archer questions I got wrong

The nurse is calculating intake for a client. The client received 0.9% saline at 125 mL/hr for six hours, three cups of cranberry juice, one cup of coffee, and one cup of water. The nurse should calculate the client's total intake as how many mL? Fill in the blank.

To calculate the client's total intake, the nurse must recall that one cup is eight ounces, equating to approximately 240 mL. The client received a 0.9% saline infusion at 125 mL/hr for six hours → 750 mL total Three cups of cranberry juice → 720 mL One cup of coffee → 240 mL One cup of water → 240 mL When added up, the total intake was 1950 mL

The nurse is assisting a client with their insulin pump. The nurse understands which insulin is commonly loaded into the pump? A. Rapid acting B. Short acting C. Intermediate acting D. Long acting

Choice A is correct. A rapid-acting insulin is the most common insulin used in insulin pumps. A rapid-acting insulin is correctional insulin and should be appropriately dosed 10-15 minutes before a client's meal or while actively eating.

While working in the resuscitation area of the emergency department, EMS notifies you that a 7-year-old male with an avulsion fracture to the left tibia is 20 minutes out. You know to expect which of the following? A. A fracture that pulls a part of the bone from the tendon or ligament. B. A fracture with which the whole cross-section of the bone is fractured. C. A fracture that results from an underlying disease or disorder, not physical trauma or stressors. D. A fracture that affects only one side of the bone.

Choice A is correct. An avulsion fracture pulls a part of the bone from the tendon or ligament. Fractures are a common occurrence and patients often present to the emergency department for treatment. A nurse should be able to recognize different types of bone fractures and plan for appropriate nursing interventions. Choice B is incorrect. A fracture with which the whole cross-section of the bone is fractured is referred to as a complete fracture. Choice C is incorrect. A fracture that results from an underlying disease or disorder, not physical trauma or stressors, is referred to as a pathological fracture. Such fractures are common with metastatic cancer, multiple myeloma, and osteoporosis. Choice D is incorrect. A fracture that affects only one side of the bone is referred to as a greenstick fracture.

The postpartum nurse is monitoring a new mother for signs of illness following vaginal delivery of a newborn infant. Which of the following is an early sign of excessive blood loss? A. Heart rate change from 80 to 125 bpm B. Blood pressure change from 125/90 to 119/82 mmHg C. A decrease in respiratory rate from 22 to 16 breaths per minute D. Reports of perineal soreness

Choice A is correct. An early sign of illness involves an increase in the patient's heart rate. Tachycardia is a rapid response to hypovolemia. A heart rate change from 80 to 125 bpm warrants further investigation into a possible illness.

The nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following would indicate the client is achieving the treatment goals? A. Mean arterial pressure (MAP) 71 mmHg B. Potassium 3.3 mEq/L C. Blood glucose 255 mg/dL D. Serum pH 7.33

Choice A is correct. For a client with DKA, hypovolemia and hyperglycemia are the primary problems. Hyperglycemia contributes to acidosis and hypovolemia. A normal MAP would indicate effective tissue perfusion and, thus, would be a favorable finding indicating that the hypovolemia has resolved. Normal MAP is between 70 and 100 mm Hg. Choices B, C, and D are incorrect. Hypokalemia is a common complication associated with DKA treatment. Regular insulin lowers blood glucose and potassium, and the nurse must be aware of hypoglycemia and hypokalemia risks. Blood glucose of 255 mg/dL is hyperglycemia and would not be a therapeutic finding. A serum pH of 7.33 indicates acidosis and warrants further treatment.

The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side B. Document the findings C. Discontinue oxytocin infusion D. Prepare for an amnioinfusion

Choice B is correct. Early decelerations are a reassuring finding caused by infant head compression, which is a normal part of labor.

A male patient, one-day post-CVA, is showing signs of left-sided neglect. To begin the rehabilitation process, the nurse caring for this patient should add the following interventions to the patient's plan of care. SATA A. Sit on the unaffected side when interacting with the patient. B. Place the phone on the patient's affected side. C. Encourage the patient to touch the affected hand with the unaffected hand. D. Place a favorite object into the hand on the affected side.

Choices B, C, and D are correct. Rehabilitation should start as early as possible for the stroke victim with unilateral neglect. In this side effect of a stroke, the patient is not aware of one side of the body. In this scenario, the patient would ignore the left side of the body and might be unaware of anything happening to his left. The key to this question is the phrase "to begin the rehabilitation process." In this case, the purpose of rehab is to help the patient become aware of the side he is currently ignoring. These answer choices will all force the patient to acknowledge his left side. Sitting on the unaffected side will allow the patient to continue to ignore the left side; thus, the nurse should encourage visitors to interact with the patient from his left side. This may mean that the visitor will have to turn the patient's head physically to the left.

The nurse provides a client with discharge instructions on his newly initiated digoxin. Which of the following statements by the client indicates that he correctly understood the instructions? SATA A. "If I note color vision changes, I will call my eye doctor right away." B. "I will check my pulse before each dose and if my pulse is less than 60 bpm, then I will not take the digoxin and call my doctor." C. "I will increase my calcium intake significantly." D. "I will make sure I get enough potassium in my daily diet." E. "The water pills that I am on may increase the risk of side effects with digoxin." F. "I should avoid medications that have licorice extract."

Choices B, D, E, and F are correct. A nurse should understand the mechanism of action of Digoxin to understand its uses, side effects, monitoring responsibilities, and patient education elements. Digoxin is a cardiac glycoside that acts via the sodium-potassium pump in the myocardium. It has inotropic (influences contractility), chronotropic (influences heart rate), and dromotropic (influences conduction speed) effects. Digoxin is a positive inotrope (increases the power of heart contraction), negative chronotrope (decreases heart rate by its effect on Sinus Node), and negative dromotrope (reduces the speed of conduction by acting at atrioventricular node level). Due to these cardiac effects of Digoxin, it is often used in patients with congestive heart failure and arrhythmias like atrial fibrillation. However, Digoxin has a narrow therapeutic index, which can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Therapeutic serum digoxin levels range from 0.5 to 2 ng/mL. A level higher than 2 ng/mL is considered toxic. The nurse needs to understand Digoxin's side effects and offer proper education to the clients. Some early side effects of Digoxin include visual aberrations (yellowish-green color changes or halos) and gastrointestinal side effects like nausea, vomiting, and lack of appetite. The first cardiac side effects include bradycardia (reduced heart rate), but cardiac arrhythmias can follow later. It is essential to monitor these early side effects, so the next dose of Digoxin can be held, and the physician can be notified. For inpatients, the nurse should always check the apical heart rate for one full minute before giving Digoxin; if the heart rate is < 60 (adults), the nurse should hold the medication and notify the physician. The heart rate threshold for holding Digoxin differs based on the age groups - in a child, the threshold is less than 70 beats per minute, and in an infant, it is less than 90-110 beats per minute. For patients being discharged home, education should be given to monitoring their pulse before every dose of Digoxin. If the pulse is < 60, hold the medication and call their doctor (Choice B). Some patients are prone to digoxin toxicity more than others: Certain electrolyte imbalances such as hypokalemia (< 3.5 mEq/L), hypercalcemia (>10.2 mg/mL), and hypomagnesemia (<1.5 mg/dL) can increase the toxicity. Patients on diuretics concomitantly for heart failure are prone to more side effects because diuretics tend to cause hypokalemia (Choice E). Such patients need to be educated regarding consuming adequate potassium-rich diets (Choice D). Elderly patients are at more risk for toxicity because they have an age-dependent decrease in liver and kidney functions. Digoxin is metabolized via the liver and kidney, so lower kidney/liver function predisposes to toxicity. Patients taking calcium channel blockers (CCBs) are also at risk for digoxin toxicity. The nurse should also be aware of specific over-the-counter medications that precipitate digoxin toxicity and educate patients accordingly. These include ephedra, which increases cardiac stimulation, and licorice extract (Choice F), which acts like aldosterone, causing sodium and water retention while increasing potassium loss. Hypokalemia, in turn, precipitates digoxin toxicity. Choice A reflects an incorrect statement by the patient. The patient should be cautioned that vision changes like yellow-green color distortions may signify early toxicity. The patient should call the prescribing physician as soon as possible to determine the cause and hold Digoxin early. The prescribing physician rather than the eye doctor should be contacted because precious time may be wasted addressing digoxin toxicity. Choice C reflects an incorrect statement by the patient. Any action that precipitates hypercalcemia should be avoided because high calcium increases toxicity (there is no need to increase calcium intake significantly).

While working in the emergency department, the nurse attends to a client who has overdosed on lorazepam. Which of the following medications does she expect the healthcare provider to order? A. Flumazenil B. Phenylephrine C. Epinephrine D. Naloxone

Flumazenil is the antidote for benzodiazepine (BZD) overdose. Lorazepam (Ativan) is a benzodiazepine, so the nurse expects to administer Flumazenil to this patient with BZD overdose.

Place the following stages of Freud's psychosexual development in the correct order. Latency stage Anal stage Oral stage Genital stage Phallic stage Correct Answer is:

Oral stage Anal stage Phallic stage Latency stage Genital stage The oral stage is first. According to Freud's psychosexual stages, children from 0 to 1 years old are in the oral stage. In this stage, children are interested in putting things in their mouths, sucking, and tasting. They will put unfamiliar objects in their mouth and derive pleasure from oral activities. The second is the anal stage. Children from 2-3 years old are in the anal stage. This is the stage when toilet training occurs. If children can complete this activity, they pass out of the anal stage, but if they struggle, they may become 'stuck' in their psychosexual development. The third is the phallic stage. Freud believes that 3-6-year-old children are in the phallic stage of psychosexual development. In this stage, boys become very attached to their mothers, whereas girls become very attached to their fathers. Fourth is the latency stage. According to Freud's psychosexual stages, children from 6 years old until puberty starts are in the latency stage. In the latency stage, children spend most of their time with peers of the same sex. This is when they begin school and tend to interact mainly with those of the same sex. Lastly is the genital stage. This stage occurs from puberty and beyond. In the genital stage, individuals are attracted to opposite-sex peers.

You are taking care of an 80-year-old patient who is post-op day one from abdominal surgery. Upon assessment, you notice bowel protruding through her incision and quickly determine that evisceration has occurred. Place the following actions in order of priority: 1. Cover the wound with a sterile normal saline dressing. 2. Take vital signs and monitor for signs of shock. 3. Call for help and stay with the patient. 4. Prepare the patient for immediate surgery. 5. Document the incident.

3. Call for help and stay with the patient. 1. Cover the wound with a sterile normal saline dressing. 2. Take vital signs and monitor for signs of shock. 4. Prepare the patient for immediate surgery. 5. Document the incident. The priority of nursing action is to call for help but stay with the patient. The nurse should tell the person who responds to notify the surgeon immediately. This is a surgical emergency, therefore the surgeon must be notified STAT. After help has been called, the nurse needs to cover the wound with a sterile 0.9% sodium chloride dressing. This helps prevent infection and keep the protruding organ moist and hydrated before surgery. The nurse should instruct the patient not to strain or cough, and keep the client in low Fowler's position (no more than 20 degrees of bed elevation) with his/her knees flexed. This position relaxes abdominal muscles and reduces abdominal muscle tension. After this, the next nursing action is to check the patient's vital signs and monitor for shock while waiting for the health care providers. If signs of shock such as tachycardia and hypotension are noted, this is a medical emergency, and the health care provider/rapid response team needs to be called to the bedside immediately. After taking vital signs, the nurse should begin preparing the patient for immediate surgery. Lastly, after the patient has been taken to surgery, the nurse needs to document the incident.

Due to an absent staff nurse, the postpartum unit is assigned a nurse from the "medical" ward as a floater. Which of the following patients should the charge nurse assign to the float nurse? A. A 20-hour postpartum client who will be discharged the following morning. B. A 16-hour postpartum client who had eclampsia during delivery. C. A 10-hour postpartum client who has soaked 4 perineal pads in one hour. D. A 5-hour postpartum client whose fundus is still not at the midline.

4Choice B is correct. This client can be assigned to the float nurse. The nurse is floating from the medical unit to the postpartum unit. Eclampsia is a complication of preeclampsia and is characterized by high blood pressure plus seizures. This client remains at risk for a seizure. The goals of management for eclampsia involve stabilizing seizures and controlling hypertension. Medical unit nurses understand and are experienced in taking care of clients having a seizure. Choice A is incorrect bc the patient needs specialized information from nurse on the unit.

The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron B. Methimazole C. Omeprazole D. Methylphenidate

Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental. Choices B, C, and D are incorrect. Methimazole is an antithyroid medication used for hyperthyroidism. This is not indicated following hypophysectomy. Omeprazole is a PPI and indicated in the treatment of peptic ulcer disease. Methylphenidate is a psychostimulant indicated in the treatment of ADHD.

The nurse is taking care of a patient that was recently rescued from a near-drowning experience. The patient is now having pulmonary edema. The nurse understands that pulmonary edema is the result of which process? A. Water washing out the alveolar surfactant B. Water introducing bacteria into the lungs and causing infection. C. Decreased intrathoracic pressure in the lungs. D. A sudden change in temperature within the lungs.

Choice A is correct. Freshwater and saltwater wash out the alveolar surfactant when they enter the lungs. This leads to alveolar collapse, intrapulmonary shunting, decreased lung compliance, and hypoxemia, which will eventually result in pulmonary edema.

The nurse is caring for a client who is prescribed enoxaparin. Which of the following findings in the medical history would require follow-up with the primary healthcare physician (PHCP)? A. Recent spinal surgery B. Diabetes mellitus C. Osteoarthritis D. Venous thromboembolism

Choice A is correct. Recent spinal surgery requires follow-up with the prescription of enoxaparin. This medication may cause a hematoma, which may consequently cause severe neurological impairment.

This nurse is caring for a client at 29 weeks gestation who is at risk for delivering preterm. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Methotrexate B. Indomethacin C. Oxytocin D. Folic acid

Choice B is correct. Indomethacin is a cyclooxygenase inhibitor and is indicated as a tocolytic in preterm labor. This medication relaxes the uterus and therefore decreases uterine contractions.

The nurse is caring for a client with an acute migraine headache. The nurse would anticipate a prescription for which medication? Select all that apply. A. Ketorolac B. Nitroglycerin C. Topiramate D. Dexamethasone E. Hydromorphone F. Acetaminophen-caffeine

Choices A, D, and F are correct. Treatment for an acute migraine headache (MH) involves abortive medications such as ketorolac (NSAID), dexamethasone (corticosteroid), and acetaminophen-caffeine. Depending on the severity of the MH, the provider takes a stepwise or aggressive approach to treatment.

Which of the following interventions are appropriate for a pediatric patient experiencing contact dermatitis? sata A. Diphenhydramine B. Hydrocortisone C. Cyclosporine D. Tacrolimus

A is correct. Diphenhydramine is a first-generation oral antihistamine that is commonly prescribed for dermatitis or eczema. These antihistamines, including diphenhydramine and Chlor-Trimeton, have a side effect of drowsiness and can help the child itch less. B is correct. Topical hydrocortisone cream is commonly prescribed to help relieve itching associated with dermatitis. Hydrocortisone can be purchased OTC and is often one of the first treatments used with contact dermatitis. C is correct. Cyclosporine is a calcineurin inhibitor. It inhibits the enzyme calcineurin in immune cells to decrease the number of inflammatory substances that the body produces. This, therefore, reduces overall inflammation, helping with contact dermatitis. D is correct. Tacrolimus is a calcineurin inhibitor. It inhibits the enzyme calcineurin in immune cells to decrease the number of inflammatory substances that the body produces. This, therefore, reduces overall inflammation, helping with contact dermatitis.

The nurse is educating a new nurse working on the pediatric unit about the causes of bacterial tonsillitis in children. Which of the following is the most common cause of bacterial tonsillitis? A. Group A beta hemolytic streptococcus B. Streptococcus pneumoniae C. Group B Streptococcus D. Neisseria meningitidis

Choice A is correct. Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis. Choice B is incorrect. Streptococcus pneumoniae is a gram-positive bacterium that causes pneumonia; this bacterium does not cause tonsillitis. Choice C is incorrect. Group B Streptococcus is a type of bacteria sometimes found in a pregnant woman's vagina or rectum; this bacterium does not cause tonsillitis. Choice D is incorrect. Neisseria meningitidis is a gram-negative bacterium that causes meningococcal diseases such as meningitis; this bacterium does not cause tonsillitis.

You are taking care of a 7-year-old female in the pediatric bone marrow transplant unit. She has been in the hospital for about a year and is working on her school work with the hospital teacher. You note that she is growing increasingly frustrated with her math homework. You know that her successful completion of academic demands is vital to her psychosocial development, as she is in which stage of psychosocial development? A. Industry vs. Inferiority B. Autonomy vs. Shame and Doubt C. Trust vs. Mistrust D. Initiative vs. Guilt

Choice A is correct. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds. In this stage, children need to cope with new social and academic demands. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, and it results in inferiority. Choice B is incorrect. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, and it leads to a sense of autonomy. When they are not successful, they think they are a failure, and it results in shame and self-doubt. Choice C is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop a sense of confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust. Choice D is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty.

The nurse is caring for a client newly diagnosed with mastitis. The nurse anticipates a prescription for which medication? A. Cephalexin B. Acyclovir C. Fluconazole D. Imiquimod

Choice A is correct. Mastitis is commonly caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis.

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

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

Which stage of cognitive development does the nurse expect her 6-month-old patient to be in? A. Sensorimotor B. Preoperational C. Concrete operational D. Formal operational

Choice A is correct. The first stage of Piaget's Stages of Cognitive Development is the sensorimotor stage. This stage occurs between 0 and 2 years old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their minds to explore. They start to form language and use it for demands. They also develop object permanence. Choice B is incorrect. The preoperational stage occurs between 2 and 7 years old. In this stage, the child is a symbolic thinker. They can use language with proper grammar to express their thoughts. Their imagination and intuition are developing rapidly. They are not yet ready to think complex abstract thoughts. Choice C is incorrect. The concrete operational stage occurs from 7 to 11 years old. In this stage, concepts are attached to specific situations. The ideas of time, space, and quantity begin to develop. Choice D is incorrect. The formal operational stage begins at age 11 and continues into adulthood. In this stage, children can use theoretical, hypothetical, and counterfactual thinking. They can reason and use abstract logic. Planning for future events and using strategy becomes possible. They can learn concepts in one area and apply them to another area.

The critical care nurse is caring for a client receiving hemodynamic monitoring. After reviewing the client's central venous pressure, the nurse should take which action based on the client's 0100 CVP reading? CVP 1900--> 10 mmHg CVP 2300--> 13 mmHg CVP 0100--> 16 mmHg A. Assess the client for fluid volume overload B. Obtain a prescription for saline fluid bolus C. Document the findings and continue to monitor D. Place the client in a side-lying position.

Choice A is correct. The normal central venous pressure (CVP) is 2 to 8 mmHg. CVP measures the amount of fluid that returns to the right atrium (or preload). This client's CVP has been trending upward, and the nurse should assess the client for hypervolemia, specifically, manifestations of right-sided heart failure. Choices B, C, and D are incorrect. Infusing additional volume may be detrimental. This would be an appropriate intervention for a client with a low CVP. These values are abnormal, and the nurse should not document and continue to monitor. This value requires action on the part of the nurse. The side-lying position is unnecessary for this client, and if the assessment confirms fluid volume overload, the client should be positioned as high-Fowlers.

The nurse is caring for a client with the following tracing on the electrocardiogram (ECG). The nurse should anticipate a prescription for which medication? See the image below. (SVT) A. Adenosine B. Atropine C. Labetalol D. Amiodarone

Choice A is correct. The tracing reflects supraventricular tachycardia (SVT). The preferred medication for individuals experiencing SVT includes the rapid administration of adenosine followed by a rapid flush of 0.9% saline. Adenosine slows the electrical conduction time through the AV node. Choices B, C, and D are incorrect. Atropine is indicated for the treatment of symptomatic sinus bradycardia. Labetalol is indicated for a hypertensive emergency and sinus tachycardia. While labetalol lowers heart rate, it would not treat the underlying cause of SVT. Amiodarone may be utilized for refractory SVT, but this drug is not the initial drug of choice for SVT. Amiodarone is a preferred drug for AFIB and VTACH.

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

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

The nurse prepares a client for a scheduled percutaneous coronary intervention (PCI). Which client statement should be reported to the primary healthcare provider (PHCP)? A. "I took my metformin this morning." B. "I get anxious when I am in closed spaces." C. "I am allergic to shellfish." D. "I may feel a warm sensation during the procedure."

Choice A is correct. This procedure involves intravenous (IV) contrast and a small chance of acute kidney injury may occur when IV contrast is given within 48 hours of metformin. Thus, the PHCP needs to be notified. Exposure to metformin prior to this procedure is not a contraindication but requires IV fluids to decrease the negative effects on the kidneys. Choices B, C, and D are incorrect. This procedure utilizes moderate sedation and is not done in a closed space. Thus, claustrophobia is not a concern. IV contrast is used during this procedure to define the coronary arteries. Contrary to a propagated myth, shellfish allergy has no relationship with IV contrast. IV contrast does cause an individual to experience a metallic taste and a warm sensation. This is an expected finding that does not require reporting to the PHCP.

The nurse is caring for a client with the following tracing on the electrocardiogram. When reviewing the client's medical history, which condition could be causing this dysrhythmia? See the image below. (sinus tachy) A. Graves' disease B. Increased intracranial pressure C. Severe hypothermia D. Myxedema coma

Choice A is correct. This tracing reflects sinus tachycardia (ST). ST can be caused by an array of conditions such as dehydration, hypo- and hyperglycemia, stress, anxiety, and thyroid conditions such as hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism, and this increased metabolic and sympathetic activity would cause tachycardia. Choices B, C, and D are incorrect. Increased intracranial pressure would manifest with bradycardia. Hypothermia causes a slowing of metabolic and sympathetic activity; thus, bradycardia is a feature of this condition. Myxedema coma is an endocrine emergency marked by severe hypothyroidism. The hallmark of severe hypothyroidism is life-threatening bradycardia.

The nurse is caring for assigned patients. The nurse should recognize that the patient at greatest risk for postpartum hemorrhage (PPH) is the patient who has which of the following? A. Uterine atony and delivered with the assistance of forceps B. Postpartum urinary incontinence and diuresis C. An active outbreak of genital herpes and had a cesarean section D. Gestational diabetes and has postpartum hyperglycemia

Choice A is correct. Uterine atony is the most common cause of PPH. This is when the uterus fails to contract after delivery. Additionally, delivery with the use of instruments such as forceps raises the risk of PPH because of the trauma that may be caused by the instruments.

The physician has ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. What is the next step to do with the urine specimen? A. Place it in a separate container and later add to the collection. B. Discard it, then the collection process begins C. Test it, then discard D. Save as part of the 24-hour collection

Choice B is correct. A 24-hour urine collection may be ordered to evaluate the type and severity of certain renal disorders. The nurse is responsible for providing the collection container and educating the patient on the correct process of collecting the specimen. At the beginning of the 24-hour urine procedure, the patient should not collect or save the first urine specimen. This first void is considered "old urine" or urine in the bladder before the test began. This specimen should be flushed and the time at which its discarded is noted. After the first discarded specimen, urine is collected for the next 24 hours.

The nurse is reviewing newly prescribed medications for a client taking lithium. Which medication requires further follow-up? A. Venlafaxine B. Hydrochlorothiazide C. Gabapentin D. Verapamil

Choice B is correct. A client taking lithium should be instructed to avoid dehydration and hyponatremia. Lithium is a salt, and when the client has decreased fluid volume, the drug will accumulate and raise the lithium level. HCTZ is a thiazide diuretic and is contraindicated for a client taking lithium because of its ability to decrease fluid and sodium levels. Choices A, C, and D are incorrect. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor and has no contraindication with lithium. Further, gabapentin and verapamil have no contraindications as gabapentin is indicated for neuropathy, and verapamil is indicated for hypertension.

The nurse is caring for a client who is two years old. The nurse should plan care knowing that this client is in which stage of Erikson's stages of psychosocial development? A. Initiative vs. Guilt B. Autonomy vs. Shame and Doubt C. Industry vs. Inferiority D. Trust vs. Mistrust

Choice B is correct. Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is what the nurse would expect for her 2-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When they are not successful, they think they are a failure, resulting in shame and self-doubt. Choice A is incorrect. Initiative vs. Guilt is the typical stage of development for preschool children, who are 3 to 5-year-olds, not your 2-year-old patient. In Initiative vs. Guilt, children start to assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval end up feeling guilty. Choice C is incorrect. Industry vs. Inferiority is the typical stage of development for school-age children, who are 6 to 11-year-olds, not your 2-year-old patient. Children need to cope with new social and academic demands in this stage. When they are successful with this, they feel competent and achieve in the industry. When they are not successful, they handle failure, resulting in inferiority. Choice D is incorrect. Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months, not your 2-year-old patient. Children develop a sense of trust in this stage when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

Which of the following findings would prompt immediate investigation when performing an assessment of a patient on a medical/surgical unit? A. Bowel sounds of 14 per minute B. High-pitched bowel sounds at a rate of 4 per minute C. Bowel sounds greater than 60 per minute D. Low-pitched bowel sounds at a rate of 30 per minute

Choice B is correct. Bowel sounds less than 5 per minute may indicate blockage and should be evaluated. Bowel sounds are high-pitched, occasional gurgles, or clicks that last from one to several seconds. They occur every 5 to 15 seconds in the average adult.

A patient with chronic renal disease is scheduled for an esophagogastroduodenoscopy (EGD). Which of the following imbalances should the nurse monitor for? A. Hypercalcemia B. Hypernatremia C. Hyperkalemia D. Hypomagnesemia

Choice B is correct. Clients are placed on nothing by mouth (NPO) before procedures such as an EGD. Clients with chronic kidney disease (CKD) are especially prone to hypernatremia upon water depletion. CKD impairs the kidney's ability to concentrate the urine, and therefore, more free water is lost in the early stages of CKD. Often, these clients need to ingest more fluids. In clients with CKD, prolonged insufficient water intake while on NPO status may result in negative water balance and the development of hypernatremia.

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake? A. Choose french fries over a baked potato B. Select a cheeseburger over a regular hamburger C. Pick sandwiches instead of wraps D. Breaded chicken is a better choice than broiled

Choice B is correct. Fast food is not desired during pregnancy because of the abundance of oils, dressings, and breading that supply a high degree of saturated fats, sodium, and calories. To optimize the client's nutritional intake, if the client insists on fast food, the nurse should recommend a cheeseburger because the cheese will add protein and calcium.

The nurse is caring for a client newly diagnosed with gout. The nurse anticipates a prescription for which medication? A. Colchicine B. Allopurinol C. Naproxen D. Prednisone

Choice B is correct. Gout is a disease that develops when high uric acid levels form crystals that accumulate in joints. Allopurinol is a medication commonly prescribed to decrease uric acid levels. Choices A, C, and D are incorrect. Colchicine, naproxen, or prednisone may be used during an acute gouty attack. The primary intention of these medications is to decrease the overall inflammation with the gouty attack.

The community health nurse is doing a home visit on a client that was admitted to the hospital two weeks ago for hypertension. The nurse notes that the client was prescribed amlodipine 5 mg daily and was advised to lose weight. The nurse should be concerned when the client notes which of the following during his visit? A. The patient states that he has already enrolled himself in a gym and is getting dietary counseling from a nutritionist. B. The nurse notes the patient drinking grapefruit juice. C. The patient asks the nurse multiple questions regarding how he can follow his treatment regimen. D. The patient stated that he has had an episode of dizziness a day after he was discharged but has since been fine.

Choice B is correct. Grapefruit juice and calcium channel blockers may combine to cause toxic effects. This should cause concern to the nurse and should necessitate further teaching regarding calcium channel blockers (ie, amlodipine).

The nurse is counseling a group of students on the dosing schedule of Rho(D) Immune Globulin. It would indicate effective understanding if the student states that Rho(D) Immune Globulin should be administered at A. 12 weeks of pregnancy and within 72 hours of delivery. B. 28 weeks of pregnancy and within 72 hours of delivery. C. 25 weeks of pregnancy and within 96 hours of delivery. D. 16 weeks of pregnancy and within 12 hours of delivery.

Choice B is correct. Guidelines recommend administering Rho(D) Immune Globulin at 28 weeks of pregnancy and within 72 hours of delivery. Maternal sensitization occurs in approximately 72 hours following the exposure of material circulation to the Rh-positive fetal RBCs. Giving Rho(D) Immune Globulin (RhoGAM) too early will not provide adequate prophylaxis against Rh isoimmunization. Giving RhoGAM after 28 weeks of gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies have already formed. Choices A, C, and D are incorrect. These time frames are incorrect for administering Rho(D) Immune Globulin.

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

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

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

Choice B is correct. Regular insulin is short-acting and will peak two to four hours after subcutaneous administration. Assessing the client at 1000 would be when the regular insulin would peak and thus, be the likely time for the client to exhibit hypoglycemia symptoms. The second peak will occur four to twelve hours after administering NPH insulin or around noon. Choices A, C, and D are incorrect. Regular insulin peaks within two to four hours after administration, and when combined with NPH, the nurse should assess the client for hypoglycemia after the first peak, which would be 1000. If the nurse waited until noon to assess for hypoglycemia, this could be detrimental as the insulin has already started to peak.

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate? A. "You're off to a great start! Tea has much less caffeine than coffee." B. "A great addition to your cup of tea would be a little lemon. It's going to help you absorb your iron pill better." C. "Right now your iron levels are low. Please eliminate all caffeine." D. "That's alright. Drinking coffee or tea won't affect the fetus."

Choice B is correct. Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption.

The nurse evaluating an oncology patient's chart notes that the patient has a tumor in his lung measuring about 4.3 cm in size and accompanying pneumonitis. His cancer does not invade the entire lung and has no metastasis or lymph node involvement. Using the TNM staging system, how would the nurse best classify this patient's tumor? A. T3 N3 M1 B. T2 N0 M0 C. T1 N1 M0 D. T2 N1 M0

Choice B is correct. The TNM tumor staging system explores tumor size (T), node involvement (N), and distant metastasis (M). This patient has a small tumor measuring 4.3 cm limited to one portion of the lung, giving it a T staging of T2. Without nodal involvement or metastasis, both N and M are 0. This question is intended to test the representation of N0 and M0 for negative lymph nodes and negative metastases, respectively. The nurse is not required to know "T" staging details.

A nursing student is currently learning about domestic violence and wonders why the abused individual cannot "just quickly get out of the relationship." Which theoretical model helps in explaining the cyclical and progressive nature of domestic and spousal abuse? A. The Cycle of Abuse and Neglect B. The Cycle of Violence C. The Cycle of Impaired Couples D. The Duluth Model

Choice B is correct. The cycle of violence is a model developed in 1979 by Lenore Walker to explain the co-existence of disorder with love. It may be tough for those who have never experienced domestic abuse to understand why it is difficult for an abused individual to "just quickly leave" the relationship. Understanding the cycle of violence may help plan appropriate interventions to break the cycle and stop domestic violence. Violence often occurs in a repetitive cycle and usually consists of three phases: (1) the Tension phase, (2) the Acute explosion phase (Crisis phase), and (3) the Honeymoon Phase (calm phase). In the first phase (tension-building), the abuser gets angry, argumentative, and starts threatening. Minor fights may occur. In this phase, victims often report a feeling of walking on eggshells. As the period progresses, tension continues to build. In the second phase (explosion/crisis), significant verbal or physical abuse will occur. Major violent acts such as physical or sexual attacks will follow and may result in injury. In the third phase (Calm phase or Honeymoon period), the abuser expresses sorrow and feelings of guilt. The abuser shows love and promises to change and get himself/herself help. The victim feels like things are getting much better, but the phase does not last. The cycle starts all over again and the three steps repeat over time. It is, therefore, hard to end an abusive relationship since the three phases of love, hope, and fear, keep the cycle moving. The cycle is progressive as well. With every period, the abuse may get worse during the explosion phase.

You have to begin an intravenous therapy line for a client who is dark-skinned. You are having difficulty locating a vein for this venipuncture. Which of these devices or procedures may be of benefit to you at this time? A. A doppler B. A surgical vein cut down C. A transillumination device D. A sonography

Choice C is correct. A transillumination device may be of benefit to you when you are having difficulty locating a vein for this venipuncture and have to begin an intravenous therapy line for a client who is dark-skinned. Transillumination devices light up the area, and this light is sufficient to locate veins regardless of the client's skin color. These devices are also capable of identifying veins that are not palpable or visible when the client is obese.

Select the skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse. A. Erythema: The application of an antiseptic spray B. Excessive dryness: Using limited mild soap for bathing C. Abrasions: The application of an antimicrobial cream D. Hirsutism: Washing the area carefully and gently

Choice B is correct. The skin disorder that is appropriately paired with an independent nursing intervention that can correct it or prevent it from getting worse is the use of limited mild soap to help with excessive dryness. Choice A is incorrect. Although the application of an antiseptic spray to correct or prevent erythema from getting worse may be indicated, the use of any antiseptic spray is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because an antiseptic topical skin spray contains a medication, you must have a doctor's prescription to use it for erythema. Choice C is incorrect. Although the application of an antimicrobial cream to correct or prevent abrasions may be indicated, the use of any antimicrobial cream is a dependent and not independent nursing intervention. Dependent nursing interventions need a doctor's order and because antimicrobial topical skin creams contain a medication, you must have a doctor's prescription to use it for erythema. Choice D is incorrect. Hirsutism is a skin disorder that is characterized by the abnormal growth of unwanted hair on areas such as a female client's face; washing the area carefully and gently will not correct or prevent it. Shaving and tweezing the unwanted hair, however, are two independent nursing interventions that can be implemented to correct hirsutism.

Which of the following would not be appropriate for the nurse to include in the teaching for a client with a diagnosis of acute low back pain? A. Smoking cessation B. Sleep in the prone position C. Use a firm mattress D. Bend at knees when lifting objects

Choice B is correct. This instruction is incorrect to recommend for this client, and therefore the correct answer to the question. Prone positioning results in excessive lumbar lordosis, which would increase the stress on the client's lower back. This client would benefit from sleeping in either a supine position or a side-lying position with a pillow between the knees and hips flexed. Choice A is incorrect. Nicotine has been shown to decrease circulation to vertebral disks. Smoking avoidance/cessation should be included in teaching for clients with low back pain.

The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching? A. "I will give this injection in the abdomen." B. "I should expel the air bubble before administering." C. "Green leafy vegetables are allowed while taking this medication." D. "This medication may increase the risk for bleeding."

Choice B is correct. This statement is incorrect and requires follow-up. Enoxaparin comes in prefilled syringes that are administered to the client subcutaneously. Since this medication comes in prefilled syringes, the air bubble should not be expelled. This is designed to remain next to the plunger to ensure the full dose is administered.

The nurse has instructed a client who is being discharged with a cane about going upstairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should move my cane up, then my weaker leg, then my stronger leg." B. "I should move my stronger leg up, then my cane and the weaker leg simultaneously." C. "I should move my stronger leg up, then my cane, followed by my weaker leg." D. "I should move my cane up, then my stronger leg, then my weaker leg."

Choice B is correct. When a client is ambulating upstairs using a cane, 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.

The ICU nurse is caring for a sedated patient on a pressure-cycled ventilator. The ventilator alarm is beeping persistently despite the patient's civil status and stable vitals. What is the most appropriate action for the RN to take first? A. Suction secretions B. Check tubing for holes or kinks C. Call respiratory therapy STAT D. Continue to monitor

Choice B is the correct answer. If the patient's presentation and vitals are stable, the nurse should check for any apparent equipment malfunction. If no air leaks or kinks are immediately identifiable, the nurse should call respiratory therapy or the rapid response team (RRT). Persistent alarms despite stable vitals may indicate the patient is trying to talk, or is developing a pneumothorax from increased intrathoracic pressure, or is biting/gagging on the endotracheal tube, or is experiencing bronchospasms. These alarms should never be ignored or turned off, as they may indicate early signs of a change in the patient's condition. Choice A is incorrect. The nurse should assess the patient and breath sounds before performing suction. Choice C is incorrect. The nurse should assess the patient, suction if needed, check the ventilator and tubing, remove excess water from the pipe, and check the endotracheal cuff pressure. If no clear cause for alarm, the nurse should then remove the patient from the ventilator and manually ventilate with an Ambu bag, then call respiratory therapy (STAT). After that, the nurse can continue to assess until mechanical ventilation is resumed. Choice D is incorrect. Alarms should not be ignored or silenced. If unable to determine the cause, the nurse should call for assistance.

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child? A. Peripheral nerve block B. Spinal anesthesia C. General Anesthesia D. Local Anesthesia

Choice C is correct. A large leg abscess will need significant time for incision and drainage (I&D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed.

A patient is being discharged from the hospital after being diagnosed with lupus erythematosus. The patient is advised to follow up with what to monitor his condition? A. HbA1C B. Daily blood pressure checks C. Monthly urine specimens D. Monthly CBC

Choice C is correct. A patient with SLE needs monthly urine specimens to check for proteinuria and any kidney functioning damage. Choices A, B, and D are incorrect. If the client has a history of diabetes, the A1C may be checked at specified intervals, but it is not indicated because of a Lupus diagnosis. Daily blood pressure checks are reported for a client with a diagnosis of hypertension or on new medication for blood pressure/heart disease. Monthly CBC is not meant for a Lupus patient.

What is the process with which members of another culture adopt the culture of the host, predominant culture? A. Immigration B. Emigration C. Acculturation D. Assimilation

Choice C is correct. Acculturation is the process with which members of another culture adopt the culture of the host, predominant religion. This adaptation allows the members of the non-dominant culture to survive and thrive in the new environment. Although acculturation and assimilation are similar, adaptation is the process with which a person develops a new cultural identity, rather than assimilating and adopting a new culture while retaining their own. Immigration is the process by which citizens of one country enter another country, whereas emigration is the process by which individuals of a nation leave it. Both immigration and emigration can lead to cultural dissonance. Choice A is incorrect. Immigration is the process by which citizens of one country enter another country. Choice B is incorrect. Emigration is the process by which individuals of a country leave it. Choice D is incorrect. Assimilation is the process with which a person develops a new cultural identity process.

The nurse is caring for a client prescribed amphotericin b. Which laboratory data is necessary for the nurse to monitor during treatment? A. Triglycerides B. Hemoglobin A1C C. Potassium D. High-density lipoprotein (HDL)

Choice C is correct. Amphotericin b is a potent antifungal that is given intravenously. Hypokalemia is a common adverse reaction associated with amphotericin b therapy. Hypokalemia associated with this medication is caused by the kidneys leaking the potassium via the collecting ducts. Potassium supplementation may be necessary during amphotericin b therapy. Choices A, B, and D are incorrect. Significant lipid levels and hemoglobin A1C alteration is not associated with amphotericin b.

Which of the following is an expected outcome for a pediatric client who is transitioning from being a toddler to a pre-school child? A. The parents will teach the child ways to perform concrete operations. B. The parents will teach the child ways to apply abstract thinking. C. The child will develop new coping strategies to adapt to a maturational crisis. D. The child will develop industry and a sense of achievement.

Choice C is correct. An expected outcome for a pediatric client who is transitioning from being a toddler to a pre-school child is that the child will develop new coping strategies to adapt to a maturational crisis. Maturational crises occur predictably along the life span with expected challenges and tasks that require the person to develop new coping strategies since previously learned coping strategies/mechanisms are no longer useful.

The nurse manager receives a complaint from a client's family member regarding the client's care provided by a specific nurse. Which initial action should the nurse manager take? A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately B. Speak with the night shift nurse regarding the complaint and discuss the care provided C. Contact the client's family member who made the complaint to discuss the situation D. Take note of the complaint and place it in the applicable employee's file

Choice C is correct. Assuming the family member rendering the complaint is listed on the client's HIPAA release form, the nurse manager's initial action should be to contact this individual to let them know they have been heard. Additionally, this point of contact allows the nurse manager to ask additional questions regarding the complaint to ultimately help in determining whether the complaint holds merit. Once the manager has determined how reliable the information from the client's family member is, the nurse manager may speak with the client (if the client is capable) before speaking with the nurse in question. Choice A is incorrect. Although the nurse manager may have a discussion with the night charge nurse at some point, this is not the nurse manager's most appropriate initial action. Choice B is incorrect. Here, the question asks for the nurse manager's most appropriate initial action. While the nurse manager will undoubtedly speak with the night shift nurse regarding the complaint and discuss the care provided, this conversation is not the nurse manager's most appropriate initial action. Choice D is incorrect. Taking note of an unverified complaint and placing it in an employee's file would be an inappropriate and unethical action by the nurse manager. The incident may go into the nurse's file, but not without investigating the matter first.

The nurse administers dobutamine to a patient with heart failure following a cardiac procedure. Which of the following should the nurse recognize as an intended effect of this medication? A. Increased heart rate B. Increased vasoconstriction C. Increased cardiac output D. Increased blood pressure

Choice C is correct. Dobutamine is a positive inotropic and chronotropic drug that helps increase myocardial contractility by selectively acting on the beta-1 receptors in the myocardium. By increasing the heart rate and contractility, dobutamine helps increase cardiac output in acute heart failure settings. Dobutamine is indicated in the short-term management of decompensated congestive heart failure. Choice A, B, and D are incorrect. Stimulation of beta-1 adrenergic receptors in the myocardial tissue results in increased heart rate ( positive chronotropic) and myocardial contractility ( positive inotropic). Dobutamine selectively stimulates these receptors and, therefore, can increase the heart rate. However, the intended therapeutic effect of dobutamine is increased cardiac output, not an increased heart rate ( Choice A).

The nurse is teaching a client about the newly prescribed medication, epoetin alfa. Which of the following should the nurse include in the teaching? A. This medication will decrease your risk for infection. B. You may notice black tarry stools while on this medication. C. This medication may raise your blood pressure. D. Take this medication with food rich in Vitamin C

Choice C is correct. Epoetin alfa is an erythropoietic growth factor indicated to increase red blood cell production for those with chronic kidney disease. This medication expands blood plasma with the therapeutic effect of increasing hemoglobin and hematocrit. It is essential to monitor the client's blood pressure while taking this medication, as an increase in blood pressure may be seen secondary to the increased blood volume. Uncontrolled hypertension is a contraindication to this medication.

The nurse is counseling a client with congestive heart failure (CHF) about newly prescribed bumetanide. The nurse determines that the teaching has been effective when the client plans to A. increase their daily intake of protein. B. record their daily urinary output. C. weigh themselves daily. D. take their blood pressure and pulse daily.

Choice C is correct. For a client with congestive heart failure prescribed bumetanide, a loop diuretic, the client should verbalize the importance of weighing themselves daily. Their daily weight should be obtained in the morning after the first void. *FALL RISK MEDICATION*

A 63-year-old male is being seen in the clinic for his annual exam. Before performing a digital rectal exam. Which of the following questions should the nurse ask? A. "Are you exercising regularly?" B. "Has your diet changed dramatically in the past year?" C. "Have you had any difficulty starting a stream of urine when you attempt to use the toilet?" D. "Are you currently experiencing constipation?"

Choice C is correct. Health care practitioners perform digital rectal exams (DRE) to check their aging male patients for benign prostatic hyperplasia (BPH) or prostate enlargement. Patients experiencing BPH may have difficulty starting a stream of urine or completely emptying their bladder.

Following treatment for a fracture, a client is now undergoing rehabilitation. The client's regimen involves performing isometric exercises. Which action is evidence that the client has fully understood the proper technique? A. The client exercises both extremities simultaneously B. The client knows their heart rate should be monitored while exercising C. The client practices forced resistance against stable objects D. The client swings their limbs through the full range of motion

Choice C is correct. Isometric exercises involve applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall. Choice A is incorrect. Isometric exercises do not include simultaneous exercising of both extremities. Choice B is incorrect. Since isometric exercises are not classified as aerobic exercises, the client's heart rate is typically not monitored while performing isometric exercises. Choice D is incorrect. In order to maintain strength in a specific group of the client's muscles, each isometric exercise is performed in one position without movement. Therefore, a client performing isometric exercises would not be swinging their limbs in their full range of motion.

The nurse caring for a three-year-old with congestive heart failure recognizes which of the following as an early sign of digitalis toxicity? A. Bradypnea B. Tachycardia C. Vomiting D. Failure to thrive

Choice C is correct. The earliest sign of digitalis toxicity is vomiting. One episode, however, does not warrant discontinuing the medication. Digoxin increases the force of myocardial contraction, decreases conduction through the SA and AV nodes, and prolongs the refractory period of the AV node. The result is increased cardiac output and reduced heart rate. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hours after a dose is administered, although they are usually drawn immediately before the next dose. In infants and small children, the first symptoms of overdose are typically cardiac arrhythmias.

A 28-year-old woman is status-post thyroidectomy and has stayed at the post-anesthesia care unit for several hours. She is now ready to return to her room. Which action demonstrates that the nurse understands the possible complications of a thyroidectomy? A. Dressings are done every 2 hours to best detect postoperative bleeding, so the nurse should place the dressings at the bedside. B. Pain is managed the moment the client returns to her room by administering narcotics promptly. C. The bedside is ready with a tracheostomy set, oxygen, and suction. D. The nurse teaches the client alternative means of communication.

Choice C is correct. The most serious complication after a thyroidectomy is ineffective airway and breathing pattern because of tracheal compression and edema. It is essential to have a tracheostomy set, oxygen, and suction available at the bedside for at least 24 hours postoperatively. The client may have difficulty communicating due to laryngeal edema or nerve damage, but it most commonly occurs due to endotracheal intubation. The client will still be able to talk but may experience hoarseness of the voice.

Which of the following clients is the most likely to receive total parenteral nutrition? A. A client who is adversely affected with dysphagia. B. A client who is adversely affected with aphasia. C. A client with a dangerous positive nitrogen balance. D. A client with a dangerous negative nitrogen balance.

Choice D is correct. A client with a dangerous negative nitrogen balance is most likely to receive total parenteral nutrition (TPN). For example, a client who has endured a severe burn injury may have a negative nitrogen balance, which requires the administration of total parenteral nutrition. Amino acids are building blocks of proteins and nitrogen is an essential component of amino acids. Therefore, protein metabolism can be determined by measuring nitrogen balance. Nitrogen balance is given by subtracting nitrogen output from nitrogen input. A negative balance means the amount lost is greater than the amount ingested. A negative nitrogen balance is used to assess malnutrition. Clients with severe negative nitrogen balance will benefit from total parenteral nutrition. Other conditions where total parenteral nutrition is indicated include advanced cancer, advanced acquired immunodeficiency disorder, and severe gastrointestinal disease, which requires complete bowel rest. Choice A is incorrect. A client who is adversely affected with dysphagia would not likely receive total parenteral nutrition. A client who is adversely affected by dysphagia would most likely receive enteral nutrition rather than parenteral nutrition to meet their nutritional needs. Enteral nutrition can be given via tube feedings in the setting of dysphagia. Choice B is incorrect. A client who is adversely affected with aphasia would not likely receive parenteral nutrition. A client who is negatively affected by aphasia has a communication disorder, rather than a nutritional disease or nutritional need. Choice C is incorrect. A client with a dangerous positive nitrogen balance would not be likely to receive parenteral nutrition to meet their nutritional needs. Additional protein is not necessary.

The nurse manager is working on a unit where his nursing staff is not comfortable taking care of patients from other cultural backgrounds. What is the most appropriate action for the manager? A. Let the staff research different articles regarding various cultures so they become more familiar with them. B. Transfer the nurses to another unit where they can't be assigned to patients from other cultures. C. Rotate the nurses' assignments so they can all have the opportunity to take care of patients from other cultures. D. Organize an activity that offers opportunities for the staff to learn about the cultures they might encounter at work.

Choice D is correct. An activity like a workshop is an excellent opportunity for staff to learn about new cultures and to identify their feelings towards other religions. They also have a chance to ask questions.

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.

The nurse is planning a staff educational conference about indwelling urinary catheters. Which of the following information should the nurse include? A. Sterile gloves should be used to perform urinary catheter care. B. Urinary specimens may be collected from a catheter bag. C. You may irrigate a catheter with warm water for poor outflow. D. Daily use of soap and water should be used around the urinary meatus.

Choice D is correct. Daily cleaning of the urinary meatus with soap and water is recommended for catheter care. Sterile gloves do not need to be used for this process as it is a clean procedure. Soap and water is an acceptable practice for daily catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the urinary meatus.

The physician places an order to administer gentamicin via IV for a client with acute diverticulitis. It is important for the nurse to know that IV gentamicin is administered: A. Over 1 minute as I.V. push B. Over 2 minutes as I.V. push C. As an I.V. side drip over 15-20 minutes D. As an I.V. side drip over 30-60 minutes

Choice D is correct. Gentamicin is an aminoglycoside that is nephrotoxic. Because of this, it should be administered slowly by intermittent infusion. The recommended duration of infusion for administration is 30-60 minutes.

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 with stress among both diabetic and non-diabetic clients. This hyperglycemia occurred as the result of increased secretion of glucocorticoids and increased gluconeogenesis that is part of the general adaptation syndrome and the "fight or flight" phenomena.

The nurse is caring for a patient with post-gastrectomy dumping syndrome. What teaching should the nurse provide for this patient? 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 10-15 minutes after every meal. D. Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content.

Choice D is correct. The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands. Choice A is incorrect. Patients experiencing dumping syndrome should be instructed to avoid drinking during meals to prevent fullness and distention. Patients should drink in between meals at least 30-45 minutes before or 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 performs an EKG on a 62-year-old female and sees the rhythm shown below. What treatment should the nurse recommend that the doctor order? (torsades de pointe) A. Sodium supplement B. Potassium rider C. Calcium rider D. Magnesium rider

Choice D is correct. This patient is demonstrating an EKG rhythm called Torsades de pointes. It is a polymorphic ventricular tachycardia that can be caused by low magnesium levels. The treatment for this patient is the management of symptoms, including cardiac arrest and IV magnesium to increase magnesium levels. Choice A is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium. Choice B is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium. Choice C is incorrect. Torsades de pointes is caused by low magnesium levels and can be corrected by administering IV magnesium.

A nurse is caring for an 80-year-old client with acute renal failure and severe anemia. The health care provider (HCP) orders two units of packed red blood cells (PRBCs) to be transfused. The nurse receives the first unit of PRBCs from the blood bank at 0845. When would the transfusion of the first unit be completed? A. 1400 B. Between 1000 and 1345 C. Within 30 minutes D. Between 1030 and 1245

Choice D is correct. This time interval is the timeframe in which the infusion would conclude if the infusion is performed based on the standard of practice for infusing one unit of packed red blood cells (PRBCs), which is between 90 minutes and 4 hours. Additionally, (1) according to the "30-minute rule," a nurse must always initiate the infusion within 30 minutes of receiving the blood product from the blood bank (if a delay is anticipated in initiating the transfusion, the nurse must return the blood product within 30 minutes to the blood bank), and (2) the transfusion must be completed within four hours of removal of blood products from controlled temperature storage (i.e., known as the "4-hour rule"), as durations longer than four hours increase the risk of bacterial growth. Therefore, the nurse may initiate the PRBCs anytime between 0845 (although unrealistic, as the nurse must cross-check the blood with another nurse) and 0915, infusing the product for a duration ranging from 90 minutes to a maximum of 4 hours, depending on the time of initiation.

Which of the following medications would the nurse expect to administer to her patient presenting with an intussusception? sata A. Cefazolin B. Lactated Ringers C. Metoprolol D. Ranitidine

Choices A and B are correct. Cefazolin is a broad-spectrum antibiotic commonly used before or after surgeries as a prophylactic antibiotic. It is a cephalosporin antibiotic. It is used when a surgical repair of intussusception is performed to prevent infection. If intussusception is complicated by infection or peritonitis, antibiotics are used for treatment purposes (Choice A). Lactated Ringers is an isotonic crystalloid solution used for maintenance IV hydration in a patient with intussusception. Intussusception is often accompanied by vomiting and severe dehydration. Aggressive hydration is therefore needed to prevent dehydration and shock (Choice B).

The nurse is caring for a client with atrial fibrillation who takes prescribed warfarin. Which alternative therapies should the nurse advise this patient to avoid? Select all that apply. A. Ginger root B. Aloe vera C. Garlic D. Ginko biloba E. Saw palmetto

Choices A, C, D, and E are correct. The client taking prescribed warfarin should avoid alternative therapies that may potentiate the anticoagulant effects and increase bleeding risk. Alternative therapies such as Ginkgo Biloba, ginger root, garlic, and saw palmetto increase the bleeding risk in a client taking warfarin. The client should be advised against taking these medications.

You are working with a patient who suffers from obsessive-compulsive disorder (OCD). They are obsessed with the dangers of germs and compulsively wash their hands hundreds of times per day. Their skin has become red and raw. Which of the following should be included in the treatment plan for this patient? A. Create a schedule for the hand washing ritual. B. Teach them about the dangers of over washing their hands. C. Add time for meditation to their daily schedule. D. Remove the sink from their room so they are unable to wash their hands.

Choices A and C are correct. Creating a schedule is one of the most critical aspects of treatment for patients with obsessive-compulsive disorder (OCD). In this schedule, it is essential to allow time for their compulsive ritual. This may sound counterintuitive, but not allowing any time for the ritual will dramatically increase their anxiety. This will not be therapeutic. Instead, we must gradually decrease the amount of time which they are allowed to practice the ritual (for example, only washing hands for 5 minutes at a time rather than 10 minutes), and increase the amount of time left between the ritual (for example, waiting 1 hour between hand washings instead of just 10 minutes) (Choice A). Adding time into the daily schedule for meditation is an appropriate intervention. Meditation is an excellent coping mechanism that the client can learn. This can be added in to replace some of their handwashing. Gradually they can spend more and more time practicing meditation and other appropriate coping mechanisms, and less and less time performing the ritual of handwashing (Choice C). Choice B is incorrect. Teaching the client about the dangers of over washing their hands will not be practical or therapeutic. This client is using the ritual of handwashing unconsciously to relieve their anxiety. They are not able to stop and will not be any more inclined to stop if they know it is terrible for them. Choice D is incorrect. Not allowing any time for the ritual is not an appropriate action for the patient with OCD. It is essential to allow time for their compulsive ritual. Not allowing any time for the behavior will dramatically increase their anxiety. This will not be therapeutic. Instead, we must gradually decrease the amount of time which they are allowed to practice the ritual (for example, only washing hands for 5 minutes at a time rather than 10 minutes), and increase the amount of time left between the ritual (for example, waiting 1 hour between hand washings instead of just 10 minutes). The ritual should never be taken away without replacing it with appropriate coping mechanisms.

Which of the following are signs of brainstem involvement in a pediatric patient with a neurologic injury? (SATA) A. Dilated pupils B. Narrowing pulse pressure C. Bradycardia D. Tachypnea

Choices A and C are correct. Sluggish, dilated, or unequal pupils are all signs of brainstem involvement and should be reported to the healthcare provider immediately (Choice A). Bradycardia, slowing of the pulse, or wide fluctuations in the heart rate are all signs of brainstem involvement and should be reported to the healthcare provider immediately (Choice C). Choice B is incorrect. A widening pulse pressure or fluctuations in blood pressure are signs of brainstem involvement. Choice D is incorrect. Deep or intermittent and gasping respirations, not tachypnea, are signs of brainstem involvement and should be reported to the healthcare provider immediately

When reviewing your client's labs in the morning, you note that his magnesium level is 3.4 mEq/L. On exam, his reflexes are decreased. Which of the following actions is appropriate? SATA A. Administer calcium gluconate. B. Repeat another level stat and continue monitoring. C. Notify the healthcare provider. D. Administer Sevelamer hydrochloride.

Choices A and C are correct. This magnesium level is critically high and must be addressed immediately. Calcium gluconate is administered as a treatment for hypermagnesemia and is appropriate to deliver as ordered. The healthcare provider should be notified right away. Decreased reflexes, headaches, confusion, and hypotension, may be seen with moderate hypermagnesemia.

The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications? SATA A. Diltiazem B. Nitroglycerin C. Clonidine D. Atorvastatin E. Warfarin

Choices A and E are correct. Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke.

The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply. A. Fever B. Night sweats C. Osler nodes D. Cardiac murmur E. Syncope F. Weight loss

Choices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other physical manifestations that may be assessed with IE include a cardiac murmur, Janeway lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of feet). Choice E is incorrect. Syncope is not a clinical feature of IE. This would be associated if the client was to have a vasovagal reaction.

The nurse is observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? SATA A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow. B. Obtains orthostatic blood pressure by having the client stand first. C. Places the cane on the unaffected side of a client who had a stroke. D. Provides a hot foot soak for a client with diabetes mellitus. E. Obtains a urine culture from an indwelling urinary catheter.

Choices A, B, D, and E are correct. When supervising a UAP, the nurse should intervene if the UAP is flexing and extending the client's elbow as that is not an active range of motion. The UAP doing the exercise for the client would be considered a passive range of motion ( Choice A). The UAP starting the orthostatic vital signs with the client standing is inappropriate. The correct sequence is supine, sitting, and standing when obtaining orthostatic blood pressures ( Choice B). During the orthostatic vitals, the observer looks for a drop in the blood pressure when the client stands up from a lying or sitting position. Neuropathy is a common manifestation in diabetic clients. Loss of sensation in the feet resulting from diabetic neuropathy may impair the client's ability to remove the feet despite the heat damage. A client with diabetes mellitus should not have feet soaked in hot water, which could impair their skin integrity and cause ulceration ( Choice D). Finally, UAPs may not perform any tasks involving sterility. This includes aspirating urine from an indwelling catheter's tubing using a sterile syringe. UAP can collect urine specimens from the urine bag for other tests. However, obtaining a specimen for urine culture ( Choice E) is a sterile procedure because contaminated urine can lead to false positive results. A sterile syringe and sterile specimen container are used during this procedure.

Which of the following statements is true regarding fetal circulation? Select all that apply. A. There are high pressures in the fetal lungs causing decreased pulmonary circulation. B. Blood shunts from left to right in the fetal circulation. C. The ductus venosus allows freshly oxygenated blood to go to the fetal brain first. D. There are higher pressures in the right atrium in the fetal circulation.

Choices A, C, and D are correct. A is correct. In fetal circulation, the alveoli are filled with fluid. This causes high pressures in the fetal lungs, which shunts blood away from the pulmonary circulation. C is correct. The ductus venosus is a bypass in fetal circulation that shunts blood away from the weak fetal liver and to the brain. This allows the brain to get fresh oxygen first. D is correct. The pressures on the right side of the heart are higher in fetal circulation than on the left side of the heart. Choice B is incorrect. Blood shunts from right to left in the fetal circulation; this is due to increased pulmonary pressures caused by the fluid-filled alveoli. The high pulmonary pressures increase pressure on the right side of the heart, creating a gradient across the foramen ovale shunting blood from right to left.

Which of the following are a type of social support? Select all that apply. A. An emotional social support B. An informational social support C. A physical help social support D. A sensory social support E. An instrumental social support F. An appraisal social support

Choices A, B, E, and F are correct: Choice A is correct. An emotional, social support is one type of social support. Passionate social support people and networks provide clients with the emotional and psychological support that is often needed to decrease client stress and enhance client coping. Choice B is correct. An informational social support is one type of social support. Informational social support people and networks provide clients with the knowledge and skills needed to adapt to and cope with a stressor. Choice E is correct. An instrumental social support is one type of social support. Helpful social support people and networks provide clients with tangible help, for example: transportation and household help. Choice F is correct. An appraisal of social support is one type of social support. Appraisal social support people and networks provide clients with the opportunity to gain insight and to self evaluate their strengths and limitations. Choices C and D are incorrect: Choice C is incorrect. Physical help social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems. Choice D is incorrect. Sensory social support is non-existent. The four types of social support are informational, emotional, instrumental, and appraisal support systems.

The nurse performs a physical assessment on a client. Which of the following would the nurse recognize as a technique of inspection? Select all that apply. A. Ecchymosis to sacral area. B. Foul odor noted to urine. C. Jugular veins distended. D. Abdomen is tympanic. E. Bowel sounds hyperactive.

Choices A, B, and C are correct. Assessing that the client has bruising over the sacral area is achieved by visually inspecting the skin. Noting the presence of a foul odor is an example of inspection that uses the sense of smell. The nurse would inspect the client's neck to note visible jugular vein distension. Choices D and E are incorrect. Assessment of tympany in the abdomen is obtained through percussion and is typically observed over areas of air-filled organs such as the intestines. Assessment of the bowel sounds is obtained through auscultation with a stethoscope.

Which of the following signs and symptoms would you expect in a patient diagnosed with Graves Disease? SATA A. Diaphoresis B. Exophthalmos C. Weight gain D. Increased appetite

Choices A, B, and D are correct. A is correct. Diaphoresis, or excessive sweating, would be expected in a patient with Graves Disease. Due to their increase in thyroid hormone, they have too much energy and a metabolism that is working too fast. This can cause increased body temperature and sweating. B is correct. Exophthalmos, or bulging eyeballs, is a severe sign of Graves Disease. Once the disease has progressed to this point, the exophthalmos is irreversible. D is correct. Increased appetite is a symptom of Graves Disease. Due to the increase in metabolism, these patients experience an increase in taste, but a significant weight loss. Choice C is incorrect. Weight loss, not gain, is a symptom of Graves Disease. Due to the increase in metabolism, these patients experience an increase in appetite, but a significant weight loss.

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. A. Diabetes mellitus B. Menieres disease C. Excessive cerumen D. Exposure to loud noise E. 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 on incident reports. Which of the following situations would require an incident report? Select all that apply. A visitor: A. refusing to wear personal protective equipment (PPE). B. activating a client's patient-controlled analgesia (PCA) device. C. requesting that their family member get pain medication. D. assisting their family member with brushing their teeth. E. stating that they fell while using the bathroom.

Choices A, B, and E are correct. Incident (sometimes termed occurrence or event) reporting is required when any activity deviates from the norm. Incident reporting may be completed for visitors. Events that warrant reporting would include the refusal to wear PPE, activating a client's PCA device, and stating that they fell while using the bathroom. Choices C and D are incorrect. A visitor advocating for a client to receive pain medication does not require reporting—the same for a visitor assisting a client with oral hygiene.

The nurse is assessing a client with pheochromocytoma. Which of the following would be an expected finding? SATA A. Hyperglycemia B. Hypertension C. Ataxia D. Oliguria E. Headache

Choices A, B, and E are correct. Manifestations of pheochromocytoma include hyperglycemia, hypertension, and headache. Other features associated with this condition include weight loss, anxiety, and palpitations. Choices C and D are incorrect. Ataxia, or uncoordinated movements, is not a feature of pheochromocytoma. Oliguria, or low urine output, is also not a feature of this condition. This would be a feature consistent with the syndrome of inappropriate antidiuretic hormone (SIADH).

The nurse is caring for a client whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms can be attributed to the client's sodium level? sata A. Lethargy B. Dry mucous membranes C. Tachypnea D. Cyanosis E. Excessive thirst

Choices A, B, and E are correct. Sodium plays a very important role in the brain, so imbalances in the serum sodium level can cause major neurological changes. The patient who is hypernatremic, or has a sodium level greater than 145 mEq/L, is at risk for changes in their level of consciousness ranging from restlessness and agitation to lethargy (Choice A), stupor, and coma. A patient who has a high sodium level will often have dry mucous membranes. Hypovolemic hypernatremia is the most common form of hypernatremia. Other causes include renal losses of free water (osmotic diuresis, post obstructive diuresis) or extrarenal losses (diarrhea, sweating, increased insensible losses). Therefore, the patient is often dehydrated and this fluid volume deficit is manifested by dry mucous membranes (Choice B) and excessive thirst (Choice E). Dry mucosa may also be secondary to the relationship sodium has with water. Water follows sodium, so where there is an increased level of sodium in the extracellular space, water leaves the cells and follows the sodium into the extracellular space. This causes dry mouth and mucous membranes.

Which of the following are appropriate to include in a teaching plan for a teen with acne? Select all that apply. A. Wash the skin twice daily with a mild cleanser and warm water. B. Use cosmetics liberally to cover blackheads. C. Use emollients on the affected areas. D. Squeeze blackheads as soon as they appear. E. Keep hair off the face and wash hair daily.

Choices A, E, and F are correct. Washing the skin removes oil and debris. Hair should be kept away from the face and washed daily to help prevent oil from the hair from getting on the forehead. Sunbathing should be avoided when using acne treatments. Acne is a condition that is characterized by clogged pores caused by dead skin cells and sebum sticking together in the orifice. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large number of bacteria inside, the pore becomes inflamed. If the inflammation goes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms, and buttocks. Treatment includes avoiding squeezing or picking the infected areas, as this may spread the infection and cause scarring. The face should be washed twice daily with a mild cleanser and warm water. Oil-free, water-based moisturizers and make-up should be used.

Which of the following signs and symptoms are characteristic of pyloric stenosis? Select all that apply. A. Weight gain B. Projectile vomiting C. Olive-shaped mass D. Anorexia

Choices B and C are correct. B is correct. Projectile vomiting, especially right after a feeding, is the characteristic sign of pyloric stenosis. Since the pylorus, the opening from the stomach into the duodenum, is hardened and stiffened, it does not allow food to pass from the stomach into the duodenum. This means that after a feeding, the food cannot pass down, so it comes up in the form of projectile vomiting. C is correct. An olive-shaped mass, specifically in the epigastric region near the umbilicus is a tell-tale sign of pyloric stenosis. This is the enlarged stiffened pylorus. Choice A is incorrect. The client experiencing pyloric stenosis would present with weight loss, not weight gain. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting. The inability to keep food and fluids down will lead to weight loss. Choice D is incorrect. Anorexia, or lack of appetite, is not a characteristic of pyloric stenosis. These patients are always hungry, because they cannot keep anything down. They are constantly trying to eat, and vomit back up due to the enlarged and stiffened pylorus not allowing food to advance to the duodenum.

You are taking care of a 45-year-old female who is being treated with electroconvulsive treatment (ECT) for severe depression. After her treatment today, which of the following nursing interventions are appropriate? Select all that apply. A. Position her supine with the head of the bed at 30 degrees B. Reorient the patient frequently C. Remain with the patient at all times D. Promote bedrest for 12-24 hours

Choices B and C are correct. It will be a very important nursing intervention to frequently reorient the patient who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be very confused and disoriented. Due to this disorientation, they will likely be scared; to make them feel safe and secure the nurse will need to frequently reorient them to their place and situation (Choice B). It will be a very important nursing intervention to remain with the patient who has just received electroconvulsive therapy. A side effect of electroconvulsive therapy is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them at all times to keep them safe (Choice C). Choice A is incorrect. Supine with the head of the bed at 30 degrees is not the best position for a patient who has just had electroconvulsive therapy. This patient is at risk for aspiration, so the appropriate positioning is on her side. This will prevent anything from entering her airway and causing an aspiration event. Supine with the head of the bed at 30 degrees would be the appropriate positioning for a patient 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 the patient who has just received electroconvulsive therapy. After they are awake and re-oriented, it is best to promote activity and get them back to their normal routine. Staying active is an important part of treating depression, so bed rest is not appropriate for this patient.

You are assessing a 4-year-old preschooler and note the following vital signs: Pulse: 146 RR: 42 BP: 72/48 Which of the following actions are appropriate given these vital signs? Select all that apply. A. Continue to assess further B. Notify the healthcare provider C. Administer IV fluids, as ordered by the provider D. Document the vital signs as normal for a preschooler

Choices B and C are correct. These vital signs are not within the normal limits for a preschooler. Typical vital signs for a preschooler are: Pulse: 80-120, RR: 20-30, and BP: 95/65. This 4-year-old is tachycardic, tachypneic, and hypotensive. The blood pressure should jump out at you as a significant concern. Hypotension is a late sign of distress in children - this patient is in shock. Their heart rate is increasing above normal to compensate for the decreasing cardiac output and perfusion to the rest of the body. They are breathing faster to exhale as much carbon dioxide as possible - they are almost surely in a state of acidosis and need to get rid of that acid. They are trying to compensate, but their body is getting tired and becoming hypotensive. With a blood pressure this low in a 4-year-old, they do not perfuse their vital organs, and immediate action is warranted. B is correct. This is an appropriate action. The health care provider should be notified immediately. The nurse has identified that the child is in shock and should immediately notify the healthcare provider. C is correct. This is an appropriate action. The nurse has identified that the child is in shock due to their hypotension and tachycardia. She notifies the health care professional and is expecting an order for IVF. This will help increase the blood pressure to provide perfusion to the vital organs. This is an appropriate action.

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? sata A. Furosemide B. Neomycin C. Naproxen D. Lactulose E. Diazepam

Choices B and D are correct. Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Choices A, C, and E are incorrect. Potassium-wasting diuretics such as furosemide should be avoided because it contributes to hypokalemia. Hypokalemia contributes to the production of ammonia. Thus, a highly preferred diuretic in mitigating ascites is potassium-sparing diuretic spironolactone. NSAIDs should be avoided because of their nephrotoxic and anticoagulation effects. Low doses of acetaminophen may be approved for mild to moderate pain. Benzodiazepines, such as diazepam, should be avoided for a client with hepatic encephalopathy. These medications can worsen a client's sensorium, putting the client at high risk for falls and injury.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. A. Liver function tests B. Creatinine C. Thyroid-stimulating hormone D. Sodium E. Potassium

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity). Choice A is incorrect. Lithium is not hepatically metabolized, and monitoring the liver function tests is irrelevant. Potassium levels would not influence lithium the way sodium does. Thus, sodium is the essential electrolyte to monitor.

The nurse is caring for a client with hyperkalemia. Which of the following treatments would the nurse recognize as appropriate options for treating this electrolyte imbalance? Select all that apply. A. Spironolactone B. Sodium polystyrene C. Regular insulin D. Hemodialysis E. Magnesium sulfate

Choices B, C, and D are correct. Sodium polystyrene is a medication that causes potassium to be excreted in the feces. This lowers the amount of potassium in circulation and is an appropriate treatment for hyperkalemia. Regular insulin is a standard and effective treatment for hyperkalemia. The standard dose is ten units given by intravenous push. Hemodialysis is an appropriate treatment for hyperkalemia. Hemodialysis can remove potassium from the blood. Choice A is incorrect. Spironolactone is a potassium-sparing diuretic. Therefore it increases the potassium that is reabsorbed and put back in circulation. This would increase serum potassium. Magnesium sulfate would have no relevance to treating either hypo or hyperkalemia. However, during a potassium disturbance, it is common for clinicians to assess the magnesium level to determine if that level is altered.

A nurse is caring for a client following the surgical repair of a detached retina in the client's right eye. Which nursing action(s) should the nurse include in the client's plan of care? Select all that apply. A. Position the client in a prone position B. Approach the client from the left side C. Instruct the client to perform deep breathing and coughing exercises D. Instruct client to avoid bending down E. Orientate the client to the environment F. Obtain a prescription for a stool softener

Choices B, D, E, and F are correct. Choice B is correct. The nurse should always approach the client from the unaffected side. Here, the nurse would approach this client from the client's left side to avoid startling the client. Choice D is correct. Activities that increase intraocular pressure, such as bending down, should be avoided. Choice E is correct. In order to prevent unwarranted injury, the client should always be oriented to his or her environment. Choice F is correct. A prescription for a stool softener is provided for multiple reasons. First, activities that increase intraocular pressure should be avoided. Since constipation and straining during defecation often increase intraocular pressure, stool softeners are administered to prevent constipation prophylactically. Second, any use of opioid pain medication during the surgical or postoperative procedure would likely inhibit gastrointestinal and colonic motility. A stool softener would assist in alleviating this medication side effect.

The nurse is assessing a client who has developed cardiac tamponade. Which of the following findings would the nurse expect to observe? A. Bibasilar crackles B. A systolic murmur C. Bradycardia D. Jugular Venous Distention E. Hypotension

Choices D and E are correct. Classic manifestations of cardiac tamponade include tachycardia, tachypnea, pericardial rub, jugular venous distention, and hypotension with a narrowed pulse pressure. Choices A, B, and C are incorrect. Bibasilar crackles, a systolic murmur, and bradycardia would not be consistent with cardiac tamponade. The client with cardiac tamponade would have tachycardia to increase cardiac output, coupled with a pericardial friction rub if the tamponade is caused by inflammation.