Nclex reading reviews chapter

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse should monitor which laboratory result during treatment with this medication?

A common side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes.

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching ?

A patent ductus arteriosus (PDA) is caused by a failure of the ductus to close within the first weeks of life. The infant may be asymptomatic or show signs of heart failure. The defect may be closed during cardiac catheterization or may require surgery. A characteristic machine-like murmur is present with PDA.

The client with trigeminal neuralgia is being treated with carbamazepine. Which laboratory result indicates that the client is experiencing an adverse effect of the medication?

Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbance, thrombophlebitis, dysrhythmia, and dermatological effects.

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication?

Bethanechol chloride can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique?

For an adult, the nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe.

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?

Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?

Phenytoin is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not skip medication doses because this could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity.

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which?

Pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. This type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis?

Signs of glomerulonephritis include headache, abdominal or flank pain, gross hematuria resulting in dark, smoky, cola-colored or red-brown urine and periorbital edema or facial edema. Clients are hypertensive and have decreased urine output. BUN levels may be elevated.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?

Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching ?

The child with viral pneumonia will not be prescribed antibiotics, it is bacterial pneumonia that requires antibiotics for treatment. It is important to monitor the infant for fever spikes because of the risk for febrile seizures. Use of a cough suppressant may be prescribed before rest times and meals if the cough is disturbing and unproductive. Promoting bed rest to conserve energy, encouraging fluid intake and the administration of antipyretics for fever, and bronchodilators are typical interventions for pneumonia.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item?

The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

The nurse is reviewing the primary health care provider's (PHCP'S) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart?

The pain associated with acute pancreatitis is aggravated when the client lies in a supine and flat position. Therefore, the nurse would verify this prescription. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis.

A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents?

The parents need to be instructed to notify the pediatrician if abdominal pain (especially in the left upper quadrant) or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bed rest is not necessary and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen.

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?

The side effects of radiation therapy include dry or moist desquamation (peeling of the skin) and the intervention includes washing the skin daily, using mild soap, applying a lubricant as prescribed. Options 1, 2, and 3 are appropriate statements.

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?

The vomiting child should be placed in an upright or side-lying position to prevent aspiration.

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?

After a tonsillectomy, if bleeding occurs, the child is turned to the side and the RN or PHCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take?

An iodine-based dye may be used during the IVP and can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Checking for allergies is the priority.

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder?

Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain should more likely characterize a problem with infection

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation.

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?

Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication?

It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear.

A client has been started on long-term therapy with rifampin. Which information about this medication should the nurse provide to the client?

Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a PHCP. The medication should be administered on an empty stomach unless it causes GI upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes red-orange discoloration of body secretions and will permanently stain soft contact lenses.

The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification?

The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area?

With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4.

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?

Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction.

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client?

Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills.

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. Discomfort is expected.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention

The client is at risk for injury to self and others and therefore should be escorted out of the dayroom

The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure?

The client undergoing a lumbar puncture (LP) is positioned lying on the side, with the knees bent, drawn up to the abdomen, and the chin tucked into the chest. This position helps to open the spaces between the vertebrae.

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client?

The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client should take which action to monitor the effectiveness of treatment?

The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client?

A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching ?

Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

An older client has recently been taking cimetidine. The nurse should monitor the client for which most frequent central nervous system side effect of this medication?

Cimetidine is a histamine 2 (H 2 )-receptor antagonist. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?

Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect.

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure?

Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures.

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?

In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A 1 C, or total cholesterol levels.

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?

Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication?

Rifabutin may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, GI disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B 6 deficiency and numbness and tingling in the extremities are associated with the use of isoniazid. Ethambutol also causes peripheral neuritis.

A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo?

The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Watching television can increase the vertigo.

The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching ?

The treatment plan for children with attention deficit hyperactivity disorder includes stimulant medications that may have the adverse effect of appetite suppression and weight loss, not overeating. Treatment for these children includes behavioral therapy, maintaining a consistent environment, and appropriate classroom placement. Regular medication administration and regular follow-up visits ar

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?

A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?

A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. Lead is an element that has a high density and high atomic number and is used to shield persons from radiation. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it into the lead container. The radiation safety officer of the institution should be notified. Although the PHCP needs to be notified, this is not the immediate action. The nurse cannot reinsert the implant. A radioactive implant is specifically placed inside the client to kill the cancer while limiting damage to adjacent tissues and organs. Touching the implant with gloves and flushing this down the toilet exposes the nurse and the environment to unsafe levels of radiation.

A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?

A macular rash that first appears on the trunk and scalp and then moves to the face and the extremities is a characteristic of chicken pox. Pseudomembrane formation in the throat is characteristic of diphtheria. A maculopapular or petechial rash primarily on the extremities is characteristic of Rocky Mountain spotted fever. Small red spots with a bluish-white center and red base are known as Koplik spots and are characteristic of measles.

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply.

A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity may be elevated to reduce edema. A wet cast is handled with the palms of the hands until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The PHCP is notified immediately if circulatory impairment occurs.

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction?

A suprapubic approach involves a lower abdominal incision to remove the prostate to treat prostate cancer. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. The incision is not on the scrotum but in the lower abdominal area. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and it usually occurs with exertional activities.

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)?

AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Homecare instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the primary health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first ?

Actions to take in the case of a child swallowing poison include assessing the child and treating the child first, not the poison. Circulation, airway and breathing, and vital signs need to be assessed. Resuscitation measures would be initiated if the assessment indicates a need. The next step is to terminate exposure to the poison, such as emptying the mouth of pills or other materials or flushing the skin with water. Then identify the poison, if possible, and take measures to prevent absorption of the poison, such as administering the antidote if known. Transport the child to an emergency department for further treatment.

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?

Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, and 4 are not necessary.

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan?

After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?

After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply

Alopecia is not a sign/symptom of testicular cancer. However, it may occur as a result of radiation or chemotherapy. Elevated PSA levels are associated with prostate cancer. Testicular swelling without pain and a feeling of heaviness in the scrotum occur with testicular cancer as a result of the tumor growing. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching ?

Although strabismus is considered a normal finding in young infants, it should not be present after 4 months of age, so the 1 year old will likely not outgrow the condition. The use of an eye patch helps to strengthen the weak eye and surgery may be required for the condition. A muscle imbalance or the paralysis of the extraocular muscles may be the cause or strabismus could be congenital.

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate?

Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?

Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the PHCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the PHCP immediately if nausea occurs. If nausea persists or results in vomiting, the PHCP should be notified.

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching ?

Antiseizure medications are given on a routine basis to prevent a seizure, they are not rescue medications given at the time of a seizure. Padding the side rails, having a child wear a medical alert bracelet, swimming with a companion, and wearing a protective helmet while riding a bike or skateboarding are just a few of the precautions that are discussed with families.

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record?

Any child who exhibits the "3 C's"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action?

Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication.

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing PHCP so that the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 2, and 4 do not have side effects that are potentially associated with hearing difficulties. Test-Taking Strategy: Focus on the subject , the

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?

Atropine sulfate is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record?

Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list?

Bedding and linens should be washed with hot water and dried on a hot setting. Thorough home cleaning is necessary to remove any remaining lice or nits. Siblings may need to be treated and combs and brushes may need to be discarded or soaked in boiling water for 10 minutes. Antilice sprays are unnecessary. Additionally, they should never be used on bedding, furniture, or a child. The pediculicide product needs to be used as prescribed, and the parents are instructed to follow package instructions for timing the application and for contraindications for their use in children.

The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?

Between 1 L/min and 3 L/min of oxygen by nasal cannula may be required to raise the PaO 2 level to 60 mm Hg to 80 mm Hg. However, oxygen is used cautiously in the client with emphysema and should not exceed 2 L/min unless specifically prescribed. Because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system.

Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis.

Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)?

Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. Chicken tenders and a baked potato with butter provide a high-calorie and high-protein meal that includes fat.

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?

Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication?

Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?

Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the PHCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery?

Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm. Pain and numbness near the incision and drainage from the surgical site are expected occurrences after mastectomy and are not indicative of a complication.

Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma.

Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid and should be reported to the RN immediately; the RN would then contact the primary health care provider. The colorless drainage should also be checked for evidence of cerebrospinal fluid; one method is to check for the presence of glucose using a dipstick. Options 1, 3, and 4 are incorrect and delay required immediate interventions.

The nurse is assigned to care for a client with a diagnosis of detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment?

Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy. Options 1, 3, 4 and 6 are not specifically associated with bleeding as a result of detached retina.

The nurse should institute which interventions for a client diagnosed with Clostridium difficile ?

Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile . Measures used to prevent the spread of C . difficile are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores. The use of a mask by the nurse, or the client when outside the client's room, is unnecessary because C . difficile is not transmitted by the respiratory route. The door does not need to be kept shut.

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching ?

Cough syrups and cold medicines are not to be given because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 mL to 1000 mL of fluids daily is important for thinning secretions

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). A normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic respons

Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output.

Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response?

Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?

Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B 12 .

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?

Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be life long, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?

Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.

The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention?

During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard during inspiration and expiration that is caused by the compression of the trachea and leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect?

Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as the "on-off phenomenon") are frequent side effects of the medication.

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions?

Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. The formation of granulation tissue is not the intent of an escharotomy, and escharotomy will not affect the formation of edema.

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately ?

Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Red-orange discoloration of secretions occurs

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation?

External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.

The nurse is assigned to care for the client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse should monitor the results of which laboratory study while the client is taking this medication?

Foscarnet is toxic to the kidneys. Serum creatinine is monitored before therapy, two to three times per week during induction therapy and at least weekly during maintenance therapy. Foscarnet may also cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus these levels are also measured with the same frequency. Recalling that this medication is nephrotoxic will direct you to the correct option.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child?

HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be prescribed fluid restrictions. The treatment also involves providing adequate nutrition, preventing infection and anticipating CNS involvement which may include seizure, stupor, and coma. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention. Encouraging the child to ambulate and administering regular insulin would result in a lowered blood glucose level. Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Waiting 30 minutes to confirm the blood glucose level delays necessary intervention.

Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy?

If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first ?

If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined.

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?

If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse because this can indicate hemorrhage. Options 1, 2, and 4 will delay necessary treatment.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify?

In a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the PHCP. In this situation, the nurse should clarify the prescription.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 mL/kg/hour to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client?

In order to prevent renal failure in the client with multiple myeloma, the nurse should encourage fluids and monitor serum calcium and uric acid levels. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 L to 2 L a day. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium and uric acid, but also to prevent protein from precipitating in the renal tubules. Oral care, encouraging coughing and deep breathing, and monitoring the red blood cell count are important for clients with cancer, but these interventions are not specific to prevention of renal failure.

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching ?

In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

The homecare nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information?

Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen because freezing affects the chemical composition of the insulin. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Freezing insulin, storing insulin in a dark, dry place and keeping the insulin at room temperature are all incorrect actions.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior?

Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client?

Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages.

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication?

Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

Which individual is least at risk for the development of Kaposi's sarcoma?

Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take?

Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

The client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?

Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy.

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion?

Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?

Milk may affect absorption of the iron. Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Water will not assist in absorption.

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?

Mumps is caused by a paramyxovirus that causes swelling from the parotid gland, causing jaw and ear pain. It is transmitted via direct contact or droplets spread from an infected person, salive from infected saliva, and possibly by contact with urine. Airborne and contact precautions are indicated during the period of communicability.

The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome?

Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased and the blood pressure is normal or slightly decreased.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of the medication? Select all that apply.

Nevirapine is a nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels. Hyperglycemia, peripheral neuropathy, and reduced bone density are not side/adverse effects of this medication.

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching ?

Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications can also cause liver abnormalities so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?

Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

The client has an as needed prescription for ondansetron. For which condition should the nurse administer this medication?

Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy.

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child?

Oxygen administration may be prescribed for the infant with HF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply.

Oxytocin stimulates uterine contractions and is a common pharmacological method to induce labor. High-dose protocols have been associated with more uterine hyperstimulation and more cesarean births related to fetal stress. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Some PHCPs prescribe the administration of oxytocin in 10-minute pulsed infusions rather than as a continuous infusion. This pulsed method, which is more like endogenous secretion of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?

Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching ?

Parents are to be instructed to use cool compresses to lessen eye irritation and wear dark glasses for photophobia. Options 1, 2, and 3 are correct measures.

The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse?

Parents of the child with Marfan syndrome should be instructed to monitor for vision problems and get regular eye examinations, avoid participation in contact sports, but it is not necessary to stay indoors. Monitor the curvature of the spine as the child grows, anticipate that antibiotics should be taken before any dental procedure to prevent endocarditis, cardiac medications to decrease stress on the aorta, and surggical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury?

Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

People at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas such as long-term care facilities, prisons, and mental health facilities; older clients; malnourished individuals, those with an infection, or an immune dysfunction or human immunodeficiency virus infection, or individuals who are immunosuppressed as a result of medication therapy; and individuals who abuse alcohol or are IV drug users.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation?

Phenylketonuria is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (1210 mcmol/L). The normal level is 0 mg/dL to 2 mg/dL (0-121 mcmol/L). A result of 0 mg/dL is a negative test result.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm 3 (10 × 10 9 /L). On the basis of this laboratory value, the nurse should perform which intervention?

Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm 3 (20 × 10 9 /L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm 3 (10 × 10 9 /L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client also needs to avoid starting bleeding from epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth

The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms?The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms?

Pleurisy is inflammation of the pleura. The most characteristic symptom of pleurisy is abrupt and severe pain. The pain almost always occurs on one side of the chest. Pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. This causes shallow breathing. A pleural friction rub may be heard.

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for

Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis.

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

Positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question?

Postoperative management for infants with hydrocephalus who have undergone ventriculoperitoneal shunt should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply

Postoperative management of Hirschsprung's disease includes taking vital signs, but avoiding taking the temperature rectally. The client needs to remain NPO (nothing by mouth) status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. The other options are correct postoperative management.

A client with diabetes mellitus visits a healthcare clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dL to 200 mg/dL (10.2 mmol/L to 11.4 mmol/L). Which medication, added to the client's regimen, may have contributed to the hyperglycemia?

Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements.

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching ?

Protection from tick bites includes wearing light colored clothing to make the ticks more visible if they get on the child. Prevention of Rocky Mountain spotted fever includes measures to take to protect getting tick bites and includes wearing long-sleeved shirts, long pants tucked into socks, and a hat. Checking for ticks on children after they have been exposed to a high-risk area and using insect repellents containing diethyltoluamide and permethrins are also measures to take.

A parent with a 6 year-old-child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching ?

Providing a reward system appropriate for the child is more effective than a punitive system to treat enuresis. Interventions for treatment of enuresis include involving the child in caring for the wet sheets and changing the bed, to assist with the child taking ownership of the problem. Limiting fluid intake at night and encouraging the child to void just before going to bed is another effective intervention.

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present?

Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally?

Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

Rationale: A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Remember that the safety of anyone present is more important than extinguishing the fire. Remember the mnemonic RACE: R (Rescue) A (Alarm) C (Confine) E (Extinguish). Test - Taking Strategy: Note the strategic word , next . Remember the mnemonic PASS to prioritize in the use of a fire extinguisher: P = P ull the pin; A = A im at the base of the fire; S = S queeze the handle; S = S weep from side to side to coat the area evenly.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement?

Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

Rheumatic fever (RF) characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition?

Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented

Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne precautions and contact precautions are required; a mask and gloves are worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 4, and 5 are not indicated for rubeola.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response?

Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?

Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse?

Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the PHCP is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which action first ?

Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

A sulfonamide is prescribed for a client with a urinary tract infection. During review of the client's record, the nurse notes that the client is taking warfarin sodium daily. Which prescription should the nurse anticipate for this client?

Sulfonamides can potentiate the effects of warfarin sodium, phenytoin, and orally administered hypoglycemics such as tolbutamide. When an oral anticoagulant is combined with a sulfonamide, a decrease in the anticoagulant dosage may be needed.

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH?

Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. The SIADH induces low sodium blood levels and results in altered neurological states, including confusion and unresponsiveness. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline. Sodium blood levels and neurological status are monitored closely and safety interventions must be instituted. The client should not be treated with an increase in fluid intake or a decrease in the sodium intake.

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has methicillin-resistant Staphylococcus aureus (MRSA). Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Methicillin-resistant Staphylococcus aureus (MRSA) is contagious and is spread to others by direct contact with infected skin or infected articles.

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?

The administration of eyedrops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications may need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure.

The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?

The antidote for cholinergic crisis is atropine sulfate. Acetylcysteine is the antidote for acetaminophen. Vitamin K is the antidote for warfarin and protamine sulfate is the antidote for heparin.

The nurse is preparing to perform an abdominal examination. Which step should be taken first ?

The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching ?

The brace needs to be worn from 16 to 23 hours a day. Braces are not curative, they slow the progression of the curvature. The skin under the brace needs to be inspected for any redness or breakdown. The child should continue to perform prescribed exercise to help maintain and strengthen the spinal and abdominal muscles.

The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan?

The cast should have not rough edges, but cutting the cast is not appropriate, the edges can be covered with waterproof adhesive tape to ensure a smooth cast edge. Instruct the parents and the child to keep the cast clean and dry, and not to stick objects down the cast. Monitoring for circulatory impairment is important.

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone.

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching ?

The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, and 4 are components of the homecare instructions to the family of a child with hepatitis.

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately ? Select all that apply

The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. The signs of perforation and shock are evidenced by fever, an increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress and need to be reported immediately. The options for hypoactive bowel sounds, profuse projectile vomiting, and ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock.

The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching ?

The client needs to be instructed to avoid exposure to the sun because of the risk of burns, resulting in altered tissue integrity. No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

The client should not drive because the device impairs the range of vision. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?

The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition?

The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed?

The client with acute pancreatitis is normally placed on an NPO status to rest the pancreas and suppress GI secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk and draw the knees up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may also help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress GI secretions.

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply .

The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Slow and shallow breathing is not associated with heart failure.

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand?

The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply.

The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure?

The most common complications associated with orchiopexy are bleeding and infection. The parents are instructed in postoperative homecare measures, including the prevention of infection, pain control, and activity restrictions. The measurement of intake and output is not required. Anticholinergics are prescribed for the relief of bladder spasms; they are not necessary after orchiopexy. Cold, wet compresses are not prescribed. The moisture from a wet compress presents a potential for infection.

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching ?

The mother should be instructed that lotions and powders should not be applied to the incision site because these items can affect the skin integrity and the healing process.

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?

The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?

The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?

The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching ?

The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents?

The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take?

The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops?

To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward. Holding the bottle, the nurse gently rests the wrist of the hand on the client's cheek and squeezes the bottle gently to allow the drop to fall into the conjunctival sac. The client is instructed to close the eyes gently and not to squeeze the eyes shut to prevent the loss of medication.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply.

Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder?

Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved within 3 to 6 months, surgery is usually indicated. Because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

A client with prostatitis resulting from kidney infection has received instructions on management of the condition at home and prevention of recurrence. Which statement indicates that the client understood the instructions?

Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client is also taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which should be included in the plan?

When administering eardrops to a child who is younger than 3 years old, the ear should be pulled down and back. For children who are older than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but hand washing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?

Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination?

With the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive Ortolani maneuver is a palpable clunk as the femoral head moves over the acetabular ring. Options 1 and 2 are data collection techniques for the identification of the clinical manifestations of hip dysplasia, but they do not describe the Ortolani maneuver. When performing the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum.

The nurse is caring for a client with an internal radiation implant. The nurse should observe which principle?

A client receiving treatment for cancer with internal radioactive implant is emitting radioactive beams and others in the environment must take precautions to avoid injury. Pregnant persons are not allowed in the room. Nurses delivering bedside care must wear a lead apron which will stop the radioactive beams. The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children less than 16 years old and pregnant women are not allowed in the client's room. These guidelines protect individuals from radiation exposure.

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis?

A definitive diagnosis of tuberculosis is confirmed through culture and isolation of Mycobacterium tuberculosis . A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise?

A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks between 6 and 14 hours; therefore, late-afternoon exercise would occur during the peak of the medication.

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is said to be stenosed.

The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication?

A side effect specific to etoposide is orthostatic hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

A client is receiving acetylcysteine, 20% solution diluted in 0.9% normal saline by nebulizer. The nurse should have which item available for a possible adverse event after giving this medication?

Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?

Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes.

The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching ?

All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-old children will want to be very active. Therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the child's temperature; provide analgesics, as needed; and monitor the urine output.

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol?

Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. β-blockers may induce this reaction particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

The client with myasthenia gravis becomes increasingly weak. The primary health care provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis?

An edrophonium injection makes the client experiencing cholinergic crisis temporarily worse. This is known as a negative test. An improvement of weakness would occur if the client were experiencing myasthenia gravis. Options 1 and 2 would not occur in either crisis.

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure?

An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

During the monitoring of a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse interpret as acceptable responses? Select all that apply.

Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow progression of joint degeneration. In addition, the improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy?

Bladder exstrophy is a congenital anomaly that is characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is unknown and there is a higher incidence among males. Options 1, 2, and 3 are not characteristics of this disorder.

A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem?

Bupropion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Bupropion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk.

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy?

Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the PHCP if these symptoms occur. The other options do not require PHCP notification.

The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the primary health care provider (PHCP)?

Clients with a seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsive medication.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?

Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur.

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, retractions, and dyspnea. Epiglottitis is the bacterial form of croup with symptoms of a high fever, sore throat, and an absence of spontaneous cough.

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented?

Common interventions used in the treatment of epididymitis include bed rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad should not be used because direct application of heat could increase blood flow to the area and increase the swelling.

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record?

Crohn's disease is characterized by nonbloody diarrhea of usually not more than four or five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity.

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. The nurse ensures that weights hang freely and that the amount of weight matches the current prescription. The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed. The nurse does not remove the weights to administer care or change the level of tension or traction based on client comfort level.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication?

Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction should the nurse reinforce in the client-teaching plan regarding this medication?

Cycloserine is an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mcg/mL reduce the incidence of neurotoxicity. The medication must be taken after meals to prevent GI irritation. The client must be instructed to notify the PHCP if a skin rash or signs of CNS toxicity are noted. Alcohol must be avoided because it increases the risk of seizure activity.

The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom?

Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client may then develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which signifi

Didanosine can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times the normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test(s) would identify an adverse effect associated with the administration of this medication?

Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and periodically throughout the treatment course. It is administered in the lowest effective dosage for the shortest time necessary. Options 1 and 3 are tests that assess kidney function.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action?

During a widespread disaster, many people will be brought to the emergency department for treatment. Health care institutions are required to have an emergency response plan in place and perform practice drills. The initial nursing action should be to activate the emergency response plan. The plan entails the other options, which include preparing triage rooms to take casualties, and obtaining sufficient supplies and medical personnel.

When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective ?

During illness, the client should monitor the blood glucose level, and he or she should notify the PHCP if the level is greater than 250 mg/dL (13.9 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice.

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply.

During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child?

Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?

Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm 3 (150 to 400 × 10 9 /L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm 3 (5-10 × 10 9 /L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication?

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is administered in the early morning without consideration to meals.

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

Flushing is a side effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the PHCP.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox.

Betaxolol hydrochloride eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for stre

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid?

Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client generally experiences pain caused by reflux resulting from ingestion of irritating foods, lying flat following meals or at night, and consuming large or fatty meals. Relief is obtained by eating small, frequent, and bland meals; histamine antagonists and antacids; and elevation of the thorax after meals and during sleep.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy?

Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid. Anemia (low red blood cell count), low platelet levels, and low white blood cell counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process.

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate?

If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding. Signs of infection should not appear immediately after a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.

The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?

If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids may also be prescribed. The client will need to be instructed about obtaining and wearing a MedicAlert bracelet, but this is not the immediate action.

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first ?

In an older client, the only symptom of a UTI may be something as vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client, and fever can be associated with a variety of conditions.

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?

Isoniazid is given to prevent TB infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?

Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork.

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?

Most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. Pain that is not relieved from these measures should be reported to the RN and PHCP because it may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. Because this is a new closed fracture and cast, infection would not have had time to set in.

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question?

Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of I&O. An IV line is maintained to administer fluids or medications, if necessary.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic.

The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?

Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention.

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?

Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma.

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition?

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring?

Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis?

SLE is an inflammatory disease of collagen contained in connective tissue. Options

The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?

The client is placed in the left Sims' position for the procedure. This position takes the best advantage of the client's anatomy for ease with introducing the colonoscope. The other options are incorrect.

The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage?

The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance. The lesion enlarges up to 50 cm to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Arthralgia and joint enlargements are most likely to occur in stage III. Neurological deficits occur in stage II.

A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially ?

The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority ?

The nurse who interprets a tuberculin skin test as positive notifies the PHCP immediately. The PHCP would prescribe a chest x-ray to determine whether the client has clinically active tuberculosis or old healed lesions. A sputum culture would be done to confirm the diagnosis of active tuberculosis. The client is placed on tuberculosis precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record, but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.

The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result?

The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L).

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching ?

The treatment for scabies involves applying a scabicide to cool, dry skin at least 30 minutes after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off. The other statements are correct.

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client?

To splint the puncture site, the client is kept on the right side for a minimum of 2 hours. It is not necessary to remain NPO for 24 hours. Permission regarding the consumption of alcohol should be obtained from the PHCP. It is not necessary to save all stools.

Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse should check the client for which sign of toxicity?

Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?

Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority ?

When a fracture is suspected, it is imperative that the area is splinted before the client is moved. Emergency help should be called if the client is not hospitalized; a PHCP is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiology tests.

Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication?

When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication.

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching ?

When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type.

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

A common adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized by pyridoxine intake.

The nurse has just administered ibuprofen to a child with a temperature of 38.8° C (102° F). The nurse should also take which action?

After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration, so oral fluids should not be withheld.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?

After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular status?

An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history?

Asparaginase is a antineoplastic enzyme that is contraindicated if hypersensitivity exists in the case of pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between the administration of doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The medication may be used for clients with a history of diabetes mellitus, myocardial infarction, or chronic obstructive pulmonary disease.

The home care nurse visits a client at home who has been prescribed prednisone 5 mg orally daily. The nurse reinforces teaching for the client about the medication. Which statement made by the client indicates a need for further teaching ?

Aspirin and other over-the-counter medications should not be taken unless the client consults with the PHCP. The client needs to take the medication at the same time every day and should be instructed not to stop. A slight weight gain as a result of an improved appetite is expected, but after the dosage is stabilized, a weight gain of 5 lb or more weekly should be reported to the PHCP. Caffeine-containing foods and fluids need to be avoided because they may contribute to steroid-ulcer development.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication?

Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the primary health care provider (PHCP) regarding the administration of this medication?

Because this medication has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. Cyclobenzaprine hydrochloride should be used only for short-term 2- to 3-week therapy.

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cardiac studies such as an echocardiogram and electrocardiogram, and a cervical radiograph are unrelated to the specific use of this medication.

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.

The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value should the nurse specifically monitor during treatment with this medication?

Busulfan can cause an increase in the uric acid level because of massive cell death of malignant cells. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Clotting time, potassium, and glucose blood levels are not specifically related to this medication.

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching ?

Children who have influenza should be kept home and away from other children until they are fever-free without the use of antipyretics. Influenza may be prevented with the annual vaccine, by avoiding other children who are sick, and with frequent hand washing.

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?

Lactose intolerance is the inability to tolerate lactose, the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and vitamin D.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold clammy skin, irritability, sweating, and tremors all are signs of hypoglycemia.

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication?

Donepezil hydrochloride is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. T

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?

During painful episodes, hot or cold packs, splinting, and positioning the affected joint in a neutral position help to reduce the pain. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement.

The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medications?

Episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. Diuretics, antibiotics, and antitussives generally do not trigger urinary retention. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?

Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance.

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention?

Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the PHCP regarding this prescription.

The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively?

Following supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines that the client understands the most effective use of this medication if the client makes which statement?

Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication may occasionally cause dizziness, headache, or drowsiness. The client should contact the PHCP if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?

HAV is transmitted by the fecal-oral route via contaminated food or infected food handlers. HBV, HCV, and HDV are most commonly transmitted via infected blood or body fluids.

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason?

Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions?

If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing on the peritoneal dialysis system is also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the nephrologist. Increasing the flow rate is an inappropriate action and is unassociated with the amount of outflow solution.

The client has been taking medication for rheumatoid arthritis for 3 weeks. During the administration of etanercept, it is most important for the nurse to collect which data?

Infection and suppression can occur as a result of etanercept. Laboratory studies are performed before and during treatment. The appearance of abnormal white blood cell and platelet counts can alert the nurse to a potentially life-threatening infection or potential bleeding. Injection site itching and edema are common occurrences following administration. A metallic taste and loss of appetite are not associated with this medication. Fatigue and joint pain occur with rheumatoid arthritis.

The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note?

Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action should the nurse plan to take?

Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist with the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to provide which information to the client?

Isoniazid is hepatotoxic, and therefore the client is taught to report signs/symptoms of hepatitis immediately (which include yellow skin and sclera). For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine during the course of isoniazid therapy.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed?

Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose.

The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection?

Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage.

The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication?

Meperidine hydrochloride is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe?

Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, periorbital and facial edema, ascites, elevated serum lipids, and anorexia. The urine volume is decreased and the urine is dark and frothy in appearance. The child with this condition gains weight.

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take?

Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or PHCP.

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care?

One-to-one suicide precautions are required for the client who has attempted suicide.

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition?

Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptom of ovarian cancer is abdominal distention or fullness. Less common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms.

The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?

Pancrelipase is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching ?

Pertussis is caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication?

Phenelzine sulfate is a monoamine oxidase inhibitor. The client should avoid consuming foods that are high in tyramine. Eating these foods could trigger a potentially fatal hypertensive crisis. Some foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, and figs.

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions for the administration of the medication. Which instruction should the nurse reinforce?

Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side/adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed?

Pulmonary edema is a life-threatening event that can result from severe heart failure. During pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client?

Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it also might signify a more serious condition that warrants PHCP notification, not the use of acetaminophen.

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan?

Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern?

Self-destructive thoughts are the highest priority.

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms?

Signs and symptoms of digoxin toxicity include gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). The serum potassium level should be between 3.5 mEq/L (3.5 mmol/L) and 5.0 mEq/L (5.0 mmol/L). The apical pulse must be greater than or equal to 60 beats per minute.

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record?

Signs and symptoms of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

The client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication?

Stavudine is an antiretroviral used to manage HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia.

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching ?

Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?

Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain. Tamoxifen does not increase glucose or potassium levels, or increase the prothrombin time.

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level?

The aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 sec. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value. The PT and INR will assess for the therapeutic effect of warfarin sodium. A decreased thrombocyte count can cause

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first ?

The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?

The client exhibits several warning signs of an inhalation injury: a history of a flame burn to the face, hoarseness, cough, carbonaceous sputum, singed facial hair, facial edema, and color change. Additionally, one of the cardinal signs of hypoxia is restlessness.

The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action?

The client should avoid pressure on the radiated area and wear loose-fitting clothing to prevent a disruption in the skin integrity. A client receiving external radiation is not radioactive and does not need to avoid other persons, including young people. A diet high in protein assists in the healing process. Avoiding sunlight and washing the skin with gentle soap and patting dry will assist with preventing skin disruption.

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client?

The client should be instructed that symptoms such as drowsiness, weakness, and fatigue are more intense in the early phase of therapy and diminish with continued medication use. The client should be instructed never to withdraw or stop the medication abruptly because abrupt withdrawal can cause visual hallucinations, paranoid ideation, and seizures. It is best for the nurse to inform the client that these symptoms will subside and encourage the client to continue the use of the medication.

A client has epididymitis as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to do which action?

The client who experiences epididymitis from UTI should increase intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream. Condom use can help prevent urethritis and epididymitis from STIs. Antibiotics are always taken until the full course of therapy is completed.

The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse?

The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed ?

The incidence of SIDS has been found to be lower in breastfed infants and infants who sleep with a pacifier. Options 1, 3 and 4 are correct.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of car

The nurse should follow standard precautions when caring for any client and wear gloves when emptying a bedpan. Linens are kept in the room as a safety precaution in case there is contamination or part of the implant is lost. The film badge dosimeter allows the nurse to visualize the estimated amount of radiation exposure during the shift. The nurse wears a lead apron to protect oneself and block the radiation waves emitted when close to the client. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply.

The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching ?

The use of either lotions or powders should be avoided because they can become sticky or cake under the brace, thus causing irritation.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?

Ultrasound of the gallbladder is a noninvasive procedure and is frequently used for emergency diagnosis of acute cholecystitis. The client may need to lie still during the procedure for short intervals of time while visualization of the gallbladder is done. The client may or may not need to be NPO (per PHCP preference), but may be instructed to avoid carbonated beverages for 48 hours before the test to help decrease intestinal gas. It is a painless test and does not require the administration of oral tablets as preparation.

The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication?

Vincristine is a vinca alkaloid antineoplastic (miotic inhibitor) medication that has an adverse effect, specifically peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate?

Weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?

With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported.

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?

A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?

Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?

After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?

Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism.

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response?

Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which should indicate that the client is experiencing a side effect?

Baclofen is a central nervous system (CNS) depressant and frequently causes drowsiness, dizziness, weakness, and fatigue. It can also cause nausea, constipation, and urinary retention. Clients should be warned about the possible reactions

The nurse is reinforcing discharge instructions to a client receiving baclofen. Which should the nurse include in the instructions?

Baclofen is a central nervous system (CNS) depressant. The client should be cautioned against the use of alcohol and other CNS depressants because baclofen potentiates the depressant activity of these agents. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Constipation rather than diarrhea is an adverse effect of baclofen. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the PHCP if fatigue occurs.

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function?

Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus . Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure?

Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. Shoe protectors are not necessary and are used in operating rooms in the surgical departments. If the client is under airborne or droplet precautions, a mask is worn by the client when going outside of the room. Goggles are not worn by clients.

Dantrolene sodium is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication?

Dantrolene acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract.

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity?

Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (e.g., quadriceps- and gluteal-setting exercises). The client may also flex and extend his or her feet. Performing active ROM to the affected leg can be harmful.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication?

Ketoconazole is an antifungal medication. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic, and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol. There is no reason for the client to restrict fluid intake. In fact, this could be harmful to the client.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

Limb restraints are often prescribed to prevent clients from pulling out tubes and injuring themselves. The restraint is prescribed for 24 hours, and the nurse must verify that the restraint is protecting the client from self-injury but not too constrictive to impair circulation or harm the skin. Limb restraints are made with padding to protect the client's skin. The nurse determines the tightness of the wrist restraint by placing two fingers under the restraint. Observing the skin and checking the temperature of the skin is not as thorough or accurate as checking the tightness of the restraint manually. Restraints need to be removed at least every 2 hours, but this does not evaluate how tight the restraint is around the wrist.

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions?

Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi . Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids.

The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?

Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. During the initial examination, clients may have crusting areas instead of intact blisters

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

Safety of the client and other clients is the priority.

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse should reinforce medication instructions about which health care measure to the client?

Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage HIV infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques?

Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action?

The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support, while the stronger side swings through.

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?

The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client.

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?

The edges of the cast can be petaled with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging and applying lotion will not alleviate the skin irritation from the cast edges. Filing the edges will cause cast material to fall into the cast and could lead to skin irritation under the cast.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?

The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

The most common adverse effects related to fluoxetine include CNS and GI system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment.

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished.

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms?

The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L (3.0 mmol/L). The nurse knows that this is which level?

The therapeutic serum level of lithium is 0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). A level of 3 mEq/L indicates toxicity.

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?

A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage. Therefore, the other options are incorrect.

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast; a cool hair dryer may be used to eliminate itching.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety.

The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first ?

A client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. The nurse realigns the client and, if ineffective, calls the PHCP. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. Providing pin care is unrelated to the problem as described.

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply?

Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding?

Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?

The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client?

The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway (to maintain airway patency if required), and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore a padded tongue blade is not placed at the bedside.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint?

The restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released. The nurse recognizes that tying the strap to the side rail is not correct and unsafe. A half-bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency. The belt restraint should be secure, and one to two fingers should easily slide between the restraint and the client's skin. The client should be able to turn from back to side while in the restraint. A purpose of a restraint is to remind the client not to get out of bed alone

The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?

Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety?

Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention.

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?

Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism.

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation?

Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clear sensorium. The most reliable indicator for determining the adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL.

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take?

When an eyedrop and an eye ointment is scheduled to be administered at the same time, the eyedrop is administered first.

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record?

A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal.

The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care?

A client who is experiencing pancytopenia (decrease in all blood cells types: red, white, and platelets) is at high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged because dehydration increases the risk for infection. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infection.

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the PHCP or return the client to the emergency department if certain signs and symptoms are noted. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected.

Which laboratory result would verify the diagnosis of bacterial meningitis?

A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?

A diet that is low in calories, carbohydrates, and sodium but ample in protein and potassium content is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, the reduction of edema and hypertension, the control of hypokalemia, and the rebuilding of wasted tissue.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?

An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, and meal amounts should not be doubled.

The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included?

Clients with cancer treated with antineoplastic medications must be aware of how to care for themselves and it is important that client teaching is included in the care plan. Because antineoplastic medications affect the bone marrow, clients are often anemic, have lower immunity, and may be at risk for bleeding. Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client should notify the PHCP for a low grade temperature such as 99.5°F (39.7° C) and a sore throat. These are often associated with low white blood cell counts.

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

Early manifestations occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease?

Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client and should tell the client that which is the most likely time for a hypoglycemic reaction to occur?

Humulin NPH is an intermediate-acting insulin. The onset of action is 1 to 2 hours, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

Ibuprofen is prescribed for a client. Which instruction should the nurse give the client about taking this medication?

Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation.

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding should be reported immediately to the primary health care provider (PHCP)?

If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?

Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?

Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse.

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication?

Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are not side effects associated with this medication, but rather are associated with hypothyroidism, which is the disorder that this medication is prescribed to treat.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?

Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days.

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis?

Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching ?

The client should be instructed to avoid sun exposure between the hours of approximately 10:00 AM and 4:00 PM . Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide?

The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 AM to 4 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action?

When antineoplastic medications are administered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once and the infusion will be stopped. The nurse will contact the PHCP. Depending on the specific medication, actions are taken to counteract the negative effects. The medication may be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication.

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first ?

When ventricular fibrillation occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection?

Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The PHCP should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished arterial pulse, and edema.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal?

When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.