Archer/Hurst questions

Beneficence is defined as _____ _______ for our clients.

"doing good"

✓ A celiac crisis is a rare event that results in severe unexplained diarrhea and _____________. This often triggers testing for celiac disease. ✓ The key intervention in a celiac crisis is the __________ of fluids and electrolytes because severe __________ may occur.

malabsorption repletion dehydration

Which client should the nurse see first? 1. 53 year old client with chest pain scheduled for a stress test today 2. 62 year old client with mild shortness of breath and chronic obstructive pulmonary disease 3. 66 year old client with angina scheduled for a cardiac catheterization this AM 4. 78 year old client who had a left hemispheric stroke 4 days ago

1. Correct: The client may be experiencing a myocardial infarction and requires further assessment. 2. Incorrect: Dyspnea is one of the three (chronic cough, sputum production, and dyspnea) primary symptoms characteristic of chronic obstructive pulmonary disease. Therefore, this client would not be a priority over a client who may be experiencing a MI. 3. Incorrect: The client is scheduled for the procedure needed for further assessment of angina. This client would be considered more stable than the client who may be having a MI. 4. Incorrect: After a stroke has occurred, medical management is aimed at preventing a second stroke from occurring and rehabilitation. This client may have significant sequelae related to the stroke, but would not be considered acute nor a priority over the client possibly having a MI.

A serum lactate level above _____ mmol/L is one of the criteria for diagnosing septic shock. Septic shock is a critical and life-threatening medical condition triggered by a severe infection. It occurs when the body's response to the infection becomes overwhelming, leading to a cascade of widespread inflammation, decreased blood pressure, compromised blood flow to vital organs, and cellular dysfunction.

2

A client comes to the clinic and states that she believes she is pregnant. What probable signs of pregnancy does the nurse expect to see? Select All That Apply 1. Amenorrhea 2. Facial chloasma 3. Fetal movement 4. Breast tenderness 5. Positive pregnancy test 6. Urinary frequency

2., & 5. Correct: Probable signs are things that most likely indicate pregnancy and are signs the primary healthcare provider will identify. Facial chloasma, also known as the mask of pregnancy, is a probable sign. A positive pregnancy test is also a probable sign of pregnancy. Why isn't it a positive sign of pregnancy? There are other conditions that can increase hCG levels.

What medication, given to help mature fetal lungs, does the nurse anticipate giving after admitting a client in preterm labor? 1. Magnesium sulfate 2. Terbutaline 3. Betamethasone 4. Nifedipine

3. Correct: Betamethasone, a steroid, is given IM to help the fetal lungs mature. 1. Incorrect: Magnesium Sulfate is given IV because it relaxes the uterus in an effort to stop contractions. 2. Incorrect: Terbutaline is given SQ because it relaxes the uterus in an effort to stop contractions. 4. Incorrect: Nifedipine is given PO because it relaxes the uterus in an effort to stop contractions. If you missed this question, go to section 2 of the maternity video to review.

A client with nausea, vomiting, and diarrhea for the past three days has been prescribed one liter of normal saline with 40 mEq (40 mmol/L) of potassium chloride to infuse at 250 mL per hour. Which assessment would the nurse report to the primary healthcare provider prior to initiating the infusion? 1. Blood pressure of 106/54 2. Apical pulse of 112 per minute 3. Tenting of the skin over the sternum 4. Urinary output of 148 mL for the past 6 hours

4. Correct: The client's output is below normal. This could indicate a problem with renal perfusion. Potassium is excreted through the kidneys, so if the kidneys are not being perfused, the client would retain potassium. The healthcare provider would need to be aware of the client's low urine output.

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? 1. Ask another nurse to confirm suspicions. 2. Call supervisor to report the intoxication. 3. Confront the nurse privately in person. 4. Discuss suspicions with unit nurse manager.

4. Correct:The greatest concern at this time is the safety of the clients to whom the intoxicated nurse is providing care. The nurses Code of Ethics dictates safe, effective care for the public with protection from incompetent or unethical practice. The chain of command for this floor nurse is to report directly to the unit nurse manager. 1. Incorrect: When dealing with ethical or legal issues, the chain of command starts with the nurse manager of the unit in question. Asking another staff nurse for a personal opinion would not provide any pertinent data and instead amounts to gossip. 2. Incorrect: In order to avoid undue conflict, the nurse needs to immediately alert the unit nurse manager and not the facility supervisor. The nurse manager must then manage any conflict that may result and bears the responsibility to control possible disruption resulting from re-assigning the impaired nurse's clients. 3. Incorrect: Direct confrontation of the allegedly impaired nurse would most likely result in denial or defensive behaviors which could place the clients at further risk. The chain of command for this staff nurse starts with the unit nurse manager who would be more qualified to deal with conflict resolution in this matter.

The nurse is caring for a client with bipolar disorder and has been prescribed carbamazepine. Which laboratory tests would need to be monitored for adverse effects? A. Urine analysis B. Complete Blood Count (CBC) C. Cardiac enzymes D. Lipid Panel

Choice B is correct. Carbamazepine has been implicated in causing blood dyscrasias. These blood dyscrasias include pancytopenia (low red blood cells, white blood cells, and platelets). Therefore, the nurse should contact the health care provider (HCP) to obtain an order to draw a baseline complete blood count (CBC) with differential before administering carbamazepine to this client. This lab result will serve as the baseline result for this client, as this lab result includes the client's baseline leukocytes, neutrophils, and thrombocytes (among other CBC results).

The nurse assists a client with cystic fibrosis pick out items on a menu. It will indicate effective teaching if the client selects meals that are A. High in fat B. Low in sodium C. Low in calories D. Low in protein

Choice A is correct. Cystic fibrosis is a multisystem disorder that may cause an individual to develop vitamin and mineral deficiencies because of dietary malabsorption. The recommended diet for a client with cystic fibrosis is a well-balanced, high-protein, high-calorie diet with high fat (impaired intestinal absorption). Dietary items rich in sodium are also encouraged because of the salt loss through the skin.

The emergency department nurse is caring for a client with an abdominal aortic aneurysm at risk of rupturing. The nurse will anticipate the primary healthcare provider (PHCP) to prescribe A. esmolol. B. dexamethasone. C. heparin. D. pantoprazole.

Choice A is correct. For a client with a suspected ruptured (or rupturing) abdominal aortic aneurysm, tight blood pressure control is essential. Having tight blood pressure control decreases the pressure on the aneurysm. Esmolol is a beta-blocker and will exert antihypertensive effects. For a client with an unstable abdominal aortic aneurysm, the nurse should provide close monitoring of their vital signs and adequate pain control.

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern? A. Headache and nausea B. Scant blood on the AV fistula C. Potassium 3.7 mEq/L (mmol/L) [3.5 - 5.0 mEq/L, mmol/L] D. Hemoglobin 8.8 mg/dL [Male: 14-18 g/dL; Female: 12-16 g/dL, Female 115-155 g/L Male 125-170 g/L]

Choice A is correct. Headache and nausea may be manifestations associated with dialysis disequilibrium syndrome (DDS). This complication is experienced by clients undergoing their first dialysis and may range from mild to severe ✓ DDS is usually self-limiting and is common during the first treatment. ✓ This is caused by removing urea, which causes a fluid shift that may lead to cerebral edema. ✓ The nurse should remain with the client and institute fall precautions. ✓ Notifying the primary healthcare provider (PHCP) should be done despite most DDS being self-limiting. ✓ Other complications of hemodialysis include hypotension, bleeding, angina, and cramps.

The nurse is caring for a client experiencing a tonic-clonic seizure. Which of the following medications should the nurse be prepared to administer? A. Lorazepam B. Phenytoin C. Carbamazepine D. Benztropine

Choice A is correct. Lorazepam is a benzodiazepine that acts as an anticonvulsant. It is often used as a first-line medication to abort prolonged or status epilepticus seizures, including tonic-clonic seizures. Lorazepam has a rapid onset of action and can be administered intravenously or intramuscularly in emergency situations to quickly terminate the seizure.

The nurse is caring for a child with nephroblastoma. The nurse plans to take which action? A. Post a sign that states, "Do not palpate abdomen" B. Recommend foods low in protein C. Insert an indwelling urinary catheter D. Initiate fluid restrictions

Choice A is correct. Nephroblastoma (Wilms tumor) is the most common childhood cancer. Common treatments include surgical removal followed by chemotherapy. Nursing care involves minimal manipulation of the abdomen (no palpation) and a posted sign. It is essential to keep the encapsulated tumor intact.

The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove? A. Macaroni and cheddar cheese B. Watermelon slices C. Caffeine free cola D. Baked chicke

Choice A is correct. Pheochromocytoma is caused by a tumor on top of the adrenal medulla, causing a surge in catecholamines to be released, thus causing the client to experience headaches, hypertension, hyperglycemia, tremor, and unintentional weight loss. A client with pheochromocytoma is advised to modify their diet so that it does not increase blood pressure. Cheddar cheese contains tyramine and should not be included in the client's diet. Other dietary modifications include limitations of caffeinated beverages, which may also raise blood pressure. This item should be removed from the client's meal tray.

The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron B. Methimazole C. Omeprazole D. Methylphenidate

Choice A is correct. Prophylactic nausea and vomiting prevention is essential following this surgery. If the client were to vomit, this would put pressure on the operative site and cause wound disruption. Following this surgery, the client is instructed not to cough, blow their nose, or sneeze. Vomiting should be avoided because it exerts pressure on the operative site, which is detrimental.

The nurse, in caring for a client on bed rest following a spinal injury, should consider which position the most appropriate to prevent foot drop? A. Supination B. Dorsiflexion C. Hyperextension D. Abduction

Choice B is correct. Dorsiflexion is the position where the foot is flexed upward, with the toes pointing toward the ceiling. This position helps maintain the ankle joint in a neutral position and prevents the foot from dropping into plantar flexion, which can lead to foot drop. Foot drop is a condition where the client is unable to dorsiflex their foot, resulting in a permanent or temporary loss of the ability to lift the front part of the foot, leading to a dragging gait. It is essential to maintain dorsiflexion to preserve the client's range of motion and prevent contractures while on bed rest, ultimately reducing the risk of foot drop.

The nurse is caring for a client in Buck traction. The nurse plans on elevating the head of the bed to A. 15 degrees. B. 90 degrees. C. 60 degrees. D. 45 degrees.

Choice A is correct. The head of the bed for a client in Buck traction (skin traction) should be kept between 10 and 20 degrees. This will ensure appropriate alignment and prevent the client from sliding into the bed. Preventing the client from sliding could decrease client discomfort when they have to be repositioned.

An emergency department (ED) nurse is caring for a client who suffered from a non-fatal drowning at a local beach. Which of the following assessment findings would the nurse anticipate? A. Hypoxia, hypercarbia, and acidosis B. Coma, hyperthermia, and alkalosis C. Hypothermia, hypocapnia, and alkalosis D. Hyperthermia, hypoxia, and acidosis

Choice A is correct. The submersion in water led to the client's respiratory impairment, resulting in an inability to oxygenate the client's tissues and organs. Anticipated findings for this client include hypoxia (decreased oxygen levels in the blood), hypercarbia (increased carbon dioxide levels in the blood due to hypoventilation), and acidosis due to the body's prolonged inability to oxygenate tissues and organs. Aspirated fluid can lead to surfactant washout and dysfunction, increased alveolar-capillary membrane permeability, decreased lung compliance, and ventilation/perfusion ratio mismatching, all of which contribute to the nurse's anticipated assessment findings in this client.

The primary healthcare provider (PHCP) is caring for a client with a neurologic injury who wants to perform a Romberg test. The nurse should instruct the client that this test will require A. standing with your arms at your side and your feet together. B. flexing the neck, bringing chin to chest. C. both elbows on a table while keeping both forearms vertical and flexing both wrists at 90 degrees. D. placing their left heel onto their right shin and run your heel down the length of the shin to the top of the foot.

Choice A is correct. To perform the Romberg test, the client should stand with arms at the sides, feet, and knees close together and eyes open. The provider will check for swaying and then ask the client to close their eyes and maintain position. If the client sways with the eyes closed but not when the eyes are open (the Romberg sign), the problem is probably related to proprioception (awareness of body position). If the client sways with the eyes both open and closed, the neurologic disturbance is probably cerebellar in origin.

The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most important? A. Assess the patient's mental status B. Provide oral hygiene C. Keep accurate intake and output measurements D. Reduce stress and discomfort

Choice A is correct. When caring for a patient with SIADH, the nurse should carefully monitor for changes in mental status and level of consciousness. SIADH causes excess free water retention and hyponatremia, which may lead to confusion and behavioral changes. These alterations in the mental state may also lead to seizures. Patients with SIADH may also experience cardiac dysrhythmias.

The nurse is triaging a group of pediatric clients. The nurse should initially follow-up on the client who is a A. 5-year-old who burned her right forearm in scalding hot water. B. 2-year-old who is drooling and does not want to swallow. C. 8-year-old child with a headache for two days. D. 10-year-old child who reports excessive thirst and has a fever.

Choice B is correct. A child who is drooling and does not want to swallow is indicative of epiglottitis, which can be a life-threatening situation. The nurse should assess this child first and inform the physician if an emergency tracheostomy is required.

The nurse is planning care for a client admitted with infective endocarditis (IE). Which assessment finding would indicate that the client is experiencing a complication? A. petechial rashes B. flank pain C. headache D. fever

Choice B is correct. An array of complications may occur with IE, including renal infarction, myocardial infarction, heart failure, pulmonary embolism, and septic arthritis. If a client has flank pain, this is concerning for a renal infarction. In a renal infarction, the septic emboli get lodged in the renal artery, creating significant pain and decreasing the blood flow to the affected kidney. Other manifestations of renal infarction include microscopic or frank hematuria.

The nurse suspects a patient on the neurological floor is experiencing autonomic dysreflexia. What action should the nurse perform first? A. Administer sublingual nitroglycerin. B. Elevate the head of the bed. C. Obtain a residual volume reading with a bladder scan. D. Perform a digital examination to assess for the presence of stool.

Choice B is correct. Autonomic dysreflexia is a severe, life-threatening condition that can occur secondary to a spinal cord injury. In response to noxious stimuli such as full bladder, line insertion, or fecal impaction, the body mounts an exaggerated sympathetic response that causes bradycardia, hypertension, facial flushing, and headache. If left untreated, autonomic dysreflexia can cause cerebral hemorrhage, pulmonary edema, and seizures. Treatment is focused on removing the underlying noxious stimuli. The nurse should first: Elevate the patient's head (sit the patient up) and lower the legs (this will help lower BP while the cause is identified). Lying down is contraindicated. Loosen any restrictive clothing (to help reduce the BP) Check the bladder catheter for kinks or other causes of obstruction to the urinary flow Monitor vitals frequently - check BP every 5 minutes. Avoid pressure on the bladder.

Which of the following medications may be prescribed to control hypertension associated with a nephroblastoma? A. Propranolol B. Enalapril C. Nitroprusside D. Digoxin

Choice B is correct. Enalapril is an ACE inhibitor used to lower blood pressure. Since clients with nephroblastoma are hypertensive due to increased renin levels, this medication is commonly prescribed to decrease their blood pressure. Any ACE inhibitor reduces blood pressure by inhibiting the formation of angiotensin II in the renin-angiotensin-aldosterone system (RAAS), so they are an excellent choice for treating hypertension caused by nephroblastoma. While ACE-I's may be nephrotoxic, this is still the recommended treatment and is therapeutic as long as the creatinine levels are monitored closely.

The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: A. Half Eclipsed Lipase Levels and Preeclampsia B. Hemolysis, elevated liver enzymes, and lowered platelets C. Hematocrit elevation, low lipase, and pancreatitis D. Hemoglobin, elevated lipids, and low plasma

Choice B is correct. HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as symptoms develop.

The nurse is caring for a child with acute glomerulonephritis (AGN). Which clinical data should the nurse monitor to determine if the client is having a complication? A. white blood cell (WBC) count B. blood pressure C. capillary blood glucose (CBG) D. urine specific gravity (USG)

Choice B is correct. Monitoring the child's blood pressure is key in preventing the client from developing hypertensive encephalopathy. This is a significant complication associated with AGN and features the client having hypertension, headache, dizziness, vomiting, and abdominal discomfort.

A 28-year-old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but cannot move the right. However, she cannot feel any pain in the left. The nurse knows these symptoms suggest which type of spinal cord injury? A. Incomplete spinal cord injury, central cord syndrome B. Incomplete spinal cord injury, Brown-Sequard syndrome C. Complete spinal cord injury, paraplegia D. Incomplete spinal cord injury, anterior cord syndrome

Choice B is correct. This is the best answer based on the patient's symptoms of weakness on one side but sensory loss (pain sensation loss) on the other. The Brown-Sequard syndrome is an incomplete spinal cord injury characterized as a weakness/paralysis (hemi-paraplegia) on the ipsilateral (same) side of the body and sensory loss (hemianesthesia) on the contralateral (opposite) side of the body below the level of injury. It is also known as the hemi-section of the spinal cord. At the level of the injury, there is a complete loss of sensation and flaccid paralysis. Below the level of the injury, there is spastic paralysis and the Babinski reflex (extensor plantar response) on the ipsilateral side. Brown-Sequard Syndrome may be due to traumatic or non-traumatic injuries. However, traumatic injuries such as gunshot wounds, stab wounds, motor vehicle accidents, or blunt trauma are more common causes than non-traumatic etiologies.

The nurse cares for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially A. developing a therapeutic rapport with the client. B. inserting a peripheral vascular access device. C. obtaining the client's vital signs. D. collecting a serum lithium level on the client.

Choice C is correct. An overdose of lithium may be fatal if not treated. Lithium has a narrow therapeutic index (0.6-1.2 mEq/L, mmol), and manifestations of toxicity include gastrointestinal symptoms of nausea, vomiting, and diarrhea predominate, and neurologic symptoms are delayed. The neurological findings may consist of confusion, ataxia, and coarse tremors. Obtaining vital signs is a priority to determine the client's overall health status.

The nurse has received a prescription for celecoxib. Which finding in the client's medical history should prompt the nurse to question the administration of this medication? A. osteoarthritis B. gout C. recent myocardial infarction D. migraine headaches

Choice C is correct. Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) used to treat osteoarthritis, gout, dysmenorrhea, and migraine headaches. NSAIDs cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction (MI) and stroke.

The nurse is caring for a client newly diagnosed with bipolar disorder. The nurse anticipates a prescription for A. sertraline. B. haloperidol. C. lamotrigine. D. buspirone.

Choice C is correct. Lamotrigine is a mood stabilizer indicated in the treatment of bipolar disorder. Lamotrigine is also used to manage epilepsy because it doubles as an anticonvulsant. Lamotrigine is efficacious for both bipolar mania and depression. Choice A is incorrect. Sertraline is an antidepressant medication used in both anxiety and depressive disorders. Antidepressant medications are not used in bipolar disorder because of their ability to cause an individual to shift into mania. Choice B is incorrect. Haloperidol is a first-generation (typical) antipsychotic medication indicated in treating psychotic disorders such as schizophrenia. While antipsychotic medications may be used for bipolar disorder, the second generation (or the atypical) are used. Medicines in the atypical class include quetiapine, cariprazine, and risperidone. Choice D is incorrect. Buspirone is an anti-anxiety medication. It is not a benzodiazepine, so dependence cannot occur. This medication takes 4-6 weeks to lower a client's anxiety. This medication is not indicated in bipolar disorder.

Which of the following over-the-counter (OTC) medications is Reye's syndrome associated with? A. Acetaminophen B. Ibuprofen C. Aspirin D. Brompheniramine/pseudoephedrine

Choice C is correct. Reye's syndrome is a potentially fatal illness that can lead to liver failure and encephalopathy. Virus-infected children who are given aspirin to manage pain, fever, and inflammation are at an increased risk of developing Reye's syndrome.

The nurse is performing a physical assessment on an adult client. The nurse should assess for tactile fremitus by A. placing the thumbs on the client's spine at the level of the ninth ribs. B. asking the client to breathe slowly and deeply through an open mouth while auscultating lung sounds. C. asking the client to say "ninety-nine" while palpating the intercoastal spaces beginning at the lung apex. D. tapping the chest over the distal interphalangeal joint with the middle finger of the opposite hand.

Choice C is correct. Tactile (vocal) fremitus describes the vibrations that can be palpated through the chest wall during speech. To assess tactile fremitus, the nurse would place hands over the lung apices in the supraclavicular areas and palpate from one side to the other while the client repeats "ninety-nine" to compare vibrations. If vibrations are uneven, it may indicate pneumothorax, inflamed lung tissue, or fluid build-up.

he nurse in the emergency department (ED) is caring for a client admitted with diabetic ketoacidosis (DKA). Which clinical data requires immediate follow-up? A. Respiratory rate (RR) 23/minute B. Capillary blood glucose 319 mg/dL (17.70 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L] C. Mean arterial pressure (MAP) 51 mm Hg D. PaO2 90 mm Hg [80-100mm Hg]

Choice C is correct. This client's mean arterial pressure (MAP) is critically low. The MAP for an adult should be at least 60 mm Hg (this will ensure adequate perfusion to critical organs), with the ideal MAP being 70 mm Hg. This client's MAP requires immediate correction because of the end-organ damage the client is likely experiencing.

The nurse is caring for a client who is receiving prescribed trazodone. Which of the following findings would indicate the client is having an adverse effect? A. Dizziness B. Sedation C. Priapism D. Dry mouth

Choice C is correct. Trazodone is a serotonergic medication indicated in the treatment of insomnia. Adversely, this medication may cause priapism which is a prolonged, painful erection of the penis. Prompt treatment is necessary because this may result in ischemia. Choices A, B, and D are incorrect. Trazodone exerts central nervous system depressive effects, and those with trazodone often experience dizziness. This medication is indicated for insomnia, and sedation would be a therapeutic (not adverse) effect. Dry mouth is a benign effect associated with the medication.

The nurse is providing discharge instructions to a client with a tracheostomy. Which of the following instructions should the nurse include? A. You may use lemon glycerin swabs for mouth care. B. Remove the old tracheostomy ties before applying the new ties. C. You may use warm tap water to clean the inner cannula. D. Wear a shower shield over the tracheostomy when bathing.

Choice D is correct. A shower shield should be placed over the tracheostomy when the client bathes. This would prevent water from entering the tracheostomy and potentially lead to pneumonia.

The nurse has become aware of the following client situations. The nurse should first follow up with the client who A. is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa. B. is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma. C. has type 2 diabetes mellitus and a morning blood glucose level of 76 mg/dL (4.22 mmol/L) [70-110 mg/dL, 44.0-6.0 mmol/L], and refuses breakfast. D. is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip.

Choice D is correct. Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. This is a major complication of appendicitis, and the nurse must immediately follow up with this client because a perforated appendix may quickly progress to peritonitis and then sepsis.

Fidelity is defined as being _______ to our promises to our clients.

faithful

The nurse is teaching a group of students a potential cause of metabolic alkalosis. It would indicate a correct understanding if a student stated which condition could cause this acid-base imbalance? A. Hyperventilation B. Urinary retention C. Opioid toxicity D. Excessive vomiting

Choice D is correct. Metabolic alkalosis is a disturbance in the body's acid-base balance characterized by an elevated blood pH and bicarbonate (HCO3-) concentration. Excessive vomiting is a common cause of metabolic alkalosis because it results in the loss of stomach acid (hydrochloric acid, HCl) through repeated vomiting. When stomach acid is lost, the body retains bicarbonate ions, which can lead to an increase in blood pH and the development of metabolic alkalosis. Choice A is incorrect. Hyperventilation causes excessive elimination of carbon dioxide (CO2) through the lungs, resulting in decreased carbonic acid (H2CO3) levels in the blood and an increase in blood pH

The nurse is caring for a client who has been prescribed a bolus of 0.9% saline. The nurse understands that the treatment goal of the saline bolus is to A. improve gas exchange. B. reduce the mean arterial pressure (MAP). C. increase the afterload. D. increase the preload

Choice D is correct. Preload is the amount of volume being returned to the heart. Specifically, it is the ventricle's "filling pressure." Preload is the blood volume in the ventricles at the end of diastole. Factors influencing preload include total blood volume, sympathetic stimulation, the force of atrial contraction, and natriuretic peptides (ANP & BNP). Since preload is affected by blood volume, providing a bolus of isotonic fluid would increase the preload. In hemodynamics, the preload is measured by central venous pressure (CVP). The average CVP is 4 to 8 mmHg. Choices A, B, and C are incorrect. A saline bolus would have no impact on gas exchange. Adversely, a fluid bolus may cause an impairment in gas exchange because of pulmonary edema. Afterload is the resistance a ventricle must push against during a contraction to eject its blood volume. As arteries constrict, afterload increases. As they dilate, it decreases. The heart must work harder as the afterload increases. The mean arterial pressure is the average systemic arterial pressure. Providing additional blood volume would increase the MAP.

The emergency department (ED) nurse cares for a client who reports persistent nausea and vomiting for three days. Which acid-based arrangement would the nurse expect based on the client's manifestations? A. A decreased pH and an elevated CO2 B. An elevated pH and a decreased CO2 C. A decreased pH and a decreased HCO3- D. An increased pH with an increased HCO3-

Choice D is correct. This client has presented with one of the most common causes of metabolic alkalosis: Persistent nausea and vomiting leading to metabolic alkalosis due to the loss of gastric acid, therefore causing an increase in the pH and HCO3-.

The nurse is observing a client ambulate with crutches using the three-point gait. Which observation requires follow-up by the nurse? The client A. places the crutches 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot prior to walking. B. advances both crutches and the injured leg forward and then moves the non-injured leg. C. has the elbows flexed 30 degrees with the hands and arms supporting the body weight. D. moves a crutch at the same time as the opposing leg.

Choice D is correct. This technique does not reflect the three-point gait. This gait pattern depicts the two-point gait, which requires at least partial weight bearing of both lower extremities. In the two-point gait, the left crutch and right leg move forward, followed by the right crutch and left leg.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply. A. Splitting B. Sublimation C. Altruism D. Projection E. Conversion

Choices A and D are correct. Severe impairments in functioning characterize borderline personality disorder. Its major features are marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others.

The nurse is caring for a client taking prescribed clozapine. Which clinical data should the nurse monitor? Select all that apply. A. Weight B. Complete blood count (CBC) C. Urine specific gravity (USG) D. Fasting blood glucose E. Total cholesterol

Choices A, B, D, and E are correct. Clozapine is an atypical antipsychotic utilized in individuals who do not respond to other antipsychotics. Out of all the atypical antipsychotics, clozapine is strongly implicated in the client developing metabolic disturbances such as hyperglycemia, weight gain, and hyperlipidemia. Additionally, an individual taking clozapine is monitored closely for neutropenia which would reflect in a depressed white blood cell (WBC) count. The WBC would be found on a CBC

The nurse is assessing a client with severe preeclampsia. Which clinical findings should the nurse anticipate? Select all that apply. hyperreflexia headache uncontrolled vomiting epigastric pain glycosuria

Choices A, B, and D are correct. Hyperreflexia, headache, and epigastric pain are typical symptoms of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Hyperreflexia is a common finding and may occur with ankle clonus. These findings arise because of neuromuscular irritability. Other findings associated with preeclampsia include hypertension, facial swelling, and proteinuria.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. A. Troponin B. Creatinine C. Thyroid-stimulating hormone D. Sodium E. Potassium

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity).

Bulimia only has one medication approved for its treatment, and it is _________

fluoxetine

The physician has diagnosed the client with benign prostatic hyperplasia (BPH) The nurse reviews the client's current medications and plans to question which prescription? Lisinopril Nortriptyline Clonidine Aspirin

Nortriptyline is a tricyclic antidepressant used for depression and obsessive-compulsive disorders. This medication is significantly anticholinergic and would further irritate the client's BPH symptoms. The other medications are not purported to aggravate this condition.

_____________ is a fungal infection of the nail plate, nail bed, or both. the client's nails typically appear deformed with a white or yellow discoloration. It can cause pain, discomfort, and disfigurement and may produce serious physical and occupational limitations and reduce the client's quality of life.

Onychomycosis

Which prescriptions should the nurse anticipate from the primary healthcare provider (PHCP) based on the history and physical? Select all that apply. A. levodopa-Carbidopa B. methylprednisolone C. lorazepam D. intravenous fluids E. venlafaxine F. Levothyroxine

Options C, D - Correct - Catatonia is a serious psychiatric syndrome that may occur with psychiatric and medical conditions. The gold standard treatment for catatonia is benzodiazepines such as lorazepam. Lorazepam is preferred because of its modulating effects on the neurotransmitter GABA. The nurse should also request a prescription for intravenous fluids because the clinical data suggests dehydration (skin tenting and dry mucous membranes) which is a likely consequence of catatonia.

___________ is drooping of the eyelid. It may be congenital or acquired and may be a clinical feature of neurological conditions such as myasthenia gravis or multiple sclerosis. _________ is the dilation of the pupil. This is not drooping of the eyelid. It may be caused by the fight or flight response and certain medications such as central nervous stimulants.

Ptosis Mydriasis

___________ is an oral medication that forms a protective layer in the gastrointestinal mucosa, which provides a physical barrier against stomach acids and enzymes. It does not neutralize or reduce acid production but is prescribed to treat and prevent both stomach and duodenal ulcers.

Sucralfate

When should the patient take sucralfate?

Sucralfate is generally prescribed 1 hour before meals and at bedtime and, for effective results, is taken on an empty stomach with a glass of water. Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to prevent altered absorption

Bipolar disorder is treated with mood stabilizers such as lamotrigine,________, and valproic acid.

lithium

Classic manifestations of ___________ _________ include tachycardia, tachypnea, jugular venous distention, and hypotension with a narrowed pulse pressure.

cardiac tamponade

Labetalol is a nonselective beta-blocker, and the client should be instructed to take their _________ _______ prior to each dose.

radial pulse If the pulse is less than 60/minute, the physician should be notified.

A ________is a localized collection of serous fluid that may accumulate under the breast incision or in the axilla around 7 to 10 days after mastectomy. Seromas may develop if the surgical drain is in place and becomes obstructed or a seroma may occur temporarily after the drain is removed. Clinical manifestations include swelling (feels like liquid moving under the skin), heaviness, and discomfort. Treatment may be as simple as unclogging the surgical drain. Remember, there has been no drainage for 24 hours.

seroma

cataonia

state of immobility and unresponsiveness lasting for long periods of time ✓ Catatonia is a syndrome that may co-occur with bipolar disorder or schizophrenia. ✓ This condition may cause symptoms such as mutism, stupor, negativism, waxy flexibility, hypokinesia, staring, and bizarre speech patterns like echolalia. ✓ Medical treatment includes parenteral benzodiazepines and electroconvulsive therapy (ECT) in severe cases. ✓ Depending on the degree of catatonia, nursing care aims to prevent complications of immobility, such as venous thromboembolism and skin breakdown. ✓ Intravenous hydration is often used to prevent dehydration when the client does not drink.

Roomberg test overview

✓ The Romberg test is used to determine if the client has issues with proprioception. ✓ When performing this test, the examiner should be nearby because the client is at risk of falling. ✓ This test is commonly used if the client has had any neurological injury.

The nurse educates the client on the prescribed tamsulosin. Which statement, if made by the client, would indicate a need for follow-up? Select all that apply -"This medication may cause me to urinate more often." -"It will be important for me to change positions slowly." -"I may notice an increase in my blood pressure." -"My urine will change to an orange or red color." -"I should notify my doctor if I have persistent dizziness."

-"This medication may cause me to urinate more often." -"I may notice an increase in my blood pressure." -"My urine will change to an orange or red color." Tamsulosin is an alpha antagonist and causes vasodilation; thus, relaxing the prostate provides the client with symptom relief. It would require follow-up if the client states that the medication will cause them to urinate more often as this medication is not a diuretic. In fact, it would decrease the number of times the client will urinate because the client can empty the bladder completely. This medication may cause a decrease in blood pressure because of its vasodilation effects. Thus, persistent dizziness should be reported because the dose may need to be adjusted. The medication does not cause changes to the color of the urine. Drugs causing urine discoloration include phenazopyridine and rifampin.

A client receiving torsemide 20 mg every day reports an onset of cramping in the lower extremities. Based on this report, what current lab finding would the nurse expect? 1. Potassium level of 3.1 mEq/L (3.1 mmol/L) 2. Calcium level of 11 mg/dL (2.75 mmol/L) 3. Sodium level of 140 mEq/L (140 mmol/L) 4. pH level of 7.40

1. Correct: Torsemide is a loop diuretic, which causes the excretion of K+. Hypokalemia can result from use of this diuretic. Normal range for potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Therefore the level of 3.1 mEq/L (3.1 mmoL/L) is hypokalemia, and a common sign and symptom includes muscle cramps.

Which signs and symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin? Select all that apply 1. Reports a tightness in throat 2. Faint expiratory wheeze on auscultation. 3. Client statement, "I feel like something is wrong." 4. Bounding radial pulse rate of 100/min 5. BP 100/70

1., 2. & 3. Correct: Swelling of face, mouth, throat, and a tightness in throat are indicative of an inflammatory response that could obstruct the airway. Wheezes and stridor are indicators of breathing difficulties seen with anaphylactic reaction. A sense that something bad is happening should serve as a warning that something bad is really going on. Suspect anaphylactic response. 4. Incorrect: The pulse rate would be increased, but the client would have a thready, weak pulse, not bounding. The pulse may also be irregular.

The nurse has been teaching the parents of a child taking methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHD). Which comments by the parents indicate adequate understanding of the important considerations for methylphenidate? Select all that apply 1. "I know that I need to monitor weight." 2. "I am supposed to call if my child has decreased attentiveness." 3. "This medication may cause increased drowsiness." 4. "I know that I need to monitor my childs height." 5. "If my child can't sleep, the dosage may need to be increased."

1., 2. & 4. Correct: Continued use of the medication may cause delays in growth and loss of appetite. Lack of appetite may cause weight loss. This drug may affect child's growth rate. The child's attentiveness should increase with this medication and if there is no improvement in attentiveness with this medication then notify the primary healthcare provider. 3. Incorrect: The medication is more likely to cause insomnia especially if administered late in the day. If this medication can cause insomnia. 5. Incorrect: If the client cannot sleep, it is likely that the afternoon dose will be decreased or omitted.

The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? Select All That Apply 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises

1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain.

What interventions should the nurse provide when caring for a client prescribed oxytocin IV? Select All That Apply 1. Label IV bag and IV tubing with oxytocin sticker. 2. Monitor for late decelerations. 3. Position client supine. 4. Piggyback oxytocin at the lowest primary IV site. 5. Provide one on one care

1., 2., 4., & 5. Correct: Always label both the IV bag with an oxytocin sticker and the IV tubing and ports. Nothing else goes through the tubing and we want it easily identified if it must be stopped. The nurse must monitor for late decelerations while the client is receiving oxytocin. If late decels occur, turn of the oxytocin immediately. Oxytocin is given IVPB at the lowest port so that if it has to be turned off, the client does not get more from the primary IV tubing. Oxytocin is a high risk alert drug. This means there is a high risk of client harm, so never underestimate the problems that can occur with oxytocin administration. The client needs one on one care.

Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Prepare a client's room for return from surgery. 2. Observe for pain relief in a client after receiving acetaminophen with codeine. 3. Assist a client with perineal care after having diarrhea. 4. Clean nares around a client's nasogasttric (NG) tube. 5. Pour a can of tube feeding into a client's percutaneous endoscopic gastrostomy (PEG).

1., 3, & 4. Correct. These are appropriate tasks for an UAP to complete. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Also, making a surgical bed for the client returning from surgery is a basic procedure. 2. Incorrect. The UAP cannot assess or evaluate or even monitor the effectiveness of pain medication. That is what you are asking the UAP to do here. The client has received a narcotic and you have asked the UAP to evaluate the effectiveness of the medication. 5. Incorrect. Administering tube feeding into a PEG tube is beyond the scope of practice for the UAP. This is a procedure which requires a licensed personnel. Catheter placement must be confirmed, client identity checked, tube site flushed with water or sterile water and flow rate determined.

The nurse is caring for a client diagnosed with chronic renal failure who has been taking Epoetin alfa for 2 months. What should the nurse monitor for pertaining to Epoetin alfa during the client's clinic visit? Select all that apply 1. Hypertension 2. Halitosis 3. Hemoptysis 4. Oliguria 5. Dependent edema

1., 3., & 5. Correct: Epoetin alfa can cause or worsen high blood pressure, induce rapid weight gain, and swelling of feet and hands . Clients may experience coughing up of blood as a result of a rapid increase in the number of RBCs

The nurse is preparing to speak to a group of clients at the community center about influenza. Which risk factors for influenza complications would be included in the session? Select All That Apply 1. Age over 65 years. 2. History of grand mal seizures 3. Diabetes 4. Renal disease 5. Clients who reside in a nursing home.

1., 3., 4. & 5. Correct: Clients who are over the age of 65, have diabetes, have renal disease, or who reside in a nursing home are all at risk for post-influenza complications.

A client in her first trimester of pregnancy has been attending educational sessions on pregnancy. What statements by the client would indicate to the nurse that client teaching has been successful? Select All That Apply 1. "Good food sources of iron includes spinach, raisins, and dark chocolate." 2. "I will eat at least 40 grams of protein a day." 3. "Taking folic acid will help prevent heart defects from occurring." 4. "Swimming is an acceptable exercise for me while I am pregnant." 5. "I can gain 2 pounds (0.9 kg) per week during my first trimester." 6. "I need to stay out of hot tubs while pregnant."

1., 4., & 6. Correct: Good sources of iron include liver, spinach, lentils, raisins, fortified cereals, dark chocolate, and dried fruits. Walking and swimming are the best exercises for a pregnant woman. Remember, no high impact. We also do not want them to get overheated, so do not let mom get into hot tubes or under heating blankets because this will increase body temperature and can cause birth defects. 2. Incorrect: Pregnant women should increase protein intake to 60 grams per day. Here's the deal, normal protein intake is about 40 to 45 grams per day. But when you are pregnant, you have a lot of tissue growth going on in your body, so you need more protein. 3. Incorrect: Folic acid helps to prevent what type of defect? Neural Tube Defects. Spinal bifida or myelomeningocele and anencephaly are the big neutral tube defects. 5. Incorrect: During the entire 1st trimester, the client should gain no more than 4 pounds (1.8 kg).

The nurse educates a client that the prescribed medication indomethacin is used to manage which symptoms? SATA 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria

1.,2., & 3. Correct: Indomethacin is a non-steroidal anti-inflammatory agent used to treat pain, inflammation, and fever.

A decrease in MAP of ___-___ mm Hg from the baseline value is the clinical criterion for the compensatory stage of shock.

10-15

The family of a client recently placed on antipsychotic medications for the treatment of schizophrenia calls the nursing hot line and reports that the client's temperature is 105.1ºF (40.6ºC), and that the client's muscles are stiff. What should the nurse tell the family? 1. Continue to monitor for signs and symptoms of infection. 2. Transport the client to the emergency room. 3. The signs and symptoms will subside within a day or so. 4. They should call the primary healthcare provider tomorrow

2. Correct. The client may be experiencing neuroleptic malignant syndrome, a potentially life threatening adverse reaction. Symptoms include high fever, unstable blood pressure and myoglobinemia. The client should be taken to the ER.

A nurse manager is monitoring staff nurse compliance with regulatory guidelines regarding administration of controlled substances. Which actions by the staff nurses indicate to the nurse manager compliance is being maintained? Select all that apply 1. Removes meperidine from computer controlled dispensing system and places in client medication drawer for later use. 2. Second nurse verifies and signs as a witness to morphine 2 mg wasted according to facility protocol. 3. Verification is made of the number of narcotics available against the inventory record prior to narcotic removal. 4. Second nurse provides verifying signature for removal of hydromorphone from the computer controlled dispensing system. 5. Narcotic discrepancy in the computer controlled dispensing system is reported to the primary healthcare provider.

2. Second nurse verifies and signs as a witness to morphine 2 mg wasted according to facility protocol. 3. Verification is made of the number of narcotics available against the inventory record prior to narcotic removal.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply 1. Turn on local news for up-to-date information on the train derailment. 2. Prepare a list of clients who could quickly be discharged or transferred. 3. Determine which personnel could be sent to the command center. 4. Notify clients that the disaster plan has been put into effect. 5. Alert all off-duty personnel to stand by in case of call- in.

2., 3. & 5. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. However, there are some basic points which are standard among all facilities. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. These individuals are selected by the charge nurse, and do not have to be nurses. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 4. Incorrect: This would unnecessarily alarm the clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.

A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself forming an obstruction is called what? A. Intussusception B. Pyloric stenosis C. Hirschsprung's disease D. Omphalocele

Choice A is correct. A gastrointestinal disease of childhood where a piece of bowel goes backward inside itself (telescoping), causing an obstruction, is called intussusception. Choice B is incorrect. Pyloric stenosis is the enlargement and stiffening of the pylorus, the opening from the stomach into the duodenum. This prevents the passage of food into the duodenum and results in projectile vomiting. Choice C is incorrect. Hirschsprung's disease is a congenital anomaly associated with absent ganglion cells in the distal colon and rectum. This results in functional obstruction at the transition zone of absent ganglia and causes dilation of the proximal colon (megacolon). Choice D is incorrect. Omphalocele is a congenital disability in which an infant's intestine or other abdominal organs are outside the body, protruding through a hole in the umbilical region.

The labor and delivery unit charge nurse has received a change-of-shift report on the following clients in labor. Which client should the charge nurse ask a staff member to see first? A. A 28-year-old primigravida at 39 weeks gestation, currently in active labor, with a fetal heart rate of 90-100 bpm. B. A 35-year-old multipara at 41 weeks gestation, currently in early labor, with a history of rapid labor in her previous delivery. C. A 20-year-old multipara at 37 weeks gestation, currently in active labor, with a history of two previous cesarean deliveries. D. A 25-year-old multipara at 38 weeks gestation, currently in early labor, with cervical dilation of 3 cm.

Choice A is correct. A normal fetal heart rate typically ranges between 120-160 bpm. A fetal heart rate of 90-100 bpm may indicate fetal distress or compromise and requires immediate assessment and intervention by a healthcare provider.

The nurse is caring for a client who has developed retinal detachment. Which of the following actions should the nurse take first? A. Instruct the client to restrict activity B. Establish a vascular access device C. Review the client's current medications D. Educate the client about topical eye ointments

Choice A is correct. A retinal detachment is an ocular emergency. The client moving may hasten the detachment. It is important to inform the client to restrict their activity, and the nurse should apply an eye patch to the affected eye

The nurse is caring for a client with an acute spinal cord injury. Which client finding would require immediate follow-up? A. absent bowel sounds B. blood pressure 134/82 mm Hg C. pulse 92/minute D. hyperreflexia

Choice A is correct. Absent bowel sounds, gastric distention, bradycardia, hypotension, and flaccid paralysis are concerning findings for spinal shock. When caring for a client following a spinal cord injury, spinal shock is one of the many complications which may occur within 48 hours following the injury. Choices B, C, and D are incorrect. This clinical data is not consistent with spinal shock. If spinal shock is suspected, the client will develop hypotension and bradycardia. This shock would depress reflexes, not cause hyperreflexia.

Which of the following most impacts a client's food preferences? A. Culture and cultural background B. The frequency of grocery shopping C. The availability of foods locally D. The costs associated with food

Choice A is correct. Culture and cultural background have the most impact on the client's food preferences. Other factors impacting the client's food preferences include religious practices, age, development level, and personal taste preferences (i.e., likes and dislikes). Although the frequency of grocery shopping, local food availability, and the costs associated with food impacts the client's access to food and subsequent affordability of cooking, these factors do not affect the client's overall food preferences in terms of their likes and dislikes.

The nurse is caring for a client who has developed dystonia following the administration of fluphenazine. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe? A. diphenhydramine B. mannitol C. thiamine D. haloperidol

Choice A is correct. Diphenhydramine is an anticholinergic and is utilized for dystonic reactions associated with antipsychotic use (such as fluphenazine, a typical antipsychotic). Dystonia is one of the earliest adverse effects and should be promptly reported to the prescriber. Choices B, C, and D are incorrect. Mannitol is an osmotic diuretic indicated for increased intracranial pressure. This medication would not be used for dystonic reactions. Thiamin is a B-vitamin and can be helpful for alcohol withdrawal. This is not indicated for the treatment of dystonia. Haloperidol is a typical antipsychotic and would be detrimental in treating dystonia. Medications like fluphenazine include haloperidol which would worsen the effect.

The nurse has received a prescription to administer intramuscular (IM) epinephrine. The nurse understands that this medication effects the A. adrenergic receptors. B. muscarinic receptors. C. cholinergic receptors. D. nicotinic receptors.

Choice A is correct. Epinephrine rapidly affects both alpha and beta-adrenergic receptors, eliciting a sympathetic response. Epinephrine is a hormone secreted by the medulla of the adrenal glands. Strong emotions such as fear or anger cause epinephrine to be released into the bloodstream, which causes an increase in heart rate, muscle strength, blood pressure, and sugar metabolism

The nurse is caring for a client who has been prescribed olanzapine. Which of the following assessment findings would warrant immediate notification to the primary healthcare physician (PHCP)? A. Muscle rigidity B. Weight gain C. Hyperglycemia D. Fatigue

Choice A is correct. Olanzapine is an atypical antipsychotic drug. Adverse reactions of olanzapine include neuroleptic malignant syndrome, which is manifested by tachycardia, delirium, fever, and muscle rigidity. Thus, muscle rigidity should be reported to the provider immediately.

A 52-year-old client with a 20-year history of alcohol abuse is hospitalized with mild ascites, jaundice, and bruising. Imaging demonstrates the presence of esophageal varices, while the client's elevated serum ammonia level indicates hepatic encephalopathy. The nurse is concerned the client's esophageal varices may rupture and proceeds to educate the client accordingly. Which item should the nurse include in the client's education session? A. "Do not lift heavy objects." B. "Avoid walking briskly." C. "Avoid taking barbiturates." D. "Avoid ingesting antacids."

Choice A is correct. Primary prophylaxis to prevent the initial variceal bleeding episode is one of the most important strategies for reducing mortality in cirrhotic clients. As such, client education plays a significant role in managing esophageal varices. Lifting heavy objects, straining during defecation, stretching, and the Valsalva maneuver may cause a marked increase in variceal pressure and should, therefore, be avoided by clients with esophageal varices, cirrhotic clients, and those with portal hypertension.

The nurse understands that a portion of the pain "assessment" entails the client's subjective, sensory, and emotional comments that indicate the quality or intensity of their pain. The client describes their pain as "crushing and sharp." Select the type of pain a client is experiencing based on this sensory description of their pain. A. Somatic pain B. Visceral pain C. Hurt D. Neuropathic pain

Choice A is correct. Somatic pain arises from skin and musculoskeletal structures. This type of pain is often reported as sharp, easily localized, gnawing, crushing or throbbing. Sources of acute somatic pain include (and are not limited to) incisional pain, pain at insertion sites of tubes, orthopedic injuries, and wound complications. Choice B is incorrect. "Crushing and sharp" are sensory descriptors of another type of pain, not visceral pain. Visceral pain typically arises from organs and linings of the body cavities. This type of pain is poorly localized, and reported as diffuse, deep cramping or pressure.

The nurse is caring for a child experiencing a celiac crisis. The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? A. Tap water enema B. Intravenous (IV) fluids C. Fluid restrictions D. Nasogastric tube (NGT) insertion

Choice B is correct. A celiac crisis is manifested by severe diarrhea, leading to significant dehydration and electrolyte derangements. A key intervention in managing a celiac crisis is to replete the lost fluids and correct the electrolyte imbalances. Choice A is incorrect. Tap water enema would be contraindicated because that would facilitate an additional bowel movement. A client with a celiac crisis has diarrhea and is at risk for fluid volume deficit. Choice C is incorrect. Diarrhea is found in a celiac crisis, and fluid restrictions would be unhelpful, if not detrimental. Choice D is incorrect. The goal is to rehydrate the client. An NGT is not indicated for this crisis. An NGT would be inserted to decompress the stomach or give medications. This is not necessary for a client with a celiac crisis.

The nurse is caring for a client requiring an emergent transfusion of packed red blood cells. The nurse checks the blood bank, but the only available blood is O + (positive). The client's blood type is A+ (positive). What is the nurse's most appropriate action? A. Arrange for a cross-match between the available blood and the client's blood. B. Call the other blood banks and ask if they have blood units available with the client's blood type. C. Notify the physician that there is no available blood in the blood bank. D. Call the client's family and tell them that he needs blood.

Choice A is correct. The ABO type of the donor should be compatible with the recipient. Type "A" can receive blood from type "A" or "O" as type "O" blood does not contain any antigens against type "A" or "B" blood. The blood can be administered once proper cross-matching is done. Choice B is incorrect. Calling other blood banks to check for blood units with the client's blood type may be a consideration, but this would take time, and in emergency situations, time is critical. The nurse should first initiate the cross-match process. Choice C is incorrect. Notifying the physician that there is no available blood in the blood bank may delay potentially life-saving treatment. Proceeding with the cross-match is essential while informing the physician of the situation. Choice D is incorrect. While involving the client's family is sometimes necessary for obtaining consent or support, it should not be the nurse's initial action in this critical situation. The immediate focus should be on arranging for the cross-match and potentially providing the needed blood to stabilize the client's condition.

A client is admitted to the behavioral health unit and diagnosed with bipolar I disorder and has acute mania. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. valproic acid B. haloperidol C. bupropion D. fluoxetine

Choice A is correct. The gold standard for treating bipolar disorder is mood stabilizers. Valproic acid (VPA) is a mood stabilizer and is efficacious in treating mania because it has a fast onset. This medication can be given by mouth or intravenously. When a client receives valproic acid, the nurse must monitor the client's liver function tests to determine if the client is experiencing the adverse effect of hepatotoxicity. Choice B is incorrect. Haloperidol is a first-generation (typical) antipsychotic. Haloperidol is efficacious in treating psychotic disorders such as schizophrenia - not bipolar disorder. Bipolar disorder is a mood disorder, not a psychotic disorder. Antipsychotics may be used in the treatment of bipolar disorder, but this would be second-generation antipsychotics such as aripiprazole, risperidone, or quetiapine. This is because second-generation antipsychotics may have mood-stabilizing properties. Choice C is incorrect. Bupropion is an atypical antidepressant. This antidepressant is helpful in giving the client energy because of its modulation of dopamine. This would be detrimental to a client with bipolar disorder because it could induce mania. Choice D is incorrect. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) and is indicated in treating anxiety and mood disorders. This has no utility in bipolar disorder. It could even destabilize the mood and induce mania.

The nurse is caring for a client with a nasogastric tube (NGT) connected to suction. Which of the following actions should the nurse perform when irrigating an NGT with water? Select all that apply. A. Draw up 30 mL of warm water into the syringe. B. Unclamp the suction tubing near the connection site to instill water. C. Place the tip of the syringe in the tube to gently instill warm water. D. Place the syringe in the blue air vent of a Salem sump or double-lumen tube. E. After instilling the water, hold the end of the NG tube over an irrigation tray. F. Observe for return of NG drainage into an available container.

Choice A is correct. The nurse irrigating a nasogastric tube connected to suction should draw 30 mL of irrigant into the syringe. This is the standard amount that is used to irrigate an NGT. Choice B is correct. The nurse should place the syringe tip in the tube to gently insert the saline solution. Choices E and F are correct. After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe NGT's drainage return flow into an available container. Choice B is incorrect. The tubing should be clamped near the connection site to protect the patient from leakage of NG drainage. Choice D is incorrect. Place the syringe in the drainage port, not the blue air vent of a Salem sump or double-lumen tube. The blue air vent decreases pressure built up in the stomach when the Salem sump is attached to suction.

The nurse in the burn unit is preparing to perform a dressing change on a client with deep partial-thickness and full-thickness burns. The nurse understands that minimizing the client's pain during the dressing change is the top priority. All the following are appropriate nursing interventions, except: A. Administer a COX-2 inhibitor orally 30 minutes before the dressing change. B. Provide a clear explanation to the client about the procedure and how it will be performed. C. Changing the client's dressing carefully and handling burned areas gently. D. Let the client watch their favorite television show while dressing change is being performed

Choice A is correct. This is an incorrect nursing intervention and, therefore, the correct answer to this question. For clients with deep partial-thickness and/or full-thickness burns, opioids (e.g., morphine sulfate) are the class of medication used to control pain. Opioid pain medication should be administered intravenously to the client at least 30 minutes before any dressing change.

The nurse is caring for a client who was recently admitted to the cardiac floor for angina. This client states that their chest pain occurs at the same time every day at rest. The client does not believe there are any precipitating factors. Which of the following types of angina is this client most likely experiencing? A. Variant angina B. Stable angina C. Unstable angina D. Nonanginal pain

Choice A is correct. Variant angina, also known as Prinzmetal's angina, occurs at about the same time every day, usually at rest. Variant angina is treated with calcium channel blockers. Choice B is incorrect. Stable angina occurs after activity and is relieved by nitroglycerin tablets. Choice C is incorrect. Unstable angina is less predictable and may precipitate myocardial infarction. Choice D is incorrect. This type of discomfort does not describe nonanginal pain.

The nurse is caring for a client in labor experiencing a prolapsed umbilical cord. The nurse anticipates that the fetal heart rate pattern will likely show A. early decelerations. B. variable decelerations. C. late decelerations. D. normal variability.

Choice B is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Common fetal heart rate patterns observed during a prolapsed umbilical cord include variable decelerations, sustained bradycardia, or prolonged decelerations. All of these patterns are non-reassuring. Choices A, C, and D are incorrect. Early decelerations are benign and are consistent with a vaginal response during fetal head compression. Late decelerations are non-reassuring and are associated with compression of the maternal inferior vena cava. Normal variability would not be expected with a prolapsed umbilical cord.

The nurse is performing a respiratory assessment of a client with abnormal breathing patterns. The client has periods of apnea with periods of gradually increasing and decreasing breaths. How should the nurse chart this breathing style? A. Neurogenic hyperventilation B. Cheyne-Stokes C. Apneustic D. Ataxic

Choice B is correct. Cheyne-Stokes respiration is characterized by apnea alternating with periods of rapid breathing. This pattern is often seen in various medical conditions, including heart failure and brain injuries. If you don't know, pick the killer answer!!!

The nurse is caring for a client who has nephrogenic diabetes insipidus. Which of the following medications should the nurse expect to be prescribed for the client? A. Prednisone B. Hydrochlorothiazide C. Verapamil D. Lithium

Choice B is correct. Hydrochlorothiazide is a thiazide diuretic and has a paradoxical effect when prescribed for individuals with diabetes insipidus. While commonly HCTZ causes a diuretic effect, when used for nephrogenic DI, it can increase the proximal sodium and water reabsorption, thereby reducing the urine output. Choice A is incorrect. Prednisone is indicated in the management of adrenal insufficiency. Choice C is incorrect. Verapamil is a calcium channel blocker and is efficacious for migraine headache prophylaxis and hypertension management. Choice D is incorrect. Lithium would be contraindicated as lithium may cause nephrogenic diabetes insipidus.

The nurse is teaching a client about diabetes mellitus type I and exercise. Which statement, if made by the nurse, would be appropriate? A. Increasing exercise would increase insulin requirements B. Increasing exercise would decrease insulin requirements C. Insulin needs do not change with exercise D. Decreasing exercise would decrease insulin requirements

Choice B is correct. Increasing one's exercise would decrease insulin requirements in a client with type I diabetes, as exercise causes the client's blood glucose to decrease. While exercising, muscles require more glucose, and any circulating insulin present becomes more efficient in lowering glucose. Exercise has a variable effect on blood glucose, depending on the timing of exercise in relation to meals and the duration, intensity, and type of exercise. In clients with type 1 diabetes, exercise can lead to hypoglycemia. Therefore, the client's blood glucose should be monitored immediately before and after exercise. The target range for blood glucose prior to exercise should be between 90 mg/dL and 250 mg/dL (5 mmol/L to 14 mmol/L). Clients who experience hypoglycemic symptoms during exercise should be advised to test their blood glucose and ingest carbohydrates or reduce their insulin dose as needed to get their glucose slightly above normal just before exercise. Choice A is incorrect. A reduction in insulin doses is typically required to prevent exercise-mediated hypoglycemia in clients participating in moderately intense exercise for a prolonged duration (>30 minutes). Choice C is incorrect. In clients with type I diabetes mellitus, insulin needs will change based on the exercise patterns of the client.

The nurse has instructed a client scheduled for an injection of dulaglutide for diabetes mellitus (type two). Which of the following statements by the client would require follow-up? A. "I should tell my doctor if I experience abdominal pain and vomiting." B. "I should take this medication within one hour of eating a meal." C. "If this medication works, I should notice a reduction in my hemoglobin A1C (HbA1c)." D. "I will receive this medication once a week."

Choice B is correct. Insulin degludec is a long-acting insulin and has no peak. This insulin not having a peak does not require that the client take this insulin with a meal. This novel drug is dosed weekly, increasing glucose control via this basal insulin. This statement is incorrect and requires follow-up. Choice A is incorrect. Insulin degludec may adversely cause pancreatitis. Cardinal features of pancreatitis include abdominal pain and vomiting, which may lead to dehydration. This statement is correct and does not require follow-up. Choice C is incorrect. The client is experiencing a therapeutic outcome if their HbA1c decreases. This lab test is completed every 3-4 months. The higher the value, the more hyperglycemic episodes the clients experienced. This statement is correct and does not require follow-up. Choice D is incorrect. This medication is dosed once a week. This is an attractive feature of this medication because it provides basal insulin to improve glycemic control. This medication is given subcutaneously.

A cardiac intensive care unit nurse is caring for a client who underwent a coronary artery bypass graft (CABG) 24 hours ago. The nursing care plan indicates a nursing diagnosis of "decreased cardiac output related to alterations in cardiac contractility." Based on the formulated nursing diagnosis, which nursing intervention should be implemented in the nursing care plan? A. Monitor the client's arterial blood gas (ABG) continuously. B. Monitor the client's weight daily and calculate the change. C. Administer prescribed opioids. D. Monitor mediastinal chest tubes for hourly output.

Choice B is correct. Monitoring the daily weight of the client and noting any changes provides the nurse with a picture of the client's fluid volume status, which is influenced by the client's cardiac output. Weight is the most reliable indicator of fluid gain and loss. Choice D is incorrect. In addition to allowing the nurse to assess the client's rate of blood loss post-surgery, hourly monitoring of mediastinal chest tubes also allows the nurse to prevent chest tubes from blocking and causing tamponade by allowing the nurse to manipulate them (if needed) to prevent clots. This nursing intervention is related to the risk of harm related to inadequate hemostasis, not decreased cardiac output.

A nurse prepares a client for computed tomography (CT) scan with intravenous (IV) iodinated contrast. The nurse should take which action? A. Ask the client if they are allergic to shellfish B. Insert a 20-gauge peripheral vascular access device C. Obtain capillary blood glucose (CBG) D. Instruct the client to decrease their fluids after the procedure

Choice B is correct. Patent vascular access of at least a 20-gauge catheter is necessary before the infusion of intravenous contrast. Extravasation of contrast media can be severe, and treatment involves stopping the infusion, removing the catheter, and elevating the extremity above the heart. This can be avoided by establishing IV patency before the infusion of contrast. Warm or cold compresses may also be helpful. Choice A is incorrect. Shellfish allergies are to tropomyosin (a muscle protein), not iodine. Thus, asking questions regarding shellfish allergy before giving an intravenous contrast agent is unnecessary and has been disproven by the American College of Radiology for quite some time. The cause of contrast reactions is unclear, and previous reactions specific to iodine contrast should be inquired about before the exam.

The nurse cares for a client newly diagnosed with anorexia nervosa in the mental health unit. The nurse should plan which intervention in the client's plan of care? A. allow the client to pick out items on the menu B. obtain an order for the client to attend psychotherapy C. encourage the client to select their meal times D. obtain a prescription for fluoxetine

Choice B is correct. Psychotherapy is the gold standard treatment for a client with an eating disorder. While therapeutic approaches may differ, the most common psychotherapeutic approach is cognitive-behavioral therapy (CBT). CBT is helpful because it examines the client's distorted thoughts to remedy the harmful behavior. Changing the client's negative thoughts regarding food and their self-image is essential in the management of most eating disorders. Choice A is incorrect. The client is newly diagnosed, and for this client, the nurse should assist the client with making menu choices. This allows the nurse to build a rapport with the client and clear up misconceptions regarding the food choice and its nutritional value. Once the client progresses in psychotherapy and their weight increases, they should be able to select their food items. Autonomy is important but not as crucial as providing structure to the client's illness.

The nurse has received a prescription for rivaroxaban. The nurse understands that this medication is prescribed to treat which condition? A. Pulmonary Hypertension B. Venous Thromboembolism (VTE) C. Congestive Heart Failure D. Hyperlipidemia

Choice B is correct. Rivaroxaban (Xarelto) is a factor Xa inhibitor and is commonly prescribed for the prevention and treatment of venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE). An advantage of rivaroxaban is that no therapeutic monitoring is required, unlike warfarin. Choice A is incorrect. Pulmonary hypertension is a condition characterized by increased blood pressure in the pulmonary arteries, which supply the lungs. Rivaroxaban is not a standard treatment for pulmonary hypertension. Choice C is incorrect. Congestive heart failure (CHF) is a condition in which the heart is unable to pump blood effectively, leading to symptoms such as fluid retention, shortness of breath, and fatigue. While anticoagulant medications like rivaroxaban may be used in some cases of heart disease to prevent clot formation in the atria (e.g., in atrial fibrillation), they are not typically prescribed primarily for CHF. Choice D is incorrect. Hyperlipidemia refers to high levels of lipids (cholesterol and triglycerides) in the blood. The primary treatment for hyperlipidemia is lifestyle modifications (diet and exercise) and lipid-lowering medications, such as statins, fibrates, or bile acid sequestrants. Rivaroxaban is not a medication used to lower lipid levels.

The nurse observes a newly hired nurse care for a client with a colostomy. Which action by the newly hired nurse requires follow-up? Select all that apply. The newly hired nurse A. empties the pouch when it is one-third to one-half full. B. washes the surrounding skin with moisturizing soap. C. indicates that the reddish appearance of the stoma as normal. D. applies sterile gloves prior to changing the device. E. applies isopropyl alcohol to the surrounding skin to promote adherence with the wafer.

Choice B is correct. This action is incorrect and requires follow-up. Moisturizing soap should not be used on the peristomal skin as it may prevent the wafer from adhering to the skin. Mild soap is the recommendation. Choice D is correct. This action is incorrect and requires follow-up. Sterile gloves are not used to provide ostomy care. Using sterile gloves would be a waste of resources. Regular clean gloves are used. Choice E is correct. This action is incorrect and requires follow-up. Isopropyl alcohol is drying to the skin and irritates it. This makes the skin's integrity more likely to become impaired. This should not be used on peristomal skin. Choice A is incorrect. The pouch should be emptied when it is one-third to one-half full. This action is correct and does not require follow-up. Choice C is incorrect. A reddish or pink moist stoma indicates adequate perfusion and is normal. Stomas that appear purple, dry, and black require follow-up with the physician because this is unexpected. This action is correct and does not require follow-up.

What percussion sound is heard over most of the abdomen? A. Hyperresonance B. Tympany C. Resonance D. Dullness

Choice B is correct. Tympany is the percussion sound heard over hollow organs. The small intestine and colon are hollow organs; they predominate over most of the abdominal cavity. Choice A is incorrect. Hyperresonance is the sound heard by tapping on the surface of the chest. It is an exaggerated chest resonance heard in various abnormal pulmonary conditions. Choice C is incorrect. Resonance is a low-pitched, hollow sound, is usually heard over healthy lung tissue. Choice D is incorrect. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

The nurse is planning care for a client with a newly diagnosed fractured pelvis. Which action would lessen the risk of fat embolism syndrome (FES)? A. Request a prescription for enoxaparin. B. Alternate with the application of ice and heat. C. Educate the client on pelvic immobilization. D. Encourage passive range of motion of the lower legs.

Choice C is correct. Aggressive immobilization is the most effective way to prevent fat embolism syndrome (FES). This also reduces the risk of internal injuries, as pelvic fractures may cause significant internal bleeding. Choice A is incorrect. Enoxaparin is an effective prescription for preventing venous thromboembolism (VTE) - but not a fat embolism. This medication is given subcutaneously with a distinct advantage over heparin because it does not require aPTT monitoring. Choice B is incorrect. Ice and heat to the pelvis would be contraindicated until internal injuries have been ruled out, and the nurse obtains a prescription for such therapy. Choice D is incorrect. The client should be encouraged to have pelvic immobilization. Passive range of motion exercises during an acute injury would be contraindicated, raising the risk for FES.

The nurse is triaging clients who were involved in a bus accident. Which client should be prioritized for transport to the local trauma center? A client who A. has pain and significant swelling in the right forearm with an intact distal pulse and sensation. B. has profuse bleeding from a chest laceration and is experiencing apnea. C. has a crushed leg reporting no sensation and has no distal pulse. D. is experiencing severe anxiety and has abrasions on both arms.

Choice C is correct. Because of their compromised circulation, this client would be red-tagged using the emergency triage tagging system (red, yellow, green, and black). Red tags require emergent care because of an immediate threat to their life. This client has a crushed leg with no distal sensation or pulse, significantly threatening their circulation. Thus, this client is prioritized for immediate evacuation to the nearest trauma center as a red tag. Choice A is incorrect. Pain and swelling are expected with a potential fracture. This client is a green tag because the distal pulse and sensation are present. Choice B is incorrect. The client who is experiencing apnea would be a black tag. A black tag is assigned when death has occurred or is imminent. An individual with apnea signifies death or impending death. Thus, the nurse should focus on the immediate (red tag) client with a crushed leg with no distal sensation or pulse. Green-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions. Choice D is incorrect. The client experiencing severe anxiety and abrasions to the arms would be classified as a green tag. Nothing in this client's situation suggests a physiological injury that needs to be seen immediately.

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client A. Trendelenburg B. Side-lying C. high-Fowler's D. Reverse Trendelenburg

Choice C is correct. Hypophysectomy is generally performed via the transsphenoidal route to remove tumors from the pituitary gland. Semi-Fowler's to Fowler's position is the most appropriate as it facilitates drainage. Choices A, B, and D are incorrect. These positions would be contraindicated after hypophysectomy. The goal of positioning the client semi- of high-Fowlers is to decrease edema and facilitate gas exchange.

The nurse supervises a student nurse prepare a client for a magnetic resonance imaging (MRI) test. Which of the following actions by the student nurse would require follow-up by the nurse? The student A. asks the client if they have claustrophobia. B. instructs the client to apply earplugs before the exam. C. moves the nitroglycerin patch from the torso to the back. D. tells the client that they will not have any exposure to radiation.

Choice C is correct. Nitroglycerin transdermal patches should be temporarily removed during the procedure because they may burn the client. The transdermal patch may contain aluminum which is contraindicated for an MRI. Moving the patch would not be helpful as it should be totally removed during the procedure. Choices A, B, and D are incorrect. An MRI questionnaire is always completed before this exam to ensure client safety. MRI units can produce sounds up to 120 decibels, resulting in hearing damage. MRIs do not use radiation; this imaging exam uses magnets to create 3D cross-sectional images of the body.

The nurse manager receives a complaint from a client's family member. The nurse manager should take which initial action? A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately B. Speak with the night shift nurse regarding the complaint and discuss the care provided C. Assess the complaint and clarify the details with the family member and client D. Take note of the complaint and place it in the applicable employee's file

Choice C is correct. The nurse manager's initial action should be to contact this individual to let them know they have been heard. Additionally, this point of contact allows the nurse manager to ask additional questions regarding the complaint to ultimately help in determining whether the complaint holds merit. The nurse must thoroughly assess the complaint before bringing it to the nurse's attention to avoid having an inaccurate and incomplete complaint. Once the manager has determined how reliable the information from the client's family member is, the nurse manager may speak with the client (if the client is capable) before speaking with the nurse in question. Choice A is incorrect. Although the nurse manager may discuss this with the night charge nurse at some point, this is not the nurse manager's most appropriate initial action. Choice B is incorrect. Here, the question asks for the nurse manager's most appropriate initial action. While the nurse manager will undoubtedly speak with the night shift nurse regarding the complaint and discuss the care provided, this conversation is not the nurse manager's most appropriate initial action. The nurse needs to assess the complaint for its validity before bringing it to the nurse's attention. Choice D is incorrect. Taking note of an unverified complaint and placing it in an employee's file would be an inappropriate and unethical action by the nurse manager. The incident may go into the nurse's file, but not without investigating the matter first.

The nurse is educating a new graduate about alterations in cortisol levels. Which of the following conditions does she explain cause an increased cortisol levels in a client? A. Addison's disease B. Congestive heart failure C. Renal failure D. Cushing's disease

Choice D is correct. Cushing's disease produces elevated cortisol levels. Cortisol is best known for helping support the body's natural "fight-or-flight" instinct in a crisis. It also plays a vital role in several other body functions, including managing the use of carbohydrates, fats, and proteins, regulating blood pressure, increasing blood sugar levels, controlling the sleep/wake cycle, and boosting energy to help manage stress and restore balance. (Addison's disease produces decreased cortisol levels)

The nurse is performing discharge teaching for a client with Graves' disease. Which of the following client statements indicates effective understanding? A. "I will take my pulse daily and report a rate less than 60 beats/minute." B. "I am going to add hot yoga to my exercise routine." C. "I will increase the amount of fiber in my diet." D. "I should tell my physician if my blood pressure's top number exceeds 140."

Choice D is correct. Grave's disease is the most common form of hyperthyroidism. A significant complication of this condition is the potential for a thyroid storm. A thyroid storm is caused by a surge in thyroid hormone in the bloodstream, which causes the client to experience tachycardia, fever, hypertension, diaphoresis, and tachydysrhythmias. Choice A is incorrect. A thyroid storm is the most concerning complication of Grave's disease and would be manifested by tachycardia, not bradycardia. Choice B is incorrect. Grave's disease causes the client to have heat intolerance, and the client performing hot yoga would not be recommended. Choice C is incorrect. This statement would be applicable to the client with hypothyroidism because constipation is a common finding. This statement is not relevant to a client with Grave's disease.

The parents of a 2-year old with Hirschsprung's disease are talking to the nurse in the family clinic. They ask the nurse about treatment options for Hirschsprung's disease; the nurse understands that the treatment of choice would be which of the following? A. A colostomy B. Senna concentrate C. Polyethylene glycol D. Pull-through procedure

Choice D is correct. In Hirschsprung's disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus. Choice A is incorrect. A colostomy is done to relieve symptoms of colonic obstruction. It is a temporary treatment for the condition until the client is old enough to undergo a colectomy. Choice B is incorrect. Hirschsprung's disease does not respond to medication due to the missing nerves in the colon. Choice C is incorrect. Hirschsprung's disease does not respond to medication due to the missing nerves in the colon.

The nurse receives a prescription for sertraline. The nurse understands that this medication is used to treat which condition? A. Schizophrenia B. Bipolar disorder C. Bulimia D. Major depressive disorder

Choice D is correct. Sertraline is an antidepressant medication used to treat generalized anxiety disorder and major depressive disorder. This medication is a selective serotonin reuptake inhibitor (SSRI).

The nurse is assessing a client immediately following a thoracentesis. The nurse understands that the most common complication following this procedure is a A. Pleural effusion B. Pneumonia C. Pulmonary embolism D. Pneumothorax

Choice D is correct. The most common complication associated with thoracentesis is a pneumothorax. The nurse should assess the client for this adverse reaction which includes the client experiencing tachypnea, coughing, decreased or absent lung sounds on the affected side, and decreased blood oxygen levels. Choices A, B, and C. These complications are not directly linked with thoracentesis as pneumothorax is much more likely to occur.

The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take? A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg) B. Turn the client using a foam wedge every two hours C. Ensure that a client's heels are supported with a pillow D. Elevate the foot of the bed to provide counter traction

Choice D is correct. The nurse should slightly elevate the foot of the bed to provide counter traction and prevent the client from being pulled downward. Choice A is incorrect. Buck traction is skin traction, and to prevent injury to the skin, the applied weight should not be more than 5 to 10 lb (2.3 and 4.5 kg). Skeletal traction can handle more weight, usually about 15 to 30 lb (6.8 to 13.6 kg), than skin traction. Choice B is incorrect. The client should not be turned from side to side while in traction, as this could move and further injure the affected extremity. The client's extremity should remain in a neutral position. The client should be placed on a mattress with air loss to prevent pressure ulcers. Choice C is incorrect. The nurse should not support the client's heel with a pillow because the pillow can contribute to pressure ulcers. The nurse should ensure that the heel hangs freely off the pillow's edge.

The critical care nurse is caring for a client who is experiencing septic shock. The healthcare team has initiated vasopressor therapy to support the client's blood pressure. Which of the following nursing actions is a priority when administering vasopressors to this client? A. Monitor for signs of fluid overload and adjust the vasopressor infusion rate accordingly. B. Continuously assess the client's level of consciousness and neurological status. C. Administer vasopressors through a peripheral intravenous (IV) line to reduce the risk of complications. D. Monitor the client's cardiac rhythm and electrocardiogram (ECG) for any abnormalities.

Choice D is correct. When administering vasopressors to a client experiencing septic shock, monitoring the client's cardiac rhythm and ECG is a priority. Vasopressors have a direct effect on the cardiovascular system, and there is a potential risk of causing arrhythmias or other cardiac complications. Therefore, continuous cardiac monitoring is crucial to promptly detect any cardiac abnormalities or dysrhythmias, allowing for immediate intervention and ensuring the client's safety and hemodynamic stability during vasopressor therapy. Choice A is incorrect. While monitoring for signs of fluid overload is important in critically ill clients, especially those receiving vasopressors, it is not the highest priority of the given options when administering vasopressors to a client experiencing septic shock. Choice B is incorrect. In septic shock, the primary concern is hypotension and inadequate tissue perfusion due to vasodilation and reduced vascular tone. While neurological changes can occur due to impaired perfusion, the immediate focus is on stabilizing the client's blood pressure and hemodynamics through vasopressor therapy. Choice C is incorrect. Administering vasopressors through a peripheral IV line is generally not recommended. Vasopressors are potent medications that can cause vasoconstriction, leading to tissue necrosis if they extravasate into the surrounding tissues. The nurse should be familiar with the facility's policy regarding the administration of vasoactive drugs.

The nurse is discussing about the functions of the parathyroid hormone (PTH) with a student. Which of the following statements would be correct for the nurse to make? Select all that apply. The parathyroid hormone A. moves calcium from bones to the bloodstream. B. promotes renal tubular reabsorption of calcium. C. controls bodily functions such as metabolism and heart rate. D. promotes renal tubular reabsorption of phosphorus. E. causes the retention of sodium and the excretion of potassium.

Choices A and B are correct. All of these options are functions of the parathyroid hormone. Parathyroid hormone (PTH) is released by the parathyroid located at the bottom of the neck behind the thyroid. PTH causes osteoclastic activity, which causes calcium to be released from the bone to the bloodstream to raise serum calcium levels. PTH further promotes renal tubular reabsorption of calcium. Choice C is incorrect. PTH primarily regulates calcium and phosphorus levels in the body and does not control functions like metabolism and heart rate. Hormones like thyroid hormones regulate metabolism, and the heart rate is primarily controlled by hormones like adrenaline and the autonomic nervous system. Choice D is incorrect. While PTH promotes the reabsorption of calcium in the kidneys, it actually decreases the reabsorption of phosphorus. PTH acts on the kidneys to increase calcium reabsorption and decrease phosphorus reabsorption, helping to maintain the appropriate balance of these minerals in the bloodstream. Choice E is incorrect. PTH does not directly affect sodium or potassium retention. Hormones like aldosterone regulate sodium retention and potassium excretion in the kidneys.

The nurse is caring for a newborn immediately following birth with an omphalocele. The nurse should take which action? Select all that apply. A. Obtain a prescription for an antibiotic B. Obtain a prescription for intravenous fluids C. Gently press the omphalocele back into the abdomen D. Wrap the omphalocele with gauze to keep it dry E. Monitor the rectal temperature frequently for hypothermia

Choices A and B are correct. Infants with omphalocele are at increased risk for infection and fluid loss due to their intestines being exposed to the open air. It would be appropriate for the nurse to obtain a prescription for both an antibiotic and intravenous fluids to prevent infection and maintain fluid balance. Choices C, D, and E are incorrect. A nurse should not reduce an omphalocele because of the high risk of injury (choice C). Surgical intervention is often necessary. When handling an omphalocele, they should do so carefully to prevent trauma to the intestines. Immediate interventions for omphalocele include covering the sac with sterile gauze soaked in normal saline to prevent the drying of abdominal contents. The dressing should be kept moist, not dry (choice D). The infant is at higher risk for cold stress because of the omphalocele; however, rectal temperatures are contraindicated for infants younger than 1-month-old due to the risk of rectal perforation. The axillary temperature should be used to assess temperature (choice E).

The nurse is caring for a client diagnosed with a myxedema coma. The nurse should anticipate a prescription for which of the following medications? Select all that apply. A. Levothyroxine B. Methimazole C. Tolvaptan D. Hydrochlorothiazide E. Hydrocortisone

Choices A and E are correct. When a client experiences a myxedema coma, it is because of severe hypothyroidism. These dangerously low levels of thyroid hormone produce symptoms such as altered level of consciousness, hyponatremia, hypothermia, hypoventilation, and hypoglycemia. Treatment is essential and is geared towards the prompt administration of intravenous levothyroxine and liothyronine. Glucocorticoids are usually added to the treatment to help mitigate the hypotension and potential overlook of adrenal dysfunction. Choices B, C, and D are incorrect. Methimazole would be contraindicated in myxedema since this is a type of antithyroid medication. Furthermore, tolvaptan is not indicated because this medication is used to treat SIADH. HCTZ is a treatment for essential hypertension and nephrogenic diabetes inspidus. It has no role in a myxedema coma.

The nurse is reviewing nonreassuring fetal heart rate patterns with a group of students. It would indicate effective understanding if the student identifies which pattern as nonreassuring? Select all that apply. A. fetal bradycardia B. variable decelerations C. late decelerations D. early decelerations E. accelerations

Choices A, B, and C are correct. Fetal bradycardia, or a decrease in fetal heart rate below 110 bpm, is a non-reassuring sign on a fetal heart rate strip. When the nurse notes this sign, the nurse must intervene by repositioning the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Also, fetal bradycardia is often a result of uterine hyperstimulation. The nurse should discontinue the infusion if the client is on an oxytocin drip. Variable decelerations, or sharp and profound drops in the fetal heart rate unrelated to the time of contractions, are a non-reassuring sign on a fetal heart rate strip. Anytime the nurse notes this sign, intervention is necessary by lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Variable decelerations are often caused by cord compression, such as a prolapsed cord, and would be an emergency requiring quick nursing intervention. Late decelerations, or dips in the fetal heart rate after a contraction, are a non-reassuring sign on a fetal heart rate strip. Anytime the nurse notes late decelerations, the nurse should lay the client on her left side, increase IV fluids, administer oxygen via face mask, and notify the healthcare provider quickly. Late decelerations are due to uteroplacental insufficiency and require intervention by the nurse.

The nurse is caring for a client with bleeding related to hemophilia. Which of the following assessment findings would be expected? Select all that apply. A. Joint pain B. Splenomegaly C. Decreased range of motion in joints D. Hematuria E. Epistaxis

Choices A, C, D, and E are correct. Hemophilia is a genetic disorder that causes a factor VIII deficiency. Factor VIII is produced by the liver and is necessary for the formation of thromboplastin in phase I of blood coagulation. Bleeding is commonly found in the joints (termed hemarthrosis), which causes joint stiffness, aches, and a decreased range of motion. Hematuria is also a clinical feature that may be evident (either grossly or by microscopy that would be shown on a urine analysis). Epistaxis is a feature as well if trauma to the nose occurs.

The nurse and two unlicensed assistive personnel (UAP) are preparing to reposition a client who requires log rolling. Which actions would be appropriate? Select all that apply. A. Place a small pillow between the client's knees. B. Places the client's arms at their side. C. Fanfold a drawsheet along the backside of the client. D. Instruct the client to laterally flex the neck during the turn. E. Roll the client as one unit in a smooth, continuous motion.

Choices A, C, and E are correct. These actions are appropriate during the process of log rolling a client. It is appropriate for a client who is to be log rolled to have a pillow placed between the client's knees to prevent tension on the spinal column and adduction of the hip. Fanning out a draw sheet under the client enables staff to have strong handles to grip without slipping. The purpose of log rolling a client is to move the client in one smooth, continuous motion to prevent twisting of the spinal column.

The nurse is caring for a client with a major thermal burn. Which initial laboratory abnormalities does the nurse anticipate in response to the burn? Select all that apply. A. Hemodilution B. Hyperkalemia c. Metabolic Acidosis D. Hyperglycemia E. Hemoconcentration

Choices B, C, D, and E are correct. Following a major burn, significant fluid and electrolyte changes occur from cellular damage, which causes potassium to leak into the extracellular space. Thus, life-threatening hyperkalemia may occur. Metabolic acidosis is likely because of the impairment the burn causes to the kidney's ability to recycle bicarbonate. The discharge of catecholamines causes glucose release from the liver, raising the blood glucose. Finally, the loss of fluid causes hemoconcentration, illustrated by elevated hematocrit. Choice A is incorrect. Initially, the client with a major thermal burn will have hemoconcentration from all of the fluid loss. Hemodilution may occur later in the process from the fluid shift.

The nurse cares for a 48-hour-old newborn who has not yet passed stool since delivery. The nurse understands that the client is at highest risk for which conditions? Select all that apply. A. Celiac disease B. Cystic fibrosis C. Anorectal anomalies D. Hirschprung's disease E. Intussusception

Choices B, C, and D are correct. A normal infant passes meconium within 24 to 48 hours after birth. Failure to pass meconium within 48 hours of life should raise suspicion for meconium ileus (cystic fibrosis), Hirschprung's disease, anorectal malformations, and meconium plug syndrome. Cystic fibrosis is a generalized dysfunction of the exocrine glands leading to increased mucus secretions, particularly in the pancreas and lungs—about 10 to 20% of clients with cystic fibrosis present with meconium ileus. Meconium ileus refers to small bowel obstruction by thickened (inspissated) meconium. Meconium ileus is one of the earliest manifestations of cystic fibrosis, and its symptoms include failure to pass meconium and abdominal distension with or without vomiting. Meconium ileus can be complicated with intestinal perforation, small bowel volvulus, and peritonitis (choice B). Anorectal abnormalities (imperforate anus) can be detected by physical examination at birth. Here, the mechanical obstruction from the structural anomaly results in failure to passage meconium (choice C). Hirschsprung's disease is a congenital anomaly that results in functional obstruction from inadequate motility (peristalsis) due to the absence of ganglion cells in the distal colon and rectum (choice D).

The nurse is counseling a client with opioid use disorder. Which of the following medications may be used to treat this disorder? Select all that apply. A. Selegiline B. Naltrexone C. Methadone D. Buprenorphine E. Bupropion

Choices B, C, and D are correct. Naltrexone, Methadone, and Buprenorphine are three agents approved for the management of opioid use disorder. These medications have various mechanisms of action. Naltrexone is an opioid receptor antagonist and may be administered as a single dose injection. Buprenorphine is a partial agonist and is available in preparations such as sublingual tablets or film. Methadone is a full agonist that may be used daily. It is dispensed in a supervised setting.

The nurse is creating a teaching plan for a client diagnosed with pheochromocytoma. Which statement, if made by the client, would require follow-up? Select all that apply. A. "It will be very important to reduce the stress in my life." B. "This condition may cause my glucose to decrease." C. "I will need to monitor my blood pressure closely." D. "If I feel tired, it is okay for me to have an energy drink." E. "Diuretics will be prescribed to help eliminate the fluid I may retain."

Choices B, D, and E are correct. These statements are incorrect and require follow-up. Pheochromocytoma is a rare tumor that sits on top of the adrenal medulla. This causes an increase in the discharge of catecholamines, causing hypertension, headache, and hyperglycemia. This condition would not cause a decrease in glucose. The client should abstain from energy drinks and caffeine because they can elevate blood pressure further. Diuretics are not used to manage this condition because fluid retention is not a clinical finding associated with this disorder. Alpha-adrenergic blockers are the treatment of choice, followed by surgery.

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. A. Nose breathing B. Occasional sneezing C. Nasal flaring D. Head bobbing E. Grunting

Choices C, D, and E are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort to pull air in through their nose, and their nares flare out with inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Head bobbing is a severe sign of respiratory distress in newborns. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Finally, grunting is a sign of respiratory distress and may be coupled with the infant developing pallor that may transition to cyanosis.

The nurse is reviewing the diet of the client with hypoparathyroidism. The nurse understands that the client should be on what type of diet?

High-calcium, low-phosphorus diet A client with hypoparathyroidism is at risk of hypocalcemia and should therefore be on a diet high in calcium and low in phosphorus. The high calcium serves to increase the client's serum calcium levels. Since calcium and phosphorus have an inversely proportional relationship, the low phosphorus portion of this diet ensures that the client's phosphorus levels are reduced to the point of not interfering with the client's calcium levels.

___________ is a condition caused by a tumor that sits on the adrenal medulla. This causes a surge in catecholamine discharge resulting in headaches, palpitations, marked hypertension, and hyperglycemia. Treatment includes antihypertensives and removal of the tumor. The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure.

Pheochromocytoma

59-year-old male arrives at the emergency department (ED) with his wife after completing international travel to several countries. Three days ago, the client reported having profuse night sweats, a persistent productive cough with some blood, a fever, shortness of breath at rest, and a lack of energy. The client's symptoms have not improved with rest and fluids. The physical assessment was normal, except the client appeared lethargic with a persistent cough. The skin was hot to the touch with slight diaphoresis. Finally, the lung fields had diffuse rhonchi. The client has a medical history of hyperlipidemia, atrial fibrillation, and osteoarthritis in both knees. He takes atorvastatin, diltiazem, and a low-dose aspirin daily. Which three (3) findings in the history and physical requires follow-up? Fever Hemoptysis Osteoarthritis Daily aspirin use Night sweats Hyperlipidemia Irregular pulse

Physical symptoms that require follow-up include fever, night sweats, and hemoptysis. These are classic pulmonary tuberculosis symptoms and should be quite concerning with the fact that the client recently had international travel, which is a risk factor for pulmonary tuberculosis. The client having an irregular pulse is an expected finding with his medical history of atrial fibrillation. Atrial fibrillation is an irregular heart rhythm, and an irregular pulse is expected. His other medical history of aspirin use, osteoarthritis, and hyperlipidemia are irrelevant to his current symptom presentation.

The nurse is performing a teaching session with a group of clients in their first trimester of pregnancy. It would be appropriate for the nurse to state that the average weight gain during pregnancy for an individual with a normal body mass index (BMI) is

The average weight gain during pregnancy for an individual with a normal BMI is 25 to 35 pounds. The amount of optimal weight gain during pregnancy is determined based on the woman's body mass index (BMI) before pregnancy. -Gaining too little weight can lead to premature birth and low infant birth weight. -Gaining too much weight can also result in premature birth and obesity of the child in later life. -Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding.

_____________ is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes. This test can be performed at the bedside and typically involves using ultrasound to guide the needle. Nursing considerations for this procedure involve witnessing the informed consent, positioning the client over a bedside table, and supporting the client during the procedure. The provider will insert a needle (after the skin has been anesthetized) attached to a syringe and will slowly aspirate fluid. This fluid may be sent for laboratory analysis. A sterile pressure dressing will be applied, and a follow-up chest x-ray will be performed. The most common complication following this procedure is a pneumothorax.

Thoracentesis

MS may cause a client to experience a ___________ sensitivity to pain because of the insult to the nervous system.

decreased

Nonmaleficence is defined as "_______ ______ ______ to our clients.

doing no harm"

The classic triad of acute bacterial meningitis consists of________, ________ _______, and _______ _______ _______. At least one of these findings is almost always present in clients with this disease. A severe, generalized headache is also a common symptom. If you knew this, then you were able to complete the sentence

fever, nuchal rigidity, and altered mental status

Schizophrenia is treated with antipsychotics such as ________, aripiprazole, and ziprasidone.

haloperidol

Isoniazid and Rifampin are both _________toxic. The client must refrain from drinking alcohol during the treatment. Considering its _______toxicity, the client should notify their provider if they experience darkening of the urine, hands, feet, or eyes. A B-complex vitamin is prescribed during isoniazid therapy to prevent peripheral neuropathy. Rifampin may cause a client to experience orange-reddish staining of the skin and urine

hepato

The clonidine patch is an effective way to a set amount of antihypertensive over 24 hours. The patch should be applied to a clean and dry area with no hair. The patch should be changed every __________ days.

seven

The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of

veracity. You demonstrate adherence to the ethical principle of veracity when you are open, frank, and truthful with all clients, even when the information may be upsetting and distressing to the client

Overview of bucks traction

✓ Buck's traction is indicated for femur fractures. ✓ Buck's traction is skin traction (temporary traction) with a weight of 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin. ✓ The use of this traction has declined because clients are being taken to surgery sooner. ✓ The weights should hang freely and not touch the floor. ✓ The pillow should be under the calf, not the knee. The pillow should end above the ankle. ✓ Complications of Buck's traction include the risk of neurovascular damage and skin breakdown from the pressure exerted by the traction. Nursing care includes assessing the circulation, movement, and sensation of the affected extremity, assessing for skin breakdown, and monitoring for venous thromboembolism.

Overview of prinzmetals angina aka Variant angina

✓ Prinzmetal's angina occurs when there is a temporary spasm or constriction of one or more coronary arteries, leading to a sudden decrease in blood flow to the heart muscle. These spasms can occur even in the absence of significant coronary artery blockages. ✓ During an episode of Prinzmetal's angina, transient changes may be seen on an electrocardiogram (ECG). These changes can include ST-segment elevation, often resembling a heart attack, which usually resolves once the spasm is relieved. ✓ Other types of angina include Stable angina Unstable angina Microvascular Angina Silent Angina Postprandial Angina Nocturnal Angina