NCLEX PREP 2
The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1.Reassess the client. 2.Conduct a staff meeting to describe the fall. 3.Document in the nurse's notes that an incident report was completed. 4.Contact the nursing supervisor to update information regarding the fall.
1. Reassess the client Frequent reassessment is necessary because the potential complications do not appear immediately after.
Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 1.The client who is taking diuretics 2.The client with hyperaldosteronism 3.The client with Cushing's syndrome 4.The client who is taking corticosteroids
1. The client taking diuretics (The client with hyperaldosteronism is at risk for hypernatremia )
Hypokalemia EKG
U waves Inverted T waves Depressed ST segment
capecitabine use and side effects
breast cancer resisitant to other therapy - bone marrow depression CBC should be done periodically
mafenide acetate use and adverse systemic effect
burn -topical can suppress renal excretion of acid causing acidosis monitor for signs of hyperventilation
Cyclophosphomide (Cytoxan) - used for breast cancer adverse side effect teaching
can cause hemorrhagic cystitis - drink copious amounts of fluid monitor urine output for hematuria should be taken on an empty stomach , hyperkalemia can occur
Isotretinoin - used for acne - systemic effect contraindications
can increase triglyceride levels vitamin A (can intensify effects or toxicity)
daunorubicin (non hodgkins lymphoma ) adverse effect
cardiotoxicity abnormal ekg cardiomyopathy heart failure - lung crackles bone marrow depression
Ropinirole Hydrochloride (Requip) use
idiopathic parkinsonian syndrome - may be administered 3/daily
betametasone is given in preterm labor to ?
increase surfactant production to stimulate fetal lung maturation - administered to clients in preterm labor at 28-32 weeks gestation if labor can be stopped for 48 hours
levothyroxine sodium - used for hypothyroidism side effects
insomnia weight loss mild heat intolerance
Pramlintide
is used for clients with types 1 and 2 diabetes mellitus who use insulin. It is administered subcutaneously before meals to lower blood glucose level after meals, leading to less fluctuation during the day and better long-term glucose control. Because pramlintide delays gastric emptying, oral medications should be given 1 hour before or 2 hours after an injection of pramlintide; therefore, instructing the client to take his or her pills 1 hour before or 2 hours after the injection is correct. Pramlintide should not be taken at the same time as other medications. Pramlintide is given immediately before the meal in order to control postprandial rise in blood glucose, not necessarily to prevent stomach upset. It is incorrect to instruct the client to take the medication after eating, as it will not achieve its full therapeutic effect
chlorothiazide is a potassium ________ diuretic.
losing diuretic monitor for decreased potassium levels
methimazole - used for hyperthyroidism common side effects
n/v/d take with food to avoid agranulocytosis thrombocytopenia
ondansetron use
nausea and vomiting
how should levothyroxine be taken. with or without food?
on an empty stomach to enhance absorption , should be done in the AM before breakfast
etoposide (used for small lung cancer) - what should the nurse monitor for?
orthostatic hypotension - should be administered slowly over 30-60 minutes to avoid hypotension
Lorazepam Contraindications
other benzos comatose state CNS depression uncontrolled severe pain and narrow angle glaucoma pregnancy breast feeding
vincristien (used for ovarian cancer) adverse effect
peripheral neuropathy happens in almost every patient
Reye's syndrome
potentially serious or deadly disorder in children that is characterized by vomiting and confusion
Rh0 immune globuline use
prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. stops her next baby from being affected by Rh incompatibility
hypocalcemia EKG
prolonged QT interval prolonged ST segment
silver sulfadiazine adverse effects
rash itching blue-green or gray skin leukopenia interstitial nephritis
signs of hip fracture
shortening and external rotation
Ventricular fibrillation
the rapid, irregular, and useless contractions of the ventricles NO P WAVES
salicylic acid (used for psoriasis) toxicity = salicylism symptoms
tinnitus dizziness hyperpnea psychological disturbances
paracentesis positioning
upright (ideally upright in a chair with feet flat on the floor and bladder emptied) - allows intestine to float posteriorly and prvnt intestinal laceration during catheter insertion.
busulfan - which lab value to monitor?
uric acid - it can cause hyperuricemia , uric acid nephropathy, renal stones, and AKI
cimetidine use and side effects
used for anti-acid H2 receptor antagonist MOST COMMON CONFUSION headache dizziness drowsiness hallucinations
dinoprostone
vaginal insert prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions
5 categories of CAM
-Mind-body therapies -Biologically based therapies -Manipulative and body-based therapies -Energy therapies -Alternative medical systems
The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary? 1."I can take aspirin or my antihistamine if I need it." 2."I need to take the medication every day at the same time." 3."I need to avoid coffee, tea, cola, and chocolate in my diet." 4."If I gain more than 5 pounds (2.25 kg) a week, I will call my health care provider (HCP)."
1 - Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP.
The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply. 1.Diarrhea may occur secondary to the metformin. 2.The repaglinide is not taken if a meal is skipped. 3.The repaglinide is taken 30 minutes before eating. 4.A simple sugar food item is carried and used to treat mild hypoglycemia episodes. 5.Muscle pain is an expected effect of metformin and may be treated with acetaminophen. 6.Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide
1, 2, 3, 4 Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea.
The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. 1.Touch 2.Eye contact 3.Personal space 4.Family presence 5.Time orientation 6.Facial expression
1, 2, 3, 5
A client complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. 1.Remove the IV catheter at that site. 2.Apply warm, moist packs to the site. 3.Notify the health care provider (HCP). 4.Start a new IV line in a proximal portion of the same vein. 5.Document the occurrence, actions taken, and the client's response
1, 2, 3, 5 Phlebitis is an inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection and can cause the development of a clot (thrombophlebitis). The nurse should remove the IV at the phlebitic site and apply warm, moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the HCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.
he nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1.Stop the infusion. 2.Notify the health care provider (HCP). 3.Prepare to apply ice or heat to the site. 4.Restart the IV at a distal part of the same vein. 5.Prepare to administer a prescribed antidote into the site. 6.Increase the flow rate of the solution to flush the skin and subcutaneous tissue.
1, 2, 3, 5 Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the IV administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. 1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Place a chair for the client across from the nurse's desk. 4.Ensure comfortable seating at eye level for the client and nurse. 5.Provide seating for the client so that the client faces a strong light. 6.Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters).
1, 2, 4 the nurse should set the room temperature at a comfortable level. The nurse should provide sufficient lighting for the client and nurse to see each other. The nurse should avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table because this creates a barrier. The distance between the nurse and the client should be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters)
Which identifies accurate nursing documentation notations? Select all that apply. 1.The client is resting in bed with the eyes closed. 2.Abdominal wound dressing is dry and intact without drainage. 3.The client seemed angry when awakened for vital sign measurement. 4.The client appears to become anxious when it is time for respiratory treatments. 5.The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
1, 2, 5 Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seemed or appears, is not acceptable because these words suggest that the nurse is stating an opinion.
Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply. 1.Electrolyte levels 2.Exercise patterns 3.Intake and output 4.Pupillary response 5.Elimination patterns 6.Deep tendon reflexes
1, 3, 5 The client with bulimia nervosa is likely to induce frequent vomiting and use diuretics and laxatives excessively. This places the client at risk for fluid and electrolyte imbalances. The nurse should monitor for both of these in this client. Excessive exercise is a characteristic of anorexia nervosa, not a characteristic of clients with bulimia. Changes in pupillary response and deep tendon reflexes are monitored in other disorders but are not associated with bulimia.
The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1.Back 2.Axilla 3.Eyelids 4.Soles of the feet 5.Palms of the hands
1, 4, 5 Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption
The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply. 1. Help regulate blood pressure. 2. Encourage immunosuppression. 3. Stimulate liver to secrete enzymes. 4. Assist to regulate acid-base balance. 5. Convert vitamin D to an active form. 6. Produce erythropoietin for red blood cell synthesis.
1, 4, 5, 6 Besides maintaining urinary elimination, the kidneys are also involved with helping to regulate blood pressure, assisting in regulating acid-base balance, converting vitamin D to an active form, and producing erythropoietin for red blood cell synthesis.
The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply. 1.The acuity level of the clients 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities
1, 5 ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments
The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication? 1."I will flush the eyes after instilling the ointment." 2."I will clean the newborn's eyes before instilling ointment." 3."I need to administer the eye ointment within 1 hour after delivery." 4."I will instill the eye ointment into each of the newborn's conjunctival sacs.
1- Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1.Reflecting a cultural value 2.An acceptance of the treatment 3.Client agreement to the required procedures 4.Client understanding of the preoperative procedures
1- Nodding or smiling by a japanese client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement, or understanding.
The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? 1.Contact the nursing supervisor. 2.Administer the dose prescribed. 3.Hold the medication until the HCP can be contacted. 4.Administer the recommended dose until the HCP can be located
1. If the HCP writes a prescription that requires clarification, the nurse's responsibility is to contact the HCP. If there is no resolution regarding the prescription because the HCP cannot be located or because the prescription remains as it was written after talking with the HCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification
The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1.Malnutrition 2.Renal insufficiency 3.Hypoparathyroidism 4.Tumor lysis syndrome
1. Malnutrition (the rest cause hyperphosphatemia)
Lithium toxicity symptoms
1.5 - 2.5 acute: GI disturbances: nausea, vomiting, diarrhea neuro finding can occur later chronic- neurologic ataxia, confusion, tremors
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? 1.Hemoglobin of 11 g/dL (110 mmol/L) 2.Fetal heart rate of 180 beats/minute 3.Maternal pulse rate of 85 beats/minute 4.White blood cell count of 12,000 mm3 (12.0 × 109/L)
2 - A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11-13 g/dL (110-130 mmol/L) ) because of the hemodilution caused by an increase in plasma volume during pregnancy.
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client
2 - A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).
The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? 1.Wait until the client's agitation has subsided before approaching the client. 2.Speak and move slowly toward the client while assessing the client's needs. 3.Speak to the client at the entrance of the room to avoid any episodes of agitation. 4.Walk up behind the client and gently put a hand on the client's shoulder while speaking.
2 - Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option.
The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply. 1.Open doors to client rooms. 2.Move beds away from windows. 3.Close window shades and curtains. 4.Place blankets over clients who are confined to bed. 5.Relocate ambulatory clients from the hallways back into their rooms
2, 3, 4 the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client's room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1.Neglecting personal grooming 2.Looking at old snapshots of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received
2, 3, 4, 5
which are high in potassium ? 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries
2, 3, 4, 6 Raisins Potatoes Cantaloupe Strawberries avocado bananas carrots fish mushrooms oranges pork beef veal spinach tomatoes
The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. 1.Respirations that are shallow 2.Respirations that are increased in rate 3.Respirations that are abnormally slow 4.Respirations that are abnormally deep 5.Respirations that cease for several seconds
2, 4 increased rate and abnormally deep
A nursing student is performing a respiratory assessment on a female adult client and is assessing for tactile fremitus. Which action by the nursing student indicates a need for further teaching? 1.Palpating over the lung apices in the supraclavicular area 2.Asking the client to repeat the word ninety-nine during palpation 3.Palpating over the breast tissue to assess and compare vibrations from 1 side to the other 4.Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine
3 - palpating over breast tissue is avoided because it usually blocks the sound
The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. 1."This medication will turn my urine orange." 2."I should decrease my oral fluids when I start this medication." 3."The amount of urine I make should increase if this medicine is working." 4."I need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5."I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin."
2, 5 In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an analog of ADH. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin is started, oral fluids should be decreased to prevent water intoxication. headache and drowsiness are a sign of water intoxication
The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply. 1.Document a late entry in the client's record. 2.Draw 1 line through the error, initialing and dating it. 3.Try to erase the error for space to write in the correct data. 4.Use whiteout to delete the error to write in the correct data. 5.Write a concise statement to explain why the correction was needed. 6.Document the correct information and end with the nurse's signature and title.
2, 6 his includes drawing one line through the error, initialing and dating the line, and then documenting the correct information. A late entry is used to document additional information not remembered at the initial time of documentation, not to make a correction of an error. Documenting the correct information with the nurse's signature and title is correct. Erasing data from the client's record and the use of whiteout are prohibited. There is no need to write a statement to explain why the correction was necessary.
The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching? 1."It is okay if I skip meals now and then." 2."I need to constantly watch for signs of low blood sugar." 3."I need to let my health care provider know if I get unusually tired." 4."I will be sure to not drink alcohol excessively while on this medication."
2- Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia. For this reason, metformin is well suited for clients who skip meals. Unusual somnolence, as well as hyperventilation, myalgia, and malaise, are early signs of lactic acidosis, a toxic effect associated with metformin.
A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? 1.Monitoring the leukocyte count for 2 days after the infusion 2.Checking the frequency and consistency of bowel movements 3.Checking serum liver enzyme levels before and after the infusion 4.Carrying out a Hematest on gastric fluids after the infusion is completed
2- The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea
The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1.Use the knee gatch on the bed. 2.Cover the legs lightly when sitting in a chair. 3.Encourage the client to cross the legs when sitting in a chair. 4.Provide pillows for the client to place under the knees as desired.
2. Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging crossing of the legs.
Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? 1.Platelet count 2.Alkaline phosphatase 3.White blood cell count 4.Complete blood cell count
2. Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline phosphatase level and elevated urinary hydroxyproline excretion.
A client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1.Constipation 2.Abdominal pain 3.An episode of diarrhea 4.Hematest-positive nasogastric tube drainage
3 - Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1.Raise the head of the client's bed. 2.Obtain hemoglobin and hematocrit levels. 3.Instruct the client to request help when getting out of bed. 4.Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
3 - ask for help if getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed
Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1."The medication is an antibacterial." 2."The medication will help heal the burn." 3."The medication is likely to cause stinging every time it is applied." 4."The medication should be applied directly to the wound.
3 - silver sulfadiazine should not cause stinging. Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing.
Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? 1.Pork roast, rice, vegetables, mixed fruit, milk 2.Crab salad on a croissant, vegetables with dip, potato salad, milk 3.Sweet and sour chicken with rice and vegetables, mixed fruit, juice 4.Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea
3 - the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered
A pregnant client is receiving oxytocin for the induction of labor. The nurse should immediately discontinue the oxytocin infusion if which is noted in the client? 1.Uterine atony 2.Severe drowsiness 3.Uterine hyperstimulation 4.Early decelerations of the fetal heart rate
3 Oxytocin is a synthetic hormone that stimulates uterine contractions and commonly is used to induce labor. A major danger associated with oxytocin induction of labor is hyperstimulation of uterine contractions, which can cause fetal distress as a result of decreased placental perfusion.
The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1.Muscle twitches 2.Decreased urinary output 3.Hyperactive bowel sounds 4.Increased specific gravity of the urine
3- Hyperactive bowel sounds (In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.)
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1."You need to stop that behavior now." 2."You will need to be placed in seclusion." 3."You seem restless; tell me what is happening." 4."You will need to be restrained if you do not change your behavior.
3. The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1.The client with colitis 2.The client with Cushing's syndrome 3.The client who has been overusing laxatives 4.The client who has sustained a traumatic burn
4 - Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse? 1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours
4 - Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by UAP. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.
A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1.Performing a procedure without consent 2.Threatening to give a client a medication 3.Telling the client that he or she cannot leave the hospital 4.Observing care provided to the client without the client's permission
4 - Invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.
A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."
4 - Laws and guidelines regarding instructional directives vary from state to state, and it is the responsibility of the nurse to know the laws. Many states prohibit any employee, including the nurse of a facility where the client is receiving care, from being a witness
Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the health care provider if which diagnosis is documented in the client's history? 1.Gout 2.Asthma 3.Myocardial infarction 4.Venous thromboembolism
4 - Megestrol acetate suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of venous thromboembolism.
What is the appropriate nursing intervention for a client diagnosed with posttraumatic stress disorder and paranoid tendencies who begins to pace and fidget? 1.Escort the client to a private, low-stimulus room. 2.Engage the client in a nonthreatening conversation. 3.Allow the client to pace unless the behavior becomes aggressive. 4.Share the observation with the client so the behavior can be recognized
4 -Sharing observations with the client may help the client recognize and acknowledge feelings. Allowing the client to pace may also allow the client to get out of control
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client? 1.A client complaining of muscle aches, a headache, and history of seizures 2.A client who twisted her ankle when rollerblading and is requesting medication for pain 3.A client with a minor laceration on the index finger sustained while cutting an eggplant 4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
4- chest pain is always first!! Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number-1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number-2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number-3 priority.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history? 1.Hypotension 2.Hypothyroidism 3.Diabetes mellitus 4.Peripheral vascular disease
4- contraindicted in cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. these conditions are worsened by the vasoconstrictive effects of ergot alkaloids
A client who has undergone renal transplantation is receiving ongoing therapy with cyclosporine. The nurse would be sure to immediately report which abnormal finding? 1.Decreased creatinine level 2.Decreased hemoglobin level 3.Decreased white blood cell (WBC) count 4.Elevated blood urea nitrogen (BUN) level
4. Cyclosporine is an immunosuppressant. The use of cyclosporine can cause nephrotoxicity. This complication is detected by assessing for elevated levels of BUN and serum creatinine. Decreased hemoglobin level and WBC count are incorrect because cyclosporine does not depress the bone marrow.
The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action? 1. Finish the bed bath and then administer the pain medication to the other client. 2. Ask the UAP to find out when the last pain medication was given to the client. 3. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client
4. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP
Normal WBC count
5,000-10,000/mm3
breast feeding a new born - how much should calories increase for the mother / day?
500
asparaginase - antineoplastic - which disorder would cause the nurse to contact the health care provider before administering? A. Pancreatitis B. DM C. MI D. COPD
A. Pancreatitis Asparaginase is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between dose administrations. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain.
alendronate - hyperparathyroidism teaching
Alendronate is a bisphosphonate used in hyperparathyroidism to inhibit bone loss and normalize serum calcium levels. Esophagitis is an adverse effect of primary concern in clients taking alendronate. For this reason the client is instructed to take alendronate first thing in the morning with a full glass of water on an empty stomach, not to eat or drink anything else for at least 30 minutes after taking the medication, and to remain sitting upright for at least 30 minutes after taking it.
The nurse caring for a client who is taking an aminoglycoside should monitor the client for which adverse effects of the medication? Select all that apply. 1.Seizures 2.Ototoxicity 3.Renal toxicity 4.Dysrhythmias 5.Hepatotoxicity
Aminoglycosides are administered to inhibit the growth of bacteria. Adverse effects of this medication include confusion, ototoxicity, renal toxicity, gastrointestinal irritation, palpitations or dysrhythmias, blood pressure changes, and hypersensitivity reactions.
Glimepiride - used for DM - which foods are acceptable to eat? A. Alchohol B. Red meats C. Whole grain cereals D. Low cal desserts E. Carbonated beverages
B, C, E alcohol can hypoglycemia low cal desserts may still have high carbs
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? A. Chess B. Writing C. Ping Pong D. Basketball
B. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension.
The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective? A. Lochia that is serous B. Normal BP C. Decreased uterine bleeding D. Decreased uterine contractions
C. Methylergonovine, an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus
magnesium toxicity symptoms
CNS depression respiratory depression loss of deep tendon reflexes sudden decline in maternal/fetal heart rate / blood pressure low urine output flushing muscle weakness pulmonary edema
Tamoxifen (Nolvadex) monitor which labs?
Calcium cholesterol triglycerides
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1.A decreased pH and an increased PaCO2 2.An increased pH and a decreased PaCO2 3.A decreased pH and a decreased HCO3- 4.An increased pH and an increased HCO3-
Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia
What can cross the placental barrier and potentially affect the fetus? Viruses bacteria nutrients antibodies medications
Large particles such as bacteria cannot pass through the placenta, but viruses, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them.
Which clients have a high risk of obesity and DM? Select all 1. Latino 2. Native American 3. Asian American 4. Hispanic 5. African American
Latino Native American Hispanic African American
food low in sodium - unless canned or salted. Peas Nuts Cheese Cauliflower Processed oat cereals
Peas, Nuts, Cauliflower good sources of phosphorus peas good source of magnesium processed foods such as cheese and oat cereals are high in sodium
exenatide use
DM TYPE 1 ONLY
Colonoscopy position
LEFT SIMS
metoclopramide
GI stimulant antiemetic used for vomiting after surgery, chemotherapy or radiation (C/I with obstruction , hemorrhage, perforation)
misoprostol use
Prevent NSAID peptic ulcers (NSAIDs block PGE1 production) Maintain patent ductus arteriosus. Ripen cervix for labor induction
pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?
Respiratory alkalosis
Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? Libel slander Assault negligence
Slander Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.
Pelvic inflammatory disease, what position is most therapeautic
Supine - Semi Fowlers - allows gravity to aid in drainage of the abdominal cavity
hyperkalemia EKG
Tall peaked T waves widened QRS complexes
The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What assessment should the nurse perform to detect the most common complication of TPN? 1.Vital signs 2.Auscultate lungs 3.Kidney function tests 4.Listen for bowel sounds
The most common complication associated with TPN is infection. Monitoring the temperature would provide data that would indicate infection in the client.
amphotericin B - use and adverse effects
antifungal vision / hearing alterations, seizures, hepatic failure, paresthesias, coagulation defects, nephrotoxicity, cardiovascular toxicity, as evidenced by hypotension and ventricular fibrillation
