flow and to assist in determining whether a DVT is present. Choice A is incorrect. A positive Homan's sign (calf pain at dorsiflexion of the foot) was once thought to be associated with thrombosis. However, the Homan's sign's utility and use have gradually waned over time because studies have continuously shown that Homan's sign is an unreliable tool. While the client's reported pain should be documented, the nurse should assess for reliable signs of a DVT (i.e., leg swelling, warmness, and pain) and further base interventions on those reliable findings. Choice D is incorrect. Intermittent pneumatic compressiondevices prevent DVT formation. These devices use bilateral leg cuffs that intermittently fill with air and briefly squeeze the lower portion of the legs to increase the venous blood flow and decrease the likelihood of thrombus formation. These devices are used for DVT prophylaxis in individuals considered high risk for DVT formation and those in whom prophylactic anticoagulation therapy is contraindicated. In this client, the presence of a DVT should be ruled out before obtaining an order for and applying intermittent pneumatic compression devices.

The nurse is providing discharge teaching to the client with a platelet count of 40,000 per mcL (40 x 10^9/L). Which of the following information should the nurse include? A. "Be sure to take your aspirin with meals daily." B. "You may continue to shave with a straight-edge razor." C. "Use a soft toothbrush and floss gently." D. "You should take a multivitamin daily."

Choice C is correct. The client has thrombocytopenia and should be on bleeding precautions. Using a soft toothbrush and flossing gently can prevent the gum tissue from bleeding. Platelets (thrombocytes) are important for blood clotting. The normal range for platelets is 150,000-400,000 per microliter (or 150-400 x 10^9/L). Choice A is incorrect. Aspirin can interfere with platelet function and should be discontinued in this client with a low platelet count. Choice B is incorrect. A straight-edge razor increases the risk of cuts and bleeding. Instead, an electric razor should be used for shaving to avoid cuts. Choice D is incorrect. Unless a nutritional etiology has been identified, multivitamins have no role in thrombocytopenia treatment. If a vitamin B12 deficiency is identified as the etiology, B12 supplements can correct thrombocytopenia.

The nurse cares for a client newly diagnosed with Trichomonas vaginalis. The nurse plans to take which appropriate action? A. Start a 24-hour urine collection B. Initiate contact precautions C. Obtain a prescription for metronidazole D. Contact the local health department

Choice C is correct. Trichomoniasis is a protozoan infection primarily spread through sexual contact. The treatment for this infection is metronidazole because of its antibiotic and antiprotozoal properties. This effective treatment may be prescribed in a single dose or over several days. Choices A, B, and D are incorrect. A 24-hour urine collection is not necessary to diagnose or verify the diagnosis of Trichomoniasis. This infection is primarily diagnosed by swabbing the vagina and viewing it under wet-mount microscopy. Contact precautions are not used for this infection because the primary mode of transmission is through sexual contact. This infection is not reported to public health services, unlike other sexually transmitted infections (syphilis, gonorrhea, chlamydia). Additional Info ✓ Trichomonas vaginalis causes Trichomoniasis. ✓ Trichomonas vaginalis is a protozoan parasite primarily spread via sexual contact. ✓ This infection is only found in humans and may cause symptoms in females such as thin, malodorous vaginal discharge that is yellow/green. ✓ Other manifestations include pelvic pain and dyspareunia ✓ Males are commonly asymptomatic. However, they may have symptoms such as urethritis with purulent discharge. ✓ Treatment of this infection is a prescription of metronidazole which may be given in a single dose.

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis.

Choice C is correct. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes. Choices A, B, and D are incorrect. Cold stress would deplete glucose stores because of the sympathetic response. Thus, hyperglycemia would not occur. Manifestations of hypoglycemia include poor muscle tone and a weak, jittery cry. Metabolic acidosis would develop due to cold stress because the lack of glucose would cause fat to be the fuel source, causing metabolic acidosis.

The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress? A. shivering B. hyperglycemia C. tachycardia D. bradypnea

Choice C is correct. When an infant's temperature decreases, their heart rate increases because of peripheral vasoconstriction. The vasoconstriction increases the infant's heart rate because of the increased afterload. Tachycardia, tachypnea, and cyanosis to the extremities are signs of cold stress. Choice A is incorrect. Infants do not shiver until approximately six months. This infant is 2 hours old, and shivering is highly unlikely. Choice B is incorrect. When an infant experiences cold stress, it causes the infant to increase their metabolic rate. The increase in metabolic rate may drive down blood glucose. Thus, it would be prudent to assess the newborn for hypoglycemia if they develop cold stress.

The nurse teaches a client scheduled for an upcoming total hip arthroplasty. Which of the following statements by the client would require follow-up? A. "I will need to bathe with chlorhexidine gluconate solution (CHG) the night before surgery to prevent an infection." B. "I will need to deep breathe and cough every 2 hours." C. "I will have to attend physical therapy sessions following my surgery." D. "I will be prescribed an anticoagulant and need to take it with a sip of water on the day of surgery."

Choice D is correct. After the surgery, the client will be prescribed VTE prevention (sequential compression devices, subcutaneous enoxaparin). The client should not take an anticoagulant or antiplatelet for 5-7 days or as directed by the surgeon before the surgery. This would raise the risk for intra- and postoperative hemorrhage. Other medications such as vitamin E, garlic, and aspirin should be avoided because these will increase the risk of bleeding. Choice A is incorrect. Infection is a concern following this surgery, and the client will be prescribed to take a bath with CHG the night before. Once the bath has been completed, the client should then sleep on clean linens and not with pets.

The nurse is caring for a client with carbon monoxide (CO) poisoning. The nurse anticipates administering oxygen via A. nasal cannula. B. venturi mask. C. simple mask. D. nonrebreather mask.

Choice D is correct. CO poisoning requires aggressive oxygenation at a FiO2 of 100%. A nonrebreather is the only delivery device to provide a FiO2 level of 100% and is used for a client with CO poisoning. Additional Info ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse? A. Restrain the client B. Escort the other clients from the room C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption D. Approach the client causing a disruption calmly while accompanied by two additional staff members

Choice D is correct. The initial intervention is to approach the client calmly, attempt to de-escalate the situation, and remove this client from the room (preferably on the client's own accord). For the safety of staff and all other individuals in the room, staff members should never make face-to-face contact with an agitated psychiatric client without being accompanied by other trained healthcare personnel.

The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right A. intention. B. alternative. C. assessment. D. task.

Choice D is correct. The right task is within the five rights. Delegation involves ensuring that the task being assigned is appropriate for delegation. It includes considering the complexity and nature of the task in relation to the competence of the person to whom it is delegated. For example, the right task would be delegating a practical/vocational nurse to administer an intramuscular (IM) injection of vitamin B12. Choice A is incorrect. While having the right intention is important in nursing practice, it is not specifically related to the concept of delegation. The focus of delegation is on the appropriateness of the task being assigned. Choice B is incorrect. The concept of having the right alternative is not directly related to the five rights of delegation. Delegation involves selecting the right person for the right task, rather than considering alternatives. Choice C is incorrect. While assessment is a crucial aspect of nursing practice, the specific term "right assessment" is not one of the five rights of delegation. Delegation involves assessing the appropriateness of the task for delegation.

You are caring for a family who is experiencing the loss of a child that was given up for adoption. This family is not sharing this loss and their accompanying grief with people outside of their family who, have in the past, served as the family's support system. What type of pain is this family experiencing? A. Complicated grief B. Anticipatory grief C. Inhibited grief D. Disenfranchised grief

Choice D is correct. This family is not sharing this loss and their accompanying grief with people outside of their family (who in the past served as the family's support system) because the damage associated with giving a child up for adoption is experiencing disenfranchised grief. Disenfranchised grief occurs after an injury that is not socially, culturally, religiously, or otherwise not acceptable, such as an abortion, a suicide, and an adoption. Choice A is incorrect. Complicated grief is abnormal grief that is prolonged in terms of its duration. Choice B is incorrect. Anticipatory grief is normal grief that occurs before the actual loss. Choice C is incorrect. Inhibited grief is abnormal grief that is characterized by the suppression of normal grief responses.

The nurse is screening clients at risk of sudden infant death syndrome (SIDS). The nurse correctly identifies which client is at the highest risk for SIDS? An infant who is A. a preterm 4-month-old female who sleeps supine and is formula fed. B. a preterm 12-month-old male who sleeps prone and is formula fed. C. a term 6-month-old male who sleeps supine and is formula fed. D. a preterm 3-month-old male who sleeps lateral and is breastfed.

Choice D is correct. This infant has four risk factors for SIDS (preterm; 3 months; male sex; sleeping in a lateral/prone position). SIDS peaks between 2 and 3 months and occurs before 12 months of age. SIDS occurs more in males than females, and the lateral and prone position for sleeping should not be used until 12 months of age. The only mitigating factor for this client is that they are breastfed. This is a mitigating factor because maternal antibodies are passed to the infant. Choice A is incorrect. This client is preterm, 4 months, and is formula fed. These are three risk factors for SIDS. Two mitigating factors are that the client is female and sleeping supine. Choice B is incorrect. This client is preterm, male, and formula fed. These are three risk factors for SIDS. The infant sleeping prone at this age (12 months) is allowed. SIDS peaks between 2 and 3 months. The infant sleeping prone at this age is not a risk factor. Choice C is incorrect. This client is male, 6 months, and is formula fed. These are three risk factors for SIDS. The client is not in the highest age bracket for SIDS; however, by definition, it occurs in individuals younger than 12 months. The mitigating factors are that the client sleeps supine and is term. SIDS is higher in preterm infants. Additional Info ✓ SIDS occurs higher in males and twins ✓ The peak incidence is between two and four months ✓ Other risk factors include exposure to cigarette smoke, prematurity, prone sleeping position, formula feeding, and overheating ✓ Mitigating factors include a cool sleeping environment, supine sleeping, room-sharing (not bed-sharing), and sleeping on firm surfaces

The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A client with A. chronic anemia requiring epoetin injections. B. a resolving pneumothorax with a chest tube. C. a tracheostomy requiring intermittent suctioning. D. septic shock requiring intravenous (IV) vasopressors.

Choice D is correct. When making client assignments, the RN should be assigned the client with the least predictable outcome who is unstable. The client with septic shock receiving intravenous vasopressors should be assigned to the RN because of the need to titrate the vasopressors. Further, this client being in shock, is not stable and requires frequent assessment. Choices A, B, and C are incorrect. An LPN should be assigned clients who are stable and with a predictable outcome. A client with a chronic illness such as anemia requiring epoetin injections can be delegated to the LPN (Epoetin, unlike RhoGAM, is not regarded as a blood product). Further, the client with a resolving pneumothorax may be assigned to the LPN because the condition is resolving. Finally, LPNs may do suction in an established tracheostomy. Additional Info ✓ When making client assignments, the nurse should always assign the most unstable client to the RN. ✓ This also involves clients requiring initial assessments or discharge teaching. ✓ The LPN may reinforce teaching, data collection, and care for clients with low acuity illnesses.

The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears? A. Provide the child with a private room B. Encourage them to play with other children in the common area C. Advise the parents to only visit during visiting hours D. Allow the parents to stay as much as they'd like

Choice D is correct. While most preschoolers can manage to be away from their parents for school, illness adds another stressor, making separation increasingly tricky. Parents should be encouraged to stay with their children as much as possible. Choice A is incorrect. Staying in a private room may be more anxiety-producing for a child separated from their healthy life. Choice B is incorrect. Because this patient is immunocompromised, they should not be spending time in the commons area with other children, as this may lead to developing infections. Choice C is incorrect. Parents should be encouraged to visit their children as much as possible.

The nurse is caring for a client with a sodium level of 130 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which of the following medications may cause this abnormality? Select all that apply. Spironolactone Hydrochlorothiazide Prednisone Sodium polystyrene Tolvaptan

Choices A and B are correct. Spironolactone, a potassium-sparing diuretic, retains potassium but causes the loss of water and sodium. By blocking aldosterone, it leads to increased potassium levels while depleting sodium and water, potentially contributing to hyponatremia. Hydrochlorothiazide, a thiazide diuretic, increases urine production, leading to sodium and water loss. While it raises serum calcium levels, it depletes other electrolytes, including sodium. Use can contribute to hyponatremia due to the loss of sodium through increased urine output. Choice C is incorrect. Prednisone, a corticosteroid, causes an increase in aldosterone, leading to sodium and water retention. While it may affect electrolyte balance, it does not directly cause hyponatremia. Choice D is incorrect. Sodium polystyrene, used for hyperkalemia, exchanges sodium ions for potassium ions in the intestines, lowering potassium levels. While it lowers potassium, it does not directly affect sodium levels and is not a primary cause of hyponatremia. Choice E is incorrect. Tolvaptan, used to treat the syndrome of inappropriate antidiuretic hormone (SIADH), depletes water but does not directly deplete sodium. While it can lead to changes in water balance, it does not cause significant sodium loss, making it incorrect in the context of low sodium levels.

The nurse is developing a plan of care for a client admitted to the mental health unit with significant paranoia. Which of the following should the nurse include in the client's plan of care? Select all that apply. Plan competitive activities with other clients. Maintain consistent caregivers. Establish a rapport using therapeutic touch. Involve the client in decision-making. Develop a plan of care that is unstructured. Immediately enroll the client in group therapy.

Choices B and D are correct. A client experiencing paranoia may be very conspiratorial, and while it is important to reinforce reality, it would be appropriate to acknowledge their feelings. Involving the client in the decision-making process and avoiding any surprises is essential. Consistent caregivers are recommended because this cements the therapeutic relationship with staff.

Fat embolism

A disruption to blood supply caused by fat globules in a blood vessel. A fat embolism occurs when fat globules are released into the bloodstream. It's most commonly associated with a trauma, such as a bone fracture. Symptoms, if present, typically occur 24 to 72 hours after the trauma. They include shortness of breath, confusion, and a rash. With supportive hospital care, most people recover. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.

The nurse is caring for a client who has an acute myocardial infarction (AMI). The nurse should anticipate an immediateprescription for which of the following? A. Aspirin B. Warfarin C. Propranolol D. Amiodarone

Choice A is correct. 325 mg of chewable aspirin should be prescribed to a client with acute myocardial infarction (AMI). This medication exerts antiplatelet effects and is the standard of care for an AMI.

A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as: A. Autocratic B. Democratic C. Participative D. Laissez-faire

Explanation Choice A is correct. In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit. Choice B is incorrect. In a democratic style of management, staff members are encouraged to participate in the decision-making process whenever possible. The majority of the decisions are made by the group, not the manager in this management style. Choice C is incorrect. In a participative style of management, problems are identified by the manager and presented to the staff with several solutions. Staff members are encouraged to provide input however, the manager makes the final decision. Choice D is incorrect. Little direction, structure, or support is provided by the manager in a Laissez-faire type of management. The manager abdicates responsibility and decision-making whenever possible in this type of management.

The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action? A. Elevate the stump on a pillow B. Check the operative site for bleeding C. Obtain an order for a physical therapy order D. Demonstrate the use of incentive spirometry (IS)

Explanation Choice B is correct. A complication following an amputation is hemorrhage. An early assessment and action of the nurse is to monitor the client for hemorrhage, which may be evident on the bandage, or if the client has a drain, a large amount of bloody drainage may be apparent. Findings that may support that the client is hemorrhaging include tachycardia with later development of hypotension. Rather the amputation is traumatic or surgically performed; it is hemorrhage that is a concerning complication.

While working on the pediatric floor, you are assigned a client with impetigo. Which of the following actions do you take to prevent the spread of this disease? A. Initiate standard precautions B. Initiate contact precautions C. Initiate droplet precautions D. Initiate airborne precautions

Explanation Choice B is correct. Clients with impetigo need to be placed on contact precautions to prevent spreading this highly contagious disease. According to the CDC, these precautions are "for clients who may be infected or colonized with specific infectious agents for which additional precautions are needed to prevent infection transmission. Contact precautions will be used for any disease in which direct contact with the infectious organism can cause illness. This includes impetigo and other conditions such as viral gastroenteritis, MRSA, and scabies. Contact precautions will require a gown and gloves before entering the room. Choice A is incorrect. According to the CDC, standard precautions are used for all client care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment (PPE) use that protect healthcare providers from infection and prevent the spread of infection from client to client. Standard precautions include performing hand hygiene, using PPE when there is possible exposure to infectious material, properly cleaning equipment and instruments, and following safe injection practices. For impetigo, standard precautions are not enough. This is a highly contagious disease that will require more precautions.

The nurse is caring for a neonate with a decreased cardiac output. If noted in this client, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension

Explanation Choice C is correct. Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses. Choice A is incorrect. Oliguria is an expected finding in an infant with a decreased cardiac output. As the kidneys are perfused less efficiently in an infant with decreased cardiac output, urination reduces or ceases altogether. Choice B is incorrect. Difficulty breastfeeding may be seen in infants with low cardiac output. Feeding is increasingly difficult for babies with poor circulation. Choice D is incorrect. Hypotension is an expected finding in an infant with low cardiac output. Normal cardiac output is required to keep blood pressure regulated.

The emergency department (ED) nurse is triaging a client who is highly suspected of having inhalation anthrax. The nurse should plan to A. place a surgical mask on the client. B. place the client in a room with negative airflow with an anteroom. C. obtain a urine sample from the client. D. report the situation to the hospital administration.

Explanation Choice D is correct. Inhalation anthrax outbreak is rare and, when it does occur, is regarded as an act of bioterrorism. The nurse must immediately notify hospital administration so an emergency response plan may be activated and public health services can be informed of the outbreak. Choice A is incorrect. Inhalation anthrax is not transmitted from person to person. It would be inappropriate to place a surgical mask on the client as the bacteria is transmitted from the source (the powder). Choice B is incorrect. No isolation precautions are necessary for a client with inhalation anthrax. Standard precautions are used for individuals with inhalation anthrax. Choice C is incorrect. Inhalation anthrax is not diagnosed via a urine sample. It is diagnosed via serum antibodies, spinal fluid, and respiratory secretions. Additional Info ✓ Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. ✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. ✓ Standard precautions are used for a client with inhalation anthrax. ✓ Nursing care aims to stabilize the client's breathing and promptly initiate treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions? Select all that apply. Major Depressive Disorder Attention Deficit Hyperactivity Disorder Obsessive-Compulsive Disorder Generalized Anxiety Disorder Bipolar Disorder

Explanation Choices A, C, and D are correct. Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI). This medication is efficacious in depression, anxiety, and obsessive-compulsive disorders. Choices B and E are incorrect. Sertraline is not indicated for bipolar disorder because it may exacerbate the condition. Attention Deficit Hyperactivity Disorder (ADHD) is a condition that is treated with psychostimulants such as amphetamines or methylphenidates.

The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected? Select all that apply. Halitosis Chorea Hallucinations Hematemesis Weight loss

Huntington's disease is a neurodegenerative disease that is not well understood. This disease causes neuropsychiatric symptoms such as chorea, dystonia, abnormal eye movements, cognitive dysfunction, dementia, hallucinations, and weight loss. Chorea refers to sudden, involuntary, and jerky movements of facial muscles, arms, and legs. Treatments include VMAT2 inhibitors such as tetrabenazine. Adjunctive treatments such as benzodiazepines may be utilized for symptoms such as uncontrolled chorea.

The nurse is performing a home visit for the parents of an infant. Which action by the parents while giving the infant a sponge bath requires follow-up by the nurse? A. Removes all of the infant's clothing for the bath B. Uses a mild soap for the bath C. Provides the bath in a warm room D. Washes and dries one part of the baby's body at a time

The nurse is performing a home visit for the parents of an infant. Which action by the parents while giving the infant a sponge bath requires follow-up by the nurse? A. Removes all of the infant's clothing for the bath B. Uses a mild soap for the bath C. Provides the bath in a warm room D. Washes and dries one part of the baby's body at a time

pertussis

whooping cough; highly contagious bacterial infection of the pharynx, larynx, and trachea caused by Bordetella pertussis See a doctor if you or your child are: Struggling to breathe. Turning blue or purple. Coughing violently. Coughing rapidly, over and over. Not drinking enough fluids. Pertussis (whooping cough) is spread via respiratory droplets so the nurse should institute droplet precautions when caring for a client with pertussis.Jul