pretest

A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse's important action at this time is to:

Check the uterine fundus and lochia--potential complication following delivery is hemorrhage.

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which of the following during the first 24 hours after the burn injury?

Elevated hematocrit levels

A nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease

Fever Constipation Failure to thrive Abdominal distention Explosive, watery diarrhea

A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed?

Liver enzyme levels --INH therapy can cause an elevation of hepatic enzyme levels and hepatitis.

The nurse is caring for a client with glaucoma. Which of the following medications, if prescribed for the client, would the nurse question?

Atropine sulfate (Isopto Atropine)--its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

Which of the following histories would place a maternity client at risk for uterine rupture?

Cesarean section birth--When a client has a cesarean delivery, an incision is made in the uterine wall. The site of the incision can produce a weakened area in the uterine wall.

A nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which of the following on data collection of the infant?

Edema caused from bleeding below the brain's periosteum

A nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should:

Elevate the leg on pillows continuously for 24 to 48 hours.--A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage.

A nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly replies by telling the instructor that this medication is:

Erythromycin ----(ophthalmia neonatorum= an eye infection acquired from the baby's passage through the birth canal.)

A nurse is preparing to administer pentamidine isethionate (Pentam 300) to an assigned client by the intramuscular route. The nurse plans to monitor which of the following most closely after administering this medication?

Blood pressure (BP)

A nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which of the following tests would the nurse anticipate to be performed to confirm the diagnosis?

Bone marrow aspiration--will identify aplastic anemia and will identify pancytopenia, a deficiency in erythrocytes, leukocytes, and thrombocytes.

Which of the following laboratory results would verify the diagnosis of bacterial meningitis?

Cloudy cerebrospinal fluid with high protein and low glucose levels

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period the nurse notes bloody drainage from the nasogastric (NG) tube. The nurse plans to:

Continue to monitor the drainage

A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse monitoring this client should look for which of the following to indicate a primary therapeutic response from the medication?

Decreased muscle spasms--Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases and multiple sclerosis.

A nurse is assigned to care for a nulliparous client who is having a precipitate delivery. The nurse reports which maternal focused observations?

Decreased periods of uterine relaxation between contractions

A nurse is reviewing the laboratory results of a client who has been diagnosed with multiple myeloma. Which of the following would the nurse expect to specifically note with this diagnosis?

Increased calcium level

A nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is: "The child:

has the ability to think abstractly."

A clinic nurse is reviewing the medical record of a client scheduled to be seen in the clinic. The nurse notes that the client is prescribed selegiline hydrochloride (Eldepryl). The nurse understands that this medication is prescribed for which diagnosis?

Parkinson's disease

A nurse is collecting admission data on a client with Parkinson's disease. The nurse asks the client to stand with the feet together and the arms at the side and then to close the eyes. The nurse notes that the client begins to fall when the eyes are closed. Based on this finding, the nurse documents which of the following in the client's record?

Positive Romberg's test

A nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?

Postpartum hemorrhage--The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding.

A nurse notes that a client is taking lansoprazole (Prevacid). On data collection, the nurse asks which question to determine medication effectiveness?

"Are you experiencing any heartburn?"--Lansoprazole is a gastric acid pump inhibitor used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD).

the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breast-feeding the infant and asks the nurse if breast-feeding can be continued. Which of the following responses is appropriate?

"Breast-feeding can continue, but your breasts should also be treated with nystatin."

A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:

A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:

The creatinine measures renal function. The normal value is ...

0.6 to 1.3 mg/dL.

A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following?

Start chest compressions.

A nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs more information if the client makes which of the following statements?

"Going to the beach will be a nice, relaxing form of activity." --The client should avoid activities that could worsen the symptoms, including stress, infection, heat (including staying out of the sun at the beach), surgery, or alcohol.

A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions?

"Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing.

A nursing instructor asks a nursing student about the characteristics of Hodgkin's disease. The instructor determines that the student needs to read about the characteristics of this disease if the student states that which of the following is an associated characteristic?

(ans:) Occurrence most often in older adults (Characteristics of the Disease: Presence of Reed-Sternberg cells, Occurrence most often in older adults, Prognosis depends on the stage of the disease, Involvement of lymph nodes, spleen, and liver)

A nurse is assigned to a client admitted with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most alike to which of the following values?

300 units/L--The normal serum amylase level is 25 to 151 units/L. In chronic cases of pancreatitis, the rise in the serum amylase level usually does not exceed three times the normal value.

An adult male client admitted with dehydration has received fluid volume replacement. The nurse determines that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which of the following values in the normal range?

48%--The normal hematocrit level for an adult male is 42% to 52%.

A nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which of the following results were present?

5000 cells/mm3--The normal WBC count ranges from 4500 to 11,000 cells/mm3.

normal white blood cell count

5000 to 10,000/μL

Isoniazid (INH) is prescribed for a 2-year-old child with a positive Mantoux test. The mother of the child asks the nurse how long the child will need to take the medication. The appropriate response is:

9 months-- Isoniazid (INH) is prescribed for a 2-year-old child with a positive Mantoux test. The mother of the child asks the nurse how long the child will need to take the medication. The appropriate response is:Rationale: Isoniazid is given to prevent tuberculosis (TB) infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy.

A client is diagnosed as having a bowel tumor, and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy?

A biopsy is done to determine whether a tumor is malignant or benign.

A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which of the following findings?

An oral temperature of 101° F orally

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?

Calcium level--Tamoxifen may increase calcium, cholesterol, and triglyceride levels.

The client with acquired immunodeficiency syndrome has begun therapy with zidovudine (Retrovir, Azidothymidine, AZT, ZDV). The nurse carefully monitors which of the following laboratory results during treatment with this medication?

Complete blood count

metabolic acidosis increases acids in the body.

Diabetes mellitus, renal failure, and malnutrition

A client newly diagnosed with renal failure will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate?

Explain that the pain will subside after the first few exchanges.--Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappears after a week or two. The infusion amount should not be decreased, and the infusion should not be slowed or stopped.

A nurse is caring for the client diagnosed with tuberculosis (TB). Which of the following findings, if made by the nurse, would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever-- The client with TB usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweating (which may occur at night), and a LLOOOW-grade fever.

A nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which of the following coexisting problems?

Hypotension--Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion.

the child is restless, the pulse rate is elevated, and the blood pressure has dropped significantly from the baseline value.

In the event of shock, the registered nurse is notified, who immediately notifies the health care provider.

A nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item would be included as part of the precautions?

Maintaining the head of the bed at 15 degrees

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis

A nurse is reviewing the results of an eye examination on a client and notes that results from the tonometry test indicate an intraocular pressure of 20 mm Hg. The nurse interprets these findings as:

Normal intraocular pressure-- The normal intraocular pressure is 12 to 22 mm Hg.

A nurse is assigned to care for a child with hypertrophic pyloric stenosis who is scheduled for pyloromyotomy. Which of the following positions would the nurse place the child in during the preoperative period?

Prone with the head of the bed elevated-- to reduce the risk of aspiration

A health care provider initiates carbidopa/levodopa (Sinemet) therapy for the client with Parkinson's disease. A few days after the client starts the medication, the client complains of nausea and vomiting. The nurse tells the client that:

Taking the medication with food will help to prevent the nausea. --Antiemetics from the phenothiazine class should not be used because they block the therapeutic action of dopamine.

A behavior modification technique known as systematic desensitization..

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

A female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing:

The development of a vesicovaginal fistula--A vesicovaginal fistula is a genital fistula that occurs between the bladder and the vagina. The fistula is an abnormal opening between these two body parts, and if this occurs, the client may experience drainage of urine through the vagina.

impetigo

Thick, honey-colored crusts

spironolactone (Aldactone)

This medication is a potassium-sparing diuretic that is used to treat edema, hypertension, fluid retention and overload, and to increase urine output.

the parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response?

When the toddler weighs 20 lb and is 1 year old

A nurse analyzes the results of laboratory studies performed on a client with peptic ulcer disease. Which of the following laboratory values would indicate a complication associated with the disease?

Hemoglobin 10.2 g/dL--most common complications of peptic ulcer disease are hemorrhage, perforation, pyloric obstruction, and intractable disease. A low hemoglobin and hematocrit level indicate bleeding.

A nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness?

"Do you have any joint pain?"--Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis.

Griseofulvin (Gris-PEG) is prescribed for a child with tinea capitis. The nurse provides instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further instructions?

"I need to administer the medication 2 hours before meals."

A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action is to prepare the client to receive:

100% humidified oxygen by face mask

normal platelet range is

150,000 to 400,000 cells/μL

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Considering the client's behavior, the nurse suspects she is dilated:

8 to 10 cm--During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm

A client informs the nurse that she has been taking acarbose (Precose) as prescribed. The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted?

A 2-hour postprandial serum glucose of 120 mg/dL--Acarbose is an oral antidiabetic medication used as an adjunct to diet to lower blood glucose in clients with type 2 diabetes mellitus whose hyperglycemia cannot be managed by diet alone.

A nurse is inspecting the stoma of a client after creation of a ureterostomy. Which of the following would the nurse expect to note?

A red and moist stoma

When reviewing the health care record of a client with ovarian cancer, the nurse recognizes which symptom as being typical of the disease?

Abdominal distention--Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, and constipation.

Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds, knowing that the therapeutic action of this medication is which of the following?

Acts directly on the skeletal muscle to relieve spasticity

The nurse reviews the client's serum phosphorus level and notes that the level is 2.0 mg/dL. The nurse understands that which condition caused this serum phosphorus level?

Alcoholism--The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client in this question is experiencing hypophosphatemia. Causative factors relate to decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

A nurse reviews the phenytoin level of a client who is taking phenytoin (Dilantin Kapseals). The nurse notes that the plasma drug level is 9 mcg/mL. Which of the following does the nurse anticipate to be prescribed for the client?

An increase in the present dosage--The dosing objective is to produce phenytoin levels between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures. At levels greater than 20 mcg/mL, signs of toxicity begin to appear.

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. The nurse responds to the client, knowing that the fallopian tubes:

Are where fertilization occurs--Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization.

A nurse is caring for a client after a modified radical mastectomy. Which of the following findings would indicate that the client is experiencing a complication related to the surgery?

Arm edema on the operative side

A nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The nurse tells the client to perform the BSE:

At a specific day of the month and on that same day every month thereafter--If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month.

A delivery room nurse performs an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that it is positioned:

At the level of the umbilicus

A nurse is caring for a client with cancer of the prostate after a prostatectomy. The nurse provides discharge instructions and plans to include which of the following?

Avoid lifting objects heavier than 20 pounds for at least 6 weeks.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. The nurse would first:

Check the client for spontaneous breathing--If unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs.

A nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. The initial nursing action upon admission of the client is to:

Check the wound sites.--The physiological integrity of the client is always assessed

A nurse caring for a client in the postoperative period following an enucleation, notes bloody staining on the surgical eye dressing. Which of the following is the appropriate initial action?

Contact the health care provider.

After weeks of witnessing a man's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which does the nurse use to determine if the autopsy can proceed?

Determination by the client's son

A nurse assists in administering first aid to a client who has been bitten by a snake on the right leg. The nurse understands that the initial action is to:

Ensure that the victim is lying down, and remove restrictive items.--initial first aid at the site of a snakebite includes having the victim lie down, removing constrictive, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part BELOW the level of the heart. Ice or a tourniquet is not applied during the acute stage.

The nurse would use which method to open the victim's airway if the victim sustained a neck injury?

Jaw thrust maneuver

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Left lateral--Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her left side.

A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia (excessive body growth )--Typically, infants of diabetic mothers are large for gestational age.

A client who has been diagnosed with multiple myeloma asks the nurse about the diagnosis. The nurse bases the response on which characteristic of the disorder?

Malignant proliferation of plasma cells and tumors within the bone

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client states that it will:

Promote healing of the perineum.

A nurse is collecting data on a client admitted to the hospital with hepatitis. Which data would indicate that the client may have liver damage?

Pruritus

The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is termed:

Psychodrama

A nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which of the following substances in CSF?

Red blood cells

The client who chronically uses nonsteroidal anti-inflammatory drugs has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted?

Relief of epigastric pain

A nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse would expect to note documentation of which early symptom of this disorder?

Ringing in the ears

A nurse is reinforcing instructions for a client regarding intranasal desmopressin acetate (DDAVP). The nurse tells the client that which of the following is a side effect of the medication?

Runny nose--Desmopressin administered by the intranasal route can cause a runny or stuffy nose. Headache, vulval pain, and flushed skin are side effects if the medication is administered by the intravenous (IV) route.

A nurse is completing a medication reconciliation form for a client. Which of the following is a primary purpose of this process?

To compare a client's medication prescriptions to all of the medications the client is taking at home

A nurse reinforces medication instructions to a client who is taking levothyroxine (Synthroid). The nurse instructs the client to notify the health care provider (HCP) if which of the following occurs?

Tremors--excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, heat intolerance, and sweating.

A health care provider asks a nurse to obtain a Salem Sump tube for gastric intubation. The nurse selects which of the following tubes from the unit storage area?

Tube with a lumen and an air vent

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check the:

Vital signs--Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised.

Foods high in calcium include..

plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal.

A nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurs with the chemotherapy?

Increased uric acid level

Kohlberg's theory

he theory provides a framework for understanding how individuals determine a moral code to guide their behavior. It also states that moral development progresses in relation to cognitive development and a person's ability to make moral judgments develops over a period of time. I

Oxygen supply to the heart cells that is deficient results in angina pectoris pain.

pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.

A nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. The nurse should give the child which of the following to treat the reaction?

½ cup of fruit juice -- ½ cup of fruit juice, ½ cup of regular (nondiet) soft drink, 8 ounces of skim milk, 6 to 10 hard candies, 4 cubes of sugar or 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup.

Which of the following individuals is least likely at risk for the development of psoriasis?

A 32-year-old African American--Psoriasis occurs equally among women and men, although the incidence is lower in darker-skinned races

A nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which of the following?

A decrease in oozing from puncture sites and gums-----Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells.

The nurse encourages the client to report which symptoms as being associated with testicular cancer?

A grainy mass palpated in a testicle and enlargement of the testes are symptoms of testicular cancer and should be reported. T

A nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which of the following data will not be needed by the laboratory for adequate evaluation of the specimen?

A list of client allergies

Prednisone is prescribed for a client with diabetes mellitus who is taking Humulin neutral protamine Hagedorn (NPH) insulin daily. Which of the following prescription changes does the nurse anticipate during therapy with the prednisone?

An increased amount of daily Humulin NPH insulin

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) has been on oral glucocorticoids and is being weaned to triamcinolone (Azmacort) by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change if the client states to report:

Anorexia, nausea, weakness, and fatigue

herpesvirus.

Clusters of fluid-filled vesicles

A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations are made?

Coughing occurs with suctioning.--he client should be encouraged to cough to help with removal of secretions from the lungs.

A nurse is assisting in caring for a client with an inoperable lung tumor and helps to develop a plan of care by addressing complications related to the disorder. The nurse includes in the plan to monitor for the early signs of vena cava syndrome. Which of the following should the nurse include in the plan of care as the early sign of this oncological emergency?

Edema of the face and eyes--Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and the client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs

A nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action would be appropriate?

Encourage oral fluids.

Sodium hypochlorite (Dakin's solution) is prescribed for a client with a leg wound containing purulent drainage. The nurse is assisting in developing a plan of care for the client and includes which of the following in the plan?

Ensure that the solution is freshly prepared before use.--b/c it is a chloride solution that is used for irrigating and cleaning necrotic or purulent wounds. It can be used for packing necrotic wounds. It cannot be used to pack purulent wounds

Which clinical manifestation is observed in the clonic phase of a seizure?

Extension spasms of the body--The clonic phase of a seizure is characterized by violent extension spasms of the entire body interrupted by muscular relaxation and accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. There is excessive salivation resulting in frothing from the mouth, biting of the tongue, profuse sweating, and a rapid pulse. The clonic jerking subsides by slowing in frequency and losing strength over a period of 30 seconds.

A nursing student is assisting in caring for a client with a lung tumor; the client will be having a pneumonectomy. The nursing instructor reviews the postop plan of care developed by the student and suggests deleting which of the following from the plan?

Monitoring the closed chest tube drainage system--Closed chest drainage usually is not used following pneumonectomy.

A nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which of the following should the nurse expect to note in the child?

Forchheimer sign refers to petechiae spots, which are reddish and pinpoint and located on the soft palate.

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that is most likely to have this taste for the client?

Frequently, beef and pork are reported to taste bitter or metallic. (Rmbr: High meat and carbohydrate consumption plays a role in the development of cancer of the pancreas, not gastric cancer.)

A client newly diagnosed with chronic renal failure has recently begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse monitors the client during dialysis for:

Headache, deteriorating level of consciousness, and twitching--Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea and vomiting, twitching, and possible seizure activity. It is caused by rapid removal of solutes from the body during hemodialysis.

A nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia--The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart.

Which of the following cardiovascular manifestations would the nurse expect to note in a client with a diagnosis of hypocalcemia?

Hypotension---Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST segment and a prolonged QT interval.

celiac disease.

Intolerance to wheat

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk?

Marking the location of the pedal pulses on the right leg-- It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period.

A nurse is caring for a client with severe back pain, and codeine sulfate has been prescribed for the client. Which of the following would the nurse include in the plan of care while the client is taking this medication?

Monitor bowel activity.--codeine can cause constipation

A nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. The appropriate nursing intervention is to:

Monitor the client for dysrhythmias.

A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about TENS unit. Which statement by the client indicates the need for further information?

Needles are inserted in the subcutaneous tissue to stimulate the nerve."--The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Needles are not used.

A nurse is reviewing the laboratory results of a client with bladder cancer and bone metastasis and notes that the calcium level is 15 mg/dL. The nurse should take which appropriate action?

Notify the health care provider--Hypercalcemia is a serum calcium ion level greater than 11 mg/dL or 5.5 mEq/L.

A client receiving parenteral nutrition (PN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?

Place the client on the left side with the head lowered. --Lying on the left side may prevent air from flowing into the pulmonary veins.

At 5:00 AM a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 7:00 AM with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to:

Prepare the client for a cesarean delivery--An indication for a cesarean delivery is the failure of labor to progress and fetal distress.

The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which of the following?

Punch biopsy of the cutaneous lesions--Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain.

A nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication?

Reaching normal serum calcium levels--Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium level. T

A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection?

Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast, or the presence of "hot spots," which are areas of the cast that are warmer than others.

A nurse is caring for a client with metastatic lung cancer. The client was medicated 2 hours ago and now reports a new and sudden sharp pain in the back. The nurse appropriately interprets this finding as possibly indicating:

Spinal cord compression--Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression is an onco

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?

Suction equipment--must be available in the event that the client aspirates.

A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which of the following to enhance compliance with therapy?

Take the medication following a meal.

A nurse is collecting data on a client with the diagnosis of anorexia nervosa. The nurse understands that objective findings may indicate:

That the client has extensive knowledge of nutrition--These clients are very knowledgeable about nutrition and the caloric value of food. The potassium level is usually low, and the blood urea nitrogen is usually elevated in clients with anorexia nervosa. Clients lose at least 15% of their original body weight in a short period.

An adolescent is admitted to the pediatric intensive care unit after suffering a seizure at school. She is alert on admission and tells the nurse that she has asthma and takes theophylline every day. She has a heart rate of 116 beats per minute with some shortness of breath. She also is complaining of nausea and vomiting. Which of the following would the nurse suspect?

The child might have a toxic theophylline level.--The early signs of theophylline toxicity are nausea, vomiting, tachycardia, headache, and irritability. Seizures indicate a toxicity level greater than 30 mcg/mL. A normal theophylline level is 10 to 20 mcg/mL.

Povidone-iodine (Betadine)

This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The other options are incorrect.

Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast cancer. The nurse assists in developing a plan of care for the client and suggests monitoring the client closely for which adverse reaction to this medication?

Thromboembolism

The client is receiving an eyedrop and an eye ointment to the right eye. The nurse should:

administer the eyedrop first, followed by the eye ointment.

Cholinergic crisis (the opposite problem)

caused by excess medication and responds to withholding of medications.

Myasthenic crisis

caused by undermedication and responds to administration of cholinergic medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon).

A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. What intervention will the client be encouraged to perform?

Avoiding foods that are highly seasoned--The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat.

A health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury..administered intrathecally. Which of the following medications should the nurse expect to be prescribed and administered by this route?

Baclofen (Lioresal)--Baclofen is the only skeletal muscle relaxant that can be administered intrathecally.

A nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which of the following?

Bilberry

A client with portosystemic encephalopathy is receiving oral lactulose (Chronulac) daily. The nurse assesses which of the following to determine medication effectiveness?

Blood ammonia level--Lactulose is a hyperosmotic laxative and ammonia detoxicant. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect.

A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

Serous drainage--A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment includes ensuring that the client:

Shampoos and dries the hair, freeing it of all hair spray and creams

A nurse is collecting data from a female client who is suspected of having mittelschmerz. Which of the following would the nurse expect to note on data collection of the client?

Sharp pain located on the right side of the pelvis--Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation.

A nurse is reading the results of the Mantoux skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets that the result is:

Negative

A client is being discharged home, and the health care provider has prescribed spironolactone (Aldactone) for the client. The nurse teaches the client about the medication. Which statement by the client would require further teaching by the nurse?

"I know I need to eat foods that are high in potassium because of the diuretic effect of the medication." ---This medication is a potassium-sparing diuretic that is used to treat edema, hypertension, fluid retention and overload, and to increase urine output.

A nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for more teaching regarding possible complications of preeclampsia?

"I should expect that my urine output will decrease."--Warning signs and symptoms of preeclampsia to be reported include decreased urinary output, headaches and blurred vision, abdominal pain, and a change in fetal movement, particularly a decrease. Constipation is not associated with preeclampsia.

A nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client says:

"My cervix is completely dilated." ---& ends with the birth of the infant.

A nurse is teaching a client with essential hypertension about medication therapy with irbesartan (Avapro). Which client statement would indicate a need for further teaching?

"The medication reduces my need for exercise."

normal hemoglobin range

females is 12 to 16 g/dL and in males is 14 to 18 g/dL.

A mother of a 3-year-old child tells the nurse that the child has been continuously scratching the skin and has developed a rash. On data collection, which finding indicates that the child may have scabies?

Fine, grayish-red lines

A postpartum client who delivered at 32 weeks of gestation would like to breast-feed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

"You can begin pumping as soon as possible after delivery with an electric breast pump."

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child?

Blood and mucus in the stools

A nurse is planning to administer amlodipine (Norvasc) to a client. The nurse plans to check which of the following before giving the medication?

Blood pressure and heart rate --Amlodipine is a calcium channel blocker. This medication decreases the rate and force of cardiac contraction.

scoliosis- brace wearing

Bracing can halt the progression of most curvatures, although it is NOT curative for scoliosis.

As the nurse approaches a client who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the Federal Crime Scene Investigation Unit; I can tell by the way you are walking." This is an example of which alteration in thinking?

Delusion--Delusions are false fixed beliefs that cannot be corrected by reasoning. Most commonly, delusional thinking involves themes of ideas of reference, persecution, grandiosity, jealousy, and control. Hallucinations are defined as sensory perceptions for which no external stimulus exists

A nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be appropriate?

Document the findings.

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response would best support the client?

The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential.

A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF?

Antistreptolysin O titer

A nurse documents that a client with a hiatal hernia is implementing effective health maintenance measures after the client reports doing which of the following?

Eating low-fat or nonfat foods

A nurse is caring for a client after a radical mastectomy. Which nursing intervention would assist with preventing lymphedema of the affected arm?

Elevating the affected arm on a pillow above heart level