ATI Practice B 201

A home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? - Place the client in high-Fowler's position. - Encourage the client to perform diaphragmatic breathing. - Instruct the client to perform a huff-coughing technique. - Administer a nebulized bronchodilator.

- Place the client in high-Fowler's position.MY ANSWERAccording to evidence-based practice, the first action the nurse should take is to place the client in an upright, or high-Fowler's, position to facilitate ease of breathing. - Encourage the client to perform diaphragmatic breathing.The nurse should encourage the client to perform diaphragmatic breathing to help manage episodes of dyspnea. However, according to evidence-based practice, there is another action the nurse should take first. - Instruct the client to perform a huff-coughing technique.The nurse should instruct the client to perform a huff-coughing technique to improve gas exchange by opening the larger airways. However, according to evidence-based practice, there is another action the nurse should take first. - Administer a nebulized bronchodilator.The nurse should administer a nebulized bronchodilator to open the airways and ease the client's breathing. However, according to evidence-based practice, there is another action the nurse should take first.

A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse intruct the parent to report to the provider?

- Swollen cervical lymph nodes The nurse should not instruct the parent to report swollen cervical lymph nodes because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Exudate on tonsils The nurse should not instruct the parent to report exudate on tonsils because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Lack of energy The nurse should not instruct the parent to report lack of energy because this is an expected manifestation of infectious mononucleosis. Other manifestations include fever and sore throat. - Onset of abdominal pain MY ANSWER: The nurse should instruct the parent to report the onset of abdominal pain to the provider because this is an indication of splenomegaly. Splenic hemorrhage or rupture can occur and is usually caused by trauma.

A nurse is assessing a client Urinary burning who has acute pyelonephritis.Which of the following findings should the nurse expect? - Pain with palpation to the substernal notch - Urinary burning - Ecchymosis over the flank - Radiating pain to the right shoulder

- Urinary burning - Pain with palpation to the substernal notchA client who has acute pyelonephritis can have discomfort in the back and flank areas. Tenderness can also be elicited by palpating the costovertebral angle, not the substernal notch, which is located at the top of the rib cage. - Urinary burningMY ANSWERA client who has acute pyelonephritis can experience burning, frequency, and urgency with urination. - Ecchymosis over the flankA client who has urolithiasis and was treated with lithotripsy can have ecchymosis over the flank area of the kidney following the procedure. - Radiating pain to the right shoulderA client who has cholecystitis can develop radiating pain to the right shoulder.

A nurse is preparing to mix NPH insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow.

1. Inject air into the vial equal to the amount of NPH insulin prescribed 2. Inject air into the vial equal to the amount of insulin aspart prescribed 3. Withdraw the prescribed volume of insulin aspart into the syringe 4. Withdraw the prescribed volume of NPH insulin into the syringe The nurse should always withdraw short-acting insulin before long-acting insulin to avoid contaminating the short-acting vial. The nurse should first prepare the NPH insulin vial by filling the syringe with air equal to the amount prescribed and injecting it into the NPH vial. Then, the nurse should prepare the insulin aspart vial by filling the syringe with air equal to the amount prescribed and inject it into the insulin aspart vial. With the syringe still in the insulin aspart vial, the nurse should withdraw the correct dose of medication into the syringe. Finally, the nurse should withdraw the correct dose of NPH insulin into the syringe.

A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? - "Avoid giving aspirin to your child." - "Place your child in a cool bath for 20 minutes twice per day." - "Lower the room temperature to stimulate shivering." - "Give eight doses of acetaminophen in 24 hours according to the child's weight."

Avoid giving aspirin to your child - "Avoid giving aspirin to your child."MY ANSWERThe nurse should instruct the parent to not administer aspirin to the child to treat a fever. Aspirin increases the risk for Reye syndrome in children and adolescents who have viral infections, such as chickenpox. - "Place your child in a cool bath for 20 minutes twice per day."The nurse should not instruct the parent to place the child in a cool bath to treat his fever. Cool baths can cause discomfort for the child and do not lower a fever. - "Lower the room temperature to stimulate shivering."The nurse should not instruct the parent to lower the room temperature to stimulate shivering, as this will increase the child's temperature because shivering produces heat. - "Give eight doses of acetaminophen in 24 hours according to the child's weight."The nurse should not instruct the parent to administer eight doses of acetaminophen in 24 hr because this is above the safe dosage range for a child. The parent should administer acetaminophen according to the child's weight and should not administer more than five prescribed doses in 24 hr.

A nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? - Cold intolerance - Diaphoresis - Weight loss - Tachycardia

Cold intolerance - Cold intoleranceMY ANSWERThe nurse should expect a client to have cold intolerance, weight gain, poor wound healing, bradycardia, hypotension, depression, constipation, and decreased body temperature as manifestations of hypothyroidism. - DiaphoresisThe nurse should expect diaphoresis as a manifestation for a client who has hyperthyroidism. - Weight lossThe nurse should expect weight loss as a manifestation for a client who has hyperthyroidism. - TachycardiaThe nurse should expect tachycardia as a manifestation for a client who has hyperthyroidism.

A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? -LDL 168 mg/dL -HDL 50 mg/dL -Total cholesterol 268 mg/dL -Triglycerides 250 mg/dL

HDL 50 mg/dL - LDL 168 mg/dLThis finding does not indicate that the client has achieved a therapeutic response from a lifestyle change because the LDL is greater than the expected reference range of less than 130 mg/dL for adult clients. - HDL 50 mg/dLMY ANSWERThis finding indicates that the client has achieved a therapeutic response from a lifestyle change because the HDL is within the expected reference range of greater than 45 mg/dL for an adult male client. - Total cholesterol 268 mg/dLThis finding does not indicate that the client has achieved a therapeutic response from a lifestyle change because the total cholesterol is greater than the expected reference range of 200 mg/dL or below for adult clients. - Triglycerides 250 mg/dLThis finding does not indicate that the client has achieved a therapeutic response from a lifestyle change because the triglycerides are greater than the expected reference range of 40 to 160 mg/dL for an adult male client.

A nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? - Heredity - Gender - Anemia - Hypoglycemia

Heredity - HeredityMY ANSWERThe nurse should identify that a common risk factor for glaucoma is heredity. Other risk factors can include aging, central retinal vein occlusion, hypertension, diabetes mellitus, retinal detachment, and severe myopia. - GenderGender is not a risk factor for the development of glaucoma. - AnemiaAnemia is not a risk factor for the development of glaucoma. - HypoglycemiaHypoglycemia is not a risk factor for the development of glaucoma.

A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? - Fruity-scented breath - Serum glucose 350 mg/dL - pH 7.32 - Hypotension

Hypotension - Fruity-scented breathThe client who has diabetic ketoacidosis can have the manifestation of fruity-scented breath caused by increased ketone levels. Clients who are in a hyperglycemic-hyperosmolar state do not develop ketone bodies. - Serum glucose 350 mg/dLThe client who is in a hyperglycemic-hyperosmolar state can have a serum glucose level greater than 600 mg/dL. A client who has diabetic ketoacidosis will have a serum glucose level greater than 300 mg/dL. - pH 7.32The client who has diabetic ketoacidosis will have a decreased pH level, or acidosis. The client who is in a hyperglycemic-hyperosmolar state maintains enough insulin to prevent the development of ketosis and acid-base imbalance. - HypotensionMY ANSWERThe client who is in a hyperglycemic-hyperosmolar state develops hypotension as a result of highly elevated glucose levels, inability of the kidneys to regulate blood osmolarity, and increased diuresis.

A nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? - Bacterial infection with Escherichia coli - Long-term use of NSAIDs - Frequent use of proton pump inhibitors - A diet that includes spicy foods

Long-term use of NSAIDs - Bacterial infection with Escherichia coliInfection with Helicobacter pylori is a risk factor for the development of peptic ulcers. E. coli is a bacteria commonly found in the intestine. - Long-term use of NSAIDsMY ANSWERLong-term use of medications, such as NSAIDs and glucocorticoids, increases the risk for peptic ulcers. - Frequent use of proton pump inhibitorsProton pump inhibitors alter the pH of the stomach by suppressing the release of gastric acid. This group of medications is used in the treatment of peptic ulcers. A risk factor for the development of peptic ulcers is increased gastric acid secretion. - A diet that includes spicy foodsAlcohol and caffeine use can contribute to the development of peptic ulcers; however, spicy foods are not an associated risk factor.

A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? - Slowly institute rewarming of the affected areas. - Place the affected areas of frostbite in a warm water bath. - Massage the affected areas of frostbite. - Position the affected areas of frostbite flat after warming.

Place the affected areas of frostbite in a warm water bath - Slowly institute rewarming of the affected areas.The nurse should rapidly institute rewarming of the affected areas until circulation is restored to limit tissue loss. - Place the affected areas of frostbite in a warm water bath.MY ANSWERThe nurse should place the client's affected areas of frostbite in a warm water bath with a temperature of 37° to 42.2° C (98.6° to 108° F) to thaw the affected areas of frostbite. - Massage the affected areas of frostbite.Massaging the client's affected areas of frostbite can cause further tissue damage. - Position the affected areas of frostbite flat after warming.The nurse should elevate the client's affected areas of frostbite above the heart after warming to decrease the potential for developing edema.

A nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect? - Heart rate 64/min - Tall T waves - Shortened PR interval - QRS 0.08 seconds

Tall T-waves - Heart rate 64/minThe nurse should identify that a heart rate of 64/min is within the expected reference range of 60 to 100/min. The nurse should monitor the client for bradycardia or tachycardia as indications of hyperkalemia. - Tall T wavesMY ANSWERThe nurse should identify that a potassium level of 6 mEq/L is above the expected reference range of 3.5 to 5 mEq/L, indicating that the client has hyperkalemia. Tall T waves are a manifestation of hyperkalemia when the potassium level is greater than 6 mEq/L, which can affect the myocardium and impact the client's surgical risk. The nurse should report this elevated potassium level to the provider. - Shortened PR intervalThe nurse should expect a client who has hyperkalemia to have a lengthened PR interval of greater than 0.2 seconds. The expected reference range for the PR interval is 0.12 to 0.2 seconds. - QRS 0.08 secondsA client who has hyperkalemia will have a wide QRS complex that is 0.13 seconds or greater. The expected reference range for the QRS is 0.04 to 0.12 seconds.

A nurse is assessing a client whose parents recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? - The client lost his house in a house fire 1 month ago. - The client has retired after 30 years of employment. - The client's parent was an older adult. - The client's parent had a chronic terminal illness.

The client lost his house in a house fire 1 month ago - The client lost his house in a house fire 1 month ago.MY ANSWERThe nurse should identify that cumulative losses, the situational loss of a house unexpectedly due to a fire, combined with the loss of a family member, increases the client's risk for maladaptive grieving. - The client has retired after 30 years of employment.The nurse should identify that anticipatory grieving facilitates the client's grieving because the client had time to begin the grief process of leaving the work place after 30 years of employment before the actual leave occurred. - The client's parent was an older adult.The nurse should identify that the loss of a child or young person increases the client's risk for maladaptive grieving. The death of an older adult can be unexpected; however, there is the opportunity to prepare for the loss as the parent ages. - The client's parent had a chronic terminal illness.The nurse should recognize that an unexpected death increases the client's risk for maladaptive grieving. A chronic terminal illness of a family member provides the client with the opportunity to prepare for the loss.

A nurse is assessing a client who has developed Clostridium difficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. difficile? - Vancomycin - Magnesium hydroxide - Rifampin - Metoclopramide

Vancomycin - VancomycinMY ANSWERThe nurse should expect the provider to prescribe vancomycin to treat C. difficile. - Magnesium hydroxideMagnesium hydroxide is prescribed as a laxative, antacid, and for the treatment of hypomagnesemia. - RifampinRifampin is prescribed for the treatment of active tuberculosis. - MetoclopramideMetoclopramide is prescribed for the treatment of postoperative nausea and vomiting.

A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine? - Total bilirubin 0.8 mg/dL - WBC count 4,000/mm3 - Platelets 190,000/mm3 - Creatinine 1 mg/dL

WBC count 4,000/mm^3 Total bilirubin 0.8 mg/dLAdverse effects of sulfasalazine include drug-induced hepatitis and hemolytic anemia. Ulcerative colitis can increase total bilirubin levels. A total bilirubin level of 0.8 mg/dL is within the expected reference range of 0.3 to 1 mg/dL. WBC count 4,000/mm3MY ANSWERAgranulocytosis, or a very low WBC count, is an adverse effect of sulfasalazine. This condition results in a decreased WBC count. The nurse should identify that a WBC count of 4,000/mm3 is less than the expected reference range of 5,000 to 10,000/mm3, indicating an adverse effect of the medication. Platelets 190,000/mm3Thrombocytopenia is an adverse effect of sulfasalazine. This condition results in decreased levels of platelets. However, a platelet level of 190,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3. Creatinine 1 mg/dLA creatinine level of 1 mg/dL is within the expected reference range of 0.5 to 1.3 mg/dL. However, this medication is used with caution for client's who have renal impairment because it can result in increased levels of creatinine.

A nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching? - "I'll wash my feet every day with soap and lukewarm water." - "I'll apply lotion to my feet daily, especially in between my toes." - "It's okay for me to go barefoot in the house, but not outside." - "I'll soak my feet every evening before bedtime."

- "I'll wash my feet every day with soap and lukewarm water."MY ANSWERThe client should keep her feet clean to prevent abrasions and infection. A client who has diabetic neuropathy has reduced sensation in the feet. Therefore, the client should use an elbow or a thermometer to test the temperature of the water and ensure that it is lukewarm. Hot water can irritate the skin and lead to breakdown. - "I'll apply lotion to my feet daily, especially in between my toes."The client should not put lotion between her toes because this creates a moist environment that can increase the risk for fungal and bacterial infections. - "It's okay for me to go barefoot in the house, but not outside."The client should not walk without protective shoes and cotton socks, inside or outside. Walking barefoot increases the risk for injuries that can result in infection and ulceration. - "I'll soak my feet every evening before bedtime."The client should not soak her feet because this can cause maceration and vulnerability to infection.

A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A. Confusion B. Flushed, moist skin C. Hyperreflexia D. Bounding peripheral pulses

A. Confusion - ConfusionMY ANSWERThe client who has respiratory acidosis can display mental cloudiness or confusion due to elevated carbon dioxide (CO2) retention as a result of hypoventilation. - Flushed, moist skinThe client who has respiratory acidosis can have pale, cyanotic, and dry skin due to hypoventilation, causing CO2 retention. - HyperreflexiaThe client who has respiratory acidosis can have hyporeflexia due to hypoventilation, causing CO2 retention. - Bounding peripheral pulsesThe client who has respiratory acidosis from hypoventilation will have hypotension that can cause weak peripheral pulses. Hypotension is due to vasodilation from CO2 retention.

A nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect? A. Orthostatic hypotension B. Hoarse voice C. Neck vein distention D. Muscle twitching

A. Orthostatic hypotension - Orthostatic hypotension MY ANSWERThe nurse should monitor the client who has a sodium level of 124 mEq/L for orthostatic hypotension. The expected reference range for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia include decreased deep tendon reflexes, headache, confusion, and lethargy. - Hoarse voice Hoarse voice is not a manifestation of hyponatremia. - Neck vein distention Neck vein distention is a manifestation of hypernatremia. - Muscle twitching Muscle twitching is a manifestation of hypernatremia.

A nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider? - Black, tarry stools - Ringing in the ears - Urinary retention - Recent hallucinations

Black, tarry stools - Black, tarry stoolsMY ANSWERA life-threatening adverse effect of warfarin is bleeding. The nurse should identify that black, tarry stools are an indication that the client is experiencing gastrointestinal bleeding. The nurse should report this information to the provider. - Ringing in the earsTinnitus is not an adverse effect of warfarin. - Urinary retentionUrinary retention is not an adverse effect of warfarin. = Recent hallucinationsHallucinations are not an adverse effect of warfarin.

A nurse is assessing a 6-month- nasal flaring old infant who has bacterial pneumonia. Which of the following manifestations should the nurse expect? A. Protruding tongue B. Facial flushing C. Nasal flaring D. Tympany with chest percussion

C. Nasal flaring - Protruding tongueA protruding tongue is an expected manifestation of epiglottitis, not bacterial pneumonia. - Facial flushingInfants who have bacterial pneumonia can have manifestations of pallor or cyanosis due to decreasing oxygen saturation levels. - Nasal flaringMY ANSWERInfants who have bacterial pneumonia can exhibit manifestations such as nasal flaring and retractions of the intercostal and substernal spaces due to attempts to breathe in more oxygen to compensate for hypoxia. - Tympany with chest percussionInfants who have bacterial pneumonia will have dullness with chest percussion due to the consolidation of secretions in the lungs along with vascular congestion and inflammation of the alveolar walls.

A nurse is assessing a client for Oliguria manifestations of heat stroke.Which of the following findings should the nurse expect? A. Hypertension B. Somnolence C. Oliguria D. Bradycardia

C. Oliguria - Hypertension The nurse should expect a client who has heat stroke to manifest hypotension. - Somnolence The nurse should expect a client who has heat stroke to manifest agitation, anxiety, and bizarre behavior. - Oliguria MY ANSWER A client who has heat stroke will manifest a body temperature of 40° C (104° F) or greater, which can lead to dehydration and oliguria. Complications include multiple organ dysfunction syndrome, which includes renal impairment. The nurse should closely monitor the client's urine output and specific gravity to assist with determining fluid needs. - Bradycardia The nurse should expect a client who has heat stroke to manifest tachycardia.

A nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching? A. Increase daily intake of foods containing vitamin A. B. Limit alcohol consumption to 10 oz daily. C. Perform exercises to strengthen the abdominal core. D. Start a daily jogging regimen.

C. Perform exercises to strengthen the abdominal core. - Increase daily intake of foods containing vitamin A.The nurse should instruct the client to increase daily intake of calcium and vitamin D to decrease the rate of bone loss. - Limit alcohol consumption to 10 oz daily.The nurse should instruct the client to limit alcohol consumption to 5 oz daily to decrease the rate of bone loss. - Perform exercises to strengthen the abdominal core.MY ANSWERThe nurse should instruct the client to perform exercises to strengthen the abdominal and back muscles to maintain stability of the spinal column and prevent vertebral fractures. - Start a daily jogging regimen.The nurse should instruct the client to avoid jarring exercises, such a jogging or horseback riding, to prevent potential vertebral compression fractures.

A nurse is providing dietary teaching for a client who hasGERD. The nurse should instruct the client to avoid which of the following items? - Caffeinated coffee - Shell fish - Apple juice - Green beans

Caffeinated coffee - Caffeinated coffeeMY ANSWERThe nurse should instruct the client who has GERD to avoid caffeinated beverages because these can decrease the tone of the lower esophageal sphincter and increase the exposure of acid to the esophagus. The client should also avoid citrus fruits, tomatoes, chocolate, peppermint, spearmint, alcohol, smoking, and the use of other tobacco products. - Shell fishShell fish does not contribute to the development of GERD or increase the exposure of acid to the esophagus. - Apple juiceApple juice does not contribute to the development of GERD or increase the exposure of acid to the esophagus. - Green beansGreen beans do not contribute to the development of GERD or increase the exposure of acid to the esophagus.

A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? A. Prothrombin time 12 seconds B. History of sinusitis several times each year C. BMI of 24 D. Report of urinating small amounts twice daily

D. Report of urinating small amounts twice daily - Prothrombin time 12 secondsThe nurse should recognize that an increased prothrombin time can increase the client's risk for hemorrhage postoperatively. However, this finding is within the expected reference range of 11 to 12.5 seconds. - History of sinusitis several times each yearThe nurse should notify the provider if the client has cardiac issues, such as hypertension, or other chronic illnesses that could affect recovery postoperatively. However, a history of sinusitis should not affect the client's perioperative care plan. - BMI of 24The nurse should recognize that clients who are obese can have conditions that can lead to medical complications following anesthesia, which can require increased medication dosages. However, a BMI of 24 is within the expected reference range of 18.5 to 25. - Report of urinating small amounts twice dailyMY ANSWERThe nurse should recognize that a report of oliguria, or urinating only small amounts daily, indicates possible impaired kidney function. Therefore, the nurse should report this finding to the provider for further evaluation. Kidney function affects medication metabolism and impaired function increases the client's risk for postoperative complications.

A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? A. "I will have my best vision 3 weeks after my surgery." B. "I should report a creamy white discharge from my eye to my doctor." C. "I will avoid getting water in my eyes until the second day after surgery." D. "I should avoid using the vacuum cleaner for several weeks."

"I should avoid using the vacuum cleaner for several weeks." - "I will have my best vision 3 weeks after my surgery." The nurse should instruct the client to anticipate an improvement in vision within days of the surgical procedure. However, the best vision will occur around 4 to 6 weeks following the surgery. - "I should report a creamy white discharge from my eye to my doctor." The nurse should instruct the client that a creamy white discharge can become dry and crusted on the eyelids or lashes. This drainage is expected and does not require reporting. However, yellow or green drainage should be reported to the provider. - "I will avoid getting water in my eyes until the second day after surgery." The nurse should instruct the client to avoid getting water in the eye for 3 to 7 days following surgery. - "I should avoid using the vacuum cleaner for several weeks." MY ANSWER The nurse should instruct the client to avoid using the vacuum cleaner for several weeks. The forward flexion and rapid, jerking movements that occur while vacuuming can increase intraocular pressure.

The nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? -"Use bisacodyl suppositories to stimulate a bowel movement" -"Avoid lifting objects greater than 50 pounds"-"Consume a clear liquid diet until symptoms resolve" -"Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic - related diarrhea"

- "Use bisacodyl suppositories to stimulate a bowel movement." The nurse should instruct the client to avoid the use of laxatives or enemas because these increase intestinal motility and increase the risk of perforation. - "Avoid lifting objects greater than 50 pounds." The nurse should instruct the client to avoid actions that will increase intra-abdominal pressure, such as straining, coughing, bending, or lifting heavy objects that could cause straining. - "Consume a clear liquid diet until symptoms resolve." MY ANSWER The nurse should recommend the client consume a clear liquid diet until manifestations such as abdominal pain, nausea, and vomiting have resolved. A clear liquid diet is low in fiber and does not stimulate intestinal motility. - "Take a probiotic 15 minutes after taking a prescribed antibiotic to prevent antibiotic-related diarrhea." The nurse should advise the client to take probiotics at least 2 hr after taking prescribed antibiotics. Probiotics can promote the presence of healthy bacteria within the bowel and can prevent relapses of diverticulitis. However, probiotics can be inactivated when taken along with antibiotics, so they should be administered at least 2 hr apart.

A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? - "You're sad now, but the grief will pass eventually." - "You should attend a grief support group to see how others cope with loss." - "What are some of the best times with your partner that you remember?" - "How are other members of the family managing?"

- "What are some of the best times with your partner that you remember?" "You're sad now, but the grief will pass eventually."While identifying a client's emotions is therapeutic, offering false reassurances, such as "the grief will pass," is nontherapeutic and inhibits the client from exploring her feelings in a manner that allows for processing of the grief response. "You should attend a grief support group to see how others cope with loss."Attending a grief support group can facilitate the grief response by allowing the client to talk about her feelings, fears, and experiences with other individuals who are also dealing with the loss of a significant other. However, the nurse is giving advice by stating the client should attend the group, which is nontherapeutic. "What are some of the best times with your partner that you remember?"MY ANSWEREncouraging the client to reminisce about her partner allows the client to acknowledge the loss and to progress through the grief process. "How are other members of the family managing?"Inquiring about other members of the family is a nontherapeutic response by the nurse because it takes the focus away from the client by changing the subject. This inhibits the client from exploring her feelings in a manner that allows for processing of the grief response.

A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which is the following actions should the nurse include? - Limit the amount of time the client spends with the newborn after birth. - Discourage the client from having other family members see the newborn. - Inform the client that an autopsy of the newborn is required by federal law. - Bathe, diaper, and dress the child before bringing the newborn to the client.

- Bathe, diaper, and dress the child before bringing the newborn to the client. - Limit the amount of time the client spends with the newborn after birth.The nurse should not place restrictions on the amount of time the client spends with the newborn after birth. Some clients need a few minutes and other clients might need hours to say their final goodbyes. - Discourage the client from having other family members see the newborn.The nurse should ask the client who she would like to visit her and the newborn. Clients often include other children and their own parents in the grieving process and want them to have the opportunity to see and hold the newborn. - Inform the client that an autopsy of the newborn is required by federal law.The nurse should ask the client about an autopsy, if it is not against her cultural or religious beliefs. The nurse should inform the client that an autopsy is optional and is not covered by insurance. - Bathe, diaper, and dress the child before bringing the newborn to the client.MY ANSWERThe nurse should treat the child as a live newborn, including bathing, diapering, and dressing the child. Applying identification bands, a hat, and swaddling the newborn in a blanket show the client that the newborn has been cared for in a meaningful way.

A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? - Ginkgo biloba - Digoxin - Hydrochlorothiazide - Acetaminophen

- Hydrochlorothiazide - Ginkgo bilobaThe nurse should identify that ginkgo biloba is administered to a client who has pain while walking due to claudication to improve blood flow to the lower extremities. - DigoxinThe nurse should identify that digoxin is administered to a client to regulate cardiac dysrhythmias, not to treat hypertension. - HydrochlorothiazideMY ANSWERThe nurse should identify that hydrochlorothiazide, a thiazide diuretic, is the first class of medication to administer to a client who has hypertension. Hydrochlorothiazide inhibits sodium, chloride, and water reabsorption in the distal tubules of the kidneys. - AcetaminophenThe nurse should identify that aspirin, not acetaminophen, is administered to decrease platelet aggregation to a client who has coronary artery disease.

A nurse is assessing a school- age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? - Inaudible lung sounds - Persistent cough - Yellow zone peak flow meter reading - Prolonged expiration phase

- Inaudible lung sounds - Inaudible lung soundsMY ANSWERWhen using the airway, breathing, and circulation approach to client care, the nurse determines the priority finding is inaudible lung sounds on auscultation. Shortness of breath with an absence of lung sounds and increased respiratory rate indicates impending respiratory failure and asphyxia. - Persistent coughA persistent cough is a manifestation of exacerbation of asthma. However, there is another finding that is the nurse's priority. - Yellow zone peak flow meter readingA yellow zone peak flow meter reading is an indication that the client's asthma is not well controlled and an exacerbation may be occurring. However, there is another finding that is the nurse's priority. - Prolonged expiration phaseA prolonged expiration phase is a manifestation of exacerbation of asthma. However, there is another finding that is the nurse's priority.

A nurse is assessing a client who has musculoskeletal trauma following a motor- vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider?

- Laboratory resultsA hematocrit of 42% and a hemoglobin of 14 g/dL are within the expected reference range. However, the nurse should continue to monitor these laboratory results because a decrease could indicate that the client is bleeding from the musculoskeletal trauma, which would require notification of the provider. - Blood pressureA blood pressure of 144/90 mm Hg is above the expected reference range. However, for a client who has musculoskeletal trauma, pain is an expected finding, and an elevation of blood pressure is an indication of pain. The nurse should also monitor the client for hypertension, which could be an indication that the client is bleeding from the musculoskeletal trauma. - Pain reportMY ANSWERThe nurse should report the client's pain level of 8 on a scale of 0 to 10 to the provider. Excessive pain in a casted arm that is unrelieved by analgesics can be an indication of compartment syndrome, which is a medical emergency. - ECG resultsSinus tachycardia indicates that the client has a heart rate above the expected reference range. However, for a client who has musculoskeletal trauma, pain is an expected finding, and an elevation of heart rate is an indication of pain.

A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium? - One small apple - One-half cup of sweet cherries - One-half cup of fresh pineapple - One small orange

- One small orange - One small appleClients who have hypokalemia should eat apples. One small apple that is 7.1 cm (2.8 in) in diameter has 159 mg of potassium. However, there is another fruit that is a better source of potassium. - One-half cup of sweet cherriesClients who have hypokalemia should eat cherries. One-half cup of sweet cherries has 171 mg of potassium. However, there is another fruit that is a better source of potassium. - One-half cup of fresh pineappleClients who have hypokalemia should eat pineapple. One-half cup of fresh pineapple has 90 mg of potassium. However, there is another fruit that is a better source of potassium. - One small orangeMY ANSWERThe nurse should recommend that a client who has hypokalemia eat oranges due to the high potassium content. One orange that is 7.1 cm (2.8 in) in diameter contains 232 mg of potassium.

A nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? -Intake of fluid is less than output of urine over the past 2 days -1kg (2.2 lb) weight gain over the past 2 days -Blood glucose 206 mg/dL -Prealbumin 13 mg/dL

-1kg (2.2 lb) weight gain over the past 2 days - Intake of fluid is less than output of urine over the past 2 daysAn intake of fluid that is less than output of urine is an indication that the client is at risk for fluid volume deficit. Manifestations of fluid volume deficit also include dry skin, poor skin turgor, and hypotension. - 1 kg (2.2 lb) weight gain over the past 2 daysMY ANSWERTotal parenteral nutrition is administered to clients who have inflammatory bowel disorders and are unable to tolerate enteral nutrition. A weight gain of 0.5 kg (1.1 lb) daily is an indication that the client is responding to the parenteral nutrition. - Blood glucose 206 mg/dLTotal parenteral nutrition is high in glucose and can cause hyperglycemia in clients. A blood glucose level of 206 mg/dL is above the expected reference range and is an indication that the client might need insulin. It does not indicate an improvement in the client's nutritional status. - Prealbumin 13 mg/dLPrealbumin levels are an indication of nutritional status. The client's prealbumin level of 13 mg/dL is less than the expected reference range of 15 to 36 mg/dL, indicating that malnutrition continues.

A nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of this medication? -Increased salivation -Bradycardia -Tinnitus -Distended bladder

-Distended bladder - Increased salivation The nurse should identify oxybutynin as having anticholinergic effects that can result in dry mouth. This adverse effect can be managed by frequently rinsing the mouth or using sugarless candy or gum. - Bradycardia The nurse should monitor the client who is taking oxybutynin for cardiovascular adverse effects such as tachycardia or chest pain. - Tinnitus The nurse should monitor the client who is taking oxybutynin for adverse effects such as blurred vision and hoarseness. - Distended bladder MY ANSWER The nurse should identify oxybutynin as having anticholinergic effects that can result in urinary retention. The nurse should monitor the client's intake and output and assess for bladder distention.

A nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? -I should avoid this medication with milk -I will return to have my cholesterol levels checked in 2 weeks -I can expect to lose weight while taking this medication -I understand that muscle tenderness is an expected result of this medication

-I will return to have my cholesterol levels checked in 2 weeks - "I should avoid taking this medication with milk."The nurse should instruct the client to take this medication without regard to foods, but that it should be taken at the same time each day. - "I will return to have my cholesterol levels checked in 2 weeks."MY ANSWER The nurse should instruct the client that their cholesterol level will be reevaluated within 2 to 4 weeks after initiating therapy, and periodically thereafter. - "I can expect to lose weight while taking this medication."The nurse should instruct the client that this medication does not assist with weight loss; however, the client should follow dietary restrictions of fat and cholesterol, which can help with weight loss. - "I understand that muscle tenderness is an expected result of this medication."The nurse should instruct the client to notify the provider if experiencing muscle pain, tenderness, or weakness because these manifestations can indicate myopathy or rhabdomyolysis.

A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? -Jugular vein distention -Fatigue -Angina -Hacking cough

-Jugular vein distention - Jugular vein distention MY ANSWER The nurse should expect to find jugular vein distention (JVD) in the client who has right-sided heart failure due to right ventricular failure and pressure building in the venous system. - Fatigue The nurse should expect to find fatigue in the client who has left-sided heart failure due to diminished cardiac output. - Angina The nurse should expect to find angina in the client who has left-sided heart failure due to impaired perfusion to the myocardium. - Hacking cough The nurse should expect to find a hacking cough in the client who has left-sided heart failure due to pulmonary congestion and fluid in the alveoli.

A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? -Serous drainage is present on the pin site dressings -Flushing of the skin on the right arm -Bounding pulse palpated in the radial artery -Numbness to the fingers on the right arm

-Numbness to the fingers on the right arm - Serous drainage is present on the pin site dressings The nurse should identify serous drainage as an expected finding in a client following placement of an external fixator of the right lower arm. However, it does not indicate the development of compartment syndrome. - Flushing of the skin on the right arm The nurse should identify pallor or duskiness of the skin as an indication of compartment syndrome of the right lower arm. - Bounding pulse palpated in the radial artery The nurse should identify a weakened pulse or an inability to palpate a pulse as an indication of compartment syndrome of the right lower arm. - Numbness to the fingers on the right arm MY ANSWER The nurse should identify a decrease in sensation, such as numbness and tingling of the fingers, as one of the first indications that the client might be developing compartment syndrome of the right lower arm. Compartment syndrome is the result of edema and ischemia, a complication following musculoskeletal injury. Other manifestations include increased pain, paralysis, pallor, and decreased or absent pulses.

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? -fever -abdominal ascites -anxious -nasogastric suctioning

-abdominal ascites A client who has a feverThe nurse should identify that fever is a risk factor for developing metabolic acidosis. Acute illnesses, often accompanied by fever, cause an accumulation of lactic acid, which can lead to a state of metabolic acidosis. A client who has abdominal ascitesMY ANSWERThe nurse should identify that a client who has abdominal ascites can experience a restriction of chest expansion, which impairs gas exchange and places the client at an increased risk for developing respiratory acidosis. A client who is anxiousThe nurse should identify that anxiety is a risk factor for developing respiratory alkalosis. As anxiety increases a client's respiratory rate, excessive CO2 is lost, creating an alkalotic state. A client who is receiving nasogastric suctioningThe nurse should identify that nasogastric suctioning is a risk factor for developing metabolic alkalosis because excess acids are lost through suctioned secretions.

A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? - A black bean burger on a whole grain bun - Oatmeal with whole milk - A baked potato with butter - A pork sausage patty on a biscuit

A black bean burger on a whole grain bun - A black bean burger on a whole grain bunMY ANSWERThe nurse should identify food choices that are low in fat but high in fiber will help manage hyperlipidemia. The client's choice of proteins that are low in solid fat and high in fiber, such as beans and a whole grain bun, indicates an understanding of the teaching. - Oatmeal with whole milkWhile oatmeal is high in fiber and can help to decrease lipid levels, the client's choice of whole milk is high in fat. The nurse should recommend the client choose milk products that are 1% or nonfat. - A baked potato with butterPotatoes are high in fiber, which can help decrease lipid levels, and baking is a healthier option than frying vegetables. However, the client's choice of butter is high in fat. The nurse should recommend the client substitute butter with trans fat-free margarine. - A pork sausage patty on a biscuitPork sausage is high in fat, as are many baked products, such as biscuits. The nurse should recommend the client choose a protein that is low in fat, such as an egg white omelet with a low fat cheese and a piece of whole grain toast, instead of a biscuit.

A nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4-year-old son is expected to react to the death of his partner. Which of the following information should the nurse include in the teaching? -A preschooler has no concept of death -A preschooler is often interested in what happens to the body after death -A preschooler often believes that death is reversible -A preschooler understands

A preschooler often believes that death is reversible - A preschooler has no concept of death.The nurse should identify that infants and young toddlers are unable to understand the concept of death. However, they tend to feel a sense of loss and might become increasingly irritable or withdrawn. - A preschooler is often interested in what happens to the body after death.The nurse should identify that school-age children generally have a greater understanding of the finality of death and are often very interested in the physical process of dying and what happens to the body after death. This interest might be related to the understanding that all people, including themselves, will eventually die. - A preschooler often believes that death is reversible.MY ANSWERThe nurse should identify that preschoolers tend to have difficulty understanding the reality of death and often believe that it is reversible. Because of magical thinking, the preschooler might think that his thoughts or behavior might have caused the person to die. - A preschooler understands that death happens to everyone.The nurse should identify that an understanding of the universality of death often is not developed until the school-age years.

A nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? Select all that apply. - Abdominal distention - Flank pain - Hypervolemia - Vomiting - Hyperactive bowel sounds

Abdominal distention, vomiting, hyperactive bowel sounds - Abdominal distention is correct. A client who has a small bowel obstruction will manifest abdominal distention from the buildup of intestinal contents that are unable to advance through the intestines. - Flank pain is incorrect. A client who has a small bowel obstruction will manifest abdominal pain. Flank pain will manifest with renal obstructions. - Hypervolemia is incorrect. A client who has a small bowel obstruction can manifest hypovolemia, not hypervolemia. As fluid from the vascular space leaks into the peritoneal cavity, circulating blood volume decreases. -Hypovolemia from a small bowel obstruction can be mild or extensive enough to lead to a shock state.Vomiting is correct. A client who has a small bowel obstruction can experience nausea and vomiting. Emesis might contain fecal contents. - Hyperactive bowel sounds is correct. A client who has a small bowel obstruction will initially manifest increased bowel sounds, also known as borborygmi, as peristalsis heightens in an attempt to move the blocked intestinal contents forward.

A nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? - Agoraphobia - Xenophobia - Acrophobia - Glossophobia

Acrophobia - AgoraphobiaAgoraphobia is the fear of open spaces, and being unable to escape. Clients who have agoraphobia might avoid leaving their homes and severely restrict their activities. - XenophobiaXenophobia is the fear of people who are different. Clients who have xenophobia might avoid leaving their homes to avoid contact with people who are different. - AcrophobiaMY ANSWERThe nurse should document that the client is experiencing acrophobia, or the fear of heights. Phobias cause an intense fear and severe anxiety when the client is exposed to the object of the phobia. - GlossophobiaGlossophobia is the fear of talking. Clients who have glossophobia might avoid leaving their own homes to avoid having to speak to others.

A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition?

Albumin level - WBC count The nurse should review the WBC count to determine if the client is experiencing an infection. - Albumin level MY ANSWER The nurse should review albumin levels to determine a client's risk for malnutrition. A client who is malnourished will have an albumin level below the expected reference range of 3.5 to 5 g/dL. - CD4 T cell count The nurse should review CD4 T lymphocyte cell counts to monitor for a decrease, which indicates a worsening of the client's illness. - C-reactive protein level The nurse should review C-reactive protein levels to monitor for inflammation. This laboratory test can assist in diagnosing coronary illness.

A nurse is caring for a school- age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? - Encourage the child to take frequent sips of cool fluids. - Apply humidified oxygen with a simple mask. - Start a peripheral access IV. - Administer an albuterol nebulizer treatment.

Apply humidified oxygen with simple mask - Encourage the child to take frequent sips of cool fluids.The nurse should encourage the child to take frequent sips of cool fluids to maintain hydration; however, there is another action the nurse should take first. - Apply humidified oxygen with a simple mask.MY ANSWERThe first action the nurse should take when using the airway, breathing, and circulation approach to client care for a school-age child who is experiencing acute asthma exacerbation is to apply humidified oxygen with a simple mask. Humidified oxygen should be administered at a level to maintain oxygen saturation above 90%. - Start a peripheral access IV.The nurse should start a peripheral access IV to administer IV fluids and prescribed medication; however, there is another action the nurse should take first. - Administer an albuterol nebulizer treatment.The nurse should administer an albuterol nebulizer treatment to dilate the bronchioles and decrease respiratory distress; however, there is another action the nurse should take first.

A nurse a reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? - LDL 100 mg/dL - Total cholesterol 199 mg/dL - Aspartate aminotransferase (AST) 45 units/L - Creatine kinase (CK) 120 units/L

Aspartate aminotransferase (AST) 45 units/L - LDL 100 mg/dLThe nurse should identify that an LDL level of 100 mg/dL is within the expected reference range of less than 130 mg/dL for a client who is taking atorvastatin, which indicates a therapeutic response. - Total cholesterol 199 mg/dLThe nurse should identify that a total cholesterol level of 199 mg/dL is within the expected reference range of less than 200 mg/dL for a client who is taking atorvastatin, which indicates a therapeutic response. - Aspartate aminotransferase (AST) 45 units/LMY ANSWERThe nurse should identify that an aspartate aminotransferase level of 45 units/L is greater than the expected reference range of 0 to 35 units/L and indicates hepatotoxicity, an adverse effect of atorvastatin. - Creatine kinase (CK) 120 units/LThe nurse should identify that a creatine kinase level of 120 units/L is within the expected reference range of 30 to 170 units/L. An elevated CK level can indicate myopathy, an adverse effect of atorvastatin.

A nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD? -Decreased salivation -Diarrhea -Tonsillitis -Globus

Globus - Decreased salivationThe client who has manifestations of GERD will have hypersalivation, or water brash. - DiarrheaThe client who has manifestations of GERD will have generalized abdominal pain and flatulence, not diarrhea. - TonsillitisThe client who has manifestations of GERD will have pharyngitis, rather than tonsillitis, and might have coughing, hoarseness, and wheezing at night. - GlobusMY ANSWERThe client who has manifestations of GERD will have globus, which is a feeling of something being in the back of the throat.

A nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need? A. The client requests to see a priest for spiritual guidance. B. The client reports coughing and a change of voice whenever he eats. C. The client reports pain immediately following physical therapy. D. The client is worried about financially supporting his family because of his illness.

B. The client reports coughing and a change of voice whenever he eats. - The client requests to see a priest for spiritual guidance.The nurse should acknowledge the client's spiritual needs, such as a request to see a priest, as important because it is the nurse's responsibility to promote the client's spiritual health. However, there is another finding that the nurse should identify as the client's priority need. - The client reports coughing and a change of voice whenever he eats.MY ANSWERWhen using Maslow's hierarchy of needs, the nurse should determine that the priority finding is the client's physiological needs, such as coughing and a change of voice whenever he eats. This finding indicates a risk for aspiration, which can impair the client's breathing and oxygenation status. Difficulty eating also creates an impairment of nutrition. Breathing, oxygenation, and nutrition are all physiological needs. Therefore, the nurse should identify this finding as the priority client need. - The client reports pain immediately following physical therapy.The nurse should identify the client's safety and security needs, such as pain following physical therapy, as important because it is the nurse's responsibility to promote the client's comfort and assist the client in receiving the optimal benefit from physical therapy. However, there is another finding that the nurse should identify as the client's priority need. - The client is worried about financially supporting his family because of his illness.The nurse should identify the client's self-esteem needs, such as financial concerns, as important because it is the nurse's responsibility to coordinate with social services or other interprofessional team members to meet client needs. However, there is another finding that the nurse should identify as the client's priority need.

A nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? - Hyperactive deep tendon reflexes - Abdominal distention - Bradycardia - Positive Trousseau's sign

Bradycardia - Hyperactive deep tendon reflexesThe nurse should expect hyperactive deep tendon reflexes in a client who has hypomagnesemia due to increased nerve impulse transmission. - Abdominal distentionThe nurse should expect abdominal distention in a client who has hypomagnesemia due to reduced gastrointestinal motility. - BradycardiaMY ANSWERThe nurse should expect to find bradycardia in a client who has hypermagnesemia, as well as other cardiac manifestations, including peripheral vasodilation and hypotension due to a reduced membrane excitability. Clients who have severe hypermagnesemia are at an increased risk for cardiac arrest. - Positive Trousseau's signThe nurse should expect a positive Trousseau's sign in a client who has hypomagnesemia due to the accompanying calcium imbalance.

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A. "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby." B. "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light." C. "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." D. "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."

C. "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet." - "Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby."The nurse should instruct the parents that placing any object in the crib is a safety hazard and significantly increases the newborn's risk for suffocation. - "Moving the crib near a window in the nursery will provide your baby with necessary fresh air and natural light."The nurse should instruct the parents to place the crib on an inner wall away from windows. Placing the crib near a window in the nursery can increase the newborn's risk of cold stress. This also is a safety hazard due to glass breakage. Cords on window treatments increase the risk of strangulation as the infant gets old enough to reach them. - "Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet."MY ANSWERThe nurse should instruct the parents to dress the newborn in a one-piece sleeper or a "sleep-sack" at bedtime, which keeps the newborn's body covered. Blankets and quilts significantly increase the newborn's risk of suffocation and should be avoided. - "Placing your baby on her tummy in the crib will hasten drowsiness and provide a more restful night's sleep."Placing the newborn on her abdomen in the crib for sleeping significantly increases the risk for suffocation and sudden infant death syndrome (SIDS). Therefore, the nurse should instruct the parents to place the newborn in the supine position at all times for sleeping.

A nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect? A. Calcium 9.5 mg/dL B. Bicarbonate 23 mEq/L C. Potassium 3 mEq/L D. pH 7.4

C. Potassium 3 mEq/L - Calcium 9.5 mg/dL The nurse should expect to find hypocalcemia in a client who has metabolic alkalosis. This value is within the expected reference range of 9 to 10.5 mg/dL. - Bicarbonate 23 mEq/L The nurse should expect to find an increased bicarbonate level in a client who has metabolic alkalosis. This value is within the expected reference range of 21 to 28 mEq/L. - Potassium 3 mEq/LMY ANSWER The nurse should expect to find hypokalemia in a client who has metabolic alkalosis due to the response to decreased blood cation levels. This decrease in potassium can lead to an increased stimulation of the nervous, neuromuscular, and cardiac systems. The client's potassium level of 3 mEq/L is below the expected reference range of - 3.5 to 5 mEq/L. pH 7.4 The nurse should expect to find an elevated pH in a client who has metabolic alkalosis. This pH value is within the expected reference range of 7.35 to 7.45.

A nurse is assessing a 6-month- old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? - Absence of tears when crying - Loss of 6% of body weight - Sunken anterior fontanel - Capillary refill greater than 2 seconds

Capillary refill greater than 2 seconds - Absence of tears when cryingThe nurse should expect an infant who has severe dehydration to have an absence of tears when crying. An infant who has mild dehydration will have tears when crying. - Loss of 6% of body weightThe nurse should expect an infant who has mild dehydration to have a weight loss of 3% to 5%. An infant who has moderate dehydration will have a weight loss of 6% to 9%. - Sunken anterior fontanelThe nurse should expect an infant who has severe dehydration to have a sunken anterior fontanel. An infant who has mild dehydration will have a flat anterior fontanel. - Capillary refill greater than 2 secondsMY ANSWERThe nurse should expect an infant who has mild dehydration to have a capillary refill time of greater than 2 seconds. Other manifestations of mild dehydration include slight thirst, decreased urine output, and moist mucus membranes.

A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include? - Soak the child's combs and brushes in hot water for 5 min. - Rinse the child's hair each day with 236.5 mL (1 cup) of vinegar. - Seal the child's nonwashable toys in plastic bags for 7 days. - Comb the child's hair daily with an extra fine-tooth comb.

Comb the child's hair daily with an extra fine-tooth comb. Soak the child's combs and brushes in hot water for 5 min.The nurse should instruct the parent to soak the child's combs and brushes in a lice-killing product for 1 hr, or boil these items for 10 min. Rinse the child's hair each day with 236.5 mL (1 cup) of vinegar.The nurse should instruct the parent that home remedies, such as vinegar, mayonnaise, and petroleum jelly, are ineffective at eradicating the infestation. Seal the child's nonwashable toys in plastic bags for 7 days.The nurse should instruct the parent to seal the child's nonwashable items in plastic bags for 14 days. Comb the child's hair daily with an extra fine-tooth comb.MY ANSWERThe nurse should instruct the parent to remove nits from the child's hair each day by combing her hair with an extra fine-tooth comb. The parent can also remove nits with tweezers or fingernails.

A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? - Congenital hypothyroidism - Meconium staining at birth - Macrosomic at birth - Congenital heart disease

Congenital heart disease - Congenital hypothyroidismThe nurse should include congenital hyperthyroidism as a risk factor for an infant developing failure to thrive. Other risk factors include neglect, parental restriction of the infant's intake, or genetic anomalies. - Meconium staining at birthThe nurse should not include meconium staining at birth as a risk factor for an infant developing failure to thrive. Risk factors include neglect, parental restriction of the infant's intake, or genetic anomalies. Meconium staining at birth can cause the infant to be more prone to fetal distress during labor and at delivery, not have failure to thrive. - Macrosomic at birthThe nurse should include preterm birth and low birth weight as risk factors for an infant developing failure to thrive. Other risk factors include neglect, parental restriction of the infant's intake, or genetic anomalies. - Macrosomic at birth can cause the infant to be more prone to fetal distress during labor and at delivery, not have failure to thrive. - Congenital heart diseaseMY ANSWERThe nurse should include congenital heart disease as a risk factor for an infant developing failure to thrive. Other risk factors include neglect, parental restriction of the infant's intake, or genetic anomalies.

A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take? - Place the client in semi-Fowler's position. - Administer IV pain medication if the client is having extremity pain. - Heat the client's body by using external rewarming devices. - Contact a specialized team to place the client on cardiopulmonary bypass.

Contact a specialized team to place the client on cardiopulmonary bypass - Place the client in semi-Fowler's position.The nurse should place the client in a supine position to prevent changes in the cardiovascular system that can lead to orthostatic hypotension and cardiac instability. - Administer IV pain medication if the client is having extremity pain.The nurse should withhold IV medications, except vasopressors, because metabolism is unpredictable until the client's core temperature is above 30° C (86° F). - Heat the client's body by using external rewarming devices.The nurse should avoid all active external rewarming with rewarming devices that can cause too rapid vasodilation for a client who has severe hypothermia. - Contact a specialized team to place the client on cardiopulmonary bypass.MY ANSWERExtracorporeal rewarming, such as cardiopulmonary bypass or hemodialysis, is the rewarming method of choice for core warming when a client has severe hypothermia. This rewarming method requires a specialized team.

A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse expect? -Weight gain -Enlarged liver -Distended abdomen -Cool extremities

Cool extremities - Weight gainThe nurse should expect to find weight gain in the client who has right-sided heart failure due to right ventricular failure and fluid retention. - Enlarged liverThe nurse should expect to find an enlarged liver in the client who has right-sided heart failure due to right ventricular failure and fluid retention. - Distended abdomenThe nurse should expect to find a distended abdomen in the client who has right-sided heart failure due to right ventricular failure and fluid retention. - Cool extremitiesMY ANSWERThe nurse should expect to find cool extremities in the client who has left-sided heart failure due to a decreased cardiac output leading to impaired tissue perfusion.

A nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse? -Gonorrhea -Herpes genitalis -Human papillomavirus -Bacterial vaginosis

Gonorrhea - GonorrheaMY ANSWERGonorrhea is an infectious condition listed on the Nationally Notifiable Infectious Conditions Listing. The nurse should report this communicable disease to the Centers for Disease Control and Prevention. - Herpes genitalisHerpes genitalis does not require reporting by the nurse. - Human papillomavirusHuman papillomavirus does not require reporting by the nurse. - Bacterial vaginosisBacterial vaginosis does not require reporting by the nurse.

A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? - Potassium level 4.2 mEq/L - WBC count 10,000/mm3 - Magnesium 2 mEq/L - Creatinine 2.5 mg/dL

Creatinine 2.5 mg/dL - Potassium level 4.2 mEq/LThe nurse should monitor and report electrolyte levels that are outside the expected reference range because aminoglycoside antibiotics, such as gentamicin, can alter those levels. However, a potassium level of 4.2 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. Therefore, there is another finding the nurse should report to the provider. - WBC count 10,000/mm3The nurse should monitor the client's WBC count to evaluate the effectiveness of the antibiotic in eliminating the infection. However, a WBC count of 10,000/mm3 is within the expected range of 5,000 to 10,000/mm3. Therefore, there is another finding the nurse should report to the provider. -Magnesium 2 mEq/LThe nurse should monitor and report electrolyte levels that are outside the expected reference range because aminoglycoside antibiotics, such as gentamicin, can cause hypomagnesemia. However, a magnesium level of 2 mEq/L is within the expected reference range of 1.3 to 2.1 mEq/L. Therefore, there is another finding the nurse should report to the provider. - Creatinine 2.5 mg/dLMY ANSWERThe greatest risk to this client is injury from decreased renal function evidenced by a creatinine level greater than the expected reference range of 0.5 to 1.3 mg/dL. Aminoglycoside antibiotics, such as gentamicin, are nephrotoxic and ototoxic. Therefore, the priority finding for the nurse to report to the provider is the client's elevated creatinine level.

A nurse is admitting a client who has peptic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? Select all that apply: - Dark, tarry stools - Bright red emesis - Increased heart rate - Increased blood pressure - Bounding peripheral pulses

Dark tarry stools, bright red emesis, increased heart rate - Dark, tarry stools is correct. The nurse should expect the client to have dark, tarry, and sticky stools containing old blood as a result of the bleed. - Bright red emesis is correct. The nurse should expect the client to have bright red blood emesis, or hematemesis. - Increased heart rate is correct. The nurse should expect the client to have an increase in heart rate as a result of the body's response to the loss of blood volume caused by bleeding or hemorrhaging. - Increased blood pressure is incorrect. The nurse should expect the client to have a decrease in blood pressure as a result of the body's response to the loss of blood volume caused by bleeding or hemorrhaging. - Bounding peripheral pulses is incorrect. The nurse should expect the client to have weak, thready peripheral pulses as a result of the body's response to the loss of blood volume caused by bleeding or hemorrhaging.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? -Brown discoloration of the lower extremities -Superficial ulcer on the medial aspect of the ankle -Dependent rubor -Telangiectasias

Dependent rubor - Brown discoloration of the lower extremitiesThe nurse should expect brown discoloration of the lower extremities in a client who has venous insufficiency. - Superficial ulcer on the medial aspect of the ankleThe nurse should expect a superficial ulcer on the ankle of a client who has venous insufficiency. Arterial ulcers are deep wounds that usually appear on or between the client's toes. - Dependent ruborMY ANSWERThe nurse should expect redness to the lower extremities, or dependent rubor, when the client's legs are dangling or in a dependent position. - TelangiectasiasThe nurse should expect telangiectasias, or spider veins, in a client who has varicose veins. These are small, intradermal veins that are visible due to vein dilation.

A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis? - Diabetes mellitus - Radical prostatectomy 2 years ago - Cholelithiasis - Taking permethrin to treat pediculosis capitis

Diabetes mellitus - Diabetes mellitusMY ANSWERThe nurse should identify that clients who have diabetes mellitus are at increased risk for the development of pyelonephritis due to a loss of bladder tone as a result of neuropathy, or from an ascending lower urinary tract infection caused by glycosuria. - Radical prostatectomy 2 years agoThe nurse should identify that clients who have structural obstructions, such as prostatitis or benign prostatic hypertrophy, can develop pyelonephritis. A client who has had his prostate removed is not at increased risk for developing pyelonephritis. - CholelithiasisThe nurse should identify that clients who have kidney stones are at increased risk for the development of pyelonephritis. A client who has gall bladder stones is not at increased risk for developing pyelonephritis. - Taking permethrin to treat pediculosis capitisThe nurse should identify that permethrin, an antiparasitic medication, is prescribed to treat pediculosis capitis. This medication is applied topically and is not excreted through the kidneys. Therefore, it does not increase the risk for the development of pyelonephritis.

A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include? - "Cover your newborn with a light blanket while she is sleeping." -"Do not bathe your newborn immediately after she eats." -"Place your newborn in a crib with a bumper pad." -"Wash your newborn's face with a mild soap."

Do not bathe your newborn immediately after she eats - "Cover your newborn with a light blanket while she is sleeping."The nurse should instruct the parent not to cover the newborn with a blanket or quilt while she is sleeping because this increases the risk for Sudden Infant Death Syndrome (SIDS). The parent should dress the newborn in a lightweight sleeper. - "Do not bathe your newborn immediately after she eats."MY ANSWERThe nurse should instruct the parent to avoid bathing the newborn immediately following a feeding to decrease the risk of regurgitation. The parent should bathe the newborn every 2 to 3 days. - "Place your newborn in a crib with a bumper pad."The nurse should instruct the parent not to place a bumper pad in the newborn's crib because this increases the risk for Sudden Infant Death Syndrome (SIDS). The parent should remove all stuffed toys and soft objects from the crib. - "Wash your newborn's face with a mild soap."The nurse should instruct the parent to wash the newborn's face with plain warm water. The parent should not use mild soap because it can irritate the newborn's eyes.

A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan? - Elevate the client's arm above the heart. - Apply heat to the client's surgical site. - Instruct the client to avoid moving their fingers. - Monitor the client's ability to complete wrist range-of-motion.

Elevate the client's arm above the heart - Elevate the client's arm above the heart.MY ANSWERThe nurse should elevate the client's arm and hand following carpal tunnel release to minimize swelling of the surgical site and decrease discomfort. - Apply heat to the client's surgical site.The nurse should apply cold packs for the first 24 to 48 hr to control edema at the surgical site. - Instruct the client to avoid moving their fingers.The nurse should encourage the client to move their fingers frequently during the postoperative period to maintain function and promote circulation. - Monitor the client's ability to complete wrist range-of-motion.The nurse should instruct the client to limit movement to the operative wrist. Restrictions in movement and lifting can be prescribed for up to 6 weeks postoperatively.

A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? -Apply warm dary packs initially then apply cool moist packs to the lower extremity -Elevate the extremity 7.6 to 15.2 cm above heart level -Gently massage the affected extremity for 10-15 min every shift -Apply a topical corticosteroid to any open areas on the affected extremity twice per day

Elevate the extremity 7.6 to 15.2 cm above heart level - Apply warm dry packs initially then apply cool moist packs to the lower extremity.The nurse should apply cool moist packs to the affected area every 2 to 4 hr until inflammation subsides then transition to warm moist packs to increase comfort and decrease swelling. - Elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level.MY ANSWERThe nurse should elevate the client's affected extremity 7.6 to 15.2 cm (3 to 6 in) above the heart to promote venous return and decrease edema. - Gently massage the affected extremity for 10 to 15 min every shift.The nurse should not massage the client's affected extremity because this action can damage the capillary beds and increase tissue necrosis in the affected extremity. - Apply a topical corticosteroid to any open areas on the affected extremity twice per day.The nurse should not apply topical steroids to any open skin lesions that are possibly infected. The steroids can decrease the immune response and worsen the infection. Antibacterial topical ointment can be applied if an infection is present.

A nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? - Elevated aspartate aminotransferase levels - Decreased skin turgor - Elevated WBC count - Decreased audio acuity

Elevated aspartate aminotransferase levels - Elevated aspartate aminotransferase levelsMY ANSWERThe nurse should identify that an elevated aspartate aminotransferase (AST) is an indication of liver injury, which is an adverse effect of excessive doses of acetaminophen. In addition to elevated liver enzymes, other indications of liver injury include diaphoresis, nausea and vomiting, abdominal pain, and diarrhea. - Decreased skin turgorThe nurse should identify that decreased skin turgor is not an adverse effect of acetaminophen. However, the nurse should assess the client for a skin rash and urticaria. - Elevated WBC countThe nurse should identify that excessive doses of acetaminophen can cause neutropenia and pancytopenia. - Decreased audio acuityThe nurse should identify that decreased audio acuity and ototoxicity are not adverse effects of acetaminophen. However, the nurse should assess the client for CNS adverse effects, which can include anxiety, headache, and insomnia.

A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media ? -Enlarged postauricular lymph nodes -Increased flatulence with constipation -Indicates a desire to such more frequently -Slow bounding heart rate

Enlarged postauricular lymph nodes - Enlarged postauricular lymph nodesMY ANSWERThe nurse should expect an infant who has otitis media to have enlarged postauricular and cervical lymph nodes, fever, pain, rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C (104° F). - Increased flatulence with constipationThe infant who has otitis media can have nonspecific manifestations of diarrhea, not flatulence with constipation. - Indicates a desire to suck more frequentlyThe infant who has otitis media will have anorexia and a decreased desire to suck due to increased pain. - Slow bounding heart rateThe infant who has otitis media can experience tachycardia, not bradycardia, because of a fever and pain.

A nurse is caring for a client Ensure a patent airway using a chin-lift maneuver who has respiratory acidosisdue to opioid oversedation.Which of the following actions should the nurse take first? - Place the client on mechanical ventilation. - Apply oxygen using a rebreather oxygen mask. - Ensure a patent airway using a chin-lift maneuver. - Administer a reversal agent to the client.

Ensure a patent airway using a chin-lift maneuver - Place the client on mechanical ventilation.The nurse should place the client on mechanical ventilation if the client's oxygen saturation levels are outside the expected reference range or if the client is experiencing respiratory muscle fatigue. However, there is another action the nurse should take first. - Apply oxygen using a rebreather oxygen mask.The nurse should apply oxygen using the least amount of oxygen to prevent hypoxemia and prevent oxygen-induced tissue damage. However, there is another action the nurse should take first. - Ensure a patent airway using a chin-lift maneuver.MY ANSWERThe first action the nurse should take when using the airway, breathing, and circulation approach to client care is to open the client's airway by performing a chin-lift maneuver. - Administer a reversal agent to the client.The nurse should administer a reversal agent to the client to reverse the opioid oversedation and adverse effects. However, there is another action the nurse should take first.

A nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? - Methylphenidate - Escitalopram - Varenicline - Lithium carbonate

Escitalopram - MethylphenidateThe nurse should plan to administer methylphenidate to a client who has ADHD. Methylphenidate is a CNS stimulant used to reduce impulsivity and increase attentiveness in clients who have ADHD. - EscitalopramMY ANSWERThe nurse should plan to administer escitalopram, an antidepressant medication, to a client who has generalized anxiety disorder. Escitalopram is a selective serotonin reuptake inhibitor (SSRI) that decreases anxiety and panic attack. - VareniclineThe nurse should plan to administer varenicline to a client who wants to stop smoking. Varenicline reduces the craving for nicotine and minimizes manifestations of withdrawal. - Lithium carbonateThe nurse should plan to administer lithium carbonate to a client who has bipolar disorder. Lithium carbonate is a mood stabilizer that decreases the occurrence of manic episodes.

A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process? A. Persistent feelings of hopelessness B. Loss of self-esteem C. Chronic physical manifestations D. Feeling anger toward family members

Feeling anger toward family members - Persistent feelings of hopelessnessThe nurse should identify that the ability to maintain a sense of hope is expected during the grieving process. Persistent feelings of hopelessness can be an indication that the client has developed a depressive disorder. - Loss of self-esteemThe nurse should identify that the ability to maintain self-esteem is expected during the grieving process. A loss of self-esteem can be an indication that the client has developed a depressive disorder. - Chronic physical manifestationsThe nurse should identify that temporary physical manifestations are an expected reaction during the grieving process. Chronic physical manifestations can be an indication that the client has developed a depressive disorder. - Feeling anger toward family membersMY ANSWERThe nurse should identify that feelings of anger towards herself, her partner, and others is an expected grief reaction and is identified as the second stage of the grieving process.

A nurse is assessing a client Fever, Dyspepsia, Eructation who has acute cholecystitis.Which of the following findingsshould the nurse expect? Select all that apply: A. Fever B. Dyspepsia C. Pain radiating to the left shoulder D. Blood-tinged stools E.Eructation

Fever is correct. The nurse should expect to find a fever in the client who has acute cholecystitis due to the inflammatory process.Dyspepsia is correct. The nurse should expect to find dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder. Pain radiating to the left shoulder is incorrect. The nurse should expect to find pain that often radiates to the right shoulder or scapula in the client who has acute cholecystitis.Blood-tinged stools is incorrect. The nurse should expect to find pale or clay-colored stools due to the lack of bile in the client who has acute cholecystitis.Eructation is correct. The nurse should expect the client who has acute cholecystitis to exhibit eructation, or belching, due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.

A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? -BMI 26 or above -Excessive sun exposure -Frequent weight-bearing exercise -Hip fracture 6 months ago

Hip fracture 6 months ago - BMI 26 or aboveThe nurse should recognize that clients who have low body weight and a thin build are at greater risk for developing osteoporosis. A BMI of 26 indicates the client is overweight. - Excessive sun exposureThe nurse should recognize that a lack of sun exposure can lead to a deficiency of vitamin D. Low calcium and vitamin D levels place a client at greater risk for developing osteoporosis. - Frequent weight-bearing exerciseThe nurse should recognize that lack of weight-bearing exercise, such as walking, is a risk factor for developing osteoporosis. - Hip fracture 6 months agoMY ANSWERThe nurse should recognize that a client who has a history of hip fracture, especially after the age of 50, is at greater risk for developing regional osteoporosis.

A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? - "Wear open-toe shoes to allow air to circulate around your feet." - "Use a heating pad set on low to warm your feet when they feel cold." - "File your toenails straight across to prevent ingrown toenails." - "Apply a thin layer of lotion between your toes twice per day."

File your toenails straight across to prevent ingrown toenails - "Wear open-toe shoes to allow air to circulate around your feet."The nurse should instruct the client to wear leather or cloth shoes that have closed toes and heels to prevent injury. The client should avoid ambulating when barefoot, even in the home. - "Use a heating pad set on low to warm your feet when they feel cold."The nurse should instruct the client to wear socks to warm the feet if they feel cold. The client should avoid the use of heating pads and hot water bottles. Poor sensory perception is associated with peripheral neuropathy and can increase the risk for burns from a heating device. - "File your toenails straight across to prevent ingrown toenails."MY ANSWERThe nurse should instruct the client to file toenails straight across. If the client's toenails are rounded during clipping, the client is at risk for developing ingrown toenails, increasing the risk for infection. - "Apply a thin layer of lotion between your toes twice per day."The nurse should instruct the client to avoid putting lotion between the toes. Lotion can increase moisture, which can increase the risk for developing an infection.

A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor? -Flushed, dry skin -Seizures -Hyperreflexia -Positive Trousseau's sign

Flushed, dry skin - Flushed, dry skinMY ANSWERThe nurse should monitor a client who has metabolic acidosis for manifestations of warm, flushed, and dry skin due to vasodilation from an increased respiratory rate and the loss of CO2. - SeizuresThe nurse should monitor for depressed central nervous system activity, such as lethargy or confusion, in a client who has metabolic acidosis. The nurse should monitor a client who has metabolic alkalosis for seizures. - HyperreflexiaThe nurse should monitor for hyporeflexia in a client who has metabolic acidosis. The nurse should monitor a client who has metabolic alkalosis for manifestations of hyperreflexia. - Positive Trousseau's signThe nurse should monitor for depressed central nervous system activity, such as lethargy or confusion, in a client who has metabolic acidosis. The nurse should monitor a client who has metabolic alkalosis for a positive Trousseau's sign.

A nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? - Focuses on the source of the anxiety - Exhibits an inability to speak - Experiences auditory hallucinations - Feels surroundings are unreal

Focuses on the source of anxiety - Focuses on the source of the anxietyMY ANSWERThe nurse should expect a client who is experiencing a moderate level of anxiety to be focused on the cause of the anxiety. The client has a decreased attention span but is able to follow simple directions. - Exhibits an inability to speakThe nurse should expect a client who is experiencing a panic level of anxiety to be unable to speak or have unintelligible speech. - Experiences auditory hallucinationsThe nurse should expect a client who is experiencing a panic level of anxiety to have hallucinations or delusions and be out of touch with reality. - Feels surroundings are unrealThe nurse should expect a client who is experiencing a panic level of anxiety to experience depersonalization, which is a feeling that they are unreal, or derealization, which is a feeling that their environment is unreal.

A nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto- injector. Which of the following instructions should the nurse include? A. "Administer the medication into your child's abdomen." B. "Expect your child to sleep for several hours after receiving the medication." C. "Place your child's unused extra syringes in the refrigerator for storage." D. "Give a second injection if the first fails to reverse your child's symptoms."

Give a second injection if the first fails to reverse your child's symptoms - "Administer the medication into your child's abdomen."The medication should be administered intramuscularly into the child's outer thigh. The nurse should instruct the parent to firmly press the device into the child's outer thigh about halfway between the hip and the knee at a perpendicular angle, holding it in place until the auto-injector function engages. - "Expect your child to sleep for several hours after receiving the medication."The nurse should instruct the parent to monitor the child for the adverse effects of epinephrine. The most common adverse effect is a feeling of nervousness, rather than apathy or somnolence. Other adverse effects include palpitations, restlessness, increased pulse rate, sweating, dizziness, insomnia, and headache. - "Place your child's unused extra syringes in the refrigerator for storage."The parent should avoid refrigeration of the epinephrine syringes because this can cause the injection mechanism to become compromised, and therefore fail to engage during the next use. The extra syringes should be stored in a dark place at room temperature. - "Give a second injection if the first fails to reverse your child's symptoms."MY ANSWERThe nurse should instruct the parent to administer a second dose, using a second auto-injector, if the first dose doesn't completely reverse the child's allergic reaction. The effects of the medication will begin to fade in 20 min. However, the child should be transported to the nearest hospital immediately because hospitalization for a few hours following administration of the injection is recommended. The nurse should instruct the parent to bring the auto-injector with the child to the hospital.

A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for this visual impairment? - Male sex - Hypertension - Chronic obstructive pulmonary disease - Osteoporosis

Hypertension - Male sexThe nurse should identify that being female, rather than male, is a risk factor for the development of AMD. - HypertensionMY ANSWERThe nurse should identify that hypertension is a risk factor for the development of AMD. Other risk factors include atherosclerosis and smoking. - Chronic obstructive pulmonary diseaseThe nurse should identify that pulmonary disorders, such as chronic obstructive pulmonary disease, are not risk factors for the development of AMD. - OsteoporosisThe nurse should identify that musculoskeletal disorders, such as osteoporosis, are not risk factors for the development of AMD.

A nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? -"I teach my children about healthy eating because my anxiety makes me want to overeat." -"I started taking kickboxing classes to release the stress I feel from work." -"I avoid thinking about problems that worry me until I have time to focus on a solution." -"I let my partner choose the movie for date night since I yelled at him when I was stressed."

I avoid thinking about problems that worry me until I have time to focus on a solution - "I teach my children about healthy eating because my anxiety makes me want to overeat." The nurse should recognize that this statement indicates the client's control of negative behaviors by developing another behavior that is the opposite. This indicates an adaptive use of reaction formation. - "I started taking kickboxing classes to release the stress I feel from work." The nurse should recognize that this statement indicates the client's transference of work-related stress into a positive outlet. This indicates an adaptive use of displacement. - "I avoid thinking about problems that worry me until I have time to focus on a solution." MY ANSWER The nurse should recognize that this statement indicates the client's conscious choice to avoid thinking about anxiety producing thoughts until he has time to focus on them in a positive way. This indicates an adaptive use of suppression. - "I let my partner choose the movie for date night since I yelled at him when I was stressed." The nurse should recognize that this statement indicates the client's attempt to make up for taking out his stress on his partner in a negative way. This indicates an adaptive use of undoing.

A nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? - "I should wash my feet with soap before I try to treat my calluses." - "I should limit wearing the same shoes 2 days in a row." - "I should use home remedies to treat any blisters or sores on my feet." - "I should use adhesive tape to secure a dressing on my foot when I have skin breakdown."

I should limit wearing the same shoes 2 days in a row - "I should wash my feet with soap before I try to treat my calluses."The client should not self treat any type of foot condition because this can lead to infection. The client should seek a health care provider for treatment of calluses, ingrown toes nails, corns, blisters, and infections. - "I should limit wearing the same shoes 2 days in a row."MY ANSWERThe client should limit wearing the same shoes 2 days in a row to prevent tissue injury of the skin on the feet. - "I should use home remedies to treat any blisters or sores on my feet."The client should not use home remedies to treat blisters, sores, or infections that develop on the feet. The client should notify the provider if the skin is broken down on the feet. - "I should use adhesive tape to secure a dressing on my foot when I have skin breakdown."The client who has peripheral neuropathy should not use adhesive tape to secure a dressing on the foot because adhesive tape can cause an increase in skin breakdown when removed.

A nurse is providing teaching about home care with a parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? - "I should apply the cream only to the areas where there is a rash." - "I should wash my child's bed linens and clothing in hot water and detergent." - "I should expect my child's rash to go away within 72 hours after starting treatment." - "I should leave the cream on my child for 4 hours before washing it off."

I should wash my child's bed linens and clothing in hot water and detergent - "I should apply the cream only to the areas where there is a rash."The parent should massage the permethrin cream into the skin all over the child's body, from the client's scalp to the client's toes. The parent can use a toothpick to apply the cream under the child's fingernails and toenails. - "I should wash my child's bed linens and clothing in hot water and detergent."MY ANSWERThe parent should wash the child's clothing and bed linens in hot water and detergent, and dry all articles in a clothes dryer on the highest heat setting. This will kill the mites and prevent transmission of the infestation. - "I should expect my child's rash to go away within 72 hours after starting treatment."The parent should expect the rash and pruritus to last approximately 2 to 3 weeks. The parent can use a soothing lotion, oatmeal bath, or topical corticosteroid to relieve pruritus. - "I should leave the cream on my child for 4 hours before washing it off."The parent should leave the permethrin cream on the child for 8 to 14 hr. The child should then take a bath or shower to shampoo their hair and wash the cream from their body.

A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching? - "I will quickly complete my household errands in the morning before taking a break." - "I will breathe out slowly through pursed lips if I feel short of breath." - "I will try to eat three large meals every day." - "I will not get a flu shot because I might get an infection."

I will breathe out slowly through pursed lips if I feel short of breath - "I will quickly complete my household errands in the morning before taking a break."The nurse should instruct the client to balance activity and rest periods by spreading activities throughout the day to prevent excessive fatigue and dyspnea. - "I will breathe out slowly through pursed lips if I feel short of breath."MY ANSWERThe nurse should instruct the client to perform pursed-lip breathing to assist with dyspnea. This technique includes breathing in through the nose, pursing the lips, and breathing out slowly. - "I will try to eat three large meals every day."The nurse should instruct the client to consume four to six smaller meals throughout the day instead of three larger meals. Large meals can cause abdominal distention, which will result in shortness of breath. - "I will not get a flu shot because I might get an infection."Clients who have COPD are at increased risk for the development of respiratory infections due to pooling of secretions. The nurse should instruct the client to receive an annual influenza vaccine to provide protection against contracting the disease. The client should also avoid crowds and people who are ill to protect against acquiring infections.

A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by MRSA. Which of the following client statements indicates an understanding of the teaching? -I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach -I will wash my clothes in cold water and detergent -I will throw away my razor after using it three times -I will apply imiquimod cream to the lesions before going to bed each night

I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach - "I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach."MY ANSWERThe client should soak for at least 5 min in a bathtub filled one-fourth full of water with ½ cup of bleach once or twice per week. This will help prevent reoccurrence of the infection. - "I will wash my clothes in cold water and detergent."The client should change underwear and clothing daily and wash all items in hot water to prevent spread of the infection. - "I will throw away my razor after using it three times."The client should use a disposable razor for shaving and throw it away after each use. The client should not share a razor with anyone else because this might spread the infection. - "I will apply imiquimod cream to the lesions before going to bed each night."The client and family members can apply mupirocin to the nares twice per day for 1 to 2 weeks to prevent infection. Imiquimod cream is used to treat condyloma, which is caused by human papilloma virus, and molluscum contagiosum, which is caused by the poxvirus.

A nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. Which of the following client statements indicates an understanding of the management of antibiotic resistant infections? -I will keep the infected area open to air to help it heal -I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours -I should sit on upholstered chairs instead of hardback chairs -I will wash all uninfected skin areas with a fresh washcloth

I will wash all uninfected skin areas with a fresh washcloth - "I will keep the infected area open to air to help it heal."The nurse should instruct the client to keep the area covered with a clean bandage to avoid infecting other areas of the body or other people. - "I can sleep in the same bed as my partner after I have been taking antibiotics for 24 hours."The nurse should instruct the client to sleep in a separate bed from others until the infection is completely healed. - "I should sit on upholstered chairs instead of hardback chairs."The nurse should instruct the client to avoid sitting on upholstered chairs or furniture to prevent soiling and spreading of the bacteria because of the difficulty to clean the upholstery thoroughly. - "I will wash all uninfected skin areas with a fresh washcloth."MY ANSWERThe nurse should instruct the client to wash the uninfected skin areas with a fresh washcloth to prevent contamination of the unaffected areas of the skin with the MRSA infection.

A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching? - "I will drink one and a half liters of fluids every day." - "I will get the pneumonia vaccine yearly." - "I will spray an aerosol disinfectant in my house every day." - "I will wash my hands whenever I come home from the grocery store."

I will wash my hands whenever I come home from the grocery store - "I will drink one and a half liters of fluids every day."The client should drink at least 3 liters of fluids daily to thin and remove respiratory secretions. - "I will get the pneumonia vaccine yearly."The client should get the pneumonia vaccine once with a potential booster immunization 5 years later. - "I will spray an aerosol disinfectant in my house every day."The client should avoid spraying aerosols in the home because irritation of the lung tissue from chemical fumes, smoke, or toxic gases can result in pneumonia. - "I will wash my hands whenever I come home from the grocery store."MY ANSWERThe client should wash his hands upon returning home from public places and avoid crowds during cold and flu season. Handwashing can prevent the spread of germs, which can cause illness.

A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? -Increased urination -Sweating -Dizziness -Loose stools

Increased urinationMY ANSWERThe nurse should expect the client to exhibit manifestations of hyperglycemia, including increased thirst, nausea, vomiting, increased urination, flushed dry skin, acetone breath odor, and a weak, rapid pulse. SweatingSweating is not an expected manifestation of diabetic ketoacidosis. However, it is a manifestation of hypoglycemia. DizzinessDizziness is not an expected manifestation of diabetic ketoacidosis. However, it is a manifestation of hypoglycemia. Loose stoolsLoose stools are not an expected manifestation of diabetic ketoacidosis. Due to dehydration, constipation might be present.

A nurse is admitting an infant Initiate droplet precautions for the infant who has pertussis. Which of the following actions should the nurse take? - Administer an antiviral medication to the infant. - Initiate droplet precautions for the infant. - Limit the infant's oral intake of fluids to 60 mL/hr. - Monitor the infant for manifestations of increased intracranial pressure.

Initiate droplet precautions for the infant. - Administer an antiviral medication to the infant.Pertussis is an infection caused by the bacterium Bordetella pertussis. The nurse should administer an antibiotic to the infant to eradicate the infection. - Initiate droplet precautions for the infant.MY ANSWERThe nurse should initiate droplet precautions for an infant who has pertussis. Other actions the nurse should take include providing humidified oxygen and suctioning secretions to prevent choking. - Limit the infant's oral intake of fluids to 60 mL/hr.The nurse should encourage oral fluid intake for an infant who has pertussis. Increasing fluid intake can help prevent dehydration and assist in thinning secretions. - Monitor the infant for manifestations of increased intracranial pressure.The nurse should monitor the infant for complications of pertussis, including otitis media, atelectasis, dehydration, and hernias. Pertussis does not increase intracranial pressure.

A nurse is planning discharge for a postpartum client. The client tells the nurse she is having subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? -Irregular bleeding -Fatigue -Shoulder pain -Recurrent urinary tract infections (UTIs)

Irregular bleeding - Irregular bleedingMY ANSWERThe nurse should inform the client that irregular bleeding is possible when using a subdermal implant as a form of contraception. Other possible adverse effects include amenorrhea, heavy bleeding, headaches, nervousness, nausea, skin changes, and vertigo. With this method, a very small rod is placed on the underside of the upper arm, just underneath the skin. The implant is hardly noticeable and compared to oral contraceptives, the failure rate is less than 1%. One of the major advantages with this method is that fertility rapidly returns after its removal. - FatigueFatigue is not a potential adverse effect of a subdermal implant for contraception. - Shoulder painHeadache, rather than shoulder pain, is an adverse effect of a subdermal implant for contraception. - Recurrent urinary tract infections (UTIs)Subdermal implant for contraception does not cause a UTI, nor does it have an adverse effect of UTIs. Recurrent UTIs are a contraindication for the use of a diaphragm for contraception.

A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? -Keep your mouth open when sneezing -Block one nostril when blowing your nose -Use an ear wick candle to remove excess cerumen from the canal -Lubricate cotton-tipped applicators with mineral oil to clean the ear canal

Keep your mouth open when sneezing - "Keep your mouth open when sneezing."MY ANSWERThe nurse should instruct the client to keep the mouth open while sneezing to reduce the pressure in the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum. - "Block one nostril when blowing your nose."The nurse should instruct the client to avoid blocking one nostril when blowing the nose because this can increase pressure within the middle ear. Sudden pressure changes can damage the ossicles and perforate the ear drum. - "Use an ear wick candle to remove excess cerumen from the canal."The nurse should instruct the client to avoid cleaning the ear canal with an ear wick candle. Inserting objects into the ear can cause trauma to the ear canal, pack cerumen up against the ear drum, and puncture the ear drum. Clients should only use commercial ear syringes designed to clean the canal and remove excess cerumen. - "Lubricate cotton-tipped applicators with mineral oil to clean the ear canal."The nurse should instruct the client to avoid inserting cotton-tip applicators into the ear canal. Inserting objects into the ear can cause trauma to the ear canal, pack cerumen up against the ear drum, and puncture the ear drum.

A nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? Select all that apply Lidocaine 5% patches Celecoxib Vancomycin Cyclobenzaprine Glucosamine

Lidocaine 5% patches is correct. The nurse should identify lidocaine 5% patches as a topical medication that can relieve joint pain associated with osteoarthritis.Celecoxib is correct. The nurse should identify celecoxib as a cyclooxygenase-2 (COX-2) inhibitor that treats osteoarthritis pain. Providers usually prescribe celecoxib when over-the-counter medications, such as NSAIDs, are no longer effective in relieving osteoarthritis pain.Vancomycin is incorrect. Vancomycin is an antibiotic that is prescribed to treat certain infections, including osteomyelitis and meningitis.Cyclobenzaprine is correct. The nurse should identify cyclobenzaprine as a muscle relaxant medication that relieves muscle spasms in the back that can occur with osteoarthritis of the vertebral column.Glucosamine is correct. The nurse should identify glucosamine as an over-the-counter dietary supplement that clients can take to relieve osteoarthritis discomfort.

A nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? - "Decrease your calcium intake." - "You should consume at least 2,400 milligrams of salt per day." - "Limit the amount of spinach in your diet." - "Increase your fluid intake to one and a half liters daily."

Limit the amount of spinach in your diet - The nurse should instruct clients who have calcium phosphate calculi to limit their intake of calcium. However, clients who develop calcium oxalate renal calculi should consume the recommended amount of calcium, which is between 800 to 1,200 mg per day. - "You should consume at least 2,400 milligrams of salt per day."The nurse should instruct the client to restrict sodium intake to less than 2,300 mg per day to increase kidney tubular calcium reabsorption. - "Limit the amount of spinach in your diet."MY ANSWERThe nurse should instruct the client to decrease intake of foods that contain oxalates. Restricting foods that are high in oxalates, such as spinach, tea, nuts, chocolate, and strawberries, can decrease the risk of further calculi formation. - "Increase your fluid intake to one and a half liters daily."The nurse should instruct the client to increase fluid intake to 2 to 3 L daily. This amount should be sufficient to dilute the urine to a pale yellow color and limit the risk of further stone formation.

A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? - Megestrol - Ondansetron - Famotidine - Pancrelipase

Megestrol - MegestrolMY ANSWERThe nurse should expect the provider to prescribe megestrol for the client who is experiencing failure to thrive related to HIV/AIDS. Megestrol increases appetite in clients who have HIV/AIDS. - OndansetronThe nurse should expect the provider to prescribe ondansetron, an antiemetic, for a client who has nausea and vomiting. - FamotidineThe nurse should expect the provider to prescribe famotidine, a histamine H2 antagonist, for a client who has gastroesophageal disease. - PancrelipaseThe nurse should expect the provider to prescribe pancrelipase, a pancreatic enzyme, for a client who has pancreatitis.

A nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? -Monitor the site daily for drainage -Leave the pressure dressing on the 48 hr -Administer aspirin if the child reports pain -Resume tub baths in 24hr

Monitor the site daily for drainage - Monitor the site daily for drainage.MY ANSWERThe nurse should instruct the guardian to monitor the site daily for manifestations of infection, such as drainage, redness, and swelling. The guardian should report these findings to the provider. - Leave the pressure dressing on for 48 hr.The nurse should instruct the guardian to remove the pressure dressing the day following the procedure. The guardian should place an adhesive bandage over the site for 2 days to decrease the risk for infection. - Administer aspirin if the child reports pain.The nurse should instruct the guardian to administer acetaminophen or ibuprofen to the child for pain. Aspirin should not be administered because it can increase the risk for bleeding. - Resume tub baths in 24 hr.The nurse should instruct the guardian that the child can shower 1 day after the procedure but should avoid tub baths for 3 days to decrease the risk of infection.

A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? -Monitor intake and output -Provide teaching about antibiotic therapy -Administer the influenza vaccine -Observe the client perform incentive spirometry

Observe the client perform incentive spirometry - Monitor intake and output. The nurse should monitor intake and output to identify manifestations of dehydration. Fever, tachypnea, and an increased metabolic rate increase the client's need for fluids. However, there is another action that is the nurse's priority. - Provide teaching about antibiotic therapy. The nurse should provide teaching about all medications the client is taking to promote compliance and an awareness of potential adverse effects. However, there is another action that is the nurse's priority. - Administer the influenza vaccine. The nurse should administer the influenza vaccine to decrease the client's risk of influenza in the future. However, there is another action that is the nurse's priority. - Observe the client perform incentive spirometry. MY ANSWER When using the airway, breathing, and circulation framework, the priority action the nurse should take is to observe the client perform incentive spirometry. Incentive spirometry improves gas exchange and oxygenation and stimulates coughing, which assists in clearing secretions.

A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include? - Apply heat to the joints following exercise. - Avoid aerobic exercises such as biking. - Perform exercise even on days when joints are painful. - Household chores can count as exercise.

Perform exercise even on days when joints are painful - Apply heat to the joints following exercise.The nurse should teach the client to apply heat to the joints prior to performing exercise to increase mobility and decrease the risk for injury. - Avoid aerobic exercises such as biking.The nurse should instruct the client to perform aerobic exercises such as biking, swimming, dancing, and walking to increase mobility and decrease pain. - Perform exercise even on days when joints are painful.MY ANSWERThe nurse should instruct the client to continue exercising even if joints are painful because consistency will help with management of the disease. The client can reduce the amount of exercise if joints are especially painful. - Household chores can count as exercise.The nurse should instruct the client to not consider household chores the same as prescribed exercises. The client should perform exercise in addition to regular chores and activities.

A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? -Flank pain with radiation toward the scrotum -150 mL emesis -Oliguria with bladder distention -Blood pressure 160/90 mmHg

Oliguria with bladder distention - Flank pain with radiation toward the scrotumA manifestation of renal calculi is the presence of severe pain in the flank region. Stationary pain in the flank is an indication that the calculi is in the kidney or upper ureter while flank pain with radiation is an indication that the calculi is in the bladder or ureter. The nurse should inform the provider that the client has pain so a prescription for an opioid can be obtained. However, another finding is the priority. - 150 mL emesisNausea and vomiting are expected manifestations for a client who has renal calculi. The nurse should inform the provider so that a prescription for an antiemetic can be obtained. However, another finding is the priority. - Oliguria with bladder distentionMY ANSWERThe greatest risk to this client is injury due to bladder obstruction as indicated by decreased urinary output in the presence of bladder distention. The calculi can create an obstruction of the bladder neck or urethra. The nurse should identify this as a medical emergency and notify the provider immediately. - Blood pressure 160/90 mm HgAn elevated blood pressure is an expected finding in a client who is experiencing pain related to renal calculi. The nurse should continue to monitor the client's blood pressure. However, another finding is the priority.

A nurse is assessing an 18- month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? A. Polyethylene glycol B. Bumetanide C. Loperamide D. Ondansetron

Ondansetron - Polyethylene glycolPolyethylene glycol is an osmotic laxative used for bowel cleansing or treatment of acute iron overdose in children. Diarrhea with dehydration is a contraindication to the use of a laxative. - BumetanideBumetanide is a loop diuretic used for the treatment of edema related to heart failure. Diarrhea with dehydration is a contraindication to the use of a diuretic. - LoperamideLoperamide is an antidiarrheal medication that should not be administered to a toddler because it can cause adverse effects, such as an ileus or death. - OndansetronMY ANSWERThe nurse should anticipate administering ondansetron to the toddler. Ondansetron is administered to toddlers who have gastroenteritis and dehydration to decrease the episodes of emesis and to help eliminate the need for intravenous fluids.

A nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?

One hand on gait belt walking behind the patient on affected side (right side) A nurse who is assisting a client who has right-sided hemiparesis with ambulating should support the client using a gait belt, be on the client's affected side, and should avoid holding the client's arm for support. If the client begins to fall, the nurse can have difficulty lowering the client to the floor, which can place the client at risk for injury, such as a shoulder dislocation. MY ANSWER A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side and support the client using a gait belt. A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side, not in front of the client, and support the client using a gait belt. A nurse who is assisting a client who has right-sided hemiparesis with ambulating should stand on the client's affected side, not the unaffected side, and support the client using a gait belt.

A nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status? -Peak expiratory flow meter testing -Spirometry monitoring -Pulmonary function testing -Chest x-ray

Peak expiratory flow meter testing - Peak expiratory flow meter testingMY ANSWERThe peak expiratory flow meter provides a means of evaluating the maximum flow of air the client expels during forceful exhalation. It provides information on how well asthma is being controlled as a part of daily monitoring and can be used when a client is having an asthma attack. The flow meter testing helps to gauge the peak-expiratory zone the client is experiencing and determines if the client should use immediate-acting bronchial dilator inhalers or seek emergency help. -Spirometry monitoringSpirometry monitoring measures airway volume and provides data about airflow obstruction or restriction. Spirometry monitoring is used to support the diagnosis of COPD and chronic restrictive pulmonary disease, such as asthma. Therefore, it does not provide information about the client's status during an asthma attack. -Pulmonary function testingA pulmonary function test assists in the diagnosis of pulmonary abnormalities. Measurements include lung capacity, such as inspiratory capacity, total lung capacity, and expiratory reserve volume. However, it is not used during an asthma attack. -Chest x-rayA chest x-ray is not a diagnostic procedure used to evaluate the client's respiratory status during an asthma attack. A chest x-ray can determine if a client has pneumonia, pulmonary effusion, a collapsed lung, and the diameter of the client's chest.

A nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? - Inform the client she will require an IV fluid bolus. - Perform rapid influenza testing. - Place a surgical mask on the client. - Request a prescription for a single dose of short-acting insulin.

Place a surgical mask on the client - Inform the client she will require an IV fluid bolus.The client's blood pressure and heart rate are within the expected reference range. The nurse should plan for an IV fluid bolus for a client who has dehydration and exhibits hypotension and tachycardia. - Perform rapid influenza testing.The nurse should recognize that findings of influenza include rapid onset myalgia, fever with chills, and weakness. The nurse should anticipate a possible prescription for rapid testing for tuberculosis. - Place a surgical mask on the client.MY ANSWERWeight loss, lethargy, night sweats, and hemoptysis suggest the client might have active tuberculosis (TB). Travel outside the U.S. increases the risk for TB. Therefore, the nurse should prevent the spread of TB by implementing airborne precautions, which includes placing a surgical mask on the client to transport her to a negative pressure room. - Request a prescription for a single dose of short-acting insulin.Expected findings for a casual blood glucose is less than or equal to 200 mg/dL. Therefore, this client does not require a dose of short-acting insulin.

A nurse in an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? -restrict oral intake to clear fluids -place a heating pad on the client's abdomen -place the client in semi-Fowler's position -Administer an enema

Place the client in semi-Fowler's position - Restrict oral intake to clear fluids.The nurse should keep the client NPO in preparation for surgery. - Place a heating pad on the client's abdomen.The nurse should not apply heat to the client's abdomen because this will increase blood flow to the area and increase the risk for perforation. - Place the client in semi-Fowler's position.MY ANSWERThe nurse should place the client in semi-Fowler's position to contain abdominal drainage in the lower abdomen and prevent it from seeping into the peritoneum. - Administer an enema.A client who has appendicitis should not receive enemas or laxatives because they can result in perforation of the appendix.

A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescription should the nurse expect the provider to prescribe? - Vitamin K - Protamine sulfate - Flumazenil - Acetylcysteine

Protamine sulfate - Vitamin KThe nurse should expect the provider to prescribe vitamin K for a client who is receiving warfarin and develops complications, such as the presence of blood in the urine or stool. - Protamine sulfateMY ANSWERThe nurse should expect the provider to prescribe protamine sulfate to reverse the anticoagulant effects of the heparin. A client who is receiving heparin is at risk for increased bleeding with manifestations such as abdominal pain, frank or occult blood in stools, petechiae, and changes in level of consciousness. - FlumazenilThe nurse should expect the provider to prescribe flumazenil to reverse the sedative effects of benzodiazepines. - AcetylcysteineThe nurse should expect the provider to prescribe acetylcysteine for a client who has an acetaminophen overdose.

A nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCO2 29 mmHg, and HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid-base imbalances? - Metabolic alkalosis - Metabolic acidosis - Respiratory alkalosis - Respiratory acidosis

Respiratory alkalosis - Metabolic alkalosisMetabolic alkalosis results from a metabolic disorder. Laboratory values will reflect an elevated pH and an elevated HCO3-. PaCO2 can be within the expected reference range or elevated if compensation is occurring. - Metabolic acidosisMetabolic acidosis results from a metabolic disorder. Laboratory values will reflect a decreased pH and a decreased HCO3-. PaCO2 can be within the expected reference range or decreased if compensation is occurring. - Respiratory alkalosisMY ANSWERThe nurse should interpret that the client's ABG values indicate respiratory alkalosis, which can be caused by hyperventilation as excessive loss of CO2 occurs with rapid respirations. Laboratory values will reflect an elevated pH and a decreased PaCO2. The client's HCO3- level is within the expected reference range. - Respiratory acidosisRespiratory acidosis can result from respiratory depression as excessive retention of CO2 occurs with decreased respirations. Laboratory values will reflect a decreased pH and an elevated PaCO2. The client's HCO3- level is within the expected reference range.

A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect? A. Presence of peristaltic waves B. Epigastric distention C. Large amounts of emesis of fecal material D. Ribbon-like stools

Ribbon-like stools - Presence of peristaltic wavesThe client who has the presence of peristaltic waves has a manifestation of an obstruction of the small bowel. - Epigastric distentionThe client who has epigastric distention has a manifestation of an obstruction of the small bowel. A client who has a large bowel obstruction will have distention in the lower abdomen. - Large amounts of emesis of fecal materialThe client who has emesis of fecal material has a manifestation of an obstruction of the small bowel. A client who has a large bowel obstruction will have minimal or no emesis. - Ribbon-like stoolsMY ANSWERThe client who has a partial obstruction of the large bowel will have ribbon-like stools with an alteration in bowel habits and blood in the stools. A client who has a partial obstruction of the small bowel can have diarrhea.

A nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess?

Right upper quadrant The nurse should assess the gallbladder for the presence of pain or discomfort as a result of biliary colic, which is caused by a gallbladder stone obstructing the bile duct. The pain can radiate from the right upper quadrant of the client's abdomen to the client's right shoulder.

A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? - Chest x-ray results show increased lung space. - Sputum culture shows gram positive bacteria. - SpO2 level is 88%. - Weight loss of 1.4 kg (3 lb) since prior visit.

Sputum culture shows gram positive bacteria - Chest x-ray results show increased lung space.A chest x-ray that shows increased lung space is nonurgent because it is an expected finding for a client who has COPD. Therefore, there is another finding that is the nurse's priority to report to the provider. - Sputum culture shows gram positive bacteria.MY ANSWERWhen using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is gram positive bacteria in the client's sputum culture. The nurse should report this finding to the provider to obtain a prescription for an antibiotic to reduce the risk for decreased gas exchange and sepsis. - SpO2 level is 88%.An SpO2 level of 88% is nonurgent because it is an expected finding for a client who has COPD. Therefore, there is another finding that is the nurse's priority to report to the provider. - Weight loss of 1.4 kg (3 lb) since prior visit.The nurse should identify that a weight loss of 1.4 kg (3 lb) since the prior visit is nonurgent because it is an expected finding for a client who has COPD. COPD can cause anorexia, fatigue, and increased metabolism from dyspnea. Therefore, there is another finding that is the nurse's priority to report to the provider.

A nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? - Palpate the left lower quadrant of the abdomen to check for rebound pain. - Start IV fluid replacement. - Treat the client's pain with oral opioid analgesics given with food. - Administer a suppository to the client in preparation for surgery.

Start IV fluid replacement - Palpate the left lower quadrant of the abdomen to check for rebound pain.The nurse should avoid palpating the client's abdomen to determine abdominal tenderness. The provider can check for rebound pain at McBurney's point by palpating the right lower quadrant between the anterior iliac crest and the umbilicus. - Start IV fluid replacement.MY ANSWERThe nurse should start IV fluid replacement to maintain fluid volume and electrolyte balance. - Treat the client's pain with oral opioid analgesics given with food.The nurse should treat the client's pain with an injectable opioid analgesic and keep the client NPO to prepare for surgery. - Administer a suppository to the client in preparation for surgery.The nurse should not administer any laxatives or give a suppository to the client to stimulate a bowel movement because this can cause perforation of the appendix.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? - Distract the client by having him complete a puzzle. - Encourage the client to take a deep breath every 2 seconds. - Administer methylphenidate to the client. - Stay with the client until manifestations subside.

Stay with the client until manifestations subside - Distract the client by having him complete a puzzle.The nurse should not expect a client who is experiencing a panic attack to be able to focus on a task. The client will be unable to process what is happening and will not be able to follow instructions. - Encourage the client to take a deep breath every 2 seconds.The nurse should encourage the client to breathe slowly and deeply to prevent hyperventilation. Taking a breath every 2 seconds can cause hyperventilation. - Administer methylphenidate to the client.The nurse should plan to administer an antianxiety medication to the client. Methylphenidate is a central nervous system stimulant used to treat ADHD. - Stay with the client until manifestations subside.MY ANSWERThe nurse should stay with the client during a panic attack until manifestations subside and the client is reoriented to reality. This ensures the client's safety and conveys concern to the client.

A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? - Coolness -Hyperpigmentation - Swelling - Distended, tortuous veins

Swelling - CoolnessThe nurse should identify that coolness of an extremity can be an indication of arterial occlusion. A manifestation of a DVT is warmth and redness in the affected area of an extremity. - HyperpigmentationThe nurse should identify that hyperpigmentation of the skin of the lower extremities can be an indication of venous insufficiency. A manifestation of a DVT is redness and warmth in the affected area of an extremity. - SwellingMY ANSWERThe nurse should identify that swelling of the affected extremity is a manifestation of a DVT. Additional manifestations include redness, warmth, and aching of the affected extremity. - Distended, tortuous veinsThe nurse should identify distended, tortuous veins as a manifestation of varicose veins. A manifestation of a DVT includes induration, or hardening, of a blood vessel.

A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication -The client's skin is warm and moist -The client reports sleeping longer during the night -The client is experiencing increased bowel movements - The client's weight is 1.4 kg (3.1 lb) less than baseline.

The client's skin is warm and moist.The nurse should recognize that warm, moist skin is a manifestation of hyperthyroidism, indicating that the medication has not been effective. The client reports sleeping longer during the night.MY ANSWERThe nurse should recognize that insomnia is a manifestation of hyperthyroidism. The client's ability to sleep longer during the night indicates a therapeutic response to the medication. The client is experiencing increased bowel movements.The nurse should recognize that an increase in bowel movements is a manifestation of hyperthyroidism, indicating that the medication has not been effective. The client's weight is 1.4 kg (3.1 lb) less than baseline.The nurse should recognize that weight loss is a manifestation of hyperthyroidism, indicating that the medication has not been effective.

A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching? - "You can safely continue taking this medication if you become pregnant." - "This medication could cause you to have thoughts of self-harm." - "You should take this medication 1 hour before eating." - "Take this medication with an antacid if stomach upset occurs."

This medication could cause you to have thoughts of self-harm - "You can safely continue taking this medication if you become pregnant."The nurse should instruct the client that benzodiazepines, such as clonazepam, can cause congenital anomalies if taken during pregnancy. The client should avoid becoming pregnant while taking the medication and should notify the provider if a pregnancy is planned or suspected. - "This medication could cause you to have thoughts of self-harm."MY ANSWERThe nurse should instruct the client that this medication can cause suicidal thoughts. The nurse should monitor the client for this adverse effect and should instruct the client to notify the provider immediately if these thoughts occur. - "You should take this medication 1 hour before eating."The nurse should instruct the client that this medication can cause stomach discomfort. Taking the medication with food helps decrease this adverse effect. - "Take this medication with an antacid if stomach upset occurs."The nurse should instruct the client to avoid taking an antacid with clonazepam because it can affect the metabolism of the medication, resulting in increased adverse effects.

A nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? - Inhale the second puff of cromolyn 2 min after the first. - Use the cromolyn following exercise if shortness of breath occurs. - Use the albuterol prior to planned exercise. - Cleanse the albuterol mouthpiece once every 2 weeks.

Use albuterol prior to planned exercise - Inhale the second puff of cromolyn 2 min after the first.Cromolyn is administered via nebulizer and is not supplied as a metered-dose inhaler. - Use the cromolyn following exercise if shortness of breath occurs.Cromolyn is a mast cell stabilizer used prophylactically to prevent attacks in children who have exercise-induced asthma. It should be administered 10 to 15 min before planned exercise. - Use the albuterol prior to planned exercise.MY ANSWERAlbuterol is a short-acting beta adrenergic medication that causes bronchodilation. In children who have exercise-induced asthma, albuterol is used prophylactically 5 to 20 min prior to exercise. - Cleanse the albuterol mouthpiece once every 2 weeks.The mouthpiece for the albuterol metered-dose inhaler should be cleaned with warm water once per week to prevent the growth of contaminants.

A nurse is providing dietary teaching to a client who is at 13 weeks gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make? - "Drink fluids between, rather than with, meals." - "Eat foods that are served warm." - "Do not go more than 6 hr between meals." - "Have a low-protein snack at bedtime."

drink fluids between, rather than with, meals - "Drink fluids between, rather than with, meals."MY ANSWERThe nurse should instruct the client to avoid drinking fluids with meals because this can increase nausea. The client should separate solid food from liquids. - "Eat foods that are served warm."The nurse should instruct the client that foods served cold often cause less nausea than foods served warm. - "Do not go more than 6 hr between meals."The nurse should instruct the client to eat every 2 to 3 hr to avoid having an empty stomach. - "Have a low-protein snack at bedtime."The nurse should instruct the client to consume a high-protein snack before going to bed. Protein is digested slower than carbohydrates and can help prevent