Archer NCLEX Study Bank Questions

1345 - Client presents for a report of straining with urination, weak urinary stream, and hesitancy during urination. Client states the problem has been going on for a few months but is getting worse because he has to use the bathroom more frequently in the middle of the night. Reports dribbling in his underwear which he finds embarrassing. Described his urine as clear and a straw yellow color. Recently started a prescribed low-dose aspirin and wonders if that could cause all his symptoms. Medical history of hypertension, obsessive-compulsive disorder, and osteoarthritis. No known allergies. Oral Temperature 98o F (36.7o C) Heart rate 83/minute Respirations 18/minute Blood pressure 134/82 mm Hg Which orders does the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply Urine analysis Post-void bladder scan Insertion of indwelling urinary catheter Testicular ultrasound Digital rectal exam

An order urine analysis to exclude infection and identify any abnormalities will be anticipated. Further, a post-void bladder scan will be done to determine the amount of residual urine in the client's bladder. Finally, a digital rectal exam will be performed, where the examiner will palpate the enlarged prostate. An indwelling urinary catheter is unnecessary and could expose the client to infection. A testicular ultrasound would be useful if the client had testicular pain, which this client does not report.

The nurse is assessing a client with possible bipolar I disorder. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which laboratory testing? A. Thyroid Stimulating Hormone (TSH) B. Complete Metabolic Panel (CMP) C. Glycated Hemoglobin A1C (HbA1c) D. C-Reactive Protein (CRP)

Choice A is correct. A TSH is the standard of care before diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client's symptoms. This is because thyroid dysfunction, specifically hypothyroidism, can mimic symptoms of depression and mood disorders. Therefore, checking TSH levels is essential to rule out thyroid-related causes of mood disturbances. Choice B is incorrect. CMP is a broad screening test that assesses various aspects of a person's health, including kidney and liver function, electrolytes, and blood glucose levels. While this panel may be ordered for general health assessment, it is not specific to bipolar disorder. Choice C is incorrect. HbA1c is a test primarily used to monitor long-term blood sugar control in individuals with diabetes. It is not relevant to the assessment of bipolar I disorder. Choice D is incorrect. CRP is a marker of inflammation and is often used to assess cardiovascular risk. It is not a routine test for bipolar I disorder but may be ordered in the context of assessing overall health and potential comorbidities.

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

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

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

Choice A is correct. Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body, but swelling in the face, lips, and eyes can be serious. The client should notify the prescriber immediately. Angioedema may also cause airway obstruction due to swelling of the soft tissues of the upper airway. If the client has trouble breathing, then they should call 911. Choices B, C, and D are incorrect. ACE inhibitors do not have a diuretic effect, and the client is not required to weigh themselves daily. This medication may cause hyperkalemia, and the client should not eat a diet rich in potassium because of the serious cardiovascular risks associated with hyperkalemia. ACE inhibitors have the tendency to be nephrotoxic, not hepatotoxic.

The nurse manager plans to establish quality metrics for the nursing unit based on national metrics and compare them to other healthcare organizations. This process is identified as A. benchmarking. B. continuous quality improvement. C. performance Improvement. D. quality management.

Choice A is correct. In Benchmarking, the nurse manager compares best practices from top hospitals with the unit and adapts the unit's methods to improve unit performance. This is often when the nurse manager compares metrics (for example, bar-coded medication administration rate) with other healthcare facilities. Choice B is incorrect. Continuous quality improvement continually assesses and evaluates the effectiveness of client care. Benchmarking may be involved with this process. However, the specific method of comparing metrics to other facilities is benchmarking. Choice C is incorrect. Performance improvement establishes a system of formal evaluation for job performance and recommends ways to improve performance as well as promote professional growth. Choice D is incorrect. Quality management oversees all activities and tasks needed to maintain a desired level of excellence. This includes determining a quality policy, creating then implementing quality planning and assurance, and quality control/improvement.

The nurse in the emergency department (ED) is caring for a client with a myocardial infarction. The nurse anticipates a prescription for which medications? Select all that apply. labetalol morphine sulfate nitroglycerin enalapril isosorbide diltiazem

Choice A is correct. Labetalol is a beta-blocker and is the mainstay treatment for acute myocardial infarction. This medication has been proven to reduce ventricular dysrhythmias, which can be fatal. Contraindications to a client receiving labetalol (or any beta-blocker) include heart block, bradycardia, or shock. Choice B is correct. Morphine sulfate has vasodilation effects and may be beneficial in dilating the coronary arteries, allowing for more perfusion to the myocardium. This medication is also used in acute pulmonary edema. The typical dosage is 4 mg. Choice C is correct. Nitroglycerin is the mainstay treatment in an MI. Nitroglycerin's potent vasodilation effects are highly efficacious. Nitroglycerin for an MI is dosed sublingual at 0.4 mg. One tablet is given every five minutes with a maximum of three tablets. Contraindications to a client receiving nitroglycerin include hypotension and a right ventricular myocardial infarction. Choice D is incorrect. Enalapril is an ACE inhibitor and is effective in treating systolic heart failure. Beta-blockers are highly preferred over ACE inhibitors because they reduce the likelihood of ventricular dysrhythmias. Choice E is incorrect. Isosorbide is a maintenance nitrate used to prevent angina. The client with acute angina should take nitroglycerin sublingually because of its rapid onset of action. Isosorbide should be taken daily, and the client taking any nitrate should avoid concurrent administration of medication such as tadalafil or sildenafil because of the risk of profound hypotension. Choice F is incorrect. Diltiazem is a calcium channel blocker that is commonly used in atrial fibrillation. This medication is intended to have a client maintain rate control with their atrial fibrillation. This medication is not used in an acute myocardial infarction.

The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the following medications should the nurse be prepared to administer? A. Lorazepam B. Phenytoin C. Carbamazepine D. Benztropine

Choice A is correct. Lorazepam is a benzodiazepine that acts as an anticonvulsant. It is often used as a first-line medication to abort prolonged or status epilepticus seizures, including tonic-clonic seizures. Lorazepam has a rapid onset of action and can be administered intravenously or intramuscularly in emergency situations to quickly terminate the seizure. Choice B is incorrect. Phenytoin is an anticonvulsant, but its onset of action is slower compared to benzodiazepines like lorazepam. It is more commonly used for long-term seizure control and is not the first choice for rapidly terminating an ongoing seizure. Choice C is incorrect. Similar to phenytoin, carbamazepine is used for long-term seizure control and is not appropriate for rapidly stopping an acute tonic-clonic seizure. It has a slower onset of action. Choice D is incorrect. Benztropine is not an anticonvulsant. It is typically used to treat extrapyramidal side effects caused by antipsychotic medications and is not indicated for seizure management.

The nurse is caring for a client who is receiving prescribed metoclopramide for gastroparesis. Which of the following findings require immediate notification to the primary healthcare provider (PHCP)? A. Muscle rigidity of the neck B. Hyperactive bowel sounds C. Frequent diarrhea D. Abdominal distention

Choice A is correct. Metoclopramide is a dopamine antagonist in treating gastroparesis, nausea, and vomiting. Dopamine antagonists may induce dystonia which is depicted in this option. This finding is highly concerning. Choices B, C, and D are incorrect. Metoclopramide increases gastric motility and may therapeutically treat gastroparesis. Hyperactive bowel sounds and frequent diarrhea may occur because of increased gastric motility. However, these findings are not concerning because they are expected with this medication. Abdominal distention is a characteristic of gastroparesis and would not be reported to the PHCP.

The nurse is providing care to an 11-week pregnant client who is complaining about hemorrhoids. The nurse recognizes that hemorrhoids can occur due to pressure on the rectal veins from the growing fetus. Which of the following measures is not recommended for alleviating hemorrhoid pain in this client? A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area.

Choice A is correct. Mineral oil is not recommended during pregnancy as it can interfere with the absorption of fat-soluble vitamins and may have adverse effects. Safer alternatives, such as increasing fiber and water intake, should be encouraged. Choice B is incorrect. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return and decreasing venous pressure. This may help reduce pressure on the rectal veins, potentially alleviating hemorrhoid pain. It is a recommended measure during pregnancy. Choice C is incorrect. Increasing fiber and water intake is a recommended measure to soften stools and prevent constipation, which can contribute to hemorrhoid development. It is considered a safe and effective approach during pregnancy. Choice D is incorrect. Applying a cold compress can provide relief by reducing inflammation and discomfort associated with hemorrhoids. It is a safe and commonly recommended measure for alleviating hemorrhoid pain during pregnancy.

A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse? A. "I'm sorry, but under the law, we're not allowed to witness living wills." B. "Let me call the doctor. Maybe he can witness it for you." C. "Your family are the only people that can serve as witnesses." D. "Let me call the hospital attorney; he needs to be present when you sign your will."

Choice A is correct. Nurses and other healthcare workers in the facility where the patient is receiving care are forbidden by law from becoming witnesses. Choice B is incorrect. This statement is inaccurate. Nurses and other healthcare workers in the facility where the patient is receiving care are forbidden by law from becoming witnesses. Choice C is incorrect. This statement is false. Witnesses for the signing of the will can be specific individuals; it does not necessarily mean only family. Choice D is incorrect. The hospital lawyer is not needed to be present in signing the living will.

The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision? A. Adjust the physician's order based on the client's pain level B. Ensure naloxone is always available C. Check the client's blood pressure before administering morphine sulfate D. Provide a high-fiber diet

Choice A is correct. Pain medication orders may be titrated based on the client's pain level. However, the nurse cannot adjust the physician's order based on the client's pain level. If the nurse wants to adjust the dosage, the nurse will need the physician to adjust the prescription. This needs to be revised because it is inappropriate, as the nurse cannot unilaterally adjust a physician's order. Choice B is incorrect. Naloxone, an opioid antagonist, should always be available as an antidote to opioids and to treat opioid overdose, including events occurring with morphine sulfate. Choice C is incorrect. Morphine sulfate has a vasodilation effect, which may, in turn, lower blood pressure. Prior to administering this medication, the nurse should assess the client's blood pressure and respiratory rate. Choice D is incorrect. Morphine sulfate diminishes propulsive peristaltic waves in the gastrointestinal tract, often resulting in constipation. Therefore, a high-fiber diet should be given to prevent this complication.

The nurse understands that a portion of the pain "assessment" entails the client's subjective, sensory, and emotional comments that indicate the quality or intensity of their pain. The client describes their pain as "crushing and sharp." Select the type of pain a client is experiencing based on this sensory description of their pain. A. Somatic pain B. Visceral pain C. Hurt D. Neuropathic pain

Choice A is correct. Somatic pain arises from skin and musculoskeletal structures. This type of pain is often reported as sharp, easily localized, gnawing, crushing or throbbing. Sources of acute somatic pain include (and are not limited to) incisional pain, pain at insertion sites of tubes, orthopedic injuries, and wound complications. Choice B is incorrect. "Crushing and sharp" are sensory descriptors of another type of pain, not visceral pain. Visceral pain typically arises from organs and linings of the body cavities. This type of pain is poorly localized, and reported as diffuse, deep cramping or pressure. Choice C is incorrect. The term "hurt" is a word the client uses to inform the health care provider that they are experiencing pain but does not give a sensory description to what type of pain they are experiencing. The nurse should further ask clarification questions to try to get to the type of pain the pain is experiencing when they report they are "hurt". Choice D is incorrect. Neuropathic pain happens when the peripheral nervous system or the central nervous system has abnormal pain processing. This pain may be described as poorly localized, shooting, burning, numbness, tingling or shock-like.

The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is: A. Systematic review and meta-analysis studies B. Expert opinions C. Qualitative studies D. Case studies

Choice A is correct. Systematic reviews and meta-analysis studies provide current, recently summarized evidence, making them the most reliable form of evidence for studies. Choice B is incorrect. Expert opinions may involve bias on the subject, making them unreliable sources of data. Choice C is incorrect. Qualitative studies involve interpretation of the database on the author's understanding of the subject, making these types of literature unreliable sources of data. Choice D is incorrect. Case studies may also involve bias from the authors, making them unreliable sources of data as well.

The nurse is caring for an older adult receiving prescribed antibiotics for an infection. The client reports frequent watery stools that are foul-smelling. To prevent the spread of any potential secondary infection, the nurse should A. Place the client on contact (enteric) precautions. B. Place a surgical mask on the client during transport to other departments. C. Place face shields outside of the client's room. D. Keep the door to the client's room closed.

Choice A is correct. The client's age, history of antibiotic therapy, and watery stools suggest Clostridium difficile infection. The initial action should be to place the client on contact precautions (contact-enteric) to prevent the spread of C. difficile to other clients. Clostridium difficile (C. difficile) is a spore-forming bacillus that infects the gastrointestinal (GI) tract and occurs during and following the treatment of different infections with antibiotics. Choice B is incorrect . The manifestations that the client experienced suggest that the client has Clostridium difficile. This infection can be triggered by antibiotic usage. The client's being an older adult also raises their risk of contracting this infection. It would be inappropriate to place a surgical mask on the client during transport to other departments because this infection is propagated by spores on surfaces and hands. Choice C is incorrect. Using a face shield is not necessary because this infection is spread by contact with contaminated surfaces or hands. Face shields are helpful in protecting the mucous membranes for procedures such as irrigating an ostomy. Choice D is incorrect. Keeping the door to the client's room closed is not appropriate because this is an infection control measure if the client has a pathogen that could be spread via aerosolized droplets (such as pulmonary tuberculosis and varicella).

The nurse in the emergency department is caring for a client with a magnesium level of 1.4 mEq/L (0.58 mmol/L) [1.5-2.5 mEq/L, 0.6-1.2 mmol/L]. You need to create a list of foods that you recommend the client should consume. What foods would you suggest adding to the list? Select all that apply. Spinach Onions Mushrooms Salmon Bananas

Choice A is correct. This client's magnesium level is borderline low, so the nurse must encourage them to eat magnesium-rich foods. Spinach is an excellent source of magnesium, offering about 140 mg per cup. Choice D is correct. Salmon is a good source of magnesium, offering about 88 mg per fillet. Choice E is correct. Bananas are a good source of magnesium, with one medium-sized banana containing approximately 32 milligrams of magnesium, about 8% of the recommended intake. Choice B is incorrect. Onions are not a significant source of magnesium. While they have various health benefits, they are not among the top choices when aiming to increase magnesium intake significantly. Choice C is incorrect. Mushrooms contain some magnesium but are not considered an exceptionally high source of this mineral compared to other foods. While they can contribute to magnesium intake as part of a balanced diet, other foods are much richer in magnesium content. Overall, mushrooms are not a good source of magnesium, as they only have about 7 mg per cup.

What EKG rhythm represents a third-degree heart block?

Choice A is correct. This rhythm represents a 3rd-degree heart block because there is no QRS complex after every other p wave. This is because the AV node has no conduction during a 3rd-degree heart block. Therefore, the p waves and QRS complexes are not interacting with each other. Choice B is incorrect. This rhythm represents a 1st-degree heart block. This rhythm occurs when the AV conduction is slowed, therefore creating a more extended time between the p wave and the QRS complex. Choice C is incorrect. This rhythm represents a 2nd-degree heart block or Mobitz type 2. This occurs when the AV node is taking longer to conduct. The PR interval may be regular or lengthened. This rhythm indicates problems in the Purkinje system. Choice D is incorrect. This rhythm is sinus tachycardia, which is a heart rate over 100 bpm.

The nurse observes a client go up the stairs with a cane. It would indicate effective teaching if the client grabs the handrail and A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. B. holds the cane in one hand and hops up each stair using the stronger leg. C. places the cane up a step, then simultaneously moves up the stronger and weaker legs. D. places the weaker leg up a step, then simultaneously moves up the stronger leg and cane.

Choice A is correct. When a client is ambulating upstairs using a cane, the client will face the stairs and place the cane on the side opposite the handrail. Then, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together. Choices B, C, and D are incorrect. These statements require follow-up because they do not follow the correct (and safe) sequence for ambulating with a cane while ascending stairs. Improper usage of a cane may result in falls.

The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel? A. A 65-year-old male requiring sterile dressing changes. B. A 26-year-old female requiring a one-person assist in ambulating to the restroom. C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube. D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.

Choice B is correct. A 26-year-old female requiring one person to assist in ambulating to the restroom would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in assisting clients with ambulation, which is within their scope of practice. Choice A is incorrect. A 65-year-old male requiring sterile dressing changes would not be an appropriate assignment for unlicensed assistive personnel. Simple dressing changes are not performed by unauthorized personnel. The UAP does not have the requisite knowledge and experience for this task. Choice C is incorrect. An 80-year-old male who is continuously receiving enteral feedings through an NG tube would not be an appropriate assignment for unlicensed assistive personnel. Administering tube feedings is not performed by unlicensed personnel. Choice D is incorrect. UAPs may assist with clean catches, but collecting urine specimens from the indwelling urinary catheter is not within their scope. This requires an LPN/VN or RN, as the specimen is not obtained from the collection bag. It is obtained by clamping the tubing and with a sterile syringe.

The nurse is caring for a client with akathisia. The nurse should anticipate a prescription for which medication? A. Modafinil B. Propranolol C. Venlafaxine D. Duloxetine

Choice B is correct. Akathisia is the most common extrapyramidal side effect (EPS) associated with antipsychotic medications. Propranolol is an effective treatment for akathisia as this helps with treating the internal sense of restlessness characterized by this effect. Choices A, C, and D are incorrect. Modafinil is a psychostimulant used in the treatment of narcolepsy. This would likely make akathisia worse and would not be indicated. Venlafaxine and duloxetine are serotonin-norepinephrine reuptake inhibitors (SNRIs) and are not used to manage akathisia.

The nurse is caring for a child with varicella zoster. The nurse should implement which transmission-based precautions? A. Droplet precautions B. Airborne and contact precautions C. Contact and droplet precautions D. Contact precautions

Choice B is correct. Contact and airborne precautions will be implemented to prevent the spread of infection. The virus may spread by coming into contact with the lesions or inhalation of the vesicular fluid or aerosolized respiratory secretions. Precautions may be discontinued once all of the lesions have dried and crusted. Airborne and contact precautions require the following PPE: gloves, gown, and N95 mask/respirator. The room should have negative airflow, and the door must remain closed. Choices A, C, and D are incorrect. These transmission-based precautions are not used for varicella-zoster.

Following the application of a fiberglass cast to treat the client's severe ankle sprain (i.e., Grade 3), a nurse performs client education. During this discussion, the client asks, "How long will my cast take to dry?" Based on this type of cast, the nurse should respond: A. Eight hours B. 30 minutes C. At least 24 hours D. At least 48 hours

Choice B is correct. Fiberglass, a waterproof synthetic casting material, can dry and become rigid within minutes. Typically, the cast will be fully dried within 30 minutes of application. Although the client would be allowed to bear weight on the cast 30 minutes after application if allowed by the health care provider (HCP), crutches or another assistive device may be indicated. Choice A is incorrect. Typically, a fiberglass cast will be fully dried within 30 minutes of application. Depending on the size and location of the cast, a plaster cast takes at least 24 hours to dry. Choice C is incorrect. Plaster was the traditional material used for casts but is used less often today. Depending on the size and location of a plaster cast, this type of cast would take at least 24 hours to dry. Here, since the client received a fiberglass cast, this would not be the correct response. Choice D is incorrect. As mentioned above, plaster was the traditional material used for casts but is used less often today. Depending on the size and location of a plaster cast, this type of cast would take at least 24 hours to dry. Clients who receive large plaster casts may require 48 hours or more to dry completely.

The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The client reports no symptoms. The initial action of the nurse should be which of the following? A. Document the finding in the medical record B. Repeat the capillary blood glucose test to validate the result C. Administer 15 grams of a quick-acting carbohydrate D. Administer 1 mg of glucagon subcutaneously

Choice B is correct. Here, since the client reports no symptoms and the scenario does not indicate the client is actively experiencing any signs or symptoms of hypoglycemia, the nurse's initial action should be to repeat the capillary blood glucose test to validate the test result. Repeating the capillary blood glucose test will help determine whether the hypoglycemic reading may have resulted from an operator or machine error. Of note, if the client were symptomatic, the nurse's initial action would not be to repeat the capillary blood glucose test to validate the test result. Choice A is incorrect. Documenting the finding of 40 mg/dL in the client's medical record without first performing an intervention would be incorrect. Choice C is incorrect. To treat hypoglycemic clients, the 15/15 rule is typically applied. Under the 15/15 rule, hypoglycemic clients eat 15 grams of carbohydrates and wait 15 minutes. Some examples of 15 grams of carbohydrates include four ounces (½ cup) of fruit juice, one tablespoon of honey, or hard candies. Of note, the 15/15 rule is typically used for clients with a blood glucose of 55-69 mg/dL. Glucagon is the recommended treatment for symptomatic hypoglycemic clients with a blood glucose level lower than 55 mg/dL. Therefore, an initial action by the nurse consisting of administering 15 grams of a quick-acting carbohydrate to an asymptomatic client with a capillary blood glucose result of 40 mg/dL (2.22 mmol/L) would be incorrect. Choice D is incorrect. Glucagon is used to treat clients whose blood glucose is too low to treat using the 15-15 rule (as described above). In an asymptomatic client with a capillary blood glucose result of 40 mg/dL (2.22 mmol/L), the initial action by the nurse should be to verify the accuracy of the test result, not administering 1 mg of glucagon subcutaneously.

The nurse is caring for a client hospitalized due to acute chronic obstructive pulmonary disease (COPD) exacerbation. What assessment finding would the nurse expect to find? A. arterial blood gas showing a carbon dioxide level of 31 mm Hg B. hyperinflated lungs on chest x-ray C. improving oxygen saturation upon exercise D. wide diaphragm on chest x-ray

Choice B is correct. In clients with COPD, there is a loss of elastic recoil in the lungs leading to hyperinflation of the lungs, as seen on chest x-ray. Prolonged hyperinflation of the lungs causes barrel chest in COPD clients. Choice A is incorrect. A normal pCo2 level is 35 -45 mmHg. A decreased pCo2 (respiratory alkalosis) is not typical in COPD. In clients with COPD, carbon dioxide is trapped in the lungs (hypercapnia), resulting in an increased carbon dioxide level (hypercapnia) and respiratory acidosis. Choice C is incorrect. COPD exacerbations typically result in decreased exercise tolerance and worsened oxygen saturation during physical activity. Improvement in oxygen saturation upon exercise would not be expected in this context. Choice D is incorrect. While a wide diaphragm may be associated with certain conditions, such as muscle weakness or paralysis, it is not a specific assessment finding expected during a COPD exacerbation.

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. Choice A is incorrect. The child's temperature needs to be reduced; however, this is not the nurse's priority. Additionally, tepid sponging alone will not cause a sustained reduction in the fever of febrile clients. When used, tepid sponging is often most effective when combined with pharmacological interventions (e.g., antipyretics) to adequately address the client's fever. Choice C is incorrect. A lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis, the mainstay of diagnosis. However, the priority nursing action is to place the client in respiratory isolation using droplet precautions upon suspicion of meningitis and arrange for diagnostic procedures once the client has been placed in isolation. Choice D is incorrect. A computed tomography scan of the brain may be ordered to rule out other pathology and determine if the client has swelling of the brain. This is not the priority compared to protecting the safety of staff and other clients.

The nurse administers a combination of regular insulin and NPH insulin subcutaneously to a client at 0800. At which time should the nurse initially assess the client for hypoglycemia based on the peaks of the medications? A. 0830 B. 1000 C. 1200 D. 1400

Choice B is correct. Regular insulin is considered a short-acting insulin and will peak two to three hours after subcutaneous administration. NPH insulin is considered an intermediate-acting insulin, with a peak of four to 12 hours following administration. Since these insulins are being co-administered, there are two separate times at which the client has the highest risk of becoming hypoglycemic based on the times when both insulins peak, the first of which initially occurs at 1000 (the second peak time beginning at 1200). Therefore, the nurse should initially assess the client for signs and symptoms of hypoglycemia at 1000. Choice A is incorrect. Based on the peak times of both regular and NPH insulin, following co-administration of these insulins subcutaneously, a nursing assessment for hypoglycemia performed at 0830 would be inappropriate, as neither type of insulin has had time to reach its peak. Choice C is incorrect. Based on the peak time of regular insulin subcutaneously, a nursing assessment for hypoglycemia performed at 1200 would be inappropriate, as the regular insulin would have already peaked. If the nurse waited until 1200 to evaluate for hypoglycemia, this could be detrimental for the client, as the regular insulin previously peaked, meaning the nurse may have missed the signs and symptoms of hypoglycemia and the opportunity to intervene. Choice D is incorrect. Based on the peak time of regular insulin subcutaneously, a nursing assessment for hypoglycemia performed at 1400 would be inappropriate, as the regular insulin would have already peaked.

The nurse is working at a women's health clinic. A client comes in suspected of having trichomoniasis. Upon physical examination of the perineal region, the nurse should expect which type of sign? A. White, "cheesy" discharge B. Malodorous, thin, yellow discharge C. Grayish-white, malodorous discharge D. No vaginal discharge

Choice B is correct. Trichomoniasis clients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis. Choice A is incorrect. A white, "cheesy" discharge is indicative of moniliasis or candidiasis, which is caused by Candida albicans. Choice C is incorrect. Grayish-white, malodorous discharges would indicate bacterial vaginosis. Choice D is incorrect. Clients with trichomoniasis yield a malodorous, thin, yellow discharge.

The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's A. right to privacy. B. right to emergency care regardless of the ability to pay. C. self-determination. D. ability to receive appropriate treatment for their pain.

Choice C is correct. A client who completes an informed consent is asserting and using their fundamental right to self-determination. Self-determination is defined as the intrinsic right of all people, including healthcare consumers, to make autonomous decisions about accepting or rejecting care or treatments, as is done with informed consent. Self-determination is respecting the client and their ability to outline care for themselves if they become incapacitated, such as formulating advanced directives. Choice A is incorrect. The right to privacy is essential for all clients. Privacy fosters an environment allowing the client to be honest. This is not an example of self-determination. Choice B is incorrect. The right to emergency care, regardless of the ability to pay, is mandated in most countries. In the United States, this is referred to as the emergency medical treatment and active labor act (EMTALA). Choice D is incorrect. The client receiving appropriate treatment for their pain is part of the client's bill of rights, not self-determination.

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 preparing to give alendronate to the client with osteoporosis. The nurse should explain to the client that the expected outcome of this medication is primarily to A. decrease bone inflammation. B. increase synovial fluid in the joint space. C. inhibit bone resorption. D. increase serum calcium levels.

Choice C is correct. Bisphosphonates such as risedronate, alendronate, ibandronate, zoledronic acid, and pamidronate are administered to inhibit bone resorption. Therefore, they decrease osteoclastic activity. The decrease in osteoclastic activity increases bone density, making the bone less prone to fracture. Choice A is incorrect. Bisphosphonates are not antiinflammatory. Osteoporosis is not an inflammatory type of condition as it results from increased osteoclastic activity, decreasing bone density. Choice B is incorrect. Bisphosphonates do not increase synovial fluid in the joint space. Osteoporosis is not a condition altering the synovial fluid in the joint space. Rheumatoid arthritis (RA) causes thickening of synovial joint fluid. Medications such as glucosamine chondroitin are used in conditions such as RA and osteoarthritis. Choice D is incorrect. Bisphosphonates do not increase serum calcium levels because they inhibit osteoclastic activity, preventing the bone's calcium from going into the blood. Bisphosphonates can also be used in hypercalcemia for this reason.

The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)? A. Elevated amylase result in a client diagnosed with acute pancreatitis B. Elevated white blood cell (WBC) count in a client with an infected leg wound. C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] in a client with diabetes mellitus (type one)

Choice C is correct. Chemotherapy agents increase clients' risk of infection due to immune suppression, specifically by decreasing neutrophils. Neutropenia, a reduction in the blood neutrophil count, is common in chemotherapy clients. The client's risk of bacterial and fungal infections increases with worsening neutropenia. Furthermore, if a bacterial or fungal infection occurs, the infection's likelihood of spreading to other parts of the body increases. Early antibiotic intervention may prevent sepsis. In a urinalysis, the presence of leukocytes and nitrites is indicative of a urinary tract infection. This result should alert the nurse regarding a potential urinary tract infection in this immunocompromised client, warranting the nurse to notify the PHCP of the result so a complete blood count (CBC) can be obtained and antibiotic therapy may be initiated immediately. Choice A is incorrect. An elevated amylase result in a client diagnosed with acute pancreatitis is an anticipated finding and would not warrant reporting the result to the PHCP. Choice B is incorrect. In a client diagnosed with an infected leg wound, an elevated white blood cell count (leukocytosis) is an anticipated finding. Leukocytosis usually occurs in response to infection, trauma, or inflammation. Since this client is known to be septic, the leukocytosis is an expected finding and, therefore, does not warrant the nurse immediately reporting this lab result to the PHCP. Choice D is incorrect. The client's serum glucose level of 235 mg/dL (13.05 mmol/L) is above the normal range of 70-110 mg/dL (4.0-11.0 mmol/). However, this is a relatively common finding in clients with type I diabetes mellitus and does not necessitate immediate reporting to the PHCP.

During a 12-hour shift on a medical-surgical unit, nurses are assigned a specific task applicable to all clients within the unit. On this shift, one nurse is assigned to perform wound care and dressing changes for those clients requiring these services, one nurse is assigned to dispense medications to all clients, and one nurse is assigned to monitor the vital signs and assist with all other nursing care. Which nursing delivery system does this example exemplify? A. Individual nursing B. Team nursing C. Functional nursing D. Primary nursing

Choice C is correct. Functional nursing involves assigning each nurse a specific task to perform for the shift. More specifically, a functional nursing delivery system ("functional nursing"), also known as task nursing, focuses on the distribution of work based on the performance of tasks and procedures, where the target of the action is not the client but rather the task. This is a task-focused method of nursing. Choice A is incorrect. Individual nursing (also known as the "total client care approach") occurs when a single nurse assumes full responsibility for delivering care to a group of clients during a shift. Individual nursing is a client-centered work method. Choice B is incorrect. Team nursing involves a group of nurses or staff assigned to care for a limited number of clients. More specifically, nurses are divided into teams and guided and coordinated by leaders, maximizing the group's capabilities and the individual qualifications and skills of each nurse. Thus, each team is responsible for the full delivery of care to the clients to whom they are assigned. Team nursing is a client-centered work method. Choice D is incorrect. The primary nursing method is based on the idea that one nurse is responsible for planning, delivering, and evaluating the care of one or more clients from the moment of admission to discharge. The delegation of care to associate nurses occurs whenever the primary nurse is not present, but the primary nurse always remains responsible for coordinating all clinical decisions and supervision during the client's hospital stay. Primary nursing is a client-centered work method.

The nurse is preparing to remove an intrajugular central venous catheter. It would be appropriate to place the client in which position for this procedure? A. Reverse Trendelenburg B. Left lateral C. Trendelenburg D. High-Fowler's

Choice C is correct. Placing the client in a supine or Trendelenburg position while removing a central venous catheter would be appropriate. One of these two positions is acceptable to decrease the risk of air embolism. The client should not have their head elevated for this procedure because that would increase the risk of air embolism. Choices A, B, and D are incorrect. The positioning of a client is essential to avoiding an air embolism. Thus, having a client in high Fowler's, lateral, or reverse Trendenlenberg would be contraindicated. If a client experiences an air embolism, turning the client to the left-lateral decubitus position would be appropriate, but not for the procedure of removing a central line itself.

The nurse is caring for a client experiencing an exacerbation of rheumatoid arthritis (RA). The nurse should obtain a prescription for A. allopurinol. B. verapamil. C. prednisone. D. methotrexate.

Choice C is correct. Rheumatoid arthritis is a chronic autoimmune disease that can lead to joint damage and disability. The steroid prednisone is a fast-acting and effective treatment for rheumatoid arthritis and is often prescribed alongside disease-modifying antirheumatic drugs. More specifically, prednisone is a corticosteroid with anti-inflammatory and immunosuppressive properties used to treat rheumatoid arthritis. In general, most clients will experience benefits from prednisone within one to four days if the prescribed dose is adequate to reduce the client's level of inflammation. Choice A is incorrect. Allopurinol, a xanthine oxidase inhibitor, is an FDA-approved urate-lowering medication most commonly used for managing gout. This medication lowers the client's uric acid levels by reducing the production of uric acid in the body. Allopurinol is not utilized in the treatment of rheumatoid arthritis. Choice B is incorrect. Verapamil is a calcium channel blocker that may be used in hypertension, Raynaud's phenomena, or migraine headache prophylaxis. This medication does not have utility in rheumatoid arthritis. Choice D is incorrect. Methotrexate is an immunomodulating medication used to prevent exacerbations of rheumatoid arthritis. This is a maintenance medication. Other maintenance medications used in RA include etanercept and hydroxychloroquine.

The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching? A. "Egg allergy is a contraindication to giving this vaccine." B. "This is a three-series vaccine that should be started at birth." C. "It is safe for breastfeeding women to receive the MMR vaccine." D. "This vaccine is safe if the client is pregnant."

Choice C is correct. The MMR vaccine is safe to administer to a client who is breastfeeding. No evidence exists of this vaccine being weakened by breastfeeding. Further, breastfeeding does not interfere with the response to the MMR vaccine. Choice A is incorrect. The MMR vaccine does not contain egg proteins and is not contraindicated in individuals with an egg allergy. The CDC does not recommend restricting MMR or Influenza vaccines to those with egg allergies. Choice B is incorrect. The yellow fever vaccine is the only vaccine that is contraindicated for severe egg allergy. This vaccine is not a three-series vaccine, nor does it start at birth. Choice D is incorrect. The ideal immunization schedule is two doses of the MMR vaccination. The first dose should be between 12 and 15 months, and the second should be between 4 and 6 years. Current studies support the idea that it is possible that a pregnant woman could pass the virus to the fetus; therefore, use during pregnancy is not recommended.

The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration? A. Digoxin to a client with atrial fibrillation B. Furosemide to a client with congestive heart failure C. Magnesium sulfate to a client with Torsades de pointes D. Labetalol to a client with a blood pressure of 160/100 mmHg

Choice C is correct. Torsades de pointes is an emergency because it is life-threatening and can progress to ventricular fibrillation and sudden cardiac death if not promptly treated. The nurse should immediately administer the prescribed magnesium sulfate to the client to prevent Torsades from degenerating into ventricular fibrillation. Choices B, A, and D are incorrect. All these medications are necessary for these clients and must be administered. However, the client with a more life-threatening condition (Torsades de pointes) should be prioritized. Furosemide is a loop diuretic used to treat congestive heart failure and edema. Digoxin is used to treat atrial fibrillation with the goal of controlling the heart rate and restoring sinus rhythm. However, some recent studies have shown increased mortality with chronic use of digoxin in atrial fibrillation. Labetalol is a beta-adrenergic and a selective alpha-1 adrenergic blocker. Therefore, it is widely used to treat arterial hypertension (from chronic to hypertensive crises). The client's blood pressure is high, but they are not exhibiting signs of target organ dysfunction (stroke, myocardial infarction, or heart failure) to suggest a hypertensive emergency. The client with Torsades de pointes should be attended to before the client with stable hypertension.

The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin? A. thiamine B. Hypericum perforatum (St. John's wort) C. warfarin D. acyclovir

Choice C is correct. Warfarin and phenytoin are two highly protein-bound drugs that may cause the displacement of each other. Warfarin is an anticoagulant, and if given to a client receiving phenytoin, it should be questioned by the nurse because it may cause the potentiation of the anticoagulant effects of the warfarin. Choice A is incorrect. Thiamine is a B vitamin and is commonly prescribed for individuals who are malnourished or consume excessive alcohol because this will prevent (or treat) Wernecke's encephalopathy. This has no known interaction with phenytoin. Choice B is incorrect. Hypericum perforatum (St. John's wort) should not be administered with serotonergic medications (certain antidepressants) because it may increase the client's risk for serotonin syndrome. This has no known interaction with phenytoin. Choice D is incorrect. Acyclovir is an antiviral medication indicated in preventing and treating herpes infections. This has no known interaction with phenytoin.

The nurse is caring for a client who has had an exacerbation of Bell's palsy. The client is experiencing paralysis of their eye, the nurse should plan to A. tape an eye patch to the affected eyelid at all times. B. instruct the client to keep both eyes closed. C. assess the pupil's size and reactivity to light. D. apply the prescribed ocular lubricant to the affected eye.

Choice D is correct. Bell's palsy is a lower motor neuron facial nerve palsy that can result in the weakness of facial muscles and the muscles responsible for eye closure (orbicularis oculi). A client with Bell's palsy who cannot blink would be unable to close the affected eye. As a result, the cornea becomes overly dry, leading to an increased risk of corneal ulceration and scarring. Eye lubricant (i.e., typically artificial tears) must be applied as often as every hour during the day to keep the eye moist and prevent corneal drying. A moisturizing eye ointment may be used at night. Choices A, B, and C are incorrect. Applying an eye patch with tape on the eyelid may cause the patch to slip into the open eye and cause a corneal abrasion. During the day, the client should protect the open eye with glasses or goggles. At night, the client may use a soft eye patch to cover the open eye, but it should not be taped to the eyelid. Instead, the soft eye pad should be secured with one end of the tape on the client's forehead and the other end on the cheek diagonally. It is not necessary for the client to keep the unaffected eye closed. Bell's palsy does not affect the pupil's reaction to light and accommodation.

In which age group is child abuse most likely to occur? A. Ten-years-old or older B. 6-10 years old C. 4-6 years old D. Birth-3 years old

Choice D is correct. Children between birth and three years of age have the highest incidence of victimization. The current rate is approximately 16 in 1,000 children. Also, the impact is higher in girls than in boys. Child abuse crosses all cultures, ages, economic levels, races, and religions, but is most prevalent in families living in poverty and those families composed of adolescent parents with young children. Nurses should never make assumptions about certain groups being at higher risk for child abuse but rather should be aware that social, economic, and personal stressors can contribute to the incidence of child abuse. Acts of commission in child abuse are situations in which the responsible person, often the parent, intentionally harms the child via physical, emotional, or sexual abuse. Acts of omission in child abuse are situations in which a parent or caregiver, to their best of abilities and often inadvertently, cannot provide adequate nutrition, shelter, warmth, appropriate seasonal clothing (e.g. winter coats), safety, and education for his or her child. Both are considered significant categories of child abuse, and situations identified in both groups must be reported. The idea of responding to both acts of commission and acts of omission is to provide safety for the child or provide what is necessary for the child to thrive and grow in a safe environment.

Which of the following is a physiological alteration that can occur with stress? A. Decreased visual acuity B. Increased peristalsis C. Decreased glucocorticoids D. Hyperglycemia

Choice D is correct. Hyperglycemia is a physiological alteration that can occur during a stress response among both diabetic and non-diabetic clients. More specifically, glucose is increased by various factors, including elevated levels of cortisol, glucagon, and epinephrine (often referred to the "fight or flight" phenomena). These hormones may, in turn, lead to insulin resistance, further increasing hyperglycemia. Choice A is incorrect. Increased, rather than decreased, vision is a physiological alteration which occurs during the "fight or flight" phenomena, allowing the individual to be more vigilant and aware of the surrounding environment. This occurs due to the release of adrenaline which causes the pupils to dilate, allowing in more light and make it easier to detect potential threats. Choice B is incorrect. During the body's stress-related response, peristalsis slows (or even stops) to allow the body to divert some (or all) resources to bodily functions deemed higher priority than gastric functioning. Therefore, decreased, not increased peristalsis occurs. Choice C is incorrect. The secretion of glucocorticoids is a classic endocrine response to stress. During the body's stress-related response, an increased, not decreased, secretion of glucocorticoids occurs.

A nurse is caring for a 4-year-old with a fever, rash, redness, swelling of the hands and feet, and cervical lymphadenopathy. The primary healthcare provider (PHCP) suspects Kawasaki disease. Which assessment would support the diagnosis of Kawasaki disease? A. Auscultate heart sounds B. Check capillary refill C. Measure blood pressure D. Inspect oral mucosa

Choice D is correct. Inspecting the oral mucosa is the priority nursing action for a child suspected of having Kawasaki disease because changes in the oral mucosa are one of the key diagnostic features of the condition, aiding in confirming the diagnosis and initiating appropriate treatment. Choice A is incorrect. While auscultating heart sounds is important in Kawasaki disease as it can help identify any potential cardiac complications such as murmurs or abnormal rhythms, the priority nursing action is to identify characteristic changes in the oral mucosa, which are key diagnostic features of Kawasaki disease. Choice B is incorrect. Capillary refill is important in evaluating peripheral perfusion, inspecting the oral mucosa is the priority action as changes in the oral mucosa are one of the key diagnostic features of Kawasaki disease. Choice C is incorrect. Blood pressure monitoring is important in evaluating the child's cardiovascular status, the priority nursing action is to inspect the oral mucosa for characteristic changes associated with Kawasaki disease, as these changes are key diagnostic features.

The nurse is preparing to administer amiodarone. Which of the following laboratory test results should the nurse monitor during the therapy? A. white blood cell (WBC) count B. serum glucose level C. serum uric acid level D. thyroid-stimulating hormone (TSH) level

Choice D is correct. TSH should be monitored because amiodarone tends to cause both hyper- and hypothyroidism. Amiodarone inhibits the peripheral conversion of T4 to T3; serum T4 and reverse T3 concentrations may be increased, and serum T3 may be decreased. TSH is a central part of a thyroid panel and should be monitored closely. Choice A is incorrect. White blood cell count does not need to be monitored with amiodarone. WBC count should be monitored for a client taking long-term corticosteroids and clozapine because both medications may cause leukopenia. Choice C is incorrect. Serum uric acid level does not need to be monitored with amiodarone. This lab may be monitored for a client with medication conditions like gout. Choice B is incorrect. Serum glucose level does not need to be monitored with amiodarone. This lab needs monitoring for a client taking insulin or total parenteral nutrition.

The nurse is developing a teaching plan for a client with post-gastrectomy dumping syndrome. Which of the following statements should the nurse make to the client? A. "Take small sips of water during meals to soften the food for easier digestion." B. "Symptoms will resolve in about 4-6 weeks as the stomach adjusts post-surgery." C. "Plan rest periods of 10 minutes after every meal." D. "Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content."

Choice D is correct. The client should be instructed to eat frequent small meals high in protein and fiber but low in carbohydrates. Additionally, liquids and solids should be separated during meals. Dumping syndrome is one of the most common causes of diarrhea in a post-gastrectomy client. Because the pyloric sphincter is bypassed or disrupted in a gastrectomy client, hyperosmolar food material (predominantly carbohydrate load) rapidly empties into the small intestine (dumping). As a result, the osmolarity in the small bowel lumen increases, drawing fluid into the bowel lumen and triggering the release of vasoactive intestinal peptides and serotonin. Early symptoms occur within 15 to 30 minutes, including nausea, vomiting, abdominal cramps/ pain, diarrhea, lightheadedness, palpitations, and flushing. A post-prandial insulin peak may occur, and hypoglycemia follows. Treatment involves incorporating dietary changes (a diet low in carbohydrates but high in fiber and protein). Choice A is incorrect. Clients experiencing dumping syndrome should be instructed to avoid drinking liquids during meals to prevent fullness and distention. Clients should be instructed only to drink in-between meals at least 30-45 minutes before eating and one hour after eating. Choice B is incorrect. Symptoms of dumping syndrome generally resolve in several months to a year after gastrectomy surgery. Choice C is incorrect. Post-meal rest periods should be at least 30 minutes to allow enough time for the digestion process to begin.

The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who A. has a closed-chest drainage system and has redness at the insertion site. B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour. C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain). D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.

Choice D is correct. The client with an ischemic stroke will require intense blood pressure monitoring because a low blood pressure will decrease cerebral perfusion, which is necessary for the unaffected areas of the brain. An optimal blood pressure for an ischemic stroke is 150/100 mm Hg to ensure cerebral perfusion. Allowing the blood pressure to be this high is considered permissive hypertension. Blood pressure lower than 150/100 mm Hg may cause further injury because of decreased cerebral perfusion. Likewise, the blood pressure should not exceed 185/110 mm Hg in an ischemic stroke because this may cause an extension of the stroke. Choices A, B, and C are incorrect. Redness at the insertion site of a chest drainage system may signify infection, but this client does not require immediate follow-up because they are not in immediate harm. Multiple bloody stools are an expectation for an exacerbation of ulcerative colitis; this client does not require immediate follow-up. The client with a concussion can expect headaches. A headache that would be concerning is if the client describes the headache as accompanied by visual loss, vomiting, and alterations in their level of consciousness.

The nurse is caring for assigned clients. Which client should be evacuated first during a fire? A client with A. below-the-knee amputation receiving patient-controlled analgesia. B. acute respiratory distress syndrome receiving mechanical ventilation. C. advanced dementia receiving enteral feedings and intravenous fluids. D. acute glomerulonephritis with an indwelling urinary catheter

Choice D is correct. When evacuating clients from a fire, the nurse should evacuate the client who is in immediate danger (the client closest to the fire). Once that has been completed, the nurse should evacuate the most ambulatory client. This is because ambulatory clients require fewer resources and can be speedily evacuated. The client with acute glomerulonephritis is most ambulatory and requires fewer resources. This client only has one device, and the nurse can quickly change the system to a leg bag or instruct the client to keep the bag below their bladder. Choices A, B, and C are incorrect. The client with a below-the-knee amputation will require significant resources to mobilize. Further, the client's PCA device must be secured before evacuation. The client receiving mechanical ventilation will require manual ventilation. Thus, requiring a significant number of resources. Finally, the client with dementia receiving enteral feedings and IV fluids must have their devices clamped and locked before evacuation. This client also is unlikely to comprehend evacuation instructions effectively and should be supervised. All these clients should be evacuated after more ambulatory clients are evacuated.

When the nurse is interpreting results from a direct Coombs test, they know that a positive result indicates which of the following? Maternal antibodies are present on the infant's red blood cells. Antibodies are present in the maternal serum. The infant is at risk for erythroblastosis fetalis. The mother is at risk for Rh immunization. The infant is experiencing hypoglycemia

Choices A and C are correct. A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C). Choice B is incorrect. The direct Coombs test does not measure antibodies in the maternal serum. Instead, the indirect Coombs test does this. Choice D is incorrect. The indirect Coombs test will check to see if the mother is at risk for Rh immunization. Choice E is incorrect. Blood glucose levels are not tested by a direct or indirect Coombs test.

The nurse is assessing a client in the second stage of labor. Which findings should be reported to the primary healthcare provider (PHCP)? Select all that apply. Sustained fetal heart rate of 170 beats per minute Early decelerations Variable decelerations The client feels the urge to push Uterine contractions every 2-3 minutes

Choices A and C are correct. A fetal heart rate of 170 beats per minute is fetal tachycardia and should be reported to the healthcare provider. Any increase in fetal heart rate above 160 is considered tachycardia. It is problematic and requires intervention when it persists for longer than 10 minutes. Variable decelerations need to be reported to the healthcare provider immediately. They are sharp and profound drops in the fetal heart rate unrelated to the time of contractions and are a non-reassuring sign on a fetal heart rate strip. Variable decelerations are caused by cord compression, such as a prolapsed cord, and are an emergency requiring quick nursing intervention. Choices B, D, and E are incorrect. Early decelerations do not need to be reported to the healthcare provider. They occur when the fetal heart rate decreases simultaneously as a contraction and are followed by a return to baseline. They occur due to the pressure of the fetus's head on the pelvis or soft tissue, and the nurse requires no intervention after an early deceleration. The client is in the second stage of labor, and feeling the urge to push is an expected finding (Ferguson reflex) and prompts the nurse to coach the client in pushing. It is usual for the client to experience contractions every 2-3 minutes lasting 60 to 75 seconds during the second stage.

The nurse is caring for a client receiving lorazepam. Which of the following reported herbal supplements would require follow-up? Select all that apply. Kava Glucosamine Valerian Garlic Saw palmetto

Choices A and C are correct. Lorazepam is a CNS depressant, and the client should avoid potentiating the effects of this medication. Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a client is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation. Choices B, D, and E are incorrect. Glucosamine is an herbal product that may benefit clients with osteoarthritis in the knees, waist, and hips. This medication does not cause CNS depression. Garlic may be taken to assist a client in reducing their cholesterol and should be avoided if the client is taking anticoagulants. This medication does not alter the CNS. Saw palmetto may be taken for men who have prostate hyperplasia. This herbal supplement does not alter the CNS.

The nurse cares for a 12-year-old client one hour post-operative following transsphenoidal hypophysectomy. After reviewing the assessment findings, the nurse should take which action? Select all that apply. See the exhibit. notify the health care provider of the urine output. request an order for intravenous (IV) fluids document the findings administer supplemental oxygen continue to monitor neurological status

Choices A, B, C, and E are correct. A is correct. This is an excessive amount of urine output for 1 hour and is concerning for diabetes insipidus, given the procedure the client recently underwent. Any urine output greater than 300 mL is alarming, and the healthcare provider should be notified immediately. Diabetes insipidus is a severe complication from neurosurgery that occurs around the pituitary. This amount of urinary output can lead to shock if not treated promptly. B is correct. Given the assessment, requesting an order for IV fluids is an appropriate nursing action. The nurse should be concerned about the possibility of DI considering the excessive urine output, and no fluid replacement is currently ordered for this client. This is concerning for shock, and IVF should be initiated to rehydrate and adequately replace losses from the urinary output. C is correct. These findings should be accurately documented to ensure proper follow-up and orders for this client. E is correct. The client's neurological status should be monitored, as mental status and behavior changes can indicate electrolyte imbalances, such as hyponatremia. Choice D is incorrect. No oxygen therapy is indicated for this client at this time. The oxygen saturation is adequate on room air.

The nurse is teaching a client about newly prescribed insulin glargine. The nurse recognizes the need for further instruction when the client makes the following statement? Select all that apply. "I will take this insulin right before my meals." "I should roll this vial of insulin before removing it with the syringe." "This insulin will help control my glucose for 24 hours." "I can only inject this insulin into my abdomen." "I'm glad to know I can mix this with my regular insulin."

Choices A, B, D, and E are correct. These statements are incorrect and require follow-up. Insulin glargine is a long-acting insulin that has no peak effect. Thus, it is not taken with meals. It is dosed once a day to provide glucose control for 24 hours. Insulin glargine is not a suspension; thus, it does not need to be rolled like NPH. This insulin is not mixed with any other insulin. Insulin glargine does not have to only be injected into the abdomen. Choice C is incorrect. This statement is factual and does not require additional teaching. Insulin glargine provides basal glucose control for up to 24 hours. This, combined with a carbohydrate-controlled diet, should decrease the client's reliance on correctional insulin.

The nurse is caring for a child with eczema. Which of the following findings should the nurse expect? Select all that apply Erythema Pruritus Papules Skin ulcers Scaly circular rash

Choices A, B, and C are correct. Erythema is the superficial reddening of the skin. This redness is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Pruritus is severe itching of the skin. Itching is one of the most common symptoms of eczema and would be an expected assessment finding for all types of eczema. Papules are solid elevations of skin with no visible fluid less than 1 cm in diameter. Although not all patients with eczema will necessarily have papules, they are a common assessment finding. Choices D and E are incorrect. Skin ulcers are round sores that develop because of a lack of oxygen-rich blood flow. This can be caused by excessive pressure placed on the skin. A scaly circular rash is a common manifestation associated with a fungal infection. This is known as ringworm. This contagious infection may affect the skin and the scalp.

The nurse is caring for a client with systolic heart failure. Which of the following heart sounds would the nurse expect to auscultate? Select all that apply. S1 S2 S3 S4 pleural friction rub

Choices A, B, and C are correct. S1 and S2 are normal heart sounds. These normal heart sounds would still be auscultated in a client with heart failure. S3 ("ventricular gallop") and S4 ("atrial gallop") are abnormal heart sounds that can be auscultated in heart failure. Both heart sounds are low-pitched and best heard at the apex, with the patient in the left lateral decubitus position. While S3 may sometimes be heard in healthy hearts (normal in children, pregnant women, and trained athletes), S4 is almost always abnormal. While S3 is a sign of systolic heart failure, S4 is heard in diastolic heart failure. Understanding these two types of congestive heart failure (CHF) is essential before discussing how S3 and S4 are produced. The nurse would expect to hear an S3 heart sound (Choice C) in systolic heart failure. S3 occurs after S2 with the opening of the mitral valve, and a passive flow makes the sound of a large amount of blood hitting a compliant left ventricle. This large amount of blood hitting the left ventricle is because of the underlying fluid volume overload seen with systolic heart failure. Choices D and E are incorrect.

The quality improvement nurse plans an initiative to reduce risk factors for falls in the acute care environment. Which of the following risk factors should the nurse recommend be addressed? Select all that apply. inadequate client assessment communication failures dim lighting a client's medical history age of the client

Choices A, B, and C are correct. The nurse should recommend addressing inadequate assessment because this is a significant risk factor for falls that may lead to client injury. The nurse can recommend a standardized fall risk assessment tool and monitor its execution. Communication failures between staff are a significant contributor to falls. The nurse should recommend addressing this by standardizing the handoff report and placing signals outside a client's room (a particular light, fall risk bands, or pictures outside of the client's room). The nurse can plausibly recommend the repair of dim environmental lighting, which is a risk factor for falls, especially when the client is ambulating within their room. Choice D is incorrect. The nurse cannot plausibly recommend addressing a client's age or medical history in reducing falls in the acute care environment because the nurse cannot control these variables. Choice E is incorrect. While they inform the nurse of a client's risk (older age, medical history of dementia, etc.), they cannot be influenced by the nurse on the quality improvement panel, nor are they related to the environment.

The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. Diabetes mellitus Menieres disease Excessive cerumen Exposure to loud noise Excessive fluid

Choices A, B, and D are correct. These are all risk factors for sensorineural hearing loss. Diabetes may cause an insult to vasculature supplying the cochlea. Thus, causing hearing loss. Meniere's disease is a condition that features vertigo, hearing loss, and tinnitus. Exposure to loud noise is a significant risk factor because of the insult it causes to the nerve fibers. Choices C and E are incorrect. Obstruction in the ear is a cause of conductive hearing loss, which may be reversed.

The nurse is teaching a group of students about using reminiscence therapy. Which statements should the nurse include in the teaching? Select all that apply. This approach helps support self-esteem This is an effective intervention in a group setting This intervention focuses on looking forward Establishing future goals is important part of this intervention Reminiscing is a way to express personal identity

Choices A, B, and E are correct. Reminiscence helps support self-esteem by having an individual look back on past accomplishments and positive life experiences. This strategy may be used one-on-one or in a group setting, facilitating rapport building with other individuals. Finally, reminiscence is a way for an individual to express their personal identity by reflecting on past accomplishments (college work, occupations, marriage, etc.). Choices C and D are incorrect. Reminiscence is about looking at the client's past to support their self-esteem by expressing previous experiences. This therapeutic approach does not involve goal setting or forward-looking approach.

The nurse is observing staff perform hand hygiene using antiseptic soap and water. Which observation by the nurse requires follow-up? Select all that apply. Dries hands thoroughly from wrist to fingers Touches the inside of the sink Hands and forearms are lower than elbows during washing Rinses hands and wrists by keeping hands down and elbows up Water splashes on the uniform

Choices A, B, and E are correct. These observations require follow-up because they are inappropriate during hand hygiene. After hand hygiene with soap and water, hands should be dried from the cleanest (the fingers) to the least clean (the wrists) with a paper towel or single-use cloth. This avoids contamination. Touching the inside of the sink would contaminate the hands, and the process would need to start over. Water should not splash on the uniform as microorganisms grow with moisture. Choices C and D are incorrect. These observations are accurate when hand hygiene is performed with soap and water. During washing with soap, keep hands and forearms lower than elbows because hands are the most contaminated parts to wash. Water flows from the least to the most contaminated area, rinsing microorganisms into the sink. When rinsing, hands and wrists should be rinsed thoroughly, keeping hands down and elbows up.

The nurse is assigned to care for a client with a sodium level of 122 mEq/L (mmol/L) [135-145 mEq/L, mmol/L]. Which assessment findings does the nurse anticipate based on this lab result? Select all that apply. Confusion Abdominal cramps Tall, peaked t-waves Hypoactive bowel sounds Nausea and vomiting

Choices A, B, and E are correct. This client's sodium level is critically low. When sodium falls below 125 mEq/L (mmol/L), it is considered severe hyponatremia. Sodium plays a key role in the brain, so low levels of this electrolyte can be devastating and produce symptoms ranging from confusion, lethargy, and stupor as well as seizures and cerebral edema. Abdominal cramps are another symptom of hyponatremia. Since water follows sodium, there are decreased levels of sodium in the blood and decreased fluid. This creates a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping. Nausea and vomiting are common signs of hyponatremia. Choice C is incorrect. Arrhythmias such as tall, peaked t-waves are not indicative of hyponatremia. Rather, tall, peaked t-waves are characteristic of hyperkalemia. Choice D is incorrect. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium also plays an important role in muscle cells; when levels are too low, this results in cramping, spasms, and hyperactive bowel sounds.

The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client? Select all that apply. Blood pressure Intracranial pressure Intravenous site Urine output Blood glucose

Choices A, C, D, and E are correct. An infusion of norepinephrine is indicated if the client is in shock. This medication helps restore vascular tone and is useful in treating life-threatening hypotension. This medication is a vesicant, and the preferred delivery is through a central line. If this is not possible, a large-bore intravenous catheter should be utilized. The patency of this catheter should be assessed frequently to prevent damaging extravasation. Blood pressure must be monitored continuously while this medication is administered to assess the desired response of increased vascular tone. This medication causes vasoconstriction, decreasing renal blood flow and decreasing urine output. Norepinephrine causes an increase in blood glucose because of its ability to cause the liver to discharge more glucose by breaking down glycogen. Choice B is incorrect. Norepinephrine is a medication used in the management of shock. The nurse must monitor the client's blood pressure, intravenous site, urine output, and blood glucose. One of the monitoring parameters not indicated is intracranial pressure (ICP) - this would be more applicable if the medication was mannitol.

A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply. Notify the patient's physician, the nursing supervisor, and the risk manager. Explain to the patient's family that the living will cannot be changed at this point. Encourage the family to discuss their feelings to try to resolve this issue. Request a consult with the facility ethics committee if needed. Advise the patient to just go along with the wishes of his adult children.

Choices A, C, and D are correct. Should such a conflict be observed, the nurse should notify the patient's physician, the nursing supervisor, and the risk manager. It is also important to encourage the family to discuss the issue among themselves and with the above individuals, to resolve the conflict. A consult with the ethics committee may also be indicated. Choice B is incorrect. The patient may revoke or change an advance directive at any time, either orally or in writing. Choice E is incorrect. By law, the patient has a right to autonomy and self-determination, including the right to choose and refuse treatment.

The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statement, if made by the client, would require further teaching? Select all that apply. "I should take this medication with meals." "I should not take this with any other medication or food." "The medication will coat my ulcer so I can eat without pain." "I will need frequent laboratory tests while taking this medication." "I may need to take magnesium supplements while on this medication."

Choices A, C, and D are correct. These statements are incorrect and require follow-up. Esomeprazole is a proton pump inhibitor (PPI) in treating esophageal erosion, GERD, and peptic ulcer disease. The medication should be taken one hour before meals and with an ample amount of water. The medication does not fortify an existing ulcer, like sucralfate. The client does not require frequent laboratory testing while on this medication. Choices B and E are incorrect. Correct teaching for a client receiving esomeprazole would include taking the medication independent of any other food or medicine as it will decrease its absorption. PPIs have the proclivity of causing hypomagnesemia, and thus, magnesium supplementation may be recommended by the PHCP.

The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply. Irrigates an indwelling catheter with warm tap water. Administers glargine insulin for a client with nothing by mouth (NPO) status. Obtains a 12-lead electrocardiogram for a client with hyperkalemia. Clamps a chest tube while the client ambulates. Repositions a client who requires log rolling by using a gait belt.

Choices A, D, and E are correct. An indwelling catheter is irrigated with sterile water or sterile normal saline. Irrigating an indwelling catheter with tap water would introduce pathogens into the bladder. A chest tube should never be clamped as it will cause a rapid increase in intrathoracic pressure, which may cause a tension pneumothorax. A client requiring log rolling should be repositioned with more than one staff member and with a transfer sheet. A gait belt is used when a client is ambulating. Choice B is incorrect. Glargine insulin is long-acting insulin with no peak. This insulin does not need to be withheld when a client is NPO. This insulin provides a client with basal glucose control preventing hyperglycemia. Choice C is incorrect. An LPN obtaining a 12-lead electrocardiogram for a client with hyperkalemia is an appropriate action.

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

Choices B and C are correct. B is correct. It will be a critical nursing intervention to frequently reorient the client who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be confused and disoriented. the nurse must frequently reorient them to their place and situation to make them feel safe and secure. C is correct. It will be a critical nursing intervention to remain with the client who has just received electroconvulsive therapy. A side effect of electroconvulsive treatment is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them to keep them safe. Choice A is incorrect. Supine with the head of the bed at 30 degrees is not the best position for a client who has just had electroconvulsive therapy. This client is at risk for aspiration, so the appropriate positioning is on their side. Supine with the head of the bed at 30 degrees would be the appropriate positioning for a client post-op from neurosurgery or at risk for increased ICP. Choice D is incorrect. It is not necessary or appropriate to promote bedrest for 12-24 hours in a client who has just received electroconvulsive therapy. After they are awake and reoriented, promoting activity and returning them to their routine is best. Staying active is essential to treating depression, so bed rest is not appropriate for this patient. Ambulation should wait until the client is fully awake and oriented. Choice E is incorrect. After ECT, the client should not be encouraged to ambulate immediately due to potential dizziness or weakness. Instead, they should rest and be closely monitored until they fully recover from anesthesia.

The nurse is caring for a client with a tracheostomy receiving oxygen via tracheostomy collar. The nurse should plan to Select all that apply. Plan to suction the tracheostomy every two to four hours Ensure that the oxygen is humidified Instill normal saline down the tracheostomy immediately before suctioning Suction the tracheostomy for a maximum of three passes Apply suction as the catheter is inserted into the tracheostomy

Choices B and D are correct. When caring for a client with a tracheostomy, suctioning should be performed only when clinically indicated. Indications for suctioning the client include tachypnea, rhonchi in the lung fields, and decreasing oxygen saturation. When suctioning a tracheostomy, the nurse should use a sterile technique, and a maximum of three passes should be completed. The oxygen must be warm and humidified for a client receiving oxygen via a trach collar. If it is not appropriately warmed or humidified, tracheal damage may occur. The humification assists with the passage of the secretions. Choices A, C, and E are incorrect. Instilling saline down the tracheostomy prior to suctioning has shown little benefit and may be harmful because it could lead to pneumonia. When the client's tracheostomy is suctioned, it should be suctioned as the catheter is withdrawn for 10-15 seconds. The suctioning should be continuous so secretions are not dropped back down the airway. Suctioning should not be scheduled; instead, it should be based on the client's respiratory assessment.

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse implement for this client? Select all that apply. Administer a long-acting bronchodilator for acute dyspnea. Encourage smoking cessation. Provide oxygen therapy at a rate of 4 liters per minute. Instruct the client to lie down in a supine position. Teach pursed-lip breathing technique.

Choices B and E are correct. Smoking is a major risk factor for the development and progression of COPD. Encouraging smoking cessation is an essential intervention to prevent further lung damage and improve the client's respiratory status. Pursed-lip breathing is a breathing technique that can help clients with COPD improve their breathing efficiency and control dyspnea. Choice A is incorrect. A client experiencing an acute episode of dyspnea would require a medication with a rapid, or 'short' onset. A long-acting bronchodilator is a medication used to provide sustained bronchodilation and relief of respiratory symptoms over an extended period. Therefore a long-acting bronchodilator would not be appropriate. Choice C is incorrect. Oxygen therapy is often necessary for clients with severe COPD and hypoxemia. However, the specific oxygen flow rate should be based on the client's oxygen saturation levels and arterial blood gas results. The nurse should assess the client's oxygenation status and consult with the healthcare provider to determine the appropriate oxygen flow rate as it may vary from client to client. Choice D is incorrect. Clients with COPD often experience dyspnea and difficulty breathing, especially when lying flat. The supine position can further compromise respiratory function by reducing lung expansion and causing discomfort. It is more appropriate to instruct the client to sit in an upright or semi-upright position, which helps optimize lung expansion and improve ventilation.

The nurse is caring for a client with a major thermal burn. Which initial laboratory abnormalities does the nurse anticipate in response to the burn? Select all that apply. Hemodilution Hyperkalemia Metabolic Acidosis Hyperglycemia Hemoconcentration

Choices B, C, D, and E are correct. Following a major burn, significant fluid and electrolyte changes occur from cellular damage, which causes potassium to leak into the extracellular space. Thus, life-threatening hyperkalemia may occur. Metabolic acidosis is likely because of the impairment the burn causes to the kidney's ability to recycle bicarbonate. The discharge of catecholamines causes glucose release from the liver, raising the blood glucose. Finally, the loss of fluid causes hemoconcentration, illustrated by elevated hematocrit. Choice A is incorrect. Initially, the client with a major thermal burn will have hemoconcentration from all of the fluid loss. Hemodilution may occur later in the process from the fluid shift.

The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply. goggles gown gloves shoe covers n95 respirator Surgical face mask

Choices B, C, and E are correct. A disseminated herpes zoster (varicella zoster, shingles) is a case where the rash spreads beyond the primary area or primary dermatome. When varicella zoster is disseminated, it can be transmitted through airborne means and by direct contact with the lesions. The isolation required is contact + airborne. This means the nurse should wear an N95 respirator, high-efficiency particulate air filter respirator, gown, and gloves. When herpes zoster is localized and can be covered, standard and contact precautions are implemented until all of the lesions have crusted over. When herpes zoster is disseminated, airborne + contact precautions are implemented for the duration of the illness. Choices A and D are incorrect. Goggles and shoe covers are not needed for airborne or contact precautions. Choice F is incorrect. A surgical face mask filters only large particles and will not protect against herpes zoster.

The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include? Select all that apply. Apply clamps to the tubing to secure it to the bed. Strip the tubing at least once every eight hours. Report any bubbling in the suction control chamber. Ambulate the client with the device below the insertion site. Palpate around the insertion site for any crackles or popping.

Choices D and E are correct. Ambulation with a chest tube is not contraindicated. If the nurse has an order from the primary healthcare provider (PHCP) and it is safe for the client to ambulate, the nurse should ambulate the client with the device distal to the insertion site. Palpating around the insertion site should be done and any crackles or popping should be reported to the PHCP because that indicates an air leak. Choices A, B, and C are incorrect. The tubing should not be clamped to the bed as this would cause an obstruction. It would be appropriate to keep extra tubing loose on the bed. Stripping the tubing would be inappropriate because it would increase the intrathoracic pressure, counterproductive to chest tube therapy. Continuous bubbling in the suction control chamber is normal because wall suction is prescribed for this client.

The infection control nurse is conducting rounds on the nursing unit and should ensure which conditions are isolated with droplet precautions? Select all that apply. Clostridium difficile Cryptococcosis meningitis Mycoplasma pneumonia Haemophilus influenzae, type b pneumonia Rheumatic fever Varicella Zoster Scabies Epiglottitis, due to Haemophilus influenzae type b Infectious mononucleosis Rotavirus gastroenteritis

Clostridium difficile → Contact (enteric) precautions with bleach Cryptococcosis meningitis → Standard precautions (Standard precautions are appropriate for all patients with meningitis (viral and fungal meningitis) unless the patient has a bacterial type that is transmitted by droplets, such as N. meningitides or H. influenzae. Bacterial meningitis requires droplet precautions. Cryptococcus is a fungus, not a bacterium) Mycoplasma pneumonia → Droplet precautions Haemophilus influenzae, type b pneumonia → Droplet precautions Rheumatic fever → Standard precautions Varicella zoster → Airborne and contact precautions Scabies → Contact precautions Epiglottitis, due to Haemophilus influenzae type b → Droplet precautions Infectious mononucleosis → Standard precautions Rotavirus gastroenteritis → Contact (enteric) precautions with bleach

The physician orders the client to be discharged and prescribes tamsulosin The nurse educates the client on the prescribed tamsulosin. Which statement, if made by the client, would indicate a need for follow-up? Select all that apply "This medication may cause me to urinate more often." "It will be important for me to change positions slowly." "I may notice an increase in my blood pressure." "My urine will change to an orange or red color." "I should notify my doctor if I have persistent dizziness."

Tamsulosin is an alpha antagonist and causes vasodilation; thus, relaxing the prostate provides the client with symptom relief. It would require follow-up if the client states that the medication will cause them to urinate more often as this medication is not a diuretic. In fact, it would decrease the number of times the client will urinate because the client can empty the bladder completely. This medication may cause a decrease in blood pressure because of its vasodilation effects. Thus, persistent dizziness should be reported because the dose may need to be adjusted. The medication does not cause changes to the color of the urine. Drugs causing urine discoloration include phenazopyridine and rifampin.

1345 - Client presents for a report of straining with urination, weak urinary stream, and hesitancy during urination. The client states the problem has been going on for a few months but is getting worse because he has to use the bathroom more frequently in the middle of the night. He reports dribbling in his underwear which he finds embarrassing. He described his urine as clear and a straw yellow color. He states that he recently started a prescribed low-dose aspirin and wonders if that could cause all his symptoms. The client has a medical history of hypertension, obsessive-compulsive disorder, and osteoarthritis. No known allergies. Oral Temperature 98o F (36.7o C) Heart rate 83/minute Respirations 18/minute Blood pressure 134/82 mm Hg The client is at highest risk of developing: urolithiasis stress incontinence cystitis prostate hyperplasia

The client is demonstrating a risk of developing prostatic hyperplasia based on the manifestations of weak urinary stream, nocturia, and dribbling in his underwear. This is likely causing him to develop overflow incontinence - not stress incontinence which is characterized by a weak urinary sphincter. The client does not report any pain with urination, and this excludes urolithiasis and cystitis.

For each client assessment finding below, click to specify if it is most consistent with a diagnosis of heat stroke or heat exhaustion: Temperature 105° F (40.5° C) Lethargy and confusion Perspiration Fluid volume deficit

The client's assessment yields overlapping features of heat exhaustion and heat stroke. However, his condition is much more aligned with heat stroke. Clinical features of heat exhaustion: flulike symptoms (nausea, vomiting, weakness), elevation in body temperature, perspiration, electrolyte disturbances Clinical features of heat stroke: body temperature over 104 degrees F, hot and dry skin, not as much perspiration, hypotension, tachycardia, tachypnea, altered mental status, electrolyte disturbances (hyponatremia, hypokalemia) Perspiration is not a reliable differential between the two conditions. It is present in both heat exhaustion and heat stroke, as individuals with heat stroke may continue to perspire.

The nurse obtains laboratory results: BUN high Creatinine high Sodium low Potassium low BG 67 For each possible intervention, click to specify if the intervention is essential or contraindicated: Seizure precautions Request a prescription for dextrose 5% in water (D5W) Measure rectal temperature frequently Apply a cooling blanket Offer cool liquids Establish continuous cardiac monitoring Request a prescription for ketorolac

The client's laboratory values are highly concerning because they show acute kidney injury (elevated creatinine), dehydration (very low sodium; high BUN), hypokalemia, and mild hypoglycemia. The client's confusion is most likely the result of critical hyponatremia. The nurse should intervene by implementing seizure precautions. The significant hyponatremia puts the client at risk of developing a seizure. Obtaining a prescription for D5W would be contraindicated as the water will lower the sodium further. The client has mild hypoglycemia, but infusing D5W would raise the glucose and lower the critically low sodium. Temperature measurement via the rectal route is essential as it provides the most accurate core temperature. The client should be cooled with blankets; thus, it is an essential intervention. T he client has hypokalemia, and establishing continuous cardiac monitoring is essential. The nurse should not offer cool liquids as his assessment showed him confused and lethargic. This could cause aspiration. Intravenous ketorolac would be contraindicated as this client has acute kidney injury, and an NSAID like ketorolac would be detrimental. Finally, NSAIDs and acetaminophen do not help with environmental emergencies such as heat stroke.

31-year-female 4 hrs postoperative laparoscopic Roux-en-Y procedure. Client fully alert and oriented. Glasgow Coma Scale 15. Reports pain at incision 4/10. 4 incisions clean, dry, and approximated with skin glue. Bowel sounds hypoactive x4. Foley catheter secured to bed w/o kinks or loops. Clear, yellow urine observed. BG was 268 mg/dL. Morbid obesity (BMI 42) Uncontrolled Diabetes Mellitus Metabolic Syndrome Select anticipated provider orders from each of the following categories. Activity: Strict Bed Rest, Head of Bed Restrictions, Out of Bed to Chair Diet: Clear Liquids, Full Liquids, Nothing by Mouth (NPO) Medications: Multivitamin, Hydrocodone-Acetaminophen, Docusate Consultations: Registered Dietician, Diabetic Educator, Ostomy Venous Thromboembolism (VTE) Prophylaxis: None, Sequential Compression Stockings, Prophylactic Anticoagulant Therapy

A significant complication following any bariatric surgery is venous thromboembolism (VTE). The client will be expected to ambulate within the first several hours after surgery (out of bed to chair). Clear liquids are introduced slowly if the client can tolerate water, and 1-ounce cups are used for each serving. A full liquid diet follows tolerance of the clear liquid diet. The client has a GCS of 15, and keeping the client NPO would be unnecessary as aspiration is not a risk. A multivitamin is a common prescription following bariatric surgery because of the risk of vitamin and mineral deficiencies caused by the altered absorption of nutrients and decreased intake of calories. It is expected for a client to have post-operative pain. Opioids such as hydrocodone (often combined with acetaminophen) are commonly prescribed to help with the discomfort. Docusate is a stool softener used to prevent opioid-related constipation. The client has undergone significant surgery and will need extensive education on nutritional choices. The client consulting with a dietician is the standard of care following this procedure. Additionally, this client has uncontrolled diabetes mellitus, and consulting with a diabetic educator would be beneficial. This surgery does not involve the placement of an ostomy, and consultation with an ostomy nurse would be unnecessary. VTE is a significant risk factor following this procedure. The nurse should work to mitigate this risk by applying sequential compression stockings and administering prophylactic anticoagulant therapy. This, combined with early mobilization, will decrease this complication.

1300 - Presents to clinic for a wound to the right ankle. Wound is 5 cm x 4 cm and shallow. Wound bed is pink with some granulation tissue; scant sanguineous drainage. Pain only with dressing changes, pain rated 5/10. Surrounding skin on affected foot is dry, darkened, and flaky. Cap refill < 3 seconds. Peripheral pedal pulse 2+ on affected foot. 3+ Ankle edema noted in both lower extremities. Denies leg pain during ambulation, endorses ankle swelling during day while walking. Only relieving factor is compression hose. Applied hot compress, but after 2-3 applications, worsened and became painful. Specify if finding is consistent with an arterial, venous, or diabetic ulcer. swelling in affected extremity pedal peripheral pulse 2+ swelling relieved with compression hose denies leg pain during ambulation shallow wound bed medical history of hypertension and diabetes mellitus worsened with hot compress

Based on the client's manifestations of a superficial wound on the ankle with granulation tissue, surrounding edema, intact peripheral pulses, and no pain with walking, this client likely has a venous stasis ulcer. Peripheral pulses are not affected in venous ulcers Venous stasis ulcers classically form in the malleolar region of the ankle and are surrounded by hyperpigmented skin that is dry and flaky. Venous ulcers are usually caused by previous venous thromboembolism, inflammation, obesity, stroke, and varicose veins. Compression hose is an essential part of treating a venous stasis ulcer or varicosities. This, combined with prescribed pentoxifylline (vasodilator and anti-inflammatory), is the recommended treatment plan. While this client has risk factors for a diabetic and arterial ulcer(s), the client's wound has granulation tissue (a sign of healing) and swelling not found in an arterial and diabetic ulcer. Specific clinical features of an arterial and diabetic foot ulcer often overlap, which includes little granulation tissue, the wound bed is deep, risk factors such as hypertension and diabetes mellitus. Arterial ulcers are usually found in between the toes and are quite painful. Diabetic ulcers found on plantar area of foot. Peripheral pulses usually present in a diabetic foot ulcer, usually diminished in an arterial ulcer. Intermittent claudication (pain in the lower extremity when walking and relieved with rest) may be found in arterial ulcers because the cause is a peripheral arterial disease. Diabetic foot ulcers have a variable pain presentation because the pain may be attenuated due to neuropathy. Compression hose is not recommended for diabetic or arterial ulcers because they further decrease arterial blood flow, which is the crux of the disease process. Hot compresses are not recommended for any ulcer.

The nurse assesses an infant who sustained a traumatic brain injury (TBI). Which assessment finding requires follow-up? Select all that apply. Bulging fontanel Tachycardia Bradycardia Ptosis Distended scalp veins

Choices A, C, and E are correct. A tense, bulging fontanel is a classic sign of increased ICP in an infant. Associated symptoms that are concerning include bradycardia and distended scalp veins. Choices B and D are incorrect. Tachycardia is a clinical manifestation of shock but not for increased ICP. The client would exhibit triad symptoms such as bradycardia, bradypnea, and widening pulse pressure. Ptosis is drooping of the eyelid and is not associated with increased ICP. Pupillary changes would be assessed as a late sign of increased ICP, which would be nonreactive on an assessment.

The nurse is caring for a client who was prescribed a clear liquid diet. Which dietary items would be appropriate for the nurse to include? Select all that apply. sherbert chocolate pudding vanilla yogurt apple juice coffee with oat milk fat-free bouillon with added salt tomato juice clear hard candy gelatin hot tea with added sugar

Correct responses A clear liquid diet is usually transparent (to light) dietary items that do not contain dairy or pulp. Items such as water, gelatin, fat-free bouillon, hot tea, apple juice, seltzer, lemonade, and ginger ale are acceptable. Clear hard candy is acceptable because it is a clear liquid when melted. Salt and sugar are food additives that are permitted. Incorrect responses A full liquid is the next step when the diet is advanced. This diet contains opaque liquids. A full-liquid diet usually contains pulp and dairy. For example, coffee is a clear liquid, whereas a coffee with creamer or milk is a full liquid. Items that are full liquid include sherbert, milkshakes, frozen yogurt, pudding, strained soups, and coffee with dairy (or nondairy alternatives such as oat milk).

The nurse is calculating the 12-hour intake for a client. The client received 0.45% saline at 85 mL/hr via continuous infusion One eight-ounce cup of ice chips One eight-ounce cup of coffee One eight-ounce cup of ice cream Three eight-ounce cups of water One eight-ounce cup of pureed vegetables The nurse should calculate the client's total liquid intake as how many mL?

Explanation: The client received 0.45% saline at 85 mL/hr x 12 hours → 1020 mL One eight-ounce cup of ice chips → 120 mL When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts One eight-ounce cup of coffee → 240 mL One eight-ounce cup of ice cream → 240 mL Three eight-ounce cups of water → 720 mL One eight-ounce cup of pureed vegetables → This is excluded from the intake calculation as pureed food(s) are not a liquid at room temperature Total → 2340 mL

1900 - Client evaluated after application of the cooling blanket and ice to axilla and groin. Client was alert, oriented x4. Generalized shivering noted in all four extremities. Indwelling urinary catheter patent with no urine output. The client's rectal temperature was 103° F (39.4° C). Peripheral pulses were palpable and still thready. The client reported that he was thirsty and tired. Which two (2) findings in the nurses' note would require immediate follow-up? Rectal temperature of 103° F (39.4° C) Generalized shivering No urine output in the past two hours Peripheral pulses still thready Client reports of thirst

Heat stroke is a potentially catastrophic emergency. This results from the body's inability to employ cooling measures and results in a high core temperature. Consequently, this causes significant electrolyte disturbances. The nurse should maintain a patent airway, remove the client from the hot environment, contact emergency services, remove their clothing, and cool the client passively until more aggressive measures may be implemented. When evaluating this client, their temperature has decreased, and their neurological status has improved. These are reassuring findings. Shivering may occur with cooling the client but should be reported promptly as it increases oxygen demand. Shivering may also increase the client's temperature, which would be detrimental. A treatment for shivering is prescribed diazepam or lorazepam. The other finding that should be reported includes the client's inability to produce urine despite receiving intravenous fluids. This should be reported to the provider in anticipation of increasing the intravenous fluid rate. The peripheral pulses still being thready is not a change and ties into the fluid volume deficit that the client is experiencing. This signifies more fluids are needed. Therefore, this assessment has not changed and does not require immediate follow-up. The client being thirsty is an expected finding and does not require follow-up as they are dehydrated.

Current Medications: Lisinopril 20 mg PO Daily Nortriptyline 25 mg PO BID Clonidine 0.1 mg PO Daily Aspirin 81 mg PO Daily The physician has diagnosed the client with benign prostatic hyperplasia (BPH) The nurse reviews the client's current medications and plans to question which prescription? Lisinopril Nortriptyline Clonidine Aspirin

Nortriptyline is a tricyclic antidepressant used for depression and obsessive-compulsive disorders. This medication is significantly anticholinergic and would further irritate the client's BPH symptoms. The other medications are not purported to aggravate this condition.

The nurse receives and implements orders from the primary healthcare provider. - Start a second peripheral vascular access - Insert an indwelling urinary catheter - Nasal cannula oxygen at 2 liters - Obtain a 12-lead electrocardiogram - Apply ice packs to the groin and axilla - Remove the client's clothing - Obtain arterial blood gas - Cooled 0.9% saline at 150 mL/hr The nurse obtains assistance from a licensed practical/vocational nurse (LPN/VN) and unlicensed assistive personnel (UAP) The nurse should delegate to the UAP: applying nasal cannula oxygen removal of the client's clothing spiking and priming saline The nurse should delegate to the LPN: insertion of indwelling urinary catheter assessment of echo insertion of peripheral vascular access device

It is within the UAPs scope to assist with removing the client's clothing. IV therapy is not within the scope of the UAP; thus, spiking and priming the tubing would be inappropriate. Oxygen is a medication, and its application cannot be delegated to the UAP. The LPN may assist the RN with inserting an indwelling urinary catheter. LPNs perform sterile procedures, and this may be appropriately delegated. While an LPN may obtain an EKG, assessing the findings of the 12-lead electrocardiogram is to be done by the RN. The insertion of a peripheral vascular access device is to be done by the RN.

The nurse is caring for a client diagnosed with schizophrenia with catatonia A 22-year-old female was admitted from the emergency department (ED) after wandering in the local park. The client was disheveled, completely mute during the assessment, and did not respond to external stimulation. The client had a fixed stare at the ceiling and a marked reduction in purposeful movements. The physical exam noted flaky skin with tenting and dry mucous membranes. Medical records reveal that this client has a history of schizophrenia. Which prescriptions should the nurse anticipate from the primary healthcare provider (PHCP) based on the history and physical? Select all that apply. levodopa-Carbidopa methylprednisolone lorazepam intravenous fluids venlafaxine Levothyroxine

Options C, D - Correct - Catatonia is a serious psychiatric syndrome that may occur with psychiatric and medical conditions. The gold standard treatment for catatonia is benzodiazepines such as lorazepam. Lorazepam is preferred because of its modulating effects on the neurotransmitter GABA. The nurse should also request a prescription for intravenous fluids because the clinical data suggests dehydration (skin tenting and dry mucous membranes) which is a likely consequence of catatonia. Options A, B, E, F - Incorrect - Dopaminergic medications (both agonists and antagonists) should be avoided. Agonists should be avoided because they would trigger psychosis, therefore, levodopa-carbidopa would be contraindicated. Antagonists may worsen catatonia and complicate treatment. Therefore, antipsychotics and levodopa-carbidopa are avoided in the treatment of catatonia. Further, steroids (methylprednisolone), serotonergic agents (venlafaxine), and thyroid hormone (levothyroxine) have no role in the treatment of catatonia.

Incoherent in responses to officers and angry. Brought for medical clearance. Hyperalert/hyperaroused and has expansive affect. Recognizes he is in hospital, but when asked what year it is says "we are in the future." Bright lights he sees sparkle and that it is showing him the future. Cannot detail medical history or medications. Does not stay on topic during interview and frequently switches. Pacing within exam room and insists on going outside to roof to see 'if he can fly.' Impaired insight and judgment. Father arrived. Son has bipolar disorder and ran out of medication several days ago. 4 days ago, noticed a change, son became more talkative and staying longer at work. Last call with son was 2 days ago, noticed that symptoms had worsened, could not go to work. The client most likely has: The client is at greatest risk for: Word choices-- hypomania, mania, self harm, ineffective health maintenance

The client is demonstrating mania as evidence by his erratic driving and impairment of cognition and judgement. This client will need to be admitted because of his risk of self-harm. This self-harm is linked to his inability to make appropriate judgments.

62-year-old male was brought to the emergency department (ED) after collapsing on a tennis court 1700: - Vital signs: BP 98/60, T 105 degrees F, HR 110 BPM, RR 25, O2 95% - Cardiovascular: all pulses palpable, thready peripheral pulses - Respiratory: clear lung fields, tachypnea, shallow respirations - Neurological: lethargic and confused Highlight the findings that require followup: - Vital Signs: BP 98/60, T 105° F (40.5° C), P 110 beats per minute, RR 25 breaths per minute, Oxygen saturation 95% - Cardiovascular: All pulses palpable, Thready peripheral pulses - Respiratory: Clear lung fields, Tachypnea, Shallow respirations - Neurological: Lethargic, Confused

The findings concerning this client in the admission note include his blood pressure, temperature, pulse, respiratory rate, thready peripheral pulses, tachypnea, shallow respirations, and lethargy & confusion. These are all findings supporting that the client is dehydrated (low blood pressure and tachycardia) caused by his high core temperature. These vital signs are all indicative of heat stroke. The client's oxygen saturation is within normal limits.

The client is transferred to the behavioral health unit and diagnosed with a manic episode. Select the anticipated provider orders from each of the following categories. - Admission Status: Involuntary, Voluntary - Medications: Valproic acid, haloperidol - Monitoring: seizure precautions, enhanced observation

This client's inability to make sound judgments makes him at risk for harm to himself and others. Thus, this client should be involuntarily admitted as the criteria for this type of admission is if the client is a danger to themselves or others. Valproic acid (VPA) needs to be administered to the client because it is a mood stabilizer. This medication has the goal to break the client's mania. Haloperidol would be inappropriate because this is indicated for psychotic disorders such as schizophrenia. Considering the client's volatile behavior, it is appropriate for the client to receive enhanced observation to minimize and risk of self-harm.

The nurse receives orders from the physician The nurse is preparing to administer a dose of valproic acid to the client. The nurse should be prepared to monitor which laboratory data while the client takes this medication? Select all that apply Complete blood count Liver function tests Arterial blood gas Urine electrolytes Valproic acid level

Valproic acid (VPA) is a mood stabilizer and may cause blood dyscrasias such as thrombocytopenia; thus, monitoring the CBC is critical. VPA is also hepatotoxic; liver function tests should be observed for any liver injury. Arterial blood gas and urine electrolytes are unnecessary to monitor while a client takes VPA. VPA does not influence urine electrolytes and would not cause any marked abnormalities.

The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding? Select all that apply. Thready pulse Jugular venous distention (JVD) Coarse tremors Tachycardia Orthostatic hypotension

Choices A, D, and E are correct. A client presenting with DKA will have signs and symptoms of dehydration that range from mild to severe. Tachycardia is a common finding in DKA because of the fluid volume deficit. This, in turn, causes a client to have a thready pulse. Orthostatic hypotension is also a common finding because of dehydration. Choices B and C are incorrect. JVD is a finding associated with fluid volume overload. A client with DKA will not have this sign because DKA is associated with dehydration. Coarse tremors would be a neurological finding that would be concerning for neurodegenerative diseases such as Parkinson's. Coarse tremors are not an expected finding with DKA.

The nurse is conducting a telephone call following up with a client with a colostomy placed two weeks ago Click to highlight the findings reported by the client that require follow-up by the nurse Nurses' Note The client reports that he has no pain at the stoma. He states that the stoma is red and moist. He reports changing the appliance daily He reports using moisturizing soap around the stoma. The client notes that he empties the pouch when it is one-half to one-third full of stool. The client stated that his stoma has been getting smaller in size since surgery.

A stoma should appear beefy red, and moist. This finding indicates adequate perfusion to the stoma. Stomas that are purple, blue, black, and dry are concerned for lack of blood flow. The appliance should not be changed daily. This will cause the client to run out of supplies, and constantly changing the appliance will increase the risk of skin irritation. The appliance should be changed every 3-5 days. Moisturizing soap should not be used around the stoma because this decreases adherence to the appliance to the skin. It is recommended that a mild soap be utilized, and the hair around the area be clipped. It is appropriate that the pouch is emptied when it is one-half to one-third full. Considering this client is two weeks post-operative, the edema should decrease, and the stoma will reach its normal size within six to eight weeks following surgery.

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply. Nausea and vomiting Constipation Pruritus Urinary retention Nystagmus

Choices A, B, C, and D are correct. Fentanyl is an opioid analgesic used to manage acute and chronic pain. Common effects associated with this drug include nausea and vomiting, constipation, pruritus, and urinary retention. Choice E is incorrect. Nystagmus is not associated with fentanyl. Ophthalmic effects associated with fentanyl include blurred vision and miosis.

62-year-old male was brought to the emergency department (ED) after collapsing on a tennis court 1700: - Vital signs: BP 98/60, T 105 degrees F, HR 110 BPM, RR 25, O2 95% - Cardiovascular: all pulses palpable, thready peripheral pulses - Respiratory: clear lung fields, tachypnea, shallow respirations - Neurological: lethargic and confused The client is most likely experiencing: PE Heat exhaustion Heat stroke

The client's assessment is most likely experiencing heat stroke. Based on the client's confusion and temperature. This is a highly concerning finding that warrants immediate medical care. Heat exhaustion does not feature confusion or high temperature. The client does not have an assessment finding of restlessness or chest pain, excluding pulmonary embolus.

Incoherent in responses to officers and angry. Brought for medical clearance. Hyperalert/hyperaroused and has expansive affect. Recognizes he is in hospital, but when asked what year it is says "we are in the future." Bright lights he sees sparkle and that it is showing him the future. Cannot detail medical history or medications. Does not stay on topic during interview and frequently switches. Pacing within exam room and insists on going outside to roof to see 'if he can fly.' Impaired insight and judgment. Father arrived. Son has bipolar disorder and ran out of medication several days ago. 4 days ago, noticed a change, son became more talkative and staying longer at work. Last call with son was 2 days ago, noticed that symptoms had worsened, could not go to work. Which client finding has the nurse most concerned? The client's: expansive affect impaired judgment medication adherence inability to stay on topic

The client's impaired judgment is of significant concern because it threatens the client's and others' safety. The impairment in judgment can enable the client to do reckless actions (go through a stop sign, initiate a confrontation with others, indiscriminate sexual activity). The other findings are not significantly important because they do not present a safety issue compared to impaired judgment.

The nurse is caring for assigned clients. The nurse should initially follow up on the client who is A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C). B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side. C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous. D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.

Choice A is correct. A complication of transsphenoidal hypophysectomy is meningitis. The client needs to be immediately assessed for other manifestations of meningitis, including photophobia, nuchal rigidity, and altered mentation. Complications following this surgery include CSF leakage, infection, optic nerve damage, and diabetes insipidus. Choices B, C, and D are incorrect. These findings do not require follow-up because all of these situations are expected. Pneumothorax produces diminished to absent breath sounds on the affected side because of lung collapse. Thus, the treatment of the chest tube is to increase negative pressure in the pleural space to promote expansion. Albuterol causes a discharge of the body's epinephrine, thus causing the client to feel nervous or jittery. This, along with an elevation in the heart rate, is an expectation and will resolve a few hours after the treatment. Peritoneal dialysis is when the client instills hypertonic fluid into the peritoneum to draw out waste products. Cramping during fluid instillation is common and can be mitigated by warming the solution and slowing down fluid instillation.

A nasogastric tube has been inserted into a client with bowel obstruction for gastric decompression. The nurse should set the suction on which setting? A. Intermittent suction at 70 mmHg B. Intermittent suction at 100 mmHg C. Continuous suction at 100 mmHg D. Continuous suction at 70 mmHg

Choice A is correct. Gastric decompression should always be intermittent and at low suction pressure. A suction pressure below 80 mmHg is considered low suction. Choices B, C, and D are incorrect. Continuous and high suction pressure for gastric decompression should be avoided as this predisposes the gastric mucosa to injury and ulceration.

The nurse is teaching a client about consuming cranberry juice to prevent recurrent simple cystitis. The nurse understands that the treatment goal of consuming cranberry is to A. increase the urine specific gravity. B. increase the urine leukocyte count. C. acidify the urine. D. increase the protein in the urine.

Choice C is correct. Cranberry has limited evidence supporting its benefits in the prevention of recurrent cystitis. The treatment goal for consuming cranberry is to make the urine more acidic. This would be reflected in the urine pH (normal 4.6-8). Acidifying the urine is theorized to make the environment more hostile to the proliferation of bacteria. Choice A is incorrect. Urine-specific gravity (USG) is not an effective assessment parameter when evaluating whether drinking cranberry juice was an effective recommendation in this situation. Increasing the urine-specific gravity would make cystitis more likely because an increased USG indicates urine concentration, supporting the finding that the client may have a fluid volume deficit. Choice B is incorrect. Leukocytes in the urine support the finding that the client may have an infection. This is not a desired effect of cranberry. Choice D is incorrect. Protein in the urine is not a desired finding. This suggests that the client may have damage to their glomerulus as a result of uncontrolled hypertension or diabetes.

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply. Intrauterine growth restriction (IUGR) Hemolytic disease of the newborn Hydrocephaly Large for gestational age infant (LGA) Stillbirth

Choices A, C, and E are correct. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from intrauterine growth restriction and hydrocephaly. Choice B is incorrect. Hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh-negative and is pregnant with an Rh-positive baby. Choice D is incorrect. Women infected with rubella while pregnant are not at an increased risk for delivering an infant who is large for gestational age.

The nurse is reviewing the medical records of clients who have sustained several falls. While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls? Select all that apply. fluoxetine temazepam bupropion ferrous sulfate hydrocodone-acetaminophen hydroxyzine docusate

Choices B, E, and F are correct. Medications directly implicated in the causation of falls include benzodiazepines, opioids, anticholinergics, and antihypertensives. • Temazepam is indicated in the treatment of insomnia and is a benzodiazepine. An alternative to this medication would be the recommendation of melatonin. • Hydrocodone-acetaminophen is indicated in the treatment of pain. Hydrocodone is an opioid and may lead to falls because of its CNS-depressing effects. • Hydroxyzine is an anticholinergic medication indicated for allergic rhinitis and anxiety. This anticholinergic medication clouds the sensorium of an older adult, which may cause falls. Choice A is incorrect. Fluoxetine, an SSRI indicated in treating depression and anxiety, is not implicated in causing falls. Fluoxetine has activating properties, which tend to keep the client alert. Choice C is incorrect. Bupropion, an atypical antidepressant, is indicated in the treatment of depression. Bupropion is also an activating medication because it modulates norepinephrine. This medication is unlikely to raise a client's risk for falls. Choice D is incorrect. Ferrous sulfate is a medication indicated to treat iron-deficiency anemia. This medication has no implication in the causation of falls. Choice G is incorrect. Docusate is a stool softener indicated in the treatment for constipation. This medication has no central nervous system (CNS) depressant effects and is not implicated in causing falls.

The nurse cares for a client who sustained a femur fracture twelve hours ago Nurses' Notes Client reports shortness of breath and stated, 'something is not right.' The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called. The client is demonstrating signs and symptoms of: pulmonary embolism myocardial infarction fat embolism syndrome compartment syndrome

Fat embolism syndrome (FES) is a severe complication following a fracture that this client is experiencing. Symptoms of FES are similar to a pulmonary embolism; however, a PE does not have the manifestation of petechiae (reddish-purple spots). FES is a severe complication usually occurring within 48 hours following a fracture. The client is not experiencing a myocardial infarction as these symptoms occur in line with their fractured femur. An EKG is appropriate to rule out an MI, but this is not likely, considering the client has a fractured femur and is within the time frame for FES. Compartment syndrome is another consequential complication of a fracture but manifests with paresthesia of the affected extremity and pain not relieved by an opioid.

For each client finding, click to specify if it is consistent with hypomania or mania. Talkative and able to still go to work Impairment in insight and judgment Worsening of symptoms leading to work absenteeism Visual hallucinations

A significant difference between hypomania and mania is its impairment in an individual's life. Hypomania causes an individual to be euphoric, have an expansive affect, and have the need for little sleep. A key difference is that hypomania typically lasts four days or less and does not impair an individual's life, whereas mania does cause an impairment. Additionally, mania may induce perceptual disturbances such as hallucinations. This is not a feature found in hypomania. Mania may require temporary hospitalization because of the lack of judgment and insight.

1345 - Client presents for a report of straining with urination, weak urinary stream, and hesitancy during urination. The client states the problem has been going on for a few months but is getting worse because he has to use the bathroom more frequently in the middle of the night. He reports dribbling in his underwear which he finds embarrassing. He described his urine as clear and a straw yellow color. He states that he recently started a prescribed low-dose aspirin and wonders if that could cause all his symptoms. The client has a medical history of hypertension, obsessive-compulsive disorder, and osteoarthritis. No known allergies. Oral Temperature 98o F (36.7o C) Heart rate 83/minute Respirations 18/minute Blood pressure 134/82 mm Hg Which assessment findings are most significant? Select all that apply. Vital signs Urinary hesitancy Aspirin prescription Urine color Urination at night Weak urinary stream

The most significant assessment findings are the client's reports of urinary hesitancy, urinary at night, and a weak urinary stream. These symptoms are not only new for the client, but he reports worsening. The client's vital signs and urine color are within normal limits, and the aspirin prescription would not relate to his current urinary problems.

The nurse reviews the physician's progress note The nurse is providing discharge education regarding the prescribed valproic acid. Which statement, if made by the client, requires follow-up? "I will need follow-up laboratory work while taking this medication." "I may need to take a multivitamin while taking this medication." "It is okay for me to skip a dose of this medication if I get nausea." "I should notify my physician if I notice any yellowing of my eyes."

This statement requires follow-up because valproic acid requires good adherence to maintain a therapeutic level between 50-125 mcg/mL. Nausea is a common side effect associated with this medication and may be minimized by the client taking the medication with food. The other statements are true regarding this medication and do not require follow-up.

1345 - Client presents for a report of straining with urination, weak urinary stream, and hesitancy during urination. The client states the problem has been going on for a few months but is getting worse because he has to use the bathroom more frequently in the middle of the night. He reports dribbling in his underwear which he finds embarrassing. He described his urine as clear and a straw yellow color. He states that he recently started a prescribed low-dose aspirin and wonders if that could cause all his symptoms. The client has a medical history of hypertension, obsessive-compulsive disorder, and osteoarthritis. No known allergies. Oral Temperature 98o F (36.7o C) Heart rate 83/minute Respirations 18/minute Blood pressure 134/82 mm Hg Which factor best explains the client's symptoms? Alterations in antidiuretic hormone Obstructed urinary tract Urinary stone formation Increased bladder control

The best explanation for the client's symptoms is an obstructed urinary tract. Age-related prostate hyperplasia is likely occurring and weakening his urinary stream and causing him to dribble in his underwear. No manifestations that the client is reporting coincide with antidiuretic hormone level alterations. The client is experiencing a decrease in bladder control - not an increase. The client does not convey flank pain, so urinary stone formation is excluded.