EAQs

When teaching an adolescent with type 1 diabetes about dietary management, which instruction should the nurse include? 1. Meals should be eaten at home 2. Foods should be weighed on a gram scale 3. A ready source of glucose should be available 4. Specific foods should be cooked for the adolescent

3. A ready source of glucose should be available An adolescent with type 1 diabetes must carry a source of simple sugar to rapidly counteract the effects of hypoglycemia

A client has been receiving digoxin. the client calls the clinic and complains of "yellow vision." Which response would the nurse provide? 1. This is related to your illness rather than your medication 2. This is an expected side effect; you will become accustomed to it over time 3. This side effect is only temporary. You should continue the medication 4. The medication may need to be discontinued. Come to the clinic this afternoon

4 Yellow vision indicates digoxin toxicity; the medication should be withheld until the health care provider can assess the client and check the digoxin blood level.

What is the minimum HR of a 14 year old?

60 bpm

Which medication requires the nurse to monitor the client for signs of hyperkalemia?

Spironolactone, a potassium sparing diuretic, can have hyperkalemia as an adverse effect

Enoxaparin 40 mg subcutaneously daily is prescribed for a client who had abdominal surgery. The nurse explains that the medication is given for what purpose?

To provide prophylaxis against postoperative thrombus formation.

When teaching a client with atrial fibrillation about a new prescription for warfarin, the nurse will include information about which vitamin?

Vitamin K

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain? 1. By withholding the medication to help prevent addiction 2. By stating the limb has been removed and that the pain is psychological 3. By acknowledging the pain is real and administering medication to relieve it 4. By explaining the phantom limb sensation will subside within a few days

3. By acknowledging the pain is real and administering medication To the client, the pain is real, requiring pain medication

Which is the purpose of active leg and foot exercises for a client who has had hip surgery? 1. Maintain muscle strength 2. Reduce leg discomfort 3. Prevent clot formation 4. Improve wound healing

3. Prevent clot formation AROM exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis

Which is the most common cause of death among adolescents? 1. suicide 2. homicide 3. accidents 4. substance abuse

3. accidents Approx 74% of adolescent deaths are caused by accidents

Captopril is prescribed for a client. Which effect would the nurse anticipate? 1. Increase urine output 2. Decreased anxiety 3. Improved sleep 4. Decreased BP

4 Captopril is an angiotensin-converting enzyme (ACE) inhibitor antihypertensive.

Which is the average optimal BP of an adolescent? 1. 85/54 mm Hg 2. 95/65 mm Hg 3. 105/65 mm Hg 4. 110/65 mm Hg

4. 110/65 mm Hg

Which type of joint permits movement in any direction? 1. Pivot 2. Hinge 3. Biaxial 4. Ball and socket

4. Ball and socket Ball and socket joints permit movement in any direction. Pivot joints permit rotation. Hinge joints allow motion in one plane. Biaxial joints permit gliding movement.

Which diagnostic procedure is used to detect muscle weakness? 1. Arthroscopy 2. Radiography 3. Myelography 4. Electromyography

4. Electromyography Electromyography is performed to detect diffuse or localized muscle weakness by determining the electric potential generated in an individual.

Which information about a client who has heart failure would the nurse communicate to the health care provider before administration of the prescribed digoxin? 1. Apical pulse rate 96 beats/min 2. Bilateral foot and ankle pitting edema 3. Crackles heard at the base of both lungs 4. Potassium level of 2.3 mEq/L

4. Potassium level of 2.3 mEq/L Symptoms of digoxin toxicity, including life-threatening dysrhythmias, can occur when digoxin is administered to a client with hypokalemia. The nurse would hold the digoxin and notify the health care provider, anticipating that potassium supplements would be prescribed before administration of digoxin.

What is the maximum acceptable HR of a 16 year old?

90 bpm

Metoprolol is prescribed for a client with hypertension. The nurse monitors the client for which adverse effect? 1. Hirsutism 2. Bradycardia 3. Restlessness 4. Angina

Bradycardia Beta blockers block stimulation of beta 1 receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest.

A client with arthritis takes large doses of aspirin. Which symptom would the nurse include when teaching the client about aspirin toxicity?

Disturbances in hearing Ringing in the ears occurs because of aspirin's effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity.

Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy? Select all that apply. 1. Take aspirin with food 2. Report ringing in the ears 3. Monitor and report excessive bleeding and bruising 4. Do not mix aspirin with medications for erectile dysfunction 5. Avoid over the counter pain medications that contain aspirin

1,2,3 and 5 Aspirin is taken with food to avoid GI upset. Ringing in the ears should be reported because it is a sign of aspirin toxicity. Excessive bruising and bleeding may be caused by decreased platelet aggregation caused by aspirin. OTC medications must be checked for aspirin.

Which radiographic test is used to view the entire skeleton? 1. Bone scan 2. Gallium and thallium scan 3. Computed tomography (CT) 4. Magnetic resonance imaging (MRI) scan

1. Bone scan A bone scan is a radionuclide test in which radioactive material is injected so that the client's entire skeleton can be viewed

The nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes the statement "I'll start to have symptoms when ______" 1. I drink less fluid 2. I have fewer platelets 3. I decrease the iron in my diet 4. I have fewer WBCs

1. I'll start to have symptoms when I drink less fluid. Dehydration precipitates sickling of RBCs and is a major causative factor for painful episodes associated with sickle cell anemia

Pulse oximetry is prescribed for a client, which would the nurse do to ensure accuracy of the reading? 1. attach the probe to a finger or earlobe 2. wait 30 minutes before obtaining a reading 3. calibrate the oximeter at least every 8 hours 4. place the probe on the abdomen or upper leg

1. attach the probe to a finger or earlobe Capillary beds are closest to the surface in a finger or earlobe which permits a more accurate measurement of arterial oxygen saturation.

The nurse determines that an adolescent with newly diagnosed type 1 diabetes has sufficient knowledge of the disorder. Which is the next appropriate action? 1. setting goals with the client 2. developing a rapport with the client 3. teaching the client how to give insulin injections 4. instructing the client how to monitor blood glucose

1. setting goals with the client

The nurse is administering 40 mg of furosemide intravenously. Which sensation reported by the client would the nurse consider when determining that it is being administered too quickly? 1. Full bladder 2. Buzzing ears 3. Fast hearbeat 4. Numb arms and legs

2 Rapid administration can cause tinnitus, loss of hearing, and ear pain.

An adolescent visits the allergy clinic for testing. Which laboratory finding indicates to the nurse that an allergic response is in progress? 1. decreased platelet count 2. increased eosinophil level 3. increased lymphocyte count 4. decreased immunoglobulin level

2. Increased eosinophil level Eosinophils increase to inhibit the inflammatory response to histamine, which is released in allergic reactions

Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina? 1. BP 142/90 2. Report of chest pain when walking 3. Sinus bradycardia, rate 54 on monitor 4. Large Q waves on ECG

3 Beta blockers such as metoprolol decrease HR so the nurse would communicate with the health care provider before giving metoprolol to a client with a slow HR

A client with supraventricular tachycardia (SVT) has a HR of 170 bpm. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective? 1. Increased urine output 2. BP of 90/60 3. HR of 98 bpm 4. No longer complaining of heart palpitations

3 Diltiazem hydrochloride's purpose is to slow the HR. SVT has a HR of 150-250 bpm; a HR of 110 bpm indicates diltiazem is having the desired effect.

Which food would the nurse instruct a client taking diltiazem to avoid?

Grapefruit juice because it can interfere with the metabolism of the medication

A health care provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication?

Administer in the abdomen

The nurse is assessing an adolescent after the administration of epinephrine. Which side effect is most important for the nurse to identify? 1. Tachycardia 2. Hypoglycemia 3. Constricted pupils 4. Decreased BP

Tachycardia Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will dilate, not constrict. Epinephrine is more likely to cause hypertension than hypotension.

Denver II screening test

test used to assess young children whose development appears to be behind the norm.

Which step would be first in advanced prehospital emergency care for a client with a history of allergic reaction to bee stings being stung by a bee? 1. Administering O2 2. Administering epinephrine 3. Administering oral liquid diphenhydramine 4. Monitoring for the development of toxic venom effects

Administering epinephrine The first step in advanced prehospital emergency care is to administer epinephrine to alleviate the symptoms of severe allergic reactions such as wheezing, facial swelling, and respiratory distress.

A client who has atrial fibrillation with rapid ventricular response is started on a continuous heparin infusion. Which clinical finding enables the nurse to conclude that the heparin is effective?

An activated partial thromboplastin time (aPTT) is twice the usual value. The desire anticoagulation effect is acheived when the aPTT is 1.5-2 times normal.

A client is receiving hydrochlorothiazide. Which physiological alteration will the nurse monitor to best determine the effectiveness of the therapy? 1. BP 2. Decreasing edema 3. Serum potassium level 4. Urine specific gravity

1 Diuretics promote urinary excretion which reduces the volume of fluid in the intravascular compartment, thus lowering BP. BP is the best determination of effectiveness because it is a direct measure of the desired outcome.

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

1 Nitroglycerin is a potent antihypertensive and antianginal medication; the nurse should instruct the client to sit and stand slowly to prevent orthostatic hypotension. The client's immediate safety takes precedence

Which diagnostic test is used for the direct visualization of ligaments, menisci, and articular surfaces of joints? 1. Arthroscopy 2. Muscle biopsy 3. Ultrasonography 4. Electromyography

1. Arthroscopy

What is the maximum recommended length for an enema tube insertion in an adolescent?

10 cm

A client admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The health care provider prescribes furosemide 40 mg IV stat to be repeated in 1 hour. Which action will best evaluate the effectiveness of the furosemide in managing the client's condition? 1. Performing daily weights 2. Auscultating breath sounds 3. Monitoring intake and output 4. Assessing for dependent edema

2 Maintaining adequate gas exchange and minimizing hypoxia with pulmonary edema are critical; therefore assessing the effectiveness of furosemide therapy as it relates to the respiratory system is the most important. Although the lessening of a client's dependent edema reflects effectiveness, it is the client's improving pulmonary status is the best indicator of how it is improving the client's condition

Which joint helps in the gliding movement of the wrist? 1. Pivot joint 2. Hinge joint 3. Biaxial joint 4. Ball and socket joint

3. Biaxial joint

While assessing the pupils of a client, a health care professional notices pupillary dilation. Which drug would have resulted in this condition? 1. Heroin 2. Atropine 3. Morphine 4. Pilocarpine

Atropine The intake of eye medications such as atropine will cause dilation of the pupils. Heroin, morphine, and pilocarpine cause pupil constriction

The nurse teaches a client's family about administration of donepezil for treatment of dementia of the Alzheimer type. Which side effect identified by the caregiver indicates to the nurse that further teaching is needed? 1. Nausea 2. Dizziness 3. Headache 4. Constipation

Constipation Donepezil, a cholinesterase inhibitor, may cause nausea, vomiting, increased salivation, diarrhea, and involuntary defecation related to the increase in GI secretions and activity caused by parasympathetic nervous stimulation; it does not cause constipation.

A client with hypertension has received a prescription for metoprolol. Which information will the nurse include when teaching this client? 1. Do not abruptly discontinue this medication 2. Consume alcoholic beverages in moderation 3. Report a HR less than 70 bpm 4. Increase the medication dosage if chest pain occurs

Do not abruptly discontinue this medication Abrupt discontinuation of metoprolol can cause rebound hypertension and an acute myocardial infarction.

When a client with a venous thrombosis is receiving warfarin, which test result would the nurse use to determine whether the daily dose it therapeutic?

International Normalized Ratio (INR)

When the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6, which action will the nurse take?

Notify the healthcare provider of the laboratory results. The therapeutic level for INR is 2-3, so the nurse would anticipate a decrease in warfarin dosage.

A client is admitted to the hospital with a diagnosis of DVT, and IV heparin sodium is prescribed. If a client experiences excessive bleeding, which medication will the nurse be prepared to administer?

Protamine sulfate

Which OTC medication would the nurse teach a client taking antihypertensive medication to avoid?

Pseudoephedrine Pseudoephedrine stimulates the sympathetic nervous system and may increase BP; it should be avoided by clients with HTN