NCLEX Prep

A charge nurse is observing a newly licensed nurse perform tracheostomy care of a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for trach care C. Obtaining sterile gloves for trach care D. Obtaining a sterile brush for trach care

B. Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action. Incorrect A. Half-strength peroxide solution is used to clean the inner cannula. C. Tracheostomy care is a sterile procedure requiring the use of sterile gloves. D. Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.

A nurse is providing information on diet to a client w/ type 2 diabetes. Which of the following statements by the client indicates understanding of the dietary recommendations for diabetes? A. The total daily intake should consist of < 400 mg cholesterol B. The total daily intake should consist of at least 65% carbs C. The daily total intake should consist of at least 10g of fiber for each 1000 calories in the diet D. The total daily intake should consist of at least 15-20% protein

D The total daily intake should consist of at least 15-20% proteins. Also, less than 200-300 mg cholesterol, 45-65% carbs, and at least 4g of fiber for every 1000 calories - protein stimulates insulin release but doesn't increase blood glucose

Steps to suction ET tube using in-line catheter

1. Turn on suction to 80-120 mmHG 2. pre-oxygenate the client by providing 100% O2 through ET tube 3. Insert the suction catheter into the ET tube until resistance is met, taking care not to apply suction w/ insertion 4. Apply suction while withdrawing the catheter from the ET tube 5. Suction the in-line catheter w/ saline to clear for next use

Labs: urine specific gravity

1.010-1.030

Labs: LDH

100-190

Labs: albumin

3.4-5.0

Labs: K+

3.5-5

Labs: Co2

35-45

Labs: pH

7.35-7.45

Labs: Creatinine

0.6-1.2

Labs: INR

0.9-1.8 2-3 if on warfarin

A nurse is caring for a client who is experiencing anxiety before competing in an athletic event. Characteristics of mild anxiety include which of the following? A. It can increase the individual's ability to perceive reality B. Although the ability to think is impaired, learning can still occur C. Changes in vocal pitch or vocal tremors are characteristic D. Functioning is ineffective

A Clients experience anxiety on a continuum of different levels of severity. Some anxiety is normal and can serve a protective fxn by motivating the client to an appropriate response. As the severity of anxiety increases, functional impairment also increases. Anxiety can be acute in reaction to a threat or chronic (developing over time during childhood or adolescence). The type of anxiety experienced in the course of routine events in life is mild. This type of anxiety has an identifiable cause and can increase the individual's awareness of reality. It is manifested in vague discomfort or restlessness, mild apprehension, irritability, or impatience. Behaviors that relieve tension may be exhibited, including lip-chewing and foot-tapping Incorrect Answers B) this describes moderate anxiety. With moderately severe anxiety, the individual has slight impairment in processing information and in perception. Although clarity of thought is reduced, the individual can still problem-solve and learn. Moderate anxiety is an escalation of mild anxiety C) Shakiness and vocal tremors or changes in pitch are characteristic of moderate anxiety D) Ineffective functioning and an inability to learn or problem solve are associated w/ severe anxiety. Perception is distorted, and the client may feel confused or have a feeling of impending doom. Dilated pupils, insomnia, hyperventilation, and tachycardia are characteristic

A nurse is reviewing a mental status examination (MSE) on a client who has Alzheimer's disease. The nurse should identify that which of the following components are part of the MSE? (SATA) A. Grooming B. Short-term memory C. Support systems D. Affect E. Presence of pain

A, B, D Determining whether a client grooms himself, his short-term memory, and affect, are components of the MSE, which includes categories concerning the client's appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others The nurse might need to perform an MSE in both mental health or medical care settings to determine a client's current ability to use cognitive processing or to re-evaluate the ability during and following treatment. While some are longer than others, basic or brief MSEs include information about time, orientation, thinking and recall, ability to follow verbal and written commands, use of language, concentration, and spatial understanding. Other, more comprehensive MSEs can include the categories below. As w/ any data collection, the nurse should consider and discuss w/ the client and family about cultural expectations and patterns regarding categories, such as appearance, eye contact and verbal communication

anisocoria

unequal pupil size

A neighbor who is a nurse is called on to assist w/ an emergency home birth. What should the nurse do to expel the placenta? A. Put pressure on the fundus B. Ask the mother to bear down C. Have the mother breastfeed the newborn D. Place gentle pressure on the cord

C Suckling will induce neural stimulation of the posterior pituitary gland, which in turn will release oxytocin and cause uterine contracts. The other options could cause uterine prolapse Manual cord traction confers no benefit to the mother and increases the risk of postpartum hemorrhage, which is the leading complication of childbirth. If the delivery of the placenta is delayed, nursing the baby will help stimulate contractions to expel the placenta b/c nursing causes the release of natural oxytocin into the body. Coughing, sneezing, and laughing can also be used

A nurse is caring for a child who has a new diagnosis of Marfan syndrome. What should the nurse prioritize in the discharge teaching for the parents? A. The child should be monitored for changes in the spine associated w/ kyphosis B. The child should have an annual eye exam C. Participation in contact sports should be avoided D. The child's dentist should be informed of this diagnosis

C The nurse should stress avoidance of contract sports. Marfan syndrome is primarily transmitted genetically by autosomal dominant inheritance, although some cases occur sporadically that are not the result of genetic inheritance. The defective gene interferes w/ synthesis of elements of the connective tissues in the body, resulting in abnormalities of the cardiovascular system, musculoskeletal system, and the eyes. Contact sports increase the risk of aortic dissection and should be avoided

A nurse who is employed in a community outpatient clinic should question which of the following prescriptions for vaccine administration? A. MMR in a client who hopes to become pregnant in the next 6 months B. DTaP to a client who has a family history of seizures C. DTap to a client who develops a rash when exposed to latex D. Hepatitis B for a client with hypersensitivity to yeast

D Hypersensitivity to yeast is an absolute contraindication to the hepatitis B virus Incorrect answers A) live virus vaccines are contraindicated one month before and during pregnancy. This is d/t a theoretical risk of transmission of a live virus to the fetus. B) contraindications to DTaP include SERIOUS allergic rxns to a previous dose or encephalopathy, including prolonged seizures not attributable to another cause, w/in 7 days of a previous dose of the vaccine C) the vaccine is contraindicated in individuals w/ a SEVERE latex allergy. A rash in response to latex (contact dermatitis) is a mild allergic rxn. Severe reactions (immediate hypersensitivity rxn) causes swelling, respiratory distress, pruritus, and hypotension (anaphylactic shock) Contraindications to vaccines refer to factors that increase the risk of a serious adverse rxn. They include yeast hypersensitivity and hepatitis B vaccine; live attenuated vaccines during pregnancy; and DTaP in individuals with serious latex allergy

Isotonic

E.g., 0.9% NS; D5W; LR no osmotic force = cells neither swell or shrink

Hypertonic

E.g., 3% NS; 5% NS; D10W; D5W w/ 1/2 NS; D5LR More concentrated solution (more solute than water) = water is removed from cells

hypotonic

E.g., 45% NS, 0.33% NS more dilute solutions (more water than solute) = causes water to enter cells ** watch for edema

Parkland Formula

Fluid resuscitation - burns 4 mL x TBSA% x wt (kg)/2 First half given in first 8hr Second half given in next 16 hr

Rule of 9s

Head: 9% Arms: 18% (9% each) Back: 18% Chest: 18% Legs: 36% (18% ea) Genitalia: 1%

Correct sequence of steps for abdominal assessment

Inspection Auscultation Percussion Palpation

intracellular

fluid inside a cell (most bodily fluids are inside cells)

Therapeutic Med Levels

Acetaminophen: 10-30 mcg/mL Carbamazepine: 5-12 mcg/mL Digoxin: 0.5-2 ng/mL Gentamicin: 5-10 mcg/mL Lithium: 0.5-1.2 mEq/L Magnesium sulfate: 4-7 mg/dL Phenobarbital: 10-30 mcg/mL Phenytoin: 10-20 mcg/mL Salicylate: 100-250 mcg/mL Valproic acid: 50-100 mcg/mL

Labs: RBC

4.5-5.0 million

Labs: triglycerides

40-50

Labs: WBC

5,000-10,000

The nurse is removing staples from a client w/ a surgical wound. Arrange the following steps in chronological order in order to successfully implement staple removal?

-Remove dressing and discard in disposable waterproof bag -inspect wound for approximation of wound edges and absence of drainage or inflammation -clean staples and healed incision w/ antiseptic swab - place lower tip of staple removed under first staple -squeeze handles together all the way w/out lifting -gently lift from skin surface when both ends of staple are visible -release handles of staple remover over disposable waterproof bag -repeats steps for every other staple -assess for healing ridge -secure approximation of incision edges before remaining staples are removed Staples are stainless steel wires attached to a client for skin closure. They are used to close scalp lacerations, after an abd incisions, and in orthopedic surgery. Removal of existing staples from a client w/ a surgical wound depends upon the stage of incision healing and extent of surgery. Staples are usually removed 7-10 days after surgery, when healing is adequate

Labs: Mg

1.5-2.5

Labs: Hgb

12-16 (female) 14-18 (male)

Labs: total chol

130-200

Labs: Na

135-145

Labs: Phos

2.5-4.5

Labs: PTT

20-36 seconds if on heparin: 1.5-2.5x normal

Labs: Pit

200K-400K

Labs: HCO3

24-26

Labs: protein

6.2-8.1

Labs: BUN

7-22

Labs: Glucose

70-110 mg/dL or 4-6 mol/L

Labs: Ca

8.5-10.5

Labs: PaO2

80-100%

Labs: PT

9-11 s

Labs: Cl

95-105

Labs: bili

< 1.0

Labs: HBA1C

<7%

A client experiencing anaphylaxis after exposure to an allergen is having which of the following types of reaction? A. Type I B. Type II C. Type III D. Type IV

A A type I allergic or hypersensitivity rxn is mediated by IgE. It occurs when an allergen binds w/ free IgE, which then binds to basophils and mast cells, causing the release of histamine. The initial rxn may be less severe, but over subsequent exposures, the response can increase. Clinical manifestations may include wheezing, urticaria, and hypotension. Severe anaphylaxis can lead to death. Treatment includes IM epinephrine, antihistamines, steroids, and IV fluid support. Incorrect Answers: B) An example of a type II rxn is ABO blood incompatibility. It is mediated by IgG and IgM and can lead to hemolytic anemia C)An example of a type III hypersensitivity rxn is caused by formation of antigen-antibody complexes in serum and includes drug fever and vasculitis. They are uncommon and involve a soluble antigen and IgG D) A type IV hypersensitivity rxn is delayed, often by up to several days. It is mediated by T-cells and can include transplant rejection

A school nurse is teaching parents about communicable disease. She tells the group that encephalitis can result as a complication of: A. Mumps B. Pertussis C. Poliomyelitis D. Scarlet fever

A Mumps is caused by a virus and may lead to encephalitis Viral infections of the CNS result in aseptic meningitis or encephalitis. Encephalitis occurs most frequently d/t viruses, including herpes simplex viruses, which cause cold sores and genital herpes; varicella zoster virus, which causes chicken pox and shingles; mumps, measles, and rubella viruses

Vital Signs

BP 120/80 HR 60-100 bpm SPO2 95-100% or 88-92% w/ COPD T 36.5-37.5 deg C (96.8-100.4 deg F) RR 12-20 rpm

A nurse is preparing to apply thigh-length antiembolic stockings to a client. Which of the following actions should the nurse plan to take? A. Measure the length of both legs from the tip of the great toe to the widest part of the thigh B. Measure the circumference of each thigh at a point 7.6 cm (3 in) above the knee cap C. Select a stocking size that is one size larger than the client's measurements indicate D. Apply the stockings first thing in the morning before the client gets out of bed

D The nurse should apply antiembolic stockings first thing in the morning and, if possible, before the client gets out of bed. When the legs are in a dependent position, such as in standing or sitting, the veins can become distended resulting in edema. The stockings should be applied before this occurs Incorrect Answers: A) for thigh-length antiembolic stockings, the nurse should measure both legs from the heel to the gluteal fold B) For thigh-length antiembolic stockings, the nurse should measure both thighs at the widest point C) The nurse should compare the client's measurements to the size chart and select the correct size stocking. Stockings that are too large will not apply adequate pressure to the legs and will not facilitate venous return

colloid

e.g., dextran, albumin Fluid moves from interstitial to intravascular compartment ** given in severe hypovolemia

intravascular

fluids inside a blood vessel

extracellular

fluids outside cells (includes interstitial fluid [fluid between cells], blood, bone, connective tissue, water)

A nurse is caring for a client w/ schizophrenia who was admitted involuntarily by family members who were concerned about his bizarre posturing, pacing, and regression. The nurse enters the day room and sits at a table w/ the client who has been sitting alone and staring at the wall. Which action is most appropriate for the nurse? A. Allow the client to leave w/out commenting B. Tell the client it is important for recovery to talk to others C. Tell the client clearly and loudly that he must return to the room D. Follow the client until he returns to his room

A Schizophrenia is a major psychiatric disorder that is characterized by at least 1 psychotic (positive) symptom (hallucinations, delusions, disorganized speech), an inability to function in daily life and neglect of basic needs. The diagnosis cannot be made unless the symptoms persist for over 6 months. During a six-month period, individuals may have times when they are not experiencing psychotic symptoms, but in those times they tend to be apathetic or depressed, which are negative symptoms of schizophrenia. The client in this presentation is demonstrating negative symptoms of schizophrenia, which include social withdrawal, impaired interpersonal function, anhedonia (inability to experience pleasure), poor personal hygiene, lack of motivation, and inability to make decisions. Bizarre posturing, pacing, rocking, and regression are other negative symptoms of schizophrenia. The negative symptoms of schizophrenia are more resistant to successful treatment compared to positive symptoms such as delusional thinking and hallucinations. The negative symptoms associated w/ social withdrawal result from attempts by the client to relieve the anxiety experienced when around others. When caring for a client w/ schizophrenia, a nurse can intervene to improve social interaction skills by minimizing demands or expectations. This demonstrates unconditional acceptance of the client by the nurse and creates a therapeutic environment. Other interventions include remaining w/ the client or nearby during periods of group activities and offering positive reinforcement when the client interacts w/ others. The nurse should make frequent, brief contacts w/ the client and assess the client's readiness for longer periods of contact w/ others.

A client has a deficiency of fat-soluble vitamins. The nurse understands that the body must produce which of the following for absorption of fat-soluble vitamins? A. Bile B. Amylase C. Intrinsic factor D. Lipase

A The fat soluble vitamins are D, E, A, K. Vitamins cannot be synthesized by the body so they must be consumed in small amounts in foods and/or supplements. They remain stored in the body for long periods of time and are associated w/ increased risk of toxicity compared to water-soluble vitamins. These must be absorbed into the enterocyte cells of the intestine after they are solubilized by bile salts into micelles Incorrect Answers B. Amylase is necessary for digestion of starches C. Intrinsic factor is necessary for absorption of B vitamins D. Lipase is necessary for digestion of lipids

A nurse is caring for a client w/ suspected HIV. Which of the following diagnostic tests and lab values are used to confirm HIV infection? (SATA) A. Western Blot B. Indirect immunofluoresence assay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid analysis

A, B Positive results of a Western blot test and indirect immunofluorescence confirm the presence of HIV infection. Incorrect: C) A CD4+ T-lymphocyte count assists w/ classifying the stage of HIV infection D) HIV RNA quantification tests are used to determine viral level and to monitor treatment E) CSF analysis is used to confirm meningitis It's important to first order tests to detect the presence of HIV before ordering tests to stage the disease

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. Select one or more: a. Heart rate of 52 bpm b. Digoxin level 1.5 ng/ml c. Yellow vision d. Increased appetite e. Constipation

A, B, C, An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 2 ng/ml). Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. Clients with digoxin toxicity often have disturbed color vision or see halos.

A nurse is preparing to complete discharge teaching for a hearing impaired client. Which of the following interventions would best facilitate successful teaching? Select all that apply. Select one or more: a. Provide the client with detailed written instructions. b. Turn off the TV and close the door to the hallway. c. Sit beside the client to discuss discharge information. d. Include the client's spouse in the teaching session e. Speak more loudly when talking to the client.

A, B, D Eliminating background noise will facilitate hearing conversational tones. Written instructions will reinforce and clarify instructions for the hearing impaired client. If the client concurs, inclusion of the spouse will be of benefit when teaching a hearing impaired client because the spouse can serve to clarify and reinforce the information after discharge. Speaking more loudly is not appropriate, rather speak more slowly and distinctly in a lower-pitched voice

An 87-year-old client has been admitted repeatedly to the acute care setting for pneumonia. The client's family asks what measures can help prevent recurrent respiratory issues. Which of the following measures should the nurse discuss to prevent respiratory issues? Select all that apply. Select one or more: a. Ambulate the client regularly, daily. b. Reassure the client during respiratory distress. c. Encourage a diet high in protein. d. Administer a prior dosage of antibiotics when the client has a cough. e. Use a humidifier to moisten the air in the client's room, when needed.

A, B, E Encourage structured activities, after learning the client's physical capabilities and provide rest periods to prevent dyspnea. Using a humidifier during drier seasons can help prevent secretions from becoming thick and difficult to expectorate. If a client is having difficulty breathing, the caregiver(s) should provide support and reassurance to decrease the client's anxiety.

A nurse is providing teaching about indications of tricyclic antidepressant (TCA) toxicity to a client who has major depressive disorder and a new prescription for imipramine. Which of the following findings of toxicity should the nurse include in the teaching? A. seizures B. agitation C. urinary hesitancy D. dry mouth E. irregular pulse

A, B, E TCA medications have adverse effects including orthostatic hypotension, sedation, and anticholinergic effects. Toxicity risks can be life-threatening. Teach: - precautions r/t falls d/t orthostatic hypotension - caution while driving d/t sedation - anticholinergic effects (can't see, can't pee, can't spit, can't shit) - Toxicity manifestations include irregular pulse, confusion, agitation and seizures. Notify provider of continuing anticholinergic effects, manifestations of toxicity, or suicidal ideation.

A nurse is providing teaching about indications of tricyclic antidepressant (TCA) toxicity to a client who has major depressive disorder and a new prescription for imipramine. Which of the following findings of toxicity should the nurse include in the teaching? (SATA) A. Seizures B. Agitation C. Urinary hesitancy D. Dry mouth E. Irregular pulse

A, B, E A) Toxicity is a risk w/ taking TCAs such as imipramine. Manifestations include cardiac, autonomic, and neurologic manifestations. Neurologic manifestations include confusion, hallucinations, seizures, and coma B) Neurologic manifestations of TCA toxicity are progressive. Initially, the patient will experience confusion, which progresses to manifestations of agitation and seizures. Finally, if left untreated, the client can enter a comatose state E) Cardiac manifestations of toxicity include tachycardia, intraventricular and atrioventricular blocks, ventricular tachycardia, and ventricular fibrillation can occur. Irregular pulse can indicate a dysrhythmia Adverse effects of TCAs can include anticholinergic effects such as urinary hesitancy and dry mouth, also orthostatic hypotension and sedation.

A nurse is assessing a client who is in the resuscitation phase of a deep partial-thickness burn over 40% of his body. Which of the following findings should the nurse expect during this phase of the burn injury? (SATA) A. Dyspnea B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit

A, C, D Dyspnea can occur during the resuscitation pase following a burn injury d/t direct or indirect airway injury. Retention of fluid through cellular shifts and leakage result in exchange and causing SOB. Hyperkalemia occurs during the resuscitation phase following a burn as a result of leakage of fluid from the intracellular space, tissue damage, and red blood cell hemolysis. Hyponatremia occurs during the resuscitation phase of a burn as a result of sodium retention in the interstitial space and fluid losses d/t tissue leakage. Incorrect Answers: B. Tachycardia occurs during the resuscitation phase following a burn d/t sympathetic nervous system compensation E. Hematocrit increases during the resuscitation phase of a burn d/t hemoconcentration as a result of fluid loss There are three phases involved w/ burn injuries: the initial or resuscitation phase, acute phase, and rehabilitative phase. The initial or resuscitation phase of the injury begins w/ the onset of the burn and lasts for 24-48 hrs. During this phase, priorities are airway management, adequate perfusion, pain relief, preventing infection, maintaining body temp, and offering emotional support. The following assessments should occur: - respiratory: most critical b/c direct or indirect injury to the respiratory tract may be present. The nurse should monitor for hoarseness, coughing, difficulty swallowing, and abnormal breath sounds on exhalation. Intubation may be required - cardiovascular: hypovolemic shock is an extreme risk factor following a burn injury. The nurse should monitor for ECG changes, fluid and electrolyte imbalances, and peripheral pulses. -renal: blood flow to kidneys may be decreased and will manifest as decreased urine output w/ increased osmolality. The nurse should monitor hourly output and lab values such as BUN, creatinine, sodium, and urine specific gravity -gastrointestinal: decreased blood flow to the gastrointestinal tract can occur. There is a risk for paralytic ileus that will manifest as decreased bowel sounds, abd distention, nausea and vomiting. The nurse should also monitor for blood in the stool and vomitus

A nurse is assessing a client who had an external fixation device applied 2 hrs ago for a fracture of the left tibia and fibula. Which of the following findings should the nurse identify as a manifestation of compartment syndrome? (SATA) A. Intense pain when the client's left foot is passively moved B. Capillary refill of 2 seconds on the client's toes on the affected side C. Hard, swollen muscle in the client's left leg D. Client report of burning and tingling of the left foot E. Client report of minimal pain relief following second dose of opioid medication

A, C, D, E These s/s are consistent with edema around the injury causing compression of nerve endings Compartment syndrome is a complication that can occur in a client who has a cast or splint w/ an elastic bandage wrap. It can also occur after a client has had an open reduction w/ internal fixation of a fracture or if the client has an external fixation of an extremity fracture. The nurse should monitor the client's neurovascular assessment, which includes circulation checks and sensory perception checks. If neurovascular compromise occurs, blood flow to the distal affected extremity is decreased from edema, and the client might report pain not relieved by analgesics and will have decreased sensation and movement of the foot and toes or hand and fingers. Compartment syndrome can occur w/in 6-8 hrs or up to 2 days after the trauma, and manifestations should be reported immediately to the provider. The nurse should monitor for and teach the client about the manifestations of compartment syndrome, which include the six 'Ps': pain, pressure, paralysis, paresthesia, pallor, and pulselessness

A nurse is reviewing the plan of care for a client who has systemic lupus erythematosus (SLE). Which of the following lab findings should the nurse anticipate? (SATA) A. positive ANA titer B. increased WBC count C. 2+ urine protein D. Increased serum C3 and C4 E. Elevated BUN

A, C, E A positive antinuclear antibody titer identifies the presence of antibodies produced against the client's own DNA. Increased urine protein and elevated BUN is an expected finding d/t the kidney injury that occurs in a client who has SLE Incorrect Answers: B) Pancytopenia (low WBC, RBC, and platelets; usually d/t problem w/ bone marrow), not an elevated WBC count, is an expected finding in a client who has SLE E) a client who has SLE is expected to have a decreased level of serum C3 and C4 Systemic lupus erythematosus is a chronic and progressive systemic inflammatory autoimmune disease of the connective tissue that can affect any body system. The nurse should review lab results that are specific to SLE, including positive ANA titer, erythrocyte sedimentation rate, C3 or C4 complements, CBC with differential, renal fxn tests, and electrolytes

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. Select one or more: a. Apply moist towels to the abdomen. b. Lie down in a supine position. c. Begin abdominal massage. d. Ensure the pouch is attached correctly. with e. Drink hot tea.

A, C, E Moist towels should be applied to the abdomen to facilitate drainage. Abdominal massage should be initiated to promote drainage. Hot tea may facilitate drainage and should therefore be encouraged.

A nurse is caring for a client who is pregnant and has a TORCH infection. Which of the following findings should the nurse expect? (SATA) A. Joint pain B. Insomnia C. Rash D. Urinary frequency E. TORCH infections have influenza-like manifestations, such as decreased appetite

A, C, E Perinatal TORCH infections are a group of five infections w/ similar presentations, including flu-like symptoms, joint pain, rash, and ocular findings. The five infections are toxoplasmosis; "other" (syphilis); rubella; cytomegalovirus (CMV); and herpes simplex virus (HSV) Incorrect Answers: B) malaise and fatigue are common, not insomnia D) urinary frequency is not a clinical finding of TORCH infection The effects of TORCH infections include significant congenital anomalies and even death. Clients should be taught early in pregnancy about proper handwashing and hygiene. Women who are pregnant should avoid activities that increase the risk for developing TORCH infections, such as cleaning cat litter boxes and consuming raw or undercooked meats

The nurse is assessing a client w/ adenofibromyomatous hyperplasia. Which of the following are symptoms that may be found in this client? A. Sensation of incomplete emptying B. Oliguria C. Post-void dribbling D. Strong urinary stream E. Nocturnal incontinence F. Flank pain

A, C, E adenofibromyomatous hyperplasia is medical terminology for benign prostatic hyperplasia (BPH). It refers o a benign increase in the size of the prostate gland. This enlargement impinges on the urethra and obstructs flow of urine from the bladder. S/S include hesitancy in initiating voiding, poor flow or diminished force of stream, intermittent stream, post-void drilling, sensation of incomplete emptying, urgency, frequency, and nocturnal incontinence. Usually treated w/ medication such as finasteride (Proscar) and surgical option including TUNA (transurethral needle ablation), TURP (transurethral resection of prostate), etc. Typically seen in men > 50 yo. Depending on size, age and health of client, and extent of obstruction BPH will be treated either symptomatically or surgically. Urinary retention can result from mechanical obstruction by enlarged prostate, w/ decompensation of bladder detrusor muscle and inability of bladder to contract adequately. The nurse should encourage the client to void q 2-4 hr and whenever the urge occurs.

A nurse is caring for a client who was admitted to the burn unit w/ burns over 35% of his body. For which of the following findings will the nurse monitor this client? (SATA) A. Hyperkalemia B. Metabolic alkalosis C. Hypoglycemia D. Elevated hematocrit E. Hypernatremia

A, D A client w/ extensive burns will usually have elevated potassium levels, elevated hematocrit, hyponatremia, metabolic acidosis, and fever. Increased serum potassium results from injury to red blood cells, which release potassium into the blood. Extensive burns also result in increased insensible fluid loss, which causes the client's blood to become more concentrated, with increased hematocrit. Fever d/t fluid loss is common during the first phase of burn treatment Incorrect Answers B) Metabolic acidosis is associated w/ severe burn injuries C) Hyperglycemia occurs as a result of decreased insulin production and transport E) Hyponatremia occurs in burns as a result of increased renal excretion Fluid shifts and electrolyte shifts in burn injuries occur in an acute, emergent stage, and in later stages of recovery. The amount of shift from plasma to interstitial fluid depends on the extent and severity of the burn, occurring when at least 20-30% of the TBSA is affected. Fluid shifts leads to hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia

After administering an oral dose of radioactive iodine to a client with Grave's disease, which of the following precautions should the nurse instruct the client to observe at home for the first 3-7 days after administration? (SATA) A. The client should use a separate toilet and flush 2-3 times after each use B. Personal laundry can be washed with family laundry C. Stop all antithyroid medications D. Do not breastfeed E. Wash hands before serving food w/ bare hands

A, D Radioactive iodine (RAI) is the first line of treatment for people who have hyperthyroidism, including those with Grave's disease. It takes up to 3 months for a maximum response, so clients should be advised to continue antithyroid medications, including those that lower production of thyroid hormone and those that reduce symptoms. To avoid transmission of radioactive material to family, clients should use a separate toilet and flush 2-3x, sleep in a separate bed, avoid sitting near others long periods of time such as on airline flights, and avoid breastfeeding, close proximity to pregnant women, and close proximity to children Incorrect Answers B) laundry should be isolated and washed separately C) medications for hyperthyroidism should continue until RAI reaches its peak effect E) clients should not use their bare hands to handle or serve food to others and should avoid sharing utensils with others

A nurse who is caring for a client w/ a history of alcohol abuse and cirrhosis expects to find which of the following abnormalities when reviewing the client's lab tests? (SATA) A. Increased prothrombin time B. Decreased bilirubin C. Decreased ammonia D. Increased albumin E. Decreased sodium

A, E Cirrhosis of the liver is the end stage of liver disease. It is characterized by fibrosis of the liver d/t the inflammatory response to inflammation and destruction of liver cells. The architecture of the liver is replaced by nodules, and this results in changes in blood flow through the liver, causing portal hypertension and decreased liver fxn. The liver is the site of production of several clotting factors that are dependent on vitamin K. When liver fxn diminishes, prothrombin production lessens which will cause the prothrombin time to increase, not decrease. It will take longer for the blood to clot. Sodium decreases after decreased albumin results in decreased intravascular osmotic pressure and allows a shift of fluids out of circulatory volume. The kidney perceives this as low volume and retains water, which causes dilution hyponatremia Incorrect Answers: B) Bilirubin is produced in the liver and excreted through the bile ducts into the intestine and gallbladder. When the liver is fibrosed, the liver cells are unable to conjugate bilirubin, which accumulates d/t obstruction of the bile ducts. Bilirubin is increased, causing jaundice C) Ammonia is produced by cleavage of amino acids in the intestine. It is absorbed and transported to the liver where it is converted to urea and excreted. When liver fxn is impaired, ammonia levels rise, causing hepatic encephalopathy. D) the liver produces large proteins from amino acids, including albumin. However, w/ liver dysfunction there is less production and the albumin level will be decreased.

A nurse in the emergency department is caring for a German-speaking female client who has been sexually assaulted. Which of the following actions will the nurse take when working w/ an interpreter to communicate with the client? (SATA) A. Use a female interpreter if possible B. Use correct medical terminology C. Use a relative or personal friend as a translator to follow HIPAA guidelines for privacy D. Request the interpreter to ask the client to acknowledge understanding by nodding E. Maintain eye contact w/ the client when speaking

A, E When working with an interpreter to communicate w/ a client who doesn't understand English, a nurse should locate a trained interpreter who is proficient in the client's native tongue. Use of a same-sex interpreter is preferable, as individuals form another culture may be less responsive to an interpreter of the opposite gender, particularly in situations that are sensitive or personal. Anxiety would occur in any client in this situation, so it is important to provide the client w/ knowledge of the upcoming actions and the order in which to expect those actions and interventions. This will help to allay some concerns. Simple instructions are more likely to be understood by both the interpreter and the client. When working with an interpreter, the nurse should remember that the communication is w/ the client and should maintain eye contact w/the client, not the interpreter. Incorrect Answers: B) Simple instructions about what to expect, including planned actions and interventions and the order in which they will occur, are appropriate. The nurse should avoid medical terminology and use simple terms that the client is more likely to understand C) The use of a professional agency or language line is preferred if there is no designated individual available for bilingual translation in a healthcare setting. Clients have a right to privacy and may not want a family member or friend to know the details of a personal health condition or situation D) The nurse should ask the translator to ask the client to voice her understanding of the information given, which can then be translated into English. This will provide more complete assurance that the client understands. Individuals will often nod to indicate understanding but may simply wish to appear cooperative or to avoid the admission that they don't understand

A nurse is providing instructions to a student nurse about administering an intermittent enteral feeding. Which of the following statements indicates understanding of this teaching? (SATA) A. Fill the feeding bag w/ enough formula to last 24 hrs B. Change administration set every 6 hours C. Leave unused portions of formula at the bedside D. Label the unused portions of the formula E. Elevate the HOB for 15 mins after administration

B, D B) feeding equipment such as the bag holding the formula, should be discarded every 6 hours to prevent bacterial contamination. Extension tubing should be changed every 24 hrs D) the unused portion of formula should be labeled w/ time and date it was opened and the client's name and room number Incorrect: A) intermittent feedings are administered four to six times/day in equal portions, with each feeding lasting 30-45 minutes C) the unused portion should be refrigerated up to 24 hours to prevent bacterial contamination E) HOB should be elevated for 30-60 minutes after feed to prevent aspiration Feedings can be infused w/out a pump as long as care is taken to monitor carefully. Gastric residuals should be measured before each feeding is started.

A nurse is caring for a postpartum client who had a vaginal delivery four hours ago. The client reports that she has been unable to void since delivery and she feels pressure in her vagina. The nurse notes the client's fundus is firm and contracted and there is significant bright red lochia. Which of the following is the most likely conditions? A. subinvolution of the uterus B. Perineal laceration C. Retained placental fragments D. Puerperal infection

B A client who complains of pain or vaginal pressure and has a large amount of bright red lochia w/ a firm uterus most likely has a perineal laceration. A client may develop a perineal laceration during delivery b/c of such factors as an extensive episiotomy, use of forceps during delivery, or a precipitous delivery. The nurse must assess the client's perineum to determine if a laceration is present, continue to monitor the amount of lochia, and monitor the client's vital signs for changes that indicate significant blood loss Incorrect Answers: A. Subinvolution of the uterus occurs when the uterus does not return to its normal size after childbirth. C. Retained placental fragments are often signified by a boggy uterus w/ increased bleeding D. Puerperal infection may cause foul-smelling drainage Tears are described as 1st to 4th degree, depending upon the size and depth of the laceration. 1st degree tears only involve the perineal skin - the skin between the vaginal opening and the rectum and the tissue directly beneath the skin. They frequently heal on their own. Fourth-degree tears extend through the anal sphincter and into the mucous membrane that lines the rectum. They usually require repair w/ anesthesia in an operating room.

A client who received 25 mL of packed red blood cells has low back pain and pruritus. After stopping the infusion, which of the following is the most appropriate action to take? A. Administer prescribed antihistamine and aspirin B. Collect blood and urine samples to send to the lab C. Administer prescribed diuretics D. Administer prescribed vasopressors

B ABO- and Rh-incompatible blood causes an antigen-antibody rxn that produces hemolysis or agglutination of red blood cells. At the first indication of any sign or symptom of a reaction, the blood transfusion is stopped. Blood and urine samples are obtained from the client and sent to the lab along with the remaining untransfused blood. Hemoglobin in the urine and blood samples taken at the time of the reaction provide evidence of a hemolytic blood transfusion rxn Incorrect Answers A, C, D - antihistamine, aspirin, diuretics, and vasopressors may be administered w/ different types of transfusion rxns. Samples are collected immediately after a reaction is noted and the infusion has been d/c'd Blood transfusion rxns occur when the recipient's immune system launches a response against cells or other components of the transfused blood product. A transfusion reaction may occur w/in the first few minutes of transfusion or hours to days later. During a transfusion, the nurse must stay alert for s/s of a reaction. These include fever or chills, flank pain, vital sign changes, nausea, headache, urticaria, dyspnea, and bronchospasm. If the nurse suspects a transfusion rxn, the nurse should immediately stop the transfusion and keep the IV line open w/ normal saline The healthcare provider and blood bank should be notified and the nurse should monitor the client's vital signs and intervene appropriately as indicated. The blood produce should be returned to the blood bank and lab samples should be collected and sent to blood bank/lab

A nurse is caring for a child who has a retinoblastoma. Which of the following findings should the nurse expect? A. Abdominal fullness B. Leukocoria C. Blast cells in the bone marrow D. Visible mass in the oropharynx

B Leukocoria, or a 'white eye reflex' is the most common manifestation of a retinoblastoma Incorrect Answers: A) abd fullness is a finding of a neuroblastoma rather than a retinoblastoma B) bone marrow invovlement is common in leukemia, rather than retinoblastoma D) A visible mass in the oropharynx is common in rhabdomyosarcoma, rather than a retinoblastoma Clinical Manifestations of Retinoblastoma: - most common: white eye reflex (leukocoria) - Second most common: strabismus - if glaucoma is also present, manifestations include a painful, red eye - Late manifestation: permanent vision loss

A nurse is caring for a client diagnosed w/ ulcerative colitis who has a new prescription for sulfasalazine. Which of the following should the nurse include when developing teaching materials for the client? A. Eat a low-protein diet and reduce caloric intake B. Maintain a fluid intake of 2,000 mL/day minimum C. Stop medication when symptoms resolve D. Limit caffeine to 1 cup of coffee w/ breakfast daily

B Ulcerative colitis is a chronic inflamatory bowel disease characterized by exacerbation and remission. Clients should follow a low-residue, high-calorie, high-protein diet supplemented by vitamins and minerals in order to maintain adequate nutrition. Low-residue foods limit the irritation of the GI tract and may decrease symptoms. A low-residue diet includes foods that are easily digested, such as rice, pasta, enriched bread, canned fruit, cooked veggies, and easily digestible meats. Foods such as raw veggies and fruits, who grains, alcohol, fried foods, and spicy foods may irritate the inflamed colon and should be avoided. Fluid intake necessary to maintain fluid balance, hydration, and electrolyte balance is 2000-3000 ml/day. Clients should be instructed to eat small, frequent meals to decrease the load of fecal material in the GI tract, which will decrease stimulation and peristalsis Adequate caloric intake is necessary to meet metabolic needs. Sulfasalazine needs to be taken on a continuous basis in order to maintain remission. The client should avoid anything that stimulates the intestine, including tobacco, alcohol, and caffeine.

A nurse is caring for a client who has narcolepsy. When assessing the client, which of the following findings should the nurse expect? A. A lack of rapid eye movement (REM) sleep B. Sudden attacks of sleep C. Sudden muscle weakness at emotional times D. Sleep apnea E. The urge to move legs when sleeping

B, C Correct - sudden muscle weakness occurs when emotions are intense (catalepsy) e.g., anger or laughter Incorrect A. narcoleptics typically begin REM sleep w/in 15 minutes of going to sleep D. sleep apnea is not applicable or related to narcolepsy E. this is a finding of restless leg syndrome not narcolepsy

A nurse caring for a client who is in labor and has HIV. Which of the following procedures should the nurse identify as being safe for this client? (SATA) A. Vacuum extraction B. Oxytocin infusion C. Use of forceps D. Cesarean birth E. Internal fetal monitor

B, D B) oxytocin infusion is a noninvasive procedure that is considered safe for this client b/c there is little risk for maternal blood exposure to the fetus D) C-section birth can be recommended for clients who have HIV, depending on their viral load, to reduce the risk for transmission of HIV to the fetus Incorrect Answers: A) Vacuum extraction should be avoided for a client who has HIV d/t the risk for maternal blood exposure and transmission of HIV to the fetus C) Use of forceps during delivery should be avoided d/t risk for fetal bleeding and exposure to maternal blood E) Internal fetal monitoring should be avoided d/t risk for fetal blood Clients who are pregnant and have HIV should have a schedule c-section at 38 weeks of gestation to decrease the risk for transmission of the virus to the fetus. The client should be given increased loads of viral medications prior to and during the scheduled c-section. A vaginal delivery is only recommended for those clients with a viral load of < 1,000 copies/mL. Invasive procedures or procedures that could cause maternal blood exposure to the fetus are not recommended. Procedures such as episiotomies, vacuum deliveries, use of forceps, and internal fetal monitoring should be avoided b/c they are considered invasive and could result in exposing fetus to maternal blood.

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. Select one or more: a. Provide initial food by mouth for a client who has experienced a brain attack. b. Transport a client who is utilizing oxygen and has a peripheral IV catheter. c. Apply a dressing to a superficial laceration on the client's arm. d. Assist a client with a new transurethral prostectomy with perineal care. e. Obtain vital signs every 4 hours for a client with ulcerative colitis.

B, D, E

A nurse is providing teaching to an adolescent and her guardian about atomoxetine. The nurse should instruct the adolescent and her guardian that atomoxetine can cause which of the following adverse effects? (SATA) A. Loose stools B. Nausea C. Weight gain D. Insomnia E. mood changes

B, D, E B) atomoxetine can cause GI distress, leading to nausea and vomiting. The nurse should instruct the adolescent to take the medication w/ food to decrease these adverse effects D) Atomoxetine can cause insomnia. The nurse should instruct the adolescent to take the medication in the morning, or no later than 6 pm, to prevent difficulty sleeping at night E) Atomoxetine can cause mood changes and changes in behavior. The nurse should instruct the adolescent to report significant mood changes or suicidal ideation to her provider Incorrect answers A) atomoxetine can cause constipation. The nurse should instruct the adolescent to increase her daily intake of fluids and foods high in fiber C) Can cause decreased appetite and weight loss. Teach to monitor weight weekly and notify the provider if unintentional weight loss occurs This medication is used to treat ADHD and increases the adolescent's ability to focus. The nurse should also instruct the client to notify the provider if she experiences darkening of the urine, yellowing of the skin, or pain in the right upper quadrant of the abdomen

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

B, D, E Each of these tests will show a positive result in patients with rheumatoid arthritis Incorrect Answers: A. a urinalysis assists to diagnose kidney failure, not rheumatoid arthritis C. BUN assists to diagnose kidney failure

A bag of TPN solution has arrived from the pharmacy and the nurse notes in the prescription that in addition to electrolytes the solution also contains medication. Which of the following medications can be mixed w/TPN? SATA A. Codeine B. Insulin C. Acetaminophen D. Ranitidine E. Vitamin C

B, D, E TPN may include vitamins or meds and rantidine or insulin are sometimes needed for digestion and metabolism. Vitamins can also be added when the client is lacking. Pain medications are typically NOT included in TPN preparations.

A nurse is applying a wound dressing to a client's stage 3 pressure ulcer. Which of the following dressing options are correctly matched to the wound stage? (SATA) A. Skin sealant for red granulating wound B. Use hydrocolloid for red granulating wound C. Use barrier ointment for red granulating wound D. Use thin hydrocolloid for moderate exudates E. Use hydrocolloid for deep granulation F. Use alginate for deep granulation

B, D, F Wound management of advanced stage pressure ulcers is not an easy task. The skin barrier is damaged and leaves the client vulnerable to infection. The healing process is lengthy, especially in the case of geriatric clients. The healing process is also affected by nutritional intake and mobility status. Wound healing begins w/ inflammation, followed by a period of granulation and proliferation, and final stages of remodeling and maturation. The granulation phase of the healing process is the stage of initial repair as new tissues are formed to facilitate remodeling of the affected area. The dressing and approach to care should be based on the best evidence to facilitate the healing process in this stage. Film, hydrocolloid, foam, and composite are appropriate dressing materials for protection of red granulation tissue. Wounds w/ minimal to moderate exudates can be dressed w/ thin hydrocolloid, thin foam, and absorbent composite, because these materials promote absorption of exudates. Impregnated gauze, alginate, cavity foam, and strip packing are used for deep granulation, to promote packing of the tissue. Periwound skin requires skin sealant and barrier ointment for protection. Stage III pressure ulcers are characterized by full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but the depth of tissue loss can be identified. Stage III may include undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow, but areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone and tendon are not visible.

A nurse is assessing a client who has HIV. Which of the following findings should the nurse identify as a manifestation of HIV-associated muscle wasting? A. Unintentional weight loss of 15% of body weight in 6 months B. Fecal impaction C. Diminished strength D. Report of increased fat gain on back of neck

C A client w/ HIV-associated muscle wasting will report a decrease in strength as well as muscle wasting caused by gastrointestinal malabsorption of nutrients Incorrect Answers A) unintentional weight loss of less than 5% of body weight may occur in pts w/ HIV-associated muscle wasting B) A client who has HIV-associated muscle wasting might report having diarrhea, rather than fecal impaction D) A client of increased fat gain in the back of the neck can be a manifestation of HIV-associated lipodystrophy. It is not a manifestation of HIV-associated muscle wasting. Lipodystrophy causes loss of fat in the limbs, face, and buttocks while increasing fat deposits on the back of the neck and the trunk. HIV-associated muscle wasting can have many causative factors. Muscle wasting can result from inflammatory changes that increase the body's calorie use, resulting in protein breakdown

A nurse is providing preconception teaching to a client who has phenylketonuria (PKU). Which of the following statements by the client indicates an understanding of the teaching? A. I should avoid getting pregnant because of this disorder B. I will need my PKU levels checked once a year when I'm pregnant C. I should avoid foods high in protein for at least 3 months prior to pregnancy D. I will need to deliver my baby by cesarean section because of this disorder

C A client who has PKU should decrease her dietary intake of protein for at least 3 months prior to conception. The client should be instructed to avoid meat and beans and eat more fruits and veggies. This will decrease the likelihood that the fetus will be exposed to high levels of PKU and will help prevent neurocognitive impairments Incorrect answers: A) There is no restriction on pregnancy for a client who has PKU. However, they will need counseling prior to conception and during pregnancy. The nurse should counsel the client regarding special dietary restrictions necessary as well as the potential cognitive and neurological impairments the child may experience B) a client with PKU will need to have phenylalanine levels monitored one to two times per week throughout pregnancy D) a client who has PKU is not at increased risk for fetal macrosomia (newborn significantly larger than average) and will not require a cesarean birth Phenylalanine is an amino acid that is converted into tyrosine once ingested. With phenylketonuria, the body is unable to form this conversion; thus, phenylalanine accumulates in the blood stream and can attack brain cells. PKU is an inherited disorder that can cause cognitive and neurological impairments. Treatment includes placing the client on a low-phenylalanine diet, which includes eating fruist and veggies and avoiding high-protein foods like meat and beans.

A client w/ HIV is taking didanosine, pentamide, and trimethoprim-sulfmethoxazole. Elevated serum amylase was noted in the laboratory report. Which of the following is the best course of action for the nurse? A. Determine of the client is compliant B. Provide instructions about the effect of drugs on serum amylase C. Call the doctor immediately D. Assess if the client has a complaint about a symptom

C Didanosine (Videx) is an antiretroviral that is prescribed for clients w/ AIDS. It functions to inhibit replication w/in cells. The major side effects from taking this drug are neutropenia, pancreatitis, peripheral neuropathy, and dry mouth. Concurrent use w/ pentamide and trimethoprim-sulfamethoxazole increases the risk for acute and fatal pancreatitis. Elevated serum amylase indicates pancreatic involvement. It is best to notify the doctor about the laboratory report and the drug interaction Incorrect Answers: A) Client compliance is evident by the elevation of serum amylase B) Instruction about drug intake and side effects is appropriate but not the best course of action D) Assessing the client about a complaint regarding a symptom is also appropriate but it is not the best course of action Suspend use of drug if pancreatitis is suspected

A nurse is planning to provide postmortem care for a client. Which of the following actions should the nurse plan to take first? A. Close the client's eyes B. Cleanse the client's body C. Elevate the HOB D. Give the client's personal items to the family

C Elevating the HOB as soon as possible prevents discoloration of the face. The nurse should also place a pillow under the client's head on the stretcher when transporting the client to another area Incorrect Answers: A) eyes should be closed to provide a natural appearance for viewing the body of the deceased but it's not the first action to take B) cleansing the body should be completed and the patient should be covered with a sheet. However, another action should be taken first D) The nurse should ask the family members if any personal items should remain w/ the body and then give any remaining items to a family member

A nurse is caring for a client who has been undergoing anticoagulation w/ heparin for 3 days. Which of the following should the nurse monitor carefully? A. Liver function tests B. Urine myoglobin C. Platelet count D. PT and INR

C Heparin is an anticoagulant agent given as an infusion or by subcutaneous injection for treatment of venous thrombosis or pulmonary embolism. After several days, the client may develop heparin-induced thrombocytopenia, which is characterized by a platelet count of <150,000 cells/mm3. The nurse should monitor the client for bleeding by assessing the gums, the stool for dark, tarry appearance, or for an increased pulse or drop in BP. The activated partial thromboplastin time (aPTT) is used to monitor the efficacy of the drug. The therapeutic level is 1.5 to 2.5x the normal value. A normal aPTT is 30-40 seconds. Protamine sulfate is the antidote to heparin in cases requiring rapid reversal of anticoagulation

A neonate develops hyperbilirubinemia and phototherapy is initiated. What should the plan of care include for an infant receiving phototherapy? A. Taking vital signs every hour B. Keeping eye shields on for 8 hours at a time C. Giving additional fluids every 2 hrs D. Covering neonate w/ a lightweight blanket

C Insensible and intestinal fluid losses increase during phototherapy; extra fluids prevent dehydration Incorrect Answer: A) The nurse does not need to assess the infant's vital signs every hour w/ phototherapy B) the eye shields should be on the baby whenever he/she is under the phototherapy lights D. The baby should never be covered w/a blanket; this prevents phototherapy lights from reaching skin Unconjugated hyperbilirubinemia is the most common for of neonatal hyperbilirubinemia. Unconjugated bilirubin has not been metabolized and cannot be excreted via the normal pathways in the urine and bowel. Accumulated bilirubin binds w/ lipids and albumin, resulting in the yellow appearance of skin and sclera. Unconjugated bilirubin is a neurotoxin that can cross the blood-brain barrier, leading to significant brain damage. Phototherapy treatment for jaundice is performed by exposure of skin to a light source, which converts unconjugated bilirubin molecules into water-soluble molecules that can be excreted by in urine and stool

A client who has been newly diagnosed w/ metastatic cancer has a prescription for morphine sulfate for analgesia but is concerned w/ the possible side effects of N/V. Which of the following should the nurse tell the client in response to this concern? A. take the medication on an empty stomach B. N/V are unusual side effects of this medication C. persistence of nausea is rare since most people develop rapid tolerance to those side effects D. You can reduce the risk of nausea and vomiting by sitting up after taking the medication

C Nausea and vomiting are among the most common side effects associated w/ opioid pain medication, but tolerance develops rapidly, and few individuals experience persistent nausea and vomiting. Use of an antiemetic medication can prevent this side effect during the period before tolerance develops. Other side effects include constipation, sedation, and respiratory depression Incorrect Answers: A. Opioid medications should be taken w/ food to reduce the risk of nausea B. N/V are among the most common adverse side effects associated w/ opioid medications D. The risk of nausea is decreased when the client is recumbent Clients w/ cancer may require long-term pain management w/ opioid analgesics. A common side effect of opioid medication is nausea and vomiting, but a tolerance rapidly develops to this effect. Until the nausea and vomiting subside, taking the medication w/ food may be helpful. Antiemetic medications can provide relief in severe cases.

A nurse is assessing a newly admitted client who reports numbness in the distal extremities and ataxia for the past 3 weeks. Which of the following nutritional deficiencies in this client could be the cause of these symptoms? A. Vitamin D B. Potassium C. Vitamin B12 D. Magnesium

C Numbness and tingling of the hands and feet are neurologic manifestations associated w/ vitamin B12 deficiency Incorrect Answers: A) vitamin d deficiency is associated with bone pain, muscle weakness, and rickets B) Irritability, decreased respirations, muscle weakness, and GI distress are associated with hypokalemia D) twitching of muscles and muscle weakness are manifestations of magnesium deficiency Vitamin B12 deficiency is associated with pernicious anemia, atrophic gastritis and gastric bypass surgery. It can also be found in strict vegans or vegetarians. Manifestations include macrocytic anemia, glossitis (characterized by pain, swelling, tenderness, and loss of papillae of the tongue), neurologic, cognitive, or psychiatric changes, particularly symmetrical paresthesias or numbness and gait problems, depression, cognitive changes, confusion, and ataxia

The nurse is caring for a client w/ jaundice. During the assessment, the nurse notes that the client complains of nausea and vomiting, decreased appetite, and upper abdominal spasms. The problem that the nurse should plan to address first is: A. Decreased appetite B. Jaundice C. Nausea and vomiting D. Upper abdominal spasms

C The nurse should first address the nausea associated w/ the jaundice. If this problem is treated the client's appetite may improve and the upper abdominal spasms may stop. After the nausea is controlled, reassess the client to ensure that problems w/ spasms and appetite are improved Incorrect Answers: A. It is important to treat the root cause (nausea) first. The client's nausea may be causing the decreased appetite B. Treatment of jaundice is not an immediate priority. It should be evaluated and the underlying illness should be treated D. The client's nausea, particularly if accompanied by vomiting, may be causing the abdominal spasms. Acute physiological needs take priority.

Which of the following medication orders for a client with DVT and overlying phlebitis is necessary to clarify w/ the prescriber before admin? A. Heparin infusion at 800 units/hr IV B. Cephalexin 250 mg by mouth C. Warfarin 1.0 mg po D. morphine sulfate 2 mg IV

C This medication order has a trailing zero

A nurse is caring for a client in hypovolemic shock after a GI bleed. The nurse knows that which of the following indicates fluid replacement therapy has been effective? A. The mean arterial blood pressure is > 65 mm Hg B. Heart rate of > 100 bpm C. Urine output > 30 mL/hr D. Respiratory rate is btwn 12-20 breaths/min

C UO is the earliest and best indicator of effectiveness of fluid replacement in hypovolemic shock. Vital signs are a late and unreliable indicator of the adequacy of fluid replacement MAP > 65 mmHg indicates that the client is reaching a normal range of fluid volume, the increase in BP can occur after vasoconstriction, a compensatory response to shock Tachycardia is a compensatory response to shock

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in teaching? A. drink a minimum of 1000 mL of fluid daily B. Increase your intake of refined-fiber foods C. Sit on the toilet 30 minutes after eating a meal D. Take a laxative every day to maintain regularity

C - Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. Incorrect: A. The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation. B. The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods. D. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.

A nurse is caring for a school-aged child who has a concussion. Which of the following manifestations are late indications of increased ICP? (SATA) A. report of headache B. nausea C. decreased motor response D. increased sleeping E. bradycardia

C, E Incorrect answers: A,B,D are all early indications of increased ICP Clinical manifestations of increased ICP based on age Infants: bulging fontanels, restlessness, high-pitched cry, hypersomnia, increased head circumference, setting-sun sign, distended scalp veins Children: forceful vomiting, diplopia, seizures, lethargy school performance declines, trouble following commands, decrease in physical activity Late manifestations: cheyne-stokes respirations, extension posturing papilledema, decrease LOC, flexion posturing, dull painful stimuli response, coma

A nurse is providing education to a client recently diagnosed w/ viral hepatitis. Which of the following are true about viral hepatitis? SATA A. Hep A. has an incubation period of 6-24 weeks B. Hep A. is transmitted via bodily fluids C. Hep. D can cause fulminant hepatitis D. Hepatitis C can be prevented by vaccine E. Lab studies for hep B. show HDV antibodies F. Hep B increases risk of liver cancer

C, F Viral hepatitis is a condition where a virus attacks the liver, causing inflammation, cellular damage, and loss of liver function. Cell-mediated immune responses trigger hyperplasia, necrosis, and cellular regeneration. Symptoms include muscle aches, anorexia, GI disturbances, and jaundice There are at least 5 types of viral hepatitis (A-E) Hep A is transmitted through the fecal-oral route and results in acute illness. Hep B, C, and D are blood-borne pathogens w/ chronic course that can result in end-stage liver disease. Theses virus are transmitted through contaminated body fluids. Vaccines are available to protect against Hep A and B. Fulminant hepatitis is essentially acute liver failure and can occur w/ hepatitis D

A nurse is caring for a client who has just been admitted after laproscopic cholecycstectomy. The patient is complaining of pain in the shoulder. In which position should the nurse place the client to provide relief? A. Dorsal recumbent B. Supine C. Sim's w/ left side down, right knee flexed D. Sim's w/ right side down, left knee flexed

C. After a laproscopic cholecycstectomy, some patients experience referred pain to the shoulder as a result of phrenic nerve and diaphragmatic irritation by retained CO2. Left side down facilitates movement of the gas pocket away from the diaphragm. Early ambulation and deep breathing should be encouraged. There is usually minimal pain after laparoscopic cholecycstectomy and it is relieved by narcotic analgesics. Client may walk to the bathroom to void. Clear liquid diet is permitted and although the client may stay overnight, many are discharged the day of surgery

A nurse is providing discharge teaching about dietary recommendations in the DASH diet to a client who has hypertension. Which of the following statements by the client indicates and understanding of the teaching? A. my daily sodium consumption should be 3,000 mg B. I should consume foods that are low in potassium C. I need to lose at least 25 lbs to see a decrease in my BP D. I should consume low-fat dairy products

D DASH = dietary approaches to stop hypertension eating plan includes a low sodium diet rich in fruits and veggies and low-fat or non-fat dairy with whole grains. It is a high fiber, low to moderate fat diet rich in potassium, calcium, and magnesium. Lifestyle modifications are the initial step in reduction of BP in individuals w/ prehypertension or hypertension. Individuals w/ severe hypertension may not be able to eliminate medication, but the DASH diet can improve response to medication and lower blood pressure. The DASH diet is associated w/ lower cholesterol, reduced insulin resistance, and reduced risk of developing diabetes when combined w/ exercise and weight loss Incorrect: A) daily sodium consumption should be 1500 mg or less B) high potassium foods assist w/ lowering blood pressure and cholesterol C) blood pressure will typically decrease when a client has a weight loss of 4.5-6.8 kg

A nurse in a mental health facility is planning care for a client who has a new prescription for risperidone to treat schizophrenia. Which of the following interventions should the nurse include in the plan of care? A. Assess client for onset of anticholinergic manifestations B. Check the client's BP daily for hypertension C. Monitor serum electrolyte levels weekly D. Instruct the client to eat low-calorie snacks to prevent weight gain

D Metabolic syndrome, including weight gain, dyslipidemia, and an increase in blood glucose levels, are common adverse effects of risperidone. The nurse should instruct the client to choose low-calorie snacks, eat a balanced diet, and carry out an exercise plan to prevent weight gain. Metabolic syndrome commonly occurs in clients taking second generation antipsychotic medications and can lead to an increased risk for diabetes mellitus and cardiovascular disease Incorrect Answers A) Risperidone doesn't cause anticholinergic manifestations such as dry mouth, decreased peristalsis, and mydriasis. These frequently occur with other second-gen antipsychotics such as clozapine and olanzapine B) Orthostatic hypotension, not hypertension, is a common adverse effect of risperidone. The client should be monitored for a decrease in BP and in increase in pulse rate when arising from a lying or sitting position. C) changes in serum electrolyte levels are not expected while taking risperidone. Nurse should monitor the client's CBC, WBC, and liver fxn tests, prolactin levels, and blood glucose levels to check for adverse effects of risperidone Assess clients for other risk factors of metabolic syndrome, including hypertension, obesity, increased triglycerides, and high blood glucose levels. Monitor the pts weight, BMI, BP, and lab values and should encourage clients to develop health promotion plans, including increased exercise and choosing balanced, low-cal meals and snacks

A nurse working in a clinic is providing discharge teaching to the parent of a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following instructions should the nurse include? A. Encourage the child to nap for 1 hr daily B. Allow the child to stay home on days when her joints are painful C. Apply cool compresses for 30 minutes every hour D. Administer prednisone on an alternate-day schedule

D Prednisone is an effective anti-inflammatory agent that can have serious adverse effects, such as immunosuppression, inhibition of bone growth, the development of osteoporosis, and cardiomyopathy. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects Incorrect Answers: A) A child who has JIA should rest during the daytime by participating in activities such as reading, watching TV, and listening to music. Sleeping during the day can promote stiffness and interfere w/ nighttime sleep B) Participating in activities, such as attending school and collaborating w/ peers, is important for the well-being of a school-aged child who has JIA. The clinic nurse should encourage the parent to collaborate w/ the school nurse to help develop a plan of care which will provide the support the child needs to succeed in school. This can include administering pain medication, modifying class schedules, and arranging for an extra set of textbooks for the child to keep at home. C) The client should use moist heat to relieve pain and stiffness. Moist heat can be delivered by using a paraffin bath, whirlpool bath, or hot packs JIA is a chronic autoimmune disease that causes inflammation in the joints, synovium, and surrounding tissues. The nurse should be aware of expected findings of JIA, such as swelling, stiffness, and loss of motion in the affected joints. The joints can also be tender to touch and warm. The nurse should be knowledgeable about diagnostic testing, therapeutic management, medications, and client education that can assist the parent and child w/ managing the disease.

A nurse is caring for a client who has just had a nasogastric tube placed. Which of the following signs or symptoms should the nurse assess for that may be complications of an NG tube? (SATA) A. skin breakdown on the lips B. Excess flatus C. Pain in the neck and shoulders D. Epigastric pain E. Aspiration pneumonia

D, E An NG tube can be inserted easily and quickly to provide feedings for a client or to decompress the stomach if needed. However, there are several potential complications that the nurse should routinely assess for, including skin breakdown from tape on the nose or face, pain in the epigastric area, and signs of aspiration which could cause pneumonia Incorrect Answers: A. skin breakdown on the lips is not an initial complication of an NG tube. This may potentially become a concern but should not be initially B. Excess flatus is not an initial concern for a patient w/ an NG tube C. pain in the neck and shoulders is not a complication of an NG tube Indications for placement of a nasogastric tube include aspiration of stomach contents to decompress the stomach of fluid, air, or blood: introduction of fluids to the stomach such as charcoal, enteral feeding and oral contrast media; and to reduce the risk of vomiting or aspiration. Contraindications include caustic ingestion or esophageal strictures (risk of perforation); coagulopathy (epistaxis risk); basilar skull fracture or severe mid-face trauma

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate for BP at the dorasalis pedis artery B. Measure the BP w/ client sitting on side of bed C. Place the cuff 7.6 cm (3 in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh

D. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure. Incorrect A. The nurse should auscultate for the blood pressure at the popliteal artery. B. The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. C. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.

Heart sounds associated w/ heart failure, aortic stenosis, and mechanical heart valve

Heart failure: a third heart sound (S3) that occurs soon after the normal (S1 and S2) heart sounds is associated w/ heart failure. S3 may be a normal finding in people under 40 years of age and some trained athletes but should disappear before middle age. It is caused by increased atrial pressure leading to increased flow rates and inflowing blood against a distended or noncompliant ventricle in mid-diastole. In patients over 40 years of age, the S3 sound is considered pathognomic for heart failure Aortic Stenosis: characterized on auscultation by a soft or normal S1, diminished or absent A2, paradoxical splitting of S2, prominent S4, and accentuated P2 when secondary pulmonary hypertension is present. An ejection click is often heard in children and young adults w/ congenital aortic stenosis. Aortic stenosis involves crescendo-decrescendo systolic murmur that begins after the first heart sound and ends just before the second heart sound Mechanical valve: loud, high-frequency metallic closing sound w/a soft opening sound. Alternatively, they may have a low-frequency opening and closing sound in the case of caged ball valves.

Pregnancy: Biophysical Profile

Variable: Non-stress test result -- 0: nonreactive (no observation of 2 accelerations in 20 minutes) -- 2: Reactive (2 accelerations in 20 minutes leach lasting 15 seconds and peaking at 15 bpm above baseline HR) Amniotic fluid index (AFI) -- 0: AFI < 5 cm or no single pocket > 2 cm -- 2: AFI > 5cm or at least one pocket of fluid > 2cm Fetal muscle tone -- 0: fetus is observed during ultrasound for muscle tone. Absent means decreased extension or flexion -- 2: Fetus is observed during ultrasound for one episode of extension w/ flexion of fetal limb or trunk Fetal movements -- 0: fetus is observed during ultrasound for 30 mins and has < 3 trunk/limb movements -- 2: fetus is observed during ultrasound for 30 minutes and has at least 3 trunk/limb movements Fetal breathing -- 0: fetus is observed for 30 minutes for breathing movements. Absent means no breathing movements by fetus or less than 30 seconds of maintained breathing during 30 minutes -- 2: fetus is observed for 30 minutes for one or more occurrence of fetal breathing movements of 30 seconds in duration