409 RQ 3

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions would the nurse include when administering this medication? Select all that apply.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol 5. Instruct the client to avoid exposure to the sun.

The nurse caring for a client who is taking an aminoglycoside would monitor the client for which adverse effects of the medication? Select all that apply.

2. Ototoxicity 3. Renal toxicity 4. Dysrhythmias

The nurse is caring for a client who has been taking a sulfonamide and would monitor for signs and symptoms of which adverse effects of the medication? Select all that apply.

3. Nephrotoxicity 4. Bone marrow suppression 5. Gastrointestinal (GI) effects

A client is diagnosed with scleroderma. Which intervention would the nurse anticipate to be prescribed?

Administer corticosteroids as prescribed for inflammation.

The nurse is administering an intravenous dose of methocarbamol to a client with a musculoskeletal injury. For which adverse effect would the nurse monitor?

Bradycardia

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder?

Kidney disease

The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication?

Liver function tests

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and would incorporate which action as a priority in the plan?

Protecting the client from infection

Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction would the nurse provide?

Take the medication with a full glass of water after rising in the morning. prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding would the nurse expect to observe?

a red, dull, thick, and immobile tympanic membrane.

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem?

a sense of a curtain falling across the field of vision.

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

a temporary worsening of the condition. an edrophonium injections makes cholinergic crisis temporarily worse.

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote would the nurse prepare for administration if prescribed?

acetylcysteine

A client with Ménière's disease is experiencing severe vertigo. Which instruction would the nurse give to the client to assist in controlling the vertigo?

avoid sudden head moments this prevents worsening of vertigo.

The nurse is developing a teaching plan for a client with glaucoma. Which instruction would the nurse include in the plan of care?

eye medications will need to be administered for life. eye drops are critical for those w/ glaucoma.

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures would the nurse include in planning for the client's safety? Select all that apply.

padding the side rails of the bed. placing an airway at the bedside. placing oxygen and suction equipment at the bedside. flushing the intravenous catheter to ensure that the site is patent.

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

speak at a normal volume.

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

the right eye is tested, followed by the left eye, and then both eyes are tested.

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear?

tinnitus

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

uric acid level of 9.0mg/dL.

The nurse is preparing to administer eye drops to a client being prepared for cataract surgery. Which actions would the nurse take to administer the drops? Select all that apply.

wash hands. put gloves on. place the drop in the conjunctival sac. pull the lower lid down against the cheekbone. close the eyes gently is intructed.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

white blood cell count 3,000. a SE of this is agranulocytosis.

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions?

"Good oral hygiene is needed, including brushing and flossing."

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply.

1. "I would not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I need to have spare crutches and tips available.

A client develops an anaphylactic reaction after receiving morphine. The nurse would take which actions? Select all that apply.

1. Administer oxygen. 2. Quickly assess the client's respiratory status. 3. Document the event, interventions, and client's response.

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures would the nurse include in the plan? Select all that apply.

1. Avoid activities that require bending over. 3. Take acetaminophen for minor eye discomfort. 5. Place an eye shield on the surgical eye at bedtime. 6. Contact the surgeon if a decrease in visual acuity occurs.

Which cast care instructions would the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply.

1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. elevated = reduced edema.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions would the nurse take? Select all that apply

1. Loosening restrictive clothing. 2. Removing the pillow and raising padded side rails. 3.) Positioning the client to the side, if possible, with the head flexed forward.

Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Keep a latex-safe supply cart available in the client's area. 5. Avoid the use of medication vials that have rubber stoppers.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

thick, yellow drainage from the pin sites. s/s of infection.

The client arrives at the emergency department, complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse would assess the client for which manifestation?

tinnitus

Oxycodone has been prescribed for a client to treat pain. Which side and adverse effects would the nurse monitor for? Select all that apply.

tremors, drowsiness, hypotension.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement?

injury to the brachial plexus nerves.

The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action would the nurse take when performing the procedure?

warm the irrigating solution to 98.6 F. needs to be warmed because a solution that is not close to the clients body temperature will cause ear injury, nausea, and vertigo.

The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

we need to encourage head turning to scan the lost visual field. homonymous hemianopsianeeds is loss of half of the visual field.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action would the nurse implement based on this finding?

instruct the client that glasses may be needed when driving. 20/20 is normal, client can read from 20 feet what a person with normal vision can read from 20 feet. 20/60 means the person can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

A client was working in the garden when insecticide accidentally sprayed into the right eye. The client calls the emergency department, frantic and screaming for help. The nurse would instruct the client to take which immediate action?

irrigate the eyes with water for at least 20 minutes until EMS arrive.

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention would be initiated immediately?

apply ice to the affected eye

Which medication, if prescribed for the client with glaucoma, would the nurse question?

atropine sulfate this is an anticholinergic medication, and its use is contraindicated in clients with glaucoma.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor?

bending or lifting. associated with herniated lumbar disc.

The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. What vital sign is most likely increased?

blood pressure

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation would the nurse expect to note in the early stages of cataract formation?

blurred vision.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

fluid separates into concentric rings and tests positive for glucose. drainage will separate into bloody and yellow concentric rings on dressing material, called halo signs.

The nurse is caring for a client with cancer. Morphine has been prescribed for the client. Specific to this medication, which intervention would the nurse include in the plan of care while the client is taking this medication?

monitor bowel activity. medication causes constipation.

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication?

monitoring blood pressure. betazolol have SE of hypotension, dizziness, nausea, diaphoresis, HA, fatigue, constipation and diarrhea.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What would be the nurse's initial action?

note the time of day the test was done. IOP is slightly higher in the morning, so it is important to check when the test was performed.

The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action would the nurse take at this time?

notify the PHCP indicates hemorrhage.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they will report which early symptom of compartment syndrome?

numbness and tingling in the fingers.

The nurse is providing instructions to a client who will be self-administering eye drops. To minimize systemic absorption of the eye drops, the nurse would instruct the client to take which action?

occlude the nasolacrimal duct with a finger after instilling the drops. applying pressure on the nasolacrimal duct prevents systemic absorption of the medication

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

i dont need to use my walker to get to the bathroom.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast?

i need to avoid getting the cast wet. must stay dry to keep its strength.

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

perform visual

A client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?

perform visual acuity test never remove object except by eye doctor.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

presence of a hot spot on the cast. areas of the cast that are warmer than others.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse would use which technique to test the client's peripheral response to pain?

pressure on nail beds.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?

providing information, giving positive feedback, and encouraging relaxation.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

respiratory or gastrointestinal infection during the previous month. has an unknown cause, but many clients report a history of respiratory or GI infection in the 1-4 weeks before the onset of neurological deficits.

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action would the nurse take?

rewrap the residual limb with an elastic compression bandage. if you don't rewrap, edema will form rapidly and cause delay in rehabilitation.

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel, and a hyphema is diagnosed. The nurse would place the client in which position?

semi fowlers position.

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?

separation of the wound edges.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL. Which finding would be expected as a result of this laboratory result?

slurred speech. therapeutic level 10-20. greater than 20 = involuntary movements of the eyes (nystagmus). greater than 30 = ataxia and slurred speech.

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action would the nurse take?

speak at a normal tone and pitch, slowly and clearly. prebycusis is a type of hearing loss that occurs with aging.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

taking medications as scheduled . taking meds correctly to maintain blood levels that are not too ow or too high is important.

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding?

temperature of 101.6 orally.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

the client is aphasic. the client has weakness on the right side of the body. the client has weakness on the right side of face and tongue. aphasic- cant discriminate words and letters.

A miotic medication has been prescribed for the client with glaucoma, and the client asks the nurse about the purpose of the medication. Which response would the nurse provide to the client?

the medication causes pupil to constrict and will lower the pressure in the eye. miotics cause pupillary constriction and are used to treat glaucoma. they lower IO pressure, and increase bloodflow to the retina and decrease retinal damage and loss of vision.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

ill try to eat my food either very warm or very cold.

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

impaired tissue perfusion. most pain can be relieved with rest, elevation, application of cold, and analgesics. IF NOT --> indicates neurovascular compromise.

The nurse is caring for a client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising?

increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

A client presents at the primary health care provider's office with complaints of a ringlike rash on the upper leg. Which question would the nurse ask first?

"Have you been camping in the last month?" to assist in identifying a cause of Lyme disease, which is a multisystem infection that results from a bite by a tick carried by several species of deer. The rash from a tick bite can be a ringlike rash occurring 3 to 4 weeks after a bite and is commonly seen on the groin, buttocks, axillae, trunk, and upper arms or legs.

The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis?

"I have an autoimmune disease that causes blistering in the skin."

The nurse has given instructions to a client who sustained a ligament injury who is returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever, redness around my incisions, or persistent drainage to my health care provider."

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction?

"I need to take hot baths because they are relaxing." avoid hot baths (because they exacerbate fatigue),

The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply.

1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified.

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.

1.Control of symptoms during periods of emotional stress 2.Normal white blood cell, platelet, and neutrophil counts 3.Radiological findings that show no progression of joint degeneration 4.An increased range of motion in the affected joints 3 months into therapy

A client arrives at the health care clinic and tells the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that the tick was removed and flushed down the toilet. Which actions are most appropriate? Select all that apply.

2. Tell the client to avoid any woody, grassy areas that may contain ticks. 3. Instruct the client to immediately start to take the antibiotics that are prescribed. 4. Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease.

The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the primary health care provider if which elevated result is noted?

3. Serum amylase level Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal.

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem?

A sedentary 65-year-old client who smokes cigarettes.

A client calls the nurse in the emergency department and reports being just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action would the nurse take?

Ask the client if they ever sustained a bee sting in the past.

The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction would be included in the teaching plan?

Avoid the use of alcohol. baclofen potentiates the depressant activity of these agents.

The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse would question the client about an allergy to which food item?

Bananas

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

Cranial nerve VII, facial nerve.

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What would be the initial nursing action?

Call the surgeon severe pain/nausea indicate increased intraocular pressure and need to be reported to the surgeon.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction would the nurse provide?

Drink 3000 mL of fluid a day.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room?

Electrocardiographic monitoring electrodes and intubation tray

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse would monitor which most closely while the client is taking this medication?

Gait The medication can cause peripheral neuropathy, and the nurse would monitor the client's gait closely and ask the client about paresthesia.

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication?

Glaucoma

The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?

Hairdressers wear gloves frequently (such as food handlers, hairdressers, and auto mechanics),

Amikacin is prescribed for a client with a bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?

Hearing loss

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

Impaired voluntary movements

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 finding?

Positive punch biopsy of the cutaneous lesions Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

A client with a hip fracture asks the nurse what is involved with Buck's (extension) traction, which is being applied before surgery. The nurse would provide which information to the client?

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels. traction reduces muscles spasms and helps immobilize a fracture.

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention would the nurse take?

Stay with the victim and encourage the victim to remain still.

The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition?

That the client has developed another infection caused by leukopenic effects of the medication

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?

The white blood cell counts and platelet counts Infection and pancytopenia are adverse effects of etanercept.

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information would the nurse include in the teaching plan?

There is the potential of decreased effectiveness of birth control pills while taking phenytoin.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery?

a positive brudzinski sign. brudzinski sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest.

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some noisy sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint?

acetylsalicylic acid aspirin is contraindicated for GI bleeding and is potentially ototoxic

A client is prescribed an eye drop and an eye ointment for the right eye. How would the nurse best administer the medications?

administer the eye drop first, followed by the eye ointment. instillation of two medications is separated by 5-10 minutes. should be administered at the same time.

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

affect is flat, with periods of emotional liability. limbic system is responsible for feelings and emotions.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?

clear mentation. altered mental state is an early sign of fat emboli, so clear mentation is a good indicator that its resolving.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

consistently uses adaptive equipment in dressing self.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops at 0900 for surgery that is scheduled for 0915. What initial action would the nurse take in relation to the characteristics of the medication action?

consult the surgeon as there is not sufficient time for the dilative effects to occur. cyclopentolate is mydriatic. its effective 25-75 minutes.

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

direct bilirubin level of 2mg/dL. OD of acetaminophen causes liver damage.

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg?

elevated on pillows continuously for 24-48 hours. minimize swelling and promote venous drainage.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

exhaling during repositioning. exhaling during activities such as repositioning or pulling up in bed opens the glottis which prevents intrathoracic pressure from rising.