ATI Exam 1- Missed Questions

The nurse has a prescription to administer sulfasalazine (Azulfidine) 2g. The medication is available in 500mg tablets. How many tablets should the nurse administer? (Fill in the blank with the numeric value only) Answer: ____tablets

4 To administer 2 g, the nurse will need to administer 4 tablets. The formula used is to first convert grams to milligrams 1g/1000mg=2g/Xmg X = 2000 mg Then, 2,000 mg/X tablets = 500 mg/1 tablet X = 4 tablets Vital Concept: Sulfasalazine is used to treat mild-to-moderate ulcerative colitis; as an adjunctive treatment in severe ulcerative colitis; and rheumatoid arthritis unresponsive to salicylates and/or NSAIDs.

While checking vital signs, the nurse notes that the client's blood pressure is 168/90 mmHg. What is the client's pulse pressure? (Enter the whole number only, no trailing zeros, no unit of measure is needed.)

78 Correct Answer: 78 The pulse pressure is defined as the difference between the systolic and the diastolic measurements with a blood pressure. In this case, 168-90 = 78, so the client's pulse pressure is 78. Vital Concept: Pulse pressure refers to the difference between the systolic and diastolic blood pressure, measured in millimeters of mercury (mmHg). The pulse pressure represents the force that the heart generates each time it contracts.

A nurse at a long-term care facility is preparing to administer a medication to a client. Which of the following client identifiers should the nurse use to identify the client? A. The client's date of birth B. The client's room number C. The printed name on the medication administration record (MAR) D. Phone number of the client's room

A Correct Answer: A. The client's date of birth The nurse should use two identifiers before administering medications. Acceptable client identifiers include: • Name • Date of birth • Medical record number • Personal telephone number • Photo identification Incorrect Answers: B. This is not an acceptable identifier because clients can have a room change, and ambulatory clients can visit other rooms. C. This is not an acceptable identifier because the nurse could have inadvertently accessed another client's MAR. D. This is not an acceptable identifier because this is not a client-specific identifier. Vital Concept: Nurses are responsible for following the "rights" of medication administration. To ensure the medication is administered to the right client, the nurse should correctly identify the client using two different identifiers.

A mother calls the clinic after her 4-year-old choked on a peanut. The mother reports that she performed abdominal thrusts and the child is breathing normally now. The nurse should tell the mother to: A. Bring the child to the ER to check for airway obstruction B. Test the child's urine for blood from internal bleeding C. Call the healthcare provider if the child begins to sweat or feels dizzy D. Observe the child for difficulty breathing because the abdominal thrusts may have caused a pneumothorax

A Correct Answer: A. Bring the child to the ER to check for airway obstruction The nurse should instruct the mother to bring the child to the ER. If aspirated, nuts may swell, leading to an airway obstruction after the initial event; endoscopy may be needed to remove fragments. Incorrect Answers: B. The child's mother does not need to test the child's urine for internal bleeding; she should bring the child to the ER. C. The mother should first bring the child to the emergency room, rather than waiting for symptoms to develop. D. The mother should have the child checked in the ER rather than looking for symptoms of a pneumothorax. Vital Concept: Common causes of children choking include foods, particularly small hard foods; coins; and toys. Foods that present a choking hazard to small children include small hard foods, including peanuts or seeds; small round foods, including berries and raisins; thick pastes like peanut butter,; fibrous foods and stringy foods like celery; and foods with leaves and stems.

What is the most appropriate method to increase the number of prepared, qualified, experienced workers during a disaster? A. Contact retired health care workers B. Call nurses in surrounding states C. Get nursing students to help D. Select volunteers in the area

A Correct Answer: A. Contact retired health care workers Retired health care workers have extensive knowledge that can aid a facility's response to a disaster situation. Incorrect Answers: B. Nurses in surrounding states may not be licensed in the state where the need exists. C and D. Nursing students and volunteers are not the most knowledgeable of the choices listed. Vital Concept: Knowledgeable workers can assist when a disaster exceeds a facility's capacity. Trained and previously licensed health care workers are an excellent option for additional help.

The nurse is auditing the Kardex and medication charts of clients with substance withdrawal and abuse. Dosages and frequencies are correctly encoded. Which of the following medications is inappropriate for clients with substance abuse and withdrawal? A. Mechlorethamine (Mustargen) B. Acamprosate (Campral) C. Buprenorphine (Subutex) D. Lorazepam

A Correct Answer: A. Mechlorethamine (Mustargen) Substance abuse is a common problem not only in American society but across the world. The major mode of treatment for these clients involves behavioral and pharmacological therapy. It is believed that these two types of treatment are more effective when combined rather than when used singly. Behavioral therapy includes behavior modification and counseling. Pharmacological therapy involves medications that are specific to the need of the client. Mechlorethamine (Mustargen) is an alkylating agent for the treatment of malignancies such as leukemia and lymphosarcoma. The nurse auditing the medication chart needs to inform the doctor immediately about the error and inform other nurses and members of the team. Incorrect Answers: B. Acamprosate (Campral) is prescribed to decrease alcohol craving. C. Buprenorphine is prescribed to diminish craving for alcohol or opioids. D. Lorazepam is prescribed to reduce post-withdrawal seizures. Vital Concept: A client with substance abuse and withdrawal can be prescribed medications to aid in withdrawal either by reducing symptoms or by preventing withdrawal. Agonist and partial agonist medications prevent opioid withdrawal by activating the opioid receptors. Benzodiazepines are commonly prescribed in alcohol withdrawal to prevent seizures and delirium tremens. Buprenorphine is a partial opioid agonist and reduces cravings.

Select the atypical antidepressant that is correctly and accurately paired with its mechanism of action. A. Mirtazapine: It increases the release of serotonin and norepinephrine B. Trazodone: It inhibits norepinephrine and serotonin uptake. C. Venlafaxine: It selectively blocks serotonin receptors. D. Duloxetine: It directly increases levels of serotonin.

A Correct Answer: A. Mirtazapine: It increases the release of serotonin and norepinephrine Mirtazapine increases the levels of serotonin and norepinephrine. Trazodone moderately blocks serotonin receptors; Venlaxafine selectively blocks the reuptake of norepinephrine; duloxetine indirectly increases serotonin levels by inhibiting serotonin reuptake. Incorrect Answers: B. Trazodone moderately blocks serotonin receptors, it does not inhibit norepinephrine uptake. C. Venlafaxine selectively blocks the reuptake of norepinephrine, it does not block serotonin receptors. D. Duloxetine indirectly increases serotonin levels by inhibiting serotonin reuptake; it does not directly increase them. Vital Concept: Mirtazapine (Remeron) is a tetracyclic antidepressant. It works by increasing the release of norepinephrine and serotonin by central alpha2-adrenergic antagonist effects. Mirtazapine has a black box warning because of increased suicidality when used for the treatment of children, adolescents, and young adults.

A nurse in the emergency department is caring for a client with a score of 11 on the Glasgow Scale. What does this score indicate? A. The client has a moderate brain injury B. The client has a high level of consciousness C. The client is at risk for falls and injuries D. The client is at risk for skin breakdown

A Correct Answer: A. The client has a moderate brain injury The Glasgow Coma Scale is used to objectively assess the level of brain damage and the level of consciousness. A score of 11 indicates that the client has a moderate brain injury and moderately impaired level of consciousness. This scale assesses and then scores indicators such as eye-opening, verbal responses, motor responses, and movement. Scores of 8 or less indicate severe damage; scores more than 13 indicate mild damage. Other scales measure risk for falls and risk for skin breakdown. Incorrect Answers: B. This score indicates the client has a moderate brain injury and not a high level of consciousness. C. The Glasgow Coma Scale does not assess for falls in a client. D. The Glasgow Coma Scale does not assess risk for skin breakdown. Vital Concept: The Glasgow Coma Scale provides a standardized method to describe and monitor changes in a client's neurological status after a traumatic brain injury. The score, known as GCS, ranges from 3 to 15. The client's verbal, motor, and eye opening responses to stimuli are graded and added together to arrive at the client's GCS.

When assisting with a client transfer, a nurse should prioritize which of the following ergonomic principles? A. Utilizing non-manual methods B. Keeping the chin up and in line with the shoulders C. Keeping the knees bent close together near the client D. Using the back and shoulder muscles to assist with lifting clients

A Correct Answer: A. Utilizing non-manual methods Most nursing injuries related to occupational disorders are linked to client handling and moving activities. The American Nurses Association (ANA) advises using nonmanual methods for assisting clients whenever possible. Incorrect Answers: B. The nurse's chin should be tucked. C. The nurse's feet should be shoulder-width apart when lifting. D. The nurse's leg muscles should be used for lifting, not the back muscles. Vital Concept: Repeated lifting of clients can create a work-related injury for a nurse, making them unable to continue to work.

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following is necessary in order for fat-soluble vitamins to be utilized? A. Bile B. Hydrochloric acid C. Intrinsic factor D. Amylase

A Correct Answer: A. Bile Bile helps to stabilize fat soluble vitamins (A,D,E,& K) and facilitates their absorption from the GI tract. Incorrect Answers: B. HCl (hydrochloric acid) is stomach acid. C. Intrinsic factor is required for vitamin B12 absorption in the ileum. D. Amylase is the digestive enzyme for starch. Vital Concept: Vitamin K absorption requires functioning pancreatic and biliary systems. Dietary vitamin K is protein-bound. The proteins are cleaved from vitamin K by pancreatic enzymes in the small intestine. Bile salts solubilizes vitamin K for absorption by the cells lining the small intestine and enters the portal circulation for transport to the liver. Vitamin K is essential for coagulation factors II, VII, IX, and X.

Which of the following actions should the nurse take to reduce the risk of client harm when administering medications? (Select all that apply.) A. Listen to the client's concerns or questions about a dose or drug B. Call the pharmacist to learn more about unfamiliar drugs C. Double-check high-risk drugs after administration D. Only prepare one client's medications at a time E. Follow the three "rights" of medication administration

A Correct Answers: A. Listen to the client's concerns or questions about a dose or drug B. Call the pharmacist to learn more about unfamiliar drugs D. Only prepare one client's medications at a time The nurse should listen carefully to the client when administering medication, as the client's concerns may highlight a problem with the medication. If the client says something such as, "I've never seen this pill before," when giving a regular medicine, it may mean that the medication is not the right one. The nurse should never give a medication without understanding the purpose and correct dose of the medication. The nurse should look up information about any medications in question before administration. The pharmacy is a good resource for explaining the type and purpose of drugs, as well as their common routes and dosages. In order to avoid confusion with medications, the nurse should only prepare one client's medications at a time. Trying to multitask can cause harmful errors. Incorrect Answers: C. High-risk drugs should be double-checked before administration, not after. E. There are six rights of medication administration, not three. Vital Concept: A medication error is any preventable event that may cause or lead to inappropriate medication use or client harm, while the medication is in the control of the health care professional, client or consumer. Medication errors include administration of an incorrect dose; failure to administer an ordered dose; administration of the wrong drug; failure to review recent lab data; wrong route of administration; failure to clarify questions regarding correct drug, dosage, or routes; and failure to clarify a prescription when it is incomplete or illegible.

A charge nurse is conducting a staff in-service about medications used during the care of a client who is experiencing acute alcohol withdrawal. Which of the following medications should the charge nurse include in the discussion? (Select all that apply). A. Lorazepam B. Carbamazepine C. Diazepam D. Naloxone E. Acamprosate

A, B, C Correct Answers: A. Lorazepam B. Carbamazepine C. Diazepam Lorazepam is a benzodiazepine used during alcohol withdrawal to decrease anxiety and reduce the risk for seizures. Carbamazepine is an anticonvulsant used during alcohol withdrawal to prevent seizures. Diazepam is a benzodiazepine used during alcohol withdrawal to decrease anxiety and reduce the risk for seizures. Incorrect Answers: D. Naloxone is an opioid antagonist used to reverse over-sedation due to opioid overdose. E. Acamprosate is used to maintain abstinence from alcohol following detoxification. It is not given in the acute stage of withdrawal. Vital Concept: Benzodiazepines, including lorazepam and diazepam, are used to treat a client undergoing alcohol withdrawal. Benzodiazepines have the following effects: • Decrease withdrawal symptoms • Stabilize vital signs • Prevent seizures • Prevent delirium tremens Other medications used in withdrawal include beta-adrenergic blockers, central alpha2-adrenergic agonists, and antiepileptics. During alcohol withdrawal therapy, the nurse should assess the client for reduction of symptoms, including tremors, agitation, delirium, and hallucinations.

A nurse is reviewing the medical history of a client who has Cushing's disease. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following conditions? (Select all that apply.) A. Infection B. Gastric ulcer C. Nephrolithiasis D. Bone fractures E. Dysphagia

A, B, D Correct Answers: A. Infection B. Gastric ulcer D. Bone fractures Suppression of the immune system places a client who has Cushing's disease at risk for infection. The overproduction of cortisol inhibits the production of a protective mucus lining in the stomach and causes an increase in the amount of gastric acid. These factors place clients who have Cushing's disease at increased risk for gastric ulcers. Clients who have Cushing's disease are at risk for bone fractures because decreased calcium absorption leads to osteoporosis. Incorrect Answers: C. Clients who have Cushing's disease are not at risk for nephrolithiasis or renal calculi, but they are at risk for neurological and cardiovascular problems. E. Clients who have Cushing's disease are not at risk for dysphagia, but they are at risk for other gastrointestinal problems, including anorexia, nausea, vomiting, and abdominal pain. Vital Concept: Cushing's disease is an endocrine disorder caused by an increased secretion of cortisol from the adrenal gland. Excess cortisol can lead to fluid and electrolyte imbalances, decreased muscle mass, osteoporosis, hyperglycemia, suppressed immune system, and depression. The nurse should monitor for these manifestations when caring for clients who have Cushing's disease to prevent further complications.

A nurse in a provider's office is planning teaching for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following information should the nurse include in the teaching plan? (Select all that apply.) A. The medication can increase the risk for infection. B. Monitoring of triiodothyronine (T3) levels will be required. C. Increase consumption of shellfish. D. Take the medication at the same time every day. E. An adverse effect of this medication is iodine toxicity.

A, B, D Correct Answers: A. The medication can increase the risk for infection. B. Monitoring of triiodothyronine (T3) levels will be required. D. Take the medication at the same time every day. Methimazole can cause agranulocytosis. The nurse should instruct the client to notify the provider if a sore throat or fever occurs because this can indicate signs of infection. Methimazole reduces thyroid hormone production. The nurse should monitor the client's T3 levels while the client is taking this medication. Methimazole should be taken at the same time every day to maintain therapeutic blood levels. Incorrect Answers: C. Methimazole reduces thyroid hormone production by blocking iodine. The nurse should instruct the client to limit consumption of iodine-containing foods, such as shellfish. E. Iodine toxicity is an adverse effect of the strong iodine solution that is given to suppress thyroid hormone production prior to surgical thyroid removal. Vital Concept: Hyperthyroidism is an endocrine disorder in which the thyroid gland produces an excess of thyroid hormone resulting in an increase in metabolism in all body organs. The most common form of hyperthyroidism is Graves' disease. Nonsurgical management for Graves' disease includes drug therapy with antithyroid drugs known as thionamides. The most frequently prescribed thionamide is methimazole. Propylthiouracil, another thionamide, is prescribed less often because it can lead to liver toxicity. These medications block the production of thyroid hormone by inhibiting the reactions of iodine in the thyroid gland. The nurse should inform clients who are taking a thionamide of the following: Thionamides can cause agranulocytosis. The client should avoid crowds and people who are ill and notify the provider if a sore throat or fever occur. Monitoring of triiodothyronine (T3) will be required during treatment. Limit iodine containing foods, such as shellfish. Thionamides should be taken at the same time every day to maintain therapeutic blood levels. Report weight gain, slow heart rate, and cold intolerance. These manifestations may indicate the onset of hypothyroidism.

A nurse is teaching a client who has rapid cycling bipolar disorder and a new prescription for carbamazepine. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Blood tests will be done weekly during the first several months of treatment." B. "You should not drink alcohol while taking this medication." C. "You will be more alert while taking this medication." D. "Refrain from taking Monoamine oxidase inhibitor medications for several days after starting this treatment." E. "Do not abruptly discontinue this medication."

A, B, E Correct Answers: A. "Blood tests will be done weekly during the first several months of treatment." B. "You should not drink alcohol while taking this medication." E. "Do not abruptly discontinue this medication." Carbamazepine causes an elevation in liver enzymes, which can cause carbamazepine or other medications to be metabolized at a faster rate. The client should avoid alcohol or taking other sedatives while taking carbamazepine. Carbamazepine can cause dizziness and sedation. The client should follow a tapering schedule as directed by the provider when discontinuing carbamazepine. Incorrect Answers: C. Drowsiness is an adverse effect of carbamazepine. The client should avoid activities that require alertness, such as driving until the client has determined how the medication affects the ability for alertness. D. The client should not take Monoamine oxidase inhibitor (MAOI) medications with or within 14 days of taking carbamazepine. Vital Concept: Carbamazepine is considered to be more effective than lithium for clients who have rapid cycling bipolar disorder. However, there are significant side effects of the medication. A client who is going to take carbamazepine must be given very specific oral and written instructions before starting the medication.

A nurse is leading an in-service about caring for clients who are receiving peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include when providing information about care for clients receiving PPN? (Select all that apply.) A. Examine trends in weight loss. B. Review prealbumin finding. C. Administer an IV solution of 20% dextrose in 0.9% sodium chloride. D. Do not refrigerate the PPN solution after it is prepared. E. Use an IV infusion pump.

A, B, E Correct Answers: A. Examine trends in weight loss. B. Review prealbumin finding. E. Use an IV infusion pump. Examining trends in weight loss will help to evaluate the outcome of PPN. Reviewing the prealbumin finding will determine if the client has a nutritional deficiency. An IV infusion pump is used to regulate the flow and provide accurate delivery of the PPN solution. Incorrect Answer: C. An IV solution of 20% dextrose is administered only as total parenteral nutrition (TPN) using a central vein. D. Once prepared, PPN solutions should be used immediately or refrigerated. The solutions should be removed from the refrigerator 1 hr before infusing so that they can reach room temperature. Vital Concept: PPN is administered to clients for whom enteral nutrition is not possible. It can be infused over 24 hr or in a cyclic pattern over 8 to 16 hr during the night to allow the client more freedom during the daytime period.

A client with ulcerative colitis is scheduled for treatment with sulfasalazine (Azulfidine). Which of the following are correct about this drug? (Select all that apply) A. Can cause folate deficiency B. Can cause hyperchloremia C. Can cause megaloblastic anemia D. Can cause anaphylactic reaction E. Can cause blindness F. Can cause thrombocytosis

A, C, D Correct Answers: A. Can cause folate deficiency C. Can cause megaloblastic anemia D. Can cause anaphylactic reaction Ulcerative colitis is a condition characterized by chronic inflammation of the intestines. It commonly affects the rectum and sigmoid colon. Ulcerative colitis is caused by an autoimmune disorder of the lower GI (gastrointestinal) tract. It is best diagnosed by endoscopy in which the affected part of the colon is visualized and examined. Diarrhea with blood and mucus is the usual symptom associated with UC. Ulcerative colitis is commonly treated with anti-inflammatory drugs such as sulfasalazine (Azulfidine), which inhibits production of prostaglandin that causes inflammatory responses. Azulfidine can have adverse effects such as folate deficiency, megaloblastic anemia, anaphylactic reaction, thrombocytopenia, and kidney damage. These adverse effects are primarily due to the chemical component of the drug that either inhibits metabolic processes or exerts toxic effects. Azulfidine is not reported to cause blindness or hyperchloremia. Vital Concept: Sulfasalazine is a locally acting anti-inflammatory medication that works in the colon, where activity is probably a result of inhibition of prostaglandin synthesis. Adverse effects include headache, pneumonitis, anorexia, diarrhea, nausea, vomiting, drug-induced hepatitis, crystalluria, infertility, oligospermia, orange-yellow discoloration of urine and exfoliative dermatitis, including Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Hematologic side effects can include agranulocytosis, aplastic anemia, and megaloblastic anemia.

A nurse is developing a plan of care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply.) A. Monitor the client for cardiac dysrhythmias. B. Observe the client for evidence of urinary tract infection. C. Initiate Intravenous (IV) fluids using 0.9% sodium chloride for the client. D. Administer a levothyroxine IV bolus to the client. E. Provide the client with cooling blankets to prevent hyperthermia.

A,B,C,D Correct Answers: A. Monitor the client for cardiac dysrhythmias. B. Observe the client for evidence of urinary tract infection. C. Initiate Intravenous (IV) fluids using 0.9% sodium chloride for the client. D. Administer a levothyroxine IV bolus to the client. A client who has myxedema can have a flat or inverted T wave as well as ST deviations. An infection, such as a urinary tract infection, can precipitate myxedema coma. The nurse should observe the client for manifestations of infection so that the underlying illness can be treated. Hyponatremia is an expected finding in the presence of myxedema coma. The nurse should administer IV therapy using 0.9% sodium chloride. Myxedema coma is a severe complication of hypothyroidism that, if left untreated, can lead to coma or death. The nurse should administer a levothyroxine IV bolus to treat the condition. Incorrect Answers: E. Clients who have hypothyroidism or myxedema coma are at increased risk for hypothermia. The nurse should provide extra clothing and blankets to a client who has myxedema coma to prevent hypothermia. Vital Concept: Myxedema coma is a severe complication of hypothyroidism that, if left untreated, can lead to coma or death. Myxedema can be precipitated by acute infections, surgical procedures, chemotherapy, and by some opioid narcotic medications. Manifestations of myxedema coma include hyponatremia, hypoglycemia, hypoventilation, hypotension, bradycardia, hypothermia, and changes in mental status and cardiac rhythm.

A nurse is providing teaching to a group of middle aged adult clients about preventing obesity. Which of the following statements should the nurse make? A. "To prevent weight gain, you should exercise for 15 minutes 3 to 4 days each week." B. "Keep a food diary of specific factors that trigger your desire to eat." C. "Using distractions to reduce the pleasure associated with eating prevents weight gain." D. "Consuming the majority of your daily calories in the evening increases metabolism."

B Correct Answer: B. "Keep a food diary of specific factors that trigger your desire to eat." The nurse should recommend that the clients keep a record of cues or factors that trigger the desire to eat. By assisting the clients to identify specific triggers that lead to eating, the nurse can promote behavior modification that leads to greater client control over these triggers. Incorrect Answers: A. The nurse should inform the clients that current physical activity guidelines recommend 30 min of moderate to vigorous exercise 5 to 7 days each week. Fifteen minutes of exercise 3 to 4 days each week is not enough to prevent weight gain. C. The nurse should recommend that the clients demonstrate awareness during meals to be more conscious of the eating experience. Distractions, such as eating meals while reading or watching television can contribute to overeating, rather than preventing weight gain. D. The nurse should recommend that the clients spread meals throughout the day and reduce calorie intake in the evening when activity is reduced. Consuming the majority of daily calories later in the day can contribute to overeating, which causes weight gain. Vital Concept: Teaching about obesity can be tricky with overweight clients. It is best to assess the readiness for information and then individualize the information taking into account the lifestyle and food preferences of the client. Food diaries can provide individuals with concrete information about food intake and the time of day or events surrounding when food desires are at their peak.

A nurse manager is teaching a group of nurses about the civil judicial process. The nurse manager should include that witness depositions take place during which of the following steps? A. Complaint step B. Discovery step C. Decision step D. Trial step

B Correct Answer: B. Discovery step The nurse manager should include in the teaching that the witnesses' depositions occur during the discovery step. The discovery step is when attorneys for the plaintiff and the defendant obtain relevant information about the case. Incorrect Answers: A. During the complaint step, the plaintiff files a document alleging either the defendant failed to provide the expected level of safe care or that the client's rights were infringed on by the defendant. C. During the decision step, the judge provides a decision, or the jury issues a verdict. D. During the trial step, both sides of the dispute are presented to the judge or jury. Vital Concept: In a court of law, there are major steps followed to settle a dispute using the civil judicial process: The first step includes the filing of a petition that outlines what the defendant failed to do or did to injure the plaintiff. When a client files a lawsuit against a nurse, the client is the plaintiff and the nurse is the defendant. The second step includes the defendant writing a response in answer to the complaint, either admitting or denying the allegations in the petition. The plaintiff must then respond with supporting information for anything the defendant did not admit to. The third step is the discovery phase, during which all the facts are gathered to support the plaintiff and defendant. These facts are obtained through the client's medical records, depositions, and interrogatories. Interrogatories are written questions asked and responded to under oath. Depositions are the questions asked to the opposing parties, other witnesses, and experts under oath to extract relevant and non-privileged information about the lawsuit. The fourth step is the trial phase, which can last 1 to 3 years after the petition is filed. If the lawsuit is not settled out of court, a trial is scheduled and the relevant facts are presented to a judge or jury. The final step is the decision phase when a judge provides a decision or a jury provides a verdict. If one party is not satisfied with the outcome, that party can file an appeal for another trial.

A nurse is planning to administer IV alteplase (Activase) to a client who is demonstrating manifestations of an acute pulmonary embolism. Which of the following actions should the nurse plan to take? A. Administer enoxaparin along with the alteplase dose. B. Hold direct pressure on puncture sites for up to 30 min. C. Administer aminocaproic acid IV prior to the alteplase infusion. D. Administer the alteplase over 2 hrs.

B Correct Answer: B. Hold direct pressure on puncture sites for up to 30 min. The nurse should plan to hold direct pressure on puncture sites for 30 min or until the oozing of blood stops. Incorrect Answers: A) Enoxaparin can increase the risk of intracranial bleeding when administered with anticoagulant therapy and is only available in a subcutaneous form. When a client receives alteplase, subcutaneous and IM injections, as well as other administration methods that cause punctures, should be avoided due to an increased risk for bleeding. C) Aminocaproic acid is an antifibrinolytic agent, which is the antidote for alteplase. Aminocaproic acid should only be administered in the event of serious bleeding that does not stop after blood products are administered or other remedies are tried. It should not be administered prior to alteplase administration. D) The nurse should administer the recommended dosage for alteplase, which is 100 mg infused over 1 hr. Vital Concept: Alteplase, a thrombolytic agent, is indicated for the treatment of acute pulmonary emboli, acute ischemic stroke, acute myocardial infarction, and occluded venous access devices. Please review the charts below that detail adverse effects of alteplase to various body systems, as well as nursing implications Adverse Effects: Body System Adverse Effects Hematological Risk of bleeding or hemorrhage Central Nervous System Intracranial hemorrhage Gastrointestinal (GI) GI bleeding Genitourinary (GU) GU bleeding Local Hemorrhage at injection sites Allergic reactions Fever and anaphylaxis Nursing implications: Nursing Assessments Nursing Considerations Assess for contraindications Active internal bleeding Recent trauma Severe uncontrolled hypertension Known bleeding tendencies Observe for manifestations of bleeding Monitor the client every 15 minutes during the first hour of therapy and 15 to 30 minutes for the duration of therapy Assess neurological status Changes can indicate intracranial bleeding Monitor pulse, BP, and respiratory status Changes can indicate signs of bleeding

A nurse is completing an admission assessment on a client who is scheduled to undergo a right knee arthroplasty. Which of the following findings should the nurse expect? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Spongy feeling of bone upon palpation E. Limited joint motion

B, C, E Correct Answers: B. Pain when bearing weight C. Joint crepitus E. Limited joint motion Pain when bearing weight is an expected finding, due to degeneration of the joint. Joint crepitus is an expected finding due to degeneration of the joint tissue. Limited joint motion is an expected finding due to degeneration of the joint tissue and. Incorrect Answers: A. Reddened skin over the joint can indicate infection and is not an expected finding. D. Upon palpation, the joint can feel hard due to bone hypertrophy. Vital Concept: Knee arthroplasty is a therapeutic procedure used to treat osteoarthritis. Clients who have osteoarthritis most commonly seek help because of the chronic pain that occurs in the larger, weight-bearing joints, such as the knee or hip. The pain increases during weight-bearing and improves or resolves with rest. Additional findings include stiffness and crepitus. Unlike rheumatoid arthritis, osteoarthritis is more likely to occur on one side of the body, although some clients have nodules on the fingers of both hands, known as Heberden's and Bouchard's nodes.

A nurse is caring for a client with metabolic syndrome at risk for cardiovascular disease. Which of the following characterizes metabolic syndrome? (Select all that apply) A. Fat redistribution over the shoulders B. Hypertriglyceridemia C. Hypotension D. Elevated fasting blood glucose E. High HDL

B, D Correct Answers: B. Hypertriglyceridemia D. Elevated fasting blood glucose Metabolic syndrome is characterized by a group of conditions that cause arteriosclerosis and increase the risk for development of diabetes, which is an independent risk factor for cardiovascular disease (CVD).. These factors are modifiable and risk can be reduced through health education and compliance with instructions. Three of the following five factors must be present for the diagnosis of metabolic syndrome: abdominal obesity, low HDL or use of LDL lowering medications; high triglycerides or use of triglyceride lowering medications: hypertension or use of antihypertensives; and elevated fasting blood glucose or use of medications to lower blood glucose. Engaging in weight reduction and an exercise program is usually encouraged for such clients. Routine and regular checkups are then scheduled for the client to monitor his health status. Vital Concept: Metabolic syndrome can be managed primarily through lifestyle changes. A nurse can help clients make recommended lifestyle changes by providing education about risk factors and how to alter them. Dietary modifications that may help prevent or control diabetes also can lower the risk of cardiovascular disease (CVD). If the client is overweight, weight loss of 7-10% is recommended. The nurse should advise clients to avoid smoking and excessive alcohol intake and to increase physical activity to reduce weight and improve blood pressure.

A nurse is caring for a client who has rheumatoid arthritis. The nurse should identify that which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) A. Urinalysis B. Erythrocyte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. C-reactive protein

B, D, E Correct Answers: B. Erythrocyte sedimentation rate (ESR) D. Antinuclear antibody (ANA) titer E. C-reactive protein An ESR is a laboratory test that diagnoses rheumatoid arthritis. This laboratory test will show an elevated result in clients who have rheumatoid arthritis. An ANA titer is a laboratory test that diagnoses rheumatoid arthritis. This laboratory test will show a positive result in clients who have rheumatoid arthritis. C-reactive protein is a laboratory test that diagnoses rheumatoid arthritis. This laboratory test will show a positive result in clients who have the disease. Diagnostic Test--Expected Result for Clients Who Have RA Rheumatoid factor (RF) Positive C-reactive protein (CRP) Positive Erythrocyte sedimentation rate (ESR) Elevated Antinuclear antibody (ANA) Positive/Elevated Hgb/Hct Decreased Incorrect Answers: A. A urinalysis assists to diagnose kidney failure, not rheumatoid arthritis. C. A BUN assists to diagnose kidney failure, not rheumatoid arthritis. Vital Concept: Rheumatoid arthritis (RA) is a chronic and progressive systemic inflammatory autoimmune disease of the synovial joints. The nurse should review client data for results of diagnostic testing for RA.

A nurse is assessing a client who received an increased dose of fluvoxamine 4 hr ago. Which of the following findings should the nurse report to the provider as indications of serotonin syndrome? (Select all that apply.) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Tachycardia E. Agitation

B, D, E Correct Answers: B. Hallucinations D. Tachycardia E. Agitation Serotonin syndrome is thought to be caused by a medication dosage that is too high or as interaction with other medications that results in overactivation of central serotonin receptors. The increased uptake of serotonin by the receptors can cause mental status changes, such as delirium, irrational thinking, and hallucinations. Cardiovascular manifestations of serotonin syndrome include tachycardia, labile blood pressure, and cardiovascular shock. Respiratory manifestations, such as apnea, can also occur. The risk for the development of serotonin syndrome is increased if the client is taking a second agent that increases serotonin, such as a monoamine oxidase inhibitor. The increased levels of serotonin can result in neurologic manifestations, such as agitation, hostility, and mood swings. Incorrect Answers: A. Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI), which is used in the treatment of obsessive-compulsive disorder. A potentially life-threatening adverse effect of SSRIs is the development of serotonin syndrome. This syndrome causes a number of manifestations that affect the autonomic stability, which results in tachycardia, labile blood pressure, and fever. C. Musculoskeletal effects are also seen with serotonin syndrome. Manifestations such as hyperreflexia, myoclonus, and incoordination are seen. These manifestations should be an indication to the nurse that the client might have developed serotonin syndrome. Vital Concept: Serotonin syndrome can develop quickly, sometimes in as little time as several hours following the administration of an SSRI or an increase in dosage. For SSRIs that have a longer half-life, serotonin syndrome can also develop after the client has stopped taking the medication. Though rare, development of serotonin syndrome is more likely if a client is taking two medications that potentiate serotonergic transmission. The nurse should instruct the client to report all prescription and over-the-counter medications, vitamins, or herbal products being taken to avoid the development of interactions and complications, such as serotonin syndrome. It is also important for the nurse to let the client know any symptoms for which she should contact the health care provider.

A nurse is providing a teaching session to newly licensed nurses about the dietary needs of a client who is recovering from pancreatitis. Which of the following foods should the nurse include in the teaching as being low in fat? (Select all that apply.) A. Ribeye steak B. Oatmeal C. Ice cream D. Fresh peaches E. Pretzels

B, D, E Correct Answers: B. Oatmeal D. Fresh peaches E. Pretzels Oatmeal is a source of easily digested carbohydrates and is low in fat. Fresh peaches are a source of easily digested carbohydrates and are low in fat. Pretzels are a source of easily digested carbohydrates and are low in fat. Incorrect Answers: A. Ribeye steak is considered a beef that is graded prime, which means it is the most heavily marbled cut of beef and has the highest fat content. C. Ice cream is not a low‑fat food source. Vital Concept: One of the most important goals of the treatment of pancreatitis is to meet the client's daily nutritional needs while decreasing pancreatic secretions. Restricting fat intake to no more than 50 g/day can help prevent some of the manifestations of pancreatitis.

A nurse is caring for a client who is postoperative and has a prescription for a clear liquid diet. Which of the following foods should the nurse offer to the client? (Select all that apply.) A. Applesauce B. Chicken broth C. Sherbet D. Pudding E. Cranberry juice

B, E Correct Answers: B. Chicken broth E. Cranberry juice The nurse should offer the client chicken broth, which is a clear liquid. The nurse should offer the client cranberry juice, which is a clear liquid. Incorrect Answers: A. The nurse should not offer applesauce to the client as it is not a clear liquid. C. The nurse should not offer sherbet to the client as it is not a clear liquid. D. The nurse should not offer pudding to the client as it is not a clear liquid. Vital Concept: Clear liquids are fluids that are transparent and liquid at room temperature. Because they are considered to leave a low residue and require a minimal amount of digestion, they are often used as the first nourishment for a client following surgery or a period of being NPO. They are typically not used for a long period of time because they do not provide adequate nutrients and calories. Clear liquids can include commercially prepared supplements.

A nurse is caring for a client who is at 32 weeks' gestation on her first prenatal visit. The client reports varicella zoster infection during the sixteenth week of pregnancy. Which of the following is the fetus at risk for? (Select all that apply.) A. Disseminated varicella infection B. Limb hypoplasia C. Aortic root abnormalities D. Jaundice E. Congenital cataracts

B, E Correct Answers: B. Limb hypoplasia E. Congenital cataracts Varicella zoster virus causes chickenpox and herpes zoster (shingles). In pregnant women, antibodies produced as a result of immunization or previous infection are transferred to the fetus via the placenta. If the mother does not have immunity, exposure may result in an infection that is transmitted to the fetus. If intrauterine exposure occurs during the first 28 weeks of gestation, the fetus is at risk of congenital varicella syndrome. Multiple abnormalities associated with congenital varicella syndrome include central nervous system abnormalities, limb hypoplasia, chorioretinitis, congenital cataracts, and delays in cognitive and motor development. Incorrect Answers: A. Disseminated varicella infection is associated with neonatal varicella. The neonate should receive prophylactic varicella immunoglobulin at birth if the mother has been exposed to varicella during the period from 5 days before birth to two days after delivery. Symptoms range from mild rash to disseminated infection. There is a high risk of serious complications, including pneumonia. C. Aortic root abnormalities are associated with Marfan syndrome. D. Jaundice and hepatomegaly may occur in a neonate who has been exposed to cytomegalovirus in utero. Vital Concept: Intrauterine exposure to varicella zoster virus during the first trimester is associated with congenital varicella syndrome. Features associated with this syndrome include microcephaly, limb dysplasia, chorioretinitis, cataracts, auditory nerve palsy, cutaneous scarring, and delays in motor and cognitive development. Neonatal varicella is associated with maternal varicella infection during the perinatal period 5 days before delivery to 2 days after birth. Infants at risk of neonatal varicella should receive IVIG or varicella zoster immune globulin at birth.

During a routine prenatal exam, a nurse is talking with the husband of a client at 35 weeks' gestation about the upcoming delivery of their first child. The husband states, "I don't know what is going on with my wife. She used to be so outgoing and caring, but she has become so withdrawn and self-involved in the last few weeks." Which of the following responses from the nurse is the most appropriate in this situation? A. "Your wife is probably feeling stressed that her life is changing very soon. I'm sure things will work out fine." B. "She is probably experiencing a form of prenatal depression. It is similar to postpartum depression but it occurs before the baby is born." C. "It is normal for some pregnant women to become more introverted in the last weeks before delivery. She needs support for coping with changes that will be coming." D. "It sounds as if your wife is having a hard time adjusting to the idea of motherhood. I will notify the health care provider, but she may need antidepressants."

C Correct Answer: C "It is normal for some pregnant women to become more introverted in the last weeks before delivery. She needs support for coping with changes that will be coming." Many pregnant women experience introversion during the first and third trimesters of pregnancy, which is a normal phenomenon that will pass. Particularly during the last few weeks before delivery, a pregnant woman is more likely to spend time alone and become focused on herself and her baby. Although this usually passes after the baby is born, many couples need reassurance and ideas for coping with the changes that come with becoming parents. Incorrect Answers: A. The nurse does not necessarily know that the mother is under intense stress. Telling the client's husband that everything will be all right only offers false reassurance and does not help the situation. B. While some women do get depressed during pregnancy, the nurse should not suggest this diagnosis before the client is diagnosed by the healthcare provider. D. The client's wife may be having a hard time adjusting to the idea of motherhood, but the nurse should not suggest that she might need antidepressants until the client has been assessed by the healthcare provider. Vital Concept: Pregnancy is a life-changing event full of physical and emotional changes. Understanding these changes will help the client have a positive experience. Mood swings during pregnancy are common. Although the pregnant woman may be excited about being pregnant, she may also feel stressed or overwhelmed. Some pregnant women have constant worries that contribute to mood swings. The nurse can assist by providing a safe space in which the client can express feelings and concerns. The nurse can suggest alternative coping strategies to assist in the transition.

A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled for surgical correction of severe scoliosis. Which of the following statements should the nurse make? A. "You will go home the same day of the surgery." B. "You will have minimal pain." C. "You may need to receive blood." D. "You will be on bedrest for the first week following surgery."

C Correct Answer: C. "You may need to receive blood." Clients who undergo surgical correction for severe scoliosis typically experience significant blood loss and can require blood replacements. Options for blood replacement include the use of a blood salvage unit during surgery, the administration of autologous blood or donor blood, and the administration of erythropoietin to stimulate new blood formation. The client's provider should discuss each of these options with the client and the client's parents or guardians. Incorrect Answers: A. Surgical correction of severe scoliosis can include realignment and fusion of the spine, along with the placement of internal fixation devices. The projected length of hospitalization is 5 to 7 days. B. Clients who have spinal instrumentation for scoliosis experience intense pain that requires a patient-controlled analgesia (PCA) pump. The nurse should provide instruction about the use of the PCA pump, which can include the use of the pump prior to exercise or ambulation and not allowing family or friends to push the PCA button. D. Clients who are postoperative following surgical repair of scoliosis are assisted with ambulation 2 to 3 days following surgery with discharge within the week. Vital Concept: Scoliosis is a spinal deformity that often involves lateral curvature and rotation of the spine. This results in asymmetry of the shoulders, ribs, and hips. The preferred treatment for moderate scoliosis with spinal curvature between 25° and 45° is bracing, which slows the progression of further curvature. For severe scoliosis with spinal curvature greater than 45°, surgery might be required. Preoperative teaching for an adolescent who is scheduled to undergo corrective surgery for scoliosis should include: Information on postoperative pain control, ambulation, and exercise Logrolling while in bed to change positions Function of the IV pump, indwelling urinary catheter, and other drainage devices that might be placed Coughing and deep breathing

Which needle gauge is most appropriate for an intramuscular injection in a 28-year-old female client? A. 30-gauge B. 27-gauge C. 25-gauge D. 14-gauge

C Correct Answer: C. 25-gauge When giving an intramuscular injection to an adult client, the nurse should use a needle that is between 22 and 25 gauge. Incorrect Answers: A. A 30-gauge needle is not large enough for an intramuscular injection. B. A 27-gauge needle would typically be used for an intramuscular injection in an infant. D. This is not a valid size needle for IM injection. Vital Concept: A needle used for an IM injection should be long enough to go through the skin and tissue to reach deep in the muscle. Needles have two measurements: a needle diameter ( gauge) and a needle length (inches or mm). The bigger the gauge, the smaller the needle diameter and the smaller the gauge, the bigger the needle diameter. The needle gauges appropriate for an IM injection range from 22 to 25 gauge. Needle length depends upon the age and size of the client and the size of the muscle selected for injection.

A client who is exhibiting manic behavior is admitted to the hospital. Considering the client's elated mood and psychomotor agitation, the charge nurse should assign the client to which of the following rooms? A. With another client who is very quiet and depressed B. Next to the day room which is very busy and provides a great deal of stimuli C. A room with minimal furnishings away from the nurse's station. D. With another client who exhibits similar behavior

C Correct Answer: C. A room with minimal furnishings away from the nurse's station. The nurse needs to decrease external stimuli as much as possible. Incorrect Answers: A. This arrangement would not be beneficial to the depressed client who may become the target of the manic client's over-activity. B. During this phase, the client needs a decrease in external stimuli. D. Two over-active clients would produce more stimuli. Vital Concept: Mania is a mood disorder that occurs periodically in bipolar disorder type 1. It is marked by a hyperactive, wildly elated and optimistic state; decreased need for sleep; the flight of ideas; distractibility; hypersexual behavior; limit testing; grandiosity; and psychomotor restlessness. Client safety is a priority during the acute manic phase. The client's environment should be calm and quiet to avoid further stimulation.

A nurse is caring for a client who asks for medication to relieve pain. Which of the following actions should the nurse take first? A. Reposition the client. B. Administer the medication. C. Determine the location of the pain. D. Offer the client a massage.

C Correct Answer: C. Determine the location of the pain. The first action the nurse should take when using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and offering the client nonpharmacological approaches to pain management. Incorrect Answers: A. The nurse should reposition the client to help reduce the pain. However, there is another action the nurse should take first. B. The nurse should administer an analgesic to help reduce the client's pain. However, there is another action the nurse should take first. D. The nurse should offer the client a therapeutic massage to promote comfort and relaxation and possibly reduce pain by improving circulation to the painful area. However, there is another action the nurse should take first. Vital Concept: In addition to determining location, the nurse should assess a client who has pain to determine the severity of the pain using a pain scale, the pain's duration, the pain's quality, and any precipitating or alleviating factors. It is also essential to determine whether the client has any other manifestations accompanying the pain, such as dizziness, nausea, or vomiting.

A neonate develops hyperbilirubinemia and phototherapy is initiated. What should the plan of care include for an infant receiving phototherapy? A. Taking vital signs every hour B. Keeping the eye shields on for 8 hours at a time C. Giving additional fluids every two hours D. Covering the neonate with a lightweight blanket

C Correct Answer: C. Giving additional fluids every two hours Insensible and intestinal fluid losses increase during phototherapy; extra fluids prevent dehydration. Incorrect Answers: A. The nurse does not need to assess the infant's vital signs every hour with phototherapy. B. The eye shields should be on the baby whenever she is under the phototherapy lights. D. The baby should not be covered with a blanket; this prevents the phototherapy lights from reaching the skin. Vital Concept: Unconjugated hyperbilirubinemia is the most common form of neonatal hyperbilirubinemia. Unconjugated bilirubin has not been metabolized and cannot be excreted via the normal pathways in the urine and bowel. Accumulated bilirubin binds with lipids and albumin, resulting in the yellow appearance of the skin and sclera. Unconjugated bilirubin is a neurotoxin that can cross the blood-brain barrier, leading to significant brain damage. Phototherapy treatment for jaundice is performed by exposure of skin to a light source, which converts unconjugated bilirubin molecules into water-soluble molecules that can be excreted by in urine and stool.

A nurse is caring for a toddler who is scheduled to have a lumbar puncture (LP). Which of the following actions should the nurse take? A. Cleanse the thoracic area with an antiseptic solution prior to the procedure. B. Apply a local anesthetic cream to the puncture site 5 minutes prior to the procedure. C. Instruct the parents to keep the toddler in a flat position for 30 minutes to one hour after the procedure. D. Position the toddler with the head extended and chin raised during the procedure.

C Correct Answer: C. Instruct the parents to keep the toddler in a flat position for 30 minutes to one hour after the procedure. The nurse should inform the parents what to expect before, during, and after the procedure. After a lumbar puncture, the toddler should lie flat for about 30 minutes. It is important for the child to remain hydrated. The nurse should encourage the child to drink a glass of water, to decrease the risk of spinal headaches. If a headache occurs, an analgesic can be prescribed by the healthcare provider. Incorrect Answers: A. The provider will insert the aspiration needle into the lumbar L4/L5 level of the spine. The lumbar area of the toddler's back should be cleansed thoroughly prior to the procedure. B. A local anesthetic cream should be applied to the lumbar area of the spine for 45 to 60 min prior to the procedure to ensure that the area is numbed to decrease the discomfort associated with inserting the spinal needle. D. The toddler should be positioned and held on his side with his head flexed forward. The toddler's knees should be flexed against his abdomen, with his back arched, in a"rolled up" position that "opens" up space between the lumbar vertebrae so the spinal needle can be inserted more readily. Vital Concept: A lumbar puncture is performed for diagnosis of possible cerebral hemorrhage or central nervous system infection. The cerebrospinal fluid is aspirated through a needle inserted into the subarachnoid space of the spinal canal at the level of L3-L4 or L4-L5; it is then sent to the lab for analysis and culture. Topical anesthetic cream or lidocaine can be applied to the puncture site approximately 1 hour prior to the procedure to numb the skin and limit the pain associated with the procedure. A small child or toddler should be positioned and held by the nurse on the side with the head flexed forward and their knees flexed toward their abdomen in a "rolled up" position. The lumbar area should be cleaned thoroughly prior to the procedure and strict aseptic technique should be observed. The child can experience an increase in intracranial pressure after the procedure and should be monitored for changes in pupil size, level of consciousness, respirations, or decrease in blood pressure.

A nurse is teaching a group of clients about mind-body therapies. Which of the following information should the nurse include about guided imagery? A. It promotes a method of exercise that involves holding specific postures, breathing, and meditation. B. It encourages a self-directed practice of relaxation of the body with rhythmic breathing. C. It concentrates on descriptive mental pictures to treat pathological conditions. D. It stimulates the immune system and maintains internal and external balance.

C Correct Answer: C. It concentrates on descriptive mental pictures to treat pathological conditions. The nurse should teach the client that guided imagery concentrates on images or a series of images to treat pathological conditions. Guided imagery encourages a change in behavior, physiological reactions, and attitudes through relaxing and decreasing the negative impact of stressors. Incorrect Answers: A. The nurse should teach the client that yoga is a method of exercise used to master the well-being of the body through exercise, holding specific postures, breathing, and meditation. B. The nurse should teach the client that meditation is a self-directed practice to relax the body with rhythmic breathing. Meditation has a positive effect on the client's physical body and psychological function. D. The nurse should teach the client that tai chi stimulates the immune system and maintains internal and external balance. This occurs by cleansing, strengthening, and circulating vital life energy and blood through breathing, special movements, and meditation. Vital Concept: Mind-body therapies are focused on realigning or producing a balance in the client's mental processes to help heal the mind and body. Yoga, meditation, hypnotherapy, guided imagery, and biofeedback are all considered mind-body therapies. Imagery where there is communication between the conscious mind and the unconscious mind and involves the client's whole body along with the senses. Guided imagery is facilitated by a therapist and can result in lowering the client's vital signs as well as the client's brain wave rhythms and patterns. Guided imagery is similar to hypnosis and helps to manage unwanted thoughts, fears, and stressors.

The infusion rate of total parental nutrition (TPN) is tapered before being discontinued. This is done to prevent which of the following complications? A. Essential fatty acid deficiency B. Dehydration C. Rebound hypoglycemia D. Malnutrition

C Correct Answer: C. Rebound hypoglycemia When dextrose is abruptly discontinued, rebound hypoglycemia can occur. The nurse should assess the client for symptoms of hypoglycemia. Incorrect Answers: A. The client would most likely not develop essential fatty acid deficiency from tapering TPN. B. The client should be well hydrated and would not necessarily develop dehydration in this situation. D. The TPN has provided nutrition; the client would not likely develop malnutrition if he is well enough to taper the dose. Vital Concept: Tapering of TPN is a common practice. It may not always be necessary to prevent rebound hypoglycemia, but reducing the rate by 50% for an hour or 2 before discontinuation is easy to do and reduces the risk of hypoglycemia. Hypoglycemia after abrupt discontinuation of TPN is a complication that occurs when endogenous insulin levels do not adjust to the sudden withdrawal of dextrose in the TPN solution. Clients with underlying conditions affecting glucose regulation may be more susceptible, but the risk of hypoglycemia is low in clients with stable glucose levels, especially in clients who are receiving another source of carbohydrates.

A nurse is caring for a client with tuberculosis who is assigned to a negative pressure isolation room. Which of the following items of personal protective equipment should be used by the client during transport to the interventional radiology suite? A. Surgical mask and isolation gown B. Surgical mask, gloves, and goggles C. Surgical mask D. N95 particulate respirator

C Correct Answer: C. Surgical mask Airborne pathogens that require isolation precautions, including a negative pressure room, include measles, varicella, and tuberculosis. When clients infected with these pathogens travel throughout the healthcare facility for necessary diagnostic or therapeutic interventions, the client should wear a surgical mask to avoid transmitting infectious organisms through the spray of respiratory secretions. Incorrect Answers: A. An isolation gown is not necessary for transport of a client on airborne precautions. B. Gloves and goggles are unnecessary to protect others from contamination by infected respiratory secretions. D. The Centers for Disease Control and Prevention (CDC) recommends the use of a particulate respirator mask by healthcare workers in contact with clients infected by airborne pathogens as protection from exposure to these microorganisms. Particulate respirators remove particles from inhaled air, so they are unnecessary for infected individuals. Vital Concept: Clients on airborne isolation are infected with pathogens transmitted through the spray of respiratory secretions. Transport should be minimized and the client should wear a surgical mask during transport. A particulate respirator is required for healthcare workers entering the room to provide care for a client on airborne isolation precautions.

A nurse is caring for a client with delusions who refuses to eat because he believes the food is poisoned. Which of the following is the most appropriate initial intervention by the nurse? A. Suggest to the client that if he does not eat soon, tube feedings will be initiated B. Suggest to the client's family that they bring food from home for the client. C. Simply state the food is not poisoned. D. Taste the food in the client's presence.

C Correct Answer: C. Simply state the food is not poisoned. A client's delusions are often dealt with most effectively initially with simple statements of the facts. The nurse should state the facts to reorient the client to reality. Incorrect Answers: A. Threats are never appropriate nursing interventions. B. This statement may reinforce the client's delusion. D. This statement is a form of entering into the delusion. It is unlikely to end the client's delusion. It enables the delusion. Vital Concept: The nurse should maintain a quiet, pleasant environment and should approach the client in a slow and calm manner. The client may respond with anxious or aggressive behaviors if startled or overstimulated. The nurse should also reorient the client to reality, by presenting reality briefly and clearly, avoiding vague or evasive statements.

A nurse is caring for a client who is planning a vaginal birth after cesarean section (VBAC). Which of the following findings on the assessment of the client is a priority for intervention for the nurse (select all that apply)? A. Increased discomfort with contractions B. Painful contractions every 4 minutes C. Maternal tachycardia D. Cessation of contractions E. Fetal tachycardia and moderate variability

C, D, Correct Answers: C. Maternal tachycardia D. Cessation of contractions Vaginal birth after cesarean section can result in increased risk of uterine rupture as a result of weakening of the uterus along the previous surgical scar. Clients who are planning VBAC should not undergo induction; after spontaneous onset of labor, they should be monitored closely throughout the intrapartum and postpartum periods. Uterine rupture is initially characterized by constant abdominal pain, abnormal fetal heart rate patterns (bradycardia is most common), cessation of uterine contractions, and loss of fetal station. This is a life-threatening emergency for mother and fetus. Maternal hemodynamic instability is characterized by hypotension and tachycardia. Caesarean delivery is indicated after stabilization with intravenous fluids. A hysterectomy is often necessary. Incorrect Answers: A. Increased discomfort with contractions is not abnormal in the setting of progression of labor. Constant abdominal pain is associated with uterine rupture. B. During active labor, contractions may occur every 2 minutes. E. Fetal tachycardia with moderate variability is expected during delivery. Vital Concept: Uterine rupture is a concern in clients in labor who have predisposing conditions, including a history of previous caesarean section of other type of uterine incision. Complete uterine rupture is characterized by tearing of the peritoneum. Emergent laparotomy, with C-section and hysterectomy usually necessary to prevent maternal/fetal mortality. References: Lowdermilk DL, et al. (2016). Maternity & women's health care, 11th ed. St. Louis, MO: Elsevier. Peer Comparison A 16% B 12% C 85% D 87% E 54% Response Time: 0:52 Difficulty level: Hard Previous 21 22

Which of the following situations would contribute to sensorineural hearing loss? Select all that apply. A. Cerumen impaction B. Chronic ear infections C. Exposure to loud noise D. Acoustic neuroma E. Use of ototoxic medications

C, D, E Correct Answers: C. Exposure to loud noise D. Acoustic neuroma E. Use of ototoxic medications Sensorineural hearing loss is a type of hearing loss that develops because of damage to the structures of the inner ear, such as the cochlea, vestibular duct, or the utricle. Alternatively, conductive hearing loss develops because of something that prevents sound from reaching the inner ear, not actual damage to the inner structures. Causes of sensorineural hearing loss include: Exposure to loud noise (preventable but not reversible) Aging (presbycusis) Head trauma Ototoxic medications Virus or disease Autoimmune inner ear disease Acoustic neuroma (a tumor that forms on a nerve in the middle ear) Heredity Malformation of the inner ear Ménière's disease Incorrect Answers: A. Cerumen impaction can cause conductive hearing loss, as explained above. B. Chronic ear infections can cause conductive hearing loss. Vital Concept: Hearing impairment is one of the most prevalent chronic conditions among older adults. The nursing hearing impairment screening evaluation should consist of a thorough history and physical examination. When communicating with a client who is hearing-impaired, the nurse should first gain the client's attention. The client should be aware of the nurse before the nurse begins talking. The nurse will speak in a quiet environment, not farther than 2 to 3 feet away from the client. Only one person should talk at a time.

A nurse is caring for a client who is having a seizure. Place the following actions in the appropriate order: 1. Protect the client's head and loosen restricting clothing 2. Stay with the client and call for help 3. Note the length of the seizure and any factors that may have caused it 4. Document the seizure and the client's condition 5. Administer anti-seizure medications

Correct Answer: 1. Stay with the client and call for help 2. Protect the client's head and loosen restricting clothing 3. Administer anti-seizure medications 4. Note the length of the seizure and any factors that may have caused it 5. Document the seizure and the client's condition Seizures occur as a result of neuronal hyper-excitation and disordered discharge. A grand mal seizure is a generalized seizure characterized by an altered level of consciousness and paroxysmal muscle spasms. The client's safety is the priority during a seizure. The nurse should call for help while remaining with the client. Nursing interventions should protect the client from traumatic injury by removing objects in the client's vicinity and positioning the client to maintain an open airway. The client should not be restrained. The nurse should protect the client's privacy as much as possible and offer support after the seizure. Although the nurse will assess and monitor the client during the seizure, documentation should be postponed until the seizure has ended and the client is stable. Documentation should include any precipitating factors, description and location of the seizure activity, and the duration of the seizure. Vital Concept: If a client is at risk for seizures, suction and Ambu bag should be readily available at bedside. During a seizure, the nurse's priority is the client's safety. The nurse should call for help while remaining with the client. A client who is having a seizure should never be restrained. Objects that might cause injury should be removed from the client's vicinity.

A nurse is assigned to care for a client with an ileal conduit. Which of the following best describes an ileal conduit? A. A bag is connected to a stoma on the abdominal wall and stool from the large intestine drains into the bag B. A feeding tube is placed directly into the stomach through the abdominal wall C. A tube is inserted into the urethra to drain urine from the bladder, which collects in a bag D. A bag is connected to a stoma on the abdominal wall and urine drains into the bag

D Correct Answer: D. A bag is connected to a stoma on the abdominal wall and urine drains into the bag An ileal conduit may be performed for a client who has most of the bladder removed through surgery, for a reason such as bladder cancer. After bladder removal, the ureters drain into the ileum of the small intestine, the end of which is then brought out through a stoma on the abdominal wall. The urine collects in a bag placed on the stoma and the client empties it regularly. Incorrect Answers: A. This describes a colostomy or ileostomy, when stool is emptied into the bag, not urine. B. This describes a gastrostomy tube, not an ileal conduit. C. This describes an indwelling urinary catheter, not an ileal conduit. Vital Concept: An ileal conduit is created using the small intestine after removing the bladder. A short segment of the small intestine is placed at an opening created surgically on the surface of the abdomen, forming a stoma.

A nurse is caring for a client newly admitted with diabetic ketoacidosis. Which of the following does the nurse expect to see when the client's arterial blood gas analysis is returned from the lab? A. Increased pH B. Decreased pO2 C. Increased pCO2 D. Decreased HCO3

D Correct Answer: D. Decreased HCO3 In diabetic ketoacidosis (DKA), there is inadequate insulin for carbohydrate metabolism and the body switches to fatty acid metabolism, producing ketones and organic acids. The bicarbonate-carbonate acid buffer system of the body maintains the pH of the body fluids, but when the buffer system is unable to compensate for acids produced by metabolism of fatty acids in DKA, bicarbonate concentration decreases with decreased pH. Incorrect Answers: A. The pH is decreased in diabetic acidosis. B. The pO2 (partial pressure of oxygen) is not decreased in diabetic acidosis. C. The pCO2 (partial pressure of carbon dioxide) may be decreased in diabetic acidosis as the body attempts to eliminate CO2 (carbon dioxide) to compensate for a low pH. Vital Concept: Diabetic ketoacidosis (DKA) is an acute life-threatening complication of diabetes that occurs primarily in clients with type 1 diabetes, although the condition can occur in type 2 diabetes. DKA is characterized by hyperglycemia, ketoacidosis, and ketonuria. It is the result of inadequate insulin for carbohydrate metabolism, causing the body to metabolize fatty acids for energy. Organic acids produced by fatty acid metabolism result in acidosis, with decreased serum bicarbonate and decreased pH. Laboratory tests in a client with DKA will typically reveal hyperglycemia (over 250 mg/dL), a bicarbonate level less than 18 mEq/L, and a pH less than 7.30, with ketonemia and ketonuria

A nurse is developing a plan of care for a client who has cervical cancer and is scheduled to receive cryotherapy. Which of the following interventions should the nurse include in the plan of care? A. Monitor the client's oxygen saturation level during the procedure. B. Instruct the client to apply heat to the insertion site. C. Encourage the client to use tampons following the procedure. D. Evaluate the client's bladder control after the procedure.

D Correct Answer: D. Evaluate the client's bladder control after the procedure. Loss of bladder or bowel control is an adverse effect of cryotherapy of the cervix. Incorrect Answers: A. The nurse should monitor the client's blood pressure to identify hypotension during and after cryotherapy. B. The client should apply cold to the insertion site to decrease pain after cryotherapy. C. The nurse should instruct the client to avoid the use of tampons. This can irritate the area where cryotherapy was performed and can increase the risk for infection. Vital Concept: Nitrous oxide is used to freeze cancer cells during cryotherapy, which is typically used to treat cancer of the cervix. The nurse should monitor the client's ability to control the bowel and bladder. Cramping and watery discharge are expected for several weeks following the procedure. The client should notify the provider if heavy bleeding or fever occurs, or if the discharge has a foul-smelling odor.

An unresponsive client with type 1 diabetes is admitted to the unit for treatment of a glucose level of 780 mg/dL with a pH of 7.0 on arterial blood gases. Which of the following does the nurse anticipate will be prescribed for intravenous treatment? A. Insulin Aspart (Novolog) B. Insulin NPH C. Insulin glargine (Lantus) D. Humulin R

D Correct Answer: D. Humulin R Humulin R is used when treating a client with diabetic ketoacidosis. It is the only type of insulin that should be used intravenously for treatment of severe diabetic ketoacidosis. The initial infusion should begin at 0.1 units/kg/hour. Regular insulin is used subcutaneously for general dosing of regular diabetes and can be given as multiple daily doses or a continuous subcutaneous infusion. Incorrect Answers: A. Aspart or Novolog is a very rapidly acting insulin that is normally given before a meal and injected subcutaneously. B. Insulin NPH is an intermediate-acting insulin formulation given subcutaneously once or twice a day. C. Insulin glargine is a long-acting insulin that is administered by subcutaneous injection. Vital Concept: When treating diabetic ketoacidosis, an IV insulin infusion is initiated with regular insulin, which is the only type of insulin given IV. The infusion is usually titrated to the client's blood glucose, which is monitored hourly. Rapid reduction of blood glucose can result in cerebral edema, so must be avoided. Insulin also causes potassium to move back into the cells, so potassium levels must be monitored closely, with supplementation added to IV fluid replacement when the client has a potassium level of 3.3 mEq/L or lower.

A healthcare provider in the emergency department has ordered gastric lavage for a client with a drug overdose. Which of the following nursing actions is appropriate? A. Place the client in the Trendelenburg position during lavage. B. Use a small-bore nasogastric tube for lavage. C. Lavage is most effective after 1-2 hours. D. Suction supplies should be available at the bedside.

D Correct Answer: D. Suction supplies should be available at the bedside. Gastric lavage, when performed for decontamination of the stomach, is performed as soon as possible after a potentially fatal overdose. An orogastric tube is used to remove any ingested toxins and to irrigate the stomach. There is a high risk of associated complications, so gastric lavage is only performed within an hour of potentially lethal overdose. Gastric lavage was also performed routinely in the past in clients with hematochezia, but it is not a sensitive test to distinguish upper from lower GI bleeding. Complications of gastric lavage include aspiration, perforation of the GI tract, and arrhythmia. Suction supplies should be placed at bedside in case of aspiration. Supplies should also be available for endotracheal intubation in the event that the client develops respiratory distress. Activated charcoal is more commonly used to decontaminate the GI tract, with sorbitol to aid in evacuation of the bowel. Activated charcoal is ineffective for some toxins, including alcohol, lithium, iron. Incorrect Answers: A. Gastric lavage is associated with a risk of aspiration. The client should be placed on the side, and the head of the bed should be elevated to minimize risk. B. A large-bore orogastric tube is used for gastric lavage so that ingested toxins such as pills can be removed and the stomach can be irrigated. C. Gastric lavage is ineffective after more than an hour has elapsed from the ingestion. Although it is important to decompress the stomach, lavage should take place as soon as possible. Vital Concept: Contraindications to gastric lavage for decontamination of the GI tract in overdose include ingestion of a caustic agent, hydrocarbon ingestion, and unprotected airway. The procedure is reserved primarily for potentially lethal overdoses within an hour of ingestion of the toxic product.