Practice exam rationales

The client is being evaluated for possible acute leukemia. What inquiry by the nurse is most important?

"Have you had a respiratory infection in the last 6 months?"; The client with leukemia is at risk for infection and has often had recurrent respiratory infections during the previous 6 months. Insomnolence, weight loss, and a decrease in alertness also occur in leukemia, but bleeding tendencies and infections are the primary clinical manifestations

Increased confusion at night is known as

"sundowning" syndromes. The increased confusion occurs when the sun begins to set and continue during the night.

Following removal of a cataract, the client should

-avoid bending over for several days because this increases intraocular pressure. -avoid aspirin because it increases the likelihood of bleeding -keep the eye shield on when sleeping.

Metronidazole (Flagyl) should be taken

-with a full 8oz glass of water -with meals

Therapeutic range for aminophylline

10-20mcg/mL. Levels greater than 20 can produce signs of toxicity.

Therapeutic range for vancomycin is

10-25 mcg/mL

The physician has ordered sodium warfarin for the client with thrombophlebitis. The order should be entered to administer the medication at

1700; administered in the late afternoon to allow for accurate bleeding times to be drawn in the morning.

Sufficient sphincter control for toilet training is present by

18-24 months

Latent or early phase of labor is from

1cm-3cm in dilation

patients with ulcers within the duodenum typically complain of pain occurring

2-3 hours after a meal, as well as at night. Pain is usually relieved by eating.

The best size cathlon for administration of a blood transfusion to a six year old is

20 gauge.

The esophageal balloon tamponade should be maintained at a pressure of

20-25mmHg to help decrease bleeding from the esophageal varices

sunscreens of at least 15 spf should be applied

20-30 minutes before going into the sun

A CD4 count of under _______ is associated with the onset of opportunistic infections.

200

Defibrillation should begin at

200 joules and be increased to 360 joules

Unless contraindicated, the client with renal calculi should receive

200mL of fluid per hour to help flush the calculi from the kidneys

The contagious stage of varicella begins

24 hours before the onset of the rash and lasts until all lesions are crusted.

A plaster-of-Paris cast takes

24 hours to dry, and the client should not bear weight for 24 hours.

The client taking isoniazid should have a negative sputum culture within

3 months (12 weeks).

Pain associated with gastric ulcers occurs

30 min after eating

When should a trough level be scheduled for a client taking gentamycin

30 min before the fourth dose; trough levels are the lowest blood levels and should be done 30 mins before the third IV dose or 30 min before the fourth IM dose

Proton pump inhibitors (-prazole) should be taken

30 minutes before a meal

The majority of children have all their deciduous teeth by age

30months

Erb's point

3rd ICS left sternal border; the point at which you can hear the valves close simultaneously

Therapeutic level of magnesium sulfate is

4.8-9.6mg/dL

Following epidural anesthesia, the client should be checked for hypotension and signs of shock every

5 minutes for 15 minutes.

The maximum recommended rate of an intravenous infusion of potassium chloride is

5-10mEq/hour, never to exceed 20mEq/hour. An intravenous infusion controller is always used to regulate the flow.

ICP normal range

5-15 mmHg

Normal CD4 count

500-1500

The maximal effects from tricyclic antidepressants (i.e., imipramine [Tofranil]) might not be achieved for up to

6 months

Usual course of treatment using combined therapy with isoniazid and rifampin is

6 months

Transition phase of labor is

8-10cm in dilation.

The recommended setting for performing tracheostomy suctioning on the adult client is

80-120mmHg

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing's disease B. Client with diabetes C. Client with acromegaly D. Client with myxedema

A The client with Cushing's disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed. Client with acromegaly has an increase in growth hormone and poses no risk to himself or others. Client with myxedema has hyperthyroidism and poses no risk to other or himself.

Sydenham's chorea

A form of chorea (involuntary muscle twitching) associated with rheumatic fever, usually occurring in childhood.

When assessing a client for risk of hyperphosphatemia, which piece of information is important for the nurse to obtain?

A history of radiation treatment in the neck region; radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, interferes with calcium and phosphate regulation

A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

A history of streptococcal infections; clients with a history of streptococcal infections could have antibodies that render the streptokinase ineffective.

Nurse is performing an assessment on a client with possible pernicious anemia. What data would support this diagnosis?

A red, beefy tongue

Child with a history of respiratory infections has an order for a sweat test to be done. What finding would be positive for cystic fibrosis?

A sweat analysis greater than 60meq/L.

ELISA test (Enzyme-linked immunosorbent assay)

A test which uses two antibodies - one linked to an enzyme - to test for the presence of certain antibodies in a blood sample and, thus, the viruses associated with those antibodies. It is often used to test for the HIV and West Nile viruses.

The client has recently returned from having a thyroidectomy. The nurse should keep what at the bedside?

A tracheotomy set; client is at risk for tracheal edema.

The nurse is making assignments for the day. which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer

A. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is not radioactive because he travels to the radium department for therapy, and the radiation stays in the department. The client in answer C is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special container and use plastic spoons and forks.

Client's cervix is 5cm dilated with 75% effacement. What phase of labor?

Active. Active phase of labor occurs when the client is dilated 4-7cm.

appropriate intervention for a client who is experiencing pruritis

Adding baby oil to the client's bath water; oils can be applied to help with the dry skin and to decrease itching. adding baby oil to bath water is soothing to the skin

The nurse has a preop order to administer valium (diazepam) 10mg and Phenergan (promethazine) 25 mg. The correct method of administering these medications is to:

Administer the medication separately. Valium is not given in the same syringe with other medications. Valium is an antianxiety medication and Phenergan is used as an antiemetic.

Vaginal exam reveals that the client's cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

Alteration in coping related to pain; transition the time during labor when the client loses concentration due to intense contractions.

The physician has ordered Eskalith (lithium carbonate) 500mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:

Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs. It takes 1-2 weeks for mood stabilizers to achieve a therapeutic effect; therefore, antipsychotic medications can also be used during the first few days or weeks to manage behavioral excitement.

The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should

Apply a blood pressure cuff to the arm; The client that is having ECT is given a sedative. When the blood pressure cuff is inflated the fingers twitch when he has a grand mal seizure.

first action that the nurse should take if she finds the client has an O2 saturation of 68% is

Apply oxygen by mask; Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation.

A vaginal exam reveals a breech presentation in a newly admitted client. What action should the nurse take?

Apply the fetal heart monitor

The charge nurse is making assignment for the day. After accepting the assignment to a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. What initial action should the charge nurse take?

Ask the nurse if she has ever had the chickenpox; the nurse who has had the chickenpox has immunity to the illness and will not transmit chickenpox to the client

Client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

Assess for signs of abnormal bleeding; The normal Protime is approximately 12-20 seconds. A Protime of 120 seconds indicates an extremely prolonged Protime and can result in spontaneous bleeding episode.

Client is scheduled for a tensilon test to check for myasthenia gravis. What medication should be kept available during the test?

Atropine sulfate; the antidote for Tensolin and is given to treat cholinergic crisis.

Client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is: A. Measure the urinary output B. Check the vital signs C. Encourage increased fluid intake D. Weigh the client

B. The large amount of fluid loss can cause fluid and electrolyte imbalance that should be corrected. The loss of electrolytes would be reflected in the vital signs. Measuring the urinary output Is important, but the stem already says that the client has polyuria. Encouraging fluid intake will not correct the problem. Weighing the client is not necessary at this time.

The nurse employed in the ER is responsible for triage of four clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. 10 year old with lacerations of the face B. 15 year old with sternal bruises C. 34 year old with a fractured femur D. 50 year old with dislocation of the elbow

B. Client with sternal bruising might be experiencing airway and oxygenation problems and should be seen first

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, heart rate 130, and resp rate 18. Which is the client's most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception

B; vital signs indicate hypovolemic shock or fluid volume deficit

The most common neurological complication of Lyme's disease is

Bell's palsy. Symptoms of Bell's palsy include complaints of a "drawing" sensation and paralysis on one side of the face.

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

Bleeding from the mouth

What symptom would be expected with an Ewing's sarcoma

Bone pain; Ewing's sarcoma is a type of bone cancer

Client arrive in the ER with a possible fractured femur. The nurse should anticipate an order for

Buck's traction; client with a fractured femur will be placed in buck's traction to realign the leg and to decrease spasms and pain.

client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

Bulging eyes; exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.

The client is admitted with a BP of 210/100. Doctor orders furosemide (lasix) 40 mg IV stat. How should the nurse administer the prescribed furosemide?

By giving it over 1-2 minutes; lasix should be given approximately 1ml per minute to prevent hypotension

Endotracheal tube recommended by the CDC for reducing the risk of ventilator-associate pneumonia

CASS (continuous aspiration of subglottic secretions) tube features an evacuation port above the cuff, making it possible to remove secretions above the cuff.

Client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

Call security for assistance and prepare to sedate the client; if the client is a threat to the staff and to other clients the nurse should call for help and prepare to administer a medication such as Haldol to sedate the client.

While caring for a client with hypertension, the nurse notes the following vital signs: BP 140/20, Pulse 120, respirations 36, temp 100.8. The nurse's initial action should be to

Call the doctor. The client is exhibiting a widened pulse pressure, tachycardia, and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders.

The nurse is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. What is the appropriate action?

Call the surgeon and ask them to see the client to clarify the information; it is the responsibility of the physician to explain and clarify the procedure to the client.

Client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

Check the blood glucose level; Hyperstat is given IV push for hypertensive crises, but it often causes hyperglycemia. The glucose level will drop rapidly when stopped.

Client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-op period for the nurse to take is to:

Check the blood pressure; best indicator of cardiovascular collapse in the client who has had an adrenal gland removed. The remaining gland might have been suppressed due to the tumor activity.

Client had a total thyroidectomy. Client complains of tingling around the mount and in the fingers and toes. What would the nurses' next action be?

Check the calcium level; the parathyroid glands are responsible for calcium production and can be damaged during thyroidectomy. The tingling can be due to low calcium levels.

Client admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Check the client's immunization record to determine the date of the last tetanus immunization. A sling should be applied to immobilize the arm and prevent dependent edema

What item is most important to remove before sending a client into surgery?

Contact lenses; leaving contact lenses in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses.

A client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

Contact the physician for an order for immune globulin; the client who is immune-suppressed and is exposed to measles should be treated with medications to boost his immunity to the virus.

The client returns to the unit from surgery with a BP of 90/50, pulse 132, Respirations 30. What action by the nurse would be of priority?

Contact the physician; the vital signs are abnormal and should be reported to the doctor immediately.

The nurse should tell the client that labor has probably begun when

Contractions are 5 minutes apart. The client should be advised to come to the labor and delivery unit when the contractions are every 5 minutes and consistent. She should also be told to report to the hospital if she experiences rupture of membranes or extreme bleeding.

A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. What nursing action is appropriate?

Cover the wound with a sterile-saline soaked dressing.

A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage

D. Facilitating perineal wound drainage; the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site.

Which client can best be assigned to the newly licensed nurse? A. Client receiving chemotherapy B. Client post-coronary bypass C. Client with a TURP D. Client with diverticulitis

D. Most stable! transurethral prostatectomy (TURP) might bleed. Needs nurse that knows how much bleeding is within normal limits

Which of the following roommates would be best for the client newly admitted with gastric resection? A. Client with Crohn's disease B. Client with pneumonia C. Client with gastritis D. Client with phlebitis

D. No infection risk A frequent stools and might transmit infections B. coughing will disturb the gastric client C. Vomiting & diarrhea; infections risk and disturb the gastric client

Client diagnosed with hypothyroidism. Nursing diagnoses that would be of highest priority?

Decreased cardiac output r/t bradycardia; the decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices (Impaired physical mobility, hypothermia, disturbed though processes)

Medication used to treat iron toxicity

Desferal (deferoxamine)

The primary purpose for closely monitoring the intake and output of a client receiving total parenteral nutrition (TPN) is to:

Detect the development of hypovolemia; Complications of TPN therapy are osmotic diuresis and hypovolemia

An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?

Discard the solution and order a new bag; crystals in the solution are not normal and should not be administered to the client. Discard the solution immediately.

Toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to

Document that the infection has completely cleared

Diet instructions that should be given to the client with recurring UTIs?

Drink a glass of cranberry juice every day. Cranberry juice is more alkaline and, when metabolized by the body, is excreted with acidic urine. Bacteria does not grow freely in acidic urine.

5-month old diagnosed with atopic dermatitis, Nursing interventions will focus on

Eczema; preventing infection by preventing scratching.

Client has surgery for removal of a Prolactinoma. What kind of intervention would be appropriate for this client?

Elevate the head of the bed 30 degrees. A prolactinoma is a type of pituitary tumor. Elevating the head of the bed 30 degrees avoids pressure on the sella turcica and helps to prevent headaches.

Client with sick cell crisis, intervention of highest priority

Encouraging fluid intake of at least 200ml per hour; it is important to keep the client in sickle cell crisis hydrated to prevent further sickling of the blood

Damage to cranial nerve VII results in:

Facial pain

After the physician performs an amniotomy, the nurse's first action should be to assess the:

Fetal heart tones; when the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort.

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should

File a formal reprimand. The next action after discussing the problem with the nurse is to document the incident by filing a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing.

Client with AIDS-related cytomegalovirus is started on Cytovene (ganci-clovir). The nurse should tell the client that the medication will be needed:

For the remainder of the client's life to prevent the reoccurrence of CMV infection

Vaginal discharge associated with trichomonas infection

Frothy vaginal discharge

Client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). What intervention should the nurse implement?

Glucometer readings as ordered; IV glucocorticoids raise the glucose levels and often require coverage with insulin.

Client with AIDS asks the nurse why he cannot have a pitcher of water left at his bedside. The nurse should tell the client that:

He should drink only freshly run water; the client with AIDS should not drink water that has been sitting longer than 15 minutes because of bacterial contamination.

Cobex (cyanocobalamin) is an injectable form of cyanocobalamin or vitamin B12. Increased

Hgb levels reflect the effectiveness of the medication

4-month old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

Hib titer; the Hemophilus influenza vaccine is given at 4 months with the polio vaccine.

To maintain Bryant's traction, the nurse must make certain that the child's:

Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

Nurse is caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

Hypersomnolence; The client is expected to become sleepy, have hot flashes, and be lethargic. A decreasing urinary output, absence of the knee-jerk reflex, and decreased respiration indicate toxicity.

Pyridoxine (vitamin B6) is usually administered with

INH (isoniazid) in order to prevent nervous system side effects

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:

Increase the infusion of normal saline; the client's BP is low so increasing the IV is priority.

What action will help facilitate the elimination of bilirubin for an infant with physiologic jaundice

Increasing the infant's fluid intake; bilirubin is excreted through the kidneys

A client is admitted with a diagnosis of renal calculi. The nurse should give priority to:

Initiating an intravenous infusion; the nurse should give priority to beginning intravenous fluids. Increasing the client's fluid intake to 3,000mL per day will help prevent the obstruction of urine flow by increasing the frequency and volume of urinary output.

Client with pancreatitis has been transferred to the ICU. What order would the nurse anticipate?

Insertion of a Levine tube; the client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a Levine tube should be anticipated.

A 9-year old is admitted with suspected rheumatic fever. What finding is suggestive of Sydenham's chorea?

Irregular movements of the extremities and facial grimacing and labile moods

The nurse recognized that discoid lupus erythematosus (DLE) differs from systemic lupus erythematosus because it:

Is confined to changes in the skin; Discoid lupus produces discoid or "coinlike" lesions on the skin.

The client using a diaphragm should be instructed to:

Keep the diaphragm in a cool location. She should refrain from leaving the diaphragm in longer than 8 hours. She should have the diaphragm resized when she gains or loses 10 pounds or has abdominal surgery.

The client is newly diagnosed with juvenile onset diabetes. What is the priority nursing diagnosis?

Knowledge deficit; NEWLY diagnosed

The home health nurse is visiting a 15 year old with sickle cell disease. what information obtained on the visit would cause concern?

Likes to play baseball; the client with sickle cell disease is likely to experience symptoms of hypoxia if he become dehydrated or lacks oxygen. Extreme exercise, especially in warm weather, can exacerbate the condition

The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother's lap. Which should the nurse do first?

Listen to heart & lung sounds If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the infant's ear first, the child will begin to cry an it will be difficult to obtain an objective finding while listening to the heart and lungs

The nurse is aware that uremic frost is often seen in clients with

Liver failure; Uremic frost is most likely related to liver disease.

First sign of dementia in the client with AIDS:

Loss of memory and loss of concentration are the first signs of AIDS dementia complex.

Cauda equina syndrome

Loss of sensory function with potential for recovery

Multiple sclerosis

Loss of the myelin sheath in portions of the brain and spinal cord

What characteristic is associated with babies born to mother who smoked during pregnancy?

Low in birth weight. Growth retardation is associated with smoking, but this does not affect the infant length.

conception is most likely to occur when

Luteinizing hormone is high; luteinizing hormone released by the pituitary is responsible for ovulation. At about day 14, the continued increase in estrogen stimulates the release of lutenizing hormone from the anterior pituitary. The LH surge is responsible for ovulation, or release of the dominant follicle in preparation for conception, which occurs within the next 10-12 hours after the LH levels peak.

Best method of evaluating the amount of peripheral edema

Measuring the extremity. A paper tape measure should be used rather than one made of plastic or cloth, and the area should be marked with a pen, providing the most objective assessment.

foods high in iron

Meats, eggs, legumes, whole grains, green leafy vegetables, carrots, and dried fruits (raisins)

The client with hyperemesis gravidarum is at risk for developing:

Metabolic acidosis with dehydration; the client with hyperemesis has persistent nausea and vomiting. With vomiting come dehydration. When the client is dehydrated, she will have metabolic acidosis.

Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large clots. The nurse should anticipate an order for?

Methergine; a drug that causes uterine contractions. Used for postpartal bleeding that is not controlled by pitocin

Before cataract removal, the client will have

Mydriatic drops instilled to dilate the pupil. This will facilitate removal of the lens.

The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. What side effect is most often associated with this drug?

Nausea; Nausea and gastrointestinal upset are very common in clients taking acetylcholinesterase inhibitors such as Exelon. Other side effects include liver toxicity, dizziness, unsteadiness, and clumsiness.

Do you need to avoid taking BP in the arm that a patient is receiving magnesium sulfate IV?

No

Method to elicit the radial nerve

Nurse instruct the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

Trendelenburg sign

Occurs with severe subluxation of one hip When the child stands on the good leg, the pelvis looks level. When the child stands on the affected leg the pelvis drops toward the good side

The influenza vaccine is usually given in

October and November

What action is contraindicated in the client with epiglottis?

Oral airway assessment using a tongue blade; a child with epiglottis has the possibility of complete obstruction of the airway. For this reason the nurse should not evaluate the airway using a tongue blade.

Alendronate (Fosamax)

Osteoporosis Agent

Viral load count in HIV that warrants hospice

Over 100k copies

Klinefelter's syndrome

Over-replication of the X chromosomes in males

Leopold maneuver sequence

Palpate client's fundus to identify fetal part, determine location of fetal back, palpate fetal part presenting at inlet, identify attitude of head

Client on a mechanical ventilator begins to fight the ventilator. What medication will be ordered for the client?

Pavulon (pancuronium bromide); a neuromuscular blocking agent that paralyzes skeletal muscles, making it impossible for the client to fight the ventilator

The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

Pepper; it is not processed and contains bacteria. Fruits should be cooked or washed and peeled.

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

Phlebostatic axis; located at the fifth intercostals space midaxillary line and is the correct placement of the manometer.

The quantitative sweat test used to diagnose children suspected of having cystic fibrosis uses

Pilocarpine iontophoresis to stimulate sweating. Chloride and sodium levels in the sweat are the measured by the test

Client with hemophilia has a nosebleed. Nursing action most appropriate to control the bleeding

Pinch the soft lower part of the nose; direct pressure to the nose stop the bleeding

Client with autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

Platelet count; Client with autoimmune thrombocytopenic purpura (ATP) have low platelet counts.

The most common opportunistic infection in infants and children with HIV is

Pneumocystis carinii pneumonia

fifth intercostals space midclavicular line

Point of maximal impulse (PMI)

The initial assessment of a newborn reveals a chest circumference of 34cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:

Positioning on the left side with head and chest elevated. Assessment suggests the presence of a diaphragmatic hernia. The newborn should be positioned on the left side with the head and chest elevated. This position will allow the lung on the right side to fully inflate.

What nursing diagnoses would be most appropriate for the primigravida as she completes the early phase of labor?

Potential fluid volume deficit related to decreased fluid intake; Clients admitted in labor are told not to eat during labor, to avoid nausea and vomiting. Ice chips may be allowed, but this amount of fluid might not be sufficient to prevent fluid volume deficit.

What lab finding would provide a definitive diagnosis of DIC?

Presence of fibrin split compound

Client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogaqstric tube is to

Prevent contamination of the suture line; allow for nourishment without contamination

Client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. what in the client's history should be reported to the doctor?

Prinzmetal's anginga; if the client has a history of Prinzmetal's angina, he should not be prescribed triptan preparations because they cause vasoconstriction and coronary spasms.

The chief purpose of the Jackson-Pratt drain is to

Provide for wound drainage.

Client in the prenatal clinic is assessed to have a BP of 180/96. The nurse should give priority to:

Providing a calm environment. A calm environment is needed to prevent seizure activity. Any stimulation can precipitate seizures.

When checking patellar reflexes, the nurse is unable to elicit a knee-jerk response. To facilitate checking the patellar reflex, the nurse should tell the client to:

Pull against her interlocked fingers, pulling against interlocked fingers will focus the client's attention away from the area being examined, thus making it easier to elicit a knee-jerk response.

The diagnosis of Hodgkin's lymphoma is confirmed by the presence of

Reed-Sternberg cells "owl's eyes".

The client with AIDs should be taught to

Refrain from taking herbals; Herbals can prolong bleeding times or interfere with antiviral medications, therefore the client should avoid the use of herbals.

Client with osteoarthritis has a prescription for Celebrex (celecoxib). What instruction should be included in the discharge teaching?

Report chest pain; Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of COX II inhibitors.

Client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

Report the finding to the doctor; Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to the lesions.

Client has been receiving cyanocobalamin (B12) injections for the past 6 weeks. What laboratory finding indicates the the medication is having the desired effect

Reticulocyte count of 1%

A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

Reverse drug toxicity and prevent tissue damage; Leucovorin is the antidote for Methotrexate and Trimetrexate which are folic acid antagonists. Leucovorin is a folic acid derivative.

Rationale for administering leucovorin calcium to a client receiving Methotrexate is to

Reverse drug toxicity; Methotrexate is a folic acid antagonist. Leucovorin is the drug given for toxicity to this drug.

The body part that would most likely display jaundice in the dark-skinned individual is the

Roof of the mouth; The oral mucosa and hard palate (roof of the mouth) are the best indicators of jaundice in dark-skinned persons.

Best position for the client in sickle cell crisis

Semi-fowler's with legs extended on the bed; provides the best oxygenation for this client

The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

Serum collection (Davol) drain. Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging.

21-year old male with Hodgkin's lymphoma. Engaged to be married and is to begin a new job. What diagnoses would be priority?

Sexual dysfunction related to radiation therapy; radiation therapy often causes sterility in male clients and would be of primary importance to this client. The psychosocial needs of the client are important to address in light of the age and life choices.

Effective means of managing discomfort from an episiotomy

Sitz baths will help with swelling and improve healing. Icepack can be used immediately after delivery.

While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:

Stop the infusion. Medication should be restarted through a new IV access.

A client with severe anemia is to receive a unit of whole blood. In the event of a transfusion reaction, the first action by the nurse should be to:

Stop the transfusion and maintain an IV of normal saline

What instruction should be given to the client who is fitted for a behind the ear hearing aid?

Store the hearing aid in a warm, dry place and clean daily. Changing batteries weekly is not necessary

Client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should include telling the client to:

Strain his urine; iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled.

A newborn is diagnosed with respiratory distress syndrome. What position is best for maintaining an open airway?

Supine with the neck slightly extended

What instruction should be given to the client taking alendronate (Fosamax)

Take the medication with water only. Client should also remain upright for at least 30 min after taking the medication

A client with a history of schizophrenia is seen in the local health clinic for medication follow-up. To maintain a therapeutic level of medication, the nurse should tell the client to avoid:

Taking OTC allergy medication; the client should avoid OTC allergy medications because many of them contain Benadryl (diphenhydramine). Benadryl is used to counteract the effects of antipsychotic medications that are prescribed for schizophrenia.

Developmental regression and cherry-red macula describes the child with

Tay Sach's disease

Mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

Tell her that 30% of newborns have a rash that will go away by one month of life; the mother is most likely describing a newborn rash. About 30% of all newborns have a rash on the face and forehead that dissipates in approximately one month.

The nurse is caring for the client who has been in a come for 2 months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?

Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff. The hospital will honor the wishes of family members even if the patient signed a donation card.

Montgomery straps are used for clients

That require frequent dressing changes or if they are allergic to certain tapes. ex: used for a client with a cholecystectomy since the client with a cholecystectomy usually has a large amount of drainage on the dressing.

Client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. What complaint by the client should alert the nurse to a problem with the client's medication?

The client complains of increased thirst and urination; signs of lithium toxicity!

A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as

The client's viral load is extremely low so he is relatively free of circulating virus.

Tuberculosis treatment

The combination of isoniazid (INH), rifampin (RIF), pyrazinamide, and ethambutol is a typical course of treatment for tuberculosis. This combination should be administered for two months followed by four more months of INH and RIF daily (6 months in all)

What nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?

The fundus is firm and 3 finger widths below the umbilicus. By the third postpartum day, the fundus should be located 3 finger widths below the umbilicus

L/S ratio and phosphatidyl glycerol level. L/S ratio of 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

The infant is at high risk for respiratory distress syndrome; When the L/S ratio reaches 2:1, the lungs are considered to be mature.

A 2-year old is admitted for repair of a fractured femur and is placed in Bryant's traction. What finding by the nurse indicates that the traction is working properly?

The infant's hips should be off the bed approximately 15 degrees.

Method to elicit patella reflex

The nurse instruct the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

Method to elicit the biceps reflex

The nurse places her thumb on the muscle inset in the ante-cubital space and taps the thumb briskly with the reflex hammer

Best site for examining for the presence of petechiae in an African American client?

The soles of the feet; petechiae is not usually visualized on dark skin. The soles of the feet and palms of the hands provide a lighter surface for assessing the client for petechiae.

Nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

There is uteroplacental insufficiency.

During assessment of a child with congenital hip dysplasia, the nurse can expect to find

Trendelenburg sign

Classification of tumor: Tis

Tumor is in situ; cancer in situ means that the cancer is still localized to the primary site. T stands for "tumor" and IS stand for "in situ"

Obstetric client's FHR is 80-90 during contractions. The first action the nurse should take is:

Turn the client to her left side; Normal FHR is 120-160bpm; 100-110bpm is bradycardia. The first action would be to turn the client to the left side and apply oxygen.

Low posterior hairline, webbed neck, and short stature describes the child with

Turner's syndrome

lecithin/sphingomyelin ratio (L/S)

Use to assess fetal lung maturity. 2:1 indicates mature lung development. 1:5:1 indicates pulmonary immaturity, <2.0 indicates increased risk for respiratory distress. <1.5 high risk for RDS.

The nurse notes a pattern on the fetal monitor that shows a drop in the FHR of 30bpm beginning at the peak of the contraction and ending at the end of the contraction. the FHR baseline is 165-175bpm with variability of 0-2bpm. What is the most likely explanation of this pattern?

Uteroplacental insufficiency; this information indicates a late deceleration. This type of deceleration is cause by uteroplacental insufficiency, or lack of oxygen.

Lidocaine is a medication frequently ordered for the client experiencing

Ventricular tachycardia; this medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of the ventricular contractions.

Lab report that provides information regarding the effectiveness of the medication regimen for a client who is HIV positive

Viral load or viral burden test; provides information on the effectiveness of the client's medication regimen as well as progression of the disease

A client with frequent UTIs asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

Void every 3 hours. Prevents stagnant urine from collecting in the bladder, where bacteria can grow. Douching after intercourse is not recommended

The most definitive diagnostic tool for HIV

Western Blot

A client with a severe corneal ulcer has an order for Gentamycin gtt q 4 hours and Neomycin 1 gtt q 4 hours. What schedule should be used when administering the drops?

When using eyedrops, allow 5 minutes between two medications.

A client having a colonoscopy is medicated with Versed (midazolam). The nurse recognizes that the client:

Will not be able to remember having the procedure done; Versed produces conscious sedation, so the client will not be able to remember having the procedure

A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

Wrapping the newborn snugly in a blanket; this will help prevent the muscle irritability that these babies often experience. Teaching the mother to provide tactile stimulation or provide for early infant stimulation are incorrect because the baby is irritable and needs quiet and little stimulation at this time.

What medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching in the client with chickenpox?

Zovirax (acyclovir)

The client receiving magnesium sulfate should have

a Foley catheter in place, and hourly intake and output should be checked.

The client with a cardiac tamponade will exhibit

a decrease of 10mmHg or greater in systolic blood pressure during inspirations. This phenomenon, known as pulsus paradoxus is related to blood pooling in the pulmonary veins during inspiration

lisinopril (Zestril) is an ACE inhibitor and is frequently given with

a diuretic such as Lasix for hypertension.

Nephrotic Syndrome

a group of clinical symptoms occurring when damage to glomerulus of the kidney resulting in severe proteinuria

Bacterial pneumonia usually presents with

a high fever and cough

A positive Babinski reflex in adults should be reported to the physician because it indicates

a lesion of the corticospinal tract

Myasthenia gravis is caused by

a loss of acetylcholine receptors, which results in the interruption of the transmission of nerve impulses from nerve endings to muscles.

24 hours after an uncomplicated labor and delivery, a client's WBC is 12,000cu/mm. The elevation in the client's WBC is most likely an indication of

a normal response to the birth process

When gathering evidence from a victim of rape, the nurse should place the victim's clothing in

a paper bag; it allows the clothes to dry without destroying evidence. Plastic and rubber retain moisture that can deteriorate evidence.

Diaphragmatic respirations

abdominal breathing

The infant with biliary atresia has

abdominal distention, poor weight gain, and clay-colored stools

Client with polycythemia vera has an

abnormal increase in the number of circulating RBCs that results in increased viscosity of the blood. Increases in BP further tax the overworked heart.

With hemolytic anemia, RBCs would be

abnormal shaped or shortened life span.

Tardive dyskinesia

abnormal, involuntary movements of the face, neck, and jaw.

When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find

active fetal movement

The client with cirrhosis and abdominal ascites requires

additional protein and calories. However, if ammonia level increases, protein intake should be restricted or eliminated.

Fetal development depends on

adequate nutrition and insulin regulation. Insulin needs increase during the second and third trimesters.

Before administering chemotherapy, the nurse should

administer an antiemetic as most chemotherapy agents cause nausea

Client has an order for FeSO4 liquid. What method of administration would be best?

administer the medication with orange juice; FeSO4 or iron, should be given with ascorbic acid (vitamin C) to help improve absorption

Intrathecally

administered into the spinal subarachnoid space (cerebrospinal fluid)

A client has an order for Demerol (meperidine) 75 mg IM to be administered 10 min before delivery. The nurse should question the order because

administering a narcotic so close to the time of delivery can result in respiratory depression in the newborn.

Client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to

administering prescribed anti-parkinsonian medication; client's symptoms suggest an adverse reaction to the medication known as neuroleptic malignant syndrome

The client taking MAOI, including Parnate, should avoid eating

aged cheeses, such as cheddar cheese, because a hypertensive crisis can result

The client with burns to the neck needs

airway assessment and supplemental oxygen. The next action should be to start an IV and medicate for pain

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.

What should be avoided while taking metronidazole (Flagyl) (two things)

alcoholic beverages and products containing alcohol should be avoided. Alcohol will cause extreme nausea if consumed. Sunlight due to photosensitivity

Doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is

alleviating pain

An advanced directive

allows the client to make known his wishes regarding care if he becomes unable to act on his own. Confusion regarding life-saving measures can occur if the client does not have an advanced directive

Akathesia, an extrapyramidal side effect of antipsychotic medication, results in

an inability to sit still or stand still.

Oculogyric crisis

an involuntary deviation and fixation of the eyes.

Stimulant medications such as ritalin tend to cause

anorexia and weight loss in some children with ADHD. Providing high-calorie snacks will help the child maintain an appropriate weight

An adverse side effect of Chloromycetin (chloramphenicol) is

aplastic anemia. Therefore, the nurse should pay particular attention to the client's complete blood count

To control the bleeding of a nose that is visibly deformed, the nurse should

apply a wrapped ice compress to the nose. Nostrils should not be pinched due to a visible deformity.

The best method and safest way to change the ties of a tracheotomy is to

apply the new ones before removing the old ones.

Intra-arterial chemotherapy primarily benefits the client by

applying greater concentrations of medication directly to the malignant tumor as well as treatment of micro-metastasis from cancerous tumors. It also lessens systemic effect but does not prevent or eradicate them

Condylomata lesion

are painless warts

Prior to a intravenous pyelogram, the nurse should

ask the client to void immediately before the study; a full bladder or bowel can obscure the visualization of the kidney ureters and urethra.

Pallor of conjunctiva

associated with anemia

White flecks in the iris

associated with down syndrome

Blue-tinged sclera

associated with osteogenesis imperfecta

Chancre lesion

associated with syphilis is not painful

Lidocaine is not used for

atrial arrhythmias

Clients with GERD should be taught to

avoid carbonated beverages, not eat 3-4 hours before going to bed, sleep on the left side to prevent reflux, and avoid spicy acidic and beverages that are irritating to the gastric mucosa

The controller for the continuous passive-motion device should be placed

away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. CPM flexes and extends the leg

Retinal hemorrhages are characteristically found in the child who has

been violently shaken

Clay-colored stools are associated with

biliary obstruction

Cigarette smoking is the number one cause of

bladder cancer

Presence of doll's eye movement indicates damage to the

brainstem or oculomotor nerve.

Tagamet (cimetidine) is a histamine blocker that

can be given in one dose at bedtime.

Whipple procedure (pancreaticoduodenectomy) is performed for

cancer located in the head of the pancreas

Client with TB has a prescription for myambutol (ethambutol HCL). The nurse should tell the client to notify the doctor immediately if he notices

changes in color vision

reaction formation (defense mechanism)

characterized by outward emotions that are opposite of internal feelings

The child with Tay Sachs disease has

cherry-red spots on the macula of the eye

Infant with hypospadias should not be

circumcised because the foreskin is used in reconstruction. Surgical correction is done when the infant is 16-18 months of age.

A nephrostomy tube is placed directly into the kidney and should never be

clamped or irrigated because of the damage that can result to the kidney.

what post-operative diet is most appropriate for the client who has had a hemorrhoidectomy?

clear-liquid. After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care to avoid constipation. Later, a high-fiber diet is encouraged.

Low roughage diet

client should avoid eating foods that are gas forming and that increase abdominal discomfort (broccoli, cabbage)

the success of the rhythm method of birth control is dependent on the

client's menses being regular.

Absent femoral pulses in an infant indicates

coarction of the aorta. This defect causes strong bounding pulses and elevated blood pressure in the upper body, and low BP in the lower extremities.

Acticoat (silver nitrate) is a

commercially prepared dressing that should be moistened with sterile water

Accutane is made from

concentrated vitamin A, a fat-soluble vitamin. Fat-soluble vitamins have the potential of being hepatotoxic, so a liver panel is needed.

Rhinitis, maculopapular rash, and hepatosplenomegaly are associated with

congenital syphilis

Common side effect of Basagel (aluminum carbonate gel)

constipation; antacids containing aluminum tend to cause constipation

Miotic eyedrops

constrict the pupil and allow aqueous humor to drain out of the Canal of Schlemm.

The first sign of latex allergy is usually

contact dermatitis, which includes swelling and itching of the hands

herpes zoster is shingle. Client with shingles should be placed in

contact precautions. Wearing gloves during care will prevent transmission of the virus.

If the client pulls the chest tube out of the chest, the nurse's first action should be to

cover the insertion site with an occlusive dressing. Afterward, the nurse should call the doctor, who will order a chest x-ray and possibly reinsert the tube.

Petaling a cast is

covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the case. Petaling the cast is done by the HCP who applied the cast.

The degree of pulmonary involvement is the greatest determinant in the prognosis of

cystic fibrosis.

The client with epilepsy is managed with anticonvulsant medication. An adverse side effect of anticonvulsant medication is

decreased WBC count.

Success with breastfeeding depends on many factors, but the most dependable reason for success is

desire and willingness to continue the breastfeeding until the infant and mother have time to adapt.

Stereotactic surgery

destroys areas of the brain responsible for intractable tremors.(Parkinson's disease)

Alpha fetoprotein is a screening test done to

detect neural tube defects such as spina bifida

Severe complication associated with Kawasaki's disease

development of a giant aneurysm

The infant with tetralogy of Fallot has four heart defects. He will be treated with

digoxin to slow and strengthen the heart.

The time it takes for alcohol to be fully metabolized is calculated by

dividing the blood alcohol level on admission by 20mg/dL (amount metabolized in an hour)

Gonorrhea

does not present as a lesion, but is exhibited by a yellow discharge.

Bromocrystine (Parlodel) is a

dopamine receptor stimulant used to treat Parkinson's disease.

The most common symptom reported by clients with multiple sclerosis is

double vision

The pregnant client who is age 42 is at risk for fetal anomalies such as

down syndrome and other chromosomal aberrations

Foods high in purine include

dried beans, peas, spinach, oatmeal, poultry, fish, liver, lobster, and oysters

Before ultrasonography, the client should be taught to

drink plenty of fluids and not void.

Clients taking Acyclovir should be encouraged to

drink plenty of fluids because renal impairment can occur.

The client with Sjogren's syndrome complains of

dryness of the eyes. The nurse can help relieve the client's symptoms by instilling artificial tears.

Although the cause remains unknown, autopsy results consistently reveal the presence of pulmonary edema and intrathoracic hemorrhages in infants

dying with SIDS

If the finger cannot be used, the next best place to apply the oxygen monitor is the

earlobe. It can also be placed on the forehead.

uterine atony is the major cause of

early postpartal hemorrhage

The client taking glyburide (Diabeta) should be taught

eat meals even if he is not hungry to prevent a hypoglycemic reaction

cor pulmonale, right ventricular failure, is characterized by

edema of the legs and feet, enlarged liver, and distended neck veins

Oxytocin challenge test shows the

effect of contraction on fetal heart rate.

The client with an abdominal aortic aneurysm is admitted in preparation for surgery. What should be reported to the doctor prior to surgery?

elevated WBC count; this indicates infection.

Client with a prolapsed cord should be treated by

elevating the hips and covering the cord with a moist, sterile saline gauze. The should use her fingers to push up on the presenting part until a cesarean section can be performed.

The treatment of galactosemia consists of

eliminating all milk and lactose-containing foods, including breast milk

Timoptic eyedrops should be used with caution in clients with a history of

emphysema; beta blockers such as timolol (timoptic) can cause bronchospasm in the client with chronic obstructive lung disease.

What instruction should be given to the client before a paracentesis

empty the bladder before the procedure to prevent the risk of puncturing the bladder when the needle is inserted. The client is positioned sitting up or leaning over an overbed table

To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should

encourage motion of the joint within the limits of pain

The nonstress test is done to

evaluate periodic movement of the fetus (measures the activity of the fetus)

Child with asthma has

expiratory wheezing and nonproductive cough

A body cast or spica cast

extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus.

Malpractice

failing to perform, or performing an act that causes harm to the client. Ex: doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage.

Delusions of grandeur are associated with

feelings of low self-esteem

Fetal heart tones head in center of abdomen

fetus is in the sacral position

The nurse is aware that Pitocin is working if the fundus is

firm and in the midline; it is used to cause the uterus to contract and decrease bleeding.

Priority nursing diagnosis for the patient with ulcerative colitis

fluid volume deficit which can lead to metabolic acidosis and electrolyte loss

Client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respiration 20. Which is the client's most appropriate priority nursing diagnosis?

fluid volume deficit; The vital signs indicate hypovolemic shock.

Symptoms associated with glaucoma

foggy loss of vision, seeing halos around lights, complaints of eye pain

The client taking methotrexate should avoid multivitamins because multivitamins contain

folic acid. Methotrexate is a folic acid antagonist.

Novalog insulin onsets very quickly, so

food should be available within 10-15 minutes of taking the insulin.

What therapy is used to treat B-Thalassemia major

frequent blood transfusions; Thalassemia is a genetic disorder that causes RBCs to have a shorter life span. Frequent blood transfusion are necessary to provide oxygen to the tissues

Histoplasmosis

fungus carried by birds.

Morphine is contraindicated in clients with

gallbladder disease and pancreatitis because morphine causes spasms of the sphincter of Oddi.

Symptoms of nontropical sprue as well as those with celiac disease are caused by the ingestion of

gluten, found in barley, rye, oats, wheat

Thayer-Martin culture (TMC) is done for

gonorrhea

The child with cystic fibrosis has sweat concentrations of chloride

greater than 60mEq/L

The nurse should provide frequent rest periods for the client with cerebral palsy because

grimacing & writhing movements decrease with relaxation and rest. Frequent rest periods help to relax tense muscles and preserve energy

According to the CDC, the ventilator-dependent client who is receiving tube feedings should

have the head of the bed elevated 30-45 degrees to prevent aspiration of gastric secretions

Attention is evaluated by

having the client count backward by beginning at 100

Registration is evaluated by

having the client immediately repeat the name of three items just named by the examiner

Orientation is evaluated by

having the client state the year, month, and day

HELLP syndrome

hemolysis, elevated liver enzymes, and low platelet count

Lesion that is painful is most likely a

herpetic lesion.

Diet associated with increased risk of colorectal cancer

high fat, refined carbs

Client recovering from acute pancreatitis needs a diet that is

high in calories and low in fat

Physician orders removal of a in-dwelling catheter the second post-op day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that

his complaints are common and will improve over the next few days; client's complaints are due to swelling associated with surgery and catheter placement

Infants under the age of 2 should not be fed

honey

Trivalent botulism antitoxin is made from

horse serum; therefore, the nurse needs to assess the client for allergies to horses

With iron-deficiency anemia, the RBCs are described as

hypochromic and microcytic.

A severe toxic side effect of Pentam (pentamidine) is

hypotension

The client with acute adrenal crisis has symptoms of

hypovolemia and shock; low bp!

The nurse is caring for a client scheduled for a surgical repair of a saccular abdominal aortic aneurysm. What assessment is most crucial during the preoperative period?

identification of peripheral pulses; because the aorta is clamped during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities.

hemoglobin of 26% and hematocrit of 32 necessitate

immediate report to the doctor; low hemoglobin and hematocrit might indicate bleeding.

Factors associated with the development of Legionnaires' disease include

immunosuppression, advanced age, alcoholism, and pulmonary disease

Anomia

inability to find words; name objects

Aphasia

inability to speak or understand

Apraxia

inability to use objects appropriately.

Central cord syndrome

incomplete loss of motor function

A client develops a temperature of 102 degrees following coronary artery bypass surgery. The nurse should notify the physician immediately because elevation in temperature

increase cardiac output

Atropine sulfate is used to

increase heart rate

Herbal supplement kava-kava (piper methysticum) can

increase the effects of anesthesia and post-operative analgesia.

The nurse is caring for the client following a thyroidectomy when suddenly the client becomes nonresponsive and pale, with a BP of 60 systolic. The nurse's initial action should be to

increase the infusion of normal saline; clients who have not had surgery to the face or neck would benefit from lowering the head of the bed. However, in this situation lowering the client's head could further interfere with the airway.

Signs of fluid overload in an infant include

increased heart rate and increased BP

Spinal fluid of a client with Guillain-Barre syndrome has an

increased protein concentration with normal or near-normal cell counts

uterus deviated to the left or right

indicates full bladder

Fetal heart tones heard in the right upper abdomen

infant is in a breech presentation

Fetal heart tones heard in right lower quadrant

infant is in the right occipital anterior presentation

Fetal heart tones heard in the left lower abdomen

infant is most likely in the left occipital transverse position.

Green stools are associated with

infection or large amounts of bile

According to Erikson, the school-age child needs the opportunity to be involved in tasks that he can complete so that he can develop a sense of industry. If he is not given these opportunities, he is likely to develop feelings of

inferiority

Cyclogel (cyclopentolate hydrochloride)

inhibits constriction of the pupil and rests the muscles of accommodation. Can be used for the client following a scleral buckling

Intradermal injection

insert the needle at a 5-15 degree angle

Child with laryngotracheobronchitis has an

inspiratory stridor and a harsh "brassy" cough

Primary cause of anemia in a client with chronic renal failure is

insufficient erythropoietin

A serologic marker of HB8 AG that is present 6 months after acute infection with hepatitis B indicated that the client

is a carrier or has chronic hepatitis

Client in labor admits to using alcohol throughout the pregnancy. the most recent use was the day before. Based on the client's history, the nurse should give priority to assessing the newborn for

jitteriness; jitteriness and irritability are signs of alcohol withdrawal in the newborn

Management of Kawasaki's disease include the use of

large doses of aspirin (acetylsalicylic acid)

The infant of a diabetic mother is usually

large for gestational age. After birth, glucose levels fall rapidly due to the absence of glucose from the mother.

Retained placental fragments are the major cause of

late post-partal hemorrhage

By writing down suspicions, the nurse leaves herself open for a suit of

libel, a defamatory tort that discloses a privileged communication and leads to a lowering of opinion of the client. Defamatory torts include libel and slander. Libel is a written statement, whereas slander is an oral statement.

The nurse caring for a client with nephrotic syndrome should

limit the number of visitors; the client with nephrotic syndrome will be treated with immunosuppressive drugs

Clients taking Amphotericin B should be monitored for

liver, renal, and bone marrow function because this drug is toxic to the kidneys and liver, and causes bone marrow suppression. Watch for changes in skin color! (jaundice)

Blood alcohol concentrations of 50mg/dL are associated with

loss of coordination, alteration in coordination and speech

Brown Sequard spinal cord injury

loss of sensation on the side opposite the cord injury

The client with signs of heptorenal syndrome should have a diet that is

low in protein and sodium to decrease serum ammonia levels

arterial ulcers

lower one third of leg, toes, web spaces. smooth edges, well defined, lack of granulation tissue, tend to be deep. severe pain, diminished or absent pedal pulses, normal edema, decreased skin temperature, thin and shiny tissue, hair loss, yellow nails. leg elevation increases pain.

Major complication of SLE is

lupus nephritis

What behavior changes would be most common for the client with hypernatremia?

mania

The client taking an MAO inhibitor should avoid OTC medications for cold and hayfever because

many contain pseudoephedrine. Combining an MAO inhibitor with pseudoephedrine can result in extreme elevation in BP

To correctly measure the client for crutches, the nurse should

measure approximately 3 inches under the axilla. Elbows should be flexed approximately 35 degrees, with the crutches 6 inches from the side of the foot.

viral load test

measurement of the amount of AIDS virus (HIV) in the bloodstream. viral load of 10,000 would be considered low When the viral load reaches less than 200 copies/ml of blood, doctors consider that HIV is undetectable.

Prothrombin Time (PT)

measures the therapeutic level of coumadin

Green-tinged amniotic fluid is indicative of

meconium staining. This finding indicated fetal distress.

Clients with Paget's disease has problems with

mobility

Ataxia affects the client's

mobility; increase risk of falls

During concrete operation, the child's though processes become

more logical and coherent

Dystonia

muscle spasm in any muscle of the body

Prostigmin is the treatment for

myasthenia gravis

The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for

nasal congestion; removal of the pituitary gland is usually done by a transphenoidal approach, through the nose. Nasal congestion further interferes with the airway.

Cholinergic crisis is the result of overmedication with anticholinesterase inhibitors. Symptoms of cholinergic crisis are

nausea, vomiting, diarrhea, blurred vision, pallor, decreased BP, and constricted pupils.

The purpose of applying Erythromycin eyedrops to the newborn's eyes is to prevent

neonatal blindness that can result from contamination with Neisseria gonorrhea.

Pernicious anemia is characterized by changes in

neurological function such as loss of coordination and loss of position sense.

Client going for therapy in the hyperbaric oxygen chamber requires

no special skin care; therefore washing the skin and patting it dry is suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin

The client who is colonized with MRSA will have

no symptoms associated with infection

2+ pulse strength

normal

The best IV fluid for correction of dehydration is

normal saline. Dextrose pulls fluid from the cell, lactated Ringer's contains more electrolytes than the client's serum, and dextrose with normal saline will also alter the intracellular fluid.

With Pernicious anemia, RBCs would be

normochromic and macrocytic

With aplastic anemia, RBCs would be

normochromic and normocytic but would be reduced in number

The client taking dissulfiram (Antabuse) should be instructed to

not eat or drink anything containing alcohol or vinegar

The client with a femoral popliteal bypass graft should avoid activities that can

occlude the femoral artery graft. Sitting in a straight chair and wearing tight clothes are prohibited for this reason.

Client with cervical cancer has a radioactive implant. The patient will be

on bedrest with a urinary catheter inserted to keep the bladder empty during radiation therapy

Antihistamines (i.e.,Benadryl) should not be used by the client with

open-angle glaucoma because they dilate the pupil and prevent the outflow of aqueous humor, which raises pressures in the eye.

Osmitrol (mannitol) is an

osmotic diuretic, which inhibits reabsorption of sodium and water. First indication of its effectiveness is an increased urinary output

What is a late-occurring symptom of oral cancer

pain

Brudzinski reflex positive if

pain occurs on flexion of the head and neck onto the chest.

Kernig's sign positive if

pain occurs on flexion of the hip and knee

Nursing care of the client with cervical tongs includes

performance of sterile pin care an assessment of the site

To prevent spinal flexion, the nurse should tell the client to

periodically lie prone without a neck pillow

Cyanocobalamin (Vitamin B12) is used for

pernicious anemia

Numbness and tingling in the extremities is common in the client with

pernicious anemia, but not those with other types of anemia

Use of a scalp vein for IV infusions allows the infant to be

picked up and held more easily

Balanced skeletal traction uses

pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur.

To collect a specimen for assessment of enterobiasis (pinworms) the nurse should educate the client to

place tape on the perianal area before going to sleep

Toddler has gross motor skills suited to

playing with a ball which can be kicked forward or thrown overhand

What nursing diagnosis would be most appropriate for a gavida 4 para 3 client as she completes the latent phase of labor?

potential fluid volume deficit related to decreased fluid intake.

When the collection chambers of the Pleuravac are full, the nurse should

prepare a new unit for continuing the collection

Nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately

prepare to administer an antiarrhythmic such as lidocaine. Lidocaine is the usual treatment for ventricular tachycardia.

Magnesium sulfate is used for

preterm labor and preeclampsia

Client with a history of diabetes is most likely to deliver a

preterm large for gestational age newborn. These newborns often lack sufficient surfactant levels to prevent respiratory distress syndrome.

Client with polycythemia vera is at risk for thrombus formation. Hydrating the client with at least 3L of fluid per day is important in

preventing clot formation.

Agonist effects are similar to those

produced by chemicals normally present in the body

In evaluating the effectiveness of IV pitocin for a client with secondary dytocia, the nurse should expect

progressive cervical dilation and more intense contraction which can increase pain

Gullian-Barre syndrome

progressive weakness and loss of sensation that begins in the lower extremities

The nurse can help alleviate the discomfort of xerostomia by

providing a saliva substitute -Eating hard candy can further irritate the mucosa and cut the tongue and lips

Common complain of the client with an abdominal aortic aneurysm is

pulsations in the periumbilical area or feeling the heart beat in the abdomen

Vaginal discharge associated with pelvic inflammatory disease

purulent vaginal discharge.

The umbilical cord needs time to dry and fall off before

putting the infant in the tub (roughly 2 weeks)

Tongue of the client with B12 insufficiency

red an beefy

When given within 8 hour of the injury, Solu-Medrol (methylprednisolone sodium succinate) has proven effective in

reducing cord swelling, thereby improving motor and sensory function

Adverse effects of Dilantin (phenytoin) include agranulocytosis and aplastic anemia; therefore the client will need

regularly scheduled blood work.

Chest tubes work to

reinflate the lung and drain serous fluid. Insertion of chest tubes is usually painful. Chest tubes also assist with cardiac function by stabilizing lung expansion

The chest-drainage system can be disconnected from suction, but the chest tube should

remain unclamped to prevent a tension pneumothorax.

Client taking an antilipidemic (i.e., rosuvastatin) should be encouraged to

report muscle weakness because this is a sign of rhabdomyolysis.

The physician has ordered Amoxil (amoxicillin) capsules for a client with esophageal varices. The nurse can best care for the client's need by

requesting an alternate form of the medication; the client with esophageal varices might develop spontaneous bleeding from the mechanical irritation caused by taking capsules. Should request an alternative form such as oral suspension

Cheyne-Stokes respirations:

respiratory cycle marked by periods of apnea lasting 10 seconds to 1 minute then followed by respirations that gradually increase in depth and frequency.

Blood alcohol concentrations of 400-600mg/dL are associated with

respiratory depression, coma, and death

following the administration of an epidural anesthetic, the nurse should monitor the client for

respiratory depression; epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing.

The client with polio has muscle weakness. Periods of

rest throughout the day will conserve the client's energy.

Early indicators of an altered level of consciousness include

restlessness and irritability.

The presence of a white or gray dot (a cat's eye reflex) in the pupils is associated with

retinoblastoma, a highly malignant tumor of the eye. The nurse should report this finding to the physician immediately so that it can be further evaluated.

Client is hospitalized with signs of transplant rejection following a recent renal transplant. Assessment of the client would be expected to reveal

rising BP; increased BP following a renal transplant is an early sign of transplant failure.

Children with autistic disorder engage in

ritualistic behaviors and are easily upset by changes in daily routine.

At 4 months the infant can

roll over

Coconut oil is high in

saturated fat and should not be used for the client on a low-cholesterol diet

It is recommended that infants up to 20lbs be restrained in a car seat in a

semi-reclining position facing the rear of the car

Lab finding that would confirm the diagnosis of acute pancreatitis

serum amylase greater than 200units/dL

Biot respirations

several short respirations followed by long, irregular periods of apnea.

Duchenne's muscular dystrophy is a

sex-linked disorder, with the affected gene on the X chromosome of the mother.

Presence of fetal hemoglobin until about 6 months of age protects affected infants from episodes of

sickle cell crisis/ sickling

Painless vaginal bleeding

sign of placenta previa.

The client with sickle cell crisis and sequestration can be expected to have

signs of hypovolemia, including decreased blood pressure

Physician has ordered Dilantin (Phenytoin) 100 mg intravenously for a client with generalized tonic-clonic seizures. The nurse should administer the medication

slowly over 2-3 minutes; should be administered slowly (no more than 50mg per minute) otherwise arrhythmias can occur

Dinoprostone (Prostin E.) is a form of prostaglandin used to

soften the cervix.

Side effects of Pulmozyme (dornase alfa) include

sore throat, hoarseness, and laryngitis

Kirschner wires are used to

stabilize small bones such as finger and toes.

Approximately 99% of males with cystic fibrosis are

sterile due to obstruction of the vas deferens.

Hemarthrosis or bleeding into the joints is characterized by

stiffness, aching, and decreased movement in the affected join

Neumega (oprellvekin)

stimulates the production of platelets

The client with a proctoepisiotomy will need

stool softeners such as docusate sodium (Colace)

What lab study should be done periodically for the client taking warfarin sodium (coumadin)

stool specimen for occult blood; to detect any intestinal bleeding

Child with epiglottitis has a

strident cough and drooling

Tail of spence

superior lateral corner of breast tissue, projects up and laterally into axilla. Area where most breast cancers are located

Respiratory stridor

symptom of partial airway obstruction

Red edematous cheeks, maculopapular rash on the trunk and extremities describes

symptoms of Fifth's disease

Epicanthal folds, low-set ears, protruding tongue describes

symptoms of down syndrome

Red papular rash, desquamation, white strawberry tongue describes

symptoms of scarlet fever

A post-operative client has an order for Demerol (meperidine) 75 mg and Phengran (promthazine) 25 mg IM every 3-4 hours as needed for pain. The combination of the two medications produces a

synergistic effect; an effect greater than that of either drug used alone

Venereal disease research lab (VDRL) and rapid plasma reagin (RPR) are screening tests done for

syphilis

Synthroid (levothyroxine) increases metabolic rate and cardiac output. Adverse reactions include

tachycardia and dysrhythmias, therefore the client should be taught to check their pulse before taking the medication

Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience

tachycardia, diarrhea, and tachypnea.

The client with cocaine addiction frequently reports formication, or "cocaine bugs", which are

tactile hallucinations.

Positioning the client on her left side will

take pressure of the vena cava and allow better oxygenation of the fetus

Client taking Precose (acarbose) should be instructed to

take with the first bite of a meal

What is the primary responsibility of the nurse for the client scheduled for surgery in the morning

taking vital signs

A nosebleed in the client with mild preeclampsia may indicate

that the client's BP is elevated; report to the HCP!

The client should not be instructed to do

the Valsalva maneuver during central venous pressure readings.

The finding that differentiates interstitial cystitis from other forms of cystitis is

the absence of bacteria in the urine.

Antagonist effects are those in which

the actions of the drugs oppose one another

Calcium gluconate is

the antidote for magnesium sulfate.

Correct use of the walker is achieved with:

the client's palms rest lightly on the handles, elbows flexed no more than 30 degrees but should not be extended, and the client walks to the middle of the walker, not to the front of the walker.

The proximal end of the double-barrel colostomy is the end toward the small intestines. This end is on

the client's right side. The distal end is on the client's left side.

The best method of birth control for the client with diabetes is

the diaphragm. A permanent intrauterine device can cause a continuing inflammatory response in diabetics that should be avoided, oral contraceptive tend to elevate blood glucose levels, and contraceptive sponges are not good at preventing pregnancy.

Agnosia

the inability to recognize familiar objects; loss of sensory comprehension

Before administering Myochrysine (gold sodium thimalate), the nurse should check

the lab work for the complete blood count and urine protein level because gold salts are toxic to the kidneys and the bone marrow.

Method to elicit the triceps reflex

the nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow

Pitocin does not affect

the position of the uterus

Before administering Theodur, the nurse should check

the pulse; Theodur is a bronchodilator, and a side effect of bronchodilators is tachycardia. Checking the pulse is important. Extreme tachycardia should be reported to the doctor

The client who is allergic to dogs, eggs, rabbits, and chicken feathers is most likely allergic to

the rubella vaccine. The client who is allergic to neomycin is also at risk.

PKU screening is usually done on

the third day of life

Following a nephrolithotomy, the client should be positioned on

the unoperated side

Client diagnosed with tuberculosis can return to work when he has

three negative sputum cultures

Adverse reactions to Depakote (divalproex sodium) include

thrombocytopenia, leukopenia, bleeding tendencies, and hepatotoxicity. Therefore, the client will need frequent lab work

The toddler with ventricular septal defect will

tire easily, not grow normally, not require any additional calories, and be susceptible to bacterial infections.

Complete cord lesion

total loss of motor, sensory, and reflex activity

the nursing diagnoses Impaired gas exchange related to hyperventilation for a patient in labor would be indicated during the

transition phase.

Florescent treponemal antibody (FTA) is the test for

treponema pallidum.

During pregnancy, the thyroid gland

triples in size. This makes it more difficult to regulate thyroid medication during pregnancy.

Low-grade temperature, blood-tinged sputum, fatigue, and night sweats are symptoms consistent with

tuberculosis

If the client experiences hypotension after an injection of epidural anesthetic, the nurse should

turn her to the left side, apply oxygen by mask, and speed the IV infusion. If the blood pressure does not return to normal, the physician should be contacted. Epinephrine should be kept for emergency administration.

common sources of E.coli

undercooked beef and shellfish

Lanoxin (digoxin) slows and strengthens the contraction of the heart. An increase in

urinary output shows that the medication is having a desires effect by eliminating excess fluid from the body

What discharge instruction is essential for the client being discharged with an implantable defibrillator

use cellphone on the right side; the client with an internal defibrillator should learn to use any battery-operated machinery on the opposite side. He should also check his pulse rate and report any dizziness or fainting.

The nurse is assisting in the assessment of the patient admitted with "extreme abdominal pain". The nurse asks the client about the medication that he had been taking because

various medications taken by mouth can affect the alimentary tract (irritate the stomach and contribute to abdominal pain)

Clients with color blindness will most likely have problems distinguishing

violets, blues, and green.

Rhinitis is often seen with

viral pneumonia

Vaginal discharge associated with endometrial cancer

watery discharge and painless bleeding

Following a tabeculoplasty (treatment of glaucoma) the nurse should instruct the client to

wear eye protection continuously for several months. Eye protection can be in the form of protective glasses or an eye shield that is worn during sleep. Keep soap and water away from the eyes, avoid using eye makeup for at least a month after surgery.

Expected side effects of steroid medications

weight gain, difficulty sleeping, and changes in mood

Child with bronchiolitis has

wheezing and intercostal retractions

Vaginal discharge associated with candida albicans

white vaginal discharge

The newborn with choanal atresia

will not be able to breathe through his nose because of the presence of a bony obstruction that blocks the passage of air through the nares.

Pyridium (phenazopyridine hydrochloride), client should be taught that the medication

will turn the urine orange or red.

Zantac (rantidine) is a histamine blocker that should be given

with meals for optimal effect.

Clients who are being retrained for bladder control should be taught to

withhold fluids after about 7pm.

To provide protection against antibody production, RhoGam should be given

within 72 hours of delivery.

Proscar (finasteride) is an androgen inhibitor. therefore

women who are pregnant or age of child-bearing should be told to avoid touching the tablets