Client needs Pt 2
The nurse is instructing a client about using the antianxiety medication lorazepam. Which statement by the client indicates a need for further education? "If I have a sore throat, I should report it to the health care provider." "I shouldn't stop taking this medicine abruptly." "I usually drink a beer every night to help me sleep." "I should get up slowly from a sitting or lying position."
"I usually drink a beer every night to help me sleep." Explanation: The client shouldn't consume alcohol or any other central nervous system depressant while taking this drug. All of the other statements indicate that the client understands the nurse's instructions.
A client with type 1 diabetes must learn how to self-administer insulin. The physician has prescribed 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction? "Administer insulin into sites above muscles that you plan to exercise heavily later that day." "Inject insulin into healthy tissue with large blood vessels and nerves." "Rotate injection sites within the same anatomic region, not among different regions." "Administer insulin into areas of scar tissue or hypotrophy whenever possible."
"Rotate injection sites within the same anatomic region, not among different regions." Explanation: The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy). To prevent lipodystrophy, the client should rotate injection sites systematically and use one anatomical region for a week. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.
Which advice should a nurse give over the phone to the parent of a 7-year-old child with right lower abdominal pain, fever, and vomiting? "Seek immediate emergency medical care." "Encourage fluids to prevent dehydration." "Give prune juice to relieve constipation." "Test for rebound tenderness in the left lower abdominal quadrant."
"Seek immediate emergency medical care." Explanation: The parent of a child with abdominal pain, fever, and vomiting (the cardinal signs of appendicitis) should be urged to seek immediate emergency care to reduce the risk of complications from potential appendix rupture. Prune juice has laxative effects and shouldn't be given because laxatives increase the risk of rupture of the appendix. Testing for rebound tenderness may elicit McBurney's sign in the right lower quadrant (an indication of appendicitis); however, the nurse shouldn't rely on the mother's findings. The child should be given nothing by mouth in case surgery is needed.
A client reports abdominal pain. Which question asked by the nurse would provide the most information about the client's pain? "What does the pain feel like?" "Is the pain radiating anywhere else?" "Does resting make the pain better?" "Does the pain come and go?"
"What does the pain feel like?" Explanation: An open-ended question (one that can't be answered with a simple "yes" or "no") provides more information than a closed-ended question, which limits the client's response. The other options are close-ended questions.
After admission for acute appendicitis, a client undergoes an appendectomy. He complains of moderate postsurgical pain for which the physician prescribes pentazocine, 50 mg by mouth every 4 hours. The nurse will evaluate the client how soon after administration of pentazocine to determine if onset has occurred? Less than 15 minutes 15 to 30 minutes 30 to 60 minutes 1 to 2 hours
15 to 30 minutes Explanation: Orally administered pentazocine has an onset of action of 15 to 30 minutes, reaches peak concentration in less than 1 hour, and has a duration of 3 to 4 hours.
When explaining to the parents the optimal time for repair of hypospadias, the nurse should indicate which as the age of choice? 1 week 4 years 6 to 18 months 2 years
6 to 18 months Hypospadias (pronounced hype-oh-spay-dee-us) is a birth defect in boys where the opening of the urethra (the tube that carries urine from the bladder to the outside of the body) is not located at the tip of the penis.
The licensed practical nurse removes a client's nasogastric (NG) tube according to the physician's order. The nurse should watch for which complication after removing an NG tube? Constipation Presence of bowel sounds Flatulence Abdominal distention
Abdominal distention Explanation: After removing an NG tube, the nurse should assess the client for such complications as abdominal distention, nausea, and vomiting. Flatulence indicates that gas from the small intestine is passing through the colon. Constipation isn't a complication associated with removing an NG tube. Bowel sounds occur when peristalsis is present, which indicates that the GI tract is functioning.
A mother brings her 13-month-old toddler to the clinic. The toddler has erythema and small vesicles that ooze on his buttocks. Which instruction should the nurse give the mother? Apply permethrin cream, leave it on for 8 hours, and then bathe the child. Wash all bed linens and clothing with hot water. Change diapers frequently and use air-drying when possible. Use cloth diapers and rubber pants until the rash heals.
Change diapers frequently and use air-drying when possible. Explanation: The child shows signs of diaper dermatitis. Therefore, the nurse should instruct the mother to change the child's diapers frequently, use air-drying if possible, and avoid rubber pants. Permethrin cream and washing all bed linens and clothing with hot water are indicated for the treatment of scabies, not diaper dermatitis.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT) next week. The client has been taking a benzodiazepine for several months. Which nursing action is appropriate? Continue administering the medication. Ask the client whether the drug is still desired. Contact the health care provider who prescribed benzodiazepine. Ask the charge nurse to clarify the order.
Contact the health care provider who prescribed benzodiazepine. Explanation: Clients who will undergo electroconvulsive therapy (ECT) should be weaned from benzodiazepine therapy several days prior to the treatment. The nurse will, therefore, contact the health care provider who prescribed the drug to request new orders to go into effect prior to the ECT treatment. The nurse will not automatically continue the medication or ask the client if the drug is desired. It is not appropriate to ask the charge nurse to clarify the order; order clarification should be directed to the health care provider.
A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching? Use logrolling technique when moving. Get up slowly, turning the entire body. Report dizziness at once. Drive in daylight hours only.
Get up slowly, turning the entire body. Explanation: A client with Meniere disease experiences dizziness, vertigo, and tinnitus. Turning the entire body, not the head, will prevent vertigo. Turning the client in bed slowly and smoothly will be helpful; logrolling isn't needed. The client shouldn't drive because the client may reflexively turn the wheel to correct for vertigo. Dizziness is expected with Meniere disease but can be prevented.
Which of the following signs and symptoms suggest that a client's abdominal aortic aneurysm is extending? Increased abdominal and back pain Retrosternal back pain radiating to the left arm Decreased pulse rate and blood pressure Elevated blood pressure and rapid respirations
Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.
Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg? Administer prescribed supplemental oxygen. Administer a prescribed decongestant. Instruct the client to breathe into a paper bag. Offer the client fluids frequently.
Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. All of the other options — such as administering a decongestant, offering fluids frequently, and administering supplemental oxygen — wouldn't raise the lowered PaCO2 level.
A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? Impaired color discrimination Increased urinary frequency Decreased hearing acuity Increased appetite
Decreased hearing acuity Explanation: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed. The other options aren't associated with streptomycin. Impaired color discrimination indicates color blindness; increased urinary frequency and increased appetite accompany diabetes mellitus.
The parent asks the nurse how many clear cellophane tape tests will the child need to have to detect pinworm infestation at virtually 100% accuracy. Which response by the nurse would be best? Three Ten Five One
Five Explanation: Detection is virtually 100% accurate with five tests. Three tests should detect infestations at about 90% accuracy. One test is only 50% accurate. Ten tests aren't necessary.
A nurse preceptor asks the graduate nurse what is the drug of choice for treating Tourette syndrome. The preceptor determines the graduate is aware of the correct medication when he accurately provides the name of which medication? Paroxetine Fluoxetine Haloperidol Fluvoxamine
Haloperidol Explanation: Haloperidol is the drug of choice for treating Tourette syndrome. Fluoxetine, fluvoxamine, and paroxetine are antidepressants and aren't used to treat Tourette syndrome.
After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond? In 4 hours In 30 minutes In 1 hour In 2.5 hours
In 30 minutes Explanation: Codeine's onset of action is 30 minutes when it's given orally. Its peak concentration occurs in about 1 hour; its half-life expires in 2.5 hours; and its duration of action is 4 to 6 hours.
A nurse is caring for a client with myasthenia gravis. Which behavior during dinner indicates to the nurse that the client is having a therapeutic response to pyridostigmine? The client begins to speak clearly. The client participates in conversation. The client talks optimistically about the future. The client swallows food without difficulty.
The client swallows food without difficulty. Explanation: In a client with myasthenia gravis, the anticholinesterase drug pyridostigmine counteracts fatigue and muscle function. When the drug achieves a therapeutic blood level, the client should be able to swallow food without difficulty. The client's ability to speak clearly, participate in conversation, and talk optimistically about the future is unrelated to the drug's effects.
A client with a pulmonary embolism has received a thrombolytic medication. What is the most important concept the nurse should reinforce with this client and his family at this time? The medication was given to break apart the blood clot blocking the pulmonary artery. The medication is taken orally and will thin the blood. The medication will prevent future clots from forming. The medication will help the client to breathe by dilating bronchial tubes.
The medication was given to break apart the blood clot blocking the pulmonary artery. Explanation: A thrombolytic medication is given I.V. to break apart or dissolve blood clots. It isn't given orally, doesn't prevent future clots from forming, and has no effect on the bronchial tubes.
A nonpregnant client tells the nurse that two recent, fasting blood glucose results were 132 mg/dL (7.3 mmol/L) and 146 mg/dL (8.1 mmol/L). The nurse should expect which actions to occur? The client should be scheduled for a CBC. The fasting blood glucose tests should be repeated two more times. These are normal results; no further action is needed. These results indicate diabetes; further follow-up is needed.
These results indicate diabetes; further follow-up is needed. Explanation: Based on American Diabetes Association guidelines, fasting blood glucose of 126 mg/dL (7 mmol/L) or more, on at least two occasions, is indicative of diabetes. These are not normal result. Further tests to make a definitive diagnosis of diabetes should be random blood glucose or glucose tolerance tests, not a fasting blood glucose or HbA1C.
A nurse is providing care for a client who has an epidural catheter postoperatively. Which sign or symptom should cause the nurse to suspect that the client is experiencing an adverse effect of the therapy? exhibits increased work of breathing reports increased incisional pain appearance of petechiae noted on the skin reports mild infrequent nausea
exhibits increased work of breathing Explanation: An adverse effect of epidural analgesia is the spread of the medication above the intended level, which can result in respiratory difficulty. Increase in the work (effort) of breathing can signal this complication. Nausea is a postoperative side effect of anesthesia. Increased level of pain and petechiae are not adverse effects of epidural anesthesia.
A nurse is caring for a client diagnosed with myocardial infarction (MI) who is prescribed a nitrate. What does the nurse identify as the purpose of giving a nitrate to this client? to calm and relax the client to relieve headaches caused by other medications to relieve pain to dilate coronary arteries
to dilate coronary arteries Explanation: Nitrates dilate the arteries, allowing oxygen to continue flowing to the myocardium. Nitrates can cause headaches but don't relieve pain, and they don't calm or relax the client.
A client taking metronidazole asks the nurse if it is okay to drink alcohol while taking this medication. What is the nurse's best response? "Abstain from alcohol while on the drug." "If you only drink beer you should be fine." "You cannot drink wine while on this medication." "It may cause an rash to develop."
"Abstain from alcohol while on the drug." Explanation: All alcoholic beverages should be avoided during metronidazole therapy and for at least one day afterward. Mixing alcohol with metronidazole will cause severe abdominal cramps, nausea, vomiting, headaches, and flushing.
The nurse is reinforcing teaching about aspirin therapy with a client diagnosed with transient ischemic attacks (TIA). Which statement made by the client indicates understanding? "Taking aspirin regularly will reduce my risk of having severe pain." "I need to take aspirin regularly to prevent headaches." "Aspirin will help prevent me from having a stroke." "If I take aspirin, I am less likely to develop a bleed in my brain."
"Aspirin will help prevent me from having a stroke." Explanation: Aspirin is taken prophylactically to prevent cerebral infarction secondary to embolism and thrombosis. Headache is not common in TIAs. Aspirin can increase the chances of intracranial hemorrhage, especially if the dose is excessive. Aspirin can help reduce specific types of pain, but will not reduce the risk of having severe pain
A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response? "If you take St. John's wort and Parkinsonian drugs, take them on alternate days." "St. John's wort is an herbal remedy that can be used to treat depression." "St. John's wort can cause a toxic reaction with the Parkinsonian drugs." "St. John's wort must be taken in large doses to help reduce depression."
"St. John's wort can cause a toxic reaction with the Parkinsonian drugs." Explanation: Taking St. John's wort can increase in the toxic effects of levodopa, causing extremely high blood pressure, blurred vision, and muscle twitching. Although St. John's wort is an herbal remedy that can be used to treat depression, these drugs should not be taken together.
For a client with an endotracheal (ET) tube, which nursing action is most essential? Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene
Auscultating the lungs for bilateral breath sounds Explanation: For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.
The nurse is caring for a client diagnosed with chronic thrombocytopenia. Before discharge, the nurse reinforces which activities to the client to decrease excessive bleeding? Select all that apply. Avoid the influenza vaccine. Avoid alcohol. Avoid aspirin and ibuprofen. Check with your health care provider about taking OTC drugs. Change any lupus treatments.
Avoid alcohol. Avoid aspirin and ibuprofen. Check with your health care provider about taking OTC drugs. Explanation: Alcohol slows the production of platelets. Two medicines that may affect platelets and raise the risk of bleeding are aspirin and ibuprofen. The influenza vaccine will not affect platelets. Other autoimmune diseases that destroy platelets include lupus and rheumatoid arthritis, so any changes in treatments can increase bleeding.
Which medication is considered safe during pregnancy? Aspirin Magnesium hydroxide Insulin Oral antidiabetic agents
Insulin Explanation: Insulin is a required hormone for any client with diabetes mellitus, including the pregnant client. Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for use during pregnancy because these agents may cause fetal harm.
The nurse is caring for a client who recently underwent unilateral adrenalectomy. For what sign would the nurse would assess to monitor for hyperkalemia? Muscle weakness Polyuria Flattened T waves on ECG Constipation
Muscle weakness Explanation: Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Polyuria, constipation, and flattened T waves are signs of hypokalemia.
A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy? Anticholinergic effects Agranulocytosis Neuroleptic malignant syndrome (NMS) Thrombocytopenia
Neuroleptic malignant syndrome (NMS) Explanation: A rare but potentially fatal condition of antipsychotic medication is called NMS. It generally starts with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Thrombocytopenia isn't a complication of antipsychotic medication. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.
Which nursing intervention is most appropriate for a client with multiple myeloma? Monitoring respiratory status Balancing rest and activity Restricting fluid intake Preventing bone injury
Preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict his fluid intake. Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell.
The parents of an infant diagnosed with hypothyroidism have been taught to count the infant's pulse. Which intervention should be reinforced in case a high pulse rate is obtained? Allow the infant to take a nap and then give the medication. Withhold the medication and give a double dose the next day. Withhold the medication and call the health care provider. Give the medication and then consult the health care provider.
Withhold the medication and call the health care provider. Explanation: If parents have been taught to count the pulse of an infant diagnosed with hypothyroidism, they should be instructed to withhold the dose and consult their health care provider if the pulse rate is above a certain value.
The nurse is caring for a client with alcohol-related acute pancreatitis. Which intervention is most appropriate to reduce the exacerbation of pain? eating low-fat foods abstaining from alcohol lying supine taking aspirin
abstaining from alcohol Explanation: Abstaining from alcohol is imperative to reduce injury to the pancreas; in fact, it may be enough to completely control pain. Lying supine usually aggravates the pain because it stretches the abdominal muscles. Taking aspirin can cause bleeding in hemorrhagic pancreatitis. During an attack of acute pancreatitis, the client usually isn't allowed to ingest anything orally.
The nurse prepares to administer morning medications to a client with hepatitis. The client's medications are listed below. Which medication should the nurse withhold? vitamin B12 one capsule twice daily lamivudine 150 mg orally twice daily phytonadione 5 mg IM once daily acetaminophen 650 mg orally every day
acetaminophen 650 mg orally every day Explanation: Acetaminophen is contraindicated in clients with liver disorder. The medication should be withheld, and the health care provider should be contacted regarding this medication. Lamivudine is an antiviral used to treat Hepatitis B, B12 is a vitamin supplement used to treat anemia associated with hepatitis, and phytonadione, a form of vitamin K, is used to prevent bleeding when the liver is not functioning properly and does not produce adequate amounts to support clotting.
The nurse on the pediatric unit is caring for a child with asthma. When assisting the health care team to develop a plan of care, which problem should the team be sure to address? excess fluid volume imbalanced nutrition activity intolerance constipation
activity intolerance Explanation: Ineffective oxygen supply and demand may lead to activity intolerance. The nurse should promote rest and encourage developmentally appropriate activities. Nutrition may be decreased, not increased, due to respiratory distress and GI upset. Dehydration is common due to diaphoresis, insensible water loss, and hyperventilation. Medications given to treat asthma may cause nausea, vomiting, and diarrhea, not constipation.
A nurse is reinforcing education to parents who are planning to give growth hormone to their child at home. What is the best time to administer growth hormone in order to achieve optimal dosing? at bedtime first thing in the morning after dinner in the middle of the day
at bedtime Explanation: Optimal dosing is usually achieved when growth hormone is administered at bedtime. Pituitary release of growth hormone occurs during the first 45 to 90 minutes after the onset of sleep, so normal physiologic release is mimicked with bedtime dosing.
The nurse is gathering data from a child suspected of ingesting paint chips from an old home. Which system does the nurse closely monitor for serious effects? renal system respiratory system central nervous system (CNS) hematologic system
central nervous system (CNS) Explanation: Damage that occurs to the CNS after lead poisoning is difficult to repair. Damage to the renal and hematologic systems can be reversed if treated early. The respiratory system is not affected until coma and death occur.
Which intervention would be prescribed first for a client who recently had a central venous access device inserted and now appears short of breath and anxious? laboratory tests chest x-ray sedation electrocardiogram
chest x-ray Explanation: Inserting an I.V. catheter in the subclavian vein can result in a pneumothorax, so a chest x-ray should be done. If it's negative, then other tests should be done, but they aren't appropriate as the first intervention.
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: assess the client's visual acuity. teach about intraocular lens cleaning. provide instructions on eye patching. demonstrate eyedrop instillation.
demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.
The nurse is reinforcing education for a client with uric acid calculi. Which type of diet should the nurse inform the client to avoid? low calcium low oxalate high oxalate high purine
high purine Explanation: To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.
The nurse is reinforcing education for a client who has hemorrhagic cystitis caused by bladder irritation from chemotherapeutic medications. Which suggestion can the nurse make to prevent this occurrence? restricting fluid intake giving antacids increasing fluid intake giving antibiotics
increasing fluid intake Explanation: Sterile hemorrhagic cystitis is an adverse effect of chemical irritation of the bladder from cyclophosphamide. It can be prevented by liberal fluid intake (at least 1 1/2 times the recommended daily fluid requirement). Antacids aren't indicated for treatment. Antibiotics don't aid in the prevention of sterile hemorrhagic cystitis. Restricting fluids would only increase the risk of developing cystitis.
Which nursing action is appropriate when administering a glycerin suppository to a client? Applying a lubricant to the suppository Removing the suppository from the refrigerator 30 minutes before insertion Instructing the client to bear down during insertion Assisting the client to a right-side lying position with the left leg flexed upward
Applying a lubricant to the suppository Explanation: A suppository should be lubricated before insertion to ease insertion and reduce discomfort. The nurse should assist the client in a left-side lying position (not right-side lying) to ease insertion. Because suppositories melt at body temperature, they usually require refrigeration until administration. Instructing the client to bear down would cause the anal sphincter to contract, making insertion difficult.
One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. Before administration of the medication, the nurse explains that the drug is given because of what reason? "Atropine improves ventilation by increasing the respiratory rate." "Atropine controls the heart rate and blood pressure." "Atropine decreases salivation and gastric secretions." "Atropine enhances the effect of anesthetic agents."
"Atropine decreases salivation and gastric secretions." Explanation: When used as preanesthesia medications, atropine and other cholinergic-blocking agents reduce salivation and gastric secretions, thus helping to prevent aspiration of secretions during surgery. Atropine increases the heart rate and cardiac contractility, decreases bronchial secretions, and causes bronchodilation. No evidence indicates that the drug enhances the effect of anesthetic agents.
A nurse is caring for a client diagnosed with bipolar disorder who is taking lithium carbonate. When reviewing information about this therapy, what instruction would be most important to reinforce with this client? "Get outside in the warm weather to exercise when possible." "Be sure to drink at least 2 ½ quarts [2500 mL] a day." "Limit your salt intake with each meal daily." "Try to slowly eliminate your caffeine intake."
"Be sure to drink at least 2 ½ quarts [2500 mL] a day." Explanation: Clients taking lithium for bipolar disorder need to maintain a high fluid intake, at least 2 ½ liters per day. Salt should not be limited because lowered sodium levels increase the risk for lithium toxicity. Exercising outdoors in warm weather is not safe; photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium. The client does not need to reduce or eliminate intake of caffeine.
A client comes to the physician's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client's knowledge of the prescribed cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction? "Client performs relaxation exercises three times per day to reduce stress." "Client's 24-hour dietary recall reveals low intake of fat and cholesterol." "Client verbalizes an understanding of the need to seek emergency help if the heart rate increases markedly while at rest." "Client walks 4 miles (6.4km) in 1 hour every day."
"Client walks 4 miles (6.4km) in 1 hour every day." Explanation: Four weeks after an MI, a client's walking program should aim for a goal of 2 miles (3.2 km) in less than 1 hour. Walking 4 miles (6.4 km) in 1 hour is excessive and may induce another MI by increasing the heart's oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. The other options indicate understanding of the cardiac rehabilitation program. The client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower the risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.
A client at 36 weeks gestation is admitted with thrombophlebitis. The client is on strict bed rest, vital signs every 4 hours, fetal heart tones every 4 hours, and an intravenous heparin drip. The client is concerned about the effect the drug might have on her baby. She states, "If it makes my blood thinner, then won't it make my baby's blood change?" Which response by the nurse would be most appropriate? "Heparin doesn't cross the placenta, so it can't get into the baby's blood system." "The heparin molecule is too large to get to the baby, so no damage will occur." "Your health care provider can answer this question. Wait until tomorrow and ask the care provider then." "This drug can't possibly change your baby's blood."
"Heparin doesn't cross the placenta, so it can't get into the baby's blood system." Explanation: Heparin has a high molecular weight and does not cross the placenta. Thus, it does not affect fetal blood. The client's concern is urgent, so the nurse should address the client's concerns and not make her wait for an explanation from the health care provider. Just telling the client that the drug cannot change the baby's blood is a vague answer and does not address the client's concerns; the nurse should explain why heparin cannot affect the baby. Use of the word "damage" may frighten the client, especially because the response does not exclude the client from injury.
A client expressed interest in using complementary alternate modalities for health benefits and asks the nurse to provide information about meditation. The nurse would provide which appropriate response to this client? "It consists of deep personal thoughts and breath control to help decrease anxiety." "It teaches that each person is surrounded by an energy field and helps restore harmony." "It is seen as natural and promotes health through the use of plants and herbs." "It applies external pressure to the energy points for pain control between acupuncture treatments."
"It consists of deep personal thoughts and breath control to help decrease anxiety." Explanation: Meditation strives to clear the mind with deep breathing and personal thoughts. Herbalists use herbs and plants to promote health. Therapeutic touch teaches that each person is surrounded by an energy field. In acupressure, the client applies external pressure to the energy points for pain control.
In the client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Hyperextending the client's palms Performing shoulder range-of-motion exercises
Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.
A client with diabetes mellitus is receiving insulin. The nursing instructor asks the nursing student to correctly describe an insulin unit. How does the student appropriately respond? "It is the smallest measurement in the apothecary system." "It is a common measurement in the metric system." "It is the basis for solids in the avoirdupois system." "It is a measure of effect, not a standard measure of weight or quantity."
"It is a measure of effect, not a standard measure of weight or quantity." Explanation: An insulin unit is a measure of effect, not a standard measure of weight or quantity. Different drugs measured in units may have no relationship to one another in quality or quantity. In the apothecary system, the minim is the smallest liquid unit of measurement and the grain is the smallest solid unit of measurement. In the avoirdupois system, solids include the ounce and pound. In the metric system, the liter is used for liquids and the gram is used for solids.
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which of the following instructions should the nurse emphasize? "Lie down for 5 to 10 minutes after taking the drug." "Repeat the dose every 15 minutes for three doses." "Store the drug in a cool, well-lit place." "Restrict alcohol intake to two drinks per day."
"Lie down for 5 to 10 minutes after taking the drug." Explanation: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.
The nurse is reinforcing education to parents of a child prescribed sulfamethoxazole-trimethoprim for a urinary tract infection. What education should the nurse include? "Return to the clinic in 3 days for another urine culture." "Give your child two pills each day, but keep the rest of the pills to give if the symptoms reappear within 2 weeks." "Make sure your child takes the medication for 10 days even if his symptoms improve in a few days." "For the drug to be effective, keep your child's urine acidic by having him drink at least a quart of cranberry juice per day."
"Make sure your child takes the medication for 10 days even if his symptoms improve in a few days." Explanation: Discharge instructions for parents of children receiving an anti-infective medication should include taking all of the prescribed medication for the prescribed time. The child will not need to have a culture repeated until the medication is completed. Drinking highly acidic juices, such as cranberry juice, may help maintain urinary health, but will not get rid of an infection already present.
When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate? Requesting an antibiotic order Encouraging increased fluid intake Reassessing vital signs every 15 minutes Administering aspirin as ordered
Encouraging increased fluid intake Explanation: During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C) on more than once occasion, which suggests infection.
A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin to control seizures, the nurse assesses for which common adverse drug reaction? Tinnitus Hypertension Excessive gum tissue growth Drowsiness
Excessive gum tissue growth Explanation: Phenytoin can lead to excessive gum tissue growth. However, brushing the teeth two or three times daily helps retard such growth. Some clients may require excision of excessive gum tissue every 6 to 12 months. Phenytoin may cause central nervous system stimulation, leading to insomnia, nervousness, and twitching; it doesn't cause drowsiness. Other adverse reactions to phenytoin include hypotension, not hypertension; and visual disturbances, not tinnitus.
A client is admitted to the acute care facility for treatment of heart failure. The nurse expects the physician to prescribe which drug? Lidocaine Hydroxychloroquine sulfate Furosemide Prednisone
Furosemide Explanation: To maintain fluid balance, which is crucial for a client with heart failure, the physician typically prescribes a diuretic, such as furosemide; vasodilating agents; and drugs that increase contractility, such as digoxin. Prednisone, a corticosteroid, and hydroxychloroquine, an antimalarial agent, aren't indicated for heart failure. Lidocaine would be used only if the client also had ventricular ectopy.
What should the nurse do when administering pilocarpine? Administer at bedtime to prevent night blindness. Flush the client's eye with normal saline solution to prevent burning. Apply pressure on the outer canthus to prevent adverse reactions. Apply pressure on the inner canthus to prevent systemic absorption.
Apply pressure on the inner canthus to prevent systemic absorption. Explanation: When administering pilocarpine, the nurse should apply pressure on the inner canthus to prevent systemic absorption of the drug. Pilocarpine doesn't cause night blindness. The outer canthus doesn't absorb eyedrops, so applying pressure there won't be helpful. Flushing the client's eye with normal saline solution after administering pilocarpine is contraindicated because it will wash the drug out of the eye, rendering treatment ineffective.
A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide regarding cast care? A foul smell from the cast is normal. Use a knitting needle to scratch itches inside the cast. Keep your right leg elevated above heart level. Cover the cast with a blanket until the cast dries.
Keep your right leg elevated above heart level. Explanation: The leg should be elevated to promote venous return and prevent edema. The cast shouldn't be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client? Anticonvulsant Antihypertensive Anticoagulant Antibiotic
Anticoagulant Explanation: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. An antibiotic isn't given routinely during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics afterward to reduce the risk of infection. An antihypertensive agent may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.
Which of the following nutritional deficiencies may delay wound healing? Lack of calcium Lack of vitamin E Lack of vitamin C Lack of vitamin D
Lack of vitamin C Explanation: Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.
A client is admitted for right leg vein ligation and stripping for varicose veins. Which nursing intervention postoperatively should the nurse include? Ask the client to remain inactive until healing is complete. Ask the client to elevate the legs when sitting. Apply ice to dressings to decrease swelling. Apply knee-high stockings over the dressing.
Ask the client to elevate the legs when sitting. Explanation: Vein ligation and stripping postoperative nursing interventions should include educating the client to elevate the legs when sitting.
A client is being discharged from the acute care facility after experiencing acute pancreatitis. Which instruction should the nurse reinforce to this client during discharge education? Avoid spicy foods and caffeine. Consume high-fat meals. Reduce daily caloric intake. Limit daily intake of alcohol.
Avoid spicy foods and caffeine. Explanation: Caffeine and spicy foods must be avoided because it is a stimulant that will further irritate the pancreas by releasing pancreatic enzymes. A client with pancreatitis must avoid all alcohol because chronic alcohol use is one of the causes of pancreatitis. The diet should be low in fat and high in calories, especially carbohydrates.
A client reports difficulty swallowing when the nurse tries to administer a medication in capsule form. What action should the nurse take to resolve this problem? Check for availability of a liquid preparation. Dissolve the capsule in a full glass of water. Break the capsule and give the contents with applesauce. Withhold the medication.
Check for availability of a liquid preparation. Explanation: The nurse should find out whether the medication is available in liquid form. Dissolving or breaking the capsule may interfere with drug action or absorption. The nurse shouldn't withhold any medication without first notifying the physician.
When checking a client's I.V. insertion site, the nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? Check the tubing for kinks and reposition the client's wrist and elbow. Discontinue the I.V. infusion at that site and have it restarted it in the other arm. Irrigate the I.V. tubing with 1 ml of normal saline solution. Elevate the I.V. fluid bag.
Check the tubing for kinks and reposition the client's wrist and elbow. Explanation: The nurse should first check for common causes of a decreased I.V. flow rate, such as kinks in the tubing and poor positioning of the affected arm. The nurse should discontinue the I.V. infusion only if other measures fail to solve the problem. Irrigating I.V. tubing may dislodge clots, if present. Elevating the I.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.
The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing? Vigorously irrigate the ulcer with ½-strength betadine. Pack the wound tightly with a wet-to-dry dressing. Clean the wound with normal saline solution. Apply a dry gauze dressing.
Clean the wound with normal saline solution. Explanation: A red, granulating foot ulcer is healing well and should be cleaned with normal saline solution or a nontoxic wound cleanser. Minimal force should be used to prevent disrupting healthy granulation tissue. A dry gauze dressing would adhere to the wound and disrupt the granulation tissue when removed. When used in a healthy, healing wound, a wet-to-dry dressing can traumatize healing tissue during removal.
A client diagnosed with cirrhosis of the liver caused by alcohol abuse is noncompliant with the prescribed protein-restricted diet. After a friend finds the client semiconscious at home, the client is admitted to the hospital. When initial laboratory test results show an elevated ammonia level, he's diagnosed with hepatic encephalopathy. The physician prescribes lactulose, 200 gram diluted in 700 ml of tap water, given as a retention enema every 4 hours. For which other condition would the nurse expect to administer lactulose? Hyperkalemia Lactic acidosis Constipation Hypoglycemia
Constipation Explanation: Lactulose also may be used to treat constipation because it produces osmotic diarrhea. It isn't therapeutic in the treatment of hyperkalemia, lactic acidosis, or hypoglycemia.
A client admitted with bacterial pneumonia is prescribed cefuroxime axetil 550 mg I.V. every 4 hours. While assessing the client, the nurse notices that cefazolin 500 mg I.V. is infusing. Which action by the nurse is most appropriate? Decreasing the infusion rate of the medication and notifying the physician of the error Increasing the infusion rate of the medication and notifying the physician of the error Discontinuing the medication and documenting assessment findings Discontinuing the medication and notifying the physician of the error
Discontinuing the medication and notifying the physician of the error Explanation: The nurse should discontinue the medication and notify the physician of the medication error. The nurse shouldn't allow the wrong medication infusion to continue. She should document her assessment findings but she must first stop the infusion and then notify the physician of the error.
A client is scheduled for a bronchoscopy. Pre-procedure, the nurse should instruct the client to avoid which activity? Coughing Walking Eating Talking
Eating Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.
The client is receiving an infusion of cytarabine through a peripheral IV catheter when he reports burning at the insertion site. The nurse notes no blood return from the catheter, but she sees redness at the IV site. The client is most likely experiencing which complication? Erythema Flare Extravasation Thrombosis
Extravasation Explanation: The client is exhibiting signs of extravasation, which occurs when the medication leaks into surrounding tissues, causing swelling, burning, or pain at the injection site. Erythema is redness of the skin that results from skin irritation. Flare is a spreading area of redness that occurs as a result of drawing a pointed instrument across the skin. Thrombosis is the formation of a clot within the vascular system; it doesn't occur during drug infusion.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? Providing pain-relief measures Promoting carbohydrate intake Limiting fluid intake Encouraging coughing and deep breathing
Limiting fluid intake Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client? Manage the client's pain. Maintain a patent airway. Monitor for hemorrhage. Evaluate vital signs every 15 minutes.
Maintain a patent airway. Explanation: The priority concern for a client who just had surgery is the client's airway, as demonstrated by the ABC principle: A = Airway, B = Breathing, and C = Circulation. Monitoring for hemorrhage and evaluating vital signs are also important, but these actions constitute second and third priorities. Pain management is important, but only after the client's airway has been stabilized.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Oxygen analyzer
Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
A client was admitted with an injury to the occipital lobe. Which nursing action should the nurse perform? Test water temperature before bathing or showering. Assist client while walking due to loss of balance. Monitor client for visual disturbances. Evaluate the client's hearing condition.
Monitor client for visual disturbances . Explanation: The nurse should monitor client for visual disturbances because the occipital lobe regulates vision. The parietal lobe primarily regulates sensory function. The cerebellum controls balance. The temporal lobe is involved in hearing.
A nurse is caring for a postoperative thyroidectomy client at risk for hypocalcemia. What intervention should the nurse implement in this client's care? Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Monitor laboratory values daily for an elevated thyroid-stimulating hormone. Observe for swelling of the neck, tracheal deviation, and severe pain. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Explanation: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system caused by hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.
A nurse is preparing to assist a client who underwent gastroplasty yesterday to ambulate. The client has an IV line in place, a nasogastric (NG) tube connected to suction, and oxygen running at 6 L/minute by way of a nasal cannula. The health care provider has ordered patient-controlled analgesia (PCA) with morphine sulfate. What is the best way to plan for this client's walking activity? Wait until a physical therapist is available. Obtain a portable oxygen tank to maintain oxygen delivery during the client's ambulation. Ask the client to withhold the PCA for 45 minutes before the walk to prevent orthostatic hypotension. Connect the NG tube to a portable suction machine while the client is walking.
Obtain a portable oxygen tank to maintain oxygen delivery during the client's ambulation. Explanation: The oxygen demands of the client who underwent gastroplasty yesterday will increase with activity, and oxygen delivery must be maintained. Obtaining a portable oxygen tank is the best way to prepare for the client's walk. The client should ambulate as much as possible, regardless of physical therapy assistance. The client needs the morphine to relieve the pain to facilitate ambulation. The NG tube does not need to be connected to suction while the client is walking. It should be clamped to prevent drainage.
The nurse is reinforcing education for parents whose child is experiencing an episode of "midnight croup," or acute spasmodic laryngitis. What should the nurse be sure to include when reinforcing education? Raise the heat on the thermostat. Provide humidified air with cool mist. Take the child into the bathroom with a cold, running shower. Give warm liquids.
Provide humidified air with cool mist. Explanation: High humidity with cool mist, such as from a cool mist humidifier, provides the most (and safest form of) relief. Cool liquids would be best for the child. If unable to take liquid, the child needs emergency care. Raising the heat on the thermostat will result in dry, warm air, which may cause secretions to adhere to the airway wall. A warm, running shower provides a mist that may be helpful to moisten and decrease the viscosity of airway secretions and may also decrease laryngeal spasm.
Two days after a transrectal biopsy of the prostate, a client calls the clinic to report his stools are streaked with blood. Which response is appropriate? Ask the client to collect a stool specimen for testing. Reassure the client that this is an expected occurrence. Tell the client to take a laxative. Tell the client to come in for examination.
Reassure the client that this is an expected occurrence. Explanation: After a transrectal prostatic biopsy, blood in the stools is expected for a number of days. Stool softeners are prescribed if the client reports constipation; straining at stool can precipitate bleeding, but laxatives generally are not necessary. Because blood in the stools is expected, testing the stools or examining the client is not necessary.
A client treated with terbutaline for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? Report a heart rate greater than 120 beats/minute to the health care provider. Call the health care provider if the fetus moves 10 times in an hour. Take terbutaline every 4 hours, during waking hours only. Increase activity daily if not fatigued.
Report a heart rate greater than 120 beats/minute to the health care provider. Explanation: Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the health care provider for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client experiencing premature labor must maintain bed rest at home.
While the nurse is collecting data on a client with depressive symptoms, the client reports taking an herbal medication to help with symptoms. When the nurse questions the client further, which herbal therapy would the client most likely report using? St. John's wort ginkgo biloba echinacea capsicum
St. John's wort Explanation: St. John's wort has been found to have serotonin-elevating properties similar to prescription antidepressants. However, its use is contraindicated in clients being treated with selective serotonin reuptake inhibitors because it can lead to serotonin syndrome. Ginkgo biloba is taken to enhance mental acuity. Echinacea has immune-stimulating properties. Capsicum is an herbal preparation used to treat arthritis.
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse reviews the client's chart and prepares to administer which neuromuscular blocking agent? Atracurium Vecuronium Succinylcholine Pancuronium
Succinylcholine Explanation: Succinylcholine, a depolarizing blocking agent, is the drug of choice when short-term muscle relaxation is desired — for example, during ECT or intubation. Vecuronium, pancuronium, and atracurium are nondepolarizing blocking agents used for intermediate- or long-term muscle relaxation.
A nurse is caring for a 10-year-old child hospitalized for treatment of acute osteomyelitis. The child's left leg is immobilized in a splint. What is the nurse's most appropriate action? Assist the client to ambulate with crutches. Support and handle the leg gently during turning and repositioning. Assist the client to bear weight on the affected limb. Encourage the client to participate in age-appropriate activities.
Support and handle the leg gently during turning and repositioning. Explanation: To prevent pressure sores, the child must turn and change positions periodically. During the acute phase of osteomyelitis, moving the affected leg may cause extreme pain and discomfort. The nurse must support and handle the leg gently during turning and repositioning. Weight bearing is contraindicated because it may cause pathologic fractures. Ambulating with crutches is an inappropriate outcome because the child is restricted to bed rest and the affected leg is immobilized to limit the spread of infection. Participation in age-appropriate activities isn't a realistic outcome because an acutely ill child isn't likely to be interested in activities; this outcome would be suitable after the acute disease phase ends.
When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do? Look for a halo sign after the drainage dries. Test the nasal drainage for glucose. Keep the client in a supine position. Have the client blow his nose.
Test the nasal drainage for glucose. Explanation: Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse looks for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose because doing so could increase the risk of injury. The nurse should elevate the client's head 30 degrees to promote drainage; the risk of infection increases if CSF is allowed to pool and stagnate.
The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription? The client is diagnosed with intractable hiccups. The client has a history of nausea and vomiting. The client is also receiving labetalol. The client had surgery and is restless.
The client is also receiving labetalol. Explanation: The combination of antipsychotics with beta blockers may lead to an increase in the effect of both medications; therefore, caution should be taken before combining these drugs. Chlorpromazine is used in the treatment of intractable hiccups, postoperative restlessness, and nausea and vomiting.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs? Constipation Dysuria Tinnitus Leg cramps
Tinnitus Explanation: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). The other options aren't associated with aspirin use or toxicity.
A nurse is reinforcing discharge instructions for a client with systemic lupus erythematosus (SLE). Which intervention is most important for the nurse to include? consume no more than 2 liters(L) of fluid daily apply sunscreens with SPF higher than 15 daily check blood sugar levels every morning before breakfast avoid foods containing peanuts
apply sunscreens with SPF higher than 15 daily Explanation: Clients with SLE have photosensitivity to sunlight and should wear SPF 15 or higher sunscreen daily, protective clothing, and/or avoid sun exposure to limit photosensitive rash or disease flares. Fluid restrictions, checking blood sugar and avoiding foods containing peanuts is not necessary for clients with SLE.
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative plan of care, the nurse should include which action? Turning the client from side to side, using the logroll technique Keeping a pillow under the client's knees at all times Placing the client in semi-Fowler's position Maintaining bed rest for 72 hours after the laminectomy
Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.
After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? With the affected hip rotated externally With the leg on the affected side adducted With the affected hip flexed acutely With the leg on the affected side abducted
With the leg on the affected side abducted Explanation: The nurse must keep the leg on the affected side abducted at all times after hip surgery to prevent accidental dislodgment of the affected hip joint. Placing a pillow or an A-frame between the legs helps maintain abduction and reminds the client not to cross the legs. The nurse should avoid acutely flexing the client's affected hip (by elevating the head of the bed excessively, for example), adducting the leg on the affected side (by moving it toward the midline, for example), or externally rotating the affected hip (by removing support along the outer side of the leg, for example) because these positions may cause dislocation of the injured hip joint.
A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock? a client with decreased hemoglobin level a client with hypotension a client with acute myocardial infarction (MI) a client with coronary artery disease (CAD)
a client with acute myocardial infarction (MI) Explanation: Of all clients with an acute MI, 15% suffer cardiogenic shock secondary to the myocardial damage and decreased function. CAD causes MI. Hypotension is the result of a reduced cardiac output produced by the shock state. A decreased hemoglobin level is a result of bleeding.
The nurse visits a client at home on the tenth postpartum day. When assessing the client's uterus, the nurse expects to find: a nonpalpable fundus in the abdomen. a fundus palpable at the umbilicus. a fundus palpable two fingerbreadths above the umbilicus. a fundus palpable one fingerbreadth below the umbilicus.
a nonpalpable fundus in the abdomen. Explanation: By the tenth day postpartum, the uterus should no longer be palpable. A fundus palpable above the umbilicus is expected during the third trimester. The fundus is palpable at or just above the umbilicus 1 hour after delivery.
A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client: has type 1 diabetes. prefers to take insulin orally. is pregnant and has type 2 diabetes. has type 2 diabetes.
has type 2 diabetes. Explanation: Oral antidiabetic agents are only effective in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. Pregnant and lactating women aren't prescribed oral antidiabetic agents because the effect on the fetus is uncertain.
A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When monitoring TPN, the nurse must take care to maintain the prescribed flow rate because giving TPN too rapidly may cause: constipation. air embolism. hyperglycemia. dumping syndrome.
hyperglycemia. Explanation: Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. Although air embolism may occur during TPN administration, this problem results from faulty catheter insertion, not overly rapid administration. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome.
The student nurse describes how to position a client for a lumbar puncture to the primary care nurse. Which description indicates that the student nurse understands the correct positioning for the procedure? lateral, with the right leg extended lateral recumbent, with flexed knees prone, with the head turned to the right supine, with the knees raised toward the chest
lateral recumbent, with flexed knees Explanation: To maximize the space between the vertebrae, the client should be placed in a lateral recumbent position during a lumbar puncture, with the knees flexed toward the chin. The needle is inserted between L4 and L5. The other positions do not allow as much space between L4 and L5.
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child? normal electrocardiogram leukocytosis normal erythrocyte sedimentation rate normal red blood cell count
leukocytosis Explanation: Leukocytosis can be seen as an immune response triggered by colonization of the pharynx with group A streptococci. The electrocardiogram will show a prolonged PR interval as a result of carditis. A low-grade fever is a minor manifestation. There should be no change in red blood cell count. The inflammatory response will cause an elevated erythrocyte sedimentation rate.
A client with allergic rhinitis is prescribed loratadine. On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because: loratadine should be taken on an empty stomach. loratadine isn't available in 10-mg tablets. loratadine isn't available in tablet form. loratadine should be taken once daily for allergic rhinitis.
loratadine should be taken once daily for allergic rhinitis. Explanation: When prescribed for allergic rhinitis, loratadine is usually taken once, not twice, daily. Loratadine is available in 10-mg tablets and should be taken on an empty stomach.
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? lying prone, with the feet higher than the head lying on one side, with the back curved lying prone, with the neck flexed sitting up, with the back straight
lying on one side, with the back curved Explanation: Lumbar puncture involves placing a needle between the lumbar vertebrae into the subarachnoid space. For this procedure, the nurse should position the client on one side with the back curved; curving the back maximizes the space between the lumbar vertebrae, facilitating needle insertion. Prone and seated positions don't achieve maximum separation of the vertebrae.
A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to? organic brain damage impaired memory perceptual impairment lack of information
perceptual impairment Explanation: Because of time spent in a dreamlike state, the client's perception is impaired. Thus, many clients with depersonalization/derealization disorder ignore self-care needs. There's no known organic brain damage with this disorder. Memory impairment is more of a problem with other dissociative disorders, such as dissociative identity disorder and dissociative amnesia. The dreamlike state does not indicate a lack of information.
A client at the eye clinic is newly diagnosed with glaucoma. What should the nurse inform the client might occur if administration of the medication is not closely adhered to? loss of central vision pupillary constriction permanent vision loss diplopia
permanent vision loss Explanation: Without proper treatment, glaucoma may progress to irreversible blindness. Treatment won't restore visual damage but will halt disease progression. Miotics, which constrict the pupil, are used in the treatment of glaucoma to permit outflow of the aqueous humor. Loss of peripheral vision and blurred or foggy vision (not diplopia) are typical in glaucoma. Loss of central vision is common in clients with macular degeneration.
The nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should: have the client lie flat in bed. elevate the client's head to 90 degrees. press the left upper abdomen. press the right upper abdomen.
press the right upper abdomen. Explanation: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux.
A client with placenta previa is hospitalized, and a cesarean birth is planned. When gathering data, what condition should the nurse closely monitor for? respiratory distress prematurity aspiration pneumonia congenital anomalies
respiratory distress Explanation: Hypoxia, resulting in respiratory distress, is a potential risk due to decreased blood volume and prematurity. The age of maturity of the neonate can be determined through established maternal dates. Congenital anomalies aren't necessarily associated with placenta previa. Aspiration pneumonia is not considered a threat unless the amniotic fluid is meconium-stained.
The physician has ordered digoxin for a client with pulmonary edema. The nurse knows that digoxin has a direct and beneficial effect on myocardial contraction in the failing heart. This effect: increases the circulating blood volume. decreases ventricular emptying capacity. decreases cardiac output. slows the conduction of impulses through the atrioventricular (AV) node.
slows the conduction of impulses through the atrioventricular (AV) node. Explanation: Digoxin's physiologic effect on the heart slows impulse conduction through the AV node. Digoxin increases cardiac output and ventricular emptying capacity and promotes diuresis, thereby decreasing the circulating blood volume.
A client with new-onset seizures of unknown cause is started on phenytoin, 750 mg IV now and 100 mg P.O. t.i.d. Which statement best describes the purpose of the loading dose? to prevent the need for surgical excision of the epileptic focus to reduce secretions in case another seizure occurs to more quickly attain therapeutic levels to ensure that the drug reaches the cerebrospinal fluid
to more quickly attain therapeutic levels Explanation: A loading dose of phenytoin and other drugs is given to reach therapeutic levels more quickly; maintenance dosing follows. A loading dose of phenytoin can be oral or parenteral. Surgical excision of an epileptic focus is considered when seizures aren't controlled with anticonvulsant therapy. Phenytoin doesn't reduce secretions.
Sildenafil has been prescribed for a client. While reviewing his medical records, the nurse would question which order? neuralgia insomnia use of multivitamins use of nitroglycerin
use of nitroglycerin Explanation: The nurse would question the use of nitroglycerin. When sildenafil and nitroglycerin are used concurrently, it may cause hypotension. Therefore, it is contraindicated to use nitrates. Insomnia and neuralgia are side effects of the medication, and sildenafil is not contraindicated with the use of vitamins.
A client with a deep vein thrombosis (DVT) is admitted to the hospital for treatment. Which medication will the nurse administer orally to prevent further thrombus formation? warfarin heparin furosemide metoprolol
warfarin Explanation: Warfarin prevents vitamin K from synthesizing certain clotting factors. This oral anticoagulant can be given long-term. Heparin is a parenteral anticoagulant that interferes with coagulation by readily combining with antithrombin; it can't be given by mouth. Neither furosemide nor metoprolol affect anticoagulation.
