exam 3

A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship? Identification Orientation Exploitation Resolution

dentificationIdentification is the stage issues are identified. This client is already known to have health concerns that would warrant a heart-healthy diet. OrientationOrientation is the phase where nurse and client first meet. In this scenario, they already have a relationship. ExploitationMY ANSWERThe nurse is actively coaching the client toward a healthier lifestyle. ResolutionThis is the end of the relationship. The nurse and client in this scenario are actively working.

During inspiration the visceral and parietal pleurae are pulled in the same direction. Select one: True False

f

During inspiration the visceral and parietal pleurae are pulled in the same direction. t/f

false

Thiazolidinediones

t2; reverse insulin resistance (Avandia, Actos)

A nurse is caring for a client who has delivered a healthy newborn. The client tells the nurse that while they are somewhat stressed about being a new parent, they are thrilled by the birth of their child. The nurse should identify that the client is experiencing which of the following types of stress? Allostatic load Distress Eustress Fight-or-flight response

Allostatic loadAllostatic load refers to chronic exposure to elevated or fluctuating endocrine or neural responses, causing excessive wear and tear on the body organs. DistressDistress refers to negative or unhealthy stress. EustressMY ANSWERPositive stress, or eustress, is often associated with accomplishment or achievement and generally produces feelings of well-being, inspiration, and motivation. Fight-or-flight responseThe fight-or-flight response is a physiological response to a threatening situation, which readies one either to forcibly engage or retreat.

A nurse is planning to reconcile medications for a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Ask a staff member who speaks the same language as the client to interpret. Ask a family member of the client to interpret the information. Search the internet for an electronic application to use for translating. Request assistance from the facility's interpreter.

Ask a staff member who speaks the same language as the client to interpret.A staff member who speaks the same language as the client is not a reliable source to interpret important information. The use of a staff member who is not directly providing care for the client is a violation of HIPAA. Ask a family member of the client to interpret the information.It is not advised to use family members for interpretation. A family member might not understand the medical terminology the nurse is using, and they might use their judgment regarding what information to tell the client and what to withhold. The use of a family member to interpret the client's words can also be a violation of HIPAA. Search the internet for an electronic application to use for translating.Electronic translating applications on the internet are not reliable sources. These services are not secure and can constitute a HIPAA violation. The nurse should obtain assistance from the facility's interpreter. Request assistance from the facility's interpreter.MY ANSWERThe nurse should request a facility-approved interpreter to assist with the communication barrier. This would also ensure that the information is correct and gives both the nurse and client an opportunity to ask questions.

A nurse is providing teaching to a client who is about to begin levothyroxine therapy to treat hypothyroidism. Which of the following instructions should the nurse include? Take levothyroxine with food to increase absorption. Take levothyroxine with an antacid to reduce gastrointestinal effects. Expect life-long therapy with the drug. Carry a carbohydrate snack at all times.

take levothyroxine with food to increase absorption.Food reduces the absorption of levothyroxine, a thyroid replacement hormone. The nurse should instruct the client to take it on an empty stomach at least 30 min before eating. Take levothyroxine with an antacid to reduce gastrointestinal effects.Antacids reduce the absorption of levothyroxine, a thyroid replacement hormone. The nurse should instruct the client to allow 4 hr between taking levothyroxine and taking an antacid. Expect life-long therapy with the drug.MY ANSWERTherapy with levothyroxine, a thyroid replacement hormone, usually continues for life because there are no other therapies that can restore thyroid function. Carry a carbohydrate snack at all times.Levothyroxine, a thyroid replacement hormone, does not cause hypoglycemia, so this precaution is not necessary. Clients who are taking hypoglycemics, such as exenatide, should always carry a carbohydrate snack to treat hypoglycemia.

A nurse is interviewing a client who is in distress and tells the nurse, "My ex-partner is suing for full custody of my children. I am so worried and don't know what to do." Which of the following questions should the nurse ask to evaluate the client's coping skills? "Can you describe your relationship with your ex-partner?" "What happens when you feel worried like this?" "What do you believe was your contribution to the relationship breakup?" "What strategies have you used in the past to deal with stress?"

"Can you describe your relationship with your ex-partner?"This question is focused on perception of the relationship rather than the client's ability to cope with and manage the current issue. "What happens when you feel worried like this?"This question is focused on expression of feelings rather than the client's ability to cope with and manage the current issue. "What do you believe was your contribution to the relationship breakup?"This question is focused on perception of the relationship rather than the client's ability to cope with and manage the current issue. "What strategies have you used in the past to deal with stress?"MY ANSWERThis question is appropriate because it focuses on investigating the client's ability to cope with and manage stressful situations.

A nurse is caring for a college student admitted for acute alcohol intoxication. The client reports feeling overwhelmed and expresses an inability to cope with stressors at school. Which of the following statements should the nurse make? "Drinking too much alcohol is not the best choice. I suggest you stop drinking." "I can see why you're using alcohol to cope; you've got a lot going on." "Let's talk about the coping methods that have worked for you in the past." "I've been stressed before too, but I tell myself that I can handle it."

"Drinking too much alcohol is not the best choice. I suggest you stop drinking."This is a judgmental response by the nurse and therefore nontherapeutic in helping the client manage their stress. "I can see why you're using alcohol to cope; you've got a lot going on."Drinking alcohol is a maladaptive response to stress. The nurse should not condone the client's abuse of alcohol as a coping mechanism. "Let's talk about the coping methods that have worked for you in the past."MY ANSWERThe nurse is using therapeutic communication techniques and building on the client's strengths to improve coping skills. Nurses use several therapeutic communication techniques to build a trusting relationship including active listening, asking open-ended questions, seeking clarification, and offering observations. "I've been stressed before too, but I tell myself that I can handle it."The nurse is using nontherapeutic communication and focusing on self, rather than the client.

A nurse is preparing to provide education to a group of newly licensed nurses about methods to enhance communication with clients. Which of the following statements should the nurse include? (Select all that apply.) "Interrupt the client occasionally during the conversation." "Respect the client during the conversation." "Use complex terms when explaining with the client." "Allow time for reflection during the conversation with the client." "Show empathy during the conversation with the client."

"Interrupt the client occasionally during the conversation" is incorrect. Interrupting the client during the conversation allows for the information to be misunderstood and hinders the communication."Respect the client during the conversation" is correct. The nurse should respect the client during the conversation to enhance communication."Use complex terms when explaining with the client" is incorrect. The nurse should use simple terms to so that the client can better understand. This would enhance communication with the client."Allow time for reflection during the conversation with the client" is correct. The nurse should allow time for reflection. This would enhance communication with the client."Show empathy during the conversation with the client" is correct. Showing empathy during the conversation enhances communication with the client.

A nurse is educating the parents of a child who has a new diagnosis of Prader-Willi Syndrome (PWS) and has been prescribed somatropin. Which of the following statements by a parent indicates understanding of the teaching? "We will use a different spot for injection each time we give the medication." "We'll give the shot in the thigh muscle rather than fatty tissue to decrease injection pain." "We'll watch our child for signs of low blood sugar while using somatropin." "We should stop the medication if our child loses weight."

"We will use a different spot for injection each time we give the medication."MY ANSWERTo avoid atrophy of the tissue, administration of somatropin includes rotating the injection site each time. The nurse should identify this statement as an understanding of somatropin administration. "We'll give the shot in the thigh muscle rather than fatty tissue to decrease injection pain."The parents should administer the somatropin injection subcutaneously rather than intramuscularly to decrease pain. This does not alter drug effectiveness. "We'll watch our child for signs of low blood sugar while using somatropin."Growth hormone administration can cause diabetes mellitus and can increase the occurrence of hyperglycemia for clients who have diabetes. The parents should closely monitor the child for polyphagia, polydipsia, and polyuria while on growth hormone therapy. "We should stop the medication if our child loses weight."A heathy loss of weight in clients who are taking somatropin is not a concern. Pediatric clients who have PWS and are taking growth hormone must be weighed often to assess for weight gain that could become problematic. Obesity is a contraindication for using somatropin for clients who have PWS.

A nurse is conducting a preoperative assessment of a client. Which of the following statements is an example of the nurse using motivational interviewing? "You said that you're sad. What is making you feel sad?" "If you want to lose weight, why do you keep eating fast food?" "Have you always struggled with depression?" "Do you have any health problems?"

"You said that you're sad. What is making you feel sad?"MY ANSWERMotivational interviewing uses OARS (open-ended questions, affirmations, reflective listening, summarizing), which includes open-ended questions. This is an example of an open-ended question because it requires more than a yes or no answer. "If you want to lose weight, why do you keep eating fast food?"This is an open-ended question, but it is judgmental and will not encourage the client to disclose more or build trust. "Have you always struggled with depression?"This is a closed-ended question that could be answered with a yes or no. "Do you have any health problems?"This is a closed-ended question that could be answered with a yes or no.

A nurse administers pramlintide at 0800 to a client who has type 1 diabetes mellitus. At which of the following times should the nurse expect the drug to exert its peak action? 0820 0900 1030 1100

0820MY ANSWERPramlintide, an amylin mimetic, peaks 20 min after administration. The nurse should monitor the client for indications of hypoglycemia, such as diaphoresis and tremors. 0900Pramlintide, an amylin mimetic, is unlikely to cause severe hypoglycemia 1 hr after administration. Aspart insulin is an injectable hypoglycemic drug that can exert its peak action at that time. 1030Pramlintide, an amylin mimetic, is unlikely to cause severe hypoglycemia 2.5 hr after administration. Regular insulin is an injectable hypoglycemic drug that can exert its peak action at that time. 1100Pramlintide, an amylin mimetic, is unlikely to cause severe hypoglycemia 3 hr after administration. Regular insulin is an injectable hypoglycemic drug that can exert its peak action at that time.

A nurse is assessing a client 5 hr after the insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider? 400 mL drainage since insertion A gush of fluid when repositioning the client About 150 mL/hr drainage over the past 2 hr Significant decrease in drainage over the past 3 hr

400 mL drainage since insertionThe nurse should expect drainage of 100 to 300 mL of fluid during the first 3 hr after pleural insertion of a chest tube. Because the chest tube was inserted 5 hr ago, 400 mL of drainage is within the expected reference range. A gush of fluid when repositioning the clientA sudden gush of drainage when repositioning a client is often due to retained blood, rather than active bleeding. Unless the total amount exceeds the expected range of drainage for this client at this time, the nurse does not need to report this to the provider. About 150 mL/hr drainage over the past 2 hrMY ANSWERAfter the first few hours, the nurse should report drainage that exceeds 70 mL/hr. Clients who lose 100 mL of blood every 15 min might require autotransfusion within 6 hr. Significant decrease in drainage over the past 3 hrThe nurse should expect drainage of 100 to 300 mL of fluid during the first 3 hr after pleural chest-tube insertion. The amount of drainage begins to decrease around 2 hr after insertion, so this is an expected finding.

A nurse in a community clinic is interviewing a client who is distressed and reports being unable to sleep following a neighborhood fire several days ago. The client has hypertension, tachycardia, and is diaphoretic. The nurse should identify that the client is experiencing which of the following types of stress? Acute stress Post-traumatic stress disorder (PTSD) Episodic acute stress Chronic stress

Acute stressMY ANSWERThe nurse should identify that the client is experiencing acute stress. Most episodes of acute stress do not have lingering health effects; however, if an individual experiences severe or prolonged stress levels, this condition could lead to mental health issues. Post-traumatic stress disorder (PTSD)Symptoms of PTSD include recurring and intrusive memories or flashbacks of the trauma, nightmares, and an exaggerated startle response to certain noises or experiences that remind them of the trauma. Episodic acute stressEpisodic acute stress occurs when someone experiences frequent and recurring episodes of acute stress. Chronic stressChronic stress is a disabling condition that occurs when stress levels are heightened, constant, and prolonged.

A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take? Administer an antagonist to reverse the effects of the anesthesia. Use an alternative method for determining the client's pain level. Administer a pain medication as prescribed for severe pain. Wait until the client is awake, alert, and able to vocalize their pain level.

Administer an antagonist to reverse the effects of the anesthesia.The client is alert to verbal stimuli but is not experiencing any distress. Therefore, administering an antagonist is not indicated. The nurse should use an alternative method to determine the client's pain level. Use an alternative method for determining the client's pain level.MY ANSWERMedications such as general anesthesia can cause cognitive deficits that could make it difficult for the client to communicate their needs. The nurse should use an alternative method for determining the client's pain level by observing facial expressions (grimacing or clenching of the teeth); body movements, including restlessness, muscle tension, or resisting movement; and vocalizing discomfort by moaning, grunting, or crying. Administer a pain medication as prescribed for severe pain.The client is drowsy but responsive to verbal stimuli. Administering a medication without properly determining the client's pain level can result in respiratory depression and hypotension. Therefore, the nurse should use another strategy to determine the client's pain level prior to administering any medication for pain. Wait until the client is awake, alert, and able to vocalize their pain level.Allowing pain to remain untreated can increase the client's pain level and require more medication, which can result in complications such as respiratory depression. The nurse should use an alternative method of determining the client's pain level and consider the client's respiratory status and blood pressure before administering a pain medication.

A nurse is caring for a client who has refused to have a biopsy. The client states, "I don't need the biopsy; I wouldn't do anything about it anyways if it's cancer." The nurse replies, "You don't want to have the biopsy because you would not seek treatment if it was cancer. Is that correct?" Which of the following therapeutic communication techniques is the nurse using? Affirmation Open-ended question Reflection Restating

AffirmationAffirmation is a therapeutic technique that uses statements meant to build the client's confidence. The nurse is simply restating the client's words, but they are not attempting to boost the client's confidence. Open-ended questionThe nurse's response is able to be answered by the client with a yes or no reply. Open-ended questions attempt to get more information from the client. They cannot be answered with a single-word answer such as yes or no. The nurse responded with a restatement or paraphrase of what the client stated. ReflectionReflection is a therapeutic technique that attempts to elicit how the client is feeling or the emotion about what they communicated. It is similar to restating, but in this case, the nurse is not trying to understand the client's feelings about their decision. RestatingMY ANSWERThe nurse is summarizing, paraphrasing, or restating the client's thoughts to confirm the nurse understands what the client is attempting to communicate.

A nurse calls the unit to tell say that they will be late for their shift. The charge nurse responds, "Don't worry, take your time and be safe." After hanging up the phone, the charge nurse then says to staff at the nurses' station, "I'm tired of that nurse always being late. I wish someone would do something about their tardiness." Which of the following communication styles is the charge nurse demonstrating? Assertive Aggressive Passive-aggressive Passive

AssertiveThe charge nurse exhibited a passive-aggressive style of communication. An assertive communicator would have effectively communicated in private to the oncoming nurse that being late for work puts other nurses at a disadvantage of having to care for additional clients and might delay client care. Assertive communicators advocate for their rights and the rights of others in a nonhostile manner. AggressiveThe charge nurse exhibited a passive-aggressive style of communication. Aggressive communicators verbally and directly express their thoughts to the person who has upset them. In this situation, the charge nurse did not express any anger or hostility at the oncoming nurse. Passive-aggressiveMY ANSWERDuring the phone call while talking with the oncoming nurse, the charge nurse was pleasant and accepting that the nurse would be late. However, once the phone call ended, the charge nurse then complained about the nurse always being late to the other staff. The charge nurse exhibited a passive-aggressive style of communication. PassiveThe charge nurse exhibited a passive-aggressive style of communication. Passive communicators have developed a pattern to avoid conflict, expression of their feelings or opinions, and standing up for themselves when boundaries are crossed.

A nurse is obtaining a health history from a client who is newly admitted. The nurse notices that the client does not make eye contact and that their arms are folded across their chest. The nurse should recognize that the client is using which of the following forms of communication? Auditory Nonverbal Emotional Energetic

AuditoryAuditory communication is what the receiver hears when the sender speaks a message. In this scenario, the client is the sender and the nurse is the receiver. However, the nurse should recognize that the client is exhibiting nonverbal communication. NonverbalMY ANSWERThe nurse should recognize the client is exhibiting nonverbal communication through their physical gestures. Nonverbal communication, also known as body language, plays an important role in interactions among nurses, clients, and their families. For instance, not making eye contact, not being engaged in the conversation, or having closed posture (folded arms, slouching) can portray a negative message. EmotionalEmotional communication refers to the speaker's emotional state when they are conveying their message. The nurse should recognize that the client is exhibiting nonverbal communication. EnergeticEnergetic communication is how the speaker projects themselves while speaking. The nurse should recognize that the client is exhibiting nonverbal communication.

A nurse is teaching a client who has a prescription for glipizide therapy to treat type 2 diabetes mellitus. Which of the following instructions should the nurse include? Avoid drinking alcohol. Sit or stand for 30 min after taking the drug. Urinate every 4 hr. Take the drug 2 hr after a meal.

Avoid drinking alcohol.MY ANSWERThe nurse should instruct the client to avoid drinking alcohol. Alcohol can interact with glipizide, a sulfonylurea, causing nausea, palpitations, and flushing. Alcohol also increases the drug's hypoglycemic effects. Sit or stand for 30 min after taking the drug.Glipizide, a sulfonylurea, is unlikely to cause esophagitis. However, it can cause gastrointestinal distress with heartburn. Urinate every 4 hr.Glipizide, a sulfonylurea, is unlikely to cause urinary retention. However, it can cause diarrhea. Clients who develop this adverse reaction should maintain hydration by drinking plenty of electrolyte-rich fluids. Take the drug 2 hr after a meal.Glipizide, a sulfonylurea, helps control hyperglycemia caused by type 2 diabetes mellitus. The client should take the drug 30 min before the first meal of the day.

A nurse is assessing a client who has a new prescription for levothyroxine. The nurse should identify which of the following findings as a contraindication for this drug? Bacterial skin infections Diabetes insipidus Immunosuppression Recent myocardial infarction

Bacterial skin infectionsClients who have bacterial skin infections can take levothyroxine, a thyroid replacement hormone. Fludrocortisone is an endocrine-system drug that requires cautious use with clients who have bacterial skin infections. Diabetes insipidusClients who have diabetes insipidus can take levothyroxine, a thyroid replacement hormone. It requires cautious use with clients who have diabetes mellitus. ImmunosuppressionClients who are immunosuppressed can take levothyroxine, a thyroid replacement hormone. Propylthiouracil (PTU) is an endocrine-system drug that requires cautious use with clients who are immunosuppressed. Recent myocardial infarctionMY ANSWERLevothyroxine, a thyroid replacement hormone, can cause tachycardia, palpitations, and hypertension, especially when the client requires a dosage adjustment. Therefore, it is contraindicated for clients who have recently had a myocardial infarction.

A nurse is caring for a client who has delivered a healthy newborn. The client is tense, refuses to hold the baby, and tells the nurse, "I have no idea how to handle having a baby. I wish this pregnancy had never happened." Which of the following statements should the nurse make? "Becoming a parent is a new experience for you. Let's talk about your concerns." "You should be thrilled about having a healthy newborn. I would be." "Why don't you hold the baby? I'm sure it will make you feel better." "How can you think that way? This is a joyous occasion and should be celebrated."

Becoming a parent is a new experience for you. Let's talk about your concerns."MY ANSWERAn individual's perceptions of and responses to the stressor determine whether the stressor is positive (eustress) or negative (distress). By using therapeutic communication skills, the nurse creates a safe environment for the client to express thoughts and feelings. "You should be thrilled about having a healthy newborn. I would be."How an individual appraises the stressor determines how they will respond to the stressor. This is a judgmental and nontherapeutic response by the nurse. "Why don't you hold the baby? I'm sure it will make you feel better."How an individual appraises the stressor determines how they will respond to the stressor. This is a nontherapeutic response by the nurse because the client's stress is being disregarded. "How can you think that way? This is a joyous occasion and should be celebrated."How an individual appraises the stressor determines how they will respond to the stressor. This is a confrontational and nontherapeutic response by the nurse.

A nurse is caring for a client who is about to begin taking somatropin. The nurse should explain the need to monitor which of the following laboratory values? (Select all that apply.) Blood amylase Creatinine clearance Urine calcium Blood glucose CBC

Blood amylase is incorrect. Somatropin, a growth hormone, is unlikely to alter blood amylase levels. Sitagliptin, an antithyroid drug, is an endocrine-system drug that requires monitoring of blood amylase levels because it can cause pancreatitis.Creatinine clearance is incorrect. Somatropin is unlikely to alter creatinine clearance. Desmopressin, an antidiuretic hormone, is an endocrine-system drug that requires monitoring of creatinine clearance.Urine calcium is correct. Somatropin can cause hypercalciuria. The nurse should monitor the client's urine calcium and instruct the client to report flank pain, urinary frequency, or hematuria.Blood glucose is correct. Somatropin can cause hyperglycemia. The nurse should monitor the client's blood glucose levels and instruct the client to report polyphagia, polydipsia, and polyuria.CBC is incorrect. Somatropin is unlikely to alter the client's CBC. Radioactive iodine-131, an antithyroid drug, is an endocrine-system drug that requires monitoring CBC.

A nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation? Clamp the chest tube. Milk the chest tube. Make sure the air vent is open. Empty the collection chamber.

Clamp the chest tube.The nurse should never clamp a chest tube during transportation, as it increases the risk for tension pneumothorax. Milk the chest tube.The nurse should not milk tubing because this increases the pressure in the intrathoracic cavity and can damage lung tissue. Make sure the air vent is open.MY ANSWERSome closed-chest drainage systems and suction devices contain a vent from the water-seal chamber. This allows the drainage unit to remain vented without suction. So, the nurse should make sure this exit vent is open when disconnecting the suction source. Empty the collection chamber.Closed-chest wet-suction drainage systems are disposable. When the collection chamber is nearly full, the nurse should replace it, rather than empty it.

A nurse is caring for a client who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flange of the outer cannula? Commercially prepared transparent dressing Cotton-filled gauze square Commercially prepared fenestrated dressing Twill tape

Commercially prepared transparent dressingTracheostomy dressings should be removed often, and the adhesive backing of a transparent dressing would be too irritating to the client's skin if removed frequently. Cotton-filled gauze squareLint or fibers from cotton-filled gauze squares place the client at risk for aspiration. Cotton-filled gauze squares are not used for a tracheostomy dressing. Commercially prepared fenestrated dressingMY ANSWERA commercially prepared tracheostomy dressing is made of material that does not unravel and has a fenestration (slit) designed to fit around the tracheostomy tube under the flanges. Twill tapeTwill tape is attached to the edges of the flanges of the tracheostomy tube to secure it in place. Twill tape is not placed underneath the flanges of the outer cannula.

A nurse is caring for a client who is 6 hr postoperative and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system? Constant bubbling in the suction-control chamber Fluctuations in the fluid level in the water-seal chamber Occasional bubbling in the water-seal chamber Continuous bubbling in the water-seal chamber

Constant bubbling in the suction-control chamberThe nurse should expect constant, gentle bubbling in the suction-control chamber. Vigorous bubbling in this chamber can disturb the client, and it also increases the rate of water evaporation while decreasing the amount of suction. Fluctuations in the fluid level in the water-seal chamberThe nurse should expect to see fluctuation in the fluid level in the water-seal chamber with inspiration and exhalation, as this reflects the expected pressure changes in the pleural space during respiration. Fluctuation stops when the lung has re-expanded, but it can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning. Occasional bubbling in the water-seal chamberThe nurse should expect occasional bubbling in the water seal chamber, especially when the client coughs or exhales forcefully. The bubbles indicate the removal of air from the pleural space, which is the expected result. Continuous bubbling in the water-seal chamberMY ANSWERExcessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should use rubber-tipped clamps to try to locate the leak by clamping the tube momentarily near the site of the chest tube insertion.

A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request? Cultural factor Developmental factor Environmental factor Physiological factor

Cultural factorMY ANSWERDeath-related rituals might be very closely tied to cultural factors such as religion. The nurse should recognize that this client is expressing a death ritual of the last rites, which is associated with Catholicism. Developmental factorThe nurse should recognize developmental and cognitive factors, such as dementia, can greatly influence a person's ability to effectively communicate. However, this client was able to communicate their wishes clearly to the nurse. Environmental factorThe nurse should recognize that environmental factors such as excessive noise, extreme temperatures, and poor or too-bright lighting can affect communication. However, this communication between the client and the nurse is about the client's request for a ritual that is associated with cultural factor. No environmental factors were noted. Physiological factorThe nurse should recognize physiological factors such as hearing or vision loss can prevent effective communication. However, this communication between the nurse and the client is not affected by physiological factors.

A nurse is caring for an older adult client who reports being stressed about their health status due to problems with short-term memory, slower reaction times when driving, and urinary frequency. The nurse should recognize that the client is experiencing which of the following types of stressors? Developmental stressors Situational stressors Adventitious stressors Socioeconomic stressors

Developmental stressorsMY ANSWERDevelopmental, or maturational, stressors vary throughout the lifespan and occur as individuals move through the stages of life. Older adults may experience stressors related to health problems and changes in mobility and cognition. Situational stressorsSituational stressors typically stem from personal, family, and work-related issues. Adventitious stressorsAdventitious stressors typically result from events such as floods, earthquakes, war, and physical assault. Socioeconomic stressorsSocioeconomic stressors are typically related to factors such as poverty, low socioeconomic status, and homelessness.

A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema? Diminished lung sounds on the affected side A dry, crackling sound at the insertion site when palpated Absence of drainage in the collection chamber Hyperresonance when percussing the affected lung

Diminished lung sounds on the affected sideDiminished lung sounds on the affected side is an indication that the lung has not yet fully re-expanded. This is not a finding associated with subcutaneous emphysema. A dry, crackling sound at the insertion site when palpatedMY ANSWERA dry, crackling sound at the insertion site is an indication of subcutaneous emphysema, which is a result of air leaking into the subcutaneous tissue surrounding the chest-tube insertion site. Absence of drainage in the collection chamberAbsence of drainage in the collection chamber is an indication of an obstruction in the chest tube or the drainage system's tubing. This is not a finding associated with subcutaneous emphysema. Hyperresonance when percussing the affected lungHyperresonance over the affected lung could be an indication of tension pneumothorax. This finding requires immediate action by the nurse. However, this is not a finding associated with subcutaneous emphysema.

A nurse is caring for a client who takes repaglinide 15 to 30 min before each meal to treat type 2 diabetes mellitus. The client asks, "If I skip a meal, what should I do?" Which of the following responses should the nurse make? Double the dose before the next meal. Take half the dose. Skip the dose. Take the usual dose.

Double the dose before the next meal.Taking a double dose of repaglinide, a meglitinide, before the next meal puts the client at risk for hypoglycemia. Take half the dose.Taking half the dose of repaglinide, a meglitinide, without the meal puts the client at risk for hypoglycemia. Skip the dose.MY ANSWERTo avoid a sudden and serious drop in blood glucose level, the client should skip the dose of repaglinide, a meglitinide, whenever skipping a meal. The nurse should also instruct the client to try to avoid skipping meals. Take the usual dose.Taking the full dose of repaglinide, a meglitinide, without the meal puts the client at risk for hypoglycemia.

A nurse is speaking with a client who is taking glipizide to treat type 2 diabetes mellitus and has called to report feeling shaky, hungry, and fatigued. Which of the following actions should the nurse instruct the client to take? Drink 16 oz of water. Perform a fingerstick blood glucose check. Take another glipizide tablet. Lie down and rest.

Drink 16 oz of water.Glipizide, a sulfonylurea, can cause diarrhea. Clients who develop this adverse reaction should maintain hydration by drinking plenty of fluids. However, the client's symptoms indicate a different adverse reaction to the drug. Perform a fingerstick blood glucose check.MY ANSWERGlipizide, a sulfonylurea, can cause hypoglycemia, which can manifest as diaphoresis, shakiness, hunger, and fatigue. The nurse should tell the client to check their blood glucose level and, if it indicates hypoglycemia, to consume a snack of 15 to 20 g (0.5 to 0.7 oz) of carbohydrates, retest in 15 to 20 min, and repeat if their blood glucose level is still low. Take another glipizide tablet.Glipizide, a sulfonylurea, treats hyperglycemia from type 2 diabetes mellitus. Clients do not take the drug PRN, but rather on a fixed, once-daily dosing schedule. It would be inappropriate to double the dosage within the same 24-hr period, even if the client were experiencing hyperglycemia. Lie down and rest.Lying down and resting can help the client feel less fatigued, but these actions do not address the adverse reaction the client is having to glipizide, a sulfonylurea.

A nurse is teaching a client about acarbose therapy to treat type 2 diabetes mellitus. Which of the following instructions should the nurse include? Eat more iron-rich foods. Avoid drinking grapefruit juice. Increase fiber intake. Avoid drinking green tea.

Eat more iron-rich foods.MY ANSWERAcarbose, an alpha-glucosidase inhibitor, can cause iron-deficiency anemia. The nurse should instruct the client to increase their intake of iron-rich foods, such as red meat, spinach, and grains. The nurse should also monitor the client's CBC. Avoid drinking grapefruit juice.Grapefruit juice is unlikely to alter the effects of acarbose, an alpha-glucosidase inhibitor. More than 1 L of grapefruit juice per day can increase the hypoglycemic effects of repaglinide, a meglitinide. Increase fiber intake.Acarbose, an alpha-glucosidase inhibitor, is unlikely to cause constipation. It can cause diarrhea and flatulence. Metformin can worsen the gastrointestinal effects of the drug. Avoid drinking green tea.Green tea is unlikely to alter the effects of acarbose, an alpha-glucosidase inhibitor. Green tea can increase the hypoglycemic effects of pioglitazone, another endocrine-system drug.

A nurse is planning a presentation about skin care for a group of older adult clients at a senior center. Which of the following actions should the nurse take to enhance client learning? Ensure the room is well lit. Have soft music playing in the background. Hand out samples of products during the teaching. Speak quickly during the teaching.

Ensure the room is well lit.MY ANSWERThe nurse should identify that a well-lit room can allow the participants to better see the presentation as well as the nurse during the teaching. Have soft music playing in the background.The nurse should identify that distractions such as background music can limit learning by the clients. Instead, the nurse should ensure the teaching environment is free of distractions. Hand out samples of products during the teaching.The nurse should identify that the use of samples can enhance learning. However, the nurse should distribute the samples prior to or following the presentation to avoid distractions during the teaching. Speak quickly during the teaching.The nurse should identify that teaching is enhanced when clients can see and hear the speaker and when the speech is clear and delivered at a slower pace.

A nurse is caring for a client who has dementia. Which of the following communication strategies should the nurse implement to communicate with the client? Explain the daily schedule to the client in detail. Turn the overhead lights on in the client's room when speaking with them. Speak in a loud voice to the client. Speak to the client clearly and at a slow pace.

Explain the daily schedule to the client in detail.The nurse should avoid detailed or lengthy explanations and directions. Clients who have dementia are better able to follow simple instructions and explanations. Turn the overhead lights on in the client's room when speaking with them.One of the factors in communication is the environment. The nurse should create an environment that enhances communication with clients who have dementia. Clients who have dementia and other cognitive deficits focus better with softer lighting. Bright lights or increased noise in the environment might decrease the client's ability to communicate. Speak in a loud voice to the client.The nurse should create an environment that enhances communication with clients who have dementia. Decreasing the volume of noise will assist the client to communicate to the best of their ability. Speak to the client clearly and at a slow pace.MY ANSWERThe nurse should speak to the client who has cognitive or developmental delays clearly and at a slower pace. The nurse should also avoid the use of complicated terms or medical terminology.

A nurse is caring for a client who is in crisis following the breakup of a long-term relationship. The client tells the nurse, "I might as well just die. My life is over." Which of the following actions should the nurse take first? Explore past positive coping strategies. Establish a follow-up plan of care. Conduct a suicidal risk evaluation. Display a neutral attitude.

Explore past positive coping strategies.While exploring positive coping strategies is an essential aspect of crisis intervention, it is not the first action the nurse should take. Establish a follow-up plan of care.While establishing a follow-up plan of care is an essential aspect of crisis intervention, it is not the first action the nurse should take. Conduct a suicidal risk evaluation.MY ANSWERThe greatest risk to this client is injury to self or others; therefore, the first action the nurse should take is to conduct a suicidal and homicidal risk evaluation. Display a neutral attitude.While the nurse should establish a therapeutic environment and display a neutral, nonjudgmental attitude toward the client, it is not the first action the nurse should take.

A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client? Have the client splint the affected side during coughing. Perform passive range-of-motion exercises. Place the client in a supine position with minimal elevation. Encourage ambulation.

Have the client splint the affected side during coughing.MY ANSWERIt is essential for a client with a chest tube to cough to prevent postoperative complications and to help drain the pleural space and expand the lungs. Splinting the affected side, such as with a pillow, can help minimize the pain of coughing. The nurse should also administer analgesia to help reduce the pain of coughing and other activities. Perform passive range-of-motion exercises.Although passive range-of-motion exercises on the affected side can help prevent postoperative complications related to immobility and preserve joint function, they can be painful for a client who has a chest tube. The nurse should administer analgesia 30 min prior to passive range-of-motion exercises to promote comfort for the client. Place the client in a supine position with minimal elevation.The client should be placed in an upright position to allow optimal lung expansion. The nurse should elevate the head of the client's bed to at least 30°. Encourage ambulation.Although ambulation can help prevent postoperative complications and help the client feel that the recovery is progressing, it can be painful with a chest tube in place. The nurse should administer analgesia 30 min prior to ambulation to promote comfort for the client.

A nurse is suctioning a client's airway using in-line suctioning. Which of the following actions should the nurse plan to take? Hyperoxygenate the client before disconnecting the ventilator. Apply suction pressure while advancing the catheter. Wear a face shield during the procedure. Reuse the catheter repeatedly.

Hyperoxygenate the client before disconnecting the ventilator.With in-line suctioning, it is not necessary to disconnect the client from the ventilator. Apply suction pressure while advancing the catheter.For any method of endotracheal or tracheostomy suctioning, applying suction when inserting the catheter is inappropriate because it could cause tissue trauma and oxygen depletion for the client. Wear a face shield during the procedure.With in-line suctioning, the nurse is not exposed to airway secretions, because the catheter is enclosed in a plastic sheath. Therefore, a face shield is not necessary. Reuse the catheter repeatedly.MY ANSWERWith in-line suctioning, the catheter attaches to the ventilator tubing and does not need to be replaced until the system is replaced. It can be used repeatedly.

A nurse is caring for a client whose partner was recently hospitalized with COVID-19. The client is experiencing manifestations related to the alarm stage of general adaptation syndrome (GAS). For which of the following manifestations should the nurse monitor? (Select all that apply.) Hypertension Dilated pupils Increased state of arousal Bradycardia Lethargy

Hypertension is correct. During the alarm stage of GAS, the client's fight-or-flight response is mobilized to meet the threat. The nurse should expect rising hormone levels during this phase to cause hypertension.Dilated pupils is correct. During the alarm stage of GAS, the nurse should expect rising hormone levels during this phase to cause dilated pupils.Increased state of arousal is correct. During the alarm stage of GAS, the nurse should expect rising hormone levels during this phase to cause an increased state of arousal.Bradycardia is incorrect. During the alarm stage of GAS, the nurse should expect that rising hormone levels during this phase can cause an increase in heart rate.Lethargy is incorrect. During the alarm stage of GAS, the nurse should expect that rising hormone levels during this phase can cause a heightened state of alertness.

A nurse is caring for a client who is taking metformin and is scheduled to undergo angiography using iodine-containing contrast dye. The nurse should identify that an interaction between metformin and the IV contrast dye increases the client's risk for which of the following conditions? Hypokalemia Hyperglycemia Acute renal failure Acute pancreatitis

HypokalemiaMetformin, a biguanide, is unlikely to cause hypokalemia when used with iodine-containing contrast dye. Regular insulin is an endocrine-system drug that can cause hypokalemia. HyperglycemiaMetformin, a biguanide, is unlikely to cause hyperglycemia when used with iodine-containing contrast dye. Glucagon is an endocrine-system drug that can cause hyperglycemia. Acute renal failureMY ANSWERMetformin, a biguanide, can interact with iodine-containing contrast dye and cause acute renal failure and lactic acidosis. The nurse should withhold metformin for 48 hr prior to and following the procedure. The nurse should also monitor the client for indications of acute renal failure or lactic acidosis, such as reduced urine output, hyperventilation, and abdominal pain. Acute pancreatitisMetformin, a biguanide, is unlikely to cause acute pancreatitis when used with iodine-containing contrast dye. Exenatide is an endocrine-system drug that can cause can cause acute pancreatitis.

A nurse at a provider's office is assessing a client who has been taking hydrocortisone for adrenal insufficiency. The client reports fatigue and feeling overwhelmed by personal responsibilities. Which of the following findings should the nurse identify as an indication the provider might need to increase the client's dosage? Hypotension Hyperglycemia Weight gain Fat redistribution

HypotensionMY ANSWERHypotension and fatigue are findings of adrenal insufficiency. During times of stress, the client might need a dosage increase to prevent adrenal insufficiency. The nurse should report the findings to the provider. HyperglycemiaThe nurse should identify hypoglycemia as an indication that the client's dosage is too low. Weight gainThe nurse should identify weight loss as an indication that the client's dosage is too low. Fat redistributionFat redistribution or a moon face appearance are Cushingoid findings. The nurse should identify fat redistribution as an indication that the client's dosage is too high.

A nurse in a provider's office is caring for a client who has hypertension during a follow-up appointment and is focusing on the client's ability to make healthy behavior changes. Which of the following statements by the nurse is an example of the use of affirmations? "I'm glad you decided to continue your fitness routine." "You could achieve better results if you applied yourself more." "You are adjusting very well for your age." "Reducing your caffeine intake is good, but you really need to stop completely."

I'm glad you decided to continue your fitness routine."MY ANSWERThis statement by the nurse builds the client's confidence and acknowledges the client's efforts to make positive changes. It is an example of the use of affirmations to acknowledge the client's efforts to make healthy behavior changes. "You could achieve better results if you applied yourself more."This statement by the nurse does not build the client's confidence or acknowledge their accomplishment. It is judgmental and does not give the client credit for their gains. "You are adjusting very well for your age."This statement by the nurse does not build the client's confidence or acknowledge their accomplishment. This statement is condescending. "Reducing your caffeine intake is good, but you really need to stop completely."This statement by the nurse does not build the client's confidence or acknowledge their accomplishment. It focuses more on what the client has not achieved than what they have achieved.

A nurse is preparing to suction a client's oral airway. Which of the following devices or methods should the nurse use? In-line suctioning Yankauer catheter Bulb syringe Open suctioning

In-line suctioningWith in-line suctioning, also called closed suctioning, the suction catheter is attached to the ventilator tubing. It is designed to remove secretion from the trachea, not from the mouth. Yankauer catheterMY ANSWERYankauer (tonsil tip) suction catheter helps clear secretions from the mouth. This is the appropriate device to use for clients who can cough effectively but cannot swallow or expectorate secretions. Bulb syringeBulb syringes are generally used for suctioning secretions from a newborn's mouth and nose. Because of the low level of suction provided, they are generally inadequate for suctioning an adult client's secretions. Open suctioningThe open method is the traditional means of suctioning an endotracheal tube or a tracheostomy in which the catheter is used only once. It is not appropriate to use this method for suctioning a client's mouth.

A nurse is assessing a client who was sexually assaulted 6 months ago and has been diagnosed with post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect? (Select all that apply.) Intrusive memories of the event Flashbacks of the event Poor work relationships Exaggerated startle response when reminded of the event Frequent episodes of diarrhea

Intrusive memories of the event is correct. A client who has PTSD can experience intrusive memories of the event.Flashbacks of the event is correct. A client who has PTSD can experience flashbacks of the event.Poor work relationships is incorrect. Having poor work relationships is not a manifestation associated with PTSD.Exaggerated startle response when reminded of the event is correct. A client who has PTSD can experience an exaggerated startle response when reminded of the event.Frequent episodes of diarrhea is incorrect. Diarrhea is not a manifestation associated with PTSD.

A nurse is assessing a client who is working at home due to COVID-19 restrictions. The client reports abdominal cramping and bloating with diarrhea and states, "I am completely stressed out from working at home." The nurse should identify that the client is experiencing manifestations of which of the following stress-related conditions? Irritable bowel syndrome Food poisoning Panic disorder Major depressive disorder

Irritable bowel syndromeMY ANSWERIrritable bowel syndrome is a condition often triggered by stress and characterized by abdominal discomfort, cramping, bloating, and diarrhea. Food poisoningSome of the symptoms the client is describing might mimic food poisoning; however, food poisoning is not a stress-related condition. Panic disorderPanic disorder is a type of anxiety disorder characterized by sudden feelings of terror. Major depressive disorderMajor depressive disorder is a mental health disorder characterized by persistently depressed mood and loss of interest in activities.

A nurse is caring for a client who is taking pioglitazone to treat type 2 diabetes mellitus. The nurse should monitor for which of the following findings? Joint pain Constipation Weight gain Dilated pupils

Joint painPioglitazone, a thiazolidinedione, is more likely to cause muscle pain than joint pain. ConstipationPioglitazone, a thiazolidinedione, is more likely to cause diarrhea than constipation. Weight gainMY ANSWERPioglitazone, a thiazolidinedione, can cause fluid retention. The nurse should monitor the client for weight gain and other indications of fluid retention or heart failure, including dyspnea, crackles, and wheezing. Dilated pupilsPioglitazone, a thiazolidinedione, is more likely to cause blurred vision than dilated pupils.

A nurse is caring for a client who is taking desmopressin. The nurse should make which of the following assessments to evaluate the drug's effectiveness? Peripheral pulses Urine output Skin integrity Blood glucose

Peripheral pulsesDesmopressin, an antidiuretic hormone, is unlikely to alter peripheral pulses. Vasopressin, another antidiuretic hormone, can cause vasoconstriction and angina pectoris. Desmopressin does not alter hemodynamics. Urine outputMY ANSWERDesmopressin, an antidiuretic hormone, treats diabetes insipidus. The nurse should monitor the client's fluid intake and urine output along with urine and serum osmolality and blood pressure. Skin integrityDesmopressin, an antidiuretic hormone, is unlikely to alter skin integrity. Propylthiouracil (PTU), an antithyroid drug, is an endocrine-system drug that requires integumentary monitoring because it can cause a rash. Blood glucoseDesmopressin, an antidiuretic hormone, is unlikely to alter blood glucose. However, it can cause hyponatremia. The nurse should monitor the client's sodium levels.

A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate? Keep the collection device upright at all times. Disconnect the system when showering. Keep the collection device at chest level at all times. Allow the tubing to hang in a dependent loop when ambulating.

Keep the collection device upright at all times.MY ANSWERThe closed-chest drainage system must be kept upright at all times to ensure that the tubing drains optimally and the system functions correctly. Disconnect the system when showering.The client must not disconnect the system at any time. Disconnecting the system can result in air entering the pleural space, which can cause or worsen a pneumothorax. Keep the collection device at chest level at all times.The nurse should instruct the client to keep the drainage system below the level of the chest when sitting or ambulating to ensure proper functioning and drainage. Allow the tubing to hang in a dependent loop when ambulating.The client should avoid creating dependent loops of tubing. When the client cannot avoid them, the nurse should lift the tubing every 15 min to allow its contents to drain.

A nurse is caring for a client who is taking metformin to treat type 2 diabetes mellitus and reports muscle pain. Which of the following adverse reactions should the nurse suspect? Lactic acidosis Anticholinergic effects Extrapyramidal effects Hypophosphatemia

Lactic acidosisMY ANSWERMetformin, a biguanide, can cause lactic acidosis, which is a life-threatening complication that manifests as muscle aches, sleepiness, malaise, and hyperventilation. The client should stop taking the drug and seek medical care immediately. Anticholinergic effectsMetformin, a biguanide, is unlikely to cause anticholinergic effects, but it can cause nausea, diarrhea, and anorexia. The nurse should inform the client that these effects should diminish with continued therapy. Extrapyramidal effectsMetformin, a biguanide, is unlikely to cause extrapyramidal effects, but it can cause dizziness and fatigue. HypophosphatemiaMetformin, a biguanide, is unlikely to cause hypophosphatemia, but it can cause vitamin B12 or folic acid deficiencies, which would manifest as weakness, fatigue, pallor, or a reddened tongue.

A nurse enters a client's room and stands near the client to ask them if they need anything. The client continues to watch the television, which is at a loud volume. Which of the following actions should the nurse take? Leave the client's room to go check on other clients. Ask the client why they are ignoring the question. Repeat the question in a loud voice. Lower the volume on the television.

Leave the client's room to go check on other clients.This action is dismissive of the client's needs and does not help to establish communication with the client. Ask the client why they are ignoring the question.This question is nontherapeutic. Asking questions with "why" can make the client feel defensive and implies criticism. Repeat the question in a loud voice.If the client has a hearing deficit, the nurse increasing the volume of their voice might not be effective in communicating with this client. Lower the volume on the television.MY ANSWERThe nurse should minimize the noise in the environment by decreasing the volume on the television when communicating with the client. Auditory communication is what the receiver hears when the sender speaks a message. It can be affected by environmental noise. The loud television presents a barrier to communication and the nurse should reduce the environmental noise.

A nurse is providing teaching to a client who is about to begin exenatide therapy to treat type 2 diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) Inject the drug subcutaneously. Expect the peak effect in 2 hr. Use the drug as a supplement to an oral hypoglycemic. Inject the drug 1 hr after a meal. Discard used pens 10 days after the first use.

MY ANSWER Inject the drug subcutaneously is correct. The client should inject exenatide, an incretin mimetic, into the subcutaneous tissue of the thigh, upper arm, or abdomen.Expect the peak effect in 2 hr is correct. Levels of exenatide peak 2 hr after administration and then decrease gradually, with a half-life of 2.4 hr.Use the drug as a supplement to an oral hypoglycemic is correct. Exenatide supplements the action of an oral hypoglycemic, such as a sulfonylurea or metformin.Inject the drug 1 hr after a meal is incorrect. The client should inject exenatide twice per day up to 60 min prior to the morning and evening meals, rather than after a meal.Discard used pens 10 days after the first use is incorrect. The client can keep prefilled exenatide injector pens in use at room temperature for up to 30 days.

A nurse is teaching a client who has a prescription for pramlintide therapy to treat type 1 diabetes mellitus. Which of the following instructions should the nurse include? Mix pramlintide with insulin in the syringe. Administer pramlintide before meals. Take pramlintide once daily at bedtime. Inject pramlintide into the upper arm.

Mix pramlintide with insulin in the syringe.Pramlintide, an amylin mimetic, supplements the effects of insulin and oral hypoglycemic drugs. However, clients should not mix it in the same syringe with insulin. Administer pramlintide before meals.MY ANSWERThe nurse should instruct the client to inject pramlintide, an amylin mimetic, 20 min before any meal that contains at least 30 g of carbohydrates. Take pramlintide once daily at bedtime.Clients should take pramlintide, an amylin mimetic, three times per day with meals. Metformin, a biguanide, is an endocrine-system drug that clients take orally once per day with their evening meal. Inject pramlintide into the upper arm.Clients should inject pramlintide, an amylin mimetic, subcutaneously into the abdomen or thigh, rather than the upper arm.

A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client? (Select all that apply.) Move the client to a quiet area or private room. Speak at a slower pace. Delay the assessment until the client's family member brings the hearing aid. Have a sign language interpreter translate the communication with the client. Stand next to the client when talking. Avoid using medical terminology.

Move the client to a quiet area or private room is correct. The nurse should reduce environmental noise as much as possible to enhance communication with this client.Speak at a slower pace is correct. Speaking at a slower pace might help the client to be able to better understand and communicate with the nurse.Delay the assessment until the client's family member brings the hearing aid is incorrect. The nurse needs to prioritize the assessment of a client who reports chest pain. Chest pain can be a manifestation of a myocardial infarction. The nurse should not wait till the client has their hearing aid. The nurse needs to implement other strategies while waiting for the family to bring the hearing aid.Have a sign language interpreter translate the communication with the client is incorrect. Not all clients who have hearing loss know or communicate with sign language.Stand next to the client when talking is incorrect. The nurse should stand in front of the client when they are talking.Avoid using medical terminology is correct. The nurse should avoid using medical terminology. These words are unfamiliar and can impede communication with all clients.

Which of the following drugs should a nurse have available for a client who is experiencing insulin toxicity? Naloxone Diphenhydramine Acetylcysteine Glucagon

NaloxoneNaloxone, an opiate antagonist, treats opioid toxicity, not insulin toxicity. DiphenhydramineDiphenhydramine, a cholinergic antagonist and an antihistamine, treats drug-induced extrapyramidal effects. Diphenhydramine is ineffective for insulin toxicity. AcetylcysteineAcetylcysteine, a mucolytic, treats acetaminophen toxicity, not insulin toxicity. GlucagonMY ANSWERGlucagon, a hyperglycemic that can be given subcutaneously, IM, or IV, is used to treat severe hypoglycemia from insulin toxicity in clients who are unconscious and for whom IV glucose is not readily available. If the client does not respond to glucagon, the nurse should administer a glucose solution IV.

A nurse is caring for a client who sustained trauma to their head and neck and will require long-term airway support. Which of the following pieces of equipment will be required for home health care for this client? Nasopharyngeal airway device Oropharyngeal airway device Endotracheal tube Tracheostomy tube

Nasopharyngeal airway deviceThis type of airway management device keeps the upper airway patent when it is at risk of becoming obstructed by the tongue or by secretions, which is a risk for clients who are unconscious. However, this is not a suitable device for long-term management of airway obstruction. Oropharyngeal airway deviceThis type of airway management device keeps the upper airway patent when it is at risk of becoming obstructed. However, because an oropharyngeal airway stimulates the gag reflex, it can only be used for a client who has an altered level of consciousness. This is not a suitable device for long-term management of airway obstruction. Endotracheal tubeAlthough this client probably had an endotracheal (ET) tube inserted initially, ET tubes are not usually left in place for more than 14 days because doing so places the client at risk for infection and airway injury. Tracheostomy tubeMY ANSWERTracheostomy tubes are used for long-term airway support. They are suitable devices for long-term management of airway obstruction.

A nurse is providing teaching to a client about taking fludrocortisone to treat adrenocortical insufficiency. Which of the following instructions should the nurse include? (Select all that apply.) Obtain weight measurement daily. Report weakness or palpitations. Have blood pressure checked regularly. Eat more iron-rich foods. Avoid drinking grapefruit juice.

Obtain weight measurement daily is correct. Fludrocortisone, a mineralocorticoid, can cause fluid and electrolyte imbalances, such as hypernatremia. Tracking weight on a daily basis can help identify weight gain and edema; reporting it can expedite any essential interventions.Report weakness or palpitations is correct. Fludrocortisone can cause hypokalemia. The nurse should monitor the client's potassium levels and tell the client to report muscle weakness or palpitations.Have blood pressure checked regularly is correct. Fludrocortisone can cause fluid retention and hypertension. The nurse should monitor the client's fluid balance and blood pressure to expedite any essential interventions.Eat more iron-rich foods is incorrect. Fludrocortisone does not cause iron-deficiency anemia. However, it can cause thrombocytopenia.Avoid drinking grapefruit juice is incorrect. Grapefruit juice is unlikely to alter the effects of fludrocortisone.

A nurse is caring for a client who is about to begin insulin glargine therapy. The nurse should identify the need for additional precautions because the client also takes which of the following types of drugs? Oral contraceptives Calcium supplements Beta blockers Iron supplements

Oral contraceptivesOral contraceptives do not specifically interact with insulin. Exenatide, another endocrine-system drug, slows the absorption of oral contraceptives. Calcium supplementsCalcium supplements do not specifically interact with insulin. They do, however, reduce the absorption of levothyroxine, another endocrine-system drug. Beta blockersMY ANSWERClients who take both insulin and beta blockers are at risk for failing to promptly recognize the symptoms of hypoglycemia because beta blockers mask symptoms such as tachycardia and tremors. Beta blockers also increase hypoglycemic effects. Iron supplementsIron supplements do not specifically interact with insulin. They do, however, reduce the absorption of levothyroxine, another endocrine-system drug.

A nurse is caring for a client who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the client's tracheostomy tube after cleaning it? Paper towels Cotton-tipped applicators Folded pipe cleaners Facial tissues

Paper towelsThe nurse should not use paper towels to dry the inner cannula after cleaning because it could leave lint or other residue that the client could aspirate. Cotton-tipped applicatorsThe nurse should not use cotton-tipped applicators to dry the inner cannula after cleaning because it could leave residue that the client could aspirate. Folded pipe cleanersMY ANSWERThe nurse should use pipe cleaners to dry the inner cannula after cleaning because they remain intact without leaving any particulate matter the client could aspirate. Facial tissuesThe nurse should not use facial tissues to dry the inner cannula after cleaning because they could leave lint or other residue that the client could aspirate.

A nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at −40 cm of water. Which of the following closed-chest drainage systems should the nurse prepare for this client? Pneumostat™ Water-seal system Heimlich valve Dry suction-control system

Pneumostat™Pneumostat™ is a type of mobile chest drain with a one-way valve that attaches directly to the chest-tube to collect fluid. This device is appropriate for a small or partial pneumothorax. It cannot accommodate this client's need for high suction pressures. Water-seal systemA traditional closed-chest water-seal drainage system regulates the amount of suction by the height of the water in the suction-control chamber, typically applying a suction pressure of −20 cm of water to the pleural cavity. This type of system might not deliver the high suction pressures this client requires. Heimlich valveA heimlich valve is a type of mobile chest drain with a one-way flutter valve that allows air to escape but keeps it from re-entering the chest cavity. This device is appropriate for a small or partial pneumothorax and does not collect fluid. It cannot accommodate this client's need for high suction pressures. Dry suction-control systemMY ANSWERSystems that use dry-suction control allow for higher suction pressures by adjusting a dial on the front surface of the system to deliver suction pressure up to −40 cm of water. Some clients need high suction pressures due to a massive air leak from the lung surface, emphysema or viscous pleural effusion, or a reduction in pulmonary compliance.

A nurse in a health clinic is interviewing a client who is upset and reports that their stress "is too much to handle." The client is unemployed, a single guardian to young children, and has periodic asthma attacks. Which of the following stress-related conditions is the client experiencing? Post-traumatic stress disorder (PTSD) Allostatic load Chronic illness Alarm stage

Post-traumatic stress disorder (PTSD)Symptoms of PTSD include recurring and intrusive memories or flashbacks of the trauma, nightmares, sweating, increased heart rate, and an exaggerated startle response to certain noises or experiences that remind them of the trauma. Allostatic loadMY ANSWERChronic exposure to elevated or fluctuating endocrine or neural responses causes excessive wear and tear on the body organs, resulting in allostatic load. The nurse should identify that the client's constant stress may be manifesting itself in physical ailments such as periodic asthma attacks. Chronic illnessThe client has periodic episodes of asthma, which are not chronic in nature. Alarm stageThe alarm stage is associated with the "fight-or-flight" response. This response is mobilized to meet the threat.

A nurse is providing discharge teaching about health promotion to a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply). Practice mindful breathing. Start each day with a to-do list. Include simple carbohydrates in the diet. Develop habits to mitigate stress. Preserve energy by reducing physical activity.

Practice mindful breathing is correct. The nurse should instruct the client to practice mindful breathing. Health promotion includes practicing mindfulness activities that build resilience. Mindful breathing includes clearing the mind and relaxing while taking in slow, deep breaths.Start each day with a to-do list is correct. The nurse should instruct the client to start each day with a to-do list. Health promotion includes prioritizing daily tasks from high to low to help lower stress levels.Include simple carbohydrates in the diet is incorrect. The nurse should instruct the client to include complex carbohydrates in their diet. Health promotion includes consuming a healthy diet that stabilizes blood sugar levels.Develop habits to mitigate stress is correct. The nurse should instruct the client to develop habits to mitigate stress. Health promotion includes building resilience to bounce back from life's various challenges.Preserve energy by reducing physical activity is incorrect. The nurse should instruct the client to increase physical activity because exercise increases overall health and provides a sense of well-being while reducing stress.

A nurse is talking about implementing self-care strategies to cope with the stress of caregiving with the partner of a client who has dementia. Which of the following strategies reported by the partner should the nurse identify as an example of effective coping? Practicing deep breathing while sitting outside Sitting by the client's bedside and drinking coffee Going out onto the patio to smoke a cigarette when feeling stressed Drinking a glass of wine every night before falling asleep

Practicing deep breathing while sitting outsideMY ANSWEREating nutritious meals, participating in active exercise, and engaging in mindfulness activities such as deep breathing are examples of healthy coping. Sitting by the client's bedside and drinking coffeeWhile being at the client's bedside might be a calming strategy, drinking caffeine can have negative effects such as anxiety and insomnia. Going out onto the patio to smoke a cigarette when feeling stressedSmoking cigarettes has a detrimental effect on health and is not an effective coping strategy. Drinking a glass of wine every night before falling asleepDrinking alcohol can have a detrimental effect on health and is not an effective coping strategy.

A nurse is caring for a client who has been charged with partner violence against their spouse. The client is angry, pacing, and yells out, "I wouldn't lose my temper if my spouse would just leave me alone. It's their fault." The nurse should identify the client is displaying which of the following defense mechanisms? Projection Compartmentalization Repression Regression

ProjectionMY ANSWERProjection involves attributing negative or uncomfortable thoughts, feelings, or motives onto another individual to avoid dealing with them as one's own. CompartmentalizationCompartmentalization refers to categorizing life experiences into separate segments to avoid facing the anxieties while in that mindset. RepressionRepression refers to concealing unpleasant or painful thoughts, memories, or beliefs in hopes of forgetting about them entirely. RegressionRegression refers to moving back to a more comfortable developmental time in life when faced with stress or anxiety.

A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication? (Select all that apply.) Psychosocial factors Cognitive factors Situational factors Environmental factors Physiological factors

Psychosocial factors is correct. The nurse should recognize that psychosocial factors are influencing communication with the client. Psychosocial factors include the client's financial situation. The client is working two jobs and going to dialysis appointments twice a week, which might require them to miss work time and pay. Furthermore, the client is the only income for this household.Cognitive factors is incorrect. The nurse should recognize that there are no indicators of cognitive factors influencing communication with this client. The client is thinking and verbalizing clearly the effects that dialysis might have on their life.Situational factors is correct. The nurse should recognize situational factors, such as the new prescription for dialysis, influencing the communication with the client. Situational factors that can affect communication cause emotions including fatigue, anxiety, grief, and fear. This client's verbal and nonverbal communication are indicators of worry, anxiety, sadness, and grief.Environmental factors is incorrect. The nurse should recognize that there are no indicators of environmental factors (extreme temperatures, excessive noise) in their communication with the client.Physiological factors is incorrect. The nurse should recognize that there are no indicators of physiological factors (hearing or vision loss) affecting communication with the client.

A nurse is teaching a client about self-administering regular insulin. The nurse should instruct the client to rotate injection sites to prevent which of the following?Rapid absorptionIntradermal injectionInjection painLipohypertrophy

Rapid absorptionRotating insulin injection sites does not prevent rapid absorption. Using the same injection site, specifically the abdomen, speeds absorption, while using the thigh allows for the slowest absorption. Intradermal injectionRotating insulin injection sites does not affect the risk for intradermal injection because the appropriate areas for insulin injection contain adequate subcutaneous tissue in most clients. Injection painRotating insulin injection sites is unlikely to affect injection pain. The depth of the injection affects pain; deeper IM injections are more painful and are also inappropriate for insulin injection. LipohypertrophyMY ANSWERLipohypertrophy is a proliferation of fat at the sites of repeated insulin injections. It affects skin sensitivity and appearance. To prevent it, the client should rotate injection sites, keeping them at least 2.5 cm (1 in) apart, and avoid using the same spot within the same month.

A nurse is providing discharge instructions to a client during a follow-up telephone call. Based on the Shannon-Weaver communication model, which of the following components of the model is the nurse demonstrating? Receiver Sender Channel Decoder

ReceiverThe person who receives the message is the receiver; therefore, the client is the receiver. SenderMY ANSWERThe nurse is initiating the message; therefore, the nurse is the sender. ChannelThe channel is the method used to send the message from the sender to the receiver, such as a phone line or cable. DecoderThe decoder receives the transmission from the channel and converts it back to a message.

A nurse is caring for a client who has pancreatic cancer that is unresponsive to treatment. The client is experiencing significant weight loss and fatigue, but when the nurse asks how they are feeling, they respond with, "Great! I'm going to beat this cancer." Which of the following defense mechanisms is the client using? Regression Projection Repression Denial

RegressionRegression refers to the movement back to a more comfortable time in life when faced with stress and anxiety. ProjectionProjection refers to attributing negative or uncomfortable thoughts, feelings, or motives to another individual to avoid dealing with them as their own. RepressionRepression refers to concealing unpleasant or painful thoughts, memories, or beliefs in hopes of forgetting about them entirely. DenialMY ANSWERDenial refers to the refusal to acknowledge or accept reality about a situation, despite what might be obvious to others, to avoid the emotional impact.

A nurse is caring for a client who has a cuffed endotracheal (ET) tube in place. Which of the following actions should the nurse plan to take? Repositioning the ET tube in the client's mouth every 12 hr Providing oral care every 24 hr Applying the securing tape over the client's ears Maintaining a cuff pressure of 35 mm Hg

Repositioning the ET tube in the client's mouth every 12 hrMY ANSWERMoving the ET tube to the other side of the client's mouth every 12 hr (or according to facility policy) helps prevent irritation to the oral mucous membranes. Providing oral care every 24 hrOral care should be performed every 12 hr. Applying the securing tape over the client's earsApplying the tape over the client's ears can result in the development of pressure injuries. Maintaining a cuff pressure of 35 mm HgThe recommended cuff pressure is 20 to 25 mm Hg to minimize the risk of injury to the tracheal mucosa.

A nurse manager is planning to introduce a new scheduling policy to the unit staff. Which of the following methods of communication should the nurse manager use? Send an email to staff via the facility's email system. Schedule a face-to-face unit staff meeting. Place a copy of the policy on a bulletin board in the hallway. Leave a voicemail on each staff member's phone.

Send an email to staff via the facility's email system.Sending a message through email will not allow either verbal or nonverbal communication between the sender and the receiver. Schedule a face-to-face unit staff meeting.MY ANSWERIn-person communication of this important policy would permit for both verbal and nonverbal modes of communication between the sender (the nurse manager) and the receiver (the unit staff). Place a copy of the policy on a bulletin board in the hallway.Placing a written copy of the policy on a bulletin board will not allow either verbal or nonverbal communication to occur between the sender and the receiver. Leave a voicemail on each staff member's phone.Sending a voicemail is a mode of verbal communication. However, without face-to-face contact, the nurse manager will be unable to send and receive verbal and nonverbal communication.

A nurse is teaching a client who is newly diagnosed with diabetes mellitus. The client tells the nurse, "Thank you. I never really knew what caused diabetes." Using the Schramm model of communication, the nurse should recognize the client's statement as an example of which of following components of the model? Sender Channel Feedback Receiver

SenderThe sender is a component of the Shannon-Weaver communication model and refers to the person initiating the communication. In this case, the sender is the nurse and the client is giving feedback. ChannelThe channel is a concept in the Shannon-Weaver communication model that refers to the method used to transmit the message. FeedbackMY ANSWERIn the Schramm model, one of the three components is feedback. Feedback is demonstrated when the receiver is allowed to let the sender know that the message was properly received. ReceiverThe Schramm model of communication identifies the person who receives the message as the decoder. The Shannon-Weaver model uses the receiver as a component, not the Schramm model.

A nurse is interviewing a client who recently experienced an act of workplace violence when an armed person held the workers at gunpoint before police intervened. The client now reports being anxious and fears the gunman might return. The nurse should identify that the client is experiencing which of the following types of crisis? Situational Cultural Maturational Adventitious

SituationalA situational crisis commonly stems from events such as divorce, job loss, an unexpected event, or a change in circumstance. CulturalCultural crises or stressors occur when one is living within a society in which they have different cultural practices and/or receive care that ignores their cultural beliefs. MaturationalMaturational crisis occurs when a person experiences a new stage of development and is challenged to adapt to the new experience. AdventitiousMY ANSWERAdventitious crises occur from natural disasters such as floods, hurricanes, or fire; or from acts of war, criminal activity, or terrorism.

When considering replacement therapy options for a client who has chronic adrenocortical insufficiency, a nurse should recognize that the provider will choose which of the following drugs? Somatropin Hydrocortisone Glucagon Desmopressin

SomatropinSomatropin, a growth hormone, treats growth hormone deficiencies, such as Turner's syndrome, rather than adrenocortical insufficiency. HydrocortisoneMY ANSWERHydrocortisone, a glucocorticoid, provides replacement therapy for acute and chronic adrenocortical insufficiency, such as Addison's disease. Hydrocortisone is identical to cortisol, the primary glucocorticoid the adrenal cortex generates. GlucagonGlucagon, a hyperglycemic, treats severe hypoglycemia from insulin toxicity, rather than adrenocortical insufficiency. DesmopressinDesmopressin, an antidiuretic hormone, treats diabetes insipidus, rather than adrenocortical insufficiency.

A nurse is caring for a client who is about to begin taking propylthiouracil (PTU) to treat hyperthyroidism. The nurse should instruct the client to report which of the following adverse effects? (Select all that apply.) Sore throat Joint pain Insomnia Bradycardia Rash

Sore throat is correct. Propylthiouracil, an antithyroid drug, can cause agranulocytosis. The nurse should monitor the client's CBC and instruct the client to report fever or sore throat.Joint pain is correct. Propylthiouracil can cause arthralgia and myalgia. The nurse should instruct the client to report these effects and take over-the-counter analgesics for pain relief.Insomnia is incorrect. Propylthiouracil is more likely to cause drowsiness than insomnia.Bradycardia is correct. Propylthiouracil can cause hypothyroidism, which manifests as bradycardia, drowsiness, and weight gain. The nurse should instruct the client to report these effects.Rash is correct. Propylthiouracil can cause urticaria or a skin rash. The nurse should instruct the client to report these effects.

A nurse is caring for a client who reports experiencing stress over an upcoming surgical procedure. Which of the following statements describes the characteristics of stress? Stress is an easily defined phenomenon regardless of viewpoint and discipline. Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one's state of equilibrium. Stress only affects the individual and does not affect the person's family, friends, or other associates. The lack of definition regarding stress does not pose a problem for the client or the nurse.

Stress is an easily defined phenomenon regardless of viewpoint and discipline.Defining stress is a complex and ambiguous endeavor, and definitions vary based upon the viewpoint and discipline of each individual researcher, clinician, health care provider, and members of the general public. Stress is a condition in which the body responds to physical, emotional, or environmental changes affecting one's state of equilibrium.MY ANSWERStress can be caused by physical, emotional, environmental, or mental changes, which can be positive or negative depending on the person's perception or appraisal of the stressor. Stress only affects the individual and does not affect the person's family, friends, or other associates.Stress affects the entire family as well as the individual and must be considered in the client's plan of care. The lack of definition regarding stress does not pose a problem for the client or the nurse.The lack of definition regarding stress can present a problem for clients, nurses, families, and all members of the health care team.

A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take? Suction for 30 seconds with each pass. Allow 2 min in between suctioning to reoxygenate the lungs. Use a rotating motion when inserting the catheter from the tracheostomy. Set the suction pressure to 180 mm Hg.

Suction for 30 seconds with each pass.The nurse should suction 10 to 20 seconds with each pass to minimize oxygen loss and allow the client to cough and deep breathe in between. Allow 2 min in between suctioning to reoxygenate the lungs.MY ANSWERThe nurse should allow 2 to 3 min in between each pass to allow the client to cough and deep breathe and allow the lungs to reoxygenate. Use a rotating motion when inserting the catheter from the tracheostomy.The nurse should use a rotating motion when withdrawing the catheter while suctioning to minimize tissue trauma and reduce suction time against the client's trachea. Set the suction pressure to 180 mm Hg.The nurse should set the suction up to 120 mm Hg for open suctioning and up to 160 mm Hg for closed system suctioning.

A nurse is conducting an educational session for clients who report experiencing stress-related disorders. A client asks the nurse which part of the body activates the stress response. Which of the following responses should the nurse provide? Sympathetic nervous system (SNS) Adrenal glands Hypothalamus Adrenocorticotropic hormone

Sympathetic nervous system (SNS)The SNS is involved in the stress response; however, the hypothalamus activates the stress response. Adrenal glandsThe adrenal glands are involved in the stress response; however, the hypothalamus activates the stress response. HypothalamusMY ANSWERThe hypothalamus activates the stress response. When a stress response is triggered, the hypothalamus sends signals to the pituitary and adrenal glands. Adrenocorticotropic hormoneThe adrenocorticotropic hormone is involved in the stress response; however, the hypothalamus activates the stress response.

A nurse is planning care for a client who is recently divorced with two young children. The client reports difficulty sleeping, feeling hopeless, and being estranged from family. The nurse should plan to monitor the client for which of the following potential manifestations of chronic stress? Systemic infection Exaggerated startle response Recurring nightmares Suicide

Systemic infectionChronic stress can exacerbate many serious health problems such as cardiovascular disease; however, it does not result in a systemic infection. Exaggerated startle responseAn exaggerated startle response is a manifestation commonly associated with PTSD, not with chronic stress. Recurring nightmaresRecurring nightmares are a manifestation commonly associated with PTSD, not with chronic stress. SuicideMY ANSWERChronic stress can cause or exacerbate serious health problems such as depression, anxiety, cancer, and suicide.

A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make? "The nurse manager will need to email the discharge instructions to you." "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act." "You will need to ask your provider to email the discharge instructions to you." "Sending the discharge instructions to you via email would be a violation of the Affordable Care Act."

The nurse manager will need to email the discharge instructions to you."No one from the facility should send the discharge instructions via email due to the potential violation of the HIPAA Privacy Act. "I am unable to send your discharge instructions via email due to the HIPAA Privacy Act."MY ANSWERThe HIPPA Privacy Act consists of rules that govern the protection of the client's protected health information (PHI). The use of emails, texting, and faxing must occur with equipment and communication lines that are secure and encrypted. All electronic communication of PHI must have these safeguards in place. Sending the discharge instructions to a personal email outside the facility would breach this law. "You will need to ask your provider to email the discharge instructions to you."The client's provider should follow the same HIPAA Privacy Act rules as the facility. "Sending the discharge instructions to you via email would be a violation of the Affordable Care Act."The ACA is a federal law that helps to expand access to affordable health care coverage and to lower costs of health care and improve quality of care. It does not write or enforce the rules that comprise the HIPAA Privacy Act.

A nurse should recognize that a provider will prescribe a lower dose of sitagliptin for a client who has type 2 diabetes mellitus and who also has which of the following? Thyroid disease Bronchitis Heart failure Renal impairment

Thyroid diseaseClients who have thyroid disease can take a regular prescribed dose of sitagliptin, a gliptin. Glipizide is an endocrine-system drug that requires cautious use with clients who have thyroid disease. BronchitisClients who have bronchitis can take a regular prescribed dose of sitagliptin, a gliptin. The drug requires cautious use with clients who have a history of pancreatitis. Heart failureClients who have heart failure can take a regular prescribed dose of sitagliptin, a gliptin. Metformin is an endocrine-system drug that is contraindicated for clients who have heart failure. Renal impairmentMY ANSWERSitagliptin, a gliptin, requires cautious use with clients who have renal dysfunction and low creatinine clearance because the kidneys eliminate the drug virtually intact. The provider should prescribe a lower dose for this client or prescribe a different hypoglycemic drug.

A nurse is caring for a client who is about to begin taking pioglitazone to treat type 2 diabetes mellitus. The nurse should explain to the client about the need to monitor which of the following laboratory values? (Select all that apply.) Thyroid-stimulating hormone (TSH) Alanine aminotransferase (ALT) LDL CBC Creatinine clearance

Thyroid-stimulating hormone (TSH) is incorrect. Pioglitazone, a thiazolidinedione, is unlikely to alter T4 or TSH. Levothyroxine, a thyroid hormone replacement, is an endocrine-system drug that requires monitoring of T4 and TSH.Alanine aminotransferase (ALT) is correct. Pioglitazone can cause liver injury. The nurse should monitor ALT at the start of therapy and then every 3 to 6 months thereafter. The nurse should tell the client to report jaundice, dark-colored urine, or abdominal pain.LDL is correct. Pioglitazone can cause elevations in both high-density lipoproteins, which is a beneficial effect, and LDLs, which is a detrimental effect. The nurse should monitor the client's plasma lipid levels at baseline and periodically throughout drug therapy.CBC is incorrect. It is not necessary to monitor CBC for clients who are taking pioglitazone. Hydrocortisone, a glucocorticoid, is an endocrine-system drug that requires monitoring of CBC.Creatinine clearance is incorrect. It is not necessary to monitor creatinine clearance for clients who are taking pioglitazone. Desmopressin, an antidiuretic hormone, is an endocrine-system drug that requires monitoring of creatinine clearance.

A nurse is caring for a client who is taking propylthiouracil (PTU) and reports weight gain, drowsiness, and depression. The nurse should identify that the client is experiencing which of the following adverse reactions to the drug? Thyrotoxicosis Hypothyroidism Lactic acidosis Radiation sickness

ThyrotoxicosisPropylthiouracil, an antithyroid drug, treats thyrotoxicosis, or hyperthyroidism. Indications of thyrotoxicosis include anxiety, palpitations, and weight loss. HypothyroidismMY ANSWERPropylthiouracil, an antithyroid drug, can cause hypothyroidism, which manifests as drowsiness, depression, weight gain, edema, and bradycardia. The nurse should request that the provider prescribe a lower dosage of the drug for the client. Lactic acidosisPropylthiouracil, an antithyroid drug, is unlikely to cause lactic acidosis. Sitagliptin is an endocrine-system drug that can cause lactic acidosis, which manifests as muscle aches, sleepiness, malaise, and hyperventilation. Radiation sicknessPropylthiouracil, an antithyroid drug, is unlikely to cause radiation sickness. Radioactive iodine-131 is an endocrine-system drug that can cause radiation sickness, which manifests as hematemesis, epistaxis, and intense nausea and vomiting.

A nurse is planning teaching for a client about wound care. Which of the following actions should the nurse take? Use medical terminology during teaching. Sit across from the client at a table in the cafeteria during teaching. Ensure the client is wearing their glasses during teaching. Use the communication technique of probing during teaching.

Use medical terminology during teaching.The nurse should avoid using terminology that the client might not understand because this will deter the client from learning. Instead, the nurse should use uncomplicated and nonmedical terminology when providing teaching to the client. Sit across from the client at a table in the cafeteria during teaching.The nurse should select an area that is private with limited distractions to enhance client learning. Providing teaching in a cafeteria can be distracting for the client and can result in a HIPAA violation. Ensure the client is wearing their glasses during teaching.MY ANSWERThe nurse should take steps to facilitate learning, such as ensuring the client's assistive devices, including eyeglasses or hearing aids, are being used. Use the communication technique of probing during teaching.The nurse should use therapeutic communication techniques when working with a client. The use of probing is nontherapeutic and can impair the nurse-client relationship and limit learning.

A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30-min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan? (Select all that apply.) Verbal Written Electronic Nonverbal Assertive

Verbal is correct. The nurse planned on teaching in a face-to-face presentation of the information. The verbal mode of communication occurs during face-to-face communication between the sender (the nurse) and the receiver (the APs). It can also occur during a telephone call.Written is correct. The written mode of communication is any form of communication in which the receiver reads the message from the sender. The nurse plans to use both face-to-face verbal communication and a written mode of communication.Electronic is incorrect. The nurse does not plan to include any electronic communication modes in the teaching session. The electric communication mode includes any communication between sender and receiver that includes the use of electronic technology. This includes email, texting, and posts on social media.Nonverbal is correct. The nonverbal mode of communication is comprised of body language. Actions such as eye contact, facial gestures, posture, and overall appearance all send messages to the receiver in addition to what the sender is saying. The nurse will be sending and receiving messages with the AP as they deliver the verbal information in a face-to-face environment.Assertive is incorrect. Assertiveness is a style of communication. It is not a mode of communication. Those who possess an assertive style of communication are effective in clearly communicating to the receivers and often advocate for themselves, peers, and clients.

A nurse is performing chest physiotherapy for a client who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the client exhales, the nurse should use which of the following techniques? Vibration Percussion Nebulization Postural drainage

VibrationMY ANSWERVibration is used during or after percussion to increase the turbulence of exhaled air and loosen secretions. PercussionPercussion involves striking the skin over congested lung fields to dislodge secretions from the bronchial walls. It does not increase air turbulence. NebulizationNebulizer therapy is often administered before postural drainage to help loosen secretions, not to increase air turbulence. Postural drainagePostural drainage allows secretions to drain by gravity from different areas of the lungs. It does not increase air turbulence.

A nurse is caring for a client who has migraine headaches and reports that they are "getting worse." Which of the following questions should the nurse ask the client to determine if the headaches are a stress-related disorder? (Select all that apply.) "What is the intensity of your migraine headaches?" "How often do the migraine headaches occur?" "Are you eligible for workers' compensation due to the migraine headaches?" "What type of support is available to you when you have a migraine headache?" "What coping strategies do you use when you experience a migraine headache?"

What is the intensity of your migraine headaches is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor.How often do the migraine headaches occur is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor.Are you eligible for workers' compensation due to the migraine headaches is incorrect. Eligibility of workers' compensation is not a factor when appraising a stress-related disorder.What type of support is available to you when you have a migraine headache is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor.What coping strategies do you use when you experience a migraine headache is correct. How an individual appraises a stressor determines how they will respond to the stressor. The onset and severity of stress-related disorders is affected by the type, frequency, and intensity of the stressor, perception of the stressor, access to support systems, and the individual's ability to effectively cope with the stressor.

A nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system? Instruct the client to inhale deeply. Submerge the end of the chest tube in 1 inch of sterile water. Gently milk the chest tube in a proximal-to-distal direction. Tape sterile gauze around the open end of the chest tube.

nstruct the client to inhale deeply.The client should be instructed to exhale, not inhale. Exhaling assists with removing as much air as possible from the pleural space, whereas inhaling increases the amount of air and could create a pneumothorax. Submerge the end of the chest tube in 1 inch of sterile water.MY ANSWERThis action creates a water seal and prevents air from entering the pleural space through the open end of the chest tube when the client inhales. Gently milk the chest tube in a proximal-to-distal direction.Milking the tube involves intermittently compressing it in the area of the clot for 1 to 2 seconds. This action could increase negative pressure within the system to a level that can damage the pleural tissue. Tape sterile gauze around the open end of the chest tube.Taping sterile gauze around the end of the tube will still allow unwanted air to be inhaled into the client's pleural space.

•Alpha-glucosidase inhibitors- Oral

t2; (acarbose) Precose, Miglitol (Glycet)

•Incretin (GLP1): Subcutaneous meds

t2; exenatide (Byetta), liraglutide (Victoza)

Meglitinide analog

t2; increase meal time insulin release (starlix)

Biguanides

t2; oral c food; increase tissue sensitivity to insulin ex. metformin (Glucophage)

DPP4 inhibitors: oral

t2; slow GLP1 breakdown increasing insulin ex. Sitagliptin (Januvia)

Sulfonylureas:

t2; stimulate insulin secretion (glipizide(Glucotrol), glyburide)