NCLEX

When the occupational health nurse is teaching unlicensed assistive personnel (UAP) about bloodborne pathogen exposure and human immunodeficiency virus (HIV) risk, which information is most important to emphasize? 1. Occupational transmission of HIV from patients to health care workers is relatively rare. 2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor. 3. Treatment for occupational exposure to HIV may include use of antiretroviral medications. 4. Postexposure treatment will include HIV testing at baseline and at several intervals after the exposure.

2. Occupational exposure to HIV-containing fluids should be reported immediately to the supervisor. if postexposure prophylaxis is to be used, antiretroviral drugs should be started as soon as possible, preferably within hours of the exposure. It is important that staff understand that reporting the possible exposure is a priority so that so that rapid assessment and treatment can be initiated. The other statements are also true but will not impact on the efficacy of any needed treatment.

In the presence of the RN, a physician asks the LVN to remove the sutures from the incision before the client is discharged. The initial response to the physician should be 1. LVNs cannot remove the sutures; the RN will do it. 2. Please write the order and the sutures will be removed. 3. We will remove them right away. 4. The LVN will get the suture removal set for you because he or she is not allowed to remove sutures.

2. Please write the order and the sutures will be removed. LVN/LPNs may remove sutures; however, both nurses must make sure that the physician has written the order to do so. A verbal order would not be sufficient in this situation.

The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium

2. Potassium Suspect hypokalemia and check the client's potassium level. Common ECG changes with hypokalemia include ST-segment depression, inverted T waves, and prominent U waves. Clients with hypokalemia may also develop heart block. Other abnormal electrolyte levels can affect cardiac rhythms, but the occurrence of U waves is associated with low potassium levels.

Which blood test result would the nurse be sure to monitor for the client taking hydrochlorothiazide (HCTZ)? 1. Sodium level 2. Potassium level 3. Chloride level 4. Calcium level

2. Potassium level Potassium is lost when a client is taking HCTZ, and potassium level should be monitored regularly.

The male client presents to the outpatient clinic reporting headaches that occur suddenly with throbbing in the right orbital area and on the right side of the forehead that last for an hour or longer and that have been occurring regularly for the past 2 weeks. Which medications should the nurse anticipate being prescribed? 1. Propranolol and almotriptan. 2. Prednisone lithium. 3. Amitriptyline and an estradiol/levonorgestrel patch. 4. Ibuprofen and metoclopramide.

2. Prednisone lithium. The client's symptoms support the diagnosis of cluster headaches, which are related to migraines but differ in several ways. Cluster headaches are less common than migraines and occur in males 5:1. Cluster headaches do not cause nausea and vomiting; they can be more debilitating than migraines; they do not have an aura; and they are not linked to genetics. The drugs of choice to treat cluster headaches are prednisone, a glucocorticoid, and lithium (Lithobid), a psychotherapeutic agent. High- dose prednisone can reduce symptoms within 48 hours, and lithium can prevent the headaches altogether. Lithium takes 1 to 2 weeks before relief is noted.

The nurse is preparing to administer warfarin. The client's current laboratory values are as follows: PT 38 Control 12.9 PTT 39 Control 36 INR 5.9 Which intervention should the nurse implement? 1. Discontinue the IV bag immediately. 2. Prepare to administer phytonadione. 3. Notify the HCP to increase the dose. 4. Administer the medication as ordered.

2. Prepare to administer phytonadione. Warfarin (Coumadin), an anticoagulant, is administered orally. AquaMEPHYTON (vitamin K) is the antidote for Coumadin toxicity. The therapeutic range for the INR is 2 to 3. With an INR of 5.9, this client is at great risk for hemorrhage and should be given the vitamin K.

Which activity can the nurse provide for a 9-year-old to encourage a sense of industry? 1. Allow the child to choose what time to take his medication. 2. Provide the child with the homework his teacher has sent. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.

2. Provide the child with the homework his teacher has sent. The school-age child is focused on academic performance; therefore, the child can achieve a sense of industry by completing his homework and staying on track with his classmates

The client diagnosed with Parkinson's disease has been on carbidopa/levodopa for 2 years and now the symptoms have increased. The HCP added the prescription safi namide to the client's daily routine. Which information should the nurse teach the client? 1. Discontinue the carbidopa/levodopa. 2. Rise slowly from a lying or sitting position. 3. Take the medication on an empty stomach. 4. There are no side effects of this medication like there are for carbidopa/levodopa.

2. Rise slowly from a lying or sitting position. The nurse should teach the side effects of the medications the client is prescribed. Safi namide (Xadago) side effects include orthostatic hypotension, dyskinesia, worsening of PD symptoms, falls, insomnia, anxiety, cough, cataracts, and indigestion. The client should notify the HCP if these occur. The medication is started at 50 mg per day for 2 weeks and can be increased to 100 mg per day thereafter.

Lindane (Kwell) shampoo is used only once because it can cause: 1. Hypertension. 2. Seizures. 3. Elevated liver functions. 4. Alopecia.

2. Seizures. Lindane (Kwell) with topical use is associated with seizures after absorption

While administering vancomycin 500 mg IV to a client with a methicillinresistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client's neck and face are becoming flushed. Which action should the nurse take next? 1. Discontinue the vancomycin infusion. 2. Slow the rate of the vancomycin infusion. 3. Obtain an order for an antihistamine. 4. Check the client's temperature.

2. Slow the rate of the vancomycin infusion. "Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing.

The nurse is preparing to administer nebivolol/valsartan to a client diagnosed with essential HTN. Which intervention should the nurse implement prior to administering the drug? Select all that apply. 1. Assess the radial pulse. 2. Take the client's blood pressure. 3. Have the unlicensed assistive personnel (UAP) obtain a full set of vital signs. 4. Ask the client if he or she is experiencing a cough. 5. Check the client's apical heart rate.

2. Take the client's blood pressure. 4. Ask the client if he or she is experiencing a cough. 5. Check the client's apical heart rate. The nurse should not ask the UAP to take the apical heart rate and blood pressure. If the nurse is administering the medication, it is the nurse's responsibility. Temperature and respirations are not needed A cough is a side effect of an ARB. The nurse should assess for possible side effects of medications

Which should the nurse include in teaching parents about administering pancreatic enzymes to their child? 1. The enzymes may be chewed or swallowed. 2. The capsules may be opened and sprinkled over acidic food. 3. Give the same amount of the medicine with meals and snacks. 4. Store the enzymes in the refrigerator.

2. The capsules may be opened and sprinkled over acidic food. When administrating enzymes to infants, the capsule may be opened and sprinkled over an acidic food, such as applesauce or mashed fruit

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is most important to discuss with the health care provider before administration of the medication? 1. The client's oxygen saturation is 92%. 2. The client receives lisinopril 10 mg/day. 3. The client's blood pressure is 150/90 mm Hg. 4. The client's potassium is 3.3 mEq/L (3.3 mmol/L).

2. The client receives lisinopril 10 mg/day. Because combination angiotensin receptor blocker-neprilysin blockers markedly increase the risk for angioedema in clients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril-valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension is increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril-valsartan.

The hospital employee health nurse is completing a health history for a newly hired staff member. Which information given by the new employee most indicates the need for further nursing action before the new employee begins orientation to patient care? 1. The employee takes enalapril for hypertension. 2. The employee has allergies to bananas, avocados, and papayas. 3. The employee received a tetanus vaccination 3 years ago. 4. The employee's tuberculin skin test has a 5-mm induration at 48 hours.

2. The employee has allergies to bananas, avocados, and papayas. A high incidence of latex allergy in seen in individuals with allergic reactions to these fruits. More information or testing is needed to determine whether the new employee has a latex allergy, which might affect the ability to provide direct patient care. The other findings are important to include in documenting the employee's health history but do not affect the ability to provide patient care.

A patient who has human immunodeficiency virus (HIV) and is taking nucleoside reverse transcriptase inhibitors and a protease inhibitor is admitted to the psychiatric unit with a panic attack. Which information about the patient is most important to discuss with the health care provider? 1. The patient exclaims, "I'm afraid I'm going to die right here!" 2. The prescribed patient medications include midazolam 2 mg IV immediately. 3. The patient is diaphoretic and tremulous and reports dizziness. 4. The symptoms occurred suddenly while the patient was driving to work.

2. The prescribed patient medications include midazolam 2 mg IV immediately. Because protease inhibitors decrease the metabolism of many drugs, including midazolam, serious toxicity can develop when protease inhibitors are given with other medications. Midazolam should not be given to this patient. The other patient data are consistent with the patient's diagnosis of panic attack and do not indicate an urgent need to communicate with the provider.

The client diagnosed with a stroke has been prescribed phenytoin. Which statement explains the scientifi c rationale for prescribing this medication? 1. The client's stroke was caused by some damage to cerebral tissue. 2. The stroke caused damage to the brain tissue that could result in seizures. 3. Hemorrhagic strokes leave residual blood in the brain that causes seizures. 4. This medication can help the client with cognitive defi cits think more clearly.

2. The stroke caused damage to the brain tissue that could result in seizures. Stroke- caused loss of function in areas of the brain leads to a problem with nerve impulse transmission; this blocked transmission can initiate a seizure. Phenytoin (Dilantin) is an anticonvulsant.

A mother requests that her child receive the varicella vaccine at the 9-month well child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease. 2. The vaccine cannot be given at that visit. 3. The vaccine will be administered after the physician examines the child. 4. A booster vaccination will be needed at 18 months of age.

2. The vaccine cannot be given at that visit. The nurse should not give the vaccine. The varicella vaccine is not usually administered prior to 1 year of age unless there are extenuating circumstances.

The nurse is reconciling the home medications on a new admit. The HCP has prescribed that the client receive home medications. Which medication(s) should the nurse discuss with the HCP? Home Medication List: furosemide 40 mg daily; ticagrelor 90 mg twice a day; aspirin 325 mg daily; levothyroxine 0.75 mg daily; digoxin 0.125 mg daily; potassium 20 mEq daily; acetaminophen 650 mg every 4 hours PRN; and ibuprofen 400 mg every 4 to 6 hours PRN. 1. Furosemide and potassium. 2. Ticagrelor and aspirin. 3. Levothyroxine and digoxin. 4. Acetaminophen and ibuprofen.

2. Ticagrelor and aspirin. 4. Acetaminophen and ibuprofen. Ticagrelor (Brilinta) is prescribed to decrease coagulation, thereby preventing strokes and blood clots; aspirin is also administered for the same reason. The nurse should question concurrent administration of these two medications. Clients frequently use acetaminophen and ibuprofen for personal preference reasons. Tylenol perhaps if having a headache and ibuprofen when having bone aches, etc. Usually not concurrently and these are PRN medications so the client chooses the medication for the symptoms he/she is experiencing at the time.

15. Which of these patients cared for by the nurse in the clinic presents the highest risk for infection with human immunodeficiency virus (HIV) during sexual intercourse? 1. Uninfected man who reports performing oral intercourse with an HIV infected woman 2. Uninfected man who is the receiver during anal intercourse with an HIV infected man 3. Uninfected woman who has had vaginal intercourse with an HIV-infected man 4. Uninfected woman who has performed oral intercourse with an HIV infected woman

2. Uninfected man who is the receiver during anal intercourse with an HIV infected man Because anal intercourse allows contact of the infected semen with mucous membrane and causes tearing of mucous membrane, there is a high risk of transmission of HIV. HIV can be transmitted through oral or vaginal intercourse as well but not as easily.

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? Select all that apply. 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs.

2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. Mouthwash should not include alcohol because it has a drying action that leaves the mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended.

The sequence of the case management process used by nurses is: 1. implementation, coordination, planning, evaluation, assessment, and monitoring. 2. assessment, planning, implementation, coordination, monitoring, and evaluation. 3. assessment, planning, coordination, implementation, monitoring, and evaluation. 4. assessment, planning, evaluation, coordination, monitoring, and implementation

2. assessment, planning, implementation, coordination, monitoring, and evaluation.

The intent of the Patient Self Determination Act (PSDA) of 1990 is to: 1. enhance personal control over legal care decisions. 2. encourage medical treatment decision making prior to need. 3. give one federal standard for living wills and durable powers of attorney. 4. emphasize patient education.

2. encourage medical treatment decision making prior to need.

A client with a diagnosis of acute myocardial infarction has new orders for aspirin 75 mg PO daily, lisinopril (Zestril®) 10 mg PO daily, furosemide (Lasix®) 10 mg PO daily, and potassium chloride (K-Dur®) 20 mEq PO bid. The nurse reviewing the serum laboratory report for the client notes a potassium level of 4.2 mEq/L, creatinine level of 2.3 mg/dL, and platelets of 250 K/μL. Based on the results of the laboratory values, the nurse should plan to consult the physician before administering the: 1. aspirin. 2. lisinopril (Zestril®). 3. furosemide (Lasix®). 4. potassium chloride (K-Dur®).

2. lisinopril (Zestril®). Lisinopril (Zestril®) should be used cautiously in a client with renal impairment. The serum creatinine level of 2.3 mg/dL is elevated (normal is 0.4-1.4 mg/dL) and indicates renal impairment. The physician should be consulted before administering the lisinopril

A patient with massive chest and head injuries is admitted to the ICU from the ER. You know that all of the following are true except: 1. a declaration of wishes or documentation of wishes regarding organ donation by the donor is not necessary for organ harvesting. 2. the physician in charge of the case is the only person allowed to decide whether organ donation will occur. 3. only the patient's legally responsible party may make the decision for organ donation for the donor if the patient is unable to do so. 4. the organ procurement organization is involved in the decision regarding which organs to harvest.

2. the physician in charge of the case is the only person allowed to decide whether organ donation will occur. The donor or legally responsible party for the donor, the physician, and the organ procurement organization are all involved in the decision regarding whether organ donation is appropriate for a specific donor.

JCAHO's 10-step process for quality improvement and the Focus-PDCA model are two models commonly adopted for the organization of Continuous Quality Improvement programs. Similarities between these models include all of the following except: 1. they use a systematic approach ensuring that participants are on common ground in their efforts. 2. they generate unique findings based on the process used. 3. they are cyclical. 4. they identify a process or problem

2. they generate unique findings based on the process used. The models used for Continuous Quality Improvement assist the development of an organized program using a systematic approach. They offer a structured means of problem identification and resolution that can be repeated over time according to need. The findings and problem solving that results is similar; although the steps of the process may have some differences.

FACES scale

3 years and older

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions? 1. Remove N95 respirator. 2. Take off goggles. 3. Remove gloves 4. Take off gown. 5. Perform hand hygiene.

3, 2, 4, 1, 5

The night shift nurse tells the oncoming dayshift nurse that the cancer patient is on around-the-clock dosing of morphine but that the patient might be having end-of-dose pain. Which question is the most important to ask the night shift nurse? 1. "How many times did you have to give a bolus dose of morphine?" 2. "Did the patient tell you that the pain was greater than a 5/10?" 3. "Did you notify the health care provider (HCP), and were changes prescribed?" 4. "Did you try any nonpharmaceutical therapies or adjuvant medications?

3. "Did you notify the health care provider (HCP), and were changes prescribed?" If the HCP was not called during the night (which is often the case), then the day shift nurse must assess the patient's current pain, talk to him or her directly about last night's pain, and gather data about the frequency of bolus doses and other options that were tried. Data about last night's care should be available in the patient's record if it is not mentioned in report.

The nurse is caring for a client diagnosed with partial onset seizures related to epilepsy. The HCP has prescribed brivaracetam. Which should the nurse discuss with the client? 1. "Be sure to see the dentist regularly because the medication can cause gingival hyperplasia." 2. "Regular lab work must be obtained to monitor the levels of the drug." 3. "Do not drive or operate heavy machinery until the HCP determines it is safe to do so." 4. "You should take baths only."

3. "Do not drive or operate heavy machinery until the HCP determines it is safe to do so." 4. "You should take baths only." Brivaracetam (Briviact) has a side effect of causing drowsiness, as do most other anticonvulsant medications. It is prescribed for partial onset seizures related to epilepsy. Clients with epilepsy are encouraged to take showers rather than baths to prevent the risk of drowning in case of a seizure.

The home health nurse is caring for a client diagnosed with congestive heart failure (CHF) who has been prescribed digoxin and furosemide. Which statements by the client indicate the medications are effective? Select all that apply. 1. "I am able to walk next door now without being short of breath." 2. "I keep my feet propped up as much as I can during the day." 3. "I have not gained any weight since my last doctor's visit." 4. "My blood pressure has been within normal limits." 5. "I am staying on my diet, and I don't salt my foods anymore."

3. "I have not gained any weight since my last doctor's visit." Weight gain would indicate that the client is retaining fl uid and the medications are not effective. No weight gain indicates the medication is effective.

The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which statement reflects a need for further education of the new mother? 1. "I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old." 2. "My baby will need to have iron supplements introduced when she is 4 months old." 3. "I will need to add iron supplements to my baby ' s diet when she is 2 months old." 4. "When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet."

3. "I will need to add iron supplements to my baby ' s diet when she is 2 months old." Premature infants have iron stores from the mother that last approximately 2 months, so it is important to introduce an iron supplement by 2 months of age. Full-term infants have iron stores that last approximately 4 to 6 months.

11. The client with a seizure disorder is prescribed phenytoin. Which statement indicates the client understands the medication teaching? 1. "If my urine turns a reddish- brown color, I should call my doctor." 2. "I should take my medication on an empty stomach." 3. "I will use a soft- bristled toothbrush to brush my teeth." 4. "I may get a sore throat when taking this medication."

3. "I will use a soft- bristled toothbrush to brush my teeth." The client should use a soft- bristled toothbrush to prevent gum irritation and bleeding. Gingival hyperplasia (overgrowth of gums) is a side effect of this medication.

The nurse realizes that a 3½-year-old ' s mother needs further education about the Denver Developmental Screening Test when she states: Select all that apply. 1. "It screens for gross motor skills." 2. "It screens for fine motor skills." 3. "It screens for intelligence level." 4. "It screens for language development." 5. "It screens for school readiness.

3. "It screens for intelligence level." 5. "It screens for school readiness. The Denver Developmental Screening Test does not test a child ' s level of intelligence. The Denver Developmental Screening Test evaluates children from 1 month to 6 years and is used to screen gross motor skills, fi ne motor skills, language development, and personal/social development not school readiness .

The unlicensed assistive personnel (UAP) asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out from not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."

3. "The client's skeletal muscles are weak because of the low phosphorus." A musculoskeletal manifestation of low phosphorus levels is generalized muscle weakness, which may lead to acute muscle breakdown (rhabdomyolysis). Phosphate is necessary for energy production in the form of adenosine triphosphate, and when not produced, leads to generalized muscle weakness.

The male client diagnosed with essential HTN tells the nurse, "I am not able to make love to my wife since I started my blood pressure medications." Which statement by the nurse is most appropriate? 1. "You are concerned that you cannot make love to your wife." 2. "I will refer you to a psychologist so that you can talk about it." 3. "You need to discuss this with your HCP." 4. "Ask your wife to come in and we can discuss it together."

3. "You need to discuss this with your HCP." This may be a side effect of the medication and is a reason for noncompliance in male clients. The HCP should be notifi ed so that the HCP can discuss the situation and possibly prescribe a different medication.

A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 44, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse ' s best response is: 1. "Your son ' s blood pressure is elevated, but the other vital signs are within the normal range." 2. "Your son ' s temperature is elevated, but the other vital signs are within the normal range." 3. "Your son ' s respiratory rate is elevated, but the other vital signs are within the normal range." 4. "Your son ' s heart rate is elevated, but the other vital signs are within the normal range."

3. "Your son ' s respiratory rate is elevated, but the other vital signs are within the normal range." A normal systolic blood pressure for a child from 3 to 6 years is 78 to 111. A normal diastolic blood pressure for a child from 3 to 6 years is 42 to 70. A normal temperature is 96.6°F to 100°F (35.8°C to 37.7°C). A normal respiratory rate for a child from 3 to 6 years is 20 to 30 breaths per minute. A normal heart rate for a child from 3 to 6 years is 75 to 120.

What time would the nurse most likely see signs and symptoms of hypoglycemia after administering NPH insulin at 0730? 1. 0930 to 1030. 2. 1130 to 1430. 3. 1130 to 1930. 4. 1530 to 1930.

3. 1130 to 1930. Peak time for NPH insulin is 4 to 12 hours.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. A 58-year-old patient on airborne precautions for tuberculosis (TB) 2. A 65-year-old patient who just returned from bronchoscopy and biopsy 3. A 72-year-old patient who needs teaching about the use of incentive spirometry 4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

3. A 72-year-old patient who needs teaching about the use of incentive spirometry Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

A nurse is assigned to the obstetrical triage area. When beginning the assignment, the nurse is given a report about 4 clients waiting to be seen. Place the clients in the order in which the nurse should see them. 1. A primigravid client at 10 weeks' gestation stating she is not feeling well with nausea and vomiting, urinary frequency and fatigue 2. A multiparous client at 32 weeks' gestation asking for assistance with finding a new HCP 3. A single mother at 4 months postpartum fearful of shaking her baby when he cries 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radiating from her symphysis to her fundus

3. A single mother at 4 months postpartum fearful of shaking her baby when he cries 4. An antenatal client at 16 weeks' gestation who has occasional sharp pain on her left side radiating from her symphysis to her fundus 1. A primigravid client at 10 weeks' gestation stating she is not feeling well with nausea and vomiting, urinary frequency and fatigue 2. A multiparous client at 32 weeks' gestation asking for assistance with finding a new HCP The first client to be seen should be the postpartum mother fearful of shaking her infant. Postpartum depression that may occur during the first year postpartum but peaks at 4 weeks postpartum, prior to menses or upon weaning. As a single mother, this client may not have support, a large factor putting woman at risk. Other factors accentuating risk include prior depressive or bipolar illness and self-dissatisfaction. Second the nurse should see the 16 week antenatal client who is likely experiencing round ligament syndrome. At this point the uterus is stretching into the abdomen causing this type of pain. The pain is on the wrong side to be attributed to appendicitis or gallbladder disease. Nursing interventions to ease the pain include a heating pad or bringing the legs toward the abdomen. The nurse should next see the primigravid client who states she is not feeling well because she is exhibiting signs and symptoms of discomfort experienced by most omen in the first trimester. The multiparous client at 32 weeks' gestation is the lowest priority as she is physically well, while the other clients have physical and psychological problems

According to the American Heart Association (AHA), which medication should the client suspected of having an MI take immediately when having chest pain? 1. Morphine. 2. Acetaminophen. 3. Acetylsalicylic acid. 4. NTG paste.

3. Acetylsalicylic acid. The AHA recommends that a client having chest pain chew two baby aspirins or one 325-mg tablet immediately to help prevent platelet aggregation and further extension of a coronary thrombosis.

The client is diagnosed with subacute bacterial endocarditis (SBE). Which HCP order should the nurse question? 1. Initiate penicillin intravenously. 2. Obtain a blood culture and sensitivity (C&S). 3. Administer a positive protein derivative (PPD) intradermally. 4. Place patient on bedrest with bathroom privileges.

3. Administer a positive protein derivative (PPD) intradermally. The nurse would question why the HCP is ordering a PPD, which is a tuberculosis (TB) skin test. TB is not a risk factor for developing SBE.

21. A patient with wheezing and coughing caused by an allergic reaction is admitted to the emergency department. Which medication will the nurse anticipate administering first? 1. Methylprednisolone 100 mg IV 2. Cromolyn 20 mg via nebulizer 3. Albuterol 3 mL via nebulizer 4. Aminophylline 500 mg IV

3. Albuterol 3 mL via nebulizer Albuterol is the most rapidly acting of the medications listed. Corticosteroids are helpful in preventing and treating allergic reactions but are not rapidly acting. Cromolyn is used as a prophylactic medication to prevent asthma attacks but not to treat acute attacks. Aminophylline is not a first-line treatment for bronchospasm.

The client diagnosed with Parkinson's disease who is taking selegiline has had hip surgery and is being admitted to the orthopedic department. The nurse is transcribing the postoperative orders. Which postoperative order should the nurse question? 1. Enoxaparin. 2. Morphine sulfate. 3. Buspirone. 4. Cefazolin.

3. Buspirone. Buspirone (BuSpar) is an anxiolytic medication prescribed for anxiety, post- traumatic stress disorder (PTSD), and many other conditions. It does have serious potential interactions with selegiline (Eldepryl), an anti-Parkinson's drug, which the patient cannot be abruptly taken off of.

A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is most important for the nurse to discuss with the health care provider? 1. Heart rate is 52 beats/min. 2. Client is also taking carvedilol for angina. 3. Client reports having chronic constipation. 4. Blood pressure is 106/56 mm Hg.

3. Client reports having chronic constipation. Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the client plan of care

The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention? 1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest 2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min 3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions 4. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary.

Common side effects of oxybutynin (Ditropan) are: 1. Increase in heart rate and blood pressure. 2. Sodium retention and edema. 3. Constipation and dry mouth. 4. Insomnia and hyperactivity.

3. Constipation and dry mouth. Common side effects are constipation and dry mouth as the oxybutynin (Ditropan) has an atropine-like effect.

The parents of a newborn are asking the nurse how to use the infant car seat and where it should be placed in their vehicle. Which is the most appropriate action by the nurse? 1. Give the parents a pamphlet explaining how to install the car seat. 2. Accompany the parents to the car and show them how to install the car seat. 3. Contact the hospital ' s car-seat safety officer and ask the officer to accompany the parents to the car for car-seat installation. 4. Show the parents a video on car-seat installation and safety and ask if they are comfortable with the information.

3. Contact the hospital ' s car-seat safety officer and ask the officer to accompany the parents to the car for car-seat installation. The car-seat safety officer is the best choice, as that individual would have the needed information and certification to help the family.

An experienced nurse is precepting a newly hired nurse who has 2 years of medical-surgical experience but limited experience with patients who have cancer. The new hire seems to be consistently under medicating the patients' pain. What should the preceptor do first? 1. Reassess all of the patients and administer additional pain medication as needed. 2. Write an incident report and inform the nurse manager about the nurse's performance. 3. Determine the new nurse's understanding and beliefs about cancer pain and treatments. 4. Ask the new nurse about past experience in administering pain medications.

3. Determine the new nurse's understanding and beliefs about cancer pain and treatments.

The client with arterial occlusive disease is postoperative right femoral-popliteal bypass surgery. Which HCP's order should the nurse question? 1. D5W 1000 mL to infuse at 75 mL/hr. 2. Ceftriaxone 500 mg every 12 hours. 3. Dipyridamole 50 mg three times a day. 4. Morphine sulfate 2 mg IVP every 4 hours

3. Dipyridamole 50 mg three times a day. Dipyridamole (Persantine) is an antiplatelet medication that should have been discontinued 5 to 7 days prior to surgery because it may cause bleeding in the postoperative client; therefore, the nurse would question why the client is receiving this medication.

The wound care nurse is applying an enzyme debridement ointment to a client with a venous stasis ulcer on the left ankle. Which priority intervention should the nurse implement? 1. Cover the wound with damp saline-soaked gauze. 2. Place dry gauze and a loose bandage over the wound. 3. Do not allow any ointment on the normal surrounding skin. 4. Apply the ointment with a sterile tongue blade.

3. Do not allow any ointment on the normal surrounding skin. The most important intervention is not to allow any of the enzymatic ointment to be placed on the normal surrounding skin because it will cause necrosis of the normal skin.

The client diagnosed with stage D CHF has a brain natriuretic peptide (BNP) level greater than 1,500. Which medication should the nurse anticipate the HCP prescribing? 1. Captopril orally. 2. Digoxin IVP. 3. Dobutamine IV. 4. Metoprolol orally.

3. Dobutamine IV. Dobutamine (Dobutrex), a synthetic catecholamine, is given for short-term IV therapy for clients in stage D CHF and is preferred to dopamine because it does not increase vascular resistance. Dobutamine increases myocardial contractility and cardiac output

The client diagnosed with chronic venous insufficiency has a venous stasis ulcer that is being treated with autolytic medication for debridement and an occlusive dressing. The nurse notices a foul-smelling odor. Which intervention should the nurse implement? 1. Assess the client's vital signs, especially the temperature. 2. Obtain a C&S of the venous stasis ulcer. 3. Document the finding and take no further intervention. 4. Ask the HCP to discontinue the medication.

3. Document the finding and take no further intervention. This is an expected result. The foul odor is produced by the breakdown of cellular debris and does not indicate that the wound is infected

The client has petechiae on the anterior lateral upper-abdominal wall. The MAR indicates the client is receiving a daily 81-mg aspirin, an IV narcotic, and a low-molecular-weight heparin. Which intervention should the nurse implement? 1. Request an order to discontinue the 81 mg aspirin. 2. Assess the client's pain level on a 1-10 scale. 3. Document the finding and take no intervention. 4. Put cool compresses on the abdominal wall.

3. Document the finding and take no intervention. The petechiae, tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal or submucosal areas, are secondary to subcutaneous injections of Lovenox, a low-molecular-weight heparin.

The nurse is providing discharge instructions for a client prescribed hydrochlorothiazide. Which instruction(s) should the nurse include? 1. Drink at least 8 to 10 glasses of water a day. 2. Weigh yourself monthly and report the weight to the HCP. 3. Eat bananas or oranges regularly. 4. Try to sleep in an upright position.

3. Eat bananas or oranges regularly. Hydrochlorothiazide (Diuril) is a thiazide diuretic. Loop and thiazide diuretics cause the body to excrete potassium in the urine. The client should attempt to replace the potassium by eating potassium-rich foods such as bananas and orange juice.

How can the nurse best facilitate the trust relationship between infant and parents while the infant is hospitalized? The nurse should: 1. Encourage the parents to remain at their child ' s bedside as much as possible. 2. Keep parents informed about all aspects of their child ' s condition. 3. Encourage the parents to hold their child as much as possible. 4. Advise the parents to participate actively in their child ' s care.

3. Encourage the parents to hold their child as much as possible. Having parents hold their child while in the hospital is an excellent means of building the trust relationship. Infants are most secure when they are being held, patted, and spoken to

The nurse is caring for a client diagnosed with sickle cell disease (SCD). Which medication would the nurse question? 1. Morphine sulfate IVP. 2. Fentanyl patch. 3. Epoetin SQ. 4. Piperacillin and tazobactam combination medication IVPB.

3. Epoetin SQ. Epoetin (Procrit) is a biological response modifi er. It stimulates the bone marrow to produce RBCs (erythropoiesis). The client with SCD produces RBCs that "sickle," increasing the levels of hemoglobin S (HbS). The client does not need more RBCs; therefore, the nurse would question administering this medication.

The daughter of a client diagnosed with Alzheimer's disease tells the home health nurse that she has been giving her mother Ginkgo biloba. Which intervention should the nurse implement? 1. Tell her to stop giving her mother the herb because it will not help. 2. Teach her that herbs have many life- threatening adverse effects. 3. Explain that the effects may only last for 6 to 12 months. 4. Ask the HCP to prescribe tacrine instead of the herb.

3. Explain that the effects may only last for 6 to 12 months. Research has determined that Ginkgo biloba has biologic activity in treating uncomplicated Alzheimer's disease (AD) for up to 12 months. At this time, medications for AD result in temporary improvement of the symptoms.

The nurse is preparing to administer phenytoin IV push (IVP). The client has an IV of D5W 0.45 NS at 50 mL/hr. Which intervention should the nurse implement? 1. Administer the phenytoin undiluted over 5 minutes via the port closest to the client. 2. Dilute the medication with NS and administer over 2 minutes. 3. Flush tubing with NS, administer diluted phenytoin, and then fl ush with NS. 4. Insert a saline lock in the other arm and administer the medication undiluted.

3. Flush tubing with NS, administer diluted phenytoin, and then fl ush with NS. Phenytoin (Dilantin), an anticoagulant, should be diluted in a saline solution and the IV tubing should be fl ushed before and after administration because a dextrose solution will cause drug precipitation.

A child comes to the clinic for diphtheria, pertussis, and tetanus (DTaP) and inactivated poliovirus vaccines. The child does not appear ill but has a temperature of 101°F (38.3°C). The nurse should take which action? 1. Withhold the vaccines and reschedule when the child is afebrile. 2. Administer acetaminophen (Tylenol) and give the vaccines. 3. Give the vaccines and instruct the parent to give acetaminophen (Tylenol) every 4 hours as needed. 4. Have the health-care provider order an antibiotic and give the vaccine.

3. Give the vaccines and instruct the parent to give acetaminophen (Tylenol) every 4 hours as needed. Immunizations can be given when the child has a low-grade fever as long as the child is not ill appearing.

Trimethoprim/sulfamethoxazole (Septra, Bactrim) should be given with: 1. Breakfast and dinner. 2. A snack. 3. Glass of water. 4. Glass of juice.

3. Glass of water. Trimethoprim/sulfamethoxazole (Septra, Bactrim) should be administered with a full glass of water on an empty stomach. If nausea and vomiting occur, giving the drug with food may decrease gastric distress.

Four clients in labor are requesting pain medication from the nurse. Which client can safely receive an opioid agonist-antagonist analgesic intravenous (IV) push at this time? 1. Gravida 1, 2 cm dilated, 50% effaced, contractions 7-10 minutes apart, crying 2. Gravida 1, 6 cm dilated, 75% effaced, contractions 2-4 minutes apart, has history of heroin use 3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3-4 minutes apart, moaning and shaking 4. Gravida 4, 10 cm dilated, 100% effaced, contractions 2-3 minutes apart, wants to push

3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3-4 minutes apart, moaning and shaking Latent: 0-6 cm cervical dilation active: 6-10 cm cervical dilation systemic analgesia may be administered to the laboring client who is in the active phase of stage 1 labor. Parameters for safe administration include stable VS, fetus with HR 110-160 bpm, well established labor contractions, cervix dilated at least 4-5 cm in primipara and 4 cm in multipara. Opioid agonist-antagonist medication commonly used are butorphanol and nalbuphine. During contractions, the uterine muscle is very tense and blood flow to the fetus is slowed. Therefore, medication reaches the fetus at a slower rate Option 1: the client is in early phase of stage 1 labor. The contraction pattern is not well established at 7-10 min apart. Option 2: this client is a heroin user and use of opioid agonist-antagonist could cause withdrawal symptoms in both the client and fetus

The nurse is caring for a male client with chronic neuropathic pain requiring roundthe- clock administration of an opioid narcotic pain medication. The client tells the nurse that he is experiencing very hard stools and then only every 4 to 5 days. Which medication should the nurse discuss with the client? 1. Tell the patient to take magnesium hydroxide every other day. 2. Teach the patient to alternate three acetaminophen 500 mg tablets with the opioid every 2 hours. 3. Instruct the client to discuss taking haloxegol with the HCP. 4. Remind the client to take bisacodyl twice a day to prevent constipation.

3. Instruct the client to discuss taking haloxegol with the HCP Haloxegol (Movantik), a mu- opioid receptor agonist, blocks the receptors in the colon from reacting to the narcotic. This medication should be considered to be added to the client's pain control regimen.

The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? 1. Ask the client about his or her bowel movements. 2. Have the client complete a diet diary for the past 2 days. 3. Instruct the client to increase oral intake to 2 to 3 L/day. 4. Ask the client to describe his urine output.

3. Instruct the client to increase oral intake to 2 to 3 L/day. An adult should take in about 2 to 3 L of fluid daily from food and liquids. Although the RN would want to know about bowel movements, dietary intake, and urine output, in this case, the priority is that the client is not taking in enough oral fluids.

The nurse is caring for clients on the telemetry unit. Which medication should the nurse administer first? 1. Digibind to the client whose digoxin level is 1.9 mg/dL. 2. Morphine sulfate IVP to the client who has pleuritic chest pain. 3. Lidocaine to the client exhibiting bigeminy. 4. Lisinopril to the client with a blood pressure of 170/90.

3. Lidocaine to the client exhibiting bigeminy. Lidocaine is a sodium channel blocker. A client with bigeminy, a life-threatening ventricular dysrhythmia, must be assessed fi rst and treated. An IV bolus of lidocaine, followed by an IV drip, is the treatment of choice offered in this question. Amiodarone may be given in place of lidocaine.

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct

3. Marks the tube 1 cm from where it touches the incisor tooth or nares The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.

Which is a toxic reaction in a child taking digoxin (Lanoxin)? 1. Weight gain. 2. Tachycardia. 3. Nausea and vomiting. 4. Seizures.

3. Nausea and vomiting. Digoxin (Lanoxin) toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular, apical heart rate.

A common adverse reaction to atropine is: 1. Diarrhea. 2. Increased urine output. 3. No tears when crying. 4. Lethargy.

3. No tears when crying. Atropine dries up secretions and also lessens the response of ciliary and iris sphincter muscles in the eye, causing mydriasis.

16. A patient with a history of liver transplantation is receiving cyclosporine, prednisone, and mycophenolate. Which finding is of most concern? 1. Gums that appear very pink and swollen 2. Blood glucose level of 162 mg/dL (9 mmol/L) 3. Nontender lump above the clavicle 4. Grade 1 + pitting edema in the feet and ankles

3. Nontender lump above the clavicle Patients taking immunosuppressive medications are at increased risk for development of cancer. A nontender swelling or lump may signify that the patient has lymphoma. The other data indicate that the patient is experiencing common side effects of the immunosuppressive medications.

For a patient receiving the chemotherapeutic drug vincristine, which side effect should be reported to the health care provider (HCP)? 1. Fatigue 2. Nausea 3. Paresthesia 4. Anorexia

3. Paresthesia

Which is the best method of distraction for an 8-year-old who is having surgery later today to insert a central line and is NPO? 1. Use the telephone to call friends. 2. Watch television. 3. Play a board game. 4. Read the central-line pamphlet he was given.

3. Play a board game. A board game is the optimal choice because school-age children enjoy being engaged in an activity with others that will require some skill and challenge

A community health center is preparing a presentation on the prevention and detection of cancer. Which task would be best to assign to the LPN/LVN? 1. Explain screening examinations and diagnostic testing for common cancers. 2. Discuss how to plan a balanced diet and reduce fats and preservatives. 3. Prepare a poster on the seven warning signs of cancer. 4. Describe strategies for reducing risk factors such as smoking and obesity

3. Prepare a poster on the seven warning signs of cancer The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs. The health care provider performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The RN has primary responsibility for educating people about risk factors.

Which drug is most important in treating an infant with transposition of the great vessels? 1. Digoxin (Lanoxin). 2. Antibiotics. 3. Prostaglandin E. 4. Diuretics.

3. Prostaglandin E. Prostaglandin E is necessary to maintain patency of the patent ductus arteriosus and improve systemic arterial fl ow in children with inadequate intracardiac mixing

A patient who has received a kidney transplant has been admitted to the medical unit with acute rejection and is receiving IV cyclosporine and methylprednisolone. Which staff member is best to assign to care for this patient? 1. RN who floated to the medical unit from the coronary care unit for the day 2. RN with 3 years of experience in the operating room who is orienting to the medical unit 3. RN who has worked on the medical unit for 5 years and is working a double shift today 4. Newly graduated RN who needs experience with IV medication administration

3. RN who has worked on the medical unit for 5 years and is working a double shift today To be most effective, cyclosporine must be mixed and administered in accordance with the manufacturer's instructions, so the RN who is likely to have the most experience with the medication should care for this patient or monitor the new graduate carefully during medication preparation and administration. The coronary care unit float nurse and the nurse who is new to the unit would not have experience with this medication

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient about the importance of adequate fluid intake and hydration 2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed 3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake 4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN.

A client is transferred from a recovery room to a surgical unit after undergoing a pyelolithotomy with placement of a nephrostomy tube. Which nursing action is least likely to benefit the client at this time? 1. Calling the physician after noting the urine output is 20 mL per hour 2. Turning the client from side to side to check for bleeding under the client 3. Teaching the client about dietary changes to prevent further stone formation 4. Straining the client's urine from both the nephrostomy tube and the urinary catheter

3. Teaching the client about dietary changes to prevent further stone formation

The nurse is assessing the preprinted medication administration record (MAR) for a client admitted with angina. Which medication order should the nurse discuss with the pharmacist? 1. The 1130 regular insulin order. 2. The 0800 metformin order. 3. The 0900 atorvastatin order. 4. The 2100 nitroglycerin (NTG) order.

3. The 0900 atorvastatin order. Lipitor should be administered in the evening (not at 0900) so that it will enhance the enzyme that works in the gastrointestinal system to help eliminate cholesterol. The nurse should notify the pharmacist and request a change in the time of administration.

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the health care provider (HCP)? 1. The patient starts crying and says she can't go on with treatment much longer. 2. The patient reports sharp, stabbing chest pain with every deep breath. 3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. 4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure.

Which statements would indicate to the nurse that a school-age child is not developmentally on track for age? Select all that apply. 1. The child is able to follow a four- to five-step command. 2. The child started wetting the bed on admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister. 5. The child is not able to follow rules.

3. The child has an imaginary friend named Kelly. 5. The child is not able to follow rules. Most school-age children do not have imaginary friends. This is much more common for children of 3 and 4 years of age Most school-age children like rules and understand the consequences of not obeying them.

The nurse in the HCP's office is completing an assessment on a client who has been prescribed digoxin for CHF. Which data indicates the medication has been effective? 1. The client's sputum is pink and frothy. 2. The client has 2+ pitting edema of the sacrum. 3. The client has clear breath sounds bilaterally. 4. The client's heart rate is 78 bpm.

3. The client has clear breath sounds bilaterally. Digoxin (Lanoxin) is a cardiac glycoside. Clear lung sounds bilaterally indicate the treatment is effective. The nurse assesses for the signs and symptoms of the disease for which the medication is being administered. If the symptoms are resolving, then the medication is effective.

The male client diagnosed with chronic migraine headaches, who has taken medications daily for years to prevent a migraine from occurring, tells the clinic nurse that now he has a headache "all the time, no matter what I take." Which situation should the nurse suspect is occurring? 1. The client has developed a resistance to pain medication. 2. The client is addicted and wants to get an increase in narcotics prescribed. 3. The client has developed medication overuse headaches. 4. The client may have a complication of therapy and has a brain tumor.

3. The client has developed medication overuse headaches. Medication overuse headaches occur when clients take headache medication every day. These headaches are also known as rebound headaches or drug- induced headaches. The headache will persist for days to weeks after the medication has been discontinued.

The client is undergoing electroconvulsive therapy for major depression and is receiving tubocurarine. Which data warrants immediate intervention by the nurse? 1. The client's apical pulse is 58 bpm. 2. The client's oral temperature is 99.8°F. 3. The client's respiratory rate is 10. 4. The client's blood pressure is 110/70.

3. The client's respiratory rate is 10. The primary effect of tubocurarine, a nondepolarizing neuromuscular blocker, is relaxation of skeletal muscles, producing a state of fl accid paralysis. Paralysis of the respiratory muscles can cause respiratory arrest; therefore, a respiratory rate of 10 would warrant immediate intervention by the nurse.

The client diagnosed with Alzheimer's disease is taking vitamin E and Ginkgo biloba. Which information should the nurse teach the client? 1. Take the medications on an empty stomach. 2. Have regular blood tests to assess for toxic levels. 3. The medications only slow the progression of the disease. 4. Use a sunscreen of SPF 15 or greater when in the sun.

3. The medications only slow the progression of the disease Medications used to treat Alzheimer's disease (AD) only slow the progression of AD. Currently no medications, prescribed or OTC, have been proved to reverse or permanently prevent progression of neuronal destruction.

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the most appropriate method of obtaining this information about the client? 1. The nurse should personally ask the client to authorize HIV testing. 2. The charge nurse should tell the client about the need for HIV testing. 3. The occupational health nurse should discuss HIV status with the client. 4. HIV testing should be performed the next time blood is drawn for other tests.

3. The occupational health nurse should discuss HIV status with the client. The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a client's HIV status and/or order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the client to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health).

The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient's only medication is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider? 1. The patient says that her right leg aches all night. 2. The right calf is warm to the touch and is larger than the left calf. 3. The patient is unable to remember her husband's first name. 4. There are multiple ecchymotic areas on the patient's abdomen.

3. The patient is unable to remember her husband's first name. Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the health care provider needs to be called

A nurse is giving ifosfamide (Ifex) as chemotherapy for a child who has leukemia. Mixed in with the ifosfamide (Ifex) is mesna (Mesnex). Mesna is given for which reason? 1. As combination chemotherapy. 2. As an antiarrhythmic. 3. To prevent hemorrhagic cystitis. 4. To increase absorption of the chemotherapy.

3. To prevent hemorrhagic cystitis. Mesna (Mesnex) is a detoxifying agent used as a protectant against hemorrhagic cystitis induced by ifosfamide (Ifex) and cyclophosphamide (Cytoxan).

The physician's role in case management includes all of the following except: 1. participate in interdisciplinary planning for patients. 2. serve as the expert for resource utilization. 3. consult with the case management team in order to facilitate timely orders as needed. 4. contribute to the documentation of the patient's needs for services.

3. consult with the case management team in order to facilitate timely orders as needed.

The physiatrist at the skilled nursing facility: 1. cares for patients with wound care needs. 2. cares for patients with digestive diseases. 3. dares for patients with rehabilitation needs. 4. cares for patients with surgical needs

3. dares for patients with rehabilitation needs. A physiatrist cares for patients with rehabilitation needs, such as a CVA or multiple trauma patients.

All of the following support the nurse as a patient advocate except: 1. ANA Code of Ethics for Nurses. 2. institutional review boards for the protection of human subjects engaged in research. 3. federal nurse practice acts. 4. JCAHO.

3. federal nurse practice acts. There are no federal, only state

The role of the nurse in the care of a potential organ donor involves all of the following except: 1. resuscitation of patients who have expressed the desire of organ donation should the situation arise. 2. facilitating decision making in families and responsible parties of potential donors. 3. focusing the goals of care to encourage recipient-donor communication. 4. assistance in coordinating educational and counseling efforts for potential donor families.

3. focusing the goals of care to encourage recipient-donor communication. Communication among donors and/or their families and responsible parties with recipients of organ donation is not encouraged in order to protect the privacy and confidentiality of the donor. Potential donors who have organs for donation must be resuscitated in the event of death in order to procure viable organs for donation. Education, facilitation of decision making, and provision of counseling are all appropriate interventions for the nurse.

The advanced directive in your patient's chart is dated August 12, 1998. The patient's daughter produces a Power of Attorney for Healthcare dated 2003 that contains different care direction(s). As the nurse you are to: 1. follow the 1998 version because it's part of the legal chart. 2. follow the 1998 version because the physician's "code" order is based on it. 3. follow the 2003 version, place it in the chart, and communicate the update appropriately. 4. follow neither until clarified by the unit manager

3. follow the 2003 version, place it in the chart, and communicate the update appropriately.

Which of the following factors could impact an individual's ability to give informed consent? 1. IQ 2. educational level 3. pain medications 4. financial status

3. pain medications

The responsibility for defining the process, setting goals, monitoring activities and evaluating nursing care in a unit-based quality improvement program is assigned to: 1. the hospital administration. 2. the Director of Continuous Quality Improvement (CQI). 3. the professional staff nurses working on the unit. 4. the Director of Nursing

3. the professional staff nurses working on the unit.

In making the decision to delegate care of this patient to the LPN, what is the priority consideration that the RN needs to make? 1. the LPN's skill level 2. the LPN's experience level—is their familiarity/competence with the skills required? 3. the stability of the patient's status 4. the number of patients within each assignment

3. the stability of the patient's status

After obtaining an initial assessment from a caregiver of a client that is experiencing dementia psychosis, the caregiver's report alerts the nurse to multiple safety risks for this client. Based on the information below, rank the information from greatest to least risk for client safety. Use all answer options. 1. Minimal food intake in the last 36 hours 2. Decreased fluid intake over the last 48 hours 3. Slept 4 hours out of the last 96 hours 4. Bladder incontinence for 36 hours

3214 For the client that is experiencing sleep deprivation (only 4 hours of sleep over a period of 8 days), coordination will be impaired, and decreased coordination and increased fatigue places the client at the greatest risk. Next, decreased fluid intake for the past two days alerts the nurse to a potential risk of dehydration for this client, while minimal food intake in the last 3 days alerts the nurse to a potential nutritional deficit for this client. Finally, though bladder incontinence places the client at risk for skin breakdown, it is the least threat for the client.

The nurse assesses a primiparous client with ruptured membranes in labor for 20 hours. The nurse identifies late decelerations on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? Select all that apply a. administering oxygen via mask to the client b. questioning the client about the effectiveness of pain relief c. placing the client on her side d. readjusting the monitor to a more comfortable position e. applying an internal fetal monitor

a. administering oxygen via mask to the client c. placing the client on her side. e. applying an internal fetal monitor Decelerations alert the nurse that the fetus is experiencing decreased blood flow from the placenta. Administering O2 will increase tissue perfusion. Placing the mother on her side will increase placental perfusion and decrease cord compression. Using an internal fetal monitor would help in identifying the possible underlying cause of the deceleration, such as metabolic acidosis. Assessing for pain relief and readjusting the monitor would have no effect on correcting the late decels.

60-year-old woman with anorexia nervosa is having an indwelling central venous access device placed in preparation for total parenteral nutrition (TPN) administration. Which of the following factors does the nurse know accounts for the client's increased risk of thrombophlebitis with a peripheral intravenous line? Select all that apply. a. age b. hypertonicity of the TPN c. hypotonicity of the TPN d. poor peripheral venous access

a. age b. hypertonicity of the TPN d. poor peripheral venous access

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines which risk factors in the client's history places the client at risk for this complication? select all that apply a. age 45 years b. BMI 28 c. previous difficulty with fertility d. administration of oxytocin for induction e. potassium 3.6 mEq/L

a. age 45 years b. BMI 28 c. previous difficulty with fertility RF include advanced age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor and use of epidural analgesia.

The nurse is preparing to provide instructions to new parents regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the parents to take which measure? a. allow the newborn infant to signal a need b. anticipate all needs of the newborn infant c. attend to the newborn infant immediately when crying d. avoid the newborn infant during the first 10 minutes of crying

a. allow the newborn infant to signal a need If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. A delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply a. allows for fetal movement b. surrounds, cushions and protects the fetus c. maintains the body temperature of the fetus d. can be used to measure fetal kidney function e. prevents large particles such as bacteria from passing to the fetus f. provides an exchange of nutrients and waste products between the birthing parent and the fetus

a. allows for fetal movement b. surrounds, cushions and protects the fetus c. maintains the body temperature of the fetus d. can be used to measure fetal kidney function The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the birthing parent and the fetus

A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor? a. an immature cardiac sphincter b. a defect in the GI system c. burping the infant too frequently d. moving the infant during the feeding

a. an immature cardiac sphincter Initial regurgitation in the neonate during the first 12-24 hours may be caused by excessive mucus and gastric irritation from foreign substances in the stomach. After the first 24 hours, regurgitation is thought to be caused by the neonate's immature cardiac sphincter. It represents an overflow of stomach contents and is probably a result of feeding the neonate too fast or too much. A defect in the GI system usually results in more severe symptoms. A small amount of regurgitation is normal, but vomiting or forceful fluid expulsion is not. Burping the infant often during a feeding can decrease the amount of air in the stomach from swallowing. However, burping too often can lead the neonate to become tired or fussy.

The nurse is administering a drug by Z-track and must follow the proper technique. Place the following steps in the appropriate order. All options must be used. 1. Withdraw the needle. 2. Administer the drug intramuscularly (IM) in the dorsogluteal site 3. Release the skin 4. Displace the skin lateral to the injection site

4, 2, 1, 3

The nurse is emptying an evacuator of a Jackson-Pratt drain. The nurse has drained the fluid into a calibrated container and has placed the container on a level flat surface. The nurse measures 20 mL of bloody fluid. Arrange the following actions the nurse should take in sequential order. All options must be used. 1. Dispose of the bloody drainage. 2. Compress the evacuator completely. 3. Replace the plug in the evacuator. 4. Cleanse the plug with an alcohol wipe. 5. Document the amount, odor, and consistency of the drainage.

4, 2, 3, 1, 5

After receiving an order from a health-care provider to complete a tracheostomy cleaning, a nurse explains the procedure to a client, washes hands, prepares the equipment, opens and sets up the supplies, and performs tracheostomy suctioning. After the suctioning, the nurse uses the gloved hand, which has been kept sterile, to unlock the inner cannula, places the inner cannula in the hydrogen peroxide solution, removes the gloves, and rewashes. Which actions should be taken by the nurse to safely complete the tracheostomy cleaning? Prioritize the nurse's actions by placing the remaining steps in the correct sequence. ______ Rinse the inner cannula in sterile normal saline ______ Clean the inner cannula ______ Put on sterile gloves ______ Replace the inner cannula securely ______ Gently tap the inner cannula to remove excess liquid ______ Remove the inner cannula from the hydrogen peroxide

4, 3, 1, 6, 5, 2

The nurse is working in an extended care facility when a nursing assistive personnel (NAP) reports that an elderly client is crying in pain. The nurse finds the client in the bathroom reporting severe constipation. What would be the appropriate order of nursing interventions to assist this client with his immediate elimination needs? All options must be used. 1. Offer oral fluids to ease the constipation. 2. Notify the physician. 3. Offer PRN medications orally, if ordered. 4. Use a gloved hand with lubricant to manually assess for fecal impaction and to stimulate the rectal wall to loosen the fecal matter

4, 3, 2, 1 This is last in the appropriate order of nursing interventions. Oral fluids should be increased but will not impact the immediate pain and constipation. Relief of the immediate pain is the priority. Aer an attempt to manually remove the impaction, and offering a PRN medication, the physician should be notified. PRN medications do not offer immediate relief and may not be effective if the impaction is solid. Aer a manual exam assessment, and an attempt to remove the stool, it would be appropriate to offer a PRN medication orally, if ordered, to prevent a repeat incident.

The nurse is considering seeking clarification for several prescriptions of pain medication. Which client circumstance is the priority concern? a. A 35-year-old opioid-naive adult will receive a basal dose of morphine via IV PCA b. A 65-year-old adult will be discharged with a rx for NSAID c. A 25-year-old is prescribed PRN IM analgesic for pain d. A 45-year-old adult is taking oral fluids and foods has orders for IV morphine

a. A 35-year-old opioid-naive adult will receive a basal dose of morphine via IV PCA The nurse would consider questioning all of the medication prescriptions, but the opioid-naïve adult has the greatest immediate risk, because use of a basal dose has been associated with an increased incidence of respiratory depression in opioid-naïve clients. Older adults are frequently prescribed NSAIDS; however, they are used with caution, and the client's history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug-drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration routes. If a client is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route.

The nurse is making assignments for the day. The staff consist of an RN, an LPN and a nursing assistant. Which client should be assigned to the NA? a. A client with laparoscopic cholecystectomy b. A client with viral pneumonia c. A client with suspected ectopic pregnancy d. A client with intermittent chest pain

a. A client with laparoscopic cholecystectomy The client with laser surgery has three or four very small incisions. These clients' vital signs become stable very quickly, and they are generally discharged within 12-24 hours. We are not, however, suggesting that the nursing assistant be assigned to obtain the post-operative vital signs. This should be done by the nurse. The registered nurse should obtain the first vital signs, and the licensed practical nurse may obtain the remaining vital signs.

When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information? a. A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume and fetal HR activity b. FHR increases during a nonstress test is an ominous sign and requires further evaluation with fetal ECG Contraction stress testing, performed on most pregnant women, can be initiated as early as 16 weeks gestation d. Percutaneous umbilical blood sampling uses a needle inserted through the vagina to obtain a sample

a. A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume and fetal HR activity Normal nonstress test findings include at least 2 qualifying accelerations in the FHR from baseline in 20 minutes. A contraction stress test or oxytocin challenge test should be performed only on women at risk for fetal distress during labor. The contraction stress test is rarely performed before 28 weeks' gestation because of the possibility of initiating labor. Percutaneous umbilical cord sampling requires the insertion of a needle through the abdomen to obtain a fetal blood sample

The 28- year- old client who is obese is reporting nervousness, irritability, insomnia, and heart palpitations. Which question should the clinic nurse ask the client fi rst? 1. "How much weight have you gained or lost within the last 12 months?" 2. "Do you make yourself vomit after eating large meals?" 3. "Is there any history of you taking illegal drugs such as amphetamines?" 4. "Have you been taking any over- the- counter appetite suppressants?"

4. "Have you been taking any over- the- counter appetite suppressants?" These physiological signs/symptoms could indicate long- term use of anorexiants (appetite suppressants); therefore, the nurse should discuss this question with the client.

The daughter of an elderly client diagnosed with Alzheimer's disease (AD) asks the nurse, "Is there anything I can do to prevent getting this disease?" Which statement is the nurse's best response? 1. "Not if you are genetically programmed to get Alzheimer's disease." 2. "Yearly brain scans may determine if you are susceptible to getting AD." 3. "There are some medications, but research has not proved they work." 4. "Hormone replacement therapy may prevent the development of AD."

4. "Hormone replacement therapy may prevent the development of AD." Hormone replacement therapy has been proved to reduce the risk of developing AD by 30% to 40% in postmenopausal women. Other medications that have been proved to aid in prevention of AD are NSAIDs.

The client diagnosed with essential HTN is taking bumetanide. Which statement by the client warrants notifying the client's HCP? 1. "I really wish my mouth would not be so dry." 2. "I get a little dizzy when I get up too fast." 3. "I usually have one or two glasses of wine a day." 4. "I have been experiencing really bad leg cramps."

4. "I have been experiencing really bad leg cramps." Bumetanide (Bumex) is a loop diuretic. Leg cramps could indicate hypokalemia, which is potentially life-threatening secondary to cardiac dysrhythmias. This needs to be reported to the HCP so that the dosage can be reduced or potassium supplements can be ordered for the client

An 8-day-old was admitted to the hospital with vomiting and dehydration. The newborn ' s heart rate is 170, respiratory rate is 44, blood pressure is 85/52, and temperature is 99°F (37.2°C). What is the nurse ' s best response to the parents who ask if the vital signs are normal? 1. "The blood pressure is elevated, but the other vital signs are within normal limits." 2. "The temperature is elevated, but the other vital signs are within normal limits." 3. "The respiratory rate is elevated, but the other vital signs are within normal limits." 4. "The heart rate is elevated, but the other vital signs are within normal limits."

4. "The heart rate is elevated, but the other vital signs are within normal limits." A normal systolic blood pressure for a child from birth to 1 month is 50 to 101. A normal diastolic blood pressure for a child from birth to 1 month is 42 to 64 A normal temperature is 96.6°F to 100°F (35.8°C to 37.7°C). A normal respiratory rate for a child from birth to 1 month is 30 to 60 A normal heart rate for a child from birth to 1 month is 90 to 160

The client diagnosed with DVT asks the nurse, "Why do I have to take my warfarin in the evening?" Which statement is the nurse's best response? 1. "The medication works more effectively while you are sleeping." 2. "The medicine should be given with the largest meal of the day." 3. "The side effects of the warfarin are less if you take it in the evening." 4. "This allows for a more accurate INR level when we draw your morning labs."

4. "This allows for a more accurate INR level when we draw your morning labs." Warfarin (Coumadin), an anticoagulant, requires blood tests to monitor to see if the medication dosage is within therapeutic range. Routine laboratory tests are drawn in the morning. If Coumadin is administered in the morning, the INR will be lower as a result of the medication's effects wearing off. If the Coumadin is taken in the evening, then the INR level will refl ect more accurately the peak blood level.

The client diagnosed with the peripheral vascular disease Raynaud's disease is prescribed isoxsuprine. Which statement indicates the client understands the discharge teaching? 1. "I will probably have palpitations and episodes of low blood pressure." 2. "I should take the medication when I go outside in the cold weather." 3. "I need to take an enteric-coated aspirin every morning with food." 4. "This medication will help increase blood fl ow to my extremities."

4. "This medication will help increase blood flow to my extremities." Isoxsuprine (Vasodilan) is a peripheral vasodilator. This medication increases blood fl ow, which is restricted in peripheral vascular diseases, such as Raynaud's disease and atherosclerosis obliterans. This statement indicates the client understands the discharge teaching.

The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a student. The student states that the patient's oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates correct understanding of this patient's curve shift? 1. "When a patient's body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve." 2. "When a patient's body temperature is elevated, there is a shift to the left because the oxygen tension level is lower." 3. "When a patient's body temperature is elevated, there is no shift in the curve because the patient is using less oxygen." 4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster."

4. "When the patient's body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster." When the need for oxygen is greater in the tissues, there is a curve shift to the right. This means that oxygen is dissociated from hemoglobin faster. Conditions that shift the curve to the right include increased body temperature, increased carbon dioxide concentration, and decreased pH or acidosis. This means that hemoglobin unloads oxygen to the tissues because they need it to support the higher metabolism, and this is a tissue protection that increases oxygen delivery to the tissues that need it the most.

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. "You can refuse to be part of the students' study."

The clinic nurse is assessing a client diagnosed with pericarditis. The client reports to the nurse, "I take an aspirin every morning to help prevent a heart attack." Which statement is the nurse's best response based on the client's medical diagnosis? 1. "Aspirin is known to prevent heart attacks. It is excellent that you take it." 2. "Have you noticed that you are bruising more easily since you started taking it?" 3. "I would recommend taking the enteric-coated aspirin to prevent gastric upset." 4. "You should quit taking the aspirin immediately and I will talk to your HCP."

4. "You should quit taking the aspirin immediately and I will talk to your HCP." The client with pericarditis should avoid taking aspirin and anticoagulants because they may increase the possibility of cardiac tamponade.

After receiving report, the nurse makes initial rounds on the medica surgical unit. Which patient should the nurse see first? a. A patient reporting pain who is receiving pain medication with a tibial fracture. b. A patient who experienced seizures overnight and is now on IV versed. c. A patient admitted with uncontrolled emesis receiving IV replacement fluid. d. A patient with pulmonary wheezes who is taking nebulized albuterol.

a. A patient reporting pain who is receiving pain medication with a tibial fracture. The patient may be experiencing compartment syndrome. After trauma to an extremity bone, swelling may occur. The natural expansion taking place during swelling is limited by the fascia surrounding the muscle, thus creating compartment syndrome. This will compress the muscle to such an extent that blood flow is compromised. A hallmark of compartment syndrome is uncontrolled pain, despite pain medication in some instances

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1.A pink, edematous hand 2.Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

4. A white color to the skin, which is insensitive to touch

The nurse is completing a.m. care with a client diagnosed with angina when the client reports chest pain. The client has a saline lock in the right forearm. Which intervention should the nurse at the bedside implement first? 1. Assess the client's vital signs. 2. Administer sublingual nitroglycerin (NTG). 3. Administer IV morphine sulfate via saline lock. 4. Administer oxygen via nasal cannula.

4. Administer oxygen via nasal cannula. The nurse would have oxygen at the bedside, and applying it would be the fi rst intervention the nurse could implement at the bedside.

The nurse is administering iron dextran to a client diagnosed with iron-deficiency anemia. Which intervention should the nurse implement? 1. Make sure the client is well hydrated. 2. Give the medication subcutaneously in the deltoid. 3. Check for allergies to fish or other seafood. 4. Administer the medication by the Z-track method.

4. Administer the medication by the Z-track method. Iron dextran (Imferon) is an iron preparation. Iron is black and stains the skin. The medication is administered deep IM in the dorsogluteal muscle in adults and the lateral thigh in small children. It is given by the Z-track method to trap the medication in the deep tissues and prevent leakage back into the shallow tissues.

The nurse in a maternity unit is reviewing the client's records. Which clients would the nurse ID as being the most at risk for developing DIC? Select all that apply a. A primigravida with abruptio placentae b. A primigravida who delivered a 10 lb infant 3 hours ago c. A gravida 2 who has just been diagnosed with dead fetus syndrome d. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood e. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

a. A primigravida with abruptio placentae c. A gravida 2 who has just been diagnosed with dead fetus syndrome e. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational HTN, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage and blood loss.

56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While the nurse is trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority nursing concept to consider in responding to this patient? 1. Elimination 2. Patient education 3. Cellular regulation 4. Anxiety

4. Anxiety The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other concepts are relevant, but if the patient leaves the clinic, the interventions may be delayed or ignored.

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team? 1. Evaluating the patient's reports of chest pain 2. Monitoring laboratory values for changes in oxygenation 3. Assessing for symptoms of respiratory failure 4. Auscultating the lungs for crackles

4. Auscultating the lungs for crackles An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN.

A client is admitted for gastrointestinal bleeding. He has a platelet count of 15,000/mm and platelets have been ordered from the blood bank. Which of the following does the nurse know are required for platelet transfusions? Select all that apply. a. ABO compatibility b. Rh compatibility c. Crossmatching d. A specialized platelet filter

a. ABO compatibility b. Rh compatibility d. A specialized platelet filter

Which finding will be most important for the nurse to report to the health care provider about a patient who is taking prednisone chronically after an organ transplant? 1. Multiple arm bruises 2. Sodium level of 146 mEq/dL (146 mmol/L) 3. Blood glucose of 110 mg/dL (6.1 mmol/L) 4. Black-colored stools

4. Black-colored stools Dark green or black stools may indicate gastrointestinal bleeding, a possible adverse effect of oral steroid use, and further assessment and treatment are needed. Although thinning of the skin, electrolyte disturbances, and changes in glucose metabolism also occur with steroids, bruising and mild changes in sodium or glucose level do not require treatment

A nurse is caring for a child who is receiving amphotericin B IV daily for a fungal infection. Prior to starting the therapy, which should the nurse review? 1. Aspartate aminotransferase and alanine aminotransferase serum levels. 2. Serum amphotericin level. 3. Serum protein and sodium levels. 4. Blood urea, nitrogen, and creatinine levels.

4. Blood urea, nitrogen, and creatinine levels. The drug tends to be nephrotoxic. Elevation of blood urea, nitrogen, and creatinine levels indicates renal damage. If these levels are elevated, the healthcare provider must be notifi ed to determine if the drug must be withheld for the day

The physician wrote a medication order for a client. The nurse thought the dosage was incorrect. She questioned the physician, who said it was all right. Still questioning, she asked another nurse, who said it was all right. The nurse gave the medicine, and the client died from an overdose. Who is liable? 1. The physician and the two nurses. 2. The physician. 3. The nurse who gave the medication. 4. Both the physician and the nurse who gave the medication.

4. Both the physician and the nurse who gave the medication.

The nurse is administering morning medications. Which medication would the nurse question administering? 1. Metformin. 2. Atorvastatin. 3. Nitroglycerin. 4. Captopril.

4. Captopril. Captopril is an ACE inhibitor used to treat high blood pressure and heart failure. Captopril is best taken on an empty stomach. This medication is contraindicated in patients taking sacubitril/valsartan (Entresto). Taking the two medications together may increase potassium levels, causing toxicity. The nurse should question this medication.

The nurse is preparing to administer medication to the following clients. Which medication should the nurse question administering? 1. Metformin to a client with type 1 diabetes who is receiving insulin. 2. Bumetanide to a client diagnosed with essential HTN. 3. Erythropoietin to a client diagnosed with end-stage renal failure. 4. Clonidine to a client diagnosed with heart failure.

4. Clonidine to a client diagnosed with heart failure. Clonidine (Catapres) is an alpha agonist. The nurse would question administering Catapres to a client with decreased cardiac output (heart failure), because this medication acts within the brain stem to suppress sympathetic outfl ow to the heart and blood vessels. The result is vasodilation and reduced cardiac output, both of which lower blood pressure.

The client diagnosed with a pituitary tumor has acromegaly. The HCP has prescribed octreotide. Which intervention should the nurse implement regarding this medication? 1. Implement fall precautions. 2. Administer calcium tablets to replace the lost calcium. 3. Have the client discuss acne- like skin problems with a dermatologist. 4. Contact the client's insurance provider to determine if the medication is covered.

4. Contact the client's insurance provider to determine if the medication is covered. Octreotide (Sandostatin), a pituitary suppressant, can cost thousands of dollars a year (about $8,000). Before beginning the treatment, the nurse and HCP must know that the client can afford the medication.

14. The nurse is caring for a patient with rheumatoid arthritis who is taking naproxen twice a day to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider? 1. Joint pain worse in the morning 2. Dry eyes bilaterally 3. Round and moveable nodules under the skin 4. Dark-colored stools

4. Dark-colored stools Naproxen, a nonsteroidal anti-inflammatory drug, can cause gastrointestinal bleeding, and the stool appearance indicates that blood may be present in the stool. The health care provider should be notified so that actions such as testing a stool specimen for occult blood and administering proton pump inhibitors can be prescribed. The other symptoms are common in patients with rheumatoid arthritis and require further assessment or intervention, but they do not indicate that the patient is experiencing adverse effects from the medications

The older adult client diagnosed with iron-deficiency anemia has been prescribed an oral iron preparation. Which information should the nurse teach the client? 1. Instruct the client to take the medication with food. 2. Teach the client to take the iron with milk products. 3. Explain that this medication may discolor the teeth. 4. Discuss taking the medication 2 hours after a meal

4. Discuss taking the medication 2 hours after a meal Oral medication (pill) will not stain the teeth, but liquid iron preparations would stain the teeth. Just because the client is elderly does not mean the client cannot take pills. The medication should be taken on an empty stomach or 2 hours after a meal because food interferes with the absorption of iron

A patient seen in the sexually transmitted disease clinic has just tested positive for human immunodeficiency virus (HIV) with a rapid HIV test. Which action will the nurse take next? 1. Ask about patient risk factors for HIV infection. 2. Send a blood specimen for Western blot testing. 3. Provide information about antiretroviral therapy. 4. Discuss the positive test results with the patient.

4. Discuss the positive test results with the patient. A major purpose of HIV testing for asymptomatic patients is to ensure that HIV-positive individuals are aware of their HIV status, take actions to prevent HIV transmission, and effectively treat the HIV infection. According to current national guidelines, the other actions are also appropriate, but the initial action will be to communicate the test results to the patient. Rapid HIV testing must be confirmed by another test, usually the Western blot test. Antiretroviral therapy is recommended for all HIV-positive patients. Risk factor information will be used in tracking patient contacts and in teaching the patient how to reduce the risk for transmission to others.

Which statement is an advantage of administering entacapone to a client diagnosed with Parkinson's disease? 1. Entacapone increases the vasodilating effect of levodopa. 2. Levodopa can be discontinued while the client is taking entacapone. 3. There are no side effects of the drug to interfere with treatment. 4. Entacapone causes blood levels of levodopa to be smoother and more sustained.

4. Entacapone causes blood levels of levodopa to be smoother and more sustained. Entacapone (Comtan) is a catechol-Omethyltransferase (COMT) inhibitor that increases the half- life of levodopa by 50% to 75%, thereby causing levodopa blood levels to be smoother and more sustained. This delays the "off" effects and prolongs the "on" effects of levodopa.

The client diagnosed with Parkinson's disease has been taking amantadine. The home health nurse notes a new finding of mottled discoloration of the skin. Which intervention should the nurse implement? 1. Ask the client if he or she has changed soap products. 2. Prepare the significant other for the client's imminent death. 3. Notify the HCP to discontinue the medication. 4. Explain that this is expected and document the finding.

4. Explain that this is expected and document the finding. Clients taking amantadine (Symmetrel), an anti-Parkinson's drug, for 1 month or longer often develop a mottled discoloration of the skin called livedo reticularis, a benign condition that will gradually disappear following discontinuation of the drug. This condition is not a reason to discontinue the medication as long as it is effective. The effectiveness of this medication begins to diminish within 3 to 6 months.

Which order prescribed for a client with hypercalcemia would the nurse be sure to question? 1. 0.9% saline at 50 mL/hr IV 2. Furosemide 20 mg orally each morning 3. Apply cardiac telemetry monitoring 4. Hydrochlorothiazide (HCTZ) 25 mg orally each morning

4. Hydrochlorothiazide (HCTZ) 25 mg orally each morning Calcium excretion is decreased with thiazide diuretics (e.g., HCTZ), so the calcium level is at risk for going even higher. Loop diuretics (e.g., furosemide) increase calcium excretion. The addition of IV fluids and cardiac monitoring are appropriate actions for monitoring and treating a client with hypercalcemia.

The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes 2. Place two 18-gauge IV lines 3. Oxygen at 3 L via nasal cannula 4. IV 5% dextrose in water (D5W) to run at 250 mL/hr

4. IV 5% dextrose in water (D5W) to run at 250 mL/hr To correct hypovolemic shock with dehydration, the client needs IV fluids that are isotonic and will increase intravascular volume, such as normal saline. With D5W, the body rapidly metabolizes the dextrose and the solution becomes hypotonic.

Which nursing diagnosis is the highest priority for the client experiencing heart failure? 1. Excess fluid volume 2. Disturbed sleep pattern 3. Activity intolerance 4. Impaired gas exchange

4. Impaired gas exchange

Why is filgrastim (Neupogen) given to a child who has received chemotherapy? 1. Reduce fatigue level. 2. Prevent infection. 3. Reduce nausea and vomiting. 4. Increase mobilization of stem cells.

4. Increase mobilization of stem cells. The drug mobilizes stem cells to produce neutrophils

A primigravid adolescent client at approximately 15 weeks' gestation who is visiting the prenatal clinic with her mother is to undergo maternal quad screening. When developing the teaching plan for this client, the nurse should include which of the following? 1. Ultrasonography usually accompanies AFP testing. 2. Results are usually very accurate until 20 weeks' gestation. 3. A clean-catch midstream urine specimen is needed. 4. Increased levels of AFP are associated with neural tube defects.

4. Increased levels of AFP are associated with neural tube defects. Increased AFP is one of the 4 lab values in a maternal quad screen. The labs are hCG, estriol and inhibin A. Increased AFP levels are associated with neural tube defects, such as spina bifida, anencephaly and encephalocele. US is used to confirm a neural tube defect only when AFP are increased. Because AFP levels are usually highest at 15-18 weeks' gestation, this is the optimum time for testing. Performing the test after this time leads to inaccurate results. The client's blood, not urine is used for the sample

The 28-year-old client diagnosed with sickle cell anemia has been admitted to the medical unit for a vaso-occlusive crisis. Which intervention should the nurse implement first? 1. Elevate the head of the client's bed. 2. Administer the narcotic analgesic. 3. Apply oxygen via nasal cannula. 4. Initiate IV fluids.

4. Initiate IV fluids IV fl uids help reverse the sickling process, which is the priority. This reversal will relieve the pain and increase the oxygenation to the cells

The nurse is caring for a client who experiences frequent generalized tonicclonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

4. Metabolic acidosis Seizures may be associated with apnea and thus hypoxemia and lactic acidosis. Lactic acidosis, a form of metabolic acidosis, occurs when cells use glucose without adequate oxygen (anaerobic metabolism); glucose then is incompletely broken down and forms lactic acid. This acid releases hydrogen ions, causing acidosis. Lactic acidosis occurs whenever the body has too little oxygen to meet metabolic oxygen demands (e.g., heavy exercise, seizure activity, reduced oxygen).

The patient describes a burning sensation in the leg. The health care provider tells the nurse that a medication will be prescribed for neuropathic pain secondary to chemotherapy. The nurse is most likely to question the prescription of which drug? 1. Imipramine 2. Carbamazepine 3. Gabapentin 4. Morphine

4. Morphine Morphine is usually not prescribed for neuropathic pain because pain relief response is poor. Other medications, some antidepressants (e.g., imipramine) and some anticonvulsants (e.g., carbamazepine and gabapentin), provide better relief.

Which is the most common adverse reaction to erythromycin? 1. Weight gain. 2. Constipation. 3. Mouth sores. 4. Nausea and vomiting.

4. Nausea and vomiting. Common adverse reactions to erythromycin include nausea, vomiting, diarrhea, abdominal pain, and anorexia. Erythromycin should be given with a full glass of water and after meals. Because these gastrointestinal adverse reactions occur commonly, it may be necessary to give erythromycin with food.

Ribavirin (Virazole) is prescribed for a hospitalized child with respiratory syncytial virus (RSV). The nurse prepares to administer the medication by which route? 1. Oral. 2. Subcutaneous. 3. Intramuscular. 4. Nebulizer.

4. Nebulizer. Ribavirin (Virazole) is an antiviral respiratory medication used in the hospital for children with severe respiratory syncytial virus. Administration is via nebulizer.

The nurse is preparing to administer 2 g/500 mL of lidocaine after administering a 100-mg IV bolus to a client with multifocal premature ventricular contractions (PVCs). Which intervention should the nurse implement? 1. Cover the IV bag and tubing with tin foil. 2. Monitor the brain natriuretic peptide (BNP) daily. 3. Hold the lidocaine drip if no PVCs are noted. 4. Obtain an infusion pump to administer the medication.

4. Obtain an infusion pump to administer the medication. Lidocaine is a very potent medication and is administered in this concentration by an IV pump to maintain a constant rate of administration. The pump also ensures that too much medication is not administered at one time, which can result in death.

The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours postpartum after a vaginal birth. What should the nurse do next? a. apply an ice pack to the perineal area b. assess the client's temperature c. have the client take a warm sitz bath d. contact the HCP for an abx

a. apply an ice pack to the perineal area The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. They are not effective after the first 24 hours. Although VS, including temp are important assessments, taking the client's temp is unrelated to the hematoma and would provide no additional info about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further treatment within 6 weeks.

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the UAP? Select all that apply a. assist the client with toileting b. inform family that the client needs a CT scan c. accompany the client while walking in the hall d. reorient the client frequently e. apply restraint belt for client safety

a. assist the client with toileting c. accompany the client while walking in the hall d. reorient the client frequently

The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for immediate further action? 1. Blood pressure decrease from 114/65 to 106/58 mm Hg 2. Respiratory rate drop from 18 to 12 breaths/min 3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min 4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

4. Persisting chest pain at a level of 1 (on a scale of 0 to 10) The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

The nurse is caring for a client diagnosed with a malignant brain tumor. Which medication should the nurse anticipate the HCP ordering? 1. Cyclophosphamide. 2. Octreotide. 3. Erythropoietin. 4. Phenytoin.

4. Phenytoin. Most drugs do not cross the blood-brain barrier, so most antineoplastic agents, such as cyclophosphamide (Cytoxan), an alkylating antineoplastic agent, are not effective against cancers in the brain. Octreotide (Sandostatin), a pituitary suppressant, is a growth hormone (GH) suppressant and is useful in the treatment of acromegaly, not malignant tumors of the brain. A brain tumor has the potential to cause erratic stimulation of the neurons in the brain, resulting in seizures. The nurse should expect the HCP to order phenytoin (Dilantin), an anticonvulsant, to prevent or control seizures.

A 2-year-old admitted to the hospital 2 days ago has been crying and is inconsolable much of the time. The nurse ' s best response to the child ' s parents who are concerned about this behavior is that the child is in the: 1. Detachment phase of separation anxiety, which is normal for children during hospitalization. 2. Despair stage of separation anxiety, which is normal for children during hospitalization. 3. Bargaining stage of separation anxiety, which is normal for children during hospitalization. 4. Protest stage of separation anxiety, which is normal for children during hospitalization.

4. Protest stage of separation anxiety, which is normal for children during hospitalization. During the protest stage of separation anxiety, children are often inconsolable and often cry more than they do when they are at home. These children also frequently ask to go home

The nurse triages a new client with a third-degree burn on the upper half of the body. Which initial nursing action is most critical for this client? Select all that apply. a. assure the airway is open b. ensure adequate pain control c. establish an IV site d. provide fluid resuscitation with D5NS e. provide fluid resuscitation with LR f. notify the client's emergency contact

a. assure the airway is open establish an IV site e. provide fluid resuscitation with LR Third-degree, or full-thickness burns extend to the subcutaneous region and may destroy the soft tissue fascia. The initial assessment for a client who presents with third-degree burns to the upper body is to rule out adverse effects on the respiratory system (e.g., secure a patent airway). Additionally, this client is at risk for hypovolemic shock; therefore, initiating intravenous (IV) access and beginning the prescribed fluid resuscitation using an isotonic solution (e.g., lactated Ringers) is a critical nursing intervention in the provision of care for this client.

The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? a. asterixis b. lethargy c. amnesia d. behavioral changes e. Kussmaul respirations

a. asterixis b. lethargy c. amnesia d. behavioral changes

A nurse is teaching a group of clients who are pregnant about iron rich foods. Which of the following foods should the nurse include? select all that apply a. beans b. fish c. dairy products d. lean red meats e. apples

a. beans b. fish d. lean red meats

A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? a. betamethasone b. indomethacin c. nifedipine d. methylergonovine

a. betamethasone Methylergonovine is prescribed for the client experiencing postpartum hemorrhage

The nurse has just received report on a labor client: a G3, T1, P0, A1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shfit will address what factors? select all that apply a. birth should occur before the change of shit in 12 hours b. stage 2 should take 30 minutes or less c. contractions will remain irregular until transition d. transition will be shorter for this multiparous client f. this client will withdraw into herself during transition

a. birth should occur before the change of shit in 12 hours b. stage 2 should take 30 minutes or less d. transition will be shorter for this multiparous client f. this client will withdraw into herself during transition A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 min or less and many multiparous clients go immediately from 10 cm dilation to birth. Contractions become regular and increase in frequency, intensity and duration as labor progresses for both primiparous and multiparous clients.

Which is the correct method to instill eardrops in a 5-year-old? 1. Pull the pinna of the ear downward and back for instillation. 2. Place cotton tightly in the ear after instillation. 3. Have the child remain upright after instillation. 4. Pull the pinna of the ear upward and back for instillation.

4. Pull the pinna of the ear upward and back for instillation. The correct way to administer eardrops in a child older than 3 years of age is to pull the pinna up and back, the same as for an adult.

The homecare nurse is visiting a client to assess the response to new medications ordered for BPH. What symptoms would indicate to the nurse the medications are not working? a. bladder pain b. fever with chills c. urinary frequency d. terminal dribbling e. nighttime sweats

a. bladder pain c. urinary frequency d. terminal dribbling

A neonate on ventilator support is diagnosed with trisomy 18 (Edwards syndrome). What would be an appropriate action by the nurse? 1. Discuss a plan to decrease ventilator support as the lungs become stronger with the parents 2. Provide parents with information on the medical treatment plan for the neonate 3. Provide the test results to the parents and give them information to read about trisomy 18 4. Request a meeting with the palliative care team and the parents to discuss end of life choices

4. Request a meeting with the palliative care team and the parents to discuss end of life choices Life expectancy of a neonate with trisomy 18 is typically a few weeks. it is characterized by severe cardiac defects and multiple MSK deformities. Trisomy 13 (Patau syndrome) also results in early death

The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? 1. Serum potassium level of 5.2 mEq/L (5.2 mmol/L) 2. Serum sodium level of 134 mEq/L (134 mmol/L) 3. Serum calcium level of 10.6 mg/dL (2.65 mmol/L) 4. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L)

4. Serum magnesium level of 0.8 mEq/L (0.4 mmol/L) Although all of these laboratory values are outside of the normal range, the magnesium level is furthest from normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

The nurse manager is responsible for determining instances where further action may be required to enhance safety of clients on the unit. Which situation does the nurse manager ensure that an incident report is completed? Select all that apply. a. blood cultures prescribed for a client are documented as sent to the lab; however, the procedure was not completed b. A nurse informs the charge nurse that a client's family member falls on the unit; however, medical care is refused by the individual c. A nurse who leaves the hospital without providing notice to the COC in the middle of the scheduled shift d. A client with a documented DNR prescription is removed from the ventilator by the nurse assigned to provide care e. A nurse is slapped in the face by a client who is currently detoxing from illicit drug use

a. blood cultures prescribed for a client are documented as sent to the lab; however, the procedure was not completed This situation warrants further investigation. b. A nurse informs the charge nurse that a client's family member falls on the unit; however, medical care is refused by the individual e. A nurse is slapped in the face by a client who is currently detoxing from illicit drug use

A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? Select all that apply a. breast tenderness b. urinary frequency c. epistaxis d. dysuria e. epigastric pain

a. breast tenderness b. urinary frequency c. epistaxis

The parent of a newborn calls the clinic and reports that when cleaning the umbilical cord, it was noted that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this parent? a. bring the infant to the clinic b. this is a normal occurrence and no further action is needed c. increase the number of times that the cord is cleaned per day d. monitor the cord for another 24-48 hours and call the clinic if the discharge continues

a. bring the infant to the clinic Signs of umbilical cord infection are moistness, oozing, discharge and reddened base around the cord. If signs of infection occur, the client needs to be instructed to notify the PHCP. If these symptoms occur, abx may be necessary

A postop client has been placed on a clear liquid diet. The nurse would provide the client with which items that are allowed to be consumed on this diet? select all that apply a. broth b. coffee c. gelatin d. pudding e. vegetable juice f. pureed vegetables

a. broth b. coffee c. gelatin

According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, what are the priority pain management strategies that the nurse would expect to see in the pain management for postsurgical patients? Select all that apply a. APAP or NSAID for management of postop pain in adults and children w/o complications b. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures c. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus d. multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies e. long-acting oral opioids, especially in the immediate postoperative period, for continuous around the clock relief f. neuraxial administration of Mg, BZD, neostigmine, tramadol or ketamine is recommended for postop pain

a. APAP or NSAID for management of postop pain in adults and children w/o complications b. Surgical site-specific peripheral regional anesthetic techniques in adults and children for procedures c. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the client has risk for cardiac complications or prolonged ileus d. multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic techniques, and nonpharmacologic therapies

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio2) and call the health care provider to discuss the patient's status.

4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio2) and call the health care provider to discuss the patient's status. The patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

A nurse is discussing essential nutrients for normal functioning of the nervous system with a client. Which of the following should the nurse include in the teaching? Select all that apply a. calcium b. thiamin c. vitamin B6 d. sodium e. phosphorous

a. calcium b. thiamin c. vitamin B6 d. sodium

A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? a. ceftriaxone b. fluconazole c. metronidazole d. zidovudine

a. ceftriaxone

The client with coronary artery disease (CAD) is prescribed nicotinic acid. The client reports fl ushing of the face, neck, and ears. Which priority intervention should the nurse implement? 1. Instruct the client to stop taking the medication immediately. 2. Encourage the client to take the medication with meals only. 3. Discuss that this is a normal side effect and will decrease with time. 4. Tell the client to take 325 mg of aspirin 30 minutes before taking the medication.

4. Tell the client to take 325 mg of aspirin 30 minutes before taking the medication. Nicotinic acid (Niacin) is a vitamin preparation used to prevent or treat pellagra, a disease of niacin defi ciency. Taking an aspirin prior to the medication will help reduce the fl ushing of the face, neck, and ears.

A healthy 65-year-old client who cares for a newborn grandchild has a clinic appointment in May. The client needs several immunizations but tells the nurse, "I hate shots! I will only take one today." Which immunization is most important to give? 1. Influenza 2. Herpes zoster 3. Pneumococcal 4. Tetanus, diphtheria, pertussis

4. Tetanus, diphtheria, pertussis Individuals who have contact with infants should be immunized against pertussis to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, before the influenza season. The herpes zoster vaccine is important to prevent shingles in the client but does not need to be administered today.

According to developmental theories, which important event is essential to the development of the toddler? 1. The child learns to feed self. 2. The child develops friendships. 3. The child learns to walk. 4. The child participates in being potty-trained.

4. The child participates in being potty-trained. Developmental theorists such as Erickson and Freud believe that toilet training is the essential event that must be mastered by the toddler

The nurse is preparing to administer medications to the following clients. Which client should the nurse question administering the medication? 1. The client receiving losartan who has a blood pressure of 168/94. 2. The client receiving the diltiazem who has 1+ nonpitting edema. 3. The client receiving the terazosin who is reporting a headache. 4. The client receiving the hydrochlorothiazide who is reporting leg cramps

4. The client receiving the hydrochlorothiazide who is reporting leg cramps Hydrochlorothiazide (HCTZ) is a thiazide diuretic. Leg cramps could indicate hypokalemia, which may lead to life-threatening cardiac dysrhythmias. Therefore, the nurse should question administering this medication until a serum potassium level is obtained.

At 9:00 pm, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? 1. The client was treated with alteplase about 8 months ago. 2. The client takes famotidine for gastroesophageal reflux disease. 3. The client has ST-segment elevations on the electrocardiogram (ECG). 4. The client reports having continuous chest pain since 8:00 am.

4. The client reports having continuous chest pain since 8:00 am. Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are usually not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use.

Which is essential for the nurse to teach the parent regarding administration of albendazole (Albenza)? 1. Fever and rash are common adverse effects. 2. The medication kills the eggs in about 48 hours. 3. The drug should be given with a meal. 4. The dose should be repeated in 2 weeks.

4. The dose should be repeated in 2 weeks. As the fi rst treatment kills the adult worms, a second treatment is done in 2 weeks to treat emerging parasites.

17. A patient with human immunodeficiency virus (HIV) who has been started on antiretroviral therapy is seen in the clinic for follow-up. Which test will be best to monitor when determining the response to therapy? 1. CD4 level 2. Complete blood count 3. Total lymphocyte percent 4. Viral load

4. Viral load Viral load testing measures the amount of HIV genetic material in the blood, so a decrease in viral load indicates that the antiretroviral therapy is effective. The CD4 level, total lymphocytes, and complete blood count will also be used to assess the impact of HIV on immune function but will not directly measure the effectiveness of antiretroviral therapy

An important aspect to consider when dealing with a low-priority concern is: 1. the patient's agreement that it is a low priority as well. 2. cost-benefit. 3. available resources. 4. all of the above

4. all of the above

"Patients receiving antibiotics through a central IV line will not experience infection" is an example of: 1. a structure indicator. 2. a process indicator. 3. a process goal. 4. an outcome indicator.

4. an outcome indicator. An outcome indicator defines the intended result of a medical and/or nursing intervention

Which client is at greatest risk for respiratory depression while receiving opioids for analgesia? a. Older adult client with chronic pain related to joint immobility 2. Client with a heroin addiction and back pain c. Young female client with advanced multiple myeloma 4. opioid-naive adolescent with an arm fracture and CF

4. opioid-naive adolescent with an arm fracture and CF At greatest risk are older adult clients, opiate-naïve clients, and those with underlying pulmonary disease. The adolescent has two of the three risk factors.

Mrs. Ruff is having gastric surgery in the morning. Obtaining her consent for the surgery is the role of: 1. the nurse taking care of the patient. 2. the operating room staff. 3. the primary care physician. 4. the surgeon.

4. the surgeon. The surgeon is responsible for the explanation of what is to be done and the risks of the procedure to that client, along with alternative procedures and probable outcomes. The nurse taking care of the patient can clarify, define a medical term, or add more details to the physician's initial information, usually expanding on the corresponding nursing care. The operating room staff does not have a role in the consent process, nor does the primary care physician.

Withdrawal of medical care includes: 1. withdrawal of comfort care. 2. withdrawal of nursing care. 3. withdrawal of socialization. 4. withdrawal of curative treatment

4. withdrawal of curative treatment Cure is no longer a goal of therapy when the decision has been made to withdraw treatment. A discussion of potential outcomes will have been part of the discussion leading to the decision of withdrawing care. Choices 1, 2, and 3 are incorrect. Nursing care, socialization, and comfort continue to be mechanisms to provide quality end-of-life care

The home health nurse caring for an elderly client with multiple new injuries suspects elder abuse. Place the following steps in the appropriate priority order for the nurse to perform. 1. Notify the appropriate authorities for the state. 2. Ensure that the client is removed from the threatening situation. 3. Document the occurrence, findings, actions, and response of the client. 4. Assess and treat the client's injuries.

4123

The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heartbeat. The fetal heartbeat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the tasks in which order? 1. Call the HCP 2. Explain that the fetal heartbeat could not be found at this time 3. Obtain different equipment and recheck 4. Ask the client if the baby is or has been moving

4321

Numeric scale

5 years and older

The nurse is preparing to administer an NTG patch to a client diagnosed with CAD. Which interventions should the nurse implement? Rank in order of performance. 1. Date and time the NTG patch. 2. Remove the old patch. 3. Clean the site of the old patch. 4. Apply the NTG patch. 5. Check the patch against the MAR.

5, 1, 2, 4, 3 5. The nurse should implement the fi ve rights of medication administration, and the first is to make sure it is the right medication and the right client 1. Before applying the NTG paste, the nurse should date and time the application paper prior to putting it on the client so that the nurse is not pressing on the client when writing on the patch. 2. The nurse should have the gloves on when removing the old application paper for the above reason. 4. Last, the nurse should administer the NTG patch application paper in a clean, dry, nonhairy place. 3. The nurse should make sure no medication remains on the client's skin.

The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the clients and has determined that all are stable and not in acute distress. Prioritize the order in which the oncoming nurse will care for the following clients, 1 being the first and 5 being the last. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for tx of meningitis. He reports a continuous HA that is partially relieved by medication. 2. Older man who underwent total knee replacement surgery 2 days ago. He is using the PCA pump frequently with good relief and occasionally asks for bolus doses. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. Older woman with advanced Alzheimer disease who requires total care for all ADL. She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a LTCF. 5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued.

5. Young man who was admitted with chest pain secondary to a spontaneous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. 3. Middle-aged woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 1. Adolescent who is alert and oriented. He was admitted 2 days ago for tx of meningitis. He reports a continuous HA that is partially relieved by medication. 2. Older man who underwent total knee replacement surgery 2 days ago. He is using the PCA pump frequently with good relief and occasionally asks for bolus doses. 4. Older woman with advanced Alzheimer disease who requires total care for all ADL. She struggles during any type of nursing care, and it is difficult to assess her subjective symptoms. She is awaiting transfer to a LTCF. All of the clients are in relatively stable condition. The client with the pneumothorax has priority because chest tubes can leak or become dislodged or blocked. Lung sounds and respiratory effort should be evaluated before and after removal of the chest tube. The woman who will be leaving the unit for diagnostic testing should be assessed and prepared, as needed, before she leaves for the procedure. In a client with meningitis, a headache is not unexpected, but neurologic status and pain should be assessed. The report of postoperative pain is expected, but this client is getting reasonable relief most of the time. Caring for and assessing the client with Alzheimer disease is likely to be very time consuming; caring for her last prevents delaying care for all the others. In addition, elderly clients with dementia benefit if the caregiver does not act rushed or hurried.

The nurse has just completed setting up an external warming device (Bear Hugger) for a 48-year-old client and is ready to initiate therapy. The core temperature taken with a rectal probe is currently 91.4° F (33° C). Which of the following actions should the nurse perform? a. Active rewarming to increase the core temperature no more than 0.9° F (0.5° C) per hour b. Active rewarming to increase the core temperature as quickly as possible c. Active rewarming to increase the core temperature to 96.8° F (36° C) d. Active rewarming to increase the core temperature to 100.4° F (38° C)

a. Active rewarming to increase the core temperature no more than 0.9° F (0.5° C) per hour The core temperature should be brought up by no more than 0.9° F (0.5° C) per hour for treatment of moderate hypothermia. Active rewarming would be discontinued when the core temperature is greater than 95° F (35° C) to prevent hyperthermia

The client asks about side effects of taking digoxin. How does the nurse respond? a. Anorexia can be a side effect of digoxin. b. Tachycardia can be a side effect of digoxin. c. Constipation can be a side effect of digoxin. d. Urinary retention can be a side effect of digoxin.

a. Anorexia can be a side effect of digoxin. Anorexia, nausea, vomiting and diarrhea are side effects of digoxin. It can cause bradycardia but does not cause urinary retention or constipation

A nurse is reviewing the effect of culture on nutrition during a staff in service. Which of the fowlloing groups prescribes eating specific foods to balance forces in the body during illness? select all that apply a. Asian culture b. African culture c. Roman Catholicism d. Hispanic/Latinx culture E. Buddhism

a. Asian culture d. Hispanic/Latinx culture Hispanic/Latinx cultural traditions can include balancing hot and cold forces within the body

A primigravid client at 39 weeks' gestation is admitted to the hopsital for induction of labor. The HCP has prescribed prostaglandin E2 gel for the client. before administering prostaglandin E2 gel to the client, the nurse should perform which action first? a. Assess the frequency of uterine contractions b. place the client in a side lying position c. determine whether the membranes have ruptured d. prepare the client for an amniotomy

a. Assess the frequency of uterine contractions Prostaglandin E2 gel is contraindicated if the client is having contractions. if there are none, the client should be placed in a semi-Fowler's position and allow for vaginal insertion of the gel.

A primigravid client at 39 weeks' gestation is admitted to the hospital in active labor. On admission, the client's cervix is 6 cm dilated. After 2 hours of active labor, the client's cervix is still dilated at 6 cm with 100% effacement at +1 station. Contractions are 3-5 minutes apart, lasting 45 sec and of moderate intensity. The nurse determines that the client is most likely experiencing which problem? a. cephalopelvic disproportion b. prolonged latent phase c. prolonged transitional phase d. hypotonic contraction pattern

a. cephalopelvic disproportion This may be caused by an inadequate pelvis of the mother or large for gestational age fetus. The HCP should be notified about the client's lack of progress. If the fetus cannot descent, a c section is warranted. The client is not experiencing a prolonged latent phase (0-3 cm dilation) because her cervix is dilated to 6 cm. She has not reached the transitional phase, characterized by a cervical dilation of 8-10 cm.

The nurse is monitoring a postpartum client who delivered 1 hour ago and received epidural anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? a. changes in VS b. signs of heavy bruising c. complaints of intense pain d. complaints of a tearing sensation

a. changes in VS Because the client received epidural anesthesia, she cannot feel pain, pressure or tearing. Changes in VS indicate hypovolemia. heavy bruising may be seen but VS changes indicate hematoma caused by blood collection in the perineal tissues

The nurse is teaching a group of parents how to promote healthy teeth in their newborn. What should the nurse include? a. clean gums with a damp washcloth after feedings b. use a firm bristled toothbrush once teeth have erupted c. beginning at birth use toothpaste the size of a pea d. allow only milk bottles in bed e. wean from bottle by 15 months

a. clean gums with a damp washcloth after feedings e. wean from bottle by 15 months At age 2, begin brushing with a pea sized amount of fluoridated toothpaste

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? a. client pain level b. inadequate urinary output c. client perception of body changes d. potential for imbalanced body fluid volume

a. client pain level

anaphylactoid syndrome of pregnancy interventions

8-10 L/min O2 by face mask or resuscitation bag with 100% oxygen, intubation and ventilation, position on side, IVF, blood products, emergency delivery

Which clients must be assigned to an experienced RN? select all that apply. a. client who was in an automobile crash and sustained multiple injuries b. client with chronic back pain related to a workplace injury c. client who has returned from surgery and has a chest tube in place d. client with abdominal cramps related to food poisoning e. client with a severe headache of unknown origin f. client with chest pain who has a history of arteriosclerosis

a. client who was in an automobile crash and sustained multiple injuries c. client who has returned from surgery and has a chest tube in place e. client with a severe headache of unknown origin f. client with chest pain who has a history of arteriosclerosis These clients should be assigned to an experienced RN because all have acute conditions that require close monitoring for any developing complications. Abdominal cramps secondary to food poisoning is an acute condition; however, the cramping, vomiting and diarrhea are usually selflimiting. The client with chronic back pain would be considered physically stable.

The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? a. closed glottis pushing b. open glottis pushing c. "rest and descent" d. squatting while pushing

a. closed glottis pushing Closed glottis pushing, or when a woman is told to hold her breath when pushing while the nurse typically counts to 10, creates the valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, encourages women to listen to their own body cues for when to breathe and when to bear down.

A nurse is teaching a client about protein needs when on dialysis. Which of the following instructions should the nurse include in the teaching? select all that apply a. consume 35 kcal/kg of body weight to maintain body protein stores b. take phosphate binders when eating protein rich foods c. increase biologic sources of protein (eggs, milk and soy) d. increase protein intake by 50% of recommended dietary allowance e. consume daily protein intake in the morning

a. consume 35 kcal/kg of body weight to maintain body protein stores b. take phosphate binders when eating protein rich foods c. increase biologic sources of protein (eggs, milk and soy) d. increase protein intake by 50% of recommended dietary allowance The client should spread protein intake throughout the day to prevent excessive intake of phosphorous and potassium

The nurse calls the PHCP regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take? a. contact the nursing supervisor b. administer the dose prescribed c. hold the medication until the PHCP can be contacted d. Administer the recommended dose until PHCP can be located

a. contact the nursing supervisor

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions would the nurse take? Select all that apply a. contact the surgeon b. instruct the client to remain quiet c. prepare the client for wound closure d. document the findings and actions taken e. place a sterile saline dressing and ice packs over the wound f. place the client in a supine position without a pillow under the head

a. contact the surgeon b. instruct the client to remain quiet c. prepare the client for wound closure d. document the findings and actions taken

Legionnaire's disease

A severe, often fatal bacterial disease characterized by pneumonia, dry cough and sometimes gastrointestinal symptoms. Caused by gram negative bacteria found in both natural and manmade water sources.

severe acute respiratory syndrome (SARS)

A type of flu caused by a coronavirus. sx include fever, dry cough, hypoxemia and PNA. Should be on contact and airborne precautions

Which nursing intervention should be included in the plan of care for a 10 month-old child with a new diagnosis of otitis media? Select all that apply. a. Assess the tympanic membrane for redness and/or bulging and report findings b. complete other aspects of the physical exam prior to the otoscopic exam c. discuss otitis media risk prevention with the parents of the child d. place the speculum just beyond the outer external ear canal with inspection d. instruct on the importance of influenza and pneumonia vaccines e. pull the pinna up and back and when inspecting the child's ear

a. Assess the tympanic membrane for redness and/or bulging and report findings b. complete other aspects of the physical exam prior to the otoscopic exam c. discuss otitis media risk prevention with the parents of the child d. instruct on the importance of influenza and pneumonia vaccines Otitis media risk prevention should be discussed with parents and includes not exposing children to secondhand smoke, avoidance of pacifiers, and breastfeeding infants instead of bottle feeding. When the ear of a child is assessed, the speculum is placed only in the outer ear, not beyond the external ear canal, due to that action causing undue pain. When the ear of children less than three years of age is examined with an otoscope, the pinna is pulled down and back.The tympanic membrane is assessed for redness and/or bulging

A patient is diagnosed with secondary syphilis. The nurse can expect the patient to have: A. "Copper penny" rash on the palms of the hands and soles of the feet B. Localized tumors in the skin, bones, and liver C. Chancres and lymphadenopathy D. General paresis

A. "Copper penny" rash on the palms of the hands and soles of the feet A client with secondary syphilis will exhibit a "copper penny" rash on the palms of the hands and soles of the feet and flu-like symptoms. Answers B and D are incorrect choices because they are exhibited by the client with tertiary syphilis. Answer C is incorrect because it is exhibited by the client with primary syphilis.

A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception? A. "Currant jelly" stools B. Projectile vomiting C. "Ribbonlike" stools D. Palpable mass over the flank

A. "Currant jelly" stools The child with intussusception has stools that contain blood and mucus, which are described as "currant jelly" stools. Answer B is a symptom of pyloric stenosis; therefore, it is incorrect. Answer C is a symptom of Hirschsprungs, therefore, it is incorrect. Answer D is a symptom of Wilms tumor; therefore, it is incorrect

The nurse is teaching a group of student nurses about drug safety. Keeping in mind Joint Commission guidelines, which of the following does the nurse teach the students? Select all that apply. A. "Do not abbreviate drug names." B. "Use daily instead of QD , Q.D. , or q.d. " C. "Rectum can be abbreviated PR , R , or Per Rec ." D. "Use OD to indicate right eye for eye medications." E. "Use the letter u to indicate units, such as with insulin."

A. "Do not abbreviate drug names." B. "Use daily instead of QD , Q.D. , or q.d. " Joint Commission guidelines dictate which abbreviations can or cannot be used. Drug names should be spelled out fully. For example, MS can be magnesium sulfate or morphine sulfate ; therefore, drug abbreviations should be avoided. The word daily should no longer be abbreviated, but spelled out in full. The rectal route should not be abbreviated, but should be spelled out as per rectum . The designation of right eye or left eye should be spelled out and not abbreviated. The word units should not be abbreviated, since it can be confused with a zero, the number 4 , or the term cc .

The nurse is talking to a client and his family about hepatitis. Which of the following statements by a family member indicate understanding of the nurse's teaching? Select all that apply. A. "Hepatitis D only occurs with hepatitis B." B. "Hepatitis A can occur at any time of the year." C. "Hepatitis D is transmitted through contaminated drinking water." D. "Hepatitis A can be spread by uncooked shellfish and contaminated water or milk." E. "Hepatitis B is spread by contact with blood or body fluids, sexual contact, or sharing dirty needles."

A. "Hepatitis D only occurs with hepatitis B." B. "Hepatitis A can occur at any time of the year." D. "Hepatitis A can be spread by uncooked shellfish and contaminated water or milk." E. "Hepatitis B is spread by contact with blood or body fluids, sexual contact, or sharing dirty needles." Hepatitis D coexists with hepatitis B and intensifies the acute symptoms. Hepatitis A can occur at any time of the year and is spread via uncooked shellfish, contaminated water or milk, and contaminated fruits and vegetables. Hepatitis B is spread by contact with blood or body fluids, sexual contact, sharing dirty needles, and contact with infected semen or saliva. Hepatitis A is seasonal and tends to occur mainly during the fall and early winter. Hepatitis D is spread by contact with blood and blood products.

The nurse is assessing a client at home who is receiving outpatient hemodialysis 12 hours a week. The nurse knows the client needs further instruction about proper diet when he states which of the following? A. "I drink prune juice when I'm constipated." B. "I drink ginger ale with lunch." C. "I drink 1 cup of milk with my dinner." D. "My bread choice is white rather than whole grain."

A. "I drink prune juice when I'm constipated." Potassium will accumulate in the blood with renal disease. As a potassium-rich food, prune juice should be avoided. Phosphorous can accumulate with renal disease. Because soft drinks contain phosphorous, only clear ones, such as ginger ale, are allowed. Dairy foods contain phosphorous, so milk intake is limited to 1 cup/day. White bread has less phosphorous than whole-grain bread and is preferred over whole-grain bread.

A school nurse is approached by a student who says that her friend has been cutting herself on the arms. The student asks the nurse not to tell anyone. Which response by the nurse is correct? A. "I have to notify her parents, because this affects her personal safety." B. "I won't tell anyone, but let me know if she starts talking about suicide." C. "I will call the hospital and let them send a psychiatrist to do an evaluation on your friend." D. "I will make it a point to run into her in the hall and notice the cuts on her arms so I can ask about them."

A. "I have to notify her parents, because this affects her personal safety." The nurse has a duty to protect the client when self-harm or suicidal behavior is present. Selfharm could lead to suicide, and the nurse must inform the parents immediately. HIPAA and client privacy take a back seat to client safety. Asking the student to inform the nurse if the friend attempts suicide delays seeking help and allows the self-destructive behavior to continue. Calling the hospital and asking for a psychiatric consult is not the appropriate way to manage the situation. Telling the student that the nurse will just run into the friend in the hall is not feasible and delays getting appropriate care for the friend.

The nurse is preparing to discharge a client with an ileal conduit done for treatment of bladder cancer. Which statement by the client indicates the need for further instruction? A. "I look forward to returning to my local health club to swim." B. "The local ostomy support group meets on Wednesday morning at 10 a.m." C. "My stoma should be cleaned daily with soap and water." D. "During the day I will wear a leg bag to collect my urine."

A. "I look forward to returning to my local health club to swim." During the initial postoperative period after an ileal conduit, the client should not swim due to the risk of infection. Attendance at an ostomy support group will help the client deal with altered body image. Cleaning the stoma with soap and water will help reduce chance of infection. Wearing a leg bag during the day to collect urine allows the client to return to a normal lifestyle. At night, a larger urine collection bag will be needed.

The nurse is preparing to discharge a client diagnosed with gout. Which statement by the client indicates understanding of dietary restrictions while managing gout? A. "I should avoid beer, anchovies, and liver." B. "I should avoid bananas, grapefruit, and oranges." C. "I should avoid dairy products such as milk and ice cream." D. "I should avoid red wine, dark chocolate, and aged cheeses."

A. "I should avoid beer, anchovies, and liver." Beer, anchovies, and liver are high in purine and should be avoided in clients prone to gout. Options 2 and 3 may be included in the diet, unless there are other reasons to avoid these foods. Option 4 lists food high in tyramine, which should be avoided by clients taking certain medications, such as MAOI. Unless the client is on one of these medications, there is no need to avoid those foods.

When assessing the client's blood pressure, the nurse should use a cuff with a width that is ____% of the circumference of the extremity. (Fill in the blank.) A. 40 B. 30 C. 20 D. 10

A. 40 the width of the blood pressure cuff used should be 40% of the circumference of the extremity. Answers B, C, and D are incorrect for assessing the blood pressure.

A client with preeclampsia is admitted with an order for intravenous magnesium sulfate. Which statement is true regarding the administration of magnesium sulfate? A. A 4 gram loading dose is administered over 20-30 minutes via infusion pump. B. Side effects include feeling cold and tremulous. C. IV infusion rate is adjusted to maintain urine output of 20 to 30 mL per hour. D. The brachial reflex is checked prior to initiation of medication.

A. A 4 gram loading dose is administered over 20-30 minutes via infusion pump. The loading dose of magnesium sulfate is usually 4 grams administered over 20-30 minutes via infusion pump. Answer B is incorrect because side effects include feeling warm and flushed. Answer C is incorrect because the IV rate is set to maintain a urine output of 30-50 mL/hr. Answer D is incorrect because the patellar reflex is assessed before dosing.

A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor? A. A WBC of 14,000 cu.mm B. Auscultation of abdominal bruit C. Complaints of lower back pain D. A platelet count of 175,000 cu.mm

A. A WBC of 14,000 cu.mm A white blood cell count of 14,000 cu.mm should be reported because it indicates infection. Answers B and C are incorrect choices because auscultation of an abdominal bruit and complaints of lower back pain are expected in the client with an abdominal aortic aneurysm. Answer D is incorrect because the platelet count is within normal limits.

The nurse has just received the change of shift report. Which client should the nurse assess first? A. A client two hours post-lobectomy with 150mL of chest drainage B. A client two days post-gastrectomy with scant drainage C. A client with pneumonia with an oral temperature of 102ºF D. A client with a fractured hip in Buck's traction

A. A client two hours post-lobectomy with 150mL of chest drainage The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later.

The physician ordered Zyprexa (olanzapine) for a patient with schizophrenia. Before administering the medication, the nurse should: A. Ask the patient to void and measure the amount B. Check the apical pulse rate C. Check the temperature D. Offer additional fluids

A. Ask the patient to void and measure the amount Before giving the medication, the nurse should ask the patient to void and measure the amount because the medication may cause urinary retention. Answers B, C, and D are not specific to the medication; therefore, they are incorrect.

A client with symptoms of myasthenia gravis is scheduled for a Tensilon (edrophoniun) test. Which medication should be kept available during the test? A. Atropine sulfate B. Lasix (furosemide) C. Prostigmine (neostigmine) D. Phenergan (promethazine)

A. Atropine sulfate Atropine sulfate is the antidote for Tensilon and is given to treat cholinergic crises that can occur during testing for myasthenia gravis. Answers B, C, and D are not used during the testing for myasthenia gravis; therefore, they are incorrect choices.

Which information should be given to the patient undergoing radiation therapy for breast cancer? A. Avoid exposing radiation areas to sunlight during treatment time and for a year after completion of therapy B. Moisturize the radiation site with oil-based lotion to prevent blistering C. Use bath oil when tub bathing to prevent drying and peeling D. Report redness and soreness of the area to the physician

A. Avoid exposing radiation areas to sunlight during treatment time and for a year after completion of therapy The patient receiving radiation therapy should avoid sunlight during the treatment period and for a year after radiation therapy is completed. Answers B and C are incorrect because they will remove the markings needed for radiation therapy. Answer D is incorrect because redness and sore skin are expected with radiation therapy.

The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied: A. Before the client arises in the morning B. With the client in a standing position C. After the client has bathed and applied lotion to the legs D. Before the client retires in the evening

A. Before the client arises in the morning The best time to apply antithrombotic stockings to the client is in the morning before the client arises. (If the physician orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings.) Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client has been standing or has just taken a bath; applying before retiring in the evening is wrong because late in the evening, more peripheral edema will be present.

The dysrhythmia most commonly seen during tracheal suctioning is: A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block

A. Bradycardia Suctioning can cause a vagal response, lowering the heart rate and causing bradycardia. Answers B, C, and D are less likely to occur; therefore, they are incorrect.

The client is admitted with a BP of 210/100. Her doctor orders furosemide (Lasix) 40mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1-2 minutes B. By hanging it IV piggyback C. With normal saline only D. With a filter

A. By giving it over 1-2 minutes Lasix should be given over 1 to 2 minutes to prevent hypotension. Answers B, C, and D are incorrect because it is not necessary to be given in an IV piggyback, with saline, or through a filter.

Six hours after birth, the newborn is found to have swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. Cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum

A. Cephalohematoma Swelling over the right parietal area of a newborn that does not cross the suture line describes a cephalohematoma, an area of bleeding outside the cranium. Answer B, molding, is overlapping of the bones of the cranium and is, therefore, incorrect. Answer C, a subdural hematoma, can be seen only on a CAT scan or xray. A caput succedaneum, in Answer D, refers to edema that crosses the suture line.

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? a. Assessment of vital signs b. Completion of abdominal examination c. Insertion of the prescribed nasogastric tube d. Thorough investigation of precipitating events

a. Assessment of vital signs The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a primary health care provider's prescription; in addition, the vital signs would be checked before performing this procedure.

The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly? A. Diminished femoral pulses B. Harlequin's sign C. Circumoral pallor D. Acrocyanosis

A. Diminished femoral pulses Diminished femoral pulses are a sign of coarctation of the aorta. Answers B, C, and D are found in normal newborns and are not associated with cardiac anomaly.

A client with ovarian cancer is receiving fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication? A. Discard the solution and order a new bag. B. Warm the solution. C. Continue the infusion and document the finding. D. Discontinue the medication.

A. Discard the solution and order a new bag. Crystals in the solution are not normal and should not be administered to the client. Discard the solution immediately. Answer B is incorrect because warming the solution will not help. Answer C is incorrect, and answer D requires a doctor's order.

The client presents to the emergency room with a hyphema. Which action by the nurse would be appropriate? A. Elevate the head of the bed and apply ice to the eye. B. Place the client in a supine position and apply heat to the knee. C. Insert a Foley catheter and measure the intake and output. D. Perform a vaginal exam and check for a discharge.

A. Elevate the head of the bed and apply ice to the eye. Hyphema is blood in the anterior chamber of the eye and around the eye. The client should have the head of the bed elevated and ice applied. Answers B, C, and D are incorrect and do not treat the problem

The physician has ordered the Schilling test for a patient with suspected pernicious anemia. What other vitamin level is often assessed at the same time as the B12 level? A. Folic acid B. Pyridoxine C. Ascorbic acid D. Thiamine

A. Folic acid The folic acid level is often assessed at the same time a Schilling test is done. Patients with pernicious anemia often have elevated levels of folic acid. Answers B, C, and D are not often assessed at the same time as a Schilling test, so they are incorrect choices

A patient of Greek descent has been prescribed Bactrim (sulfamethoxazole-trimethoprim) for treatment of a urinary tract infection. Before beginning the medication, the patient should be assessed for which of the following disorders? A. G6PD deficiency B. ß-thalassemia C. Sickle cell anemia D. Von Willebrand disease

A. G6PD deficiency The client should be assessed for G6PD deficiency. Cells with reduced levels of G6PD break more easily when exposed to some drugs such as sulfonamides, aspirin, quinine derivatives, high doses of vitamin C, and thiazide diuretics. Answers B, C, and D do not relate to the question; therefore, they are incorrect.

A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature: A. Increase cardiac output B. Indicate cardiac tamponade C. Decrease cardiac output D. Indicate graft rejection

A. Increase cardiac output Elevations in temperature increase the cardiac output. Answer B is incorrect because temperature elevations are not associated with cardiac tamponade. Answer C is incorrect because temperature elevation does not decrease cardiac output. Answer D is incorrect because elevations in temperature in the client with a coronary artery bypass graft indicate inflammation, not necessarily graft rejection.

A client is admitted with a diagnosis of polycythemia vera. The nurse should closely monitor the client for: A. Increased blood pressure B. Decreased respirations C. Increased urinary output D. Decreased oxygen saturation

A. Increased blood pressure The client with polycythemia vera has an abnormal increase in the number of circulating red blood cells that results in increased viscosity of the blood. Increases in blood pressure further tax the overworked heart. Answers B, C, and D do not directly relate to the condition; therefore, they are incorrect.

A nine-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham's chorea? A. Irregular movements of the extremities and facial grimacing B. Painless swellings over the extensor surfaces of the joints C. Faint areas of red demarcation over the back and abdomen D. Swelling, inflammation, and effusion of the joints

A. Irregular movements of the extremities and facial grimacing The child with Sydenham's chorea will exhibit irregular movements of the extremities, facial grimacing, and labile moods. Answer B is incorrect because it describes subcutaneous nodules. Answer C is incorrect because it describes erythema marginatum. Answer D is incorrect because it describes polymigratory arthritis.

Which finding is expected in a client with a ruptured spleen? A. Kehr's sign B. Chvostek's sign C. Kernig's sign D. Trendelenburg's sign

A. Kehr's sign The client with a ruptured spleen can be expected to exhibit Kehr's sign (increased abdominal pain exaggerated by deep breathing with pain being referred to the right shoulder). Answers B, C, and D are not specific to a ruptured spleen

A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to: A. Lie prone and let her feet hang over the mattress edge B. Lie supine, with her feet rotated inward C. Lie on her right side and point her toes downward D. Lie on her left side and allow her feet to remain in a neutral position

A. Lie prone and let her feet hang over the mattress edge Lying prone and allowing the feet to hang over the end of the mattress will help prevent flexion contractures. The client should be told to do this several times a day. Answers B, C, and D do not help prevent flexion contractures; therefore, they are incorrect

The nurse is caring for a client hospitalized with nephrotic syndrome. Based on the client's treatment, the nurse should: A. Limit the number of visitors. B. Provide a low-protein diet. C. Discuss the possibility of dialysis. D. Offer the client additional fluids.

A. Limit the number of visitors. The client with nephotic syndrome will be treated with immunosuppressive drugs. Limiting visitors will decrease the chance of infection. Answer B is incorrect because the client needs additional protein. Answer C is incorrect because dialysis is not indicated for the client with nephrotic syndrome. Answer D is incorrect because additional fluids are not needed until the client begins diuresis.

A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has: A. Low blood pressure B. A slow, regular pulse C. Warm, flushed skin D. Increased urination

A. Low blood pressure The client with acute adrenal crisis has symptoms of hypovolemia and shock; therefore, the blood pressure would be low. Answer B is incorrect because the pulse would be rapid and irregular. Answer C is incorrect because the skin would be cool and pale. Answer D is incorrect because the urinary output would be decreased.

Which medication does the nurse expect to be ordered for the postpartal patient with bleeding uncontrolled by Pitocin (oxytocin)? A. Methergine (methylergonovine maleate) B. Aquamephyton (phytonadione) C. Amicar (aminocaproic acid) D. Celestone (betamethasone)

A. Methergine (methylergonovine maleate) Methergine (methylergonovine) produces uterine contractions and is used for postpartal bleeding that is not controlled by Pitocin (oxytocin). Answers B, C, and D are incorrect because they are not used to control postpartal bleeding

The nurse is caring for a client with acromegaly. Following a transphenoidal hypophysectomy, the nurse should: A. Monitor the client's blood sugar. B. Suction the mouth and pharynx every hour. C. Place the client in low Trendelenburg position. D. Encourage the client to cough.

A. Monitor the client's blood sugar. Following a hypophysectomy, the nurse should check the client's blood sugar because insulin levels may rise rapidly resulting in hypoglycemia. Answer B is incorrect because suctioning should be avoided. Answer C is incorrect because the client's head should be elevated to reduce pressure on the operative site. Answer D is incorrect because coughing increases pressure on the operative site that can lead to a leak of cerebral spinal fluid.

The client taking aminopylline tells the nurse that he is going to begin a smoking cessation program when he is discharged. The nurse should tell the client to notify the doctor if his smoking pattern changes because he will: A. Need his aminophylline dosage adjusted B. Require an increase in antitussive medication C. No longer need annual influenza immunization D. Not derive as much benefit from inhaler use

A. Need his aminophylline dosage adjusted Changes in smoking patterns should be discussed with the physician because they have an impact on the amount of aminophylline needed. Answer B is incorrect because clients with COPD are placed on expectorants, not antitussives. Answer C is incorrect because an annual influenza vaccine is recommend for all those with lung disease. Answer D is incorrect because benefits from inhaler use should be increased when the client stops smoking.

The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is: A. Nephritis B. Cardiomegaly C. Desquamation D. Meningitis

A. Nephritis The major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers B and D are incorrect. Answer C is incorrect because the SLE produces a "butterfly" rash, not desquamation

A client is being monitored using a central venous pressure monitor. If the CVP is 1 cm of water, the nurse should: A. Notify the physician immediately B. Slow the intravenous infusion C. Auscultate the lungs for rales D. Administer a diuretic

A. Notify the physician immediately A CVP reading of 1 cm of water indicates decreased circulating volume and should be reported to the physician immediately. Answers B, C, and D indicate CVP readings greater than 8 cm of water and are associated with increased blood volume or right-sided heart failure.

The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of: A. Offering high-calorie snacks B. Watching for signs of infection C. Observing for signs of oversedation D. Using a sunscreen with an SPF of 30

A. Offering high-calorie snacks Stimulant medications such as Ritalin tend to cause anorexia and weight loss in some children with ADHD. Providing high-calorie snacks will help the child maintain an appropriate weight. Answer B is incorrect because the medication does not mask infection. Answer C is incorrect because the medication is a central nervous system stimulant, not a depressant. Answer D has no relationship to the medication; therefore, it is incorrect.

The nurse is assigned to care for a newborn with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Offering the newborn water between formula feedings B. Maintaining the newborn's temperature at 98.6ºF C. Minimizing tactile stimulation D. Decreasing caloric intake

A. Offering the newborn water between formula feedings Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temperature is important but will not assist in eliminating bilirubin; therefore, Answer B is incorrect. Answers C and D are incorrect choices because they do not relate to the question

Which of the following is the best indication of resolution of a paralytic ileus? A. Passage of stool B. Eructation C. Presence of bowel sounds D. Decreasing abdominal girth

A. Passage of stool The best indication of resolution of paralytic ileus is the passage of stool or flatus. Answers B, C, and D are not specific indicators of resolution; therefore, they are incorrect

The nurse is teaching a client with Parkinson's disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to: A. Periodically lie prone without a neck pillow. B. Sleep only in dorsal recumbent position. C. Rest in supine position with his head elevated. D. Sleep on either side, but keep his back straight.

A. Periodically lie prone without a neck pillow. Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson's disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because position changes during sleep; therefore, it is incorrect.

A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to: A. Prevent strangulation of the bowel B. Prevent malabsorptive disorders C. Decrease secretion of bile salts D. Increase intestinal motility

A. Prevent strangulation of the bowel Surgical repair of an inguinal hernia is recommended to prevent strangulation of the bowel, which could result in intestinal obstruction and necrosis. Answer B does not relate to an inguinal hernia; therefore, it is incorrect. Bile salts, which are important to the digestion of fats, are produced by the liver, not the intestines; therefore, answer C is incorrect. Repair of the inguinal hernia will prevent swelling and obstruction associated with strangulation, but it will not increase intestinal motility; therefore, answer D is incorrect.

The nurse is planning care for the patient with celiac disease. In teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast? A. Puffed wheat B. Banana C. Puffed rice D. Cornflakes

A. Puffed wheat Clients with celiac disease should refrain from eating foods containing gluten. Foods with gluten include wheat, barley, oats, and rye. The other foods are allowed.

The physician has prescribed Oxycontin (oxycodone) for a client following an exploratory laparotomy. Which of the following is an adverse effect associated with the medication? A. Pulmonary edema B. Increased blood pressure C. Nervousness D. Rapid pulse

A. Pulmonary edema Adverse effects of opioids such as oxycodone include pulmonary edema, hypotension, seizures, hepatitis, and ventricular tachycardia. Answers B, C, and D are side effects of the medication, not adverse effects; therefore, they are incorrect choices

The nurse is assessing a client with symptoms of hyperphosphatemia. Which of the following is most likely related to the client's symptoms? A. Radiation to the neck B. Recent orthopedic surgery C. Minimal physical activity D. Adherence to a vegan diet

A. Radiation to the neck t. The most likely reason for the client's symptoms is radiation to the neck because it might have damaged the parathyroid glands that regulate calcium and phosphorus. Answers B, C, and D are not reasons for hyperphosphatemia; therefore, they are incorrect

The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important? A. Reinforcing the need for a balanced diet B. Encouraging the client to drink 16 ounces of fluid with each meal C. Telling the client to eat a diet low in fiber D. Instructing the client to limit his intake of fruits and vegetables

A. Reinforcing the need for a balanced diet The nurse should reinforce the need for a diet balanced in all nutrients and fiber. Foods that often cause diarrhea and bloating associated with irritable bowel syndrome include fried foods, caffeinated beverages, alcohol, and spicy foods. Therefore, answers B, C, and D are incorrect

The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with: A. Speaking and writing B. Comprehending spoken words C. Carrying out purposeful motor activity D. Recognizing and using an object correctly

A. Speaking and writing The client with expressive aphasia has trouble forming words that are understandable. Answer B is incorrect because it describes receptive aphasia. Answer C refers to apraxia and answer D refers to agnosia, so they are incorrect.

The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to: A. Teaching the client to report a nosebleed B. Instructing the client to maintain strict bed rest C. Telling the client to notify the doctor of pedal edema D. Advising the client to avoid sodium sources in the diet

A. Teaching the client to report a nosebleed A nosebleed in the client with mild preeclampsia may indicate that the client's blood pressure is elevated. Answers B, C, and D are incorrect because the client will not need strict bed rest, pedal edema is common in the client with preeclampsia, and the client does not need to avoid sodium, although the client should limit or avoid high-sodium foods.

The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife? A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ retrieval staff. B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband. C. Explain that it is necessary for her to donate her husband's organs because he signed the permit. D. Refrain from talking about the subject until after the death of her husband.

A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ retrieval staff. The hospital will certainly honor the wishes of family members even if the patient has signed a donor card. Answer B is incorrect, answer C is not empathetic to the family and is untrue, and answer D is not good nursing etiquette and, therefore, is incorrect.

The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from placement of iridium seeds for prostate cancer

A. The client receiving linear accelerator radiation therapy for lung cancer The client receiving linear accelerator therapy for cancer does not pose a radiation risk to the nurse who is pregnant. Answers B, C, and D pose a risk because of the type of radiation being used; therefore, they are incorrect choices.

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing's disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema

A. The client with Cushing's disease The client with Cushing's disease should receive placement in a private room since his condition makes him more susceptible to infection. The clients in Answers B, C, and D do not require a private room.

Before administering eye drops, the nurse should recognize that it is essential to consider which of the following? A. The eye should be cleansed with warm water to remove any exudate before instilling the eye drops. B. The patient will be more comfortable if allowed to instill his own eye drops. C. Eye drops should be instilled with the patient looking down. D. Eye drops should always be warmed before instilling in the patient's eyes.

A. The eye should be cleansed with warm water to remove any exudate before instilling the eye drops. Before instilling eye drops, the nurse should cleanse the area with warm water to remove any exudates. Answers B, C, and D are not true statements, so they are incorrect

The nurse is caring for a client receiving hemodialysis. During hemodialysis, the client becomes anxious, experiencing tachypnea and hypotension. The nurse suspects which complication of hemodialysis? A. air embolism B. clotting of the graft site C. dialysis encephalopathy D. disequilibrium syndrome

A. air embolism This client is exhibiting signs of an air embolism, which is a complication of hemodialysis. The nurse should stop the dialysis immediately and turn the client on the left side in the Trendelenburg's position. The health care provider should be notified immediately. The nurse should administer oxygen and assess vital signs and pulse oximetry. Positioning the client in this manner helps to trap the air in the right side of the heart so it cannot travel to the lungs. Clotting at the graft site would be present when there is no thrill to palpate or a bruit to auscultate. A clotted graft site would not produce this client's signs. Dialysis encephalopathy is caused by aluminum toxicity from dialysate water that contains aluminum. Signs include mental cloudiness, speech disturbances, bone pain, and seizures. Disequilibrium syndrome is characterized by nausea and vomiting, headache, hypertension, muscle cramps, and confusion.

The nurse is caring for a group of clients in an alcohol rehabilitation facility. A local news station is doing a story on addiction, and a representative comes to the facility, asking to interview a client. A client agrees to appear in the story, and the crew films an interview in the dayroom, showing a glimpse of other clients. Which violation has the nurse committed? A. allowing clients in a substance abuse facility to be interviewed by the media B. violating the HIPAA need to know rule C. releasing information about a minor without parental consent D. There is no violation.

A. allowing clients in a substance abuse facility to be interviewed by the media HIPAA rules do not allow clients in a substance abuse facility to be interviewed, even if the client agrees to do so. Not only was the client shown on TV, but other clients were also shown in the dayroom, which violates their right to privacy. The need to know rule applies when releasing client information to those providing direct care to the client, but not to others who are not involved in the client's care. There is no indication in this scenario that the client is a minor

A 92-year-old male client with Alzheimer's frequently experiences urinary incontinence. Which intervention should the nurse do first ? A. apply a condom catheter B. insert an indwelling catheter C. apply a diaper D. offer the urinal every 2 hours

A. apply a condom catheter Using a condom catheter to drain urine in the least intrusive manner is the best intervention for maintaining skin integrity and preventing infection. An indwelling catheter puts the client at risk of an infection. A diaper would allow the urine to be kept in contact with the skin thereby affecting skin integrity. Offering the urinal every 2 hours is unlikely to be effective in controlling urine output.

The nurse provides care for a one-month-old infant who is admitted with a probable diagnosis of pyloric stenosis. What laboratory data supports the infant's probable diagnosis? Select all that apply. a. BUN 19 mg/dL b. elevated pH c. elevated WBC d. hct 60% e. K 3.0 mEq/L

a. BUN 19 mg/dL b. elevated pH d. hct 60% e. K 3.0 mEq/L Pyloric stenosis is an uncommon condition in infants that blocks food from entering the small intestine. Large amounts of vomiting are noted in the infant who is diagnosed with this condition resulting in dehydration and electrolyte imbalances; therefore, the nurse anticipates a basic metabolic panel (BMP) and BUN level to be drawn. Additionally, a hematocrit level may also be drawn to determine if the child has existing anemia prior to surgical intervention which carries a risk for hemorrhage Pyloric stenosis causes severe vomiting; therefore, an elevated BUN level is expected due to dehydration.

The nurse is performing an assessment on a client who suspects being pregnant and is checking the client for probable signs of pregnancy. The nurse would assess for which probably signs of pregnancy? Select all that apply a. Ballottement b. Chadwick's sign c. Uterine enlargement d. Positive pregnancy test e. Fetal heart rate detected by a nonelectronic device f. outline of fetus via radiography or US

a. Ballottement b. Chadwick's sign c. Uterine enlargement d. Positive pregnancy tes

The nurse is caring for a client with deep vein thrombosis (DVT). Which should be included in the plan of care? A. bed rest with the affected extremity elevated B. bed rest with the bed in reverse Trendelenburg C. walking slowly in the hall with assistance to prevent pneumonia D. sitting up in the chair for all meals and during visitation time

A. bed rest with the affected extremity elevated Clients with DVT should be on bed rest to prevent movement of the DVT and pressure changes that occur with walking and other weight-bearing activities. The affected extremity should be elevated. Placing the bed in reverse Trendelenburg will increase pressure on the affected extremity. Walking is contraindicated for clients with DVT; while preventing hospital-acquired pneumonia is important, client safety takes priority over pneumonia prevention at this time. The client may still use an incentive spirometer and practice coughing and deep breathing to clear the lungs without ambulating. Sitting up in a chair is also contraindicated until the DVT has resolved and the health care provider has prescribed activity for the client.

The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse? A. call again and apologize to the client for the wait B. stand behind the bed at the client's head, and pull her up gently from her armpits C. since the client is small, pull her up in the bed by pulling on the draw sheet, alternating sides D. if the client is able to roll and bend her knees, lower the head of the bed and place it in Trendelenburg's position while helping the client bend her knees and push up

A. call again and apologize to the client for the wait The nurse should never attempt to pull a client up in bed without assistance, no matter how small the client is. The nurse risks injuring her back by doing so. The nurse should call again and wait a few moments for help. Pulling the client up by the armpits increases the risk of skin shear or a skin tear to the client. Trying to pull the client up by pulling on one side of the draw sheet at a time is ineffective and may result in skin shear on the client. If other help is not available, a lifting assistive device should be used for the client. With a client who can self-position, option 4 may be used if no other help is available and if the client can tolerate the position with the head down; however, another person or a lifting device should be used whenever possible to avoid injury to the nurse and client.

The nurse is assessing a client with Addison's disease. The nurse expects to note which of the following? A. craving of salty foods B. weight gain C. craving of sweet foods D. hyperactivity

A. craving of salty foods The impaired ability of the adrenal gland to produce the hormone aldosterone (a mineralocorticoid), which helps the kidney retain sodium, results in a craving for salty foods. Weight loss is associated with the disease. Loss of appetite, rather than craving for sweet foods, is consistent with Addison's disease. Fatigue and muscle weakness are typically seen with Addison's disease.

The nurse is monitoring the labs of a client admitted with viral hepatitis. Which of the following lab findings would the nurse expect for this client? Select all that apply. A. decreased ALT levels B. increased AST levels C. elevated ammonia levels D. low serum albumin levels E. shortened prothrombin time

A. decreased ALT levels B. increased AST levels C. elevated ammonia levels D. low serum albumin levels

A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply. A. excessive sweating B. constipation C. inability to tolerate cold D. leg cramps

A. excessive sweating D. leg cramps Excessive sweating and leg cramps are side effects of thyroid replacement therapy. Diarrhea rather than constipation is a side effect of thyroid replacement therapy. Inability to tolerate heat rather than cold is a side effect as well.

The nurse is caring for a client taking sulfonamides to treat a urinary tract infection. Which of the following should the nurse monitor for in this client? Select all that apply. A. fever or sore throat B. reddish-pink urine C. side effects such as dyspnea, chest pains, chills, and cough D. urinary output of 1200 mL daily to minimize the risk of renal damage E. the need to decrease the dosage if the client takes warfarin sodium (Coumadin) or phenytoin (Dilantin)

A. fever or sore throat D. urinary output of 1200 mL daily to minimize the risk of renal damage E. the need to decrease the dosage if the client takes warfarin sodium (Coumadin) or phenytoin (Dilantin) The nurse should monitor for fever or sore throat, as sulfonamides can cause leukopenia, hemolytic anemia, thrombocytopenia, and agranulocytosis. If the client develops a fever or sore throat, the health care provider should be notified. The client should drink 8 - 10 glasses of water daily to maintain daily urinary output of 1200 mL to minimize the risk of renal damage. If the client takes warfarin sodium, phenytoin, or oral hypoglycemics, it may be necessary to reduce the dosage of the medication: sulfonamides potentiate the effects of those drugs. Sulfonamides can cause the urine to turn dark brown or red when taken with some combination sulfonamide medications. Dyspnea, chest pains, chills, and cough are side effects of urinary tract antiseptics such as Macrodantin and Macrobid.

The nurse is caring for a client who is sedated and on the ventilator in ICU. The family expresses concern about controlling the client's pain when he cannot speak. The nurse explains that assessing pain in a nonverbal client involves watching for which of the following signs? Select all that apply. A. grabbing at the bed rails B. biting the ventilator tubing C. facial grimacing D. stiffness or rigidity of the body E. decreased urinary output F. increased blood pressure and heart rate as shown on the cardiac monitor

A. grabbing at the bed rails B. biting the ventilator tubing C. facial grimacing D. stiffness or rigidity of the body F. increased blood pressure and heart rate as shown on the cardiac monitor Grabbing at the bed rails and general restlessness may indicate pain. Biting the ventilator tubing and breathing over the vent due to increased respiratory rate are other indicators of pain. Facial grimacing and frowning is another pain indicator. Guarding an area of the body during the "sedation vacation" or stiffness or rigidity can indicate a pain response. Blood pressure and heart rate generally increase when experiencing pain. Decreased urinary output is not an indicator of pain. Based on the client's injury, disease process, or surgical procedures, the nurse should be able to anticipate what type and intensity of pain the client may experience. When multiple indicators suggest pain, the nurse should administer pain medications as ordered. It is important to remember that just because a client is sedated does not mean he is not experiencing pain.

The nurse is caring for a client diagnosed with a cerebral aneurysm. Which precautions would the nurse put in place for this client? Select all that apply. A. keep the room dark and avoid direct, bright lights B. allow frequent visitors to provide social interaction to the client C. administer deep vein thrombosis (DVT) prophylaxis as ordered D. encourage the client to breathe deep and cough to clear secretions E. keep the client on bed rest in a side-lying or semi-Fowler's position

A. keep the room dark and avoid direct, bright lights C. administer deep vein thrombosis (DVT) prophylaxis as ordered E. keep the client on bed rest in a side-lying or semi-Fowler's position The client should not be encouraged to cough or perform other activities that mimic the Valsalva maneuver. Stool softeners should be given to avoid straining with bowel movements.

The nurse is taking care of a 12-year-old male who sustained 30% full-thickness burns on his chest and arms 20 hours ago. To maintain optimal fluid and electrolyte balance, the nurse expects to administer which of the following? A. lactated Ringer's B. D10W C. plasma D. normal saline

A. lactated Ringer's Lactated Ringer's is typically administered in the first 24 hours because its composition is similar to the extracellular fluid that has shifted from damage to the skin. D10W is less ideal than Lactated Ringer's at this time post-burn as it lacks sodium, chloride, lactate, potassium, and calcium. Plasma would be administered in the next 24 hours. Normal saline will not meet the fluid and electrolyte requirements for the client at this stage in his recovery

The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply. A. monitor daily weights and intake and output B. monitor serum electrolytes and glucose levels daily C. change IV tubing every 48 hours or per facility protocol D. change the IV site dressing every 24 hours or per facility protocol E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available

A. monitor daily weights and intake and output B. monitor serum electrolytes and glucose levels daily E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available TPN tubing should be changed every 24 hours or per facility protocol. IV site dressing changes should be performed every 48 to 72 hours or per facility protocol.

The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply. A. music B. therapeutic massage C. stretching exercises D. relaxation

A. music B. therapeutic massage D. relaxation

A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply. A. offer a communication board B. ask simple yes/no questions C. ask open-ended questions D. offer an electrolarynx

A. offer a communication board B. ask simple yes/no questions Communication boards are highly effective in allowing clients to express their needs. Similarly, yes/no questions allow ease in communicating needs with minimal frustration. Open-ended questions require oral communication the client with an endotracheal tube cannot perform. An electrolarynx, a batterypowered handheld device that transmits sound when pressed against the oropharyngeal cavity, is used for clients with a tracheostomy.

The nurse is caring for a client in the intensive care unit. The nurse recognizes that to prevent sensory alteration in a client, the nurse needs to do which of the following interventions? Select all that apply. A. orient the client to person, place, and time during every contact B. limit visitors to one 15-minute visit per 8- hour shift C. explain all nursing care D. keep the lighting level consistent throughout the day

A. orient the client to person, place, and time during every contact C. explain all nursing care Manage the therapeutic environment to provide an appropriate level of stimuli to the client. Orienting the client and explaining interventions actively engages the client in normal cognitive activities. Limiting visitors to one 15-minute visit per 8- hour shift will produce a nonstimulating environment. The level of lighting should be varied throughout the day to provide the client with a sense of normalcy.

The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply . A. prepare to administer IV fluids B. notify the health care provider C. order a mechanical soft diet for the client D. administer the next dose of lithium when it is due E. observe the client for confusion and slurred speech

A. prepare to administer IV fluids B. notify the health care provider E. observe the client for confusion and slurred speech Lithium has a narrow therapeutic range of 0.6 to 1.2 mEq/L. A level of 2.2 mEq/L indicates moderate toxicity. The nurse should notify the health care provider immediately, as severe toxicity can cause tonic-clonic seizures, coma, or death. Treatment typically involves administering IV fluids to dilute the concentration of the medication, holding the medication, and possible hemodialysis in severe cases. The client may exhibit signs of toxicity such as confusion, slurred speech, and severe diarrhea. A mechanical soft diet will not treat the toxicity. The nurse would hold the next dose and prepare to draw lab work, including lithium and electrolyte levels, BUN and creatinine, and a CBC.

The pediatric nurse is preparing a child with acute lymphocytic leukemia for discharge. The discharge plan should include all but which of the following statements? A. restrict naps to allow more complete rest at night B. increase intake of protein, iron, and vitamin C to provide nutrients required for hemoglobin production C. keep a food diary to evaluate dietary intake D. restrict antacids, tetracyclines, and phosphorous salt

A. restrict naps to allow more complete rest at night Arranging rest periods throughout the day helps promote the client's ability to participate in an array of desired activities. Increasing intake of protein, iron, and vitamin C aids in hemoglobin production. Keeping a food diary helps document actual nutritional intake. Restricting antacids, tetracyclines, and phosphorous salts will avert absorption of iron.

A client is diagnosed with Meniere's disease. Which nursing diagnosis would take priority for this client? A. risk for injury B. disturbed body image C. low self-esteem D. impaired skin integrity

A. risk for injury Meniere's disease occurs when the pressure of the fluid in part of the inner ear gets too high. As a result, the client is at risk for injury related to altered mobility because of gait disturbance and vertigo. While hearing loss may occur, this does not result in disturbed body image, low self-esteem, or impaired skin integrity

The nurse is caring for a group of clients in an infectious disease unit. The nurse understands that which of the conditions listed are required to be reported by the CDC? Select all that apply. A. tetanus B. scarlet fever C. chlamydia D. Lyme disease E. group B streptococcal infection

A. tetanus C. chlamydia D. Lyme disease Tetanus, chlamydia, and Lyme disease are designated as reportable diseases by the CDC. Reportable diseases are considered to be a national concern due to their seriousness, the risk of death, or the ease with which they spread. Untreated tetanus can lead to laryngospasm, pneumonia, pulmonary embolism, and difficulty breathing. Chlamydia can cause permanent damage to a woman's reproductive system and may cause a potentially fatal ectopic pregnancy. Lyme disease can spread to any organ in the body and may cause permanent damage to the brain, heart, and neurological system. Scarlet fever and group B streptococcal infection are not reportable under current CDC guidelines.

The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse. A. unable to work simple toys B. unable to understand simple instructions C. unable to say first and last name D. unable to name any colors or numbers

A. unable to work simple toys B. unable to understand simple instructions By the age of 3 a child should be able to work simple toys and understand simple instructions. In contrast, the ability to say the first and last name and to name colors or numbers are milestones that occur at 4 years old.

A nurse is planning care for a client with human immunodeficiency virus. The nurse knows to wear gloves under the following circumstance(s). Select all that apply. A. when there is an open wound B. during all client contact C. when starting an IV D. when drawing blood for a specimen

A. when there is an open wound C. when starting an IV D. when drawing blood for a specimen

A 6 month old infant has been admitted with a diagnosis of meningococcal meningitis. The PHP has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? a. place client on droplet precautions b. administer ceftriaxone 25 mg IV TID c. prepare client for LP d. start IV of D 5 1/4 NS at 25 mL/hr e. draw blood cultures every 8 hours x 3

ADECB

The nurse provides care for a client who is admitted for the treatment of an infected pressure injury. The client reports frequent heartburn and is prescribed lansoprazole for gastroesophageal reflux disorder (GERD). Which complication is the client more susceptible to based on the prescribed medication? a. C diff b. esophageal cancer c. tremors d. PUD

a. C diff Lansoprazole is a PPI that is prescribed for clients who are diagnosed with GERD, a condition where the backward flow of acid from the stomach causes the client to experience heartburn and can lead to injury of the esophagus. A noted adverse reaction of this medication is an increased risk of Clostridioides difficile (C. diff) colitis. Additionally, the client is likely to require antibiotic therapy to treat the infected pressure injury which further increases the client's risk for C. diff colitis. C. diff colitis is highly communicable and causes abdominal pain, diarrhea, and fever which can be life-threatening.

propofol nursing considerations

Administer into larger veins. DO not infuse through a filter. Allow 3-5 minutes between dosage adjustments. Incompatible with other IV meds, blood and plasma. Prolonged use may turn urine green. Assess CNS function daily, d/c gradually. Teach to use caution when performing activities after use. Abnormal dreams or anesthesia awareness may occur

topical GC

Antiinflammatory, antipruritic and vasoconstrictive.

The client is being treated with Vancomycin for MRSA when the nurse notes that his neck is red. Place in ordered sequence the actions to be taken by the nurse: a. call the doctor b. turn off the vancomycin c. administer Benadryl d. take VS

B, D, A, C Benadryl might be needed, but an order must be obtained for any medication.

The nurse is precepting a new nurse in the psychiatric unit. The nurse is discussing interventions for schizophrenia. Which statement by the student nurse indicates an understanding of management of schizophrenia? Select all that apply. A. "I should be warm and friendly to put the client at ease." B. "I can reassure the client that he is in a safe environment." C. "Puzzles or word games are good activities to engage in." D. "I can help the client use art or writing to express his feelings." E. "I won't tell the client when I'm leaving him so he won't get upset."

B. "I can reassure the client that he is in a safe environment." C. "Puzzles or word games are good activities to engage in." D. "I can help the client use art or writing to express his feelings." Interventions for schizophrenia include reassuring the client that the environment is safe and engaging in simple, concrete activities such as puzzles or word games. Art, writing, and music can help the client safely express his feelings. A neutral approach is less threatening than an overly warm and friendly approach. The nurse should inform the client when she is leaving to orient the client to reality and reassure him.

The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication? A. "I will take the medication each morning after breakfast." B. "I will check my heart rate before taking the medication." C. "I will report visual disturbances to my doctor." D. "I will stop the medication if I develop gastric upset."

B. "I will check my heart rate before taking the medication." . Synthroid (levothyroxine) increases metabolic rate and cardiac output. Adverse reactions include tachycardia and dysrhythmias; therefore, the client should be taught to check her heart rate before taking the medication. Answer A is incorrect because the client does not have to take the medication after breakfast. Answer C does not relate to the medication; therefore, it is incorrect. The medication should not be stopped because of gastric upset; therefore, answer D is incorrect.

The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)? A. "I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn." B. "I will need to schedule a home visit for PKU screening when the baby is three-days-old." C. "I will remind the midwife to save a specimen of cord blood for the PKU test." D. "I will have the PKU test done when I take her for her first immunizations."

B. "I will need to schedule a home visit for PKU screening when the baby is three-days-old." PKU screening is usually done on the third day of life. Answer A is incorrect because the baby will not have had sufficient time to ingest protein sources of phenylalanine. Answer C is incorrect because blood is obtained from a heel stick, not from cord blood. Answer D is incorrect because the first immunizations are done at six weeks of age, and by that time, brain damage will already have occurred if the baby has PKU

The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse? A. "I will not let him use a straw." B. "I will turn on the television during meals." C. "Instead of whole pills, I will crush the pill and place it in custard." D. "He will sit up for a half hour after eating."

B. "I will turn on the television during meals." The client will need to focus his attention on proper swallowing technique during meals, making television undesirable. Talking while eating should also be avoided. Unless recommended by a speech pathologist, use of a straw can increase aspiration by administering a bolus of liquid. As approved by the pharmacist, whole pills may be crushed and placed in a soft food item such as custard to allow complete administration. To prevent the chance of aspiration, the client should remain sitting upright after consuming a meal.

Which statement should be included in the teaching session of a client scheduled for a renal biopsy? A. "You will be placed in a sitting position for the biopsy." B. "You may experience a feeling of pressure or discomfort during aspiration of the biopsy." C. "You will be asleep during the procedure." D. "You will not be able to drink fluids for 24 hours following the study."

B. "You may experience a feeling of pressure or discomfort during aspiration of the biopsy." The client may experience a feeling of pressure or discomfort as the biopsy is aspirated. Pain medication is usually given to make the client more comfortable during the procedure. Answer A is incorrect because the client will be positioned prone, not placed in a sitting position, for the biopsy. Answer C incorrect because the client is awake. Answer D is incorrect because the client can eat and drink following the biopsy.

A client with ascites is scheduled for a paracentesis. Which instruction should be given to the client before the procedure? A. "You will need to lay flat during the procedure." B. "You need to empty your bladder before the procedure." C. "You will be asleep during the procedure." D. "The doctor will inject a medication during the procedure."

B. "You need to empty your bladder before the procedure." The client scheduled for a paracentesis should be told to empty the bladder, to prevent the risk of the bladder being punctured when the needle is inserted. A paracentesis is done to remove fluid from the peritoneal cavity. The client will be positioned sitting up or leaning over a table, making Answer A incorrect. The client is usually awake during the procedure, and medications are not commonly instilled during the procedure; therefore, Answers C and D are incorrect.

The nurse is performing the Glasgow coma scale on a client. The assessment is as follows: eye opening, to pain; motor response, localizes pain; verbal response, inappropriate words. The nurse interprets which score is correct for this client? A. 9 B. 10 C. 11 D. 12

B. 10 The Glasgow coma scale ranges from 3 to 15 and is a measure of neurological function. Based on the findings for this client, the score is 10.

Which obstetrical client is most likely to have an infant with respiratory distress syndrome? A. A 28-year-old with a history of alcohol use during the pregnancy B. A 24-year-old with a history of diabetes mellitus C. A 30-year-old with a history of smoking during the pregnancy D. A 32-year-old with a history of pregnancy-induced hypertension

B. A 24-year-old with a history of diabetes mellitus The client with a history of diabetes is most likely to deliver a preterm large for gestational age newborn. These newborns often lack sufficient surfactant levels to prevent respiratory distress syndrome. Answers A, C, and D are less likely to have newborns with respiratory distress syndrome, so they are incorrect choices.

A gravida 2 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after an amniotomy? A. Fetal heart tones of 160 beats per minute B. A moderate amount of straw-colored clear vaginal fluid C. A small amount of greenish vaginal fluid D. A small segment of the umbilical cord protruding from the vagina

B. A moderate amount of straw-colored clear vaginal fluid Immediately after an amniotomy, the nurse should expect to see a moderate amount of straw-colored clear fluid. Answers A, C, and D are not expected after an amniotomy; therefore, they are incorrect answers.

The registered nurse on a pediatric unit is making assignments for the day. Which patient should not be assigned to the nurse who is pregnant? A. A child with cystic fibrosis who is receiving Nebcin (tobramycin) B. An infant with respiratory syncytial virus receiving Virazole (ribavirin) C. A child with Hirschsprung's disease scheduled for barium enema D. A child with Meckel's diverticulum scheduled for radiographic scintigraphy

B. An infant with respiratory syncytial virus receiving Virazole (ribavirin) The nurse who is pregnant should not be assigned to care for the infant with RSV treated with Virazole (aerosolized ribavirin) because the medication can harm the fetus. Answers A, C, and D are incorrect because she may be assigned to care for the child with cystic fibrosis receiving tobramycin, the child with Hirschsprung's disease scheduled for barium enema, and the child with Meckel's diverticulum going for radiographic scintigraphy.

Vaginal exam of a term gravida 2 para 1 reveals a breech presentation. The nurse should take which action at this time? A. Prepare the client for a Caesarean section B. Apply the fetal heart monitor C. Place the client in the Trendelenburg position D. Perform an ultrasound exam

B. Apply the fetal heart monitor Applying a fetal heart monitor is the appropriate action at this time. Answers A, C, and D are not indicated at this time; therefore, they are incorrect choices.

The nurse is caring for a client with a diagnosis of cirrhosis who is experiencing pruritis. Which of the following is an appropriate nursing intervention? A. Suggesting that the client take warm showers twice daily B. Applying a lotion containing menthol or camphor to the skin after bathing C. Applying powder to the client's skin D. Placing warm compresses on the affected areas

B. Applying a lotion containing menthol or camphor to the skin after bathing Applying antipruritic lotions containing menthol, camphor, or mint oil to the skin will make the client with pruritis more comfortable. Answer A is incorrect because two warm showers daily will increase dryness and itching. Answer C is incorrect because powder is drying and may increase itching. Answer D is incorrect because placing warm compresses on the affected areas will increase the itching.

A client with suspected renal cancer is to be scheduled for an intravenous pyelogram. Before the IVP, the nurse should: A. Offer additional fluids B. Ask the client to empty his bladder C. Withhold the client's medication for 8 hours before the IVP D. Administer pain medication

B. Ask the client to empty his bladder The nurse should ask the client to empty his bladder because a full bladder or full bowel can obscure the visualization of the kidney and ureters. Answer A is incorrect because fluids are increased after the test. Answer C is incorrect because there is no need to withhold medication for 8 hours before the test. Answer D is incorrect because the client will not require pain medication.

Which term describes the play activity of the preschool aged child? A. Cooperative B. Associative C. Parallel D. Solitary

B. Associative Play of the preschool aged child is described as associative. At this stage, children are more interested in playing with other children than they are with playing with toys. The child may talk to other children and exchange toys or play games without any rules. Answer A describes the play of a school-aged child. Answer C describes the play of a toddler. Answer D describes the play of an infant

Which instruction should be given to a client who is fitted with a behind-the-ear hearing aid? A. Remove the ear mold and clean with alcohol B. Avoid exposing the hearing aid to extremes in temperature C. Use a cotton-tipped applicator to clean debris from the hole in the middle of the hearing aid D. Continue to use cosmetics and spray cologne as before

B. Avoid exposing the hearing aid to extremes in temperature The client should be instructed to avoid exposing the hearing aid to extremes in temperature. Answer A is incorrect because the ear mold is cleaned with soap and water, not alcohol. Answer C is incorrect because a toothpick is used to clean debris from the hole in the middle of the part that goes in the ear. Answer D is incorrect because hair spray, cosmetics, oils, and spray colognes should not be used near the hearing aid.

The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning an order for which of the following diagnostic tests? A. Abdominal ultrasound B. Barium enema C. Complete blood count D. Computed tomography (CT) scan

B. Barium enema . A barium enema is contraindicated in the client with diverticulitis because it can cause bowel perforation. Answers A, C, and D are appropriate diagnostic studies for the client with suspected diverticulitis

A client with pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's: A. Deep tendon reflexes B. Blood pressure C. Urine output D. Tissue turgor

B. Blood pressure The nurse should give priority to checking the client's blood pressure since pentamidine, if infused too rapidly, can cause severe hypotension and hypoglycemia. Answers A, C, and D do not relate specifically to the medication; therefore, they are incorrect choices.

The nurse is caring for a child with suspected epiglottitis. Which finding is not associated with epiglottitis? A. Drooling B. Brassy cough C. Muffled phonation D. Inspiratory stridor

B. Brassy cough . Brassy cough is associated with laryngotracheobronchitis, not epiglottitis. Answers A, C, and D are associated with epiglottitis; therefore, they are incorrect choices.

A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system: A. Can be disconnected from suction if the chest tube is clamped B. Can be disconnected from suction, but the chest tube should remain unclamped C. Must remain connected by means of a portable suction D. Must be kept even with the client's shoulders during the transport

B. Can be disconnected from suction, but the chest tube should remain unclamped The chest-drainage system can be disconnected from suction, but the chest tube should remain unclamped to prevent a tension pneumothorax. Answer A is incorrect because it could result in a tension pneumothorax. Answer C is not a true statement; therefore, it is not correct. Answer D is incorrect because the chest-drainage system should be kept lower than the client's chest and shoulders.

The nurse is teaching infant CPR to a group of newly graduated nurses hired to work in the labor and delivery unit. The nurse understands that proper technique with infants includes which action? Select all that apply. A. The femoral artery is checked for a pulse following each cycle of CPR. B. Chest compression depth should be approximately 1.5 inches, or 4 cm. C. A single rescuer should use three fingers on the dominant hand to do compressions. D. Rest the infant facedown on the forearm with the hand supporting the head and jaw. E. If arrest is witnessed the emergency response system should be activated before beginning CPR.

B. Chest compression depth should be approximately 1.5 inches, or 4 cm. E. If arrest is witnessed the emergency response system should be activated before beginning CPR. CPR on infants less than 1 year of age includes a chest compression depth of approximately 1.5 inches, or 4 cm. A witnessed arrest calls for activating the emergency response system before initiating CPR. An automated external defibrillator should be retrieved before starting CPR. The pulse checkpoint on an infant is the brachial artery. A single rescuer should use two fingers for compression, regardless of which hand is dominant. Resting the infant facedown on the forearm is proper positioning for performing the Heimlich maneuver. CPR is performed with the infant lying face up and flat on a firm surface

The nurse is preparing a client for surgery who requests to "go as he is." Which item is most important for the nurse to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Dentures

B. Contact lenses The most important item to remove are contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. At the client's request, the other items may go with the client to surgery and be removed in the holding area. The nursing staff in those areas should be notified so the items can be properly cared for and returned with the client after surgery. Therefore, Answers A, C, and D are incorrect.

The morning weight for a client indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD? A. Polycythemia B. Cor pulmonale C. Left ventricular failure D. Compensated acidosis

B. Cor pulmonale Answers A and D do not cause weight gain, so they're incorrect. And answer C would be reflected in pulmonary edema, so it's incorrect.

The patient states, "My stomach hurts about two hours after I eat." Based upon this information, the nurse suspects the patient likely has a: A. Gastric ulcer B. Duodenal ulcer C. Peptic ulcer D. Curling's ulcer

B. Duodenal ulcer Individuals with ulcers within the duodenum typically complain of pain occurring 2-3 hours after a meal, as well as at night. The pain is usually relieved by eating. The pain associated with gastric ulcers, answer A, occurs 30 minutes after eating. Answer C is too vague and does not distinguish the type of ulcer. Answer D is associated with a stress ulcer.

The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain? A. Norco (hydrocodone/APAP) B. Erythrocin (erythromycin) C. Zyrtec (cetirizine) D. Aldactone (spironolactone)

B. Erythrocin (erythromycin) Antibiotics such as erythromycin are most likely to cause abdominal pain. Answers A, C, and D are not associated with causing abdominal pain; therefore, they are incorrect choices.

Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. One-year-old B. Four-year-old C. Eight-year-old D. Twelve-year-old

B. Four-year-old Because of their increased mobility, manual dexterity and curiosity, the four-year-old is at greater risk for accidental poisoning. Other accidental injuries in this age group include being struck by a car, falls, burns, and drowning. Answer A is incorrect because the one-year-old lacks the developmental skill to be at risk for accidental poisoning. Answers C and D are incorrect because the eight-year-old and twelve-year-old are at less risk because they are aware of the dangers of accidental poisoning.

The nurse is caring for a client with ß-thalassemia major. Which therapy is used to treat ß-thalassemia major? A. IV fluids B. Frequent blood transfusions C. Oxygen therapy D. Iron therapy

B. Frequent blood transfusions ß-thalassemia is an inherited disorder that causes the red blood cells to have a shorter life span. Frequent blood transfusions are necessary to treat the anemia and provide oxygen to the tissues. Answer A is incorrect because fluid therapy will not help; Answer C is incorrect because oxygen therapy will also not help; and Answer D is incorrect because iron should not be given to the patient with ß-thalassemia.

The physician has ordered Brethine (terbutaline) for a patient with premature labor. The nurse is aware that the medication may cause: A. Bradycardia B. Hyperglycemia C. Decreased muscle tone D. Hot flashes

B. Hyperglycemia Hyperglycemia is one of the side effects of Brethine (terbutaline). Answers A, C, and D are not associated with Brethine, so they are incorrect choices.

When performing an assessment on the client with emphysema, the nurse finds that the client has a barrel chest. The alteration in the client's chest is due to: A. Collapse of distal alveoli B. Hyperinflation of the lungs C. Long-term chronic hypoxia D. Use of accessory muscles

B. Hyperinflation of the lungs Clients with emphysema develop a barrel chest due to the trapping of air in the lungs, causing them to hyperinflate. Answers C and D are common in those with emphysema but do not cause the chest to become barrel shaped. Answer A does not occur in emphysema

Which order would the nurse anticipate for a client hospitalized with acute pancreatitis? A. Vital signs once per shift B. Insertion of a nasogastric tube C. Patient controlled analgesia with Demerol (meperidine) D. Low-fat diet as tolerated

B. Insertion of a nasogastric tube The nurse should anticipate an order for insertion of a nasogastric tube because the client with acute pancreatitis frequently has nausea and vomiting. Gastric decompression using a nasogastric tube prevents gastric juices from flowing into the duodenum. Answer A is incorrect because the vital signs, especially respirations, should be checked every four to eight hours or more often, as needed. C is incorrect because morphine or hydromorphone, not meperidine, is used to control pain. Answer D is incorrect because the client with acute pancreatitis is NPO.

The nurse is caring for a postoperative patient when suddenly the patient becomes less responsive and pale, with a BP of 70/40. The nurse's initial action should be to: A. Increase the rate of IV fluids B. Lower the head of the bed C. Notify the physician D. Obtain a crash cart

B. Lower the head of the bed The nurse's initial action should be to lower the head of the bed because the client is obviously hypotensive. Answers A, C, and D are measures that may be needed later; therefore, they are incorrect.

A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 mEq/L. What behavior changes would be most common for this client? A. Anger B. Mania C. Depression D. Psychosis

B. Mania The client with serum sodium of 170mEq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.

Which diet would the nurse expect to see ordered for a patient with nephrotic syndrome? A. Low carbohydrate potassium B. Moderate protein C. Low calcium D. Increased potassium

B. Moderate protein A diet containing moderate protein, low sodium, and low saturated fat will be ordered for the client with nephrotic syndrome. Answers A, C, and D do not meet the nutritional needs of the client; therefore, they are incorrect.

During an intake assessment, the nurse asks the client if he has an advanced directive. The reason for asking the client this question is: A. The nursing staff needs to know about funeral arrangements. B. Much confusion regarding care can occur with the client's family if there is no advanced directive. C. An advanced directive allows the medical personnel to make decisions for the client. D. An advanced directive allows active euthanasia to be carried out.

B. Much confusion regarding care can occur with the client's family if there is no advanced directive. An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding care and life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect choices because the nursing staff doesn't need to know about funeral plans, the nursing staff cannot make decisions for the client, and active euthanasia is illegal in most states in the United States

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia? A. Difficulty in breathing after exertion B. Numbness and tingling in the extremities C. A faster than usual heart rate D. Feelings of lightheadedness

B. Numbness and tingling in the extremities Numbness and tingling in the extremities is common in the client with pernicious anemia, but not those with other types of anemia. Answers A, C, and D are incorrect because they are symptoms of all types of anemia.

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid: A. Holding the infant B. Offering a pacifier C. Providing a mobile D. Offering sterile water

B. Offering a pacifier . The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect

The nurse is seeing a client in the clinic who has shingles (herpes zoster). The client is concerned about spreading the disease to others. How should the nurse respond? A. It is only possible to have one episode of the disease. B. Persons with leukemia are at higher risk. C. Persons of all ages should receive the zoster vaccine (Zostavax). D. Persons between 30 and 40 years old are at high risk.

B. Persons with leukemia are at higher risk. Persons with suppressed or compromised immune systems, such as occurs with leukemia, are at higher risk to acquire shingles. Although rare, a second and even third episode of shingles can occur. A zoster vaccine is recommended for persons 60 years and older, the timeline for highest risk of acquiring herpes zoster.

Which measure helps reduce nipple soreness associated with breastfeeding? A. Feeding the baby during the first 48 hours after delivery B. Placing a finger between the baby's mouth and the breast to break suction after feeding C. Applying warm, moist soaks to the breast several times per day D. Wearing a support bra during the day

B. Placing a finger between the baby's mouth and the breast to break suction after feeding Using a finger between the baby's mouth and breast to break the suction helps to reduce nipple soreness associated with breast feeding. Answers A, C, and D do not help prevent or reduce nipple soreness; therefore, they are incorrect.

A client in labor has an order for Demerol (meperidine) 75mg. IM to be administered 10 minutes before delivery. The nurse should: A. Wait until the client is placed on the delivery table and administer the medication. B. Question the order because the medication might cause respiratory depression in the newborn. C. Give the medication IM during the delivery to prevent pain from the episiotomy. D. Give the medication as ordered.

B. Question the order because the medication might cause respiratory depression in the newborn. The nurse should question the order because administering a narcotic so close to the time of delivery can result in respiratory depression in the newborn. Answers A, C, and D are incorrect because giving the medication prior to or during delivery can cause respiratory depression in the newborn.

Which information obtained from the mother of a child with cerebral palsy correlates to the diagnosis? A. She was born at 40 weeks gestation. B. She had meningitis when she was six months old. C. She had physiologic jaundice after delivery. D. She has frequent sore throats.

B. She had meningitis when she was six months old. The diagnosis of meningitis at age six months correlates to a diagnosis of cerebral palsy. Cerebral palsy, a neurological disorder, is often associated with birth trauma or infections of the brain or spinal column. Answers A, C, and D are not related to the question

Which finding is expected in an 18-month-old with normal growth and development? A. She dresses herself. B. She pulls a toy behind her. C. She can build a tower of eight blocks. D. She can copy a horizontal or vertical line.

B. She pulls a toy behind her. Children at 18 months of age like push-pull toys. Children at approximately three years of age begin to dress themselves and build a tower of eight blocks. At age four, children can copy a horizontal or vertical line. Therefore, Answers A, C, and D are incorrect.

The nurse is evaluating the client's pulmonary artery pressure (PAP). The nurse is aware that PAP evaluates: A. Pressure in the left ventricle B. Systolic, diastolic, and mean pressure in the pulmonary artery C. Pressure in the pulmonary veins D. Pressure in the right ventricle

B. Systolic, diastolic, and mean pressure in the pulmonary artery The pulmonary artery pressure (PAP) measures the systolic, diastolic, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle; therefore, Answers A, C, and D are incorrect.

28-year-old client has just given birth. At one minute the baby appears healthy, with the exception of bluish hands. Which of the following would the nurse midwife pronounce? A. The Apgar score is 11. B. The Apgar score is 9. C. The Apgar score is 6. D. The Apgar score is 4.

B. The Apgar score is 9. Apgar scoring consists of 5 areas (muscle tone, heart rate, reflex response, color, breathing) with a possible score of 0, 1, or 2 for each area. An Apgar of 9 is correct: four of the five categories for this example rate a score of 2 (subtotal of 8) with 1 point for good color with bluish hands (or feet). The maximum score achievable is 10. A score of 4 or 6 will require support, typically in breathing.

A client with cervical cancer is staged as Tis. A staging of Tis indicates that: A. The cancer stage cannot be assessed. B. The cancer is localized to the primary site. C. The cancer shows increasing lymph node involvement. D. The cancer is accompanied by distant metastasis.

B. The cancer is localized to the primary site. A staging of Tis or cancer in situ means that the cancer is still localized to the primary site. T stands for "tumor," and the is stands for "in situ." Cancer is staged in terms of tumor, node involvement, and metastasis. Answers A, C, and D are incorrect because Answer A refers to a tumor staging of Tx; Answer C refers to a tumor staging of N1, N2, or N3; and Answer D refers to a tumor staging of M1.

A client with hyperthyroidism is taking Eskalith (lithium carbonate) to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client's medication? A. The client complains of blurred vision. B. The client complains of increased thirst and increased urination. C. The client complains of increased weight gain over the past year. D. The client complains of rhinorrhea.

B. The client complains of increased thirst and increased urination. . Increased thirst and increased urination are signs of lithium toxicity. Answers A and D are not associated with the use of lithium; therefore, they are incorrect. Answer C is an expected side effect of the medication; therefore, it is incorrect

The clinic record for a client reads: gravida 3, para 2. The admitting nurse is most correct to confirm which prenatal history? A. The client has been pregnant three times and had two stillbirths. B. The client has been pregnant three times and had two children born after 20 weeks' gestation. C. The client has been pregnant three times and had two miscarriages. D. The client has been pregnant three times and had two children born after 24 weeks' gestation.

B. The client has been pregnant three times and had two children born after 20 weeks' gestation. Gravida refers to any pregnancy, including the current one, regardless of length. Para refers to birth after 20 weeks' gestation whether the infant is born dead or alive

Which clients can be assigned to share a room in the emergency department during a disaster? A. A client with schizophrenia having visual and auditory hallucinations and the client with ulcerative colitis B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and fractured arm C. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

B. The client who is six months pregnant with abdominal pain and the client with facial lacerations and fractured arm Out of all of these clients, it is best to place the pregnant client and the client with a broken arm and facial lacerations in the same room. These two clients probably do not need immediate attention and are least likely to disturb each other. The clients in Answers A, C, and D need to be placed in separate rooms because their conditions are more serious, they might need immediate attention, and they are more likely to disturb other patients.

The client is admitted after an abdominal cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration. B. The client will require frequent dressing changes. C. The straps provide support for drains that are inserted into the incision. D. No sutures or clips are used to secure the incision

B. The client will require frequent dressing changes. Montgomery straps are used to secure abdominal dressings that require frequent dressing changes, such as the client with an abdominal cholecystectomy. This client is not at higher risk of evisceration than other clients, so Answer A is incorrect. Montgomery straps are not used to secure the drains, so Answer C is incorrect. Sutures or clips are used to secure the wound of the client with an abdominal cholecystectomy, so Answer D is incorrect.

The physician has prescribed Vermox (mebendazole) for a child with pinworms. Which statement is true regarding the medication? A. Medication is administered intramuscularly. B. The entire family will need to take the medication. C. Medication will be repeated in two months. D. Intravenous antibiotic therapy will be ordered.

B. The entire family will need to take the medication. The entire family will need to take the medication. Answers A, C, and D are untrue statements; therefore, they are incorrect choices.

Which one of the following statements is correct when measuring the client for crutches? A. A distance of five fingerbreadths should exist between the top of the crutch and the axilla. B. The nurse should measure three inches between the top of the crutch and the axilla. C. The client's elbows should be flexed at a 10º angle. D. The crutches should be extended 8 to 10 inches from the side of the foot

B. The nurse should measure three inches between the top of the crutch and the axilla. To correctly measure the client for crutches, the nurse should measure approximately three inches between the axilla and the top of the crutch. Answer A is incorrect because the distance is too great. Answer C is incorrect because the client's elbows should be flexed at approximately a 35º angle, not a 10º angle, as stated. The crutches should be approximately 6 inches from the side of the foot, not 8 to 10 inches, as stated in answer D

The nurse is making initial rounds on a client with a C5 fracture stabilized by Crutchfield tongs. Which equipment should be kept at the bedside? A. Forceps B. Torque wrench C. Wire cutters D. Screwdrive

B. Torque wrench A torque wrench is kept at the bedside of the client immobilized with Crutchfield tongs. The device is used to make sure the right amount of pressure is placed on the screws during adjustment. Forceps, wire cutters, and a screwdriver, in Answers A, C, and D, would not be used and, therefore, are incorrect.

Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular bradycardia

B. Ventricular tachycardia Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions. It is not used for the treatment of atrial arrhythmias; thus, Answer A is incorrect. Answers C and D are incorrect choices because lidocaine slows the heart rate, so it is not used for the treatment of heart block or bradycardia.

A client with a deep decubitus ulcer is receiving therapy in the hyperbaric oxygen chamber. Before therapy, the nurse should: A. Apply a lanolin-based lotion to the skin. B. Wash the skin with water and pat dry. C. Cover the area with a petroleum gauze. D. Apply an occlusive dressing to the site.

B. Wash the skin with water and pat dry. The client going for therapy in the hyperbaric oxygen chamber requires no special skin care; therefore, washing the skin with water and patting it dry are suitable. Lotions, petroleum products, perfumes, and occlusive dressings interfere with oxygenation of the skin; therefore, answers A, C, and D are incorrect.

A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of: A. Slow pulse rate, weight loss, diarrhea, and cardiac failure B. Weight gain, lethargy, slowed speech, and decreased respiratory rate C. Rapid pulse, constipation, and bulging eyes D. Decreased body temperature, weight loss, and increased respirations

B. Weight gain, lethargy, slowed speech, and decreased respiratory rate Symptoms of myxedema include weight gain, lethargy, slow speech, and decreased respirations. Answers A and D do not describe symptoms associated with myxedema; therefore, they are incorrect. Answer C describes symptoms associated with Graves disease.

A newly graduated nurse is working in the pediatric unit. Which client assignment is most appropriate for this nurse? A. a 2-year-old with hemophilia A who has suddenly become less responsive B. a 15-year-old with sickle cell disease complaining of lower right quadrant abdominal pain C. a 6-year-old who just had a tonsillectomy 2 hours earlier and is frequently swallowing D. a 12-year-old with newly diagnosed type 2 diabetes whose parents need teaching on insulin

B. a 15-year-old with sickle cell disease complaining of lower right quadrant abdominal pain Clients with sickle cell disease commonly present with pain during a crisis. The newly graduated nurse is qualified to assess the client's pain and administer ordered pain medications. A client with a clotting disorder and a decreased level of consciousness is an emergency situation due to possible intracerebral bleeding and is not appropriate for an inexperienced nurse. Swallowing after a tonsillectomy indicates possible bleeding and should be assessed by the more experienced nurse. Client teaching is an important and more advanced skill that takes time to develop. Insulin is a high-alert drug, and incorrect information from the new nurse may cause harm to the client.

The nurse is caring for a group of clients in a medical/surgical unit. Which client does the nurse understand to be at highest risk for developing decubitus ulcers? A. a 27-year-old client who fractured her arm playing volleyball B. a 6-year-old client on pelvic skin traction for muscle spasms C. a 42-year-old obese client with controlled atrial fibrillation who uses a wheelchair D. a 70-year-old client with heart failure who uses a cane for ambulation in the room and hall

B. a 6-year-old client on pelvic skin traction for muscle spasms The client in pelvic traction is on bed rest wearing a traction belt around the pelvis. This client is the most immobile of the clients listed. The client who fractured her arm playing volleyball is able to get up and easily change positions, even with an arm brace. The client who uses a wheelchair is able to be out of the bed. The client who uses a cane for ambulation is walking in the room and hall and is active. The client's condition, medical diagnosis, and treatment plan—not age—determine how great the risk is for developing decubitus ulcers. The greater the immobility, the greater the risk.

The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception? A. a client in a halo vest following an automobile accident B. a child with severe autism who is having a tonsillectomy C. a teenager who broke her leg during cheerleader practice D. a schoolteacher who was hospitalized for shortness of breath

B. a child with severe autism who is having a tonsillectomy Clients with severe autism experience altered thought processes. Adding an unfamiliar environment (the hospital) with pain from a surgical procedure compounds the risk of altered sensory perception. The client in the halo vest may have pain and restricted mobility, but he does not have as great a risk for altered perception as the child with severe autism. A teenager who broke her leg during cheerleader practice is more likely to have a large social group and be less isolated. A schoolteacher is more likely to work in a stimulating environment and have many social contacts. Risk factors for altered perception include emotional disorders, a nonstimulating environment, acute illness, limited mobility, pain, decreased cognitive ability, and impaired hearing or vision.

Medical management of a client with acute diverticulitis should include which treatment? A. increased fiber in diet B. administration of antibiotics C. pain medication administration D. liquid diet for 1 - 2 days

B. administration of antibiotics Acute diverticulitis results from inflammation of the diverticula, typically from an infection. As such, the priority treatment is administration of antibiotics to address the root cause of the condition. Gradually increasing fiber in the diet will occur during the recovery stage of the disease. Pain medication for residual pain would be a second management approach after initiation of antibiotic protocol. To promote rest of the intestinal tract, a liquid diet is advisable for an undeterminable time.

The nurse is caring for a client with a history of schizophrenia, alcohol abuse, bipolar disorder, and noncompliance with treatment and medications. The client has also been arrested in the past for violent behavior. Which action by the nurse is the most important when caring for a potentially violent client? A. treat the client with courtesy and respect B. always maintain an open pathway to the door C. be sure the client swallows his pills and does not "cheek" them D. ask permission from the client before drawing blood or performing other invasive procedures

B. always maintain an open pathway to the door When caring for mentally unstable or possibly violent clients, staff safety is the primary concern. The nurse should avoid getting blocked into a corner between the client and the door. If possible, the client should be in a room near the nurses' station, and the nurse should notify someone else before he enters the room. Taking another nurse or client care technician when entering the room is another way to maintain safety. All clients should be treated with courtesy and respect, especially someone who may be prone to paranoia. It may be necessary to observe the client closely for "cheeking" pills instead of swallowing them. Some medications may be ordered in IV form in order to ensure that the client receives the medication if he has surreptitiously avoided swallowing pills in the past. Always ask permission before touching or approaching the client to avoid startling him. If the client refuses medications or blood draws, do not argue. Chart the refusal in the medical record and notify the health care provider.

A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety? A. administer Xanax 6 mg PO B. apply a vest restraint device C. request a family member stay with the client around the clock D. move the client closer to the nurses' station

B. apply a vest restraint device In an effort to maintain client safety with the least restrictive method, the nurse may apply a vest restraint device to subtly remind the client to not get out of bed. As a mild sedative, Xanax dosage would begin at 0.25 mg two to three times daily. The stated dosage of 6 mg is an excessive amount of medication. Requesting a family member to stay around the clock would inappropriately relegate the responsibility for safety from the hospital to the family. Moving the client closer to the nurses' station will not promote client safety.

A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions? A. move the client closer to the nursing station to allow close monitoring B. apply the restraint in compliance with hospital policy C. consult with a more experienced nurse on a course of action D. check on the client every 30 minutes to ensure her safety

B. apply the restraint in compliance with hospital policy Applying the restraint is in compliance with hospital policy and, as ordered, provides for client safety. Moving the client closer to the nursing station is inadequate to provide a safe environment. The NCLEXRN exam wants to see what the test taker would do rather than passing the responsibility to someone else. Monitoring the client consistent with hospital policy would be in addition to appropriate use of a restraining device.

The family of a hospice client wishes to visit at midnight. Which of the following actions by the nurse would be the most appropriate? A. tell the family that visiting hours are over B. ask the client if he wishes to see his family C. allow two family members to visit at a time D. provide entrance for the entire family to visit

B. ask the client if he wishes to see his family The nurse should give the client a sense of control by asking if he wishes to see his family. Clients in hospice typically have open visiting hours. Hospice environments encourage family visits, and neither limit the number of visitors (in this case, to two) nor disallow large groups of visitors

The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply. A. check the dressing every 8 hours for excessive drainage B. assess the pupils for signs of increased intracranial pressure C. position the client flat with the head rotated away from the surgical site D. monitor the client's respiratory status, including rate and pattern of breathing E. notify the health care provider if the dressing is saturated or the client has

B. assess the pupils for signs of increased intracranial pressure D. monitor the client's respiratory status, including rate and pattern of breathing E. notify the health care provider if the dressing is saturated or the client has Following a craniotomy, the nurse should monitor the pupils for signs of increased intracranial pressure. Report dilated or pinpoint pupils or pupils that are slow to react or nonreactive to light to the health care provider. Respiratory status is monitored closely, as even minor hypoxia can increase cerebral ischemia. Notify the surgeon immediately if the dressing is saturated or if the client has more than 50 mL drainage in 8 hours, as this can cause hypovolemic shock. Immediately post-op the nurse should check the dressing every 1 or 2 hours. The drainage area can be marked once a shift to obtain a baseline. Clients with supratentorial craniotomies should be positioned with the head elevated 30 degrees in a neutral, midline position. Avoid extreme hip or neck flexion, which can cause increased intracranial pressure.

The nurse is teaching a smoking cessation program. He will state that which of the following benefits of quitting appear within one year? A. risk of coronary heart disease is the same as that of a nonsmoker B. carbon monoxide level in blood drops to normal C. risk of dying from lung cancer is about half that of a smoker's D. risk of having a stroke is reduced to that of a nonsmoker's

B. carbon monoxide level in blood drops to normal Within 12 months after quitting, the carbon monoxide level in a smoker's blood drops to normal. At 15 years after quitting, the risk of coronary heart disease is the same as that of a nonsmoker. At 10 years after quitting, the risk of dying from lung cancer is about half that of a smoker's. At 5 to 15 years after quitting, the risk of having a stroke is reduced to that of a nonsmoker's.

A client with a colostomy is experiencing mild diarrhea. Which instruction should the nurse give the client? A. drink two 8-oz glasses of water B. eat two bananas C. eat five prunes D. eat a salad with vinaigrette dressing

B. eat two bananas Bananas help to bind the stool thereby reducing diarrhea. Drinking additional fluids should be encouraged but will not reduce the diarrhea. Prunes promote peristalsis thereby increasing diarrhea. A salad has fiber that will increase diarrhea.

The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply. A. replace electric razor with a straight razor B. encourage frequent periods of rest C. instruct on a potassium-restricted diet D. monitor the client's mental status

B. encourage frequent periods of rest D. monitor the client's mental status Due to diffuse destruction of hepatic cells with cirrhosis of the liver, the client will experience fatigue and need frequent rest periods throughout the day. An inability of the liver to filter toxins can lead to hepatic encephalopathy making assessment of the client's mental status imperative. Due to impaired clotting function, clients need safety measures implemented such as replacing a straight shaving razor with an electric one. Sodium rather than potassium should be restricted with cirrhosis of the liver

The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply. A. normal childhood B. family history of depression C. recent major life change D. Lipitor used to treat high blood pressure

B. family history of depression C. recent major life change D. Lipitor used to treat high blood pressure Known risk factors associated with clinical depression include family history of depression and a recent major life change. Certain medications are known to cause depression in some patients including prednisone, calcium channel blockers, birth control pills, and statins. High levels of anxiety—demonstrated as irritability—are commonly seen in childhood.

The nurse is caring for a client whose lab results show triglycerides of 380 and cholesterol level of 240. Which foods would the nurse educate the client about including in his diet when he is discharged? Select all that apply. A. wheat toast with sugar-free jelly B. grilled salmon seasoned with herbs C. an egg-white omelet with vegetables D. natural honey from a local farmer's market E. plain grilled steak prepared with pepper only

B. grilled salmon seasoned with herbs C. an egg-white omelet with vegetables Salmon is a cold-water fish that is rich in omega-3 fatty acids, a good fat that can help lower triglycerides. Grilling eliminates the need for oils or butter, which are high in saturated fat. Herbs offer a very low-calorie way to add flavor to grilled fish. An egg-white omelet eliminates the yolks, which contain the bulk of fat, and vegetables add flavor and nutrients. Animal-based foods are naturally higher in fat; therefore, vegetables such as spinach or red peppers are a better choice than cheese. Wheat toast is not a good choice since it is high in carbohydrates; too many carbohydrates convert into sugar which raises triglycerides. Although the jelly is sugar free, the high amount of carbohydrates in the whole wheat bread make it a poor choice. Natural honey is still very high in sugar, which should be avoided when trying to lower triglyceride levels. Plain grilled steak is not a good choice as it is an animal-based product that is high in fat. A four-ounce serving of sirloin contains about 16 grams of fat, 6 grams of which is saturated. The average person, especially a male, tends to eat far larger servings, which exponentially increases the amount of fat. Skinless poultry is a lower fat choice.

While preparing a client for a colonoscopy, the nurse would be correct to implement which interventions? Select all that apply. A. instruction on high fiber diet the day before the procedure B. instruction that a sedative will be administered before the procedure C. instruction not to eat or drink 6 - 12 hours before the procedure D. instruction not to eat or drink 18 hours before the procedure

B. instruction that a sedative will be administered before the procedure C. instruction not to eat or drink 6 - 12 hours before the procedure Before the procedure a sedative will be administered. The typical pre-procedure diet is low fiber or clear liquids only for one to three days prior to the procedure. Clients should not eat or drink 6 - 12 hours pre-procedure.

A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply. A. provide the client with a call-light device B. keep the bed in the lowest position C. use a beveled floor mat at bedside D. implement a bed alarm

B. keep the bed in the lowest position C. use a beveled floor mat at bedside D. implement a bed alarm Keeping the bed in the lowest position reduces the impact if the client falls from the bed. Special flooring provides a cushioned surface that reduces impact. A bed alarm will notify staff if the client moves from the bed. Providing a call-light device to a client with Parkinson's is ineffective as the client's ability to use the device is impaired because of fine motor movement limitation.

The nurse is preparing to deliver an infusion of vancomycin through a client's peripherally inserted central catheter (PICC). Shortly after the infusion begins the IV pumps beeps, indicating a blockage. How should the nurse proceed? Select all that apply. A. start a peripheral IV in the opposite limb B. notify the PICC nurse if unable to clear the blockage C. use a 5 mL syringe to flush the PICC with sterile saline D. ask the client to raise and lower the arm or cough E. attempt to flush the line by aggressively pushing heparin to clear the blockage F. use a 10 mL syringe to gently flush the PICC with sterile saline or tPA as ordered

B. notify the PICC nurse if unable to clear the blockage D. ask the client to raise and lower the arm or cough F. use a 10 mL syringe to gently flush the PICC with sterile saline or tPA as ordered After attempting to clear the PICC following facility protocol, the nurse should notify the PICC nurse if he is unsuccessful. The catheter may be positional, which can be corrected by having the client raise and lower the arm or cough. A 10 mL syringe should be used to flush PICCs, as smaller syringes can increase pressure within the catheter and cause it to rupture or damage the blood vessels. Starting a peripheral IV in the opposite limb would not be a first-line intervention. Depending on the IV medications the client is receiving and length of expected therapy, the health care provider will determine if the PICC can be removed and a peripheral IV placed. This should only be done with a prescriber's order. Aggressive force should never be used to try and clear a catheter, since this may cause a clot to dislodge or a fibrin tail to break off.

A client admitted for treatment of a deep venous thrombosis of the calf complains of dyspnea and chest pain. What is the best response by the nurse? A. administer oxygen at 2L/min as ordered prn B. place client in a semi-Fowler's position C. prepare client for diagnostic tests D. obtain vital signs

B. place client in a semi-Fowler's position The client is experiencing symptoms of a pulmonary embolism. The best action by the nurse is to place the client in a semi-Fowler's position to enable a clear airway. Obtaining vital signs would be action number 2, to compare to established baseline data. Administering oxygen as ordered would be the third response to provide adequate oxygenation of the client. Last, prepare the client for diagnostic tests such as blood gases, ventilation-perfusion lung scan, and pulmonary angiography.

The nurse is caring for a 9-year-old boy who presented to the ED after a penetrating injury from a BB gun. The client is diagnosed with a hyphema. The nurse proceeds to place the client in which position? A. flat in bed B. semi-Fowler's C. Trendelenburg's D. lateral on the unaffected side

B. semi-Fowler's The client should be in a semi-Fowler's position to keep the hyphema away from the cornea's optical center. Positioning the client flat in bed or in Trendelenburg's increases pressure on the site. The lateral position should be avoided until after the hyphema resolves.

The nurse working in an outpatient clinic has the opportunity to teach a client recently diagnosed with irritable bowel syndrome (IBS). Which of the following topics would be most appropriate for the nurse to include? Select all that apply. A. daily iced tea intake B. stress reduction techniques C. limit fluids D. daily probiotic

B. stress reduction techniques D. daily probiotic Anxiety increases sympathetic stimulation to the bowels, thereby increasing symptoms. Reducing anxiety will lessen the incidence of IBS episodes. The precise mechanism on how probiotics aid in IBS symptoms is not known, but it is thought to alter the bacteria found in the intestines. Ingestion of cold liquids will increase intestinal mobility that is contraindicated in IBS. Further, caffeine is considered a trigger food for symptoms of IBS. Fluid intake should be increased to compensate for fluid loss associated with frequent bowel elimination.

The nurse is preparing to administer furosemide IM to a 6-month-old client with edema. Which location is the preferred injection site for this client? A. the gluteus medius B. the vastus lateralis C. the dorsogluteal site D. the ventrogluteal muscle

B. the vastus lateralis The vastus lateralis is the preferred injection site for babies under 7 months of age. It may be used from birth to adulthood. The gluteus medius and the ventrogluteal site should be used only in infants older than 7 months. The dorsogluteal site should not be used for injections due to the risk of damaging the sciatic nerve and puncturing blood vessels.

The nurse is teaching a client diagnosed with gastroesophageal reflux disease (GERD) about dietary measures to manage symptoms. Which food does the nurse advise the client to avoid? A. bananas B. tomatoes C. white bread D. grilled salmon E. steel-cut oatmeal

B. tomatoes The nurse should instruct the client to eat a low-fat, high-fiber diet, avoiding acidic foods. Tomatoes are highly acidic and consumption of tomatoes or tomato-based sauces can worsen the symptoms of GERD. Bananas are low in fat and acid and contain fiber. White bread does not contain acid and has fiber. Grilled salmon is a low-fat choice that avoids fried foods, which are high in fat and irritating to clients with GERD. Steel-cut oatmeal is a low-fat, high-fiber option.

The nurse is caring for a client who refuses to get out of bed. He tells the nurse, "I'm too tired to get up. I'm sick. I'm supposed to rest in the hospital." For which complications of immobility does the nurse understand that the client is at risk? Select all that apply. A. decreased appetite B. urinary tract infection C. orthostatic hypotension D. muscular atrophy and foot drop E. boredom, frustration, and anxiety F. increased length of hospitalization

B. urinary tract infection C. orthostatic hypotension D. muscular atrophy and foot drop E. boredom, frustration, and anxiety F. increased length of hospitalization Prolonged immobilization can lead to urinary stasis, which can cause a urinary tract infection. Decreased cardiac circulation leads to orthostatic hypotension, which can cause dizziness upon standing. Lack of physical exercise can cause the muscles to atrophy, especially over a long period of time. Foot drop is another side effect of prolonged lack of exercise. Lack of mental stimulation causes boredom, frustration, and anxiety in some clients. In addition, respiratory effects of immobility can cause pneumonia. Complications of immobility can lead to longer hospital stays, particularly in clients who have multiple complications or comorbidities.

fentanyl nursing considerations

BBW coprescribed with BZD or CNS depressants only if alternate treatments are unavailable. Do not use with MAOIs, acute or severe bronchial asthma or respiratory depression. Tolerance and dependency may result from long term use. available as transdermal patch. Increased risk of serotonin syndrome. Use with caution in pregnancy, breastfeeding, head injury, increased ICP or IOP, liver or kidney dysfunction, mental illness, emotional disturbance, drug seeking behavior. Rx CII

The nurse performed Leopold's maneuvers and determined that the fetal position is right occiput anterior (ROA). Identify the area where the nurse would place the Doppler most easily hear fetal heart sounds.

Because the fetus is determined to be in an ROA, a vertex position, the convex portion of the fetus lying closest to the uterine wall would be located in the lower right quadrant of the abdomen.

Pertussis

Bordetella pertussis average incubation is 7-10 days but can range from 6-20 days. Greatest during the catarrhal stage when discharge from respiratory secretions occurs. Discharge from respiratory tract of the infected person. Direct contact or droplet spread from infected person; indirect contact with freshly contaminated articles

A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter? a. Check size of existing catheter and balloon b. ask client when the catheter was last changed c. clamp and empty the present catheter bag d. gather clean gloves and basin of hot soapy water

a. Check size of existing catheter and balloon It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and potential for infection. Although the nurse may empty a catheter bag, if the client uses one, there is no need to clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not include clamping since the catheter does not require long tubing like a regular catheter. Also urine bags are generally emptied at scheduled times each shift

Bronchiolitis and RSV

Bronchiolitis is an inflammation of the bronchioles that cause production of thick mucus that occludes bronchiole tubes and small bronchi. RSV causes acute viral infection and common cause of bronchiolitis. RSV is highly communicable and usually transferred via droplets or direct contact. Prevention include breastfeeding, avoidance of tobacco smoke and use of good handwashing. Administer palivizumab, monoclonal ab to high risk infants

The nurse is preparing to receive an 18-month-old client from surgery who had repair of a congenital hip deformity. What type of traction does the nurse anticipate setting up for the client?

Bryant traction Bryant's traction is used following corrective surgery to repair congenital hip deformities. It involves wrapping the child's legs with moleskin tape and an adhesive elastic bandage which is attached to a series of ropes and weights. The tension helps keep the end of the femur in the hip socket during the healing process.

The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. "She is very irritable lately." B. "She sleeps quite a bit of the time." C. "Her gums look too big for her teeth." D. "She has gained about 10 pounds in the last six months."

C. "Her gums look too big for her teeth." Hyperplasia of the gums is associated with Dilantin therapy. Answer A is not related to the therapy; Answer B is a side effect; and Answer D is not related to the question

A client is scheduled for a hypophysectomy following the discovery of a pituitary gland tumor. The nurse is teaching the client about the procedure. Which statement by the client indicates effective learning? Select all that apply. A. "I should brush my teeth with a soft toothbrush." B. "I can remove the pad under my nose the next morning." C. "I will avoid bending my head down or bending forward." D. "I will not blow my nose until cleared by my health care provider." E. "I will need to breathe through my mouth due to the nasal packing."

C. "I will avoid bending my head down or bending forward." D. "I will not blow my nose until cleared by my health care provider." E. "I will need to breathe through my mouth due to the nasal packing." Following a hypophysectomy, the client is at increased risk of bleeding and increased intracranial pressure. To minimize the risk of increased pressure and bleeding, the client should avoid bending the head down and putting pressure on the nose. Blowing the nose should be avoided until approved by the health care provider. The client will need to mouth breathe while the nasal packing is in place. Brushing the teeth can increase intracranial pressure, which delays healing. The drip pad should remain in place for 2 or 3 days and be removed by the surgeon or by the client following the surgeon's guidelines.

The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching? A. "I had my leg removed because of diabetes." B. "My exercises are going well." C. "My left leg hurts after I wrap my stump." D. "I use canes to walk to the bathroom."

C. "My left leg hurts after I wrap my stump." Pain in the residual limb indicates the wrapping is too tight and should be reapplied. Peripheral vascular disease due to diabetes mellitus is a common reason for surgical removal of a lower limb. Range-of-motion exercises are standard after an amputation. Use of adaptive devices such as canes to ambulate is standard post-amputation.

The nurse is performing discharge teaching for a client with an implanted defibrillator. What discharge instruction is essential? A. "You cannot prepare food in a microwave." B. "You should avoid shoulder movement on the side of the defibrillator for six weeks." C. "You should use your cell phone on your right side." D. "You won't be able to fly on a commercial airliner with an implanted defibrillator."

C. "You should use your cell phone on your right side." The client with an implanted defibrillator should use a cell phone or any battery-operated device on the right side or the side opposite the implanted device. The client should also check the pulse rate and report dizziness or fainting. Answers A, B, and D are incorrect because the client can prepare food in the microwave, move the shoulder on the affected side, and travel in an airplane.

The physician has ordered Coumadin (sodium warfarin) for a client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100

C. 1700 Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. This allows for accurate bleeding times to be drawn in the morning. Therefore, Answers A, B, and D are incorrect.

The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is: A. 40-60mmHg B. 60-80mmHg C. 80-120mmHg D. 120-140mmHg

C. 80-120mmHg The recommended setting for performing tracheostomy suctioning on the adult client is 80-120mmHg. Answers A and B are incorrect because the amount of suction is too low. Answer D is incorrect because the amount of suction is excessive.

Which of the following newborns is at greatest risk for iron deficiency anemia? A. A newborn who is fed infant formula B. A newborn delivered at 32 weeks gestation C. A newborn who is one of a set of quadruplets D. A newborn who is breastfed

C. A newborn who is one of a set of quadruplets Multiple-birth babies have reduced fetal iron stores, making them at greater risk for iron deficiency anemia. The newborns mentioned in Answers A, B, and D are less likely to have iron deficiency anemia.

Which of the following findings would be expected in the infant with biliary atresia? A. Rapid weight gain and hepatomegaly B. Dark stools and poor weight gain C. Abdominal distention and poor weight gain D. Abdominal distention and rapid weight gain

C. Abdominal distention and poor weight gain The infant with biliary atresia has abdominal distention, poor weight gain, and clay-colored stools. Answers A, B, and D do describe the symptoms associated with biliary atresia; therefore, they are incorrect.

A client admitted to the emergency room with multiple injuries develops Cullen's sign. The nurse is aware that the client has sustained damage to the: A. Frontal lobe B. Lungs C. Abdominal organs D. Spinal cord

C. Abdominal organs Cullen's sign, a bluish discoloration around the umbilicus, is an indication of damage to the abdominal organs leading to hemorrhage. Answers A, B, and D are incorrect because the frontal lobe, the lungs, and the spinal cord are not involved in Cullen's sign.

The nurse identifies ventricular tachycardia on the cardiac monitor. The patient has a pulse rate of 160 with a regular rhythm. The nurse should give priority to: A. Administering atropine sulfate B. Requesting a stat potassium level C. Administering amiodarone D. Defibrillating at 360 joules

C. Administering amiodarone The treatment for ventricular tachycardia is administration of a medication such as amiodarone that will slow and correct the abnormal rhythm. Answer A is incorrect because atropine sulfate will further increase the heart rate. Answer B is incorrect because it is not a priority at this time. Answer D is incorrect because defibrillation is used for the client with pulseless ventricular tachycardia or ventricular fibrillation. Defibrillation should begin at 200 joules and be increased to 360 joules.

Which infant is exempt from the recommendations of the American Academy of Pediatrics "Back to Sleep" campaign against SIDS? A. An infant with intussusception B. An infant with pyloric stenosis C. An infant with gastroesophageal reflux D. An infant with a cleft palate

C. An infant with gastroesophageal reflux The infant with gastroesophageal reflux (GER) is exempted from the recommendations of the American Academy of Pediatrics "Back to Sleep" campaign against SIDS. Answers A, B, and D are incorrect because the infants should be placed on their backs for sleep.

A 25-year-old client arrives in the emergency room with a possible fracture of the right femur. The nurse should anticipate an order for: A. Bryant's traction B. Ice to the entire extremity C. Buck's traction D. An abduction pillow

C. Buck's traction The adult client with a fractured femur will be placed in Buck's traction to realign the leg and to decrease spasms and pain. Bryant's traction is used for children weighing less than 30 pounds with leg fractures, so answer A is incorrect. Ice might be ordered to the site after repair of the fracture, but not for the entire extremity, so Answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, Answer D is incorrect.

Which of the following describes the language development of a two-year-old? A. Doesn't understand yes and no B. Understands the meaning of all words C. Can combine three or four words D. Repeatedly asks "why?"

C. Can combine three or four words The two-year-old can combine three to four words. Answers A and B are incorrect because the two-year-old understands yes and no, but does not understand the meaning of all words. Answer D is incorrect because seeking information and asking "why?" is typical of the three-year old.

The nurse is teaching a group of nursing students about proper client positioning. Which statement by a student nurse indicates an understanding of proper positioning? A. A client receiving an enema should be placed on the right side in the Sims' position. B. A client with a below-the-knee amputation should be positioned with the affected limb elevated at a 45-degree angle. C. Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed. D. Clients with a craniotomy should be positioned with the head of bed at a 20- degree angle with the head in a neutral, midline position.

C. Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed. Clients with pulmonary edema should be positioned upright with the legs dangling over the side of the bed to decrease venous return. Clients receiving an enema should be positioned on the left side in the Sims' position to allow the gravity flow of the solution to follow the direction of the colon. Client with lower limb amputations should have the affected limb supported but not elevated in order to prevent flexion contractures. Clients with a craniotomy should be positioned with the head of bed at a 30- to 45-degree angle to promote venous drainage from the head.

The nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. Which food would have to be eliminated from this client's diet? A. Roasted chicken B. Noodles C. Cooked broccoli D. Custard

C. Cooked broccoli The client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli. Foods such as those listed in Answers A, B, and D are allowed

A client with nontropical sprue has an exacerbation of symptoms. Which meal selection is responsible for the recurrence of the client's symptoms? A. Tossed salad with oil and vinegar dressing B. Baked potato with sour cream and chives C. Cream of tomato soup and crackers D. Mixed fruit and yogurt

C. Cream of tomato soup and crackers The symptoms of nontropical sprue as well as those of celiac are caused by the ingestion of gluten, found in wheat, oats, barley, and rye. Creamed soup and crackers as well as some cold cuts contain gluten. Answers A, B, and D do not contain gluten; therefore, they are incorrect.

The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided? A. Bran flakes B. Peaches C. Cucumber and tomato salad D. Whole wheat bread

C. Cucumber and tomato salad The client with diverticulosis should avoid foods with seeds. The foods in Answers A, B, and D will help prevent constipation that increases the likelihood of diverticulitis.

Which medication is used to treat iron toxicity? A. Narcan (naloxone) B. Digibind (digoxin immune Fab) C. Desferal (deferoxamine) D. Zinecard (dexrazoxane)

C. Desferal (deferoxamine) Desferal (deferoxamine) is used to treat iron toxicity. Answers A, B, and D are incorrect because they are antidotes for other drugs: Narcan is used to treat opiate toxicity, Digibind is used to treat digitalis toxicity, and Zinecard is used to treat doxorubicin toxicity

An elderly client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in clients with a history of: A. Diabetes B. Gastric ulcers C. Emphysema D. Pancreatitis

C. Emphysema Beta blockers such as timolol (Timoptic) can cause bronchospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in the client with diabetes, gastric ulcers, or pancreatitis; therefore, answers A, B, and D are incorrect.

Which of the following is an expected finding in the assessment of a client with bulimia nervosa? A. Extreme weight loss B. Presence of lanugo over body C. Erosion of tooth enamel D. Muscle wasting

C. Erosion of tooth enamel Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with bulimia nervosa. Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.

When reviewing the client's chart, the nurse should pay close attention to the results of which pulmonary function test? A. Residual volume B. Total lung capacity C. FEV1 /FVC ratio D. Functional residual capacity

C. FEV1 /FVC ratio The FEV1 /FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answers A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.

Which statement is true regarding the measurement of fetal heart tones? A. The normal range for FHT is 100-180 beats per minute. B. A Doppler ultrasound can detect FHT at 18 to 20 weeks gestation. C. FHT can be detected at eight weeks gestation using vaginal ultrasound. D. A TOCO monitor is an invasive means of measuring FHT

C. FHT can be detected at eight weeks gestation using vaginal ultrasound FHT can be detected at 8 weeks gestation using vaginal ultrasound. Answers A, B, and D are untrue statements.

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority? A. Anxiety B. Impaired skin integrity C. Fluid volume deficit D. Nutrition altered, less than body requirements

C. Fluid volume deficit Fluid volume deficit can lead to metabolic acidosis and electrolyte loss. The other nursing diagnoses in answers A, B, and D might be applicable but are of lesser priority.

The nurse is performing an assessment on a client with possible pernicious anemia. Which finding is specific to pernicious anemia? A. A weight loss of 10 pounds in six months B. Fatigue C. Glossitis D. Pallor

C. Glossitis Glossitis (red, beefy tongue) is a specific characteristic of the client with pernicious anemia. Answers A, B, and D are not specific to pernicious anemia because they may occur with other conditions; therefore, they are incorrect choices.

Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis? A. Brushing the teeth B. Drinking a glass of juice C. Holding a cup of coffee D. Brushing the hair

C. Holding a cup of coffee The warmth from holding a cup of coffee or hot chocolate helps to relieve the pain and stiffness in the hands of the client with rheumatoid arthritis. Answers A, B, and D do not relieve the symptoms of rheumatoid arthritis; therefore, they are incorrect.

The nurse is caring for a client newly diagnosed with diabetes type 2. The health care provider plans to start the client on a rapid-acting insulin. Which insulin does the nurse anticipate noting on the order? A. Lantus B. Levemir C. Humalog D. Humulin 70/30

C. Humalog Humalog, NovoLog, and Apidra are all rapid-acting insulins. Lantus and Levemir are longacting insulins. Humulin 70/30 is an intermediate-acting insulin.

A two-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization: A. Will need to be repeated when the child is four years of age B. Is given to determine whether the child is susceptible to pertussis C. Is one of a series of injections that protects against diphtheria, pertussis, tetanus, and H.influenzae b D. Is a one-time injection that protects against measles, mumps, rubella, and varicella

C. Is one of a series of injections that protects against diphtheria, pertussis, tetanus, and H.influenzae b The immunization protects the child against diphtheria, pertussis, tetanus, and H. influenzae b. Answer A is incorrect because a second injection is given before four years of age. Answer B is not a true statement, and answer D is not a one-time injection, nor does it protect against measles, mumps, rubella, or varicella.

A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client's history, the nurse should give priority to assessing the newborn for: A. Respiratory depression B. Wide-set eyes C. Jitteriness D. Low-set ears

C. Jitteriness Jitteriness and irritability are signs of alcohol withdrawal in the newborn. Answer A is incorrect because it would be associated with use more recent than one day ago. Answers B and D are characteristics of a newborn with fetal alcohol syndrome, but they are not a priority at this time; therefore, they are incorrect.

An adolescent client with cystic acne has a prescription for Accutane (isotretinoin). Which lab work is needed before beginning the medication? A. Complete blood count B. Clean-catch urinalysis C. Liver profile D. Thyroid function test

C. Liver profile Accutane is made from concentrated vitamin A, a fat-soluble vitamin. Fat-soluble vitamins have the potential of being hepatotoxic, so a liver panel is needed. Answers A, B, and D do not relate to therapy with Accutane; therefore, they are incorrect.

A nursing student is assigned to a client with an endotracheal tube on a ventilator. Upon entering the client's room the primary care nurse is alerted by observing which of the following? A. The head of the bed is elevated 45 degrees. B. The cuff on the endotracheal tube is inflated. C. Normal saline is present at the bedside table. D. The client is wearing an intermittent compression device on each leg.

C. Normal saline is present at the bedside table. The presence of normal saline is of concern as it should not be used in the endotracheal tube to promote secretion removal. The head of the bed should be elevated 30 - 45 degrees at all times to prevent ventilator-associated pneumonia. The cuff on the endotracheal tube should be sufficiently inflated to ensure the patient receives proper ventilator parameters. Wearing an intermittent compression device on both legs provides deep vein thrombosis prophylaxis, an appropriate measure.

The nurse is caring for a patient following a thyroidectomy. Which of the following is an early symptom of hypocalcemia? A. Positive Chvostek's sign B. 3+ deep tendon reflexes C. Numbness or tingling of the toes and extremities D. Prolonged ST and QT intervals

C. Numbness or tingling of the toes and extremities Early symptoms of hypocalcemia include numbness and tingling of the toes and extremities as well as around the mouth. Answers A, B, and D are later symptoms; therefore, they are incorrect.

The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client's vision? A. Temporal lobe B. Frontal lobe C. Occipital lobe D. Parietal lobe

C. Occipital lobe The occipital lobe is responsible for vision. The temporal lobe is responsible for taste, smell, and hearing. The frontal lobe is responsible for judgment, foresight, and behavior. The parietal lobe is responsible for ideation, sensory functions, and language; therefore, Answers A, B, and D are incorrect

A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client: A. On her right side B. Supine with a small pillow C. On her left side D. In knee chest position

C. On her left side Positioning the client on her left side will take pressure off the vena cava and allow better oxygenation of the fetus. Answers A and B do not relieve pressure on the vena cava; therefore, they are incorrect. Answer D is the preferred position for the client with a prolapsed cord; therefore, it is incorrect for this situation

A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to: A. Prevent swelling and dysphagia B. Decompress the stomach C. Prevent contamination of the suture line D. Promote healing of the oral mucosa

C. Prevent contamination of the suture line The primary reason for the NG to is to allow for nourishment without contamination of the suture line. Answer A is not a true statement; therefore, it is incorrect. Answer B is incorrect because there is no mention of suction. Answer D is incorrect because the oral mucosa was not involved in the laryngectomy.

Before administering Theo-Dur (theophylline), the nurse should check the patient's: A. Urinary output B. Blood pressure C. Pulse D. Temperature

C. Pulse Theo-Dur (theophylline) is a bronchodilator, and a side effect of bronchodilators is tachycardia, so checking the pulse is important. Extreme tachycardia should be reported to the doctor. Answers A, B, and D are not necessary.

The nurse is caring for a client scheduled for repair of an abdominal aortic aneurysm. Which pre-op assessment is most important? A. Level of anxiety B. Exercise tolerance C. Quality of peripheral pulses D. Bowel sounds

C. Quality of peripheral pulses Assessment of the quality of peripheral pulses is most important because the aorta is clamped during AAA repair. This decreases blood flow to the kidneys and lower extremities. Answers A, B, and D are not as important pre-op assessments for the client having a AAA repair, so they are incorrect.

The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client? A. RSS 1 B. RSS 2 C. RSS 3 D. RSS 4 E. RSS 5 F. RSS 6

C. RSS 3 The client who responds quickly, but only to commands has a Ramsay score of 3. The client with an RSS of 1 is restless, anxious, or agitated. Clients with an RSS of 2 are alert, oriented, and cooperative. Clients with an RSS of 4 respond briskly to stimulus. A client with a sluggish response to stimulus is scored as a 5. A client with an RSS of 6 is deeply sedated and does not respond to stimulus.

The physician has made a diagnosis of "shaken child" syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of "shaken child" syndrome? A. Fracture of the clavicle B. Periorbital bruising C. Retinal hemorrhages D. Fracture of the humerus

C. Retinal hemorrhages Retinal hemorrhages are characteristically found in the child who has been violently shaken. Answers A, B, and D may result from trauma other than that related to abuse; therefore, they are incorrect.

The nurse is caring for a client with Crohn's disease. How should the nurse educate the client regarding nutrition and hydration? A. Drink coffee each morning, as this can help stimulate the appetite. B. Avoid enteral supplements, as they may decrease the appetite for solid foods. C. Select high-calorie, low-fiber, high-protein, and high-vitamin foods for each meal. D. Drink clear liquids as soon as they are tolerated, and then progress the diet rapidly in order to obtain needed nutrients.

C. Select high-calorie, low-fiber, high-protein, and high-vitamin foods for each meal. Clients with Crohn's must have adequate nutrition to promote wound and fistula healing and prevent loss of lean muscle mass. High-calorie, lowfiber, high-protein, and high-vitamin foods should be available at every meal to maximize nutritional benefits. Coffee should be avoided, since clients with Crohn's should avoid caffeine. Enteral supplements may be given through a gastrostomy tube to supplement solid foods eaten by the client and should not cause a decrease in appetite. The diet should progress slowly, not rapidly.

The nurse is preparing a client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim's position

C. Sitting in a straight chair The client with an axillo-popliteal bypass graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Answers A, B, and D are incorrect because resting in a supine position, resting in a recliner, and sleeping in right Sim's position are allowed

The nurse is teaching the client the appropriate way to use an inhaler. Which action indicates the client needs additional teaching? A. The client takes a deep breath and holds it for 3 or 4 seconds. B. The client places the inhaler mouthpiece beyond his lips. C. The client inhales with lips tightly sealed to mouthpiece. D. The client exhales slowly using purse lipped breathing.

C. The client inhales with lips tightly sealed to mouthpiece. Keeping the lips tightly sealed encourages nasal breathing, which interferes with the inhaler effectiveness. Answers A, B, and D indicate correct use of the inhaler.

The nurse is preparing to discharge a client who was treated for tuberculosis. Which guidelines for home management should the nurse include in his discharge teaching? Select all that apply. A. The client may resume his normal activities. B. The family should maintain respiratory isolation at home. C. The medication regimen should be followed diligently as prescribed. D. The client may return to work when three sputum cultures are negative. E. The nurse should educate the client about the medication and possible side effects and their management

C. The medication regimen should be followed diligently as prescribed. D. The client may return to work when three sputum cultures are negative. E. The nurse should educate the client about the medication and possible side effects and their management The medication regimen for tuberculosis may last up to 12 months, depending on the medications. Strict adherence is important to prevent a relapse. The client may return to most jobs after three sputum cultures are negative. Teaching the client about possible side effects and management of medication helps ensure compliance with treatment. The client should return to his previous activity level gradually, following the health care provider's recommendations. There is no need for the family to maintain respiratory isolation at home since they have already been exposed.

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is: A. The bladder fills more rapidly because of the medication used for the epidural. B. Her level of consciousness is altered. C. The sensation of the bladder filling is diminished or lost. D. To allow her to rest uninterrupted after delivery.

C. The sensation of the bladder filling is diminished or lost. Epidural anesthesia decreases bladder sensation and the need to void. A full bladder decreases the progression of labor. Answers A, B, and D are incorrect because they contain untrue statements.

Which observation indicates that a student nurse needs further teaching in the proper way to assess central venous pressure? A. The student places the client in a supine position to read the manometer. B. The student places the zero reading of the monometer at the phlebostatic axis. C. The student instructs the client to perform the Valsalva maneuver during the CVP reading. D. The student records the CVP reading as the level noted at the top of the meniscus.

C. The student instructs the client to perform the Valsalva maneuver during the CVP reading. The client should not be instructed to perform the Valsalva maneuver during central venous pressure reading. Such a request indicates that the student needs further teaching. Answers A, B, and D are incorrect because they indicate that the student understands the teaching on how to correctly check the CVP.

A client with an ileostomy is being discharged. Which teaching should be included in the plan of care? A. Using Karaya powder to seal the bag B. Irrigating the ileostomy daily C. Using Stomahesive as a skin protector D. Using a stool softener as needed

C. Using Stomahesive as a skin protector The nurse should teach the client with an ileostomy regarding the use of Stomahesive as a skin protector. Answer A is not correct because the bag will not seal if the client uses Karaya powder. Answer B is incorrect because there is no need to irrigate an ileostomy. Answer D is incorrect because the stools are liquid

The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value indicates an adverse effect of the medication? A. Uric acid of 5mg/dL B. Hematocrit of 33% C. WBC 2000 per cubic millimeter D. Platelets 150,000 per cubic millimeter

C. WBC 2000 per cubic millimeter An adverse effect of Tegretol (carbamazepine)is a decrease in white blood cell count. The values in Answers A and D are within normal limits, and Answer B is a lower limit of normal; therefore, Answers A, B, and D are incorrect.

Which of the following is the best indicator of the diagnosis of HIV? A. WBC B. ELISA C. Western blot D. CBC

C. Western blot

A client newly diagnosed with diabetes is started on Precose (acarbose). The nurse should tell the client that the medication should be taken: A. one hour before meals B. 30 minutes after meals C. With the first bite of a meal D. Daily at bedtime

C. With the first bite of a meal Acarbose is to be taken with the first bite of a meal. Answers A, B, and D are incorrect because they specify the wrong schedule for taking the medication

A client who is three days postpartum and is bottlefeeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide? A. reduce fluid intake to 1,500 ml/day B. take a warm shower twice a day C. apply a tight binder around her breasts D. come in to see the physician immediately as this is abnormal

C. apply a tight binder around her breasts A tight binder is recommended for the client bottle-feeding her baby to reduce engorgement. Limiting fluid intake will not impact breast engorgement. A warm shower will stimulate milk production. As engorgement is normal several days postdelivery, seeing the physician is not necessary.

The nurse on the inpatient memory care unit is caring for a client with Alzheimer's who exhibits wandering behavior. The 24-hour observer calls the nurse to report that the client left the unit. It would be most appropriate for the nurse to take which of the following actions? A. notify the family B. notify security along with a description of the client C. ask the observer in what direction the client headed D. ask other staff on the unit to assist in finding the client

C. ask the observer in what direction the client headed To locate the client, the nurse must first determine the direction the client went. The observer is most likely to know which path the client took. Notifying family members can wait until the client is located. Security may not be readily available. Staff will first need to know the direction the client took in order to assist in recovery.

The nurse is caring for a comatose client with a Salem sump tube. Which action by the nurse is correct regarding care of this client? A. clamp the air vent during tube feedings B. place the client on the left side in a high- Fowler's position C. assess the position of the Salem sump before each feeding D. infuse bolus feedings with a pump or by gently plunging into the stomach

C. assess the position of the Salem sump before each feeding The Salem sump's position should be checked before each feeding by aspirating gastric content and measuring pH (should be 3.5 or less). Administering feedings through an improperly positioned tube may cause aspiration. The air vent should not be clamped and should be kept above stomach level. The comatose client should be placed on the right side in the high-Fowler's position. Bolus feedings should be infused via a pump or allowed to flow by gravity. Feedings should never be forcibly plunged into the client.

A nurse is giving instructions to parents of a child who had a tonsillectomy. Which instruction is the most important? A. drink orange juice to relieve discomfort B. drink extra milk to relieve discomfort C. avoid drinking from a straw D. rinse twice a day with antiseptic mouthwash

C. avoid drinking from a straw Drinking from a straw is very problematic post-tonsillectomy for two reasons: First, the sucking motion may disrupt the clot at the operative site. Second, insertion of the straw into the mouth may disrupt the clot at the operative site. Orange juice and antiseptic mouthwash will irritate the tissue at the operative site. Milk promotes mucus production, which increases the need to swallow, potentially irritating the operative site. Still, drinking from a straw presents the most potential harm.

The oncology nurse is caring for a 24-year-old male client with testicular cancer. Cisplatin IV has been ordered. Which lab value would the nurse notify the health care provider about before administering this medication? A. iron 129 mcg/dL B. ammonia level 52 mcg/dL C. creatinine clearance 23 mL/minute D. brain natriuretic peptides (BNP) 36 pg/mL

C. creatinine clearance 23 mL/minute Cisplatin is contraindicated and should not be given to clients with a creatinine clearance below 30 mL/min. The iron level is within normal limits and is not a contraindication of administering cisplatin. The ammonia level is also within normal limits, which is important to monitor as cisplatin should be used cautiously with hepatic impairment. BNP is used to measure the severity of heart failure; this value is within the normal range.

A 22-year-old female primigravida who is at 36 weeks' gestation is seen in the ED with a low platelet count, ALT of 68 U/L, AST of 55 U/L, and a continuous, severe headache that has lasted three days. The nurse prepares for what to occur? A. amniocentesis B. ultrasound of the baby C. delivery of the baby D. C-section

C. delivery of the baby The client is experiencing preeclampsia. The only cure for preeclampsia is to deliver the baby. The mother, rather than the baby, is in danger, making an amniocentesis or an ultrasound unnecessary. A Csection is not medically necessary in this situation. Given the pregnancy is 36 weeks' gestation, the lung function of the baby is sufficiently developed for delivery.

The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply. A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity

C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other Clients who are easily bored, have poor and shallow interpersonal relationships, and enjoy being the center of attention have histrionic personality disorder, which is one of the four types of Cluster B personality disorders. Clients who are impulsive, exhibit unpredictable behavior, experience extreme mood shifts, are easily angered, and play people against each other exhibit borderline personality disorder, which is a Cluster B personality disorder. Other Cluster B personality disorders include narcissistic and antisocial personality disorders. Preoccupation with rules and details, hoarding, ritualistic behavior, and extreme devotion to work are characteristics of obsessivecompulsive personality disorder, which is one of the Cluster C personality disorders. Other Cluster C personality disorders include dependent and avoidant personality disorders. Clients who are suspicious of others and engage in magical thinking, eccentric behavior, paranoia, and relationship deficits exhibit schizoid personality disorder, which is a Cluster A personality disorder. Clients who are suspicious and untrusting of others, are argumentative, are controlling of others, and have thoughts of grandiosity have paranoid personality disorder, which is a Cluster A disorder. The other Cluster A disorder is schizotypal personality disorder.

A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first ? A. activated charcoal per pharmacy B. start an IV with D5W to keep the vein open C. gastric lavage PRN D. acetylcysteine (Mucomyst) for age per pharmacy

C. gastric lavage PRN The maximum recommended dose for acetaminophen is 4 g/day. The client ingested 9 g as a one-time dose, which is sufficient to induce liver impairment. The priority action is to remove as much of the medication from the stomach as possible. The second action would be activated charcoal. IV fluids will not affect the metabolism of acetaminophen by the liver yet may be used to maintain hydration. Acetylcysteine is effective in third-stage liver injury; given the time interval of ingestion, it would be premature to administer this pharmaceutical.

The nurse is caring for a client who has a nasogastric tube for medication administration and tube feedings. How should the nurse care for the tube during her shift? Select all that apply. A. flush tube every 4 hours with hot water to maintain patency B. allow the feeding and tubing to hang until empty, up to 48 hours C. maintain the head of bed in a high-Fowler's position during feedings D. check residuals and replace them unless the amount is greater than 300 mL E. check under the adhesive tape on the nose daily to assess for skin breakdown F. assess the bowel sounds before feeding, and feed at half the rate if bowel sounds are absent

C. maintain the head of bed in a high-Fowler's position during feedings E. check under the adhesive tape on the nose daily to assess for skin breakdown In order to prevent aspiration, the head of the bed should be in a high-Fowler's position whenever feedings are infusing. The tape on the nose should be removed daily and the skin assessed for breakdown; the tape should then be replaced, using care not to move the tube. The tube should be flushed every 4 hours using tepid water, not hot. Using hot water can cause discomfort and possibly burn the client. Tubing and feedings must be changed every 24 hours, even if there is still feeding left in order to prevent bacterial growth. Residuals should be replaced unless the amount is greater than 250 mL. In that case, discard the extra and consider slowing the feeding rate using the health care provider's guidelines. If no bowel sounds are present, hold the feeding and contact the health care provider.

Along with traditional therapy, a client asks the nurse about alternative therapies for chronic pain. Which could the nurse provide to the client? A. yoga B. acupuncture C. music therapy D. hypnosis

C. music therapy Music therapy is effective as an alternative therapy for chronic pain and may be done by the nurse. Yoga, acupuncture, and hypnosis may be effective alternative therapies but are not within the domain of nursing.

A nurse is preparing discharge instructions for a client with a below-the-knee amputation. Which instruction would be a priority ? A. sterile wound management B. elevation of residual limb C. performing prescribed exercises D. reporting occurrence of phantom limb pain immediately

C. performing prescribed exercises The nurse should advise the client to exercise as instructed to prevent contracture formation. Aseptic dressing wound management is acceptable. Elevation of the residual limb should be avoided to prevent contracture formation. As phantom limb pain is common, reporting on an imminent basis is unnecessary.

The nurse is caring for a client receiving total parenteral nutrition (TPN). During the assessment, the nurse notes absence of breath sounds on the right side, where the central catheter is placed. Which of the following does the nurse suspect is responsible for this abnormal assessment finding? A. air embolism B. fluid overload C. pneumothorax D. refeeding syndrome

C. pneumothorax A pneumothorax is one of the complications of TPN. It is caused by improper central catheter placement or by a catheter that has migrated. Absence of breath sounds on the affected side, chest or shoulder pain, tachycardia, cyanosis, and sudden shortness of breath are indications of pneumothorax. The nurse should notify the health care provider and prepare the client for a portable chest X-ray. An air embolism is another complication of TPN. Signs and symptoms of air embolism include respiratory distress; a weak, rapid pulse; chest pain; dyspnea; hypotension; and a loud churning sound auscultated over the pericardium. Fluid overload would not present as absence of breath sounds; instead, expected findings include hypertension, bounding pulses, increased respiratory rate, distended veins in the hands and neck, and moist crackles. Signs of refeeding syndrome include arrhythmias, vomiting, shortness of breath, weakness, ataxia, and seizures. It occurs in severely malnourished clients who are undergoing nutritional replacement therapy.

The nurse is caring for a client with breast cancer who has an order for doxorubicin IV. The nurse anticipates which common side effect of this medication? A. permanent hair loss B. halos around objects and blurred vision C. red urine for 1 - 2 days after administration D. facial flushing and red streaking along the vein

C. red urine for 1 - 2 days after administration Doxorubicin causes red urine for 1 - 2 days after administration. Hair loss is temporary; regrowth begins 2 - 3 months after treatment is completed. Visual changes are not a side effect of this medication. Facial flushing and red streaking along the vein only occur when infused too rapidly; therefore, this should not be an expected side effect.

A primigravid client at 34 weeks' gestation is experiencing contractions every 3-4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effeaced. While the nurse is assessing the client's VS, the client says, "I think my bag of water just broke." Which intervention would the nurse do first? a. Check the status of the FHR b. Turn the client to her right side c. test the leaking fluid with nitrazine paper d. perform a sterile vaginal exam

a. Check the status of the FHR Determine whether a prolapsed cord has occurred. Complications of PROM include a prolapsed cord or increased pressure on the fetal umbilical cord inhibiting fetal nutrient supply. Variable decels or fetal bradycardia may be seen on the external fetal monitor. The cord also may be visible. Turning the client to her right is not necessary. If the cord does prolapse, the client should be placed in a knee to chest or Trendelenburg position.

The nurse is caring for a client with sternal wires following a coronary artery bypass graft (CABG). The client complains of severe pain when coughing and deep breathing. What nonpharmacological measures can the nurse take to increase client comfort? Select all that apply. A. apply hot packs to the sternum B. give morphine PRN for pain before client coughs C. suggest using audio books or relaxing music as a distraction D. teach the client how to use a pillow to splint the chest when coughing E. encourage the client to engage in prayer, meditation, or other activities F. properly position the head of the bed to minimize pressure on the sternum

C. suggest using audio books or relaxing music as a distraction D. teach the client how to use a pillow to splint the chest when coughing E. encourage the client to engage in prayer, meditation, or other activities F. properly position the head of the bed to minimize pressure on the sternum Listening to audio books or music can take the client's focus off the pain. Distraction is a useful tool to shift focus away from pain and also includes music therapy and art therapy when appropriate for the client. Splinting the sternum when coughing is one of the most important things post-CABG clients can do to increase their comfort. If the client engages in prayer, meditation, or other rituals at home, he should be encouraged to continue those practices in the hospital. This is respectful to the client and his beliefs and/or culture and allows him to have some measure of control on maintaining normal routines. The bed should be positioned so as to not increase pressure on the sternum. Hot or cold packs should not be used on the sternum, as this area is a fresh post-op site and should be kept clean. Also, the packs may place pressure on the sternum and cause more discomfort. Warm, not hot, heat packs may be used on the back to relieve aches from bed positioning if approved by the health care provider. Morphine is a pharmacological method of pain relief.

The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client's right to emergency services, regardless of ability to pay, is provided by which piece of legislation? A. HIPAA B. the Continuity of Care Act C. the Patient's Bill of Rights D. the Code of Ethics for Nurses

C. the Patient's Bill of Rights

A 10-year-old is sent home from school with a report of having lice. The nurse should instruct the parent on which intervention? A. wash the hair for three continuous days with dandruff shampoo B. isolate all clothing of the child for one week C. treat with an approved pediculicide agent according to directions D. shave the child's head, then cleanse with herbal shampoo

C. treat with an approved pediculicide agent according to directions Treating hair lice most commonly requires application of an over-the-counter pediculicide (medication that kills lice). Leave on the hair according to label instructions. If the child has long hair, a second bottle may be necessary. Washing the hair with dandruff shampoo is ineffective. For clothing and items that cannot be washed in hot water/hot heat drying, sealing them in a plastic bag for two weeks is recommended. Shaving the child's head and cleansing with herbal shampoo is ineffective.

A young child with a rash that's raised and has circumscribed areas filled with fluid comes to the school nurse. What type of rash should the nurse document? A. maculopapular rash B. heat rash C. vesicular rash D. pustular rash

C. vesicular rash Vesicular rashes contain small raised, sacs filled with clear liquid. A maculopapular rash is characterized by a flat, red area on the skin covered with small confluent bumps. A heat rash appears as tiny red pimples, bumps, or spots usually on the back of the neck or lower back. Pustular rash presents with pustules smaller than 5 - 10 mm filled with pus.

Magnesium sulfate

CNS depressant and antiseizure medication used to stop preterm labor (less used for this purpose), prevent and control seizures in eclampsia

A client admitted to the inpatient mental health unit asks if mail can be received from family. Which statement by the nurse indicates adequate understnading of client rights? a. Clients can receive and send mail, but staff must check for hazards b. clients are not allowed to receive mail while hospitalized c. receiving mail from family is not encouraged d. clients are allowed to send or receive mail after the first 72 hours after admission

a. Clients can receive and send mail, but staff must check for hazards

Prostaglandin F2a

Carboprost tormethamine is used for postpartum hemorrhage

Cystic fibrosis

Common symptoms associated with pancreatic enzyme deficiency and pancreatic fibrosis caused by duct blockage, progressive chronic lung disease as result of infection, sweat gland dysfunction resulting in increased NaCl sweat concentrations. Emphysema and atelectasis as airways become increasingly obstructed. Chronic hypoxemia causes contraction and hypertrophy of muscle fibers in pulmonary arteries and arterioles, leading to pulmonary HTN and cor pulmonale. Pneumothorax from ruptured bullae and hemoptysis from erosion of bronchial wall occur as disease progresses. Meconium ileus in newborn earliest manifestation, intestinal obstruction caused by thick intestinal secretions, Frothy and foul smelling stools, deficiency of fat soluble vitamins which can result in easy bruising, bleeding and anemia. Malnutrition and FTT. Hypoalbuminemia from diminished absorption of protein, leading to generalized edema. Rectal prolapse from large, bulky stools and increased intraabdominal pressure. Pancreatic fibrosis and place risk for DM. Dehydration and electrolyte imbalances. Can delay puberty, fertility inhibited by highly viscous cervical secretions. Individuals with penises are usually sterile from blockage of vas deferens.

A nurse is planning care for a client who is receiving treatment for malnutrition. The client is scheduled for d/c to their home where they live alone. Which of the following actions should the nurse include in the plan of care? Select all that apply a. Consult social services to arrange home meal delivery b. encourage the client to purchase nonperishable boxed meals c. advise the client to purchase frozen fruits and vegetables d. recommend drinking a supplement between meals e. Educate the client on how to read nutrition label

a. Consult social services to arrange home meal delivery c. advise the client to purchase frozen fruits and vegetables d. recommend drinking a supplement between meals e. Educate the client on how to read nutrition label Boxed meals contain a lot of sodium

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? a. Deflate the cuff on the tube. b. Place the inner cannula into the tube. c. Ensure that the client is able to speak. d. Ensure that the client is able to swallow.

a. Deflate the cuff on the tube. Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube.

An US is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the US indicate that abruptio placentae is present. On the basis of these findings, the nurse would prepare the client for which anticipated prescription? a. Delivery of the fetus b. complete bed rest for the remainder of the pregnancy c. strict monitoring of I&Os d. The need for weekly monitoring of coagulation studies until the time of delivery

a. Delivery of the fetus

morphine nursing considerations

Continuous dosing is more effective than prn; may be given by patient-controlled analgesia (PCA) PO: onset 15-60 minutes, peak 30-60 minutes, duration 3-6 hours IM: onset 10-15 minutes, peak 30-50 minutes, duration 2-4 hours (usually 3) IV: onset less than 5 minutes, peak 18 minutes, duration 3-6 hours subQ: onset 10-15 minutes, peak 30-50 minutes, duration 2-4 hours (usually 3) Withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia Physical dependency may result from long-term use Monitor for increased respiratory and CNS depression when given with cimetidine, clomipramine, nortriptyline, or amitriptyline Rx C-II; Preg Cat C

diphtheria

Corynebacterium diphtheriae, incubation period 2-5 days. Variable, until virulent bacilli are no longer present (3 negative cultures of discharge from nose and nasopharynx, skin and other lesions), usually 2 weeks but can be 4 weeks. Discharge from the mucous membrane of the nose and nasopharynx, skin and other lesions o the infected person. Direct contact, carrier or contaminated articles.

The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client? A. "Walk about a mile a day to prevent calcium loss." B. "Increase the fiber in your diet." C. "Report nausea to the doctor immediately." D. "Drink at least eight large glasses of water a day."

D. "Drink at least eight large glasses of water a day." Cytoxan (cyclophosphamide) can cause hemorrhagic cystitis, so the client should drink at least eight glasses of water a day. Answers A and B are not necessary and, so, are incorrect. Nausea often occurs with chemotherapy, so answer C is incorrect.

The physician has ordered a culture for a male patient suspected of having N.gonorrhea. Which information should the nurse give the patient? A. "It will be necessary to obtain a sample of blood for an antibody screen." B. "We will need to obtain a swab of nasopharyngeal secretions." C. "A morning sample of urine will be needed." D. "Emptying the bladder one hour before the test may affect results.

D. "Emptying the bladder one hour before the test may affect results. Male patients should not void within one hour of culture collection because voiding washes secretions out of the urethra. Answer A and C are incorrect because blood and urine are not used to detect N. gonorrhea. Answer B is incorrect because oropharyngeal secretions, not nasopharyngeal secretions, are used for culture

The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother? A. "Rock her to sleep every night until she is in a deep sleep." B. "Give diphenhydramine 12.5 mg orally to put the baby to sleep." C. "If she starts waking up a lot in the middle of the night, put her in the bed with you." D. "Give the last feeding as late as possible, and put her in the bed awake without a bottle."

D. "Give the last feeding as late as possible, and put her in the bed awake without a bottle." Feeding the infant as late as possible and putting her in bed awake without a bottle helps the infant learn to recognize cues for bedtime, and learn to fall asleep on her own. Rocking the infant will not allow her to learn to self-soothe. The infant should never be given diphenhydramine simply to make her sleep for the parents' convenience. The nurse should not act in the role of a prescriber by advising the mother to give medication to make her sleep. Infants should never share the bed with parents for safety reasons

An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client? A. "Tell me when you feel me touch your arm." B. "Tell me when you stop hearing the tuning fork sound." C. "Do you have problems with balance?" D. "How much is two plus four plus seven?"

D. "How much is two plus four plus seven?" Asking the client to add a simple series of numbers tests problem solving, a function of the frontal lobe. Tactile sensation is a parietal lobe function. Hearing function is a temporal lobe function. Balance is a function of the cerebrum.

The nurse is caring for a client in the clinic who takes captopril and ramipril for hypertension. The health care provider renews the client's prescriptions and leaves the room. Which comment by the client would prompt the nurse to notify the health care provider immediately ? A. "I am able to start walking longer at the gym without getting tired." B. "Occasionally I am slightly dizzy when standing, so I get up slowly." C. "I don't get short of breath anymore now that my blood pressure is controlled." D. "I am going to my gynecologist tomorrow for my 12-week pregnancy checkup."

D. "I am going to my gynecologist tomorrow for my 12-week pregnancy checkup." Ramipril is a category C drug during the first trimester of pregnancy; it is a category D drug in the second and third trimesters. Captopril is a category D drug in pregnancy. The health care provider must be notified and the medications discontinued immediately. ACE inhibitor therapy may increase exercise tolerance in clients once hypertension is controlled. Dizziness upon standing is a common side effect of ACE inhibitors, and clients should be reminded to stand up slowly from a sitting position. Improved blood pressure control decreases shortness of breath in many clients.

The nurse in an ambulatory care clinic is admitting a 27-year-old client with severe systemic lupus erythematosus (SLE). In assessing the client's health history, the nurse knows to question which of the following statements? A. "I avoid being outside on sunny days." B. "The medications I take make me bloated." C. "My work schedule is down to four hours a day." D. "I get an eye exam annually."

D. "I get an eye exam annually." SLE is a chronic autoimmune disorder treated with a variety of medications. One such drug is an antimalarial drug that produces retinal toxicity. Eye exams every six months, rather than annually, are advised to monitor ocular changes. Avoidance of sunlight prevents the skin rash that occurs with SLE. Also, sensitivity to light is seen in persons with lupus. High-dose prednisone, commonly prescribed with severe SLE, will result in water retention and the appearance of being bloated. Due to fatigue, the work schedule is limited for persons with lupus

A client is brought to the mental health clinic by her sister after the death of their father. Which statement made by the client's sister suggests the client may have abnormal grieving? A. "My sister still has episodes of crying, and it's been three months since Daddy died." B. "My sister seems to have forgotten a lot of the bad things that Daddy did in his lifetime." C. "My sister has really had a hard time after Daddy's funeral." D. "My sister doesn't seem sad at all and acts like nothing has happened.

D. "My sister doesn't seem sad at all and acts like nothing has happened. Abnormal grieving may be exhibited by a lack of feeling sad when the circumstances would normally create such feelings. Answers A, B, and C are all normal expressions of grief.

A student nurse is preparing to administer the client's first dose of tetracycline while the charge nurse observes. What statement by the student nurse prompts the charge nurse to provide further teaching? Select all that apply. A. "Tetracycline may be given with grapefruit juice." B. "After taking tetracycline, the client should wait two hours before eating." C. "It should be given with caution in clients with liver or renal dysfunction." D. "The client may have an antacid along with the tetracycline if it causes GI upset." E. "It should be taken on an empty stomach at least one hour before meals with a glass of milk."

D. "The client may have an antacid along with the tetracycline if it causes GI upset." E. "It should be taken on an empty stomach at least one hour before meals with a glass of milk." Antacids interfere with absorption of tetracycline, along with food, milk, and milk products. Aluminum, calcium, and magnesium decrease absorption of the drug. It may be taken on an empty stomach with another liquid besides milk. Grapefruit juice does not interfere with tetracycline, which should be given on an empty stomach at least one hour before meals or two hours afterward. Tetracycline should be given with caution in clients with renal or liver dysfunction, and blood panels should be monitored.

A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client? a. 1 cup beef broth B. 1 baked potato with the skin C. 1/2 cup raisins D. 1 cup rice

D. 1 cup rice One cup of rice is considered a low-potassium food. The foods in Answers A, B, and C are incorrect because they contain higher amounts of potassium

The physician has prescribed imipramine (Tofranil) for a client with depression. The nurse should continue to monitor the client's affect because the maximal effects of tricyclic antidepressant medication do not occur for: A. 48-72 hours B. 5-7 days C. 2-4 weeks D. 3-6 months

D. 3-6 months The maximal effects from tricyclic antidepressants might not be achieved for up to six months after the medication is started. Answers A and B are incorrect because the time for maximal effects is too brief. Answer C is incorrect because it refers to the initial symptomatic relief rather than maximal effects.

Which client is best assigned to a newly licensed nurse? A. A client receiving chemotherapy B. A clientpostcoronary artery bypass graft C. A client with a transurethral prostatectomy D. A client with diverticulosis

D. A client with diverticulosis The best client to assign to a newly licensed nurse is the client whose condition is most stable; in this case, it is the client with diverticulosis. The client receiving chemotherapy, the client with post-coronary artery bypass graft, and the client with a transurethral prostatectomy need a nurse experienced in caring for clients with these diagnoses, so Answers A, B, and C are incorrect.

A 20-year-old female has a prescription for Sumycin (tetracycline). While teaching the client how to take her medicine, the nurse learns that the client is also taking an oral contraceptive. Which instruction should be included in the teaching plan? A. Oral contraceptives will decrease the effectiveness of the tetracycline. B. Anorexia often results from taking oral contraceptives with antibiotics. C. Toxicity can result when taking these antibiotics and an oral contraceptive together. D. Antibiotics can decrease the effectiveness of oral contraceptives.

D. Antibiotics can decrease the effectiveness of oral contraceptives. Taking antibiotics and oral contraceptives together decreases the effectiveness of the oral contraceptives. Answers A, B, and C are not necessarily true.

The charge nurse is making assignments for the day. After accepting the assignment to care for a client with leukemia, the nurse tells the charge nurse that her child has chickenpox. Which initial action should the charge nurse take? A. Change the nurse's assignment to another client. B. Explain to the nurse that there is no risk to the client. C. Ask the nurse if the chickenpox have crusted. D. Ask the nurse if she has ever had the chickenpox.

D. Ask the nurse if she has ever had the chickenpox. The nurse who has had the chickenpox has immunity to the illness and will not transmit chickenpox to the client. Answer A is incorrect because there could be no need to reassign the nurse. Answer B is incorrect because the nurse should be assessed before coming to the conclusion that she cannot spread the infection to the client. Answer C is incorrect because there is still a risk, even though chickenpox has formed scabs.

The nurse is caring for a client who is taking bethanechol chloride (Urecholine) for neurogenic bladder. Which of the following does the nurse understand is correct concerning this medication? A. This is the primary treatment for clients with a urinary obstruction. B. If the client cannot swallow pills, the medication may be given by the IV or IM route. C. Urecholine should be given with food to prevent nausea and vomiting. D. Atropine sulfate should be readily available when a client receives this medication.

D. Atropine sulfate should be readily available when a client receives this medication. Atropine sulfate is the antidote for Urecholine, which can cause transient complete heart block. Urecholine is contraindicated in clients with urinary obstructions or strictures. It should never be given by IV or IM routes. It should be given on an empty stomach to decrease the risk of nausea and vomiting.

A client is admitted with a Ewing's sarcoma. Which symptom would be expected due to this tumor's location? A. Hemiplegia B. Aphasia C. Loss of balance D. Bone pain

D. Bone pain Ewing's sarcoma is a bone cancer that usually affects the flat bones such as the ribs, so bone pain would be expected. Answers A, B, and C are not associated with this type of cancer and are incorrect.

A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication? A. Processed cheese B. Cottage cheese C. Cream cheese D. Cheddar cheese

D. Cheddar cheese . The client taking MAOI, including Parnate, should avoid eating aged cheeses, such as cheddar cheese, because a hypertensive crisis can result. Answer A is incorrect because processed cheese is less likely to produce a hypertensive crisis. Answers B and C do not cause a hypertensive crisis in the client taking an MAOI; therefore, they are incorrect.

The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to: A. Continue the same caloric intake and increase the amount of fat intake B. Increase his activity level to stimulate his appetite C. Increase the amount of complex carbohydrates and decrease the amount of fat intake D. Decrease the amount of complex carbohydrates while increasing calories, protein, vitamins, and minerals

D. Decrease the amount of complex carbohydrates while increasing calories, protein, vitamins, and minerals The client with COPD needs additional calories, protein, vitamins, and minerals. Answer A is incorrect because the client needs more calories but not more fat. Answer B is not feasible, will increase the O2 demands, and will result in further weight loss. Answer C leads to excess acid production and an increased respiratory workload

A client is diagnosed with emphysema and cor pulmonale. Which findings are characteristic of cor pulmonale? A. Hypoxia, shortness of breath, and exertional fatigue B. Weight loss, increased RBC, and fever C. Rales, edema, and enlarged spleen D. Edema of the lower extremities and distended neck veins

D. Edema of the lower extremities and distended neck veins Cor pulmonale, or right-sided heart failure, is characterized by edema of the legs and feet, enlarged liver, and distended neck veins. Answer A is incorrect because the symptoms are those of left-sided heart failure and pulmonary edema. Answer B is not specific to the question; therefore, it is incorrect. Answer C is incorrect because it does not relate to cor pulmonale

The physician has ordered Prostin E2 (dinoprostone) gel to induce labor. After inserting the gel, which action should the nurse take? A. Raise the head of the bed B. Apply nasal oxygen at 2L/min C. Help the client to the bathroom D. Elevate the client's hips for 30 minutes

D. Elevate the client's hips for 30 minutes After inserting the Prostin E2 gel, the nurse should elevate the client's hips for 30 minutes to prevent loss of the gel. Answers A, B, and C do not prevent loss of the gel, so they are incorrect choices.

A client is admitted to the postpartal unit with a large amount of lochia rubra, uterine enlargement, and excessive clots. Which medication will likely be ordered for the client? A. Fentanyl (sublimaze) B. Stadol (butorphanol) C. Prepidil (dinoprostone) D. Hemabate (carboprost tromethamine)

D. Hemabate (carboprost tromethamine) Hemabate is a prostaglandin F 2∂ used to treat postpartal hemorrhage. Answers A, B, and C are not used in the treatment of postpartal hemorrhage, so they are incorrect choices.

The nurse is caring for a client with a recent laparoscopic hemicolectomy. Which finding should be reported to the physician? A. Sluggish bowel sounds B. Pain and tenderness at the umbilicus C. Passage of small amount of liquid stool D. Increasing abdominal girth

D. Increasing abdominal girth Increasing abdominal girth indicates over distention of the bowel frequently associated with the development of an ileus. Answers A, B, and C are expected following a laparoscopic hemicolectomy

A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to: A. Prevent insensible water loss B. Provide a moist environment with oxygen at 30% C. Prevent dehydration and reduce fever D. Liquefy secretions and relieve laryngeal spasm

D. Liquefy secretions and relieve laryngeal spasm The primary reason for placing a child with croup under a high humidity mist tent is to liquefy secretions and relieve laryngeal spasms. Answers A, B, and C are inaccurate statements; therefore, they are incorrect.

A school nurse is explaining the dangers of anabolic steroid use to a group of high school athletes. Which organ is adversely affected by the use of anabolic steroids? A. Kidney B. Stomach C. Pancreas D. Liver

D. Liver Anabolic steroids are toxic to the liver, especially if used with other drugs that are also hepatotoxic. Answers A, B, and C are not organs affected the most by the use of anabolic steroids; therefore, they are incorrect

The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client? A. Potato chips B. Diet cola C. Apple D. Milkshake

D. Milkshake The milkshake will provide needed calories and nutrients for the client with mania. Answers A, B, and C are incorrect choices because they do not provide as many calories or nutrients as the milkshake

A client is admitted following the repair of a fractured tibia with cast application. Which nursing assessment should be reported to the physician? A. Pain beneath the cast B. Warm toes C. Pedal pulses weak and rapid D. Paresthesia of the toes

D. Paresthesia of the toes Paresthesia of the toes is not normal and can indicate compartment syndrome. At this time, pain beneath the cast is normal and, therefore, would not be reported as a concern. The client's toes should be warm to the touch, and pulses should be present. Answers A, B, and C, then, are incorrect

The nurse is caring for an obstetrical patient admitted with HELLP syndrome. The nurse anticipates an order for which medication? A. Yutopar (ritodrine) B. Brethine (terbutaline) C. Methergine (methylergonovine) D. Pitocin (oxytocin)

D. Pitocin (oxytocin) The nurse should anticipate an order for Pitocin to begin contractions. The treatment of the patient with HELLP syndrome is delivery of the fetus. Answers A, B, and C are incorrect because ritodrine and terbutaline are used to treat premature labor, and methylergonovine is used to treat postpartal hemorrhage.

The following are all nursing diagnoses appropriate for a gravida 4 para 3 in labor. Which one would be most appropriate for the client as she completes the latent phase of labor? A. Impaired gas exchange related to hyperventilation B. Alteration in placental perfusion related to maternal position C. Impaired physical mobility related to fetal-monitoring equipment D. Potential fluid volume deficit related to decreased fluid intake

D. Potential fluid volume deficit related to decreased fluid intake Clients admitted in labor are not to eat or drink. Ice chips might be allowed, but the amount of fluid might not be sufficient to prevent fluid volume deficit. Answers A, B, and C are not the most appropriate for the client completing the latent phase of labor, so they are incorrect.

In evaluating the effectiveness of IV Pitocin (oxytocin) for a client with secondary dystocia, the nurse should expect: A. A rapid delivery B. Cervical effacement C. Infrequent contractions D. Progressive cervical dilation

D. Progressive cervical dilation The expected effect of Pitocin (oxytocin) is progressive cervical dilation. Answers A, B, and C are not associated with the use of Pitocin.

The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P wave B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval

D. Prolonged QT interval Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, vertigo, headache, visual disturbances, and confusion. Answers A, B, and C are not related to the use of quinidine

A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is: A. Loss of sensation in the lower extremities B. Back pain that lessens when standing C. Decreased urinary output D. Pulsations in the periumbilical area

D. Pulsations in the periumbilical area The client with an abdominal aortic aneurysm frequently complains of pulsations or feeling the heart beat in the abdomen. Answers A and C are incorrect because they are not associated with abdominal aortic aneurysm. Answer B is incorrect because back pain is not affected by changes in position.

The physician has ordered an alkaline ash diet for a patient with recurrent cysteine kidney stones. Which of the following should be included in the patient's diet? A. Cranberries B. Grapes C. Plums D. Rhubarb

D. Rhubarb The client prescribed an alkaline ash diet should consume rhubarb, legumes, milk and milk products, and green vegetables. Answers A, B, and C are found on an acid ash diet and should be limited

The nurse is providing dietary instructions to the mother of a fouryear-old diagnosed with celiac disease. Which food, if selected by the mother, would indicate her understanding of the dietary instructions? A. Wheat toast B. Spaghetti C. Oatmeal D. Rice

D. Rice Selection of a food that contains little or no gluten indicates that the mother understands the dietary instruction. The child with celiac disease should be on a gluten-free diet. Gluten is primarily contained in grains such as wheat, oats, barley, and rye. The grains are replaced with rice, corn, and millet. Answers A, B, and C contain gluten, so they are incorrect choices

The first exercise that should be performed by the client who had a mastectomy one day earlier is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball

D. Squeezing a ball The first exercise that should be done by the client following a mastectomy is squeezing the ball. Answers A, B, and C are incorrect because they are performed later

The nurse notes that a post-operative client's respirations have dropped from 14 to 6 breaths per minute. The nurse administers Narcan (naloxone) per standing order. Following administration of the medication, the nurse should assess the client for: A. Pupillary changes B. Projectile vomiting C. Wheezing respirations D. Sudden, intense pain

D. Sudden, intense pain Narcan is a narcotic antagonist that blocks the effects of the client's pain medication; therefore, the client will experience sudden, intense pain. Answers A, B, and C do not relate to the client's condition and the administration of Narcan; therefore, they are incorrect.

A nurse is preparing a client scheduled for a right mastectomy. Which statement indicates the need for further intervention? A. The client refuses to sign the blood consent since she is a Jehovah's Witness. B. The client identifies the right breast as the surgical site for a right mastectomy. C. The client signs the consent form with an X, which is witnessed by two licensed personnel. D. The client expresses doubt over her decision and asks the nurse to explain more about the procedure.

D. The client expresses doubt over her decision and asks the nurse to explain more about the procedure.

Which statement describes the contagious stage of varicella? A. The contagious stage is one day before the onset of the rash until the appearance of vesicles. B. The contagious stage lasts during the vesicular and crusting stages of the lesions. C. The contagious stage is from the onset of the rash until the rash disappears. D. The contagious stage is one day before the onset of the rash until all the lesions are crusted.

D. The contagious stage is one day before the onset of the rash until all the lesions are crusted. The contagious stage of varicella begins 24 hours before the onset of the rash and lasts until all the lesions are crusted. Answers A, B, and C are inaccurate regarding the time of contagion.

A two-year-old is hospitalized with a diagnosis of Kawasaki's disease. A severe complication of Kawasaki's disease is: A. The development of Brushfield spots B. The eruption of Hutchinson's teeth C. The development of coxa plana D. The creation of a giant aneurysm

D. The creation of a giant aneurysm . A severe complication associated with Kawasaki's disease is the development of a giant aneurysm. Answers A, B, and C are incorrect because they have no relationship to Kawasaki's disease.

A mother asks why her newborn has lost weight since his birth one week ago. The best explanation of weight loss in the newborn is: A. The newborn is dehydrated. B. The newborn is hypoglycemic. C. The newborn is not used to the formula. D. The newborn loses weigh because of the passage of meconium stools and loss of fluid.

D. The newborn loses weigh because of the passage of meconium stools and loss of fluid. A newborn normally loses weight in the first week of life. A loss of 10% is normal due to the passage of meconium stools and fluid loss. There is no evidence to indicate dehydration, hypoglycemia, or problems with formula are the result of the weight loss; therefore, Answers A, B, and C are incorrect.

The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that: A. There is no test to measure abnormal hemoglobin in newborns. B. Infants do not have insensible fluid loss before a year of age. C. Infants rarely have infections that would cause them to have a sickling crises. D. The presence of fetal hemoglobin protects the infant.

D. The presence of fetal hemoglobin protects the infant. The presence of fetal hemoglobin until about six months of age protects affected infants from episodes of sickling. Answer A is incorrect because it is an untrue statement. Answer B is incorrect because infants do have insensible fluid loss. Answer C is incorrect because respiratory infections such as bronchiolitis and otitis media can cause fever and dehydration, which cause sickle cell crisis.

As the client reaches 8 cm dilation, the nurse notes a pattern on the fetal monitor that shows a drop in the fetal heart rate of 30 beats per minute beginning at the peak of the contraction and ending at the end of the contraction. The FHR baseline is 165-175 beats per minute with a variability of 0-2 beats per minute. What is the most likely explanation of this pattern? A. The fetus is asleep. B. The umbilical cord is compressed. C. There is a vagal response. D. There is uteroplacental insufficiency.

D. There is uteroplacental insufficiency. The most likely explanation for the pattern is late deceleration. This type of deceleration is caused by uteroplacental insufficiency, or lack of oxygen. Answer A is incorrect because there is no data to support the conclusion that the fetus is asleep, Answer B is incorrect because cord compression results in a variable deceleration, and Answer C is incorrect because it is indicative of an early deceleration.

A five-year-old child is hospitalized for correction of congenital hip dysplasia. During the assessment of the child, the nurse can expect to find the presence of: A. Scarf sign B. Harlequin sign C. Cullen's sign D. Trendelenburg sign

D. Trendelenburg sign The nurse can expect to find the presence of Trendelenburg sign. (While bearing weight on the affected hip, the pelvis tilts downward on the unaffected side instead of tilting upward, as expected with normal stability.) Scarf sign is a characteristic of the preterm newborn; therefore, answer A is incorrect. Harlequin sign can be found in normal newborns and indicates transient changes in circulation; therefore, answer B is incorrect. Answer C is incorrect because Cullen's sign is an indication of intra-abdominal bleeding.

The nurse is assisting in the care of a patient who is two days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to: A. Avoid a high-fiber diet B. Continue to apply ice packs C. Take a laxative daily to prevent constipation D. Use a sitz bath after each bowel movement

D. Use a sitz bath after each bowel movement The use of a sitz bath will help with the pain and swelling associated with a hemorrhoidectomy. The client should eat foods high in fiber, so answer A is incorrect. Ice packs, as stated in answer B, are ordered immediately after surgery only. Answer C is incorrect because taking a laxative daily can result in diarrhea.

A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately? A. Prepare an injection of vitamin K B. Irrigate the urinary catheter with 50 mL of normal saline C. Offer the client additional oral fluids D. Withhold the medication and notify the physician

D. Withhold the medication and notify the physician Urokinase is a thrombolytic agent used in the treatment of deep vein thrombosis, pulmonary embolus, or myocardial infarction. The presence of dark brown or rust-colored urine suggests bleeding. The nurse should withhold the medication, call the doctor immediately, and prepare to administer Amicar. Answer A is incorrect because vitamin K is not the antidote for urokinase. Answers B and C are incorrect because they do not address the adverse problem of bleeding.

The nurse is caring for a client who has an order for ceftriaxone IV. The client is awake and alert and has been taking PO medications and eating. The IV ceftriaxone is not available in the automatic medication dispenser. What should the nurse do next? A. hold the medication since the client is afebrile B. call the pharmacy to send up the missing IV medication C. obtain the PO ceftriaxone from the medication dispenser and administer it D. call the health care provider and see if the client can be switched over to oral ceftriaxone

D. call the health care provider and see if the client can be switched over to oral ceftriaxone If the client is eating and tolerating meals, the nurse should ask the health care provider if the client can take the medication in PO form. The oral form is more convenient for the client and lessens the need to repeatedly access the IV, which increases the risk of infection. If the health care provider declines to change the form of the medication, the nurse would then contact the pharmacy for the missing medication. The nurse should not hold medication without notifying the health care provider, nor should the nurse administer medication in a form different from what was ordered.

The nurse is caring for a client with abdominal aortic aneurysm. Which observation by the nurse indicates the need for immediate intervention? A. complaints of yellow-tinted vision B. sudden onset of frothy, pink sputum C. urinary output of 75 mL/hr. per urinary catheter D. complaints of sudden and severe back pain and shortness of breath

D. complaints of sudden and severe back pain and shortness of breath Sudden back pain and shortness of breath indicate rupture of the aneurysm, which is an emergency. The nurse should notify the health care provider, monitor neurological and vital signs, and remain with the client. Yellow-tinted vision is a finding of digitalis toxicity. Frothy, pink sputum is a sign of pulmonary edema. Urinary output of 75 mL/hr. is a normal urinary output.

The nurse is taking a history from a client in an outpatient clinic. The client has been taking duloxetine (Cymbalta) for fibromyalgia. Which of the following over-the-counter medications would cause the nurse some concern if the client says she is taking it? A. aspirin B. garlic supplements C. vitamin B6 D. cough medicine with dextromethorphan

D. cough medicine with dextromethorphan Cymbalta increases the body's serotonin level. A rare but life-threatening condition called serotonin syndrome may occur when someone takes two or more medications that increase the body's serotonin levels. Cough medicines that contain dextromethorphan may interact with Cymbalta and cause serotonin syndrome. The other over-the-counter medications have no known interaction with Cymbalta.

The nurse is admitting a client with schizophrenia. The client is extremely socially withdrawn, is unable to perform activities of daily living, has an inappropriate affect, and has grimacing mannerisms. The nurse understands that this client is experiencing which type of schizophrenia? A. residual schizophrenia B. paranoid schizophrenia C. catatonic schizophrenia D. disorganized schizophrenia E. undifferentiated schizophrenia

D. disorganized schizophrenia Characteristics of disorganized schizophrenia include extreme social withdrawal, inability to perform activities of daily living, inappropriate affect, and grimacing mannerisms. Residual schizophrenia is characterized by being diagnosed with schizophrenia in the past, extreme social isolation, and impaired role functioning. Several years may pass between episodes. Paranoid schizophrenia includes hostility, delusions, violence, persecutory themes, and suspiciousness. Clients with catatonic schizophrenia experience waxy flexibility, psychomotor disturbances, stupor, and excessive purposeless motor activity. They may also be automatically obedient to directions and exhibit stereotypical or repetitive behaviors. Undifferentiated schizophrenia does not meet the definition of paranoid, disorganized, or catatonic schizophrenia. It is characterized by disorganized speech, delusions and hallucinations, flat affect, social withdrawal, and catatonic or disorganized behavior.

The nurse is caring for an elderly female client in an extended-care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate? A. provide written materials to explain medications B. stand in front of the client when addressing her C. limit room lighting to create a relaxed environment D. encourage use of radio and CDs

D. encourage use of radio and CDs Auditory diversional activities, such as radios and CDs, should be encouraged. Regular-size printed material will not be readable. Instead, provide the client with large-size printed instructions. Stand to the side of the client when addressing her as central vision is impaired with AMD. Adequate lighting, such as natural or halogen, is preferred to improve vision for patients with limited acuity.

While driving, the client forgets how to get home. Which lobe could be dysfunctional? A. temporal B. parietal C. occipital D. frontal

D. frontal The frontal lobe regulates intellectual functions, such as complex problem solving. The temporal lobe regulates memory, speech, and comprehension. The parietal lobe regulates reading ability, writing ability, and spatial relationships. The occipital lobe is responsible for vision function.

The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply. A. hypertension; slow, labored breathing B. decreased urine output; warm, pink skin C. increased urine output; cool, clammy skin D. hypotension; weak pulse; cool, clammy skin

D. hypotension; weak pulse; cool, clammy skin Classic signs of cardiogenic shock include a rapid pulse that weakens; cool, clammy skin; and decreased urine output. Hypotension is another classic sign.

The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client's risk of skin breakdown? A. high risk B. mild risk C. severe risk D. moderate risk

D. moderate risk This client is at moderate risk for skin breakdown. The Braden scale is a tool used to assess client's risk of skin breakdown. A score of 15 - 16 indicates mild risk, 12 - 14 indicates moderate risk, and a score of less than 11 indicates severe risk.

The nurse is preparing her client for an MRI to evaluate intracranial hemorrhage. Which finding in the client history would prompt the nurse to notify the health care provider? A. vertigo B. atrial fibrillation C. allergy to contrast dye D. past military duty in Iraq

D. past military duty in Iraq Metallic items including shrapnel cannot go into an MRI because they can become dislodged. If a client has past military duty, further questioning should be done to determine if he served in combat and was exposed to any shrapnel. Caution should also be used with anyone who may have had a gunshot wound in the past. Vertigo, atrial fibrillation, and allergy to contrast dye do not affect an MRI. Clients with allergy to contrast dye may require prophylactic treatment before undergoing a CT with contrast.

The nurse is assisting the health care provider to perform a renal biopsy. Which position should the nurse place the client in? A. in the semi-Fowler's position B. on the same side of the kidney to be biopsied C. on the side opposite of the kidney to be biopsied D. prone with a pillow under the shoulders and abdomen

D. prone with a pillow under the shoulders and abdomen Clients having a renal mass removed should be placed in a prone position with a pillow under the shoulders and abdomen. Options 1, 2, and 3 are incorrect positions for this procedure.

A client is having a tonic-clonic seizure. Which of the following should the nurse do first ? A. call for assistance B. restrain the client C. turn the client on her side D. provide a safe environment

D. provide a safe environment As safety is the top priority during seizure activity, the nurse should remove any objects in the immediate area that may cause the client harm. Calling for assistance is not the first course of action. Restraining a client during a seizure is contraindicated. Turning the client on her side is important yet it is a secondary action.

Which treatment should be included in the immediate management of acute appendicitis? A. prevent fluid volume deficit B. administer antibiotic therapy C. reduce anxiety D. relieve pain

D. relieve pain Relieving pain is the most immediate need for management. Preventing fluid volume deficit by infusion of IV fluids should occur once the client has experienced initial control of pain. Administration of antibiotic therapy will be important during the recovery phase. Reducing anxiety is important and will be partially addressed with the reduction of pain

Which precaution must a nurse take when checking the blood pressure of an HIV-positive client? A. wear gloves B. wear a gown C. use contact precautions D. wash hands

D. wash hands Washing hands is sufficient since taking a client's blood pressure does not involve contact with blood or secretions. The other listed precautions would be appropriate if blood or secretions is involved

rivaroxaban nursing considerations

Dose reduction required in renal impairment PO: give doses greater than 15 mg with food; lower doses may be given without regard to food Stop med 24 hours before surgery Monitor closely for signs of bleeding or excessive bruising Rx; Preg Cat C

infectious mononucleosis

Epstein Barr virus, incubation 4-6 weeks. Oral secretions, blood transfusions, or transplantation. Direct intimate contact

Contraceptives

Estrogen-progestin combinations suppress ovulation and change cervical mucus making it difficult for sperm to enter. Those only containing progestin are less effective than combined. Usually taken for 21 days and stopped for 7

dystocia assessment

Excessive abdominal pain Abnormal contraction pattern Fetal distress Maternal or fetal tachycardia Lack of progress in labor

A client is crying and grimacing but denies pain and refuses pain medication because "my brother is a drug addict and has ruined our lives." What is the priority intervention for this client? a. Encourage expression of fears and past experiences b. Provide accurate information about the use of pain medication c. Explain that addiction is unlikely among acute care clients d. Seek family assistance in resolving this problem

a. Encourage expression of fears and past experiences This client has strong beliefs and emotions related to the issue of the brother's addiction. First, encourage expression. This indicates to the client that the feelings are real and valid. It is also an opportunity to assess beliefs and fears. Giving facts and information is appropriate at the right time. Family involvement is important, and their beliefs about drug addiction may be similar to those of the client.

A client who is 34 weeks pregnant is admitted to the labor and birth room with the diagnosis of preeclampsia. The client's vital signs are as follows: BP 149/92 mmHg, pulse 62 bpm, RR 18 breaths/min, temp 98.4 F. What is the priority intervention? a. Encourage the client to lie in a lateral position b. administer an antihypertensive agent c. notify the HCP of the client's BP d. check the cervix

a. Encourage the client to lie in a lateral position Attempt to lower the BP by putting the client in left lateral position. Other interventions may be appropriate later.

fetal distress assessment

FHR < 100 bpm or > 160 bpm, meconium stained amniotic fluid, fetal hypoactivity or hyperactivity, progressive decrease in baseline variability, severe variable decels, late decels

The nurse is given an order to give the client milrinone (Primacor). For what reason might this drug be ordered? a. For congestive heart failure b. For hypertension c. For cardiac arrhythmias d. For bradycardia

a. For congestive heart failure

The client is given an alpha agonist. What might it be used for? a. For hemostasis b. To dilate the arteries c. To dilate the veins d. To decrease afterload

a. For hemostasis Alpha agonists can be given for hemostasis in cases of bleeding. They act as vasoconstrictors, raising the blood pressure. They do not decrease afterload but instead increase afterload through vasoconstriction

endometritis interventions

Fowler's position to facilitate drainage of lochia, private room, no need to isolate newborn. Proper handwashing, contact precautions, I&O and fluid intake, IV abx. Back rubs, position changes, pain meds. Oxytocin may be prescribed

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? a. contraction duration of 95 sec. b. contraction frequency of every 3 min c. contraction intensity of 45 mmHg d. uterine resting tone of 10 mmHg

a. contraction duration of 95 sec. Uterine contractions decrease circulation through the spiral arterioles and the intervillous space which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-90 sec. A duration exceeding 90 sec can result in reduction of blood flow to the placenta due to uterine hypertonicity. Uterine frequency should be 2-5 contractions every 10 min. If contractions occur less than 2 min apart, fetal distress can occur. The intensity of contractions should be 25-50 mmHg. Intrauterine pressure of more than 80 mmHg is a sign of hypertonicity of the uterus. Uterine resting tone of 20 mmHg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and the fetus, ensuring well oxygenation

An infant of a birth parent infected with HIV is seen in the clinic each month and is being monitored for sx indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assess the infant for which sign? a. cough b. liver failure c. watery stool d. nuchal rigidity

a. cough The most common opportunistic infection of children infected with HIV is PJP. Cough is a common sign of this infection. Cytomegalovirus infection is also opportunistic but is not the most common. Liver failure is a common sign of this complication.

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with their skin? a. crusting b. wrinkling c. deepening of expression lines d. thinning and loss of elasticity in the skin

a. crusting wrinkling, deepening of expression lines and thinning and loss of elasticity in the skin are all expected

psoriasis treatment

GC: mild, should not be applied to face, groin, axilla or genitalia Tazarotene: vitamin A derivative, local reactions include itching, burning, stinging, dry skin, and redness, others include rash, desquamation, contact dermatitis, inflammation, fissuring and bleeding. Sensitization to sunlight can occur. Medication usually applied once daily in evening to dry skin. Calcipotriene: analog of vitamin D, can cause local irritation, high dose applications rarely have caused hypercalcemia coal tar: suppresses DNA synthesis, miotic activity and cell proliferation. Has an unpleasant odor and may cause irritation, burning, stinging, can also stain the skin and increase sensitivity to sun. May increase risk for cancer. Keratolytics: soften scales and loosen horny layer of skin, resulting in minimal peeling to extensive desquamation. Salicylic acid: can be absorbed systemically and can cause salicylism, which is dizziness and tinnitus, hyperpnea and psych disturbances. Not applied to large surface areas or open wounds. Sulfur: promotes peeling and drying and used to treat acne, dandruff, seborrheic dermatitis and psoriasis systemic: methotrexate: reduce proliferation of epidermal cells. Can be toxic, cause GI effects such as diarrhea and ulcerative stomatitis and bone marrow depression leading to blood dyscrasias. Can be hepatotoxic. Teratogenic. acitretin: inhibits keratinization, proliferation and differentiation of cells, has antiinflammatory and immunomodulator actions, used for severe and those who have not responded to safer meds. D/C in pregnancy. Dermatological effects include hair loss, skin peeling, dry skin, rash, pruritus, and nail disorders, others include rhinitis from mucous membrane irritation, inflammation of the lips, dry mouth, dry eyes, nosebleed, gingivitis, stomatitis, bone and joint pain, and spinal disorders. Can be hepatotoxic, elevated TG and reduce HDL. Should not be taken with EtOH, vitamin A or tetracycline. Cyclosporine: immunosuppressant that inhibits proliferation of B and T cells, can be toxic and cause kidney damage. Used for severe and those who have not responded to safer meds. Systemic biological (should be tested for TB or other infections before use). Injected into skin or blood, they block the altered immune system. Some are TNF-a blockers, some bind to inflammation and cause IL, some are human ab against IL. ADR include URTI, abdominal pain, HA, rash, infection site reactions and UTI. They may promote serious infections, such as bacterial sepsis, invasive fungal infections, TB and reactivation of hep B. Some increase risk of developing lymphoma. CI for certain cancers, severe or recurrent infections, HF or demyelinating neuro diseases, caution in numbness and tingling. Should not receive any live virus vaccines. Should not receive BCG vaccine during 1 year before and after taking. Phototherapy: coal tar and UVB irradiation photochemotherapy (psoralen and UVA)

naproxen ADR

GI bleeding, blood dyscrasias, tinnitus, insomnia, vision changes, rash, angioedema, jaundice, tachycardia, GI disturbance

Prostaglandins ADR

GI effects such as diarrhea, N/V and cramps, fever, chills, flushing, HA and hypotension. Uterine tachysystole (>/= 12 contractions in 20 min without alteration in FHR), hyperstimulation of uterus, fetal passage of meconium.

tramadol nursing considerations

Give with antiemetic for nausea, vomiting Take with or without food May cause serotonin or neuroleptic malignant syndrome-like reactions Avoid OTC medications unless approved by provider Rx

Scarlet fever

Group A B hemolytic strep, incubation period 2-5 days, with range of 1-7 days. Communicable about 10 days during the incubation period and clinical illness, during the first 2 weeks of the carrier stage, although may persists for months. Nasopharyngeal secretions of infected person and carriers. Direct contact with infected person or droplet spread, indirectly by contact with contaminated articles, ingestion of contaminated milk or other foods

brain tumor assessment

HA worse on awakening and improves during the day, vomiting unrelated to feeding or eating, ataxia, seizures, behavioral changes, clumsiness, awkward gait, diplopia, facial weakness

carboprost ADR

HA, N/V/D, fever, tachycardia, HTN

loratadine ADR

HA, dry mouth, diarrhea, rash, stomach pain, tachycardia

ibuprofen ADR

HA, tinnitus, nausea, anorexia, dizziness, blood dyscrasias, constipation, GI bleeding

Contraceptive CI

HTN, thromboembolic disease, CVA or CAD, estrogen dependent cancers and pregnancy.

Oxytocin intervention

Have mg sulfate available. Monitor VS q15 min esp BP and HR, weight, I&O, LOC and lung sounds. Monitor contractions, FHR, Use IV infusion device. Administer O2 if needed. Monitor for hypertonic contractions and nonreassuring FHR. Signs of water intoxication.

The cervix of a 15-year-old primigravid client admitted to the labor area is 2 cm dilated and 50% effaced. Her membranes are intact, and contractions are occurring every 5 to 6 minutes. Which of the following should the nurse recommend at this time? a) Walking around in the hallway. b) Sitting in a comfortable chair for a period of time. c) Resting in the right lateral recumbent position. d) Lying in the left lateral recumbent position.

a) Walking around in the hallway. Most authorities suggest that a woman in an early stage of labor should be allowed to walk if she wishes as long as no complications are present. Birthing centers and single room maternity units allow women considerable latitude without much supervision at this stage of labor. Gravity and walking can assist the process of labor in some clients. If the client becomes tired, she can rest in bed in the left lateral recumbent position or sit in a comfortable chair. Resting in the left lateral recumbent position improves circulation to the fetus

Mometasone adverse effects

Hoarseness, oropharyngeal fungal infections, HA, sore throat, nasal congestion, cold symptoms, N/V/D, muscle or joint pain

Roseola

Human Herpesvirus type 6, incubation period 5-15 days, communicable period unknown but thought to extend from the febrile stage to the time the rash first appears . Unknown transmission

Erythema infectiosum (fifth disease)

Human parvovirus incubation 4-14 days, may be 20 days, communicable period uncertain but before onset of sx in most children. Source: infected person. Transmission unkown, possibly respiratory and blood.

hypertrophic pyloric stenosis interventions

I&Os, vomiting episodes and stools, daily weights, signs of dehydration and electrolyte imbalances. Pyloromyotomy if needed (incision through muscle fibers of pylorus, may be performed by laparoscopy)

buprenorphine/naloxone nursing consideratiosn

IM onset 15 min, peak 1 hour, IV onset 1 min, peak 5 min. SL onset and peak unknown. avoid hazardous activities until reaction known. Avoid alcohol and CNS depressants. Rx CV (parenteral), CIII (tablet)

Rhogam interventions

IM, not IV. monitor for temp and tenderness

Herpes zoster (shingles)

In clients with history of chicken pox, shingles is caused by reactivation of the varicella zoster virus, it can occur during any immunocompromised state in clients with history of chicken pox. The dormant virus is located in the dorsal nerve root ganglia of the sensory cranial and spinal nerves. Eruptions occur in a segmental distribution on the skin along the infected nerve and show up after several days of discomfort in the area. Diagnosis is determined by visual exam and by Tzanck smear to verify a herpes infection and viral culture. Postherpetic neuralgia can remain after the lesions resolve. it is contagious to individuals who never had chicken pox and who have not been vaccinated against the disease.

enoxaparin nursing considerations

Injection: subQ; can be given IV during cardiac procedures Do not use in patients with a history of heparin-induced thrombocytopenia Use with caution in patients with impaired renal function or morbid obesity Monitor closely for signs of bleeding or excessive bruising Stop med 12-24 hours before surgery Rx; Preg Cat B

Iron deficiency anemia

Iron stores are depleted, resulting in decreased supply of iron for manufacture of Hgb in RBC, RBC are microcytic and hypochromic. Excessive cow's milk intake (>/= 24 oz/day), lack of adequate consumption of food rich in iron. Iron supplementation should not be taken w/ milk

Which instruction should the nurse include in discharge teaching for a client who is newly diagnosed with ulcerative colitis and prescribed methotrexate? Select all that apply. a. "A low-fiber, high-protein, high-calorie diet is important." b. "You should restrict your intake of fluid each day drinking no more than 1 liter." c. "avoid using NSAIDs such as ibuprofen for aches and pains." d. "You may be more susceptible to illnesses while taking this medication" e. "You should continue to take your prescribed medication even if symptoms resolve."

a. "A low-fiber, high-protein, high-calorie diet is important." c. "avoid using NSAIDs such as ibuprofen for aches and pains." d. "You may be more susceptible to illnesses while taking this medication" e. "You should continue to take your prescribed medication even if symptoms resolve." This low residue diet lessens trauma to the colon thus decreases symptoms.Fluids should be increased to two or three L per day, not restricted to help maintain fluid and electrolyte balance for a client who is diagnosed with ulcerative colitis. The inflamed colon and diarrhea make it hard for the colon to absorb fluid and nutrients.

A nurse is reinforcing dietary teaching to a client who has T2DM. Which of the following instructions should the nurse include? select all that apply a. "Carbs should comprise 55% of daily caloric intake." b. "use hydrogenated oils for cooking." c. "You can add table sugar to cereals." d. "Eat something if you choose to drink alcohol." e. "Use the same portion sizes to exchange carbs."

a. "Carbs should comprise 55% of daily caloric intake." c. "You can add table sugar to cereals." d. "Eat something if you choose to drink alcohol." e. "Use the same portion sizes to exchange carbs."

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? a. "Do you have any allergies?" b. "Will you be able to wash your own hair?" c. "Are there any areas you want us to spend more time bathing?" d. "Do you have any preferences regarding how we help you bathe?"

a. "Do you have any allergies?"

The nurse conducts a nutritional screening for an infant who is three months of age and diagnosed with a congenital heart defect (CHD). Which question is appropriate for the nurse to include when collecting data from the child's caregiver? Select all that apply. a. "Does your child spit up frequently?" b. "Is your child holding the bottle with feedings?" c. "What type of formula do you give to your baby?" d. "How long does your child take to finish a bottle?" e. " What was your child's weight at the last visit to the cardiologist?"

a. "Does your child spit up frequently?" c. "What type of formula do you give to your baby?" d. "How long does your child take to finish a bottle?" e. " What was your child's weight at the last visit to the cardiologist?" Excess energy expenditure that is associated with bottle feeding that takes longer than 20 minutes must be addressed to ensure adequate nutritional intake; therefore, this question is appropriate for the nurse to include in the nutritional screening.

An antenatal client is discussing her anemia with the nurse in the prenatal clinic. After a discussion about sources of iron to be incorporated into her daily meals, the nurse knows the client needs further instruction when she responds with which statement? a. "I can meet two goals when I drink milk: lots of iron and meeting my calcium needs at the same time." b. "Drinking coffee, tea and sodas decreases the absorption of iron." c. "I can increase the absorption of iron by drinking orange juice when I eat." d. "Cream of wheat and molasses are excellent sources of iron."

a. "I can meet two goals when I drink milk: lots of iron and meeting my calcium needs at the same time."

fexofenadine purpose

Management of rhinitis and allergy symptoms

A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking the contraceptives. The nurse realizes the client needs further explanation when she makes which statement? a. "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." b. "my boyfriend can buy levonorgestrel from the pharmacy if he is over 18 years old." c. "The birth control works by preventing ovulation or fertilization of the egg." d. "I may feel nauseated and have breast tenderness or a HA after using the contraceptive."

a. "I can wait up to 4 days after intercourse to start taking these to prevent pregnancy." Levonorgestrel can reduce the chance of pregnancy if taken within 72 hours of unprotected intercourse, and then 12 hours after.

Ergot alkaloid

Methylergonovine maleate directly stimulates uterine muscle, increases the force and frequency of contractions and produces a firm tetanic contraction of the uterus. Can produce arterial vasoconstriction and vasospasm of coronary arteries. Administered postpartum not before birth of placenta. Used for postpartum hemorrhage.

Medications for postpartum hemorrhage

Methylergonovine, oxytocin, Prostaglandin (carboprost tromethamine)

opioid interventions

Monitor VS, esp resp rate, FHR and contractions, BP changes (hypotension), maintain client in recumbent position (elevate hip with wedge pillow). Record pain relief level, monitor for ladder distention and retention. Have naloxone ready

contraceptive interventions

Monitor VS, instruct adminsitration of medication (may take up to 1 week for full effect), monitor blood glucose, report signs of thromboembolic complications, notify OB if vaginal bleeding or menstrual irregularities. Use alternative method of birth control when taking abx, BSE regularly and annual exams

Dystocia Interventions

Monitor for fetal distress ○ Notify the health care provider for any fetal distress ● Medications ○ Pain medications ○ IV Fluids ○ Tocolytics ■ Given for hypertonic contractions (terbutaline & mag sulfate) ○ Oxytocin ■ Given for hypotonic contractions ● Rest between contractions! Need to focus during contractions. ● Patients with hypotonic contractions may be encouraged to walk to try and get the contractions into a pattern. abx to prevent infection, change maternal position frequently. Rest and comfort, assess fatigue and pain.

CF interventions

Monitor resp status, chest physiotherapy, use a Flutter, a mucus clearance device. Forced expiratory technique (huffing) to mobilize secretions for expectoration. Bronchodilator medication. Physical exercise program, Abx, O2. Lung transplant may be an option. High calorie, high protein and well balanced diet, multivitamins and ADEK. Replace pancreatic enzymes. Monitor for GERD. Monitor BG and salt intake. Signs of retinopathy or nephropathy.

aspirin ADR

N/V, rash, dyspnea, tinnitus, GI bleeding

triamcinolone nursing considerations

Nasal spray: onset few days, peak 3-4 days PO/IM: peak 1-2 hours Use regular peak flow monitoring to determine respiratory status Rx; Preg Cat C

mometasone nursing considerations

Nasal spray: onset few days, peak up to 3 weeks Use regular peak flow monitoring to determine respiratory status Rx; Preg Cat C

fluticasone nursing considerations

Nasal spray: onset within 2 days, peak 1-2 weeks Use regular peak flow monitoring to determine respiratory status Rx; Preg Cat C

Phytonadione

Newborn is at risk for hemorrhagic disorders because coagualtion factors synthesized in liver depend on phytonadione which is not synthesized until intestinal bacteria are present. Newborns are deficient for first 5-8 days of life

Which client statement signifies to the nurse that additional teaching is necessary regarding the diagnosis of vaginal candidiasis and the prescribed clotrimazole for treatment? Select all that apply. a. "I should always wipe front to back to decrease my risk for getting another bacterial infection." b. "It is best to use the cream at bedtime so that it can remain in place for several hours." c. "My partner will need to be tested so we don't pass this back and forth." d. "sexual intercourse will need to be avoided for the duration of treatment." e. "Voiding after intercourse will prevent the risk of UTI."

a. "I should always wipe front to back to decrease my risk for getting another bacterial infection." c. "My partner will need to be tested so we don't pass this back and forth." e. "Voiding after intercourse will prevent the risk of UTI." It is best to abstain from sexual intercourse until the inflammation associated with vaginal candidiasis resolves; therefore, this statement indicates a correct understanding of the information presented regarding the treatment of this fungal infection.

After instructing a primiparous client who is bottle feeding about burping, which client statement indicates that the client needs further teaching? a. "I will burp him after 15 min of feeding him formula." b. "After he takes 1/2 oz of formula, I will burp him." c. "I will burp him while he is in an upright position." d. "I will gently pat his back to get him to burp."

a. "I will burp him after 15 min of feeding him formula." The entire feeding should take only 15-20 min and the neonate should be burped before the feeding is complete.

The novice nurse provides care to neonates on the maternal-newborn unit with the assistance of a nurse preceptor. Which statement made by the novice nurse while preparing to give an intramuscular (IM) injection to a neonate requires the nurse preceptor to intervene? a. "I will clean the deltoid muscle in a circular motion and let it dry before injecting the medication." b. "I will use aseptic technique when preparing the site for administration of the injection." c. "I will draw up the medication using a small, tuberculin syringe." d. "The appropriate needle gauge for this IM injection is 22."

a. "I will clean the deltoid muscle in a circular motion and let it dry before injecting the medication." Medication that is prescribed for IM injection of the newborn is often less than 1 mL in total volume; therefore, it is appropriate to use a small, tuberculin syringe. This action does not require the nurse preceptor to intervene.

Kawasaki disease parent education

Notify if fever 101F or higher. Signs of salicylate toxicity include tinnitus, HA, vertigo and bruising. Sx of cardiac complications include chest pain or tightness, cool and pale extremities, abdominal pain, N/V, irritability, restlessness and uncontrollable crying. Avoid live vaccines

PE interventions

O2, HOB elevated, monitor for signs of resp distress, IVF and anticoagulants

postpartum hemorrhage interventions

O2, Notify OB, elevate legs to at least a 30 degree angle, check uterus, massage atonic fundus, IVF, uterotonic meds (oxytocin, prostaglandins). IVF LR or NS, client should have 2 patent IV lines, the second IV should be 16-18 G catheter. monitor VS and insert indwelling urinary catheter to monitor perfusion of kidneys. Administer blood, prepare for possible surgery

A client who is newly diagnosed with asthma is prescribed inhaled albuterol and beclomethasone. Which statements should the nurse include when providing instruction on the proper use of the prescribed medications? Select all that apply. a. "If you need both inhalers use the albuterol first to open airway." b. "Rinse your mouth and swallow the water after use of beclomethasone." c. "Use the beclomethasone metered dose inhaler as a rescue medication if you experience trouble breathing." d. "Wash the mouthpiece of albuterol inhaler at least once a week." e. Wash the mouthpiece of beclomethasone inhaler daily to decrease your risk of thrush f. "You do not need to use beclomethasone if albuterol provides you symptom relief

a. "If you need both inhalers use the albuterol first to open airway." d. "Wash the mouthpiece of albuterol inhaler at least once a week." e. Wash the mouthpiece of beclomethasone inhaler daily to decrease your risk of thrush

celecoxib nursing considerations

Onset: 24-48 hours, duration 12-24 hours Can take without regard to meals Do not take if allergic to sulfonamides, aspirin, or NSAIDs Rx

hydroxyzine nursing considerations

PO onset 15-30 min, duration 4-6 hours, avoid use w/ alcohol, CNS depressants, notify provider of dx of glaucoma, ulcers, enlarged prostate, liver disease, HTN, seizures or hyperthyroidism. Rx

diphenhydramine nursing considerations

PO peak 2-4 hours, IM onset 30 min, peak 2-4 hours, take w/ meals for GI sx, absopriton rate may slightly decrease, take at bedtime only if using as sleep iad, should be d/c 4 days before skin allergy tests, avoid driving and other hazardous activities if drowsiness occurs, avoid alcohol, CNS depressants OTC, Rx

dabigatran nursing considerations

PO: may take without regard to meals Do not crush or chew capsules Closely monitor for signs of bleeding Increased risk of bleeding when combined with aspirin, other antiplatelets, or anticoagulants Stop med 24 hours before surgery Rx; Preg Cat C

aspirin nursing considerations

PO: onset 15-30 minutes, peak 1-2 hours, duration 4-6 hours Rectal: onset slow, 20%-60% absorbed if retained 2-4 hours With long-term use, check for liver damage: dark urine, clay-colored stools, yellowing of skin and sclera, itching, abdominal pain, fever, diarrhea For arthritis, give 30 minutes before exercise; may take 2 weeks before full effect is felt Discard tablets if vinegar-like smell Do not give to children or teens with flulike symptoms or chickenpox; Reye syndrome may develop OTC; Preg Cat C

hydromorphone nursing considerations

PO: onset 15-30 minutes, peak 30-60 minutes, duration 4-6 hours IM: onset 15 minutes, peak 30-60 minutes, duration 4-5 hours IV: onset 10-15 minutes, peak 15-30 minutes, duration 2-3 hours subQ: onset 15 minutes, peak 30-90 minutes, duration 4 hours Rectal: duration 6-8 hours Do not give if respirations are less than 12 per minute Avoid use with alcohol, CNS depressants Withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia Physical dependency may result from long-term use Elderly patients may require lower doses Rx C-II; Preg Cat C

codeine nursing considerations

PO: onset 30-45 minutes, peak 60-120 minutes, duration 4-6 hours IM/subQ: onset 10-30 minutes, peak 30-60 minutes, duration 4-6 hours Do not give if respirations are less than 12 per minute Avoid use with alcohol, CNS depressants Withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia Physical dependency may result from long-term use Rx C-II, III, IV, V (depends on route); Preg Cat C

methadone nursing considerations

PO: onset 30-60 minutes, peak 30-60 minutes, duration 4-6 hours (with continuous dosing, duration of action may increase to 22-48 hours) Do not give if respirations are less than 12 per minute Avoid use with alcohol, CNS depressants Withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia Physical dependency may result from long-term use Rx C-II; Preg Cat C

acetaminophen nursing considerations

PO: onset less than 1 hour, peak 30 minutes to 2 hours, duration 4-6 hours Rectal: onset slow, peak 1-2 hours, duration 3-4 hours Take crushed or whole with full glass of water Can give with food or milk to decrease GI upset Signs of chronic poisoning: rapid, weak pulse; dyspnea; cold, clammy extremities Signs of chronic overdose: bleeding, bruising, malaise, fever, sore throat, anorexia, jaundice OTC; Preg Cat B

oxycodone nursing considerations

PO: peak 30-60 minutes, duration 4-6 hours Controlled-release: peak 3-4 minutes, duration 12 hours Do not give if respirations are less than 12 per minute Avoid use with alcohol, CNS depressants Withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia Physical dependency may result from long-term use Rx C-II; Preg Cat B (controlled-release); Preg Cat C (Percocet)

Legg-Calve-Perthes disease interventions

PT, crutches to avoid bearing weight, bed rest, casting, brace, hip replacement surgery

The nurse provides care for a school-age client who experiences frequent nosebleeds. What instruction should the nurse emphasize to the child's parents? Select all that apply. a. "If your child has difficulty breathing with a nosebleed it is important to seek immediate care." b. "Have you child lean forward when a nosebleed occurs." c. "Place an ice pack on the bridge of your child's nose when a bleed occurs." d. "Encourage your child to look up during a nosebleed." e. "It is important to teach your child to avoid triggers for the nosebleeds."

a. "If your child has difficulty breathing with a nosebleed it is important to seek immediate care." b. "Have you child lean forward when a nosebleed occurs." c. "Place an ice pack on the bridge of your child's nose when a bleed occurs." e. "It is important to teach your child to avoid triggers for the nosebleeds." Triggers for nosebleeds include picking or scratching the nose; therefore, it is important to teach the pediatric client to avoid these triggers.

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction? a. Frequently likes to sit in the hot tub to reduce joint stiffness b. Prefers to place the patch only on the upper anterior chest wall c. saves and reuses the old patches when he can't afford new ones d. Changes the patch every 4 days rather than the prescribed 72 hours

a. Frequently likes to sit in the hot tub to reduce joint stiffness According to the American Society for Pain Management Nursing, prescribing opioid medication based solely on pain intensity should be prohibited because there are many other factors to consider (e.g., age, health conditions, medication history, respiratory status). Age, small body mass, and underlying respiratory disease put the 73-year-old client at greatest risk for overmedication and respiratory depression. Clients with history of opioid addiction will have a different response to medication and may need higher doses to achieve relief. IV morphine may actually worsen migraine headaches, and other first-line drugs (metoclopramide and prochlorperazine and subcutaneous sumatriptan) are more effective. Hydromorphone is not typically prescribed for the pain associated with chronic of rheumatoid arthritis.

The nurse provides care for a pediatric client with a tracheostomy. Which assessment finding indicates that the client requires suctioning? Select all that apply a. HR of 170 bpm b. restlessness c. RR of 65 breaths per minute d. rhonchi on auscultation e. pulse ox reading of 85%

a. HR of 170 bpm b. restlessness c. RR of 65 breaths per minute d. rhonchi on auscultation e. pulse ox reading of 85%

A primigravid client has completed her first prenatal visit and blood work. Her lab test for the Hep B surface antigen (HBsAg) is +. The nurse can advise the client that the plan of care for this newborn will include which interventions? Select all that apply a. Hep B immune globulin at birth b. series of 3 Hep B vaccinations per recommended schedule c. Hep B screening when born d. Isolation of infant during hospitalization e. universal precautions for mother and infant f. CI for breastfeeding

a. Hep B immune globulin at birth b. series of 3 Hep B vaccinations per recommended schedule e. universal precautions for mother and infant The infant should not be screened or isolated because the infant is already Hep B positive. Women who are positive for Hep B surface antigen are able to breastfeed.

The clinic nurse is updating the medications being taken by an anxious middle-aged client, and sees that the physician prescribed an antidiuretic hormone. The nurse knows the medication has which of the following effects on the kidneys? a. Increases water reabsorption and urine concentration b. Decreases water reabsorption and dilutes the urine c. Regulates sodium retention d. Controls potassium secretion

a. Increases water reabsorption and urine concentration Antidiuretic hormone (ADH) is produced by the pituitary gland, and acts in the distal tubule and collecting ducts to increase water reabsorption and urine concentration

The occupational health nurse is notified that a construction worker is experiencing an anaphylactic reaction. The worker is found outside and has several layers of protective clothing on. Which action by the nurse is best? a. Inject epipen directly into the worker's thigh without removing any clothes b. take the worker's coat off, roll up the sleeve and inject epipen in the upper arm c. quickly remove as much of the client's clothing as possible and give the epipen in the thigh d. remove the worker's protective gloves and inject epipen into a vein in the hand

a. Inject epipen directly into the worker's thigh without removing any clothes While it is appropriate to administer the epinephrine into the client's thigh, it is not appropriate to remove clothing as this is a waste of time in a potentially life-threatening situation.

Which action will the nurse instruct the client to take to assist in the recovery of acute otitis media? Select all that apply. a. Limit head movement to decrease ear pain b. complete all prescribed abx c. avoid sleeping on the affected ear d. avoid blowing your nose or coughing e. Instill diluted alcohol in the ear BID

a. Limit head movement to decrease ear pain b. complete all prescribed abx

nephrotic syndrome interventions

Regular diet without added salt, Na restricted in massive edema. CS therapy, immunosuppressant therapy, diuretics, plasma expanders. Only kidney condition where you increase amount of protein

The client with a head injury is admitted into the intensive care unit (ICU). Which HCP medication order should the ICU nurse question? Select all that apply. a. Morphine. b. Mannitol. c. Methylprednisolone. d. Phenytoin. e. Oxygen.

a. Morphine. c. Methylprednisolone. Administering narcotics to clients with head injuries may mask signs of increased intracranial pressure, so the nurse questioning this medication would be appropriate. Research supports the fi nding that clients with head injuries who are treated with anti- infl ammatory corticosteroids are 20% more likely to die within 2 weeks after the head injury than those who aren't so treated. The nurse should question this medication.

Common side effects to anti-arrhythmic drugs include the following: Select all that apply. a. Nausea and vomiting b. Hypotension c. Pro-arrhythmic effect d. Constipation e. Diarrhea

a. Nausea and vomiting c. Pro-arrhythmic effect e. Diarrhea

A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The HCP asks the nurse to verify spontaneous ROM using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. What action should the nurse take next? a. Notify the HCP that the membranes are ruptured b. perform a sterile vaginal exam to assess the cervix c. document the findings of the nitrazine test d. offer the client a sterile sanitary pad after performing perineal care

a. Notify the HCP that the membranes are ruptured

The nurse is monitoinrg a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the FHR between contractions is 100 bpm. Which nursing action is most appropriate? a. Notify the PHCP b. continue to monitor the FHR c. encourage the client to continue pushing with each contraction d. instruct the client's coach to continue to encourage breathing techniques

a. Notify the PHCP

The client's first day of her last period was February 1. Which of the following should the nurse tell the client is her expected date of delivery? a. November 8 b. October 8 c. December 1 d. November 20

a. November 8 November 8 is 9 months and 7 days later.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. a. Platelets 35,000 mm3 b. sodium 150 mEq/L c. potassium 5 mEq/L d. segmented neutrophils 40% e. serum creatinine 1 mg/dL f. white blood cells, 3000 mm3

a. Platelets 35,000 mm3 b. sodium 150 mEq/L d. segmented neutrophils 40% f. white blood cells, 3000 mm3 Segmented neutrophils 62-68%

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for 2 weeks. Which suggestion would be most helpful? a. Practice relaxation techniques before bedtime. b. drink a cup of hot chocolate before bedtime c. drink a small glass of wine with dinner d. exercise for 300 minutes just before bedtime

a. Practice relaxation techniques before bedtime.

Which statement best identifies the rationale for why the nurse reinforces the need for continued prenatal care throughout the pregnancy with an adolescent primigravid client? a. Pregnant adolescents are at high risk for pregnancy-induced HTN b. Gestational DM during pregnancy commonly develops in adolescents c. Adolescents need additional instruction related to common discomforts d. The father of the baby is rarely involved in the pregnancy

a. Pregnant adolescents are at high risk for pregnancy-induced HTN Other risks for adolescents include low birth weight, preterm labor, iron deficiency anemia and cephalopelvic disproportion. gestational DM can occur with any pregnancy regardless of the age of the mother. Adolescent mothers have better nutrition when they attend group classes and are subject to peer pressure.

The nurse is caring for a 24 y/o primigravid client scheduled for emergency surgery because of a probable ectopic pregnancy. What is the most important thing for the nurse to do? a. Prepare to witness an informed consent for surgery b. assess the client for massive external bleeding c. Explain that the fallopian tube can be salvaged d. monitor the client for uterine contractions

a. Prepare to witness an informed consent for surgery Typically, if bleeding is occurring, it is internal, and there is only scant vaginal bleeding with no discoloration. The nurse cannot determine whether the fallopian tube can be salvaged, this can be accomplished only during surgery. If the tube has ruptured, it must be removed. If the tube has not ruptured, a linear salpingostomy may be done to salvage the tube for future pregnancies. With an ectopic pregnancy, although the client is experiencing abdominal pain, she is not having uterine contractions

Reye's syndrome interventions

Rest and decrease stimulation, monitored for increased ICP, signs of altered hepatic function

A client arrives at the ER with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? Select all that apply a. daily glass of white wine b. bacon and eggs on weekends c. smoking two cigars every day d. one half liter of soda daily e. baked cod twice a week f. BMI 31.5 kg/m2

a. daily glass of white wine d. one half liter of soda daily e. baked cod twice a week f. BMI 31.5 kg/m2 Large amount of purine in the body contribute to the development of crystals. Alcohol, including wines and beer, increases these crystals as do sugary drinks. Red meats like liver, kidneys and even raw steak should be avoided along with specific fish such as cod, tuna, sardines and anchovies. Another contributing factor is obesity

Rhogam CI

Rh +, hx of systemic allergy to prep w/ human immunoglobulins

Rocky mountain spotted fever

Rickettsia rickettsii, incubation 2-14 days, Tick from a mammal, most often from wild rodents and dogs. Bite of infected tick

Rubella (German measles)

Rubella virus, incubation 14-21 days. Communicable from 7 days before to about 5 days after rash appears. Source: nasopharyngeal secretions, virus also present in blood, stool and urine. Airborne or direct contact with droplets. Indirectly via articles freshly contaminated with secretions, feces or urine, transplcental

Contraceptive interventions

Should be avoided with hepatotoxic meds. Interfere with the activity of bromocriptine and anticoagulants and increase toxicity of TCA. May alter blood glucose levels. Abx decrease absorption and effectiveness of contraceptives

Sickle cell anemia

Situations that precipitate sickling include fever, dehydration and emotional or physical stress, any condition that increases the need for oxygen or alters the transport of O2 can result in sickle cell crisis.

mastitis interventions

Stress good hand washing with client, Administer antibiotics, Teach pt how to milk breasts and ease off engorgement, Teach pt how to avoid engorgement, Apply ice between feedings, fluid intake 2500-3000 mL/day, encourage manual expression of milk with use of breast pump q3-4 hours, supportive bra, analgesics

osteosarcoma interventions

Support, prep for prosthetic fitting if necessary. Assist in problems with self image. Education about potential phatom limb pain.

TORCH infections

T - toxoplasmosis O - other (syphilis) R - rubella C - cytomegalovirus H - herpes

meloxicam nursing considerations

Take without regard to meals Rx

While providing care for a client who is recovering from an abdominal aortic aneurysm (AAA) repair, which clinical manifestation should the nurse immediately report to the healthcare provider (HCP)? Select all that apply. a. decreased UOP b. HR 120 beats/min c. scrotal ecchymosis d. sudden pelvic pain e. thready pedal pulses

a. decreased UOP b. HR 120 beats/min c. scrotal ecchymosis d. sudden pelvic pain e. thready pedal pulses Surgical repair of a AAA usually involves the placement of a stent that is inserted through the femoral artery. Some clients, however, will require a surgical incision and graft placement. It is essential to monitor for, and report immediately any manifestations that are indicative of leakage or dissection. These signs and symptoms may include scrotal ecchymosis, sudden pelvic pain, tachycardia, decreased urine output, and weak/thready pulses.

A nurse is caring for a client who is pregnant and is to undergo a contraction stress test. Which of the following findings are indications for this procedure? select all that apply a. decreased fetal movement b. IUGR c. postmaturity d. placenta previa e. amniotic fluid emboli

a. decreased fetal movement b. IUGR c. postmaturity

The nurse has just answered a call light for a client who is two days post-op for abdominal surgery. The client states, "I coughed and heard this pop." The nurse assesses the surgical site and observes dehiscence of the wound. Which of the following should the nurse do FIRST? a. Stay with the client and have a colleague notify the physician. b. Help the client to lie with his head slightly elevated and with knees bent. c. Apply warm, sterile normal saline soaks. d. Help the client to sit up, which will reduce the harmful effects of further coughing.

a. Stay with the client and have a colleague notify the physician. CORRECT: The nurse should stay with the client and have a colleague notify the physician first. The second thing the nurse should do is help the client lie with his head slightly elevated (low Fowler's position) with knees bent in to decrease abdominal tension and monitor the client's vital signs. The nurse should not place anything on the wound unless it has eviscerated, and then cover the extruding wound contents with warm, sterile normal saline soaks. The nurse would not help the client to sit up. Instead, the nurse would help the client to a low Fowler's position with knees bent in to decrease abdominal tension and monitor the client's vital signs

The nursing home nurse finds a 92-year-old client on the floor during rounds. The client is not responsive. Vital signs have been taken by the certified nursing assistant: blood pressure 98/52, heart rate 120, respirations 28, and oxygen saturation 94%. The client has a history of falls, hypertension, and an extensive cardiac history. The client's chart indicates a signed physician order that states "Do not resuscitate" and "Do not intubate" (DNR/DNI). Which of the following should the nurse do? a. Stay with the client and have another staff member call 911. b. Begin CPR and have another staff member call 911. c. Move the client into the bed and call the physician. d. Call the family and ask what they would like to have done for the client.

a. Stay with the client and have another staff member call 911.

A nurse is caring for a client who is 3 days postpartum and breastfeeding her baby. The following assessment is made by the nurse: episiotomy area: red and edematous; breasts: firm and tender on palpation; fundus: firm 2 fingerbreadths below umbilicus. What nursing actions are indicated? select all that apply a. Suggest that the client apply cool compress to breasts b. encourage the client to sit on a supportive device c. ask the client how often the baby feeds d. suggest the client take cool sitz baths twice a day e. obtain specimen for C&S from episiotomy site

a. Suggest that the client apply cool compress to breasts c. ask the client how often the baby feeds The client is experiencing symptoms of engorgement. Cool compresses between feedings can help decrease swelling. Determining when the baby last fed is critical as frequent feedings can help relieve symptoms. The nurse must also assess how long the baby feeds, if it has a correct latch and if it empties breast during feeds. Sitting on supportive devices is not necessary as the episiotomy is healing. Cool sitz baths do not promote circulation to the area, instead they cause vasoconstriction and decrease blood flow to the area, delaying healing and increasing discomfort.

A client in labor is transported to the delivery room and prepared for a c section. After the client is transferred to the delivery room table, the nurse would place the client in which position? a. Supine position with a wedge under the right hip b. Trendelenburg's position with the legs in stirrups c. prone position with the legs separated and elevated d. semi-Fowler's position with a pillow under the knees

a. Supine position with a wedge under the right hip Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. A wedge placed under the right hip provides displacement of the uterus

The HCP prescribes amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. What does the nurse explain is the primary purpose of the procedure to the client? a. decreases the frequency and severity of variable decels b. minimizes the possibility of fetal metabolic alkalosis c. increases the FHR accelerations during a contraction d. raises the amniotic fluid index to more than 15 cm

a. decreases the frequency and severity of variable decels Oligohydramnios is associated with variable FHR decels due to cord compression. Maintenance of an adequate amniotic fluid volume during labor provides protective cushioning of the umbilical cord and minimizes cord compression. Cord compression can result in fetal metabolic acidosis, not alkalosis. Amnioinfusion is used to minimize cord compression, not increase the FHR accelerations during a contraction. The goal is to maintain the amniotic fluid index at 8 cm.

After teaching a diabetic primigravida about symptoms of hyperglycemia and hypoglycemia, the nurse determines that the client understands the instruction when she says that hyperglycemia may be manifested by which symptom? a. dehydration b. pallor c. sweating d. nervousness

a. dehydration Dehydration, polyuria, fatigue, flushed hot skin, dry mouth and drowsiness are manifestations of hyperglycemia. Pallor, sweating and nervous ness are early signs of hypoglycemia.

warfarin nursing considerations

Therapeutic PT @ 1.5-2.5 times the control, INR @ 2.0-3.0 Onset: 12-24 hours, peak 1.5-3 days; duration 3-5 days Avoid foods high in vitamin K: many green leafy vegetables Do not interchange brands; potencies may not be equivalent Do not take any drug or herb without provider approval—may change effect Avoid ASA-containing products and NSAIDs Oral anticoagulants may cause red-orange discoloration of alkaline urine, interfering with some lab tests Wear medical information tag Antidote: vitamin K Rx; Preg Cat X

heparin nursing considerations

Therapeutic PTT @ 1.5-2.5 times the control without signs of hemorrhage IV: peak 5 minutes, duration 2-6 hours (give over 1 minute) Injection: give deep subQ; never IM (danger of hematoma), onset 20-60 minutes, duration 8-12 hours Antidote: protamine sulfate within 30 minutes Assess for signs of hemorrhage Avoid ASA-containing products and NSAIDs Wear medical information tag Abrupt withdrawal may precipitate increased coagulability Rx; Preg Cat C

A client is admitted with a fib and HF secondary to chronic HTN. Current meds include digoxin, captopril, carvedilol, furosemide and warfarin. Based on this profile, what lab work is essential for the nurse to monitor? a. digoxin level b. potassium level c. PT/INR d. aPTT e. CPK-MB

a. digoxin level b. potassium level c. PT/INR CPK-MB goes up with MI

The nurse is reinforcing teaching to a group of parents about transmission of the chickenpox virus and the imporance of vaccination. Which modes of transmission for chickenpox should be included in the discussion? a. direct contact b. indirect contact c. airborne d. droplet e. common vehicle

a. direct contact b. indirect contact c. airborne

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2-3 minutes, with a duration of 60 seconds. An internal FHR monitor is in place. The baseline FHR has been 120-122 Bpm for the past hour. What is the priority nursing action? a. discontinue the infusion of oxytocin b. notify the PHCP c. place oxygen on at 8-10 L/min via face mask d. contact the client's primary support person if not currently present

a. discontinue the infusion of oxytocin Oxytocin cancause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse would reposition the laboring client. notifying the PHCP, applying oxygen and increasing the rate of IVF are indicated.

The nurse provides care for an adolescent client who is diagnosed with chronic kidney disease (CKD) and is prescribed hemodialysis. The client states, "I hate the way my arm looks!" Which action by the nurse is best to promote the child's body image? a. Support the client's choice for clothing b. Tell the client, "It could be much worse." c. Educate the client on why dialysis is important d. Ask the client, "Do you know anyone else with a fistula?"

a. Support the client's choice for clothing The use of fashionable and comfortable clothing that may disguise anatomic abnormalities and dialysis tubing is an intervention that can promote an adolescent's body image; therefore, supporting the adolescent's clothing choices is the best action by the nurse. Pediatric clients with disturbances in body image are often encouraged to spend time with others who have similar diagnoses as peer opinions are often better accepted than those by individuals in authority. While this is an appropriate action by the nurse it is not best as the choice of clothing is one that an adolescent independently makes thus supporting this is the best action by the nurse

The nurse is caring for a client who has a history of gastric bypass surgery and is now being seen for her first prenatal visit. Which interventions should be included in the plan of care? Select all that apply a. Take a prenatal vitamin with 400 mcg of folic acid b. Refer the client to a RD c. Draw glucose levels at each prenatal visit d. Counsel her that she will most likely gain all of her weight back e. Check urine at each visit for protein and glucose f. Monitor with nonstress tests beginning at 20 weeks

a. Take a prenatal vitamin with 400 mcg of folic acid b. Refer the client to a RD e. Check urine at each visit for protein and glucose Prenatal care includes a general supplementation of 400 mcg of folic acid, and clients with a history of gastric bypass should be referred to a dietician to determine adequate nutrient intake. All pregnant clients have their urine routinely checked for protein and sugar. There is no indication for checking glucose levels at each visit. Gastric bypass clients are not at risks of gaining all of their weight back.

The nurse performs an assessment for a pediatric client who presents with urticaria. Which question should the nurse ask when collecting data during the health history interview to determine a potential cause for the child's symptoms? Select all that apply. a. "Is your child experiencing any stress?" b. "Is your child taking any new medications?" c. "Has your child eaten any new foods recently?" d. "When was your child's last tetanus vaccination?" e. "Was your child out in the sun more today than normal?"

a. "Is your child experiencing any stress?" b. "Is your child taking any new medications?" c. "Has your child eaten any new foods recently?" e. "Was your child out in the sun more today than normal?" Urticaria (i.e., hives) is a type I hypersensitivity reaction that is caused by an immunologically mediated antigen-antibody response of histamine release from mast cells. This skin condition usually begins rapidly and may disappear in a few days; however, it can take up to 6 weeks to resolve. The most common causes of this reaction are as follows: animal stings, environmental stimuli (e.g., cold, heat, tight clothing, sun), foods, infections, medications, and stress. Based on this data, the questions the nurse includes when collecting health history data for this client includes the following: "Is your child experiencing any stress?" "Is your child taking any new medication?" "Has your child eaten any new foods recently?" "Was your child out in the sun more today than normal?"

A nurse in a clinic is caring for a client who is postop following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? a. "It is good to know that I won't have a tubal pregnancy in the future." b. "The doctor said that this surgery can affect my ability to get pregnant again." c. "I understand that one of my fallopian tubes had to be removed." d. "Ovulation an still occur because my ovaries were not affected."

a. "It is good to know that I won't have a tubal pregnancy in the future."

A 39 y/o multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which client statement indicates effective teaching? a. "My fallopian tubes will be tied off through a small abdominal incision." b. "reversal of a tubal ligation is easily done, with a pregnancy success rate of 80%" c. "After this procedure, I must abstain from intercourse for at least 3 weeks." d. "Both of my ovaries will be removed during the tubal ligation procedure."

a. "My fallopian tubes will be tied off through a small abdominal incision." Reversal of a tubal ligation is not easily done and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2-3 days after the procedure.

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply a. "My fertility can return as early as 21 days after my baby's birth b. "I have the hospital phone number if I have any questions." c. "If I have any breathing problems, chest pain, or pounding fast HR, I will seek medical assistance." d. "My mother is coming to help for a month, so I will be fine." e. "I know if I get fever or chills or change in lochia to call the HCP." f. "I will continue my prenatal vitamins until my postpartum checkup or longer."

a. "My fertility can return as early as 21 days after my baby's birth b. "I have the hospital phone number if I have any questions." c. "If I have any breathing problems, chest pain, or pounding fast HR, I will seek medical assistance." e. "I know if I get fever or chills or change in lochia to call the HCP." f. "I will continue my prenatal vitamins until my postpartum checkup or longer."

Hydrocodone/acetaminophen purpose

Treatment of moderate to severe pain

oxycodone purpose

Treatment of moderate to severe pain

hydroxyzine purpose

Treatment of pruritus, pre-op anxiety, and post-op nausea/vomiting; potentiation of opioid analgesics and sedation

naproxen nursing considerations

Treatment of rheumatoid, juvenile, and gouty arthritis; osteoarthritis; primary dysmenorrhea Patients with asthma, ASA hypersensitivity, or nasal polyps have increased risk of hypersensitivity Contact provider if blurred vision or ringing or roaring in ears, which may indicate toxicity Contact provider if black stools, flulike symptoms Contact provider if changes in urinary pattern, increased weight, edema, increased pain in joints, fever, or blood in urine, which may indicate kidney damage Avoid use with ASA, steroids, and alcohol May increase risk of MI or stroke OTC, Rx; Preg Cat B

VUR assessment

UTI, bloody urine, cloudy urine with foul odor, urgency, wetting pants or leakage of urine. Abdominal mass, anorexia, poor weight gain, constipation

Which recommendation should the nurse include when providing education to an adolescent client to avoid tooth decay and dental caries? Select all that apply. a. drink tap water instead of bottled water b. decrease amount of sugary beverages c. include dairy products like greek yogurt, or cottage cheese in the diet d. limit the intake of candy e. when possible brush teeth after every meal

a. drink tap water instead of bottled water b. decrease amount of sugary beverages c. include dairy products like greek yogurt, or cottage cheese in the diet d. limit the intake of candy e. when possible brush teeth after every meal Increasing intake of dairy products allows for calcium to be replenished for strong teeth and healthy bone development.

A nurse is completing a prenatal assessment on a woman who is 28 weeks' pregnant with gestational HTN. Which findings should be reported to the PCP? Select all that apply a. dull HA b. weight gain of 1 lb per week c. blurred vision d. 1+ urine protein e. fundal height of 28 cm

a. dull HA c. blurred vision d. 1+ urine protein

The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse would make which statement to the client? a. "Take a deep breath when I tell you, and hold it while I remove the tube." b. "Take a deep breath when I tell you, and bear down while I remove the tube." c. "Take a deep breath when I tell you, and slowly exhale while I remove the tube." d. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

a. "Take a deep breath when I tell you, and hold it while I remove the tube." The client would take a deep breath, because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath and the tube is withdrawn slowly and evenly over the course of 3 to 6 seconds (coil the tube around the hand while removing it) while the breath is held. Bearing down could inhibit the removal of the tube. Exhaling is not possible during removal because the airway is temporarily obstructed during removal. Breathing normally could result in aspiration of gastric secretions during inhalation.

pregnancy cardiac disease intervention

VS and FHR, limit activity, monitor for signs of cardiac stress and decompensation (cough, fatigue, dyspnea, chest pain, tachycardia, HF and peripheral edema), adequate nutrition, avoid excessive weight gain, cardiac monitor and external fetal monitor, bed rest, oxygen, manage pain, limited controlled pushing efforts to decrease cardiac stress

abruptio placentae interventions

VS and FHR, monitor for bleeding, pain and increase in fundal height, bed rest, O2, IVG, blood products, Trendelenburg, prepare for delivery, monitor for DIC

chorioamnionitis intervention

VS and FHR, monitor for uterine tenderness, contractions and fetal activity, C&S, abx and neonatal cultures after birth

placenta previa interventions

VS, FHR, US, avoid vaginal exams, bed rest, monitor bleeding, IVF, blood products or tocolytic. Complete placenta previa requires c section

glomerulonephritis interventions

VS, I&O, urine, daily weight, limit activity. Restrictions of Na and K during periods of oliguria. Monitor for complications (kidney failure, hypertensive encephalopathy, seizures, pulmonary edema, fluid volume overload, HF), administer diuretics, antihypertensives and abx. Seizure precautions

Magnesium sulfate interventions

VS, esp respirations q30-60 min, assess renal function and ECG, Mg levels q6hr. Always administer via infusion monitoring device. Keep calcium gluconate available, resuscitation equipment, monitor DTR hourly. Monitor UOP

ectopic pregnancy interventions

VS, monitor bleeding and procedures for rupture and shock, methotrexate, laparotomy and removal of pregnancy, abx, rhogam

vulvar hematoma interventions

VS, monitor for pain, inspect perineal area, ice, analgesics, I&Os, encourage fluids and voids, catheterization if needed, blood replacement, monitor for signs of infection, temp, pulse rate, abx, incision and evacuation of hematoma if necessary

carboprost interventions

VS, vaginal bleeding and uterine tone

Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? select all that apply a. ecchymosis b. bleeding gums c. palpable spleen d. pain e. petechiae

a. ecchymosis b. bleeding gums c. palpable spleen e. petechiae Thrombocytopenia means low plt. Any client w/ low pt is at risk for bleeding. Spleen and liver are often slightly palpable

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements would be included in the teaching plan? Select all that apply a. "The ductus arteriosus allows blood to bypass the fetal lungs." b. "One vein carries oxygenated blood from the placenta to the fetus." c. "The normal fetal heartbeat range is 160 to 180 beats per minutes in pregnancy" d. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." e. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

a. "The ductus arteriosus allows blood to bypass the fetal lungs." b. "One vein carries oxygenated blood from the placenta to the fetus." d. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." The normal fetal heartbeat range is considered to be 110-160 bpm. 2 arteries carry deoxygenated blood and waste products from the fetus, and one umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries

When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further teaching is needed when the client makes which statement? a. "The elbows should be flexed at 10 degrees." b. "I should not lean on the crutches with my armpit." c. "When going upstairs, my non-surgical leg goes up first." d. "Both crutches are held in one hand when sitting down."

a. "The elbows should be flexed at 10 degrees." The elbows should be flexed at 30 degrees

A primiparous client at 10 weeks' gestation questions the nurse about the need for an US. She states, "I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the US now? Select all that apply a. "The test helps us view the gross anatomy of the fetus." b. "We need to determine the gestational age." c. "The test will determine if the fetus is viable." d. "We must determine fetal position." e. "We must determine that there is a sufficient nutrient supply for the fetus."

a. "The test helps us view the gross anatomy of the fetus." b. "We need to determine the gestational age."

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? a. "This is a normal finding." b. "This is indicative of atrial flutter." c. "This is indicative of atrial fibrillation." d. "This is indicative of impending reinfarction."

a. "This is a normal finding." The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 seconds. The remaining options are incorrect and indicate that further education is needed.

A nurse is teaching about food safety and foodborne illness to a group of adults at a local community center. Which of the following information should the nurse include? a. "Unpasteurized fruit juice is a common cause of foodborne illness." b. "Stroe hard boiled eggs in the refrigerator for up to 2 weeks." c. "The recommended cooking temperature for ground beef is 145 f." d. "The onset of norovirus is 5-7 days after exposure to the bacteria."

a. "Unpasteurized fruit juice is a common cause of foodborne illness." Store hard boiled eggs no longer than 1 week. Recommended cooking temperature for ground beef is 160 F. The onset of norovirus is 24-48 hr after exposure to the virus.

On arrival at the ED, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's BP is 70/50 mmHg and her pulse is 120 bpm. The nurse notifies the HCP immediately because of the possibility of which complication? a. ectopic pregnancy b. abruptio placentae c. gestational trophoblastic disease d. complete abortion

a. ectopic pregnancy The client's signs indicate a probable ectopic pregnancy, which can be confirmed by US or by culdocentesis. The HCP is notified immediately because the hypovolemic shock may develop without external bleeding. Once the fallopian tube ruptures, blood will enter the pelvic cavity, resulting in shock. Abruptio placentae would be manifested by a board like uterus in the third trimester. Gestational trophoblastic disease would be suspected if the client exhibited no FHR and symptoms of pregnancy induced HTN before 20 weeks gestation. A client with complete abortion would exhibit a normal pulse and BP with scant vaginal bleeding

The nurse is discussing pain relief methods for a pregnant first time mother. The discussion should include which labor support methods? Select all that apply a. effleurage b. positive reinforcement c. guided imagery d. pattern-paced breathing e. self containment theory f. progressive relaxation

a. effleurage c. guided imagery d. pattern-paced breathing f. progressive relaxation

The nurse and an UAP are caring for clients in a birthing center. Which tasks should the nurse delegate to the UAP? select all that apply a. emptying a urinary catheter from a postpartum client b. assisting an active labor client with breathing and relaxation c. ambulating a postcesarean client to the bathroom d. calculating hourly IV totals for a preterm labor client e. intake and output catheterization for culture and sensitivity f. calling a report of normal findings to the HCP

a. emptying a urinary catheter from a postpartum client b. assisting an active labor client with breathing and relaxation c. ambulating a postcesarean client to the bathroom d. calculating hourly IV totals for a preterm labor client

The nurse provides education to new parents who will be providing formula to meet the infant's nutritional needs. Which parental statement indicates a need for additional education related to the mixing and administering formula? Select all that apply. a. "Using less powdered formula will help my baby sleep between feedings." b. "Heating the bottle in the microwave can create hot spots that are dangerous." c. "Once I feed my child, any remaining milk will not be discarded." d. "Store brand formula provides the same amount of nutrients as name brand formula." e. "Warming the bottle under warm tap water for several minutes will be sufficient for heating."

a. "Using less powdered formula will help my baby sleep between feedings." c. "Once I feed my child, any remaining milk will not be discarded." In order to meet the infant's nutritional needs, formula must be prepared exactly as directed which means that it is not appropriate to decrease the amount of powdered formula that is used. Formula can be safely heated through the use of warm water submission or placing the bottle under running warm water. The formula should feel lukewarm and should be evenly warmed throughout.

The prenatal client tells the nurse that she has been eating ginger cookies to treat her nausea and vomiting. Which response by the nurse is best? a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." b. "It is safer to use a prescription medication than eating ginger while you are pregnant." c. "Wait at least 2 hours to take your prenatal vitamin after eating ginger cookies." d. "You should immediately stop eating ginger containing foods."

a. "When consumed as a spice in foods, ginger is generally considered safe in pregnancy." Prescription medications ma be necessary to treat severe nausea and vomiting in pregnancy but they can have side effects such as sedation. Prenatal vitamins should be taken when clients experience the least nausea rather than waiting a specific time after a food.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse would immediately ask the client which question? a. "Where is the pain located?" b. "Are you having any nausea?" c. "Are you allergic to any medications?" d. "Do you have your nitroglycerin with you?"

a. "Where is the pain located?" If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, location, duration, and quality. Although the questions in the remaining options all may be components of the assessment, none of these questions is the initial assessment question for this client.

Which statement should the nurse include when providing education to the client who is diagnosed with Addison disease and prescribed steroid therapy twice per day? Select all that apply. a. "You should check your blood sugar before meals and at bedtime." b. "During stressful times, the dosage may need to be decreased." c. "Have your eyes checked yearly while on hydrocortisone." d. "Immediately stop hydrocortisone if you feel emotional or irritable." e. "Take your prescribed hydrocortisone by mouth with a meal."

a. "You should check your blood sugar before meals and at bedtime." c. "Have your eyes checked yearly while on hydrocortisone." e. "Take your prescribed hydrocortisone by mouth with a meal." Stress often requires the steroid therapy to be increased, not decreased. Cataract formation is a side effect of steroid therapy.

The nurse in labor and birth area receives a telephone call from the emergency dept announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby is coming... Help!" Fetal head is crowning. The nurse should obtain which information first? a. estimated date of birth b. amniotic fluid status c. gravida and parity d. prenatal history

a. estimated date of birth A priority assessment for the nurse to make is to determine the estimated date of birth or probable gestational age of the fetus. If the gestation is < 37 weeks, the neonatal team should be called to begin resuscitative efforts if needed. Amniotic fluid status is not important at this point because if the fetal skull is crowning, birth is imminent.

When developing a series of parent classes on fetal development, the nurse should include which feature as being developed by the end of the 3rd month? a. external genitalia b. myelinization of nerves c. brown fat stores d. air ducts and alveoli

a. external genitalia Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approx 21-24 weeks. Air ducts and alveoli develop later in the gestational period, at approx 25-28 weeks

A nurse at an urban community health agency is developing an education program for city leaders about homelessness. Which of the following groups should the nurse include as the fastest growing segment of the homeless population? a. families with children b. adolescent runaways c. individuals who have experienced spouse or partner violence d. older adults

a. families with children

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient? a. fat b. iron c. sodium d. calcium

a. fat Breast milk has higher fat content than cow's milk

A client asks why she feels so much variability in fetal activity each day. The nurse explains that fetal movement is affected by which factors? Select all that apply a. fetal sleep b. barometric pressure c. blood glucose d. time of day e. cigarette smoking

a. fetal sleep c. blood glucose d. time of day e. cigarette smoking Cigarette smoking causes carbon monoxide to cross the placenta, which reduces fetal oxygen. Pregnant women are more likely to notice fetal movement while they are sitting or lying down. Most will notice fetal movement in the evening.

A client has been admitted with a diagnosis of pneumocystis carinii pneumonia (PCP). What initial assessment findings would the nurse expect? a. fever b. night sweats c. hemoptysis d. dry cough e. dyspnea

a. fever d. dry cough e. dyspnea

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a. firm fundus at the symphysis b. menstrual discharge c. striae that are silver in color d. soft breasts without milk

a. firm fundus at the symphysis By 4-6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time.

The nurse is assessing fetal presentation in a multiparous client. The illustration below indicates what type of presentation? a. frank breech b. complete breech c. footling breech d. vertex

a. frank breech In frank breech, there is flexion of the fetal thighs and extension of the knees. The feet rest at the side of the fetal head. In complete breech, there is flexion of the fetal thighs and knees, the fetus appears to be squatting. Footling breech occurs when there is an extension of the fetal knees and one or both feet protrude through the cervix. Vertex presentation occurs with the head engaged in the pelvis.

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? Select all that apply a. frozen yogurt b. pudding c. hot cocoa in milk d. cheddar cheese e. watermelon

a. frozen yogurt b. pudding c. hot cocoa in milk d. cheddar cheese

A 38 y/o client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for which signs and symptoms? a. gestational HTN b. gestational diabetes c. hypothyroidism d. polycythemia

a. gestational HTN Hydatidiform mole is suspected when the following are present: gestational HTN before 24th week of gestation, brownish or prune colored vaginal bleeding, anemia, absence of fetal heart tones, passage of hydropic vessels, uterine enlargement greater than expected for gestational age and increased HCG levels. Gestational diabetes is related to an increased risk of preeclampsia and UTI, but not associated with hydatidiform mole. Hyperthyroidism, not hypothyroidism occurs with hydatidiform mole. If it does occur, it can be serious, possibly life threatening from cardiac problems. Polycythemia is not associated with hydatidiform mole.

A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? select all that apply a. gonorrhea b. chlamydia c. HIV d. GBS e. TORCH infection

a. gonorrhea b. chlamydia c. HIV d. GBS

The nurse is performing an assessment on a client who has developed cirrhosis. Which of the following signs and symptoms should the nurse expect to see? Select all that apply. (A) Dull abdominal ache (B) Cyanosis (C) Poor tissue turgor (D) Bruises (E) Fruity breath

(A) Dull abdominal ache (C) Poor tissue turgor (D) Bruises

The nurse is assessing a client admitted with a cerebrovascular accident (CVA). The physician has ordered a swallow study. The nurse knows which of the following lobes of the cerebral hemisphere is involved in the control of voluntary muscle movement, including those necessary for the production of speech and swallowing? (A) Frontal (B) Parietal (C) Temporal (D) Occipital

(A) Frontal The frontal lobe deals with higher levels of cognitive functions, such as reasoning and judgment. It also contains several cortical areas involved in the control of voluntary muscle movement, including those necessary for the production of speech and swallowing. The parietal lobe is associated with sensation, and is involved in writing and some aspects of reading. The temporal lobe is associated with auditory processing, olfaction, and word meaning. The occipital lobe is involved in vision

An older adult male client with a history of myasthenia gravis is admitted to the medical/surgical unit. Which of the following tests should the nurse expect to see ordered? Select all that apply. (A) Tensilon test (B) Nerve conduction studies (C) Lumbar puncture (D) EEG (E) Electromyography

(A) Tensilon test (B) Nerve conduction studies (E) Electromyography Myasthenia gravis produces sporadic but progressive weakness and abnormal fatigue in skeletal muscles. The Tensilon test confirms the diagnosis by temporarily improving muscle function aer an IV injection of edrophonium or neostigmine. CORRECT: Nerve conduction studies test for receptor antibodies Lumbar puncture is a test used to diagnose multiple sclerosis, a result of progressive demyelination of the white matter of the brain and spinal cord. An EEG is a test used to diagnose multiple sclerosis, a result of progressive demyelination of the white matter of the brain and spinal cord. CORRECT: Electromyography helps differentiate nerve disorders from muscle disorders.

The nurse is providing discharge teaching to a client stabilized after an acute attack of primary gout. Which of the following foods should the nurse instruct the client to avoid to prevent future attacks? (A) Cauliflower, asparagus, and mushrooms (B) Anchovies, liver, and lentils (C) Cherries, strawberries, and blueberries (D) Cereal, pasta, and rice

(B) Anchovies, liver, and lentils A client with gout should avoid high-purine foods, such as anchovies, liver, sardines, and lentils

An older adult female, newly diagnosed with type 2 diabetes, is ready for discharge. When providing discharge instructions, the nurse teaches the client that the key to preventing diabetic foot complications is which of the following? (A) Taking the medication as ordered (B) Following the recommended diet (C) Surgical intervention (D) Regular evaluation of the look and feel of her feet

(B) Following the recommended diet

The laboratory values of an adult male client reveal the presence of hepatitis B surface antigens and hepatitis B antibodies. Which of the following laboratory results should the nurse also expect to see? Select all that apply. (A) Elevated serum albumin (B) Low serum globulin (C) Elevated serum transaminate (ALT and AST) (D) Prolonged prothrombin time (PT) (E) Low urine bilirubin

(C) Elevated serum transaminate (ALT and AST) (D) Prolonged prothrombin time (PT)

An elderly man is admitted to the hospital from the Emergency Department during the night shift. The nurse is assessing the client's cerebellar function. Which of the following questions should the nurse ask the client? (A) "Who is the current president of the United States?" (B) "Do you have trouble swallowing fluids or foods?" (C) "Do you have any muscle pain?" (D) "Do you have problems with balance?"

(D) "Do you have problems with balance?" The nurse evaluates cerebellar function by testing the client's balance and coordination

36-year-old primigravid client with a history of diabetes is admitted with preeclampsia. Which of the following actions should the nurse take FIRST? (A) Administer low-dose aspirin as ordered. (B) Ask the physician for an order for calcium supplements. (C) Monitor the client's blood pressure. (D) Prepare the client for delivery.

(D) Prepare the client for delivery. Although frequent monitoring of blood pressure is a part of the management of preeclampsia, this is not the first thing the nurse should do. CORRECT: The nurse should prepare the client for delivery, which is the most effective treatment for preeclampsia

Esophageal atresia and tracheoesophageal fistula

- esophagus terminates before it reaches the stomach , ending in a blind pouch , and/or a fistula is present that forms an unnatural connection with the trachea

A 40 y/o client at 8 weeks' gestation has a 3 y/o child with Down syndrome. The nurse is discussing amniocentesis and chorionic villus sampling as genetic screening methods for the expected baby. The nurse is confident that the teaching has been understood when the client makes which statement? a. "Each test identifies a different part of the infant's genetic makeup." b. "Chorionic villus sampling can be performed earlier in pregnancy." c. "The test results take the same length of time to be completed." d. "Amniocentesis is a more dangerous procedure for the fetus."

/b. "Chorionic villus sampling can be performed earlier in pregnancy." CVS can be performed approx 8-12 weeks, while amniocentesis cannot be performed until between 11 weeks' gestation and end of the pregnancy. Because CVS takes a piece of membrane surrounding the infant, this procedure can be completed earlier. Both identify the genetic makeup of the fetus in its entirety rather than a portion of it. Laboratory analysis of CVS takes less time to complete. Both procedures place the fetus at risk of same complications (bleeding, cramping, fever and fluid leakage from vagina)

CRIES scale

0-6 months, crying, requires oxygen, increased VS, expression, sleepless

Which instruction should the nurse include in the education plan for a young female client who is preparing for a radioactive iodine uptake (RAIU) test? Select all that apply. a. "You will need a negative pregnancy test before the test can be performed." b. "Necklaces should be removed prior to the test." c. "It is important to not eat or drink for at least 12 hours before the test." d. "Medication that will sedate you will be used to help you relax during the test." e. "Stop taking all thyroid hormone medication for 5-7 days before the test."

a. "You will need a negative pregnancy test before the test can be performed." b. "Necklaces should be removed prior to the test." e. "Stop taking all thyroid hormone medication for 5-7 days before the test." Jewelry is removed from the neck during the scans to allow for unimpaired visualization of the area. Therefore, the nurse includes this statement in the teaching session. The client who is prescribed an RAIU test is NPO (i.e., nothing by mouth) for 2 to 4 hours, not 12 hours, prior to the ingestion of radioactive iodine.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last? 1. call for immediate assistance 2. Turn the client to her side 3. assess for ROM 4. maintain airway

1, 2, 4, 3

The nurse is providing instructions to a pregnant client with HIV infection regarding care of the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response would then nurse make to the client? a. "You will need to bottle-feed your newborn." b. "You will need to feed your newborn by NG tube feeding." c. "You will be able to breast/chest feed for 6 months and then will need to switch to bottle feeding" d. "You will be able to breast/chest-feed for 9 months and then will need to switch to bottle feeding."

a. "You will need to bottle-feed your newborn."

The nurse plans care for a toddler-age client who is newly diagnosed with type 1 diabetes mellitus (DM). Which action by the nurse in the provision of care for this child is developmentally appropriate? a. helping the client choose a phrase for hypoglycemia b. teaching the client to perform finger stick glucose testing c. instructing the client to perform urine ketone testing d. monitoring the client for symptoms of depression

a. helping the client choose a phrase for hypoglycemia The toddler-age client is dependent on parents and caregivers for the management of type 1 DM and is at risk for hypoglycemia due to "picky eating" habits; therefore, early identification and treatment of hypoglycemia is essential in the provision of care for this pediatric client. A developmentally appropriate action by the nurse for this child is to assist in choosing a word or phrase that can be communicated to others when hypoglycemia occurs.

Which anticoagulants would the nurse expect to administer when caring for a primigravid client at 12 weeks' gestation who has class II cardiac disease due to mitral valve stenosis? a. heparin b. warfarin c. enoxaparin d. ardeparin

a. heparin Heparin is typically the drug of choice. Warfarin is a category D drug. Enoxaparin is sometimes used but clients are typically switched to heparin near labor because it is used along with spinal or epidural anesthesia presents an increased risk of bleeding in the epidural or spinal space. Ardeparin can also cause fetal malformations

Which instruction from the nurse is appropriate for a client who is prescribed fentanyl patches for pain control as part of the hospice plan of care? Select all that apply. a. "apply the patch to a flat area of intact skin for maximal absorption." b. "do not use warm compresses or a heating pad over the fentanyl patch to enhance absorption." c. "Remove and replace the fentanyl patch every 24 hours" d. "If someone else in your family will apply the patch for you, be sure they wear gloves and wash their hands." e. "do not trim or tear the patch before applying it to your skin." f. "fold the used patch with the sticky sides together before disposal."

a. "apply the patch to a flat area of intact skin for maximal absorption." b. "do not use warm compresses or a heating pad over the fentanyl patch to enhance absorption." d. "If someone else in your family will apply the patch for you, be sure they wear gloves and wash their hands." e. "do not trim or tear the patch before applying it to your skin." f. "fold the used patch with the sticky sides together before disposal." Fentanyl patches are changed every 72, not 24 hours; therefore, this is not accurate information for the nurse to include in the teaching session for this client.

A charge nurse is providing information about fat emulsion added to TPN to a group of nurses. Which of the following statements by the charge nurse are appropriate? select all that apply a. "concentration of lipid emulsion can be up to 30%" b. "Adding lipid emulsion gives the solution a milky appearance." c. "Check for allergies to soybean oil." d. "Lipid emulsion prevents essential fatty acid deficiency." e. "lipids provide calories by increasing the osmolality of the PN solution."

a. "concentration of lipid emulsion can be up to 30%" b. "Adding lipid emulsion gives the solution a milky appearance." c. "Check for allergies to soybean oil." d. "Lipid emulsion prevents essential fatty acid deficiency."

After conducting a class for female adolescents about human reproduction, the nurse concludes teaching has been effective when a student makes which statement? a. "under ideal conditions, sperm can reach the ovum in 15-30 minutes, resulting in pregnancy." b. "I will not become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." c. "Sperms from a healthy male usually remain viable in the female reproductive tract for 96 hours." d. "After an ovum is fertilized by a sperm, the ovum contains 21 pairs of chromosomes."

a. "under ideal conditions, sperm can reach the ovum in 15-30 minutes, resulting in pregnancy." A couple should abstain from coitus 3-4 days before ovulation (10-14) and 3-4 days after ovulation (15-19). Sperm can remain viable for 24-72 hours in the female reproductive tract.

A client has just had a c section for a prolapsed cord. In reviewing the client's history, which factors place a client a trisk for cord prolapse? select all that apply a. -2 station b. low birth weight infant c. ROM d. breech presentation e. prior abortion f. low lying placenta

a. -2 station b. low birth weight infant c. ROM d. breech presentation With a negative station, there is room between the fetal head and the maternal pelvis for the cord to slip through. A small infant is more mobile within the uterus, and the cord can rest between the fetus and the inside of the uterus or below the fetal head. With a large infant, the head is usually in a vertex presentation and occludes the lower portion of the uterus, preventing the cord from slipping by. When membranes rupture, the cord can be swept through with the amniotic fluid. In a breech presentation, the fetal head is in the fundus and the smaller portions of the fetus settle into the lower portion of the uterus allowing the cord to lie beside the fetus.

During a 2-hour birth preparation class focusing on the labor and birth process for primigravid clients, the nurse is describing the maneuvers that the fetus goes through during the labor process when the head is in the presenting part. In which order do these maneuvers occur? 1. engagement 2. flexion 3. descent 4. internal rotation

1, 3, 2, 4 Engagement refers to the fetus' entering the true pelvis and occurs before descent in primiparas and concurrently in multiparous women. If the head is the presenting part, the normal maneuvers during labor and birth are descent, flexion, internal rotation, extension, external rotation and expulsion. These maneuvers are called cardinal movements.

The oncoming day shift nurse has just received hand over report from the night shift nurse. List the order of priority for assessing and caring for the following patients, with 1 being first and 4 being last. 1. A patient who developed tumor lysis syndrome around 5:00 am A patient who is currently pain free but had breakthrough pain during the night 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours

1, 3, 2, 4 Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed before leaving the unit, and any final preparations for surgery should be completed. A patient with breakthrough pain needs a thorough pain assessment, an investigation of pain patterns, and a chart review of all attempted pharmaceutical and nonpharmaceutical interventions; the health care provider may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics.

The nurse is supervising an LPN/LVN who says, "I gave the client with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!" In which order should the nurse perform the following actions? 1. Assess the client's heart rate. 2. Complete a medication error report. 3. Ask the LPN/LVN to explain how the error occurred. 4. Notify the health care provider of the incorrect medication dose.

1, 4, 3, 2 The first action after a medication error should be to assess the client for adverse outcomes. The nurse should evaluate this client for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report.

The client diagnosed with CVA is reporting a headache. Which interventions should the rehabilitation nurse implement? Rank in order of priority. 1. Assess the client's neurological status. 2. Administer oral acetaminophen. 3. Have the client swallow a drink of water. 4. Ask the client to give his or her date of birth. 5. Ask the client to rate pain on a scale of 1-10.

1, 5, 4, 3, 2 The nurse should apply the nursing process and always assess the client unless the client is in distress. The nurse must determine if this is routine pain for which the HCP has prescribed acetaminophen or if it is a complication that warrants medical intervention. 5. The nurse must then determine how much pain the client is in to determine which medication would be most appropriate. The pain scale will also help evaluate the effectiveness of the medication. 4. The nurse must identify the client prior to administering the medication. 3. Because the client has had a CVA, the nurse must determine if the client can swallow prior to administering medication. If the client has problems swallowing water, then the nurse should thicken liquids to help prevent aspiration. 2. The nurse should administer the medication after all the previous steps are completed.

The client with arterial occlusive disease is taking clopidogrel. Which statement by the client warrants intervention by the nurse? 1. "I am taking the herb ginkgo to help improve my memory." 2. "I am a vegetarian and eat a lot of green, leafy vegetables." 3. "I have not had any blood drawn in more than a year." 4. "I always use a soft-bristled toothbrush to brush my teeth."

1. "I am taking the herb ginkgo to help improve my memory." Clopidogrel (Plavix) is an antiplatelet medication. Ginkgo, an herb, can increase bleeding when taken with an antiplatelet medication such as aspirin or Plavix. Therefore, this statement warrants intervention and the nurse should encourage the client to quit taking ginkgo. Ginkgo has been shown to have a benefi cial effect of increasing blood fl ow to the brain, but in this case, the risk of bleeding warrants the nurse's intervention.

The nurse is monitoring a patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. "Last night my back really hurt, and I had trouble sleeping." 2. "My leg has been giving out when I try to stand." 3. "My bowels are just not moving like they usually do." 4. "When I try to pass urine, I have difficulty starting the stream."

1. "Last night my back really hurt, and I had trouble sleeping." Back pain is an early sign of spinal cord compression occurring in 95% of patients. The other symptoms are later signs.

Which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay? 1. "My child is able to stand but is not yet taking steps independently." 2. "My child has a vocabulary of approximately 15 words." 3. "My child is still sucking his thumb." 4. "My child seems to be quite wary of strangers."

1. "My child is able to stand but is not yet taking steps independently." The child should be walking independently by 15 to 18 months. Because this toddler is 18 months and not walking, a referral should be made for a developmental consult.

The client diagnosed with polycythemia vera is being discharged. Which discharge instruction should the nurse teach the client? 1. "Take the warfarin as ordered." 2. "Do not abruptly stop taking prednisone." 3. "Rise slowly from a seated position to prevent hypotension." 4. "Restrict fluids to 1,000 to 1,500 mL per day

1. "Take the warfarin as ordered." Warfarin (Coumadin) is an anticoagulant. Polycythemia vera is a malignant overproduction of RBCs. The blood becomes viscous and has a tendency to clot. Anticoagulants are ordered to prevent clot formation

The nurse is interviewing a patient who was treated several months ago for breast cancer. The patient reports taking nonsteroidal anti-inflammatory drugs (NSAIDs) for back pain. Which patient comment is cause for greatest concern? 1. "The NSAIDs are really not relieving the back pain." 2. "The NSAID tablets are too large, and they are hard to swallow." 3. "I gained weight because I eat a lot before taking NSAIDs." 4. "The NSAIDs are upsetting my stomach in the morning."

1. "The NSAIDs are really not relieving the back pain." Primary cancers (lung, prostate, breast, and colon) may metastasize to the spine. In spinal cord compression, back pain is a common early symptom. Later symptoms include weakness, loss of sensation, urinary retention or incontinence, and constipation.

The postpartum nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame would the nurse relay to the client regarding the return of bowel function? a. 3 days postpartum b. 7 days postpartum c. on the day of birth d. within 2 weeks postpartum

a. 3 days postpartum

The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. 1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 3. "When was your last bowel movement?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 5. "Over the past month have you had any dizziness or tinnitus?" 6. "Do you have episodes of drowsiness or decreased alertness?"

1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 6. "Do you have episodes of drowsiness or decreased alertness?" Older adults may be taking drugs that disrupt acid-base balance, especially diuretics and aspirin. Ask about specific risk factors, such as any type of breathing problem. Also ask about headaches, behavior changes, increased drowsiness, reduced alertness, reduced attention span, lethargy, anorexia, abdominal distention, nausea or vomiting, muscle weakness, and increased fatigue. Ask the client to relate activities of the previous 24 hours to identify activity intolerance, behavior changes, and fatigue. Answers 3 and 5 are not common concerns with acidosis.

The onset of Humalog insulin is: 1. 10 to 15 minutes. 2. 30 minutes to 1 hour. 3. 1 to 2 hours. 4. 2 to 4 hours.

1. 10 to 15 minutes.

People at risk are the target populations for cancer screening programs. According to the latest screening recommendations from the American Cancer Society, which of these asymptomatic patients need extra encouragement to participate in cancer screening? Select all that apply. 1. A 21-year-old white American woman who is sexually inactive, for a Pap test 2. A 30-year-old Asian-American woman, for an annual mammogram 3. A 45-year-old African-American man, to talk with health care provider about prostate cancer 4. A 50-year-old white American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy 6. A 70-year-old Asian-American woman who had a total hysterectomy 15 years ago (not for cancer reasons), for a Pap test

1. A 21-year-old white American woman who is sexually inactive, for a Pap test 3. A 45-year-old African-American man, to talk with health care provider about prostate cancer 4. A 50-year-old white American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy At 21 years of age, women should have a Pap smear, regardless of sexual activity. African-American men starting at age 45 years should talk to their health care providers about prostate cancer and risk versus benefits of prostate-specific antigen testing. Colonoscopy and annual fecal occult blood testing are recommended for those with average risk starting at age 50 years. Annual mammograms are recommended for women at the age of 45 to 54 years. Women who have had a total hysterectomy for reasons other than cancer do not need a Pap test.

The nurse provides care for a client who is newly prescribed transdermal contraception containing ethinyl estradiol and levonorgestrel. Which finding requires the nurse to question the prescription with the healthcare provider (HCP)? Select all that apply. a. The client is 35 y/o b. the client is BRCA positive c. the client reports occasional migraines d. the client is considered morbidly obese e. the client reports regular menstrual cycles f. The client has a history of factor V leiden thrombophilia

a. The client is 35 y/o b. the client is BRCA positive c. the client reports occasional migraines d. the client is considered morbidly obese f. The client has a history of factor V leiden thrombophilia One type of combination hormonal contraceptives is an ethinyl estradiol and levonorgestrel transdermal patch. The transdermal patch has an increased risk for thromboembolism, a potentially life threatening complication. Contraindications for the use of this type of contraceptive includes the following: advanced age (e.g., 35 years of age or greater); BRCA positive; migraines; morbid obesity; and a history of Factor V Leiden thrombophilia. Individuals who are noted to have these contraindications will require additional evaluation from the HCP; therefore, these findings require the nurse to question the prescription to enhance client safety.

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply. 1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy 4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer 5. A 76-year-old patient newly diagnosed with type 2 diabetes 6. A 69-year-old patient with emphysema to be discharged tomorrow

1. A 38-year-old patient with moderate persistent asthma awaiting discharge 2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift 6. A 69-year-old patient with emphysema to be discharged tomorrow The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing care for patients with more complex needs.

The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? 1. A 68-year-old client with chronic emphysema 2. A 58-year-old client who uses antacids every day 3. A 48-year-old client with an anxiety disorder 4. A 28-year-old client with salicylate intoxication

1. A 68-year-old client with chronic emphysema Clients at greatest risk for acute acidosis are those with problems that impair breathing. Older adults with chronic health problems are at greater risk for developing acidosis. Whereas a client who misuses antacids is at risk for metabolic alkalosis, a client with anxiety is at risk for respiratory alkalosis. A client with salicylate intoxication is at risk for metabolic acidosis.

Which notations indicate accurate nursing documentation by the nurse? Select all that apply a. The client slept through the night b. abdominal wound dressing is dry and intact without drainage c. The client seemed angry when awakened for measurement of VS d. The client appears to become anxious when it is time for respiratory treatments e. The client's left lower medial leg wound is 3 cm in length without redness, drainage or edema

a. The client slept through the night b. abdominal wound dressing is dry and intact without drainage e. The client's left lower medial leg wound is 3 cm in length without redness, drainage or edema

Which client is at risk for the development of a sodium level at 130 mEq/L a. The client who is taking diuretics b. The client with hyperaldosteronism c. The client with Cushing's syndrome d. The client who is taking corticosteroids

a. The client who is taking diuretics

The client is exhibiting the ASYSTOLE. Which interventions should the nurse implement? Select all that apply. 1. Administer atropine. 2. Assess the client's apical heart rate. 3. Administer epinephrine. 4. Initiate cardiopulmonary resuscitation. 5. Administer lidocaine.

1. Administer atropine. 2. Assess the client's apical heart rate. 3. Administer epinephrine. 4. Initiate cardiopulmonary resuscitation. Atropine, an antidysrhythmic, decreases vagal stimulation, increases the heart rate, and is the drug of choice for a client exhibiting asystole. The nurse should determine if the telemetry reading is artifact or if the client is in asystole before administering any treatment. IV epinephrine, a sympathomimetic, vasoconstricts the peripheral circulation and shunts the blood to the central circulation (brain, heart, lungs) in clients who do not have a heartbeat Asystole (no heartbeat) requires the nurse to start CPR

The client with coronary artery disease (CAD) is prescribed cholestyramine. Which intervention should the nurse implement when administering the medication? 1. Administer the medication with fruit juice. 2. Instruct the client to decrease fi ber when taking the medication. 3. Monitor the cholesterol level before giving medication. 4. Assess the client for upper abdominal discomfort.

1. Administer the medication with fruit juice. Cholestyramine (Questran) is a bile acid sequestrant. This medication should be administered with water, fruit juice, soup, or pulpy fruit (applesauce, pineapple) to reduce the risk of esophageal irritation.

When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. Administration of chemotherapy requires precautions to protect self and others. 2. Many chemotherapeutic drugs are vesicants. 3. Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common.

1. Administration of chemotherapy requires precautions to protect self and others.

The client diagnosed with Alzheimer's disease (AD) is prescribed rivastigmine. Which medication should the nurse question administering to the client? 1. Amitriptyline. 2. Warfarin. 3. Phenytoin. 4. Prochlorperazine.

1. Amitriptyline. Tricyclic antidepressants, fi rstgeneration antihistamines, and antipsychotics can reduce the client's response to cholinesterase inhibitors. Antipsychotics are useful for clients whose behavior is erratic and uncontrollable in the end stage of the disease. The cholinesterase inhibitor rivastigmine (Exelon) would not be useful in endstage disease.

Which patient is at greatest risk for pancreatic cancer? 1. An older African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis

1. An older African-American man who smokes Pancreatic cancer is more common in African Americans, men, and smokers. Other associated factors include older age, alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation

Which of the following would the nurse instruct the parent about treating a pediculosis infestation? 1. Apply spinosad (Natroba) to the scalp, leave it in place for 4 minutes, and then add water. 2. Apply chlorhexidine (Hibiclens) to the scalp with sterile gloves and leave on overnight. 3. Apply terbinafine (Lamisil) as a thin layer to the scalp twice a day for 5 days. 4. Apply collagenase (Santyl) to the scalp with cotton applicator, leave in place overnight, then shampoo.

1. Apply spinosad (Natroba) to the scalp, leave it in place for 4 minutes, and then add water. Spinosad (Natroba) causes neuronal excitation leading to lice paralysis and death.

The nurse is assessing a multigravid client at 12 weeks' gestation who has been admitted to the ED with sharp right sided abdominal pain and vaginal spotting. Which information should the nurse obtain about the client's history? select all that apply a. history of STI b. number of sexual partners c. LMP d. C section e. contraceptive use

a. history of STI b. number of sexual partners c. LMP e. contraceptive use The client may be experiencing an ectopic pregnancy. Contributing factors include a prior history of STI that can scar the fallopian tubes. Multiple sex partners increase the risk of STI. knowledge of the client's LMP and contraceptive use may support or rule out the possibility of an ectopic pregnancy. The client's history of c sections would not contribute information valuable to the client's current situation or potential diagnosis of ectopic pregnancy

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important? 1. Arrange for testing for Zika virus infection. 2. Discuss need for multiple fetal ultrasounds during pregnancy. 3. Describe potential impact of Zika infection on fetal development. 4. Assess for symptoms such as rash, joint pain, conjunctivitis, and fever.

1. Arrange for testing for Zika virus infection. Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the client is asymptomatic.

The client is admitted into the ED reporting a profuse salivation, excessive tearing, and diarrhea. The client tells the nurse he had been camping and living off the land. Which medication should the nurse anticipate administering? 1. Atropine. 2. Diphenhydramine. 3. Magnesium/aluminum hydroxide. 4. Pantoprazole.

1. Atropine. The client reports living off the land, and the symptoms reported are clinical manifestations of muscarinic poisoning from eating wild mushrooms. Therefore, the nurse should anticipate administering the antidote, which is atropine, a muscarinic agonist.

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 4. Checking oxygen saturation using pulse oximetry

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client's temperature 3. Assessing the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1. Auscultating lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations A focused assessment focuses on a limited or short term problem.

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply. 1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 3. Wash all bedding in cold water to reduce and destroy dust mites. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma.

1. Avoid potential environmental asthma triggers such as smoke. 2. Use the inhaler 30 minutes before exercising to prevent bronchospasm. 4. Be sure to get at least 8 hours of rest and sleep every night. 5. Avoid foods prepared with monosodium glutamate (MSG). 6. Keep a symptom and intervention diary to learn specific triggers for your asthma. Bedding should be washed in hot water to destroy dust mites. All of the other points are accurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? a. The need for sensory stimulation b. The amount of home care support available c. The ability to perform activities of daily living d. The type of transportation available for follow-up care

a. The need for sensory stimulation A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment would also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

A 3 day post-operative client with a left knee replacement is reporting chills and nausea. Temperature: 100.8ºF/38.2ºC, pulse: 94, respiration: 28 and blood pressure is 146/90. What is the nurse's best action? 1. Call the surgeon immediately. 2. Administer extra strength acetaminophen per prescription. 3. Assess the surgical site. 4. Offer extra blankets and increase fluids.

1. Call the surgeon immediately. The client's symptoms are indicative of infection and the HCP needs to be notified and may want diagnostic tests performed. Other actions treat the symptoms and provide comfort but doesn't fix the problem

The client with increased intracranial pressure is receiving mannitol. Which data would cause the nurse to hold the administration of this medication? a. The serum osmolality is 330 mOsm/kg. b. The urine osmolality is 550 mOsm/kg. c. The blood urea nitrogen (BUN) level is 8 mg/dL. d. The creatinine level is 1.8 mg/dL.

a. The serum osmolality is 330 mOsm/kg. The normal serum osmolality is 275 to 300 mOsm/kg. The osmotic diuretic mannitol (Osmitrol) is held if the serum osmolality exceeds 310 to 320 mOsm/kg.

When preparing a 20 y/o client for a serum pregnancy test, the nurse should include what information? a. The test has a high degree of accuracy within 1 week after ovulation. b. The test is identical in nature to an OTC home pregnancy test c. A positive result is considered a presumptive sign of pregnancy. d. A urine sample is needed to obtain quicker results

a. The test has a high degree of accuracy within 1 week after ovulation. The serum pregnancy test measures hCG and is highly accurate within 1 week after ovulation. OTC or home pregnancy tests are performed on urine and typically require higher levels of hCG to obtain a positive result. Certain conditions other than pregnancy, such as choriocarcinoma, can cause increased hCG levels.

After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which problem? a. hydrocephalic infant b. abruptio placentae c. intrauterine growth restriction d. poor placental perfusion

a. hydrocephalic infant Congenital abnormalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth restriction and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction, Intrauterine growth restriction is possible due to poor placental perfusion, which results from increased vasoconstriction

With plans to breastfeed her neonate, a pregnant client with insulin-dependent diabetes asks the nurse about insulin needs during the postpartum period. Which statement about postpartum insulin requirements for breastfeeding mothers should the nurse include in the explanation? a. They fall significantly in the immediate postpartum period b. They remain the same as during the labor process c. They usually increase in the immediate postpartum period d. They need constant adjustment during the first 24 hours

a. They fall significantly in the immediate postpartum period The client has been NPO for a period of time during labor and the labor process has used maternal glycogen stores. If the client breastfeeds, lower blood glucose levels decrease the insulin requirements. With insulin resistance gone, the client commonly needs little or no insulin during the immediate postpartum period. After the first 24 hours, insulin requirements may fluctuate markedly, needing adjustment during the next few days as the mother's body returns to a nonpregnant state

The nurse in the ED is preparing to administer alteplase to a client whose initial symptoms of a stroke began 2 hours ago. Which interventions should the nurse implement? Select all that apply. 1. Check the client's armband for allergies. 2. Hang the medication via IV piggyback (IVPB) and infuse over 90 minutes. 3. Check the results of the client's CT scan of the brain. 4. Teach the client this medication dissolves clots. 5. Monitor the client's partial thromboplastin time (PTT) during drug administration.

1. Check the client's armband for allergies. 2. Hang the medication via IV piggyback (IVPB) and infuse over 90 minutes. 3. Check the results of the client's CT scan of the brain. 4. Teach the client this medication dissolves clots. 5. Monitor the client's partial thromboplastin time (PTT) during drug administration. The nurse should always check the client's armband prior to administering medication. There are three types of strokes: thrombotic, embolic, and hemorrhagic. The nurse must know that the client has not had a hemorrhagic stroke before hanging a medication that destroys clots. Administering alteplase (Activase), a thrombolytic medication, to a client who has had a hemorrhagic stroke can result in the client's death. Teaching the client can be done after the medication has been administered. The client will be receiving heparin to prevent re- clotting of the thrombus along with thrombolytic medication; therefore, the nurse should monitor the PTT

The HCP has informed the labor nurse that he believes the uterus has inverted in a primiparous client who has just given birth. Which findings would help to confirm this diagnosis? select all that apply a. hypotension b. gush of blood from the vagina c. intense, severe tearing type of abdominal pain d. uterus is hard and in a constant state of contraction e. inability to palpate the uterus f. diaphoresis

a. hypotension b. gush of blood from the vagina e. inability to palpate the uterus f. diaphoresis

The nurse is preparing to administer an oral medication to a client diagnosed with a stroke. Which interventions should the nurse implement? Select all that apply. 1. Crush all oral medications and place them in pudding. 2. Elevate the head 30 degrees. 3. Ask the client to swallow a drink of water. 4. Have suction equipment at the bedside. 5. Insert a nasogastric tube to administer medications

1. Crush all oral medications and place them in pudding. 3. Ask the client to swallow a drink of water. Some medications can be crushed and administered in pudding if the client has diffi culty swallowing, but the nurse needs to be aware that enteric- coated or timed- release medications should not be crushed. The head of the bed should be elevated to 90 degrees when the client is swallowing food or medications. The client's ability to swallow must be assessed before attempting to administer any oral medication. Water is the best fl uid to use because it will not damage the lungs if aspirated. Equipment is usually charged to the client. The nurse should fi rst determine if suction equipment is needed prior to setting it up.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which patterns would the nurse watch for on the ECG as a result of the lab value? Select all that apply a. U waves b. Absent P waves c. Inverted T waves d. depressed ST segment e. widened QRS complex

a. U waves c. Inverted T waves d. depressed ST segment

A school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. Which of the following cause should the nurse include in the teaching? select all that apply a. illness b. malnutrition c. adolescence d. trauma e. pregnancy

a. illness b. malnutrition d. trauma

The client diagnosed with early- stage Parkinson's disease has been prescribed pramipexole. Which side effects of this medication should the nurse discuss with the client? Select all that apply. 1. Daytime somnolence. 2. On-off effect. 3. Excessive salivation. 4. Pill-rolling motion. 5. Stiff muscles.

1. Daytime somnolence. 5. Stiff muscles. Daytime somnolence is seen in about 22% of clients taking pramipexole (Mirapex), a dopamine agonist medication. A few clients experience an overwhelming and irresistible sleepiness that comes on without warning. Stiff muscles are a sign of an adverse side effect of pramipexole (Mirapex), a dopamine agonist medication, indicating a need to discontinue the medication.

The nurse assesses a client with a nasogastric (NT) tube in place that is being used for continuous feedings when the tube marking the original location is noted as being considerably lower than during the previous assessment. Which is the nurse's first action? a. immediately stop the feeding and listen to the client's breath sounds b. advance the tube to the original marking and place bilateral wrist restraints c. aspirate the tube for gastric contents and notify the HCP d. pull the tube out and obtain a rx to reinsert the NG tube

a. immediately stop the feeding and listen to the client's breath sounds

The client taking digoxin has a serum digoxin level of 4.2 ng/mL. Which medication should the nurse anticipate the HCP prescribing? 1. Digitalis binder Fab antibody fragments. 2. Furosemide. 3. The HCP will not prescribe any medications. 4. Digoxin

1. Digitalis binder Fab antibody fragments. Digoxin (Lanoxin) is a cardiac glycoside. Digitalis binder Fb antibody fragments (Digibind) is a digitalis antibody. When digoxin overdose is suspected, as it would be with a digoxin level of 4.2 ng/ mL, Fb antibody fragments bind digoxin and prevent it from acting. The therapeutic range of digoxin is 0.5 to 1.2 ng/ mL and the toxic range is 2.0 ng/mL or higher.

The nurse is administering the combination medication chlorthalidone and atenolol to a client diagnosed with chronic HTN. Which interventions should the nurse implement? Select all that apply. 1. Do not administer if the client's blood pressure is less than 90/60. 2. Do not administer if the client's apical pulse is less than 60 bpm. 3. Teach the client how to prevent orthostatic hypotension. 4. Encourage the client to eat potassium-rich foods. 5. Monitor the client's oral intake and urinary output.

1. Do not administer if the client's blood pressure is less than 90/60. 2. Do not administer if the client's apical pulse is less than 60 bpm. 3. Teach the client how to prevent orthostatic hypotension. 4. Encourage the client to eat potassium-rich foods. 5. Monitor the client's oral intake and urinary output. Tenoretic (chlorthalidone and atenolol in combination) is a thiazide diuretic and a beta blocker. Thiazide diuretics do not cause excess loss of potassium, but the client should be encouraged to eat potassium-rich foods to prevent hypokalemia, which may occur as a result of increased urination Tenoretic (chlorthalidone and atenolol in combination) is a thiazide diuretic and a beta blocker. The nurse should monitor the client's intake and output to determine if the medication is effective.

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply. 1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 3. Eat three large meals every day focusing on calories and protein. 4. Organize your work area so that what you use most is easy to reach. 5. Get all of your activities accomplished then take a nap. 6. Don't hold your breath while performing any activities.

1. Do not rush through your morning activities of daily living. 2. Avoid working with the arms raised. 4. Organize your work area so that what you use most is easy to reach. 6. Don't hold your breath while performing any activities. Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to pace activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller more frequent meals may be less tiring. Teach the patient to avoid breath-holding while performing any activity because this interferes with gas exchange.

A patient with systemic lupus erythematosus (SLE) is admitted to the hospital with acute joint inflammation. Which information obtained in the laboratory testing will be of highest concern to the nurse? 1. Elevated blood urea nitrogen level 2. Increased C-reactive protein level 3. Positive antinuclear antibody test result 4. Positive lupus erythematosus cell preparation

1. Elevated blood urea nitrogen level A high number of patients with SLE develop nephropathy, so an increase in blood urea nitrogen level may indicate a need for a change in therapy or for further diagnostic testing such as a creatinine clearance test or renal biopsy. The other laboratory results are expected in patients with SLE.

Why is indomethacin (Indocin) given to a preterm neonate? 1. Encourage ductal closure. 2. Prevent hypertension. 3. Promote release of surfactant. 4. Protect the immature liver.

1. Encourage ductal closure. Preterm neonates with good renal function may receive indomethacin (Indocin), a prostaglandin inhibitor, to encourage patent ductus arteriosus closure

The client with a venous stasis ulcer is being treated with dextranomer, which are highly porous beads. The nurse notes the beads are a grayish-yellow color. Which intervention should the nurse implement? 1. Flush the beads with normal saline and apply a new layer of beads. 2. Take no intervention because this is the normal color of the beads. 3. Apply a new layer of beads without removing the grayish-yellow beads. 4. Prepare the client for surgical debridement of the wound.

1. Flush the beads with normal saline and apply a new layer of beads. Dextranomer (Debrisan) is a debriding agent. The grayish-yellow color indicates the beads are saturated, at which point their cleansing intervention stops. The beads should be fl ushed from the wound with normal saline and a fresh layer should be applied.

The nurse is talking to a group of older women about breast cancer. Based on the most recent guidelines from the American Cancer Society and the American Society of Clinical Oncology, what will the nurse tell the group about the current recommendations for breast cancer screening? 1. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended. 2. For women older than the age of 55 years with average risk for breast cancer, mammography screening is recommended every 3 to 5 years. 3. For women older than the age of 70 with average risk for breast cancer, annual screening mammography is not recommended. 4. Starting at age 40 years, all women with average risk for breast cancer should have annual clinical breast examination and mammography screening.

1. For older women in good general health and a life expectancy of 10 or more years, biennial or annual mammography screening is recommended. Recent guidelines from the American Cancer Society and the American Society of Clinical Oncology include specific recommendations for screening based on age include the following: • Between ages 40 and 44 years, women can be offered annual screening. • Starting at age 45 years, for women at average risk for breast cancer, regular screening mammography is recommended. • For women 45 to 54 years old, annual screening mammography is recommended. • For women 55 years and older, either biennial screening or continuing annual screening may be appropriate. • At any age, as long as they are in good general health and have a life expectancy of at least 10 years, older women should continue screening mammography. • At any age, average-risk women should not undergo a clinical breast examination for breast cancer screening.

A 5-year-old boy has always been one of the shortest children in class. His mother tells the school nurse that her husband is 6 ′ tall and she is 5 ′ 7 ″. What should the nurse tell the child ' s mother? 1. He is expected to grow about 2 inches every year from ages 6 to 9 years. 2. He is expected to grow about 3 inches every year from ages 6 to 9 years. 3. He should be seen by an endocrinologist for growth-hormone injections. 4. His growth should be re-evaluated when he is 7 years old.

1. He is expected to grow about 2 inches every year from ages 6 to 9 years.

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply. 1. How soon after you wake up in the morning do you smoke? 2. Do other members of your family smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 5. Do you smoke indoors or outside? 6. Do you have a difficult time not smoking in places where it is not allowed?

1. How soon after you wake up in the morning do you smoke? 3. Do you smoke when you are ill? 4. Do you wake up in the middle of your sleep time to smoke? 6. Do you have a difficult time not smoking in places where it is not allowed?

Which medication should the nurse question administering to a client diagnosed with stage C CHF? 1. Ibuprofen. 2. Amlodipine. 3. Spironolactone. 4. Atenolol.

1. Ibuprofen Ibuprofen (Motrin) is an NSAID. NSAIDs promote sodium retention and peripheral vasoconstriction—interventions that can make CHF worse. Additionally, they reduce the effi cacy and intensify the toxicity of diuretics and ACE inhibitors. The nurse should question this medication

The client diagnosed with a migraine headache rates the pain at a 4 on a 1-10 scale. Which medication should the nurse administer? 1. Ibuprofen orally. 2. Butorphanol intramuscularly. 3. Dihydroergotamine intranasally. 4. Sumatriptan subcutaneously.

1. Ibuprofen orally.

The client diagnosed with Alzheimer's disease is prescribed galantamine. Which interventions should the nurse implement? Select all that apply. 1. Inform the client to take the medication with food. 2. Check the client's BUN and creatinine levels. 3. Teach the client to wear a MedicAlert bracelet with information about the medication. 4. Assess the client's other routine medications. 5. Discuss not abruptly discontinuing the medication.

1. Inform the client to take the medication with food. 2. Check the client's BUN and creatinine levels. 4. Assess the client's other routine medications. Galantamine's (Reminyl's), a cholinesterase inhibitor, most common side effect is gastrointestinal disturbance. This can be minimized if the medication is taken with food. Galantamine (Reminyl), a cholinesterase inhibitor, is excreted by the kidneys. The dose is limited for clients with renal or liver impairment and used with caution in clients with severe impairment. The effects of cholinesterase inhibitors may be reduced by fi rst- generation antihistamine medications, tricyclic antidepressants, and antipsychotics, and the client should not take these medications simultaneously. The nurse should ask the client about other medications taken

The client diagnosed with a brain tumor is prescribed mannitol to be administered intravenously. Which interventions for this medication should the nurse implement? Select all that apply. 1. Inspect the bottle for crystals. 2. Record intake and output every 8 hours. 3. Auscultate the client's lung fi elds. 4. Perform a neurological examination. 5. Have calcium gluconate at the bedside.

1. Inspect the bottle for crystals. 2. Record intake and output every 8 hours. 3. Auscultate the client's lung fi elds. Mannitol (Osmitrol), an osmotic diuretic, can crystallize in the containers in which it is packaged, and the crystals must not be infused into the client. The nurse should inspect the bottle for crystals before beginning the administration. Mannitol (Osmitrol) is an osmotic diuretic and works by pulling fl uid from the tissues into the blood vessels. Clients diagnosed with heart failure or who may be at risk for heart failure may develop fl uid volume overload. Therefore, the nurse should assess lung sounds before administering this medication.

The client who has been prescribed phenytoin for epilepsy calls the clinic and reports a measles- like rash. Which intervention should the nurse implement? 1. Instruct the client to come to the clinic immediately. 2. Determine if the client is drinking grapefruit juice. 3. Encourage the client to apply a hydrocortisone cream to the rash. 4. Explain that this is a common side effect of this medication.

1. Instruct the client to come to the clinic immediately. This morbilliform (measles- like) rash may progress to a more serious reaction to phenytoin (Dilantin), an anticonvulsant; therefore, the client should come to the clinic immediately and the medication should be stopped immediately.

The client diagnosed with a brain tumor has been placed on narcotic analgesic medications to control the associated headaches. Which interventions should the nurse implement? Select all that apply. 1. Instruct the client to increase fluids while taking the medications. 2. Talk to the client about taking bulk laxatives daily. 3. Teach the signifi cant other to perform a neurological assessment. 4. Discuss limiting the amount of medication allowed per day. 5. Explain safety issues when taking narcotic medications.

1. Instruct the client to increase fluids while taking the medications. 2. Talk to the client about taking bulk laxatives daily. 5. Explain safety issues when taking narcotic medications. The client is at risk for constipation because of the effects of narcotics on the gastrointestinal tract. The client should be encouraged to increase the amount of fluid intake The medication may need to be increased, not limited, to control the pain. The amount of pain medication needed should be provided.

The client newly diagnosed with a seizure disorder also has type 2 diabetes. The HCP prescribes phenytoin for the client. Which intervention should the nurse implement? 1. Instruct the client to monitor his or her blood glucose more closely. 2. Explain that the phenytoin will not affect the client's antidiabetic medication. 3. Discuss the need to discontinue oral hypoglycemic medication and take insulin. 4. Call the HCP to discuss prescribing the phenytoin.

1. Instruct the client to monitor his or her blood glucose more closely. Serum glucose must be monitored more closely because phenytoin may inhibit insulin release, thus causing an increase in glucose level.

The nurse is caring for a client newly diagnosed with Parkinson's disease who is receiving levodopa. Which interventions should the nurse implement? Select all that apply. 1. Instruct the client to rise slowly from a seated or lying position. 2. Teach about on-off effects of the medication. 3. Discuss taking the medication with meals or snacks. 4. Tell the client that the sweat and urine may become darker. 5. Inform the client about having routine blood levels drawn.

1. Instruct the client to rise slowly from a seated or lying position. 2. Teach about on-off effects of the medication. 4. Tell the client that the sweat and urine may become darker. Initially levodopa can cause orthostatic hypotension. The client should be taught to rise slowly to prevent falls. The client may experience an "on" effect of symptom control when the medication is effective and an "off" effect near the time for the next dose of medication.

The client with a seizure disorder is prescribed fosphenytoin. Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to wear a MedicAlert bracelet and carry identifi cation. 2. Tell the client to not self- medicate with over- the- counter (OTC) medications. 3. Encourage the client to decrease drinking of any type of alcohol. 4. Discuss the importance of maintaining good oral hygiene. 5. Explain the importance of maintaining adequate nutritional intake.

1. Instruct the client to wear a MedicAlert bracelet and carry identifi cation. 2. Tell the client to not self- medicate with over- the- counter (OTC) medications. 5. Explain the importance of maintaining adequate nutritional intake. The client should wear a MedicAlert bracelet and carry identifi cation so that an HCP and others possibly providing care know that the client has a seizure disorder. The client should not take any OTC medications without fi rst consulting with the HCP or pharmacist because many medications interact with fosphenytoin (Cerebyx), an anticonvulsant. Phenytoin (Dilantin) may cause anorexia, nausea, and vomiting; therefore, the client should maintain an adequate nutritional intake.

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply. 1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 3. Ensure that the pneumococcal vaccine is administered. 4. Use a kinetic bed to continuously change the client's position. 5. Provide oral care with chlorhexidine solution at least daily.

1. Keep the head of the client's bed elevated to at least 30 degrees. 2. Assess the client's readiness for extubation at least daily. 5. Provide oral care with chlorhexidine solution at least daily. The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential.

The client on telemetry is showing multifocal PVCs. Which antidysrhythmic medication should the nurse administer? 1. Lidocaine. 2. Atropine. 3. Adenosine. 4. Epinephrine.

1. Lidocaine. Lidocaine, an antidysrhythmic, suppresses ventricular ectopy and is a fi rst-line drug for the treatment of ventricular dysrhythmias

The nurse is completing an admission assessment on a client being admitted to a medical unit diagnosed with pneumonia. The client's list of home medications includes furosemide, Metamucil, and galantamine hydrobromide. Which intervention should the nurse implement fi rst? 1. Make sure the client has a room near the nursing station. 2. Check the client's WBC count and potassium level. 3. Have the UAP get ice chips for the client to suck on. 4. Determine the client's usual bowel elimination pattern.

1. Make sure the client has a room near the nursing station. Galantamine hydrobromide (Reminyl) is a cholinesterase inhibitor and is prescribed for mild to moderate Alzheimer's disease. The safety of the client should be the nurse's fi rst concern. Moving the client to a room that can be observed more closely is one of the fi rst steps in a falls prevention protocol.

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)? 1. Measuring ankle and brachial pressures in a client for whom the anklebrachial index is to be calculated 2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing 3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography 4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

1. Measuring ankle and brachial pressures in a client for whom the anklebrachial index is to be calculated Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision? 1. Observing how well the patient performs pursed-lip breathing 2. Planning a nursing care regimen that gradually increases activity tolerance 3. Assisting the patient with basic activities of daily living (ADLs) 4. Consulting with the physical therapy department about reconditioning exercises

1. Observing how well the patient performs pursed-lip breathing Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN's scope of practice.

The long- term- care facility nurse is caring for a client diagnosed with a cerebrovascular accident (CVA) 6 months ago who has residual cognitive defi cits. The HCP has ordered alprazolam to be administered at bedtime. Which interventions should the nurse initiate for this client? Select all that apply. 1. Offer toileting every 2 hours. 2. Move the client close to the nurse's station. 3. Administer the medication at 2100. 4. Administer the medication with a full glass of water. 5. Do not administer if the client's apical pulse is less than 60 bpm.

1. Offer toileting every 2 hours. 2. Move the client close to the nurse's station. 3. Administer the medication at 2100. Alprazolam (Xanax), an antianxiety medication, has a side effect of drowsiness, which is why the HCP chose this medication for the client— to help the client rest at night. The client has cognitive defi cits and should be on fall precautions, so it is hoped that assisting the client to the bathroom every 2 hours will prevent the client from falling while trying to get to the bathroom. The client at risk for falling should be as near the nursing station as possible. This allows the staff to keep a closer watch on the client. The medication is ordered for bedtime, usually 2100 in most health- care facilities.

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

1. Perform endotracheal intubation and initiate mechanical ventilation. A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.

The emergency department nurse received a client with multiple hematomas who has an INR of 7.2. Which medication should the nurse prepare to administer? 1. Protamine sulfate. 2. Heparin. 3. Phytonadione. 4. Vitamin C

1. Protamine sulfate. AquaMEPHYTON, vitamin K, is the antidote for Coumadin toxicity, which is supported by an INR of 7.2 and the bruising. The therapeutic range is 2 to 3.

At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first? 1. Put the client on "nothing by mouth" (NPO) status. 2. Teach the client about the procedure. 3. Insert an IV catheter in the client's forearm. 4. Attach the client to a cardiac monitor.

1. Put the client on "nothing by mouth" (NPO) status. Because transesophageal echocardiography is performed after the throat is numbed using a topical anesthetic and with the use of IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the echocardiogram but do not need to be implemented immediately

A health-care provider has ordered amoxicillin (Amoxil) 500 mg IVPB q8h for a child with tonsillitis. Which action by the nurse is appropriate? 1. Question the order because the route is incorrect. 2. Give the medication as ordered. 3. Call the health-care provider because the dosing frequency is incorrect. 4. Call the health-care provider and question the dose of the drug.

1. Question the order because the route is incorrect. Amoxicillin is only given orally, so the order should be questioned.

The client diagnosed with bacterial endocarditis is being discharged home receiving IV antibiotic therapy. Which interventions should the nurse implement? Select all that apply. 1. Refer the client to home health-care services. 2. Teach the client to report an elevated temperature. 3. Explain how to use the IV pump. 4. Contact the hospital pharmacy to provide an IV pump. 5. Discuss the need for prophylaxis before dental procedures

1. Refer the client to home health-care services. 2. Teach the client to report an elevated temperature. 5. Discuss the need for prophylaxis before dental procedures IV antibiotics are prescribed for up to 6 weeks. The client is discharged home and will receive this therapy with the assistance of a home health-care nurse The nurse must teach the client self-monitoring for manifestations of endocarditis. The client should take his or her temperature daily and report an elevated temperature Prophylactic antibiotics are administered prior to invasive procedures (such as teeth cleaning) so that there will not be an exacerbation of the endocarditis

The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 3. Assess skin turgor by pinching the skin over the back of the hand 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake 6. Seeking a dietary consult to increase fluids on meal trays

1. Reminding the client to avoid commercial mouthwashes 2. Encouraging mouth rinsing with warm saline 4. Observing the lips, tongue, and mucous membranes 5. Providing mouth care every 2 hours while the client is awake

The home health-care nurse is visiting a client diagnosed with DVT who is taking warfarin. The nurse assesses a large hematoma on the abdomen and multiple small ecchymotic areas scattered over the body. Which intervention should the nurse implement? 1. Send the client to the emergency department immediately. 2. Encourage the client to apply ice to the abdominal area. 3. Inform the client that this is expected when taking this medication. 4. Instruct the client to wear a MedicAlert bracelet at all times.

1. Send the client to the emergency department immediately. Abnormal bleeding is a sign of warfarin (Coumadin), an anticoagulant, overdose. The client needs to be assessed immediately and have a stat INR laboratory test.

Clients' rights are 1. Specifically written into many laws. 2. A position paper that was developed by the American Hospital Association. 3. A declaration of the World Health Organization. 4. Not supported by statutory law.

1. Specifically written into many laws.

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will the nurse implement first? 1. Start oxygen using a nonrebreather mask. 2. Infuse 5% dextrose in water at 100 mL/hr. 3. Administer the first dose of oral oseltamivir. 4. Obtain blood and sputum specimens for testing.

1. Start oxygen using a nonrebreather mask. Because the respiratory manifestations associated with avian influenza are potentially life threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems.

In the care of a patient with neutropenia, what tasks should the nurse instruct unlicensed assistive personnel (UAP) to perform? Select all that apply. 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4°F (38°C) 4. Gathering the supplies to prepare the room for protective isolation 6. Practicing good hand-washing technique Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

Which should the nurse include in the discharge teaching plan for a child beginning growth hormone therapy? 1. The child is expected to grow 3 to 5 inches during the first year of treatment. 2. The parents must measure the child ' s weight and height weekly. 3. The child will need to continue the therapy until he or she is 21 years old. 4. There are no side effects from taking growth hormones.

1. The child is expected to grow 3 to 5 inches during the first year of treatment.

The male client at the outpatient client was diagnosed with folic acid deficiency anemia and given a sample of oral folic acid. At the follow-up visit the nurse assesses the client to determine effectiveness of the treatment. Which data indicates the treatment is effective? 1. The client has gained 2 pounds and has pink buccal mucosa. 2. The client does not have any paresthesias of the hands and feet. 3. The client stopped drinking any alcoholic beverages. 4. The client can tolerate eating green, leafy vegetables.

1. The client has gained 2 pounds and has pink buccal mucosa. Symptoms of folic acid defi ciency include pallor, pale mucous membranes, fatigue, and weight loss. A weight gain and pink buccal mucosa indicate an improvement in the client's condition and that the medication is effective.

The client diagnosed with migraine headaches that occur every 2 to 3 days is placed on preventive therapy with propranolol. Which data indicate the medication is effective? 1. The client has had only one headache in the past week. 2. The client's apical pulse is 78 bpm. 3. The client has developed orthostatic hypotension. 4. The client supplemented propranolol with sumatriptan four times.

1. The client has had only one headache in the past week. This indicates an improvement in the number of headaches the client normally experiences and is the only option that indicates an improvement in a condition.

Which statement is the advantage of prescribing donepezil over other cholinesterase inhibitors? 1. The dosing schedule for donepezil is only once a day. 2. Donepezil is the only one that can be given with an NSAID. 3. Donepezil enhances the cognitive protective effects of vitamin E. 4. There are no side effects of donepezil.

1. The dosing schedule for donepezil is only once a day.

Which should the nurse include in the teaching plan for a child started on metoclopramide (Reglan)? 1. The drug increases gastrointestinal motility. 2. The drug decreases tone in the lower esophageal sphincter. 3. The drug prevents diarrhea. 4. The drug induces the release of acetylcholine.

1. The drug increases gastrointestinal motility. Metoclopramide (Reglan) is a gastrointestinal stimulant that increases motility of the gastrointestinal tract, shortens gastric emptying time, and reduces the risk of the esophagus being exposed to gastric content.

The nurse is evaluating a patient with human immunodeficiency virus (HIV) who is receiving trimethoprim-sulfamethoxazole (TMP-SMX) as a treatment for Pneumocystis jiroveci pneumonia. Which information is most important to communicate to the health care provider? 1. The patient reports a blistering rash. 2. The patient's fluid intake is 2 L/day. 3. The patient's potassium is 3.4 mg/dL (3.4 mmol/L). 4. The patient enjoys spending time outside in the sun.

1. The patient reports a blistering rash. Because TMP-SMX can cause Stevens-Johnson syndrome (a lifethreatening skin condition), a blistering rash indicates a need to discontinue the medication immediately. Two L/day of fluid is adequate to prevent crystalluria and renal damage associated with TMP-SMX. TMP-SMX can cause hyperkalemia; the nurse will report the potassium level to the provider, but the low potassium level is not caused by the medication. Patient teaching about photosensitivity is needed, but the nurse does not need guidance from the provider to implement this action.

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus? 1. The patient was recently in a motor vehicle crash. 2. The patient participated in an aerobic exercise program for 6 months. 3. The patient gave birth to her youngest child 1 year ago. 4. The patient was on bed rest for 6 hours after a diagnostic procedure.

1. The patient was recently in a motor vehicle crash. Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT) and pulmonary embolus (PE). None of the other findings are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short

patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living (ADLs)? Select all that apply. 1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 4. Use a rectal thermometer to obtain a more accurate body temperature. 5. Be sure the patient's footwear has a firm sole when the patient ambulates. 6. Assess the patient for any signs or symptoms of bleeding.

1. Use a lift sheet when moving and positioning the patient in bed. 2. Use an electric razor when shaving the patient each day. 3. Use a soft-bristled toothbrush or tooth sponge for oral care. 5. Be sure the patient's footwear has a firm sole when the patient ambulates.

Which method is the most effective way to present an educational program on abstinence to adolescents? 1. Use peer-led programs that emphasize the consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4. Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.

1. Use peer-led programs that emphasize the consequences of unprotected sexual contact. Adolescents are most concerned with what their peers think and feel. They are most receptive to information that comes from another adolescent

A nurse reports to employee health services for an injury to the hand from a needle stick. The needle was used on a client who is known to be HIV positive. Which interventions should be taken by the occupational health nurse in employee health services? SELECT ALL THAT APPLY. 1. Wash the exposed site with soap and water 2. Test for HIV antigens now, in 6 weeks, and then again in 3 months 3. Administer postexposure prophylaxis medications within 1 to 2 hours 4. Counsel on safe sexual practices until follow-up testing is complete 5. Place the employee on leave until testing indicates the employee's HIV status is negative

1. Wash the exposed site with soap and water 3. Administer postexposure prophylaxis medications within 1 to 2 hours 4. Counsel on safe sexual practices until follow-up testing is complete Occupational blood exposure is an urgent medical concern and care should be sought immediately. Washing can reduce the amount of virus present and may prevent transmission. After an HIV exposure, infection may have occurred even though tests for HIV are negative; it may take up to 1 year for the development of a positive antibody test. Prophylactic treatment is started as soon as possible (preferably within 1 to 2 hours) and lasts for 4 weeks. If results of HIV-antibody testing return positive, treatment continues.

An example of a process standard on a med-surg unit is: 1. a procedure for changing IV tubing. 2. a policy for staffing. 3. the job description of the CEO (chief executive officer). 4. a procedure for checking waveforms on a patient being treated on an intra-aortic balloon pump

1. a procedure for changing IV tubing. Process standards define the actions and behaviors required by staff to provide care. A procedure for changing IV tubing is a psychomotor skill that is applied to helping the patient meet their goals.

As a type of quality indicator, an example of a structure standard is: 1. a written philosophy. 2. a procedure for a straight catheterization. 3. a protocol for treatment of a patient with chest pain. 4. the diagnostic work-up for a patient with abdominal pain.

1. a written philosophy. Structure standards define all the conditions needed to operate, direct, and control a system. They do not address patient care but rather describe structure with regard to purpose; such as philosophy, objectives, goals, hours of operation, and management responsibility

An ombudsman is: 1. an individual, usually an employee of the government or an institution, who investigates consumer complaints and assists in achieving a fair resolution. 2. a lawyer designated to try a case. 3. an individual hired by a family as their representative. 4. a family member designated to make decisions for an individual.

1. an individual, usually an employee of the government or an institution, who investigates consumer complaints and assists in achieving a fair resolution.

Once signed, informed consents are legally valid: 1. as defined by facility policy. 2. for one year. 3. until discharge. 4. for 30 days.

1. as defined by facility policy.

Case managers functions encompass a variety of roles including all of the following except: 1. financial planner. 2. clinical expert. 3. patient educator. 4. outcomes manager.

1. financial planner.

For individuals who are no longer capable of speaking for themselves, the order of surrogacy for their healthcare decision making is: 1. guardian, DPOAHC, spouse, adult children of patient, parents of patient, adult brothers and sisters of patient. 2. spouse, DPOAHC, parents of patient, adult children of patient. 3. DPOAHC, spouse, adult children of patient, adult brothers and sisters of the patient. 4. spouse, guardian, adult children of patient, DPOAHC.

1. guardian, DPOAHC, spouse, adult children of patient, parents of patient, adult brothers and sisters of patient.

As a nurse discharge planner explaining available outpatient services to a family contemplating discharge, you explain that rehab or skilled care: 1. is focused on short-term functional outcomes. 2. deals with chronic decline in health status due to chronic illness. 3. maintains cognitive function. 4. includes respite care

1. is focused on short-term functional outcomes.

You are caring for a multiple trauma victim in the ICU who has just been evaluated as brain dead. You know: 1. most religions approve of organ donation as an act of charity. 2. the age of the donor will determine whether organs may be donated or not. 3. organ donation will disfigure the body and alter funeral arrangements such as arrangements for an open casket funeral. 4. many religions prohibit organ donation

1. most religions approve of organ donation as an act of charity.

The power a nurse exerts when he/she works to accomplish goals and effect change in an agency or in policy is considered what type of power? 1. political 2. personal 3. positional 4. professional

1. political Political power results from one's ability to work within systems or agencies or through policy in order to effect change. Personal power is based upon one's charisma and self-confidence and is often found in informal leadership situations. Positional power is based on designated authority in a legitimized position within which the power is exercised. Professional power is based upon one's professional skills and abilities resulting from one's recognized expertise in an area of practice.

Mg normal values

1.5-2.5

A client is experiencing pain during the first stage of labor. What should the nurse instruct the client to do to manage her pain? Select all that apply? a. Walk in the hospital room b. use slow chest breathing c. request pain medication on a regular basis d. lightly massage the abdomen e. sip ice water

a. Walk in the hospital room b. use slow chest breathing d. lightly massage the abdomen Pain during the first stage of labor is primarily caused by hypoxia of the uterine and cervical muscle cells during contraction, stretching of the lower uterine segment, dilatation of the cervix and perineum and pressure on adjacent structures. Ambulating will assist in increasing circulation of blood to the area and relaxing the muscles. Slow chest breathing is appropriate during the first stage of labor to promote increased oxygenation as well as relaxation. Chest breathing and massaging increase oxygenation and relaxation of uterine muscles. Pain medication is not used during the first stage of labor because most medications will slow labor; anesthesia is considered during second stage.

When providing care to the client who has undergone a dilatation and curettage (D&C) after a spontaneous abortion, the nurse administers hydroxyzine as prescribed. What is an expected outcome? a. absence of nausea b. minimized pain c. decreased uterine cramping d. improved uterine contractility

a. absence of nausea Hydroxyzine has a tranquilizing effect and also decreases nausea and vomiting. It doesn't decrease fluid retention, reduce pain, decrease uterine cramping or promote uterine contractility. One of the ADR is sleepiness.

When developing a nursing care plan for an infant receiving phototherapy, the nurse should include what information in the plan of care? select all that apply a. adequate skin exposure to photohtearpy b. allowing mother to hold infant as much as she wishes c. eye protection d. supplemental water between feedings e. thermoregulation

a. adequate skin exposure to phototherapy c. eye protection e. thermoregulation There is a 30 min limit to when the mother can hold the baby during feedings. Supplemental water is not needed in addition to the fluid they get from the breast feeding.

The nurse provides care for a pediatric client who is 18 months of age and weighs 26 pounds. The child is prescribed ibuprofen 100 mg every 6 hours for a temperature greater than 38 degrees C (100.4 degrees F). Which is the best action by the nurse based on the current data? a. administer the med as prescribed b. clarify the dose by weight with the practitioner c. clarify the frequency of administration with the practitioner d. administer APAP instead of ibuprofen for fever reduction

a. administer the med as prescribed The safe dose range for ibuprofen for a child is 4-10 mg/kg/dose older than 6 months, can be safety administered up to 4x/day.

When does the anterior fontanel close?

18 months

The nurse is preparing for a pediatric trauma admission in which traction will be applied to immobilize a femur fracture for a child. The nurse reviews the forms of traction and the purposes for each before gathering equipment prior to the child's arrival. Match the type of traction on the left with the type of injury or indication on the right. All options must be used 1. Bryant's traction 2. Russell's traction 3. 90 degree traction 4. Buck's traction 5. Cervical traction a. Stabilizes a spinal fracture or muscle spasm b. used on the femur if skin traction isn't suitable c. temporarily immobilizes a fractured leg d. may reduce fractures of the hip or femur e. used in children younger than age 2 to reduce femur fractures or stabilize hips

1E 2D 3B 4C 5A

FLACC scale

2 months to 7 years face, legs, activity, cry, consolability

The nurse is preparing to administer the initial IV antibiotic to a client with an arterial ulcer on the right ankle. The client has a saline lock in the right forearm. In which order should the nurse prepare to administer the medication? Rank in order of performance. 1. Inject 3 mL of normal saline into the saline lock. 2. Check to see if a C&S test has been done. 3. Flush the IV tubing with the antibiotic. 4. Determine if the client has any known allergies. 5. Connect the antibiotic medication to the saline lock.

2, 4, 3, 1, 5

When does posterior fontanel close?

2-3 months

The 29- year- old female client is taking tanacetum parthenium, for chronic migraine headaches. Which information should the nurse teach the client? 1. "Decrease the dose of prescription NSAIDs while taking this herb." 2. "Do not breastfeed and avoid getting pregnant while taking feverfew." 3. "The medication will immediately relieve a migraine headache." 4. "Menstrual problems will become worse while taking this medication."

2. "Do not breastfeed and avoid getting pregnant while taking feverfew." The client is of childbearing age and should be warned that tanacetum parthenium crosses the placental barrier and may cause problems with the fetus. The nurse should teach the client to avoid pregnancy and not to breastfeed while taking feverfew.

A 4-year-old boy has been hospitalized because he fell down the stairs. His mother is crying and states, "This is all my fault." Which is the nurse ' s best response? 1. "Accidents happen. You shouldn't blame yourself." 2. "Falls are one of the most common injuries in this age-group." 3. "It may be a good idea to put a gate on the stairs." 4. "Your son should be proficient at walking down the stairs by now."

2. "Falls are one of the most common injuries in this age-group." Falls are one of the most common injuries, and it may make the parent feel better to know that this is common.

The client with a serum cholesterol level of 320 mg/dL is taking the medication ezetimibe. Which statement by the client indicates the client needs more teaching concerning this medication? 1. "This medication helps decrease the absorption of cholesterol in my intestines." 2. "I cannot take this medication with any other cholesterol-lowering medication." 3. "I need to eat a low-fat, low-cholesterol diet even when taking the medication." 4. "It will take a few months for my cholesterol level to get down to normal levels."

2. "I cannot take this medication with any other cholesterol-lowering medication." Ezetimibe (Zetia) is an antihyperlipidemic medication. This is not a true statement; therefore, the client needs more teaching. Zetia acts by decreasing cholesterol absorption in the intestine and is used together with statins to help lower cholesterol in clients whose cholesterol levels cannot be controlled by taking statins alone.

The mother of an 11-month-old with iron-defi ciency anemia tells the nurse that her infant is currently taking iron and a multivitamin. Which statement made by the mother should be of concern to the nurse? 1. "I give the iron and multivitamin at the same time each morning." 2. "I give the iron and multivitamin in the morning 6-oz bottle." 3. "I give the iron and multivitamin 2 hours before I feed the morning bottle." 4. "I give the iron and multivitamin in oral syringes toward the back of the cheek."

2. "I give the iron and multivitamin in the morning 6-oz bottle." Medications should never be mixed in a large amount of food or formula because the parent cannot be sure that the child will take the entire feeding. Formula decreases the absorption of iron.

Which statement indicates to the nurse that the client with coronary artery disease (CAD) understands the medication teaching for taking aspirin daily? 1. "I will probably have occasional bleeding when taking this medication." 2. "I will call 911 if I have chest pain unrelieved and I will chew an aspirin." 3. "If I have any ringing in my ears, I will call my HCP." 4. "I should take my daily aspirin on an empty stomach for better absorption."

2. "I will call 911 if I have chest pain unrelieved and I will chew an aspirin." Aspirin is administered as an antiplatelet to prevent coronary artery occlusion. It is not administered for chest pain. If the client has chest pain that is not relieved with NTG, the client should call the EMS and get medical treatment immediately. Taking an extra aspirin may prevent further cardiac damage.

Which statements by an infant ' s mother lead the nurse to believe that she needs further education about the nutritional needs of a 6-month-old? Select all that apply. 1. "I will continue to breastfeed my son and will give him oatmeal cereal two times a day." 2. "I will start my son on fruits and gradually introduce vegetables." 3. "I will start my son on carrots and will introduce one new vegetable every few days." 4. "I will not give my son any more than 4 to 6 ounces of baby juice per day." 5. "I will make sure my son gets cereal three times a day."

2. "I will start my son on fruits and gradually introduce vegetables." 4. "I will not give my son any more than 4 to 6 ounces of baby juice per day." 5. "I will make sure my son gets cereal three times a day." Breastfeeding is the ideal nutrition for the fi rst year of life. Cereal can be introduced between 4 and 6 months of age and offered twice a day Infants should be started on vegetables prior to fruits. The sweetness of fruits may inhibit infants from taking vegetables Infants can be given fruit juice by 6 months of age, but it is recommended not to exceed 4 to 6 ounces per day Infants need another source of iron by 4 to 6 months of age, so cereal is introduced twice a day.

The client diagnosed with Parkinson's disease is prescribed amantadine. Which information should the nurse teach the client? 1. "Do not get the fl u vaccine because there may be interactions." 2. "If the symptoms return, you should notify the HCP." 3. "The dose should be decreased if you are taking other Parkinson's disease medications." 4. "If a dry mouth develops, discontinue the medication immediately."

2. "If the symptoms return, you should notify the HCP." The effectiveness of amantadine (Symmetrel) may diminish in 3 to 6 months. If signs and symptoms of Parkinson's disease (PD) recur, the client should notify the HCP.

The client with a venous stasis ulcer has exudate. A calcium alginate dressing is applied to the draining ulcer. The client asks the nurse, "How often will the dressing be changed?" Which statement is the nurse's best response? 1. "The dressing will have to be changed daily." 2. "It will be changed when the exudate seeps through." 3. "The doctor will determine when the dressing is changed." 4. "It will not be changed until the wound is healed."

2. "It will be changed when the exudate seeps through." The dressing is changed when the exudate seeps through the dressing or at least every 7 days

The HCP prescribed an angiotensin-converting enzyme (ACE) inhibitor for a client diagnosed with CHF. Which instruction should the nurse provide? 1. "Eat a banana or drink orange juice at least twice a day." 2. "Notify the HCP if you develop localized edematous areas that itch." 3. "Expect to have a dry cough early in the morning on arising." 4. "Your symptoms of congestive heart failure should improve rapidly."

2. "Notify the HCP if you develop localized edematous areas that itch." A condition in which there are localized edematous areas (wheals), accompanied by intense itching of the skin and mucous membranes, is called angioedema. This is an adverse reaction to an ACE inhibitor and should be reported to the HCP.

The spouse of a client discharged following a transurethral prostatectomy (TURP) calls a clinic because the client continues to have pink-tinged urine 2 days after the procedure. Which response by the nurse is most appropriate? 1. "Bring him right into the clinic so that we can evaluate why his urine is pink-tinged." 2. "This is normal. His urine will be pink-tinged for several days after the procedure." 3. "Is he eating more leafy green vegetables or taking any over-the-counter medications?" 4. "His urine should be clear amber by now so there might be bleeding. Increase his fluids."

2. "This is normal. His urine will be pink-tinged for several days after the procedure." The client may continue to pass small clots and tissue debris and have pink-tinged urine for several days after surgery.

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? 1. "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." 2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." 3. "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." 4. "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

2. "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients."

The nurse hears in hand-off report that the patient with cancer received an as needed (PRN) oral dose of lorazepam. Which question is the oncoming nurse most likely to ask the off-going nurse in relation to the medication? 1. "What did the patient say about the location and level of the pain?" 2. "Were you able to determine what was making the patient so anxious?" 3. "When is the patient allowed to have another dose of lorazepam?" 4. "Did the patient have a normal bowel movement after the medication?

2. "Were you able to determine what was making the patient so anxious?" Lorazepam is a benzodiazepine, and it is not a first-line drug for cancer pain. It can be used for anxiety, insomnia, alcohol withdrawal, and muscle spasms and may be used in combination with other antiemetics for cancer-induced nausea and vomiting. If the trigger factors for anxiety are identified, the nursing staff can plan nonpharmaceutical interventions.

An 80-year-old client is being discharged from the hospital after a total knee replacement. Her only son has decided to take care of her at his home. During discharge planning, it is most appropriate for the nurse to ask the son: 1. "Are you sure this is the best thing for you to do?" 2. "Will caring for your mother affect your lifestyle?" 3. "Do you own your own car?" 4. "Is your home paid off?"

2. "Will caring for your mother affect your lifestyle?"

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse's best response? 1. "Let's elevate the head of your bed and see if that helps." 2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." 3. "Sometimes patients also experience dry mouth and difficulty with swallowing." 4. "I will call your health care provider and let him know about this."

2. "Your voice should improve in 6 to 8 weeks after completion of the radiation." Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips. Elevating the head of the bed may help with oxygenation but will not help with hoarseness. Responses 3 and 4 are important but do not speak directly to the patient's concern.

A child with cystic fibrosis (CF) is placed on an oral antibiotic to be given four times a day for 14 days. Which of the following schedules is the most appropriate? 1. 8 a.m., 12 p.m., 4 p.m., 8 p.m. 2. 7 a.m., 1 p.m., 7 p.m., 12 midnight. 3. 9 a.m., 1 p.m., 5 p.m., 9 p.m. 4. 10 a.m., 2 p.m., 6 p.m., 10 p.m.

2. 7 a.m., 1 p.m., 7 p.m., 12 midnight. Antibiotics should be scheduled to maintain therapeutic blood levels and not interfere with the child ' s sleep. This schedule allows for dosing every 6 hours during the day and allows the child to get 7 hours of uninterrupted sleep at night.

Four clients arrive simultaneously at the emergency department. Which client requires the most rapid action by the triage nurse to protect other clients from infection? 1. A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis 2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection 3. A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection 4. A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

2. A 5-year-old client who has a new pruritic rash and a possible chickenpox infection Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the emergency department. The child with the rash should be quickly isolated from the other clients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB.

The nurse assesses a primiparous client with ruptured membranes in labor for 20 hours. The nurse identifies late decels on the monitor and initiates standard procedures for the labor client with this wave pattern. Which interventions should the nurse perform? select all that apply a. administering O2 via mask to the client b. questioning the client about the effectiveness of pain relief c. placing the client on her side d. readjusting the monitor to a more comfortable position e. applying ani internal fetal monitor

a. administering O2 via mask to the client c. placing the client on her side e. applying ani internal fetal monitor Decels alert the nurse that the fetus is experiencing decreased blood flow from the placenta. Adminsitering O2 will increase tissue perfusion. Placing the mother on her side will increase placental perfusion and decrease cord compression. Using an internal fetal monitor would help in identifying the possible underlying cause of the decels, such as metabolic acidosis.

Which of the following best describes the function and purpose of the unusual occurrence (incident) report? 1. A legal part of the chart used to furnish data about the incident. 2. A hospital record used to record the details of the incident for possible legal reference. 3. A legal hospital business record that is subject to subpoena and can be used against the hospital personnel. 4. A hospital record that is entered into the client's chart if he or she dies.

2. A hospital record used to record the details of the incident for possible legal reference.

Which cancer patients could be placed together as roommates? Select all that apply. 1. A patient who has a very low neutrophil count 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who had a laminectomy for spinal cord compression 5. A patient who is undergoing brachytherapy for prostate cancer 6. A patient with terminal cancer who is receiving end-of-life care

2. A patient who underwent debulking of a tumor to relieve pressure 4. A patient who had a laminectomy for spinal cord compression Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with a low neutrophil count and the patient who had a recent bone marrow transplantation need protective isolation. The patient who is undergoing brachytherapy needs a private room because radiation is being emitted while the implant is in place. The patient with terminal cancer needs comfort measures, such as privacy, family members at the bedside, and symptom relief. In addition, observing a roommate who has end-of-life symptoms could be very stressful for another patient.

The client who is 1-day postoperative open-heart surgery is exhibiting the following strip and has a T 101.6, P 110, R 24, and BP 128/92. Which intervention should the nurse implement? 1. Continue to monitor the client and take no intervention. 2. Administer acetaminophen. 3. Administer quinidine sulfate. 4. Administer disopyramide.

2. Administer acetaminophen. Acetaminophen (Tylenol) is an antipyretic medication. Sinus tachycardia may be caused by elevated temperature, exercise, anxiety, hypoxemia, hypovolemia, or cardiac failure. Because the client's temperature is elevated, an antipyretic should be administered

A child is to receive phenytoin (Dilantin) 100 mg IV for seizure prophylaxis. Which intervention is appropriate when administering this drug? 1. Mix it in dextrose 5% in water and give over 1 hour. 2. Administer no faster than 2 mg/kg/min. 3. Do not use an inline filter. 4. Monitor temperature prior to and after administration.

2. Administer no faster than 2 mg/kg/min. Phenytoin (Dilantin) should be given slowly (1-2 mg/kg/min) via pump. Rapid infusion may cause hypotension, arrhythmias, and circulatory collapse.

Which information about a client who has meningococcal meningitis is the best indicator that the nurse can discontinue droplet precautions? 1. Pupils are equal and reactive to light. 2. Appropriate antibiotics have been given for 24 hours. 3. Cough is productive of clear, nonpurulent mucus. 4. Temperature is lower than 100°F (37.8°C).

2. Appropriate antibiotics have been given for 24 hours. Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued.

The client with epilepsy is seen in the clinic and has a serum phenytoin level of 5.4 mg/dL. Which intervention should the nurse implement? 1. Request that the laboratory verify the results of the test. 2. Ask the client when the dose was taken last. 3. Instruct the client to not take the phenytoin for 2 days. 4. Discuss the need to increase the dose of the medication.

2. Ask the client when the dose was taken last. This level is below the therapeutic range of 10 to 20 mg/dL; therefore, the nurse should determine if the client is taking the medication as directed.

The nurse is administering digoxin to a client diagnosed with CHF. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's carotid pulse for 1 full minute. 2. Check the client's current potassium level. 3. Ask the client if he or she is seeing a yellow haze around objects. 4. Have the client squeeze the nurse's fi ngers. 5. Teach the client to get up slowly from a sitting position.

2. Check the client's current potassium level. 3. Ask the client if he or she is seeing a yellow haze around objects. The client's apical pulse, not the carotid pulse, should be assessed. Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure. The client's potassium level, as well as the digoxin level, is monitored because high levels of potassium impair therapeutic response to digoxin and low levels can cause toxicity. The most common cause of dysrhythmias in clients receiving digoxin is hypokalemia from diuretics that are usually given simultaneously. Yellow haze indicates the client may have high serum digoxin levels. The therapeutic range for digoxin is relatively small (0.5 to 1.2), and levels of 2.0 or greater are considered toxic.

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Assess puncture site and dressing for leakage. 2. Check vital signs every 15 minutes for 1 hour. 3. Auscultate for absent or reduced lung sounds. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory. 6. Teach the patient symptoms of pneumothorax.

2. Check vital signs every 15 minutes for 1 hour. 4. Remind the patient to take deep breaths. 5. Take the specimens to the laboratory.

A nurse is administering cyclophosphamide (Cytoxan) to a child with leukemia. Which action by the nurse would be appropriate? 1. Monitoring serum potassium levels. 2. Checking for hematuria. 3. Obtaining daily weights. 4. Obtaining neurological checks every 4 hours.

2. Checking for hematuria. Hemorrhagic cystitis is a major side effect of cyclophosphamide (Cytoxan); checking the urine for blood is an appropriate intervention.

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? 1. Client requiring discharge teaching about coronary artery stenting before going home today 2. Client receiving IV furosemide to treat acute left ventricular failure 3. Client who just transferred in from the radiology department after a coronary angioplasty 4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

2. Client receiving IV furosemide to treat acute left ventricular failure An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have acute coronary syndrome and with collaborative treatments such as coronary angioplasty and coronary artery stenting.

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently? 1. Client with peripheral arterial disease who complains of leg cramps when walking 2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope 3. Client with a new permanent pacemaker who has severe itchiness at the wound site 4. Client with angina who took nitroglycerin twice in the last week while exercising

2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope Lightheadedness and syncope may indicate that the client's heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other clients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday

2. Continuous bubbling in the water-seal chamber Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.

Which should a nurse anticipate be prescribed in chelation therapy for a child receiving frequent blood transfusions? 1. Dalteparin sodium (Fragmin). 2. Deferoxamine (Desferal). 3. Diclofenac (Voltaren). 4. Diltiazem (Cardizem).

2. Deferoxamine (Desferal). Deferoxamine (Desferal) is an antidote for acute iron toxicity.

Which assessment finding strongly suggests that the patient with cancer is having incident pain? 1. Frequently reports pain about 30 to 35 minutes before next scheduled dose 2. Demonstrates protectiveness of right arm whenever moving or standing up 3. Reports a continuous burning and tingling sensation in left lower leg 4. Appears quiet, withdrawn and depressed when family leaves after visiting

2. Demonstrates protectiveness of right arm whenever moving or standing up Incident pain is pain that is associated with an event, such as walking, position change, or coughing. In this case, movement is the incident that causes pain and the patient's reaction to protect the arm. Pain 30 to 45 minutes before the next scheduled dose is breakout pain. Burning and tingling are descriptors of neuropathic pain. Depression and withdrawal could occur with all types of pain, especially severe chronic pain. When friends and family are not available, the nurse could try other forms of distraction.

The nurse is going to give a 6-month-old a dose of ceftriaxone (Rocephin) IM. What must the nurse do when the 1.5-mL dose arrives from the pharmacy? 1. Administer the injection into the deltoid muscle. 2. Divide the dose into two injections. 3. Administer the injection into the dorsogluteal muscle. 4. Give dose as a single injection into the vastus lateralis muscle.

2. Divide the dose into two injections. The nurse should not deliver more than 1 mL per IM injection to a 6-month-old

Which statement is the scientific rationale for prescribing and administering donepezil? 1. Donepezil works to bind the dopamine at neuron receptor sites to increase ability. 2. Donepezil increases the availability of acetylcholine at cholinergic synapses. 3. Donepezil decreases acetylcholine in the periphery to increase movement. 4. Donepezil delays transmission of acetylcholine at the neuronal junction.

2. Donepezil increases the availability of acetylcholine at cholinergic synapses. Cholinesterase inhibitors increase the availability of acetylcholine at cholinergic synapses, resulting in increased transmission of acetylcholine by cholinergic neurons that have not been destroyed by the Alzheimer's disease.

After chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory result requires particular attention? 1. Platelet counts 2. Electrolyte levels 3. Hemoglobin levels 4. Hematocrit levels

2. Electrolyte levels Tumor lysis syndrome can result in severe electrolyte imbalances and potential kidney failure.

Which actions should be taken by a nurse when caring for a client who is experiencing dyspnea due to heart failure and chronic obstructive pulmonary disease (COPD)? SELECT ALL THAT APPLY. 1. Apply oxygen 6 liters per nasal cannula 2. Elevate the head of the bed 30 to 40 degrees 3. Weigh the client daily in the morning 4. Teach the client pursed-lip breathing techniques 5. Turn and reposition the client every 1 to 2 hours

2. Elevate the head of the bed 30 to 40 degrees 3. Weigh the client daily in the morning 4. Teach the client pursed-lip breathing techniques Elevating the head of the bed will promote lung expansion. Daily weights will assess fluid retention. Fluid volume excess can increase dyspnea and cause pulmonary edema. Pursed-lip breathing techniques allow the client to conserve energy and slow the breathing rate

The client diagnosed with CHF is prescribed enalapril. Which statement explains the scientific rationale for administering this medication? 1. Enalapril increases the levels of angiotensin II in the blood vessels. 2. Enalapril dilates arteries, which reduces the workload of the heart. 3. Enalapril decreases the effects of bradykinin in the body. 4. Enalapril blocks the intervention of antidiuretic hormone in the kidney

2. Enalapril dilates arteries, which reduces the workload of the heart. Enalapril (Vasotec) is an ACE inhibitor. By reducing the levels of angiotensin II, ACE inhibitors dilate blood vessels, reduce blood volume, and prevent or reverse angiotensin II pathological changes in the heart and kidneys.

Morphine sulfate (Duramorph) 2 mg IV q2h prn for pain is ordered for a 12-yearold who has had abdominal surgery. Which is the most appropriate nursing action? 1. Administer the morphine sulfate (Duramorph) using a syringe pump over 1 hour. 2. Encourage the child to use incentive spirometer every hour during the day and when awake at night. 3. Ask the health-care provider to change the medication to meperidine (Demerol). 4. Administer the morphine sulfate (Duramorph) with Benadryl (diphenhydramine) to prevent itching.

2. Encourage the child to use incentive spirometer every hour during the day and when awake at night. Because morphine sulfate (Duramorph) can depress respirations and the child has just had abdominal surgery, deep breathing should be encouraged.

A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to assign to an LPN/LVN? 1. Develop a "quit plan" 2. Explain how to apply a nicotine patch 3. Discuss strategies to avoid relapse 4. Suggest ways to deal with urges for tobacco

2. Explain how to apply a nicotine patch

To obtain an adolescent ' s health information, the nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of the parents. 4. Gather information only from the parents.

2. Gather information during a casual conversation. Frequently adolescents will share more information when it is gathered during a casual conversation.

Which complication associated with a diagnosis of cerebral palsy (CP) does the nurse consider a risk for safety? Select all that apply. a. impaired vision b. seizure activity c. growth problems d. mental impairment e. abnormal sensory perception

a. impaired vision b. seizure activity d. mental impairment e. abnormal sensory perception Cerebral palsy (CP) is a medical condition that describes a range of nonspecific clinical symptoms characterized by abnormal motor pattern and postures. It is caused by abnormal brain function that is nonprogressive in nature. While some children who are diagnosed with CP will exhibit mild symptoms, others may have significant impairment that threatens the client's safety; specifically, hearing, vision and sensory/perceptual deficits increase the child's risk for injury. Complications associated with a diagnosis of CP increases the child's risk for injury and include the following: abnormal sensation or perception, impaired hearing or vision, mental impairments, and seizure activity.

A nurse is teaching a group of female clients about RF for developing osteoporosis. Which of the following RF should the nurse include? select all that apply a. inactivity b. family history c. obesity d. hyperlipidemia e. cigarette smoking

a. inactivity b. family history e. cigarette smoking

20. An 18-year-old college student with an exacerbation of systemic lupus erythematosus (SLE) has been receiving prednisone 20 mg/day for 4 days. Which action prescribed by the health care provider is most important for the nurse to question? 1. Discontinue prednisone after today's dose. 2. Give a "catch-up" dose of varicella vaccine. 3. Check the patient's C-reactive protein level. 4. Administer ibuprofen 800 mg PO TID.

2. Give a "catch-up" dose of varicella vaccine. The varicella (chickenpox) vaccine is a live-virus vaccine and should not be administered to patients who are receiving immunosuppressive medications such as prednisone. The other medical actions may need some further clarification by the nurse. Prednisone doses should be tapered gradually when patients have received long-term steroid therapy, but tapering is not usually necessary for short-term prednisone use. Measurement of C-reactive protein level is not the most specific test for monitoring treatment, but the test is inexpensive and frequently used. High doses of nonsteroidal anti-inflammatory drugs such as ibuprofen are more likely to cause side effects such as gastrointestinal bleeding but are useful in treating the joint pain associated with exacerbations of SLE.

If the nurse is involved in a situation in which he or she must countersign the charting of a paraprofessional, which of the following will most aid in decreasing legal liability? 1. Read the document before signing it. 2. Have personal knowledge of the information contained in the document. 3. Make sure the information is accurate. 4. Check with a second nurse to see if the information is accurate.

2. Have personal knowledge of the information contained in the document.

The male client diagnosed with urinary retention is receiving bethanechol. Which intervention should the nurse implement? 1. Limit the client's fluid intake to 1,000 mL daily. 2. Have the client's urinal readily available. 3. Maintain hourly intake and output for the client. 4. Monitor the client's serum creatinine level.

2. Have the client's urinal readily available. This medication relaxes the urinary sphincters and increases voiding pressure by contracting the detrusor muscle of the bladder; therefore, the client will need to have a urinal available for frequent urination.

A 17 y/o gravid client presents for her regularly scheduled 26-week prenatal visit. She appears disheveled, is wearing ill-fitting clothes and does not make eye contact with the nurse. Which items should the nurse discuss with the client? select all that apply a. intimate partner violence b. substance abuse c. depression d. blood glucose screening e. hCG levels

a. intimate partner violence b. substance abuse c. depression d. blood glucose screening

The client with a brain tumor is reporting a headache that is a 5 on a scale of 1-10. The client's medication administration record (MAR) has acetaminophen 2 po PRN pain, hydrocodone po PRN pain, morphine 4 mg IVP PRN pain, and lorazepam 1 mg IVP PRN. Which medication should the nurse prepare to administer? 1. Acetaminophen 2 tablets. 2. Hydrocodone 2 tablets. 3. Morphine 4 mg IVP. 4. Lorazepam 1 mg IVP.

2. Hydrocodone 2 tablets Hydrocodone (Vicodin), a narcotic analgesic, is equivalent to codeine. It is useful for the relief of moderate to severe pain, 4-6 on the pain scale. This client has a brain tumor, which would include increasing intracranial pressure and pain; therefore, this would be the most appropriate medication at this time.

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider? 1. Clopidogrel 75 mg/day 2. Ibuprofen 200 mg every 4 hours as needed 3. Metoprolol succinate 50 mg/day 4. Nitroglycerin patch 0.4 mg/hr

2. Ibuprofen 200 mg every 4 hours as needed Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for clients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the client but should be verified because the orders were received by telephone.

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Increase the flow rate of the irrigation solution until the urine is a light pink. Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots. The nurse would need to increase the irrigation rate until the urine becomes light pink

Which specific instruction does the charge nurse give the unlicensed assistive personnel (UAP) helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times. 109

2. Inform the nurse immediately if the client's respiratory rate and depth increases. If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises. Breaths are deep and rapid and not under voluntary control, a pattern called Kussmaul respiration. The client may not require oxygen. Although it's important to record reflux and constipation, this is not related to metabolic acidosis nor is keeping the water pitcher full specific to this condition.

The client with arterial occlusive disease is prescribed pentoxifylline. Which information should the nurse discuss with the client? 1. Explain that the medication should be taken on an empty stomach. 2. Instruct the client to avoid smoking when taking this medication. 3. Discuss that common side effects are fl ushing of the skin and sedation. 4. Encourage the client to wear long sleeves and a hat when in the sunlight.

2. Instruct the client to avoid smoking when taking this medication. Pentoxifylline (Trental) is a hemorrheologic agent. The client should avoid smoking because nicotine increases vasoconstriction

The nurse is discussing chlorothiazide with the client diagnosed with essential HTN. Which discharge instruction should the nurse discuss with the client? 1. Encourage the intake of sodium-rich foods. 2. Instruct the client to drink adequate fluids. 3. Teach the client to keep strict intake and output records. 4. Explain taking the medication at night only.

2. Instruct the client to drink adequate fluids. Chlorothiazide (Diuril) is a thiazide diuretic. The client should drink adequate amounts of fl uids to replace insensible loss of fl uids and to help prevent dehydration

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy? 1. Blood pressure is 106/54 mm Hg. 2. International normalized ratio (INR) is 1.2. 3. Bruises are noted at sites where blood has been drawn. 4. Client reports eating a green salad for lunch every day

2. International normalized ratio (INR) is 1.2. An INR of 1.2 is not within the expected therapeutic range of 2 to 3 and indicates a need for an increase in warfarin dose. The blood pressure is in the low-normal range. Although the client will be encouraged to avoid injury, increased bruising is common when clients are taking anticoagulants and not a reason to discontinue the medication. Although foods that are high in vitamin K will have an impact on INR, this is not a concern when these foods are eaten consistently because the warfarin dose will be adjusted accordingly

Which stressor is common in hospitalized toddlers? Select all that apply. 1. Social isolation. 2. Interrupted routine. 3. Sleep disturbances. 4. Self-concept disturbances. 5. Fear of being hurt.

2. Interrupted routine. 3. Sleep disturbances. 5. Fear of being hurt.

Which foods would the nurse recommend to the mother of a 2-year-old with iron deficiency anemia? 1. 32 oz of whole cow ' s milk per day. 2. Meats, eggs, and green vegetables. 3. Fruits, whole grains, and rice. 4. 8 oz of juice, three times per day

2. Meats, eggs, and green vegetables.

The nurse is caring for a client newly diagnosed with immunohemolytic anemia. Which medication should the nurse anticipate the HCP ordering? 1. Filgrastim. 2. Methylprednisolone. 3. A transfusion of red blood cells (RBCs). 4. Leucovorin.

2. Methylprednisolone. Methylprednisolone (Solu Medrol) is a glucocorticoid. The fi rst-line therapy for immunohemolytic anemia is steroids, which are temporarily effective in most clients. Splenectomy followed by immune suppressive therapy usually follows. Plasma exchange therapy may be done if immune suppressive therapy is not successful.

6 hours after undergoing abdominal hysterectomy, a client has a strong urge to void and voids 25 mL into the bedpan. Based on this data, the nurse determines that the client: a. is experiencing urine retention and needs to be catheterized b. is probably dehydrated and needs additional IVF c. needs more time to try to void and tells the client to try again in 1 hour d. has developed a UTI and needs abx

a. is experiencing urine retention and needs to be catheterized urinary control may not return for 6-8 hours due to effects of anesthesia and bladder manipulation during surgery. The nurse should further assess for bladder distention by palpating and percussing the bladder and should intervene with catheterization as appropriate. Fluid status is closely monitored in the OR, it is unlikely that the client is dehydrated

A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? select all that apply a. joint pain b. malaise c. rash d. urinary frequency e. tender lymph nodes

a. joint pain b. malaise c. rash e. tender lymph nodes

The client in CHF is prescribed milrinone lactate. Which priority intervention should the nurse implement? 1. Assess the client's respiratory status. 2. Monitor the client's telemetry strip. 3. Check the client's apical pulse rate. 4. Evaluate the BNP.

2. Monitor the client's telemetry strip. Milrinone lactate (Primacor) is a phosphodieaterase inhibitor. Primacor inhibits the enzyme phosphodiesterase, thus promoting a positive inotropic response and vasodilation. Severe cardiac dysrhythmias may result from this medication; therefore, the client's telemetry should be monitored.

The nurse is administering medications at 1600. Which medication should the nurse administer fi rst? 1. Humalog insulin to a client with a blood glucose level of 200 mg/dL. 2. Morphine to a client with a headache rated an 8. 3. Divalproex to a client diagnosed with migraine headaches. 4. Metoclopramide to a client with gastric stasis.

2. Morphine to a client with a headache rated an 8. Morphine may be used to treat severe migraine headaches when other measures have not been effective. This client needs the medication as soon as possible (pain is rated as 8), and this should be the first medication administered.

Which nurse is demonstrating the first step in managing cancer pain by using the ABCDE (ask, believe, choose, deliver, and empower) clinical approach to pain management as recommended by the Agency for Healthcare Research and Quality? 1. Nurse J asks if the time of the prescribed dose of medication can be changed. 2. Nurse K asks the patient to describe pain and uses a numerical pain scale. 3. Nurse L asks the patient to participate and to contribute in pain management. 4. Nurse M asks about pain management options that are appropriate for the patient.

2. Nurse K asks the patient to describe pain and uses a numerical pain scale.

What findings does the nurse anticipate when providing care for a client who is diagnosed with anorexia nervosa? Select all that apply. a. lack of menses b. bradycardia c. emaciation d. excessive physical activity e. inability to tolerate cold

a. lack of menses b. bradycardia c. emaciation d. excessive physical activity e. inability to tolerate cold Due to the decreased body fat and low levels of estrogen, clients who are diagnosed often experience cessation of the menstrual cycle; therefore, this is an expected clinical manifestation for a client who is diagnosed with anorexia nervosa. Bradycardia is the result of a decreased metabolic rate that often accompanies a diagnosis of anorexia nervosa. Additionally, this client may also have electrolyte imbalances that increase the risk for cardiac dysrhythmias; therefore, this is a clinical manifestation anticipated for this client. Emaciation, or being abnormally thin, is the result of extensive dieting and the fear of weight gain for a client who is diagnosed with anorexia nervosa; therefore, this is an anticipated clinical manifestation for this client. Excessive physical activity is performed to ensure weight loss is maintained due to the fear of gaining weight; therefore, this is an expected assessment finding for a client who is diagnosed with anorexia nervosa. Due to the decreased metabolic rate associated with anorexia nervosa, the client will manifest with cold intolerance; therefore, this is an anticipated clinical manifestation anticipated for the client.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. listening to lung sounds b. palpating for organomegaly c. assessing for JVD d. assessing for peripheral and sacral edema

a. listening to lung sounds

A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? select all that apply a. meat b. flaxseed c. beans d. eggs e. milk

a. meat d. eggs e. milk

The nurse provides care for a preschool-age pediatric client who is diagnosed with cystic fibrosis (CF). In addition to vitamin supplements, which vitamin A rich food should the nurse recommend to the child's caregiver? Select all that apply. a. milk b. cereal c. carrots d. spinach e. broccoli

a. milk c. carrots d. spinach e. broccoli

The nurse is caring for a primipara who have birth yesterday and has chosen to breastfeed her neonate. Which assessment finding is considered unusual for the client at this point postpartum? a. milk production b. diaphoresis c. constipation d. diuresis

a. milk production New mothers begin to produce milk at about the 3rd day postpartum and colostrum is produced until that time. For clients who have breastfed another infant during pregnancy, having milk shortly after birth is not unusual. Diaphoresis and diuresis are considered normal during this time as the body excretes the additional fluids that are no longer needed. Constipation may continue due to progesterone, consummation of iron and trauma to perineum

Which home care instructions would the nurse provide to the parent of a child with AIDS? select all that apply a. monitor the child's weight b. frequent handwashing is important c. the child needs to avoid exposure to other illnesses d. the child's immunization schedule will need revision e. clean up body fluid spills with bleach solution f. fever, malaise, fatigue, weight loss, vomiting and diarrhea are expected to occur and do not require special intervention

a. monitor the child's weight b. frequent handwashing is important c. the child needs to avoid exposure to other illnesses e. clean up body fluid spills with bleach solution

A nurse is planning care for a client who has ESRD. Which of the following should the nurse include in the plan of care? select all that apply a. monitor the client's weight daily b. encourage the client to comply with fluid restrictions c. evaluate I&O d. instruct the client on restricting calories from carbs e. monitor for constipation

a. monitor the client's weight daily b. encourage the client to comply with fluid restrictions c. evaluate I&O e. monitor for constipation constipation can result from fluid restrictions

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? a. monitor urine for dark, cloudy, foul smelling urine b. place client on I&O monitoring c. decrease fluid intake to 1L/day d. advise client to wear protective clothes outside while taking levofloxacin e. monitor for hypotension, tachycardia, fever

a. monitor urine for dark, cloudy, foul smelling urine b. place client on I&O monitoring d. advise client to wear protective clothes outside while taking levofloxacin e. monitor for hypotension, tachycardia, fever With pyelonephritis, urine will be dark, cloudy and foul smelling due to bacteria. Levofloxacin could make the client sunburn more easily. Monitor for septic shock, a complication of pyelonephritis. Sx include hypotension, tachycardia and fever

A primigravid client is admitted as an outpatient for an external cephalic version. Which factor would be a contraindication for the procedure? a. multiple gestation b. breech presentation c. maternal Rh-negative blood type d. history of gestational diabetes

a. multiple gestation External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent the need for a c section. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie. CI to the procedure include multiple gestation because of the potential for fetal injury or uterine injury, severe oligohydramnios, contraindications to a vaginal birth (cephalopelvic disproportion) and unexplained third trimester bleeding.

Which nonpharmacologic pain management strategy is appropriate for the pediatric nurse to implement in addition to distraction when providing care for a child who experiences a vaso-occlusive pain crisis? Select all that apply. a. music b. hypnosis c. relaxation d. guided imagery e. behavior modification

a. music b. hypnosis c. relaxation d. guided imagery e. behavior modification Providing adequate pain management is an essential nursing action in the provision of care for a child who experiences a vaso-occlusive crisis related to a diagnosis of SCD. Effective pain management helps to decrease the child's stress level which is essential as elevated stress may contribute to further sickling and additional discomfort. While pharmacologic pain management strategies are important in the provision of care for this child, the use of distraction with nonpharmacologic pain management techniques are just as important. Appropriate nonpharmacologic pain management strategies include behavior modification, guided imagery, hypnosis, massage, music, play, relaxation, and/or therapeutic touch. These strategies are most effective when implemented to augment the child's pain medication regimen. Rationales

The nurse notes that a client's ABG results reveal a pH of 7.50 and PaCO2 of 30 mmHg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply a. nausea b. confusion c. bradypnea d. tachycardia e. hyperkalemia f. light-headedness

a. nausea b. confusion d. tachycardia f. light-headedness

The nurse explains to a newly admitted primigravid client in active labor that according to the gate control theory of pain, a closed gate means that the client should experience what type of pain? a. no pain b. sharp pain c. light pain d. moderate pain

a. no pain The gate control theory of pain refers to the gate control mechanisms in the substantia gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never perceived at a brain level as pain

An occupational health nurse is consulting with senior management of a local industrial facility. When discussing work-related illness and injury, the nurse should include which of the following factors as physical agents? Select all that apply a. noise b. age c. lighting d. viruses e. stress

a. noise c. lighting viruses are biological agents

A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? select all that apply a. occupation b. menstrual history c. childhood infectious diseases d. recent history of falls e. recent blood transfusions

a. occupation b. menstrual history c. childhood infectious diseases

The nurse assesses a client who is diagnosed with choloelithiasis and acute cholecystitis. Which data supports the client's current medical diagnosis? Select all that apply. a. onset of pain after consuming a high fat meal or snack b. pain reported as 6/10 in the peritoneal area c. reports a history of N/V d. states pain radiates from RUQ to shoulder e. temp of 100.6 F and report of chills f. umbilical pain that lasts for more than an hour at a time

a. onset of pain after consuming a high fat meal or snack c. reports a history of N/V d. states pain radiates from RUQ to shoulder e. temp of 100.6 F and report of chills Acute cholecystitis is an inflammation of the gallbladder (i.e., a small pear-shaped organ on the right side of the abdomen) that stores and releases bile. Choloelithiasis is the presence of gallstones in the gallbladder which is a common cause for acute cholecystitis. When stones are present in the gallbladder, they block the common bile duct which can cause bile to build up leading to inflammation. Fat in the diet can trigger the gallbladder to start contracting thus increasing the production of bile. Signs and symptoms can include severe pain in the upper right center of the abdomen that can spread across the right shoulder and back, as well as nausea, vomiting, and fever.

When the nurse is assessing a 34 year old multigravid client at 34 weeks' gestation experiencing moderate vaginal bleeding, which symptom would most likely alert the nurse that placenta previa is present? a. painless vaginal bleeding b. uterine tetany c. intermittent pain with spotting d. dull lower back pain

a. painless vaginal bleeding With placenta previa, the placenta is abnormally implanted, covering a portion or all of the cervical os. Uterine tetany, intermittent pain with spotting and dull lower back pain are not associated. Uterine tetany is associated with oxytocin administration. Intermittent pain with spotting commonly is associated with a spontaneous abortion. Dull lower back pain is commonly associated with poor maternal posture or a UTI with renal involvement

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings would the nurse expect to observe? select all that apply a. pallor b. edema c. anorexia d. proteinuria e. weight loss f. decreased serum lipids

a. pallor b. edema c. anorexia d. proteinuria

During a birth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which exercise would be most helpful? a. pelvic rocking b. deep breathing c. tailor sitting d. squatting

a. pelvic rocking

The nurse prepares to assist with gastric lavage for a client who is admitted for the treatment of a drug overdose. The client is intubated and mechanically ventilated. Which is the first action by the nurse? a. place the client in a left lateral decubitus position b. insert a NG tube into the client's stomach c. administer 200-300 mL of body temp water to the client d. give the client's prescribed activated charcoal once clear outflow is obtained

a. place the client in a left lateral decubitus position Place the client in either a left lateral decubitus or supine position, depending on condition. Insert an orogastric or nasogastric tube into the client's stomach. Verify placement with a chest x-ray. Administer 200 to 300 mL of body temperature water via the tube until outflow is clear. Give the prescribed activated charcoal.

When instructing a client about the proper use of condoms for pregnancy prevention, the nurse should include which instruction to ensure maximum effectiveness? a. place the condom over the erect penis before coitus b. Withdraw the condom after coitus when the penis is flaccid c. Ensure that the condom is pulled tightly over the tip of the penis before coitus d. Obtain a prescription for a condom with nonoxynol 9

a. place the condom over the erect penis before coitus The penis should be withdrawn before it becomes flaccid, otherwise semen may escape from the condom, providing an opportunity for possible fertilization. Space should be left at the tip of the penis to allow the condom to hold the sperm. Condom with nonoxynol 9 are sold OTC.

The nurse preceptor supervises a novice nurse in the provision of care for a client who is 24 hours postoperative following a left knee replacement. Which action performed by the novice nurse requires intervention by the nurse preceptor? Select all that apply. a. placing a large pillow beneath the client's left knee b. placing an abductor pillow while the client is in bed c. placing an ice pack upon the client's left knee d. placing an immobilizer on the client's left knee for ambulation e. resuming the client's knee flexion and extension exercises using a specialized physical therapy machine

a. placing a large pillow beneath the client's left knee b. placing an abductor pillow while the client is in bed Placing a large pillow under the knee is contraindicated during the immediate postoperative period of care for a client who has a knee replacement because this positioning could potentially result in contracture. The nurse should keep the knee extended with a pillow placed under the lower leg or ankle. An abductor pillow is utilized for clients who have hip, not knee replacement.

The clinic nurse reads the results of a TB test on a 3 y/o child. The results indicate an area of induration measuring 10 mm. The nurse would interpret these results as which finding? a. positive b. negative c. inconclusive d. definitive and requiring a repeat test

a. positive Induration measuring 10 mm or more is considered to be a positive in children younger than 4 y/o and in children with chronic illness or at high risk for exposure to TB. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as immunosuppressed or with HIV. A reaction of 15 mm or more is positive in children 4 y/o without any RF

When developing the collaborative plan of care with the HCP for a multigravid client at 10 weeks' gestation with a history of cardiac disease who was being treated with digitalis therapy before this pregnancy, the nurse should instruct the client about which modification regarding the client's drug therapy regimen? a. possible need for an increased dosage b. need for weekly drug level monitoring c. switching to a different medication d. addition of a diuretic to the regimen

a. possible need for an increased dosage Clients on cardiac medications may need increase in dose as their blood volume increases. Drug level monitoring may be needed after dose change or if the client presents with toxicity but weekly monitoring is unnecessary. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if CHF is not controlled by Na and activity restrictions

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld? a. prednisone b. ferrous sulfate c. cyclobenzaprine d. conjugated estrogen

a. prednisone before and during surgery, dose may be increased temporarily and may be given parenterally rather than orally

The nurse is caring for a client with meningitis and implements which transmission based precaution for this client? a. private room or cohort client b. personal respiratory protection device c. private room with negative airflow pressure d. mask worn by staff when the client needs to leave the room

a. private room or cohort client

A nurse is conducting a nutrition class at a local community center. Which of the following information should the nurse include in the teaching? a. progress toward limiting saturated fat to 7% total daily intake b. good bowel function requires 35 g/day of fiber for females c. limit cholesterol consumption to 400 mg/day d. normal functioning cardiac systems depends on B-complex vitamins

a. progress toward limiting saturated fat to 7% total daily intake Good bowel function requires 25 g/day of fiber for females, and 38 g/day for males. Cholesterol consumption should be limited to between 200 and 300 mg/day Normal functioning nervous system, instead of cardiac depends on B complex vitamins

A child has been diagnosed with acute otitis media of the right ear. Which interventions would the nurse include in the plan of care? Select all that apply a. provide a soft diet b. position the child on the left side c. administer an antihistamine twice daily d. irrigate the right ear with NS every 8 hours e. administer ibuprofen for fever every 4 hours as prescribed and as needed f. instruct the parents about the need to administer the prescribed abx for the full course of therapy

a. provide a soft diet e. administer ibuprofen for fever every 4 hours as prescribed and as needed f. instruct the parents about the need to administer the prescribed abx for the full course of therapy A soft diet is recommended to avoid pain that can occur with chewing

A primigravid client whose cervix is 7 cm dilated with the fetus at 0 station in a left occipitoposterior (LOP) position has severe back pain. What intervention is most indicated? a. provide firm pressure to the client's sacral area b. prepare the client for a c section c. prepare the client for a precipitate birth d. maintain the client in a left side lying position

a. provide firm pressure to the client's sacral area This pain is greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of firm pressure to the sacral area can help alleviate the pain

After determining that a client diagnosed with a stroke has adequate swallowing ability, the nurse develops interventions to safely provide oral feedings to the client. What interventions should the nurse include in this plan of care? a. provide mouth care prior to feeding b. flex head forward for eating c. have dietary puree foods d. use crushed ice as a stimulant for swallowing e. offer thickened liquids to drink f. position client in semi fowler's after feeding

a. provide mouth care prior to feeding b. flex head forward for eating d. use crushed ice as a stimulant for swallowing e. offer thickened liquids to drink Chin tuck is used to reduce residual particles of food pocketing in the epiglottic valleculae.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and intensity. What is the priority nursing action? a. provide pain relief measures b. prepare the client for an amniotomy c. promote ambulation every 10 minutes d. monitor the oxytocin infusion closely

a. provide pain relief measures Hypertonic uterine contractions are painful, occur frequently and are uncoordinated. Management depends on the cause .Relief of pain is the primary intervention to promote a normal labor pattern.

Which interventions are appropriate for the care of an infant? select all that apply a. provide swaddling b. talk in a loud voice c. provide the infant with a bottle of juice at nap time d. hang mobiles with black and white contrast designs e. caress the infant while bathing or during diaper changes f. allow the infant to cry for at least 10 min before responding

a. provide swaddling d. hang mobiles with black and white contrast designs e. caress the infant while bathing or during diaper changes

Which interventions would the nurse include when creating a care plan for a child with hepatitis? select all that apply a. providing a low fat, well balanced diet b. teaching the child effective handwashing techniques c. scheduling playtime in the playroom with other children d. notifying the PHCP if jaundice is present e. instructing the parents to avoid administering medications unless prescribed f. Arranging for indefinite homeschooling because the child will not be able to return to school

a. providing a low fat, well balanced diet b. teaching the child effective handwashing techniques e. instructing the parents to avoid administering medications unless prescribed jaundice is an expected finding and does not need to be reported

A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during contractions. The nurse should instruct the client to change from slow chest breathing to which breathing technique? a. rapid, shallow chest breathing b. deep chest breathing c. rapid pant-blow breathing d. slow abdominal breathing

a. rapid, shallow chest breathing Deep chest breathing is appropriate for the early phase of labor, in which the client exhibits less frequent contractions. When transition nears, a rapid pant-blow pattern of breathing is used. Slow abdominal breathing is very difficult for clients in labor

The nurse is educating a mother-to-be about possible danger signs during the last three months of pregnancy. Which of the following would not cause the nurse concern about danger signs? a. rectal bleeding b. continuous HA c. Marked swelling of hands d. Blurred vision

a. rectal bleeding Although hemorrhoids could cause rectal bleeding, it is vaginal bleeding that would concern the nurse.

Which technique to promote active relaxation would the nurse include in the teaching plan for a 16 y/o primigravid client in early labor? a. relaxing uninvolved body muscles during uterine contractions b. practicing being in a deep, meditative sleep like state c. focusing on an object in the room during the contractions d. breathing rapidly and deeply between contractions

a. relaxing uninvolved body muscles during uterine contractions Active relaxation involves relaxing uninvolved muscle groups while contracting a specific group and using chest breathing techniques to lift the diaphragm off the contracting uterus. A deep, meditative, sleep like state is a form of passive relaxation. Focusing on an object in the room is part of Lamaze technique for distraction. Breathing rapidly and deeply can lead to hyperventilation and is not recommended

The nurse notes that a 6 year old child does not recognize that objects exist when the objects are outside the visual field. Based on this observation, which action would the nurse take? a. report the observation to the pediatrician b. move the objects in the child's direct field of vision c. teach the child how to visually scan the environment d. provide additional lighting for the child during play activities

a. report the observation to the pediatrician It is normal for the infant or toddler not to recognize that objects continue to be in existence if out of the visual field but is not normal for the 6 year old. The child is not progressing normally through the developmental stages.

A client is being admitted with a spinal cord transection at C7. Which assessments take priority upon the client's arrival? select all that apply a. respirations b. temp c. bladder function d. reflexes e. BP

a. respirations b. temp e. BP The nurse should assess for spinal shock, which is the immediate response to spinal cord transection. Hypotension occurs, and the body loses core temp to environmental temp. The nurse must treat client immediately to manage hypotension and hypothermia. The nurse should also ensure that there is an adequate airway and respirations, there may be respiratory compromise due to intercostal muscle involvement.

The nurse is reviewing a pediatrician's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vasoocclusive crisis. Which prescriptions documented in the child' record would the nurse questions? Select all that apply a. restrict fluid intake b. position for comfort c. avoid strain on painful joints d. apply nasal oxygen at 2 L/min e. provide a high calorie, high protein diet e. give meperidine, 25 mg IV every 4 hours for pain

a. restrict fluid intake e. give meperidine, 25 mg IV every 4 hours for pain Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine induced seizures. Normeperidine, a metabolite of meperidine, is a CNS stimulant that produces anxiety, tremors, myoclonus and generalized seizure when it accumulates with repetitive dosing.

The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply a. review the current status of each labor client with the primary nurse b. admit the new labor client sent from the triage area c. complete the work of the nurse who had to leave 30 min early d. follow up with the primary nurse after a birth e. complete report of unit with the oncoming charge nurse

a. review the current status of each labor client with the primary nurse d. follow up with the primary nurse after a birth e. complete report of unit with the oncoming charge nurse

The nurse notes documentation that a client is exhibiting Cheyne-stokes respirations. On assessment of the client, the nurse would expect which finding? a. rhythmic respirations with periods of apnea b. regular rapid and deep, sustained respirations c. totally irregular respiration in rhythm and depth d. irregular respirations with pauses at the end of inspiration and expiration

a. rhythmic respirations with periods of apnea Can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic hyperventilation is a regular rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons. Ataxic respirations are totally irregular in rhythm and depth and indicate a dysfunction in the medulla. Apneustic respirations are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons

To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination, the nurse should palpate which cranial sutures? a. sagittal b. lambdoidal c. coronal d. frontal

a. sagittal When the fetus is in the LOA position, the occiput faces the mother's left. The lambdoid suture is on the side of the skull. The coronal suture is a horizontal suture across front portion of the fetal skull that forms the anterior fontanelle It may be felt with a brow presentation. The frontal suture may be felt with a brow or face presentation

A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. The nurse determines that the couple needs further instruction when they identify which factor as a cause of male infertility? a. seminal fluid with an alkaline pH b. frequent exposure to heat sources c. abnormal hormonal stimulation d. immunologic factors

a. seminal fluid with an alkaline pH A slightly alkaline pH is necessary to protect the sperm from the acidic secretions of the vagina and is a normal finding. Immunologic factors produced by the man against his own sperm (autoantibodies) or the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility.

A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report: a. severe headache b. slight nausea c. decreased urination d. itching

a. severe headache Severe headache can indicate impending seizure activity. Slight nausea is expected when beginning the therapy, so answer B is incorrect. The client with renal failure already has itching and decreased urination, so answers C and D are incorrect

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse correctly interpret this rhythm? a. sinus tachycardia b. sinus bradycardia c. sinus dysrhythmia d. NSR

a. sinus tachycardia Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? Select all that apply a. smoking on social occasions b. BMI of 28 c. alopecia d. trisomy 21 e. history of reflux

a. smoking on social occasions b. BMI of 28 e. history of reflux

A nurse is providing teaching about food allergies to a group of new parents. Infants who react to which of the following foods typically outgrow the sensitivity? select all that apply a. soy b. wheat c. cow's milk d. eggs e. fish

a. soy c. cow's milk

When developing a teaching plan for a client who is 8 weeks pregnant, the nurse would suggest what foods to meet the client's need for increased folic acid? Select all that apply a. spinach b. bananas c. seafood d. yogurt e. beans

a. spinach d. yogurt Green, leafy vegetables, such as asparagus, spinach, brussels sprouts and broccoli are rich of folic acid. Beans, peas and lentils are also good sources. Banans are rich in potassium, seafood is rich in iodine and yogurt is rich in calcium.

A primiparous client who will be bottlefeeding her neonate asks, "What is the best position for the baby to nap after feeding"" Which position should the nurse recommend? a. supine b. on the left side c. prone without a pillow d. upright on caregiver's lap

a. supine Although the mother may desire to hold the infant in her lap after feeding, this is not necessary unless the infant has reflux

After administering hydralazine 5 mg IV as prescribed for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for which complication? a. tachycardia b. bradypnea c. polyuria d. dysphagia

a. tachycardia Hydralazine works to lower BP by peripheral dilation without interfering with placental circulation. Bradypnea and polyuria are usually not associated.

The nurse is administering IV mag sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. What are desired outcomes of this therapy? Select all that apply a. temperature 98F, pulse 72 bpm, RR 14 breaths/min b. UOP < 30 mL/h c. FHR with late decels d. BP < 140/90 mmhg e. DTR 2+ f. Mag level = 5.6 mg/dL

a. temperature 98F, pulse 72 bpm, RR 14 breaths/min e. DTR 2+ f. Mag level = 5.6 mg/dL While extreme elevations in BP must be avoided, achieving a normal pressure carries the risk of decreasing perfusion to the fetus. The therapeutic mg level of 5-8 mg/dL must be maintained

The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? select all that apply a. the acuity level of the clients b. specific requests from the staff c. the clustering of the rooms on the unit d. the number of anticipated client discharges e. client needs and workers' needs and abilities

a. the acuity level of the clients e. client needs and workers' needs and abilities

A 24 y/o primigravid client who gives birth to a viable term neonate is prescribed oxytocin IV after delivery of the placenta. Which sign would indicate to the nurse that the placenta is about to be delivered? a. the cord lengthens outside the vagina b. there is decreased vaginal bleeding c. the uterus cannot be palpated d. The uterus changes to discoid shape

a. the cord lengthens outside the vagina The most reliable sign that the placenta has detached from the uterine wall is lengthening of the cord outside the vagina. Other signs include a sudden gush of vaginal blood. Usually, when placenta detachment occurs, the uterus becomes firmer and changes in shape from discoid to globular. This process takes about 5 min. if the placenta does not separate, manual removal may be necessary to prevent postpartum hemorrhage

A nurse has been providing care for multiple clients on a telemetry unit. Which scenario(s) may be considered client abandonment? Select all that apply. a. the nurse finds an empty room and takes a quick power nap b. the nurse abruptly leaves the floor to pick up at item at the gift shop c. the nurse exits the unit without providing a report to the oncoming nurse d. The nurse is a no-call, no-show for the assigned shift the next day e. The nurse asks a peer to cover while she retrieves an item from the car

a. the nurse finds an empty room and takes a quick power nap b. the nurse abruptly leaves the floor to pick up at item at the gift shop c. the nurse exits the unit without providing a report to the oncoming nurse Examples of client abandonment may include sleeping on the job, leaving the unit without notification and ensuring client care coverage is in place, or failure to provide a report to the next shift. Situations in which the nurse never reports to work may be considered unprofessional but do not constitute client abandonment.

The HCP has performed an amniotomy on a laboring client. Which details must be included in the documentation of this procedure? Select all that apply a. time of rupture b. color and clarity of fluid c. FHR and pattern before and after the procedure d. size of amnio hook used during the procedure e. odor and amount of fluid

a. time of rupture b. color and clarity of fluid c. FHR and pattern before and after the procedure e. odor and amount of fluid

Before placing the fetal monitoring device on a primigravid client's fundus, the nurse performs Leopold's maneuvers. The nurse explains that third maneuver is done for which reason? a. to determine whether the fetal presenting part is engaged b. to locate the fetal cephalic prominence c. to distinguish between a breech and a cephalic presentation d. to locate the position of the fetal arms and legs

a. to determine whether the fetal presenting part is engaged Leopold's maneuvers are performed to determine the presentation and position of the fetus. The third maneuver determines whether the fetal presenting part is engaged in the maternal pelvis. The first maneuver distinguishes between a breech and a cephalic presentation through palpation of the top of the fundus. The second maneuver locates the fetal back, arms and legs. The FHR monitoring device should be placed near the fetal skull and back for optimal FHR monitoring. The fourth maneuver is done to locate the fetal cephalic prominence if the fetus is in a cephalic position

A school nurse is teaching a group of students how to read food labels. Which of the following is a required component of food labels that the nurse should include in the teaching? select all that apply a. total carbs b. total fat c. calories d. magnesium e. dietary fiber

a. total carbs b. total fat c. calories e. dietary fiber

A nurse is conducting a nutritional class on minerals and electrolytes. The nurse should include which of the following foods is a major source of magnesium? a. tuna b. tomatoes c. eggs d. oranges

a. tuna

A multigravid client who is 10 cm dilated is admitted to the labor and delivery unit. In addition to supporting the client, what is the priority action? a. turning on the infant warmer b. increasing IVF c. determining the client's preferences for pain control d. providing client education regarding care of the newborn

a. turning on the infant warmer Nursing care includes providing support, preparing for birth, assessing for potential complications and providing for care of the newborn. Turning on the warmer is the best choice for providing for the care of the newborn. Oxygen and IVF may be indicated if variable or late decels are noted. It is likely too late for pharmacologic pain relief for a multigravid client.

The nurse is checking a 9 month old's developmental status. What finding would be of concern to the nurse? a. unable to transfer a toy from one hand to the other b. cannot stand without support c. does not notice or mind when a parent leaves d. has not acquired a 6 word vocabulary

a. unable to transfer a toy from one hand to the other

A nurse at a community clinic is conducting a well-child visit with a preschool age child. The nurse should identify which of the following manifestations as a possible indication of child neglect? select all that apply a. underweight b. healing spiral fracture of the arm c. genital irritation d. burns on the palms of the hands e. poor hygiene

a. underweight e. poor hygiene

The nurse provides care for a client who is admitted for the treatment of a pulmonary pseudomonas infection and is prescribed gentamicin. Which finding warrants immediate practitioner notification? Select all that apply. a. vertigo b. tinnitus c. dizziness d. muscle cramps e. decreased UOP

a. vertigo b. tinnitus c. dizziness e. decreased UOP Common side effects of gentamicin may include agitation, back pain, and muscle aches and cramps. Adverse reactions associated with gentamicin include ototoxicity and nephrotoxicity. Symptoms of ototoxicity may include dizziness, ringing in the ears (i.e., tinnitus), and vertigo while symptoms of nephrotoxicity may include decreased urine output and elevations in blood urea nitrogen (BUN) and creatinine levels. Symptoms of adverse reactions should be reported to the practitioner for additional evaluation and treatment.

While completing the nutritional history of a client admitted with pernicious anemia, the nurse determines that the client follows a strict vegan diet. What education should the nurse provide to the client? Select all that apply a. vitamin B12, a nutrient needed to prevent pernicious anemia, is found in some foods like meat, fish, eggs and milk b. in order to increase intake of vitamin B12, your diet must contain beef or chicken liver at least once per week c. in addition to eating plants, you should eat dairy products and eggs in order to prevent pernicious anemia d. vegetables high in protein include cabbage, carrots and squash e. pernicious anemia occurs when the body produces RBC that are larger than normal and result in lower than normal RBC count

a. vitamin B12, a nutrient needed to prevent pernicious anemia, is found in some foods like meat, fish, eggs and milk e. pernicious anemia occurs when the body produces RBC that are larger than normal and result in lower than normal RBC count For a vegetable to qualify as a low protein source, it must contain 4g or less of protein. Green vegetables, such as lettuce, cabbage, bell pepper and asparagus provide only 1-2 g of protein per serving. Orange vegetables, including carrots, sweet potatoes and squash also contain only 1-2 g.

A nurse is providing teaching to a client who follows vegan dietary practice. The nurse should instruct the client that there is a risk of having a deficit in which of the following nutrients? select all that apply a. vitamin D b. fiber c. calcium d. vitamin B12 e. whole grains

a. vitamin D c. calcium d. vitamin B12 Instruct the client to ensure an adequate consumption of vitamin D because most dietary vitamin D is consumed via fortified milk products.

The nurse is assessing a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to notify the PHCP if the client is also taking which medications? a. warfarin b. glimepiride c. amlodipine d. simvastatin e. atorvastatin

a. warfarin b. glimepiride c. amlodipine NSAIDS can amplify the effects of anticoagulants. Hypoglycemia may occur if concurrently taking an oral antidiabetic agent. A high risk of toxicity exists if concurrently taking a calcium channel blocker.

The nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? select all that apply a. wear a supportive bra b. rest during the acute phase c. maintain a fluid intake of at least 3 L/day d. take the prescribed abx until the soreness subsides e. continue to breast feed if the breasts are not too sore f. avoid decompression of the breasts by breast feeding or breast pump

a. wear a supportive bra b. rest during the acute phase c. maintain a fluid intake of at least 3 L/day e. continue to breast feed if the breasts are not too sore

Which instructions should the nurse give to a client with PAD? select all that apply a. wear clean, loose, soft cotton socks b. wear extra socks in the winter c. limit walking to one block at a time d. warm the fingers or toes by using an electric heating pad e. avoid sunburn during the summer

a. wear clean, loose, soft cotton socks b. wear extra socks in the winter e. avoid sunburn during the summer A client with PAD is at high risk for injury, thus the client should be able to recognize the signs of potential thermal dangers to prevent skin breakdown. In the winter or if the client has cold feet, they should be encouraged to wear an extra pair of socks and a larger shoe size. Getting a sunburn during the summer puts the client at risk for tissue injury and skin breakdown

rupture of vagina assessment

abdominal pain or tenderness, chest pain, stopped or fail to progress contractions, rigid abdomen, absent FHR, signs of shock, fetus palpated outside uterus (complete rupture)

hemophilia assessment

abnormal bleeding in response to trauma or surgery, epistaxis, joint bleeding causing pain, tenderness, welling and limited ROM, tendency to bruise easily, results of tests that measure plt function are normal, those that measure clotting factor function may be abnormal

scarlet fever assessment

abrupt high fever, flushed cheeks, vomiting, HA, enlarged lymph nodes in the neck, malaise, abdominal pain. Red, fine sandpaper like rash develops in the axilla, groin and neck and spreads to cover the entire body except the face. Rash blanches with pressure, pink or red lines of petechiae are noted in areas of deep creases and folds of the joints. Desquamation, sheetlike sloughing of the skin on palms and soles, appears by weeks 1-3. The tongue is initially coated with a white, furry covering with red projecting papillae (white strawberry tongue), by the third to fifth day, the white sloughs off, leaving a red swollen tongue (red strawberry tongue). Tonsils are reddened, edematous and covered with exudate. Pharynx is edematous and beefy red

anaphylactoid syndrome of pregnancy assessment

abrupt onset of respiratory distress and chest pain, cyanosis, fetal bradycardia and distress.

VUR interventions

abx for UTI, deflux procedure, in which a gel like mixture is injected into the wall of the bladder where the ureter joins the bladder that acts as a valve to help prevent the flow of urine backward toward the kidney

Acne treatment

acne lesions that are mild may be treated with nonpharm measures such as gentle cleansing 2-3x daily (oil based moisturizing products need to be avoided), dermabrasion or comedo extraction.

fertility medications

act to stimulate follicle development and ovulation in functioning ovaries and combined with HCG to maintain follicles once ovulation has started.

prostaglandins CI

active cardiac, hepatic, pulmonary or kidney disease, acute PID, fever or infection, for those who's not indicated for vaginal delivery, fetal malpresentation, history of c section or major uterine surgery, hx of difficult or traumatic labor, hypersensitivity, nonreassuring FHR, placenta previa or unexplained vaginal bleeding, regular progressive uterine contractions, significant cephalopelvic disproportion

Reye's syndrome

acute encephalopathy that follows a viral illness and characterized by cerebral edema and fatty changes in the liver, fluid and electrolyte imbalance, acid base imbalance and coagulopathies. Administration of aspirin is not recommended for children with a febrile illness or with varicella or flu or other viral illness because of its association with Reye's syndrome. Goal of treatment is to maintain effective cerebral perfusion and control increasing ICP.

celiac disease assessment

acute or insidious diarrhea, steatorrhea, anorexia, abdominal pain and distention, muscle wasting, particularly in the buttocks and extremities, vomiting, anemia, irritability celiac crisis - fasting, infection or ingestion of gluten, cause profuse watery diarrhea and vomiting.

Kawasaki disease assessment

acute stage: fever, conjunctival hyperemia, mucositis (cracked red lips and strawberry tongue), extremity changes including swelling of the hands and feet and erythema of palms and soles, rash, enlargement of cervical lymph nodes, increased irritability, arthritis, CV findings such as tachycardia and gallop sounds subacute: begins with resolution of fever and continues until outward clinical sx have resolved. Cracking lips and fissures, desquamation of skin on tips of fingers and toes, joint pain, cardiac manifestations, thrombocytosis (hypercoagulability) convalescent stage: appears normal but signs of inflammation may be present, labs are abnormal

sickle cell anemia interventions

adequate hydration and blood flow through PO and IVF. Electrolyte replacement as needed. O2 and blood transfusion as prescribed to increase tissue perfusion, exchange transfusions which reduce number of circulating sickle cells and risk of complications. Analgesics around the clock. Assist the child to assume a comfortable position so that the child keeps the extremities extended to promote venous return, HOB no more than 30 degrees to avoid putting strain on painful joints and do not raise the knee gatch of bed. Encourage high calorie, high protein diet w/ folic acid. Administration of hydroxyurea, an antimetabolite prevent formation of sickle shaped RBC and decrease vasoocclusive events. Administer abx as prescribed. Monitor for complications, including increasing anemia, decreased perfusion and shock (mental status changes, pallor, VS changes). Ensure that child receives pneumococcal and meningococcal vaccines and annual flu vaccine because of susceptibility to infection secondary to functional asplenia. A splenectomy may be necessary for recurrent splenic sequestration

Triamcinolone adverse effects

agitation, oropharyngeal fungal infections, HA, blurred vision, N/V/D, increased cough, bronchitis

rubeola interventions

airborne and contact precautions, quiet activities and bed rest, cool mist vaporizer, dim lights if photophobia, antipyretics, vitamin A supplements

Rubella interventions

airborne, droplet and contact precautions, isolate from pregnant people

chicken pox interventions

airborne, droplet, contact precautions. Antiviral agent in immunocompromised persons to decrease number of lesions, shorten the duration of fever and decrease itching, lethargy and anorexia. Immuneglobulin are recommended for immunocompromised, who have no previous history of varicella and are likely to contract the disease and have complications as an adult

oxytocin ADR

allergies, dysrhythmias, changes in BP, uterine rupture and water intoxication. May produce uterine hypertonicity. High dose can cause hypotension with rebound HTN. Postpartum hemorrhage can occur because uterus may become atonic when the medication wears off. Should not be used in those who cannot deliver vaginally or with hypertonic uterine contractions. CI in herpes

gluten free diet

allowed meat such as beef, pork, poultry and fish, eggs, milk and some dairy, vegetables, fruits, rice, corn, gluten free flour, puffed rice, cornflakes, cornmeal and precooked gluten free cereals. prohibit commercially prepared ice cream, malted milk, prepared pudding, grains, wheat, rye, oats or barley such as bread, roll, cookies, cakes, crackers, cereal, spaghetti, macaroni ,beer and ale

medications to treat actinic keratosis

aminolevulinic acid, diclofenec gel, fluorouracil, imiquimod cream, ingenol mebutate

Acetaminophen adverse effects

anemia (long term use), liver and kidney failure, dyspnea (prolonged high doses), angioedema, hives, itching

hyperhemolytic crisis in sickle cell anemia

anemia, jaundice, reticulycytosis

Ginseng

anti-inflammatory, has estrogen effects, enhance the immune system and improve mental and physical abilities. Decreases effects of anticoagulants and NSAIDs. Use with caution with estrogen because can cause clotting. Should not be taken with corticosteroids because can result in high levels of corticosteroids. High levels can cause liver problems

subinvolution interventions

assess VS, uterus and fundus, monitor for uterine pain and vaginal bleeding. Elevate legs to promote venous return, encourage frequent voiding, monitor Hgb and hct. Methylergonovine maleate which provides sustained contraction of uterus

Rubella vaccine interventiosn

assess for allergy to duck eggs, question administration if client or other family members are immunocompromised

tonsillitis/adenoiditis interventions

assess for infection, bleeding and clotting studies because throat is vascular. Assess for any loose teeth. Position prone or side lying to facilitate drainage. Do not suction unless there is airway obstruction. Signs of bleeding, discourage coughing, clearing throat or nose blowing. Ice collar or analgesics. Antiemetics. Provide clear, cool, noncitrus and noncarbonated fluids. Avoid red, purple or brown liquids. Avoid milk products because they coat the throat, causing the child to cough to clear the throat. Soft foods 1-2 days postop. No straws, forks or sharp objects. Mouth odor, slight ear pain and low grade fever may occur few days postop. Instructed to notify if bleeding, persistent earache or fever. Keep away from crowds, resume normal activities 1-2 weeks postop.

Hemolytic uremic syndrome

associated with bacterial toxins, chemicals and viruses that cause AKI in children. Acquired hemolytic anemia, thrombocytopenia, kidney injury and CNS sx

carboprost CI

asthma

early childhood psychosocial crisis

autonomy vs. shame and doubt

B Thalassemia major

autosomal recessive, reduced production of one of the globin chains in synthesis of hgb. Supportive treatment, goal of therapy is to maintain mormal hgb through blood transfusion. Bone marrow transplantation may be offered. Splenectomy with severe splenomegaly who requires repeated transfusion (assist in relieving abdominal pressure and may increase life span of supplemental RBC)

fexofenadine nursing considerations

avoid alcohol, CNS depressants, notify provider if taking erythromycin or ketoconazole, if taking aluminum magnesium antacid, take antacid a few hours before or after fexofenadine. OTC, rx

HIV interventions

avoid invasive procedures that can trasmit disease such as amniocentesis and fetal scalp sampling. Avoid episiotomy, oxytocin, place heavy absorbent pads under hips to absorb amniotic fluid and blood, promptly remove neonate from parent's blood after delivery, suction fluids, administer zidovudine if prescribed. Restrict breast feeding

A client admitted to the unit after application of a skin graft is prescribed biafine topical emulsion for the donor site. The client has lung cancer and receives both chemotherapy and radiation treatments. Which is the priority teaching point for the nurse to provide to the client about the prescribed biafine? a. "Apply sunblock when using this medication to avoid burns." b. "Do not apply the medication for 4 hours after radiation therapy" c. "Wash the skin with soap, water or saline prior to applying medication." d. "Use 1/4-1/2 inch of medication when applying to the donor site for treatment."

b. "Do not apply the medication for 4 hours after radiation therapy" Biafine is a wound dressing that is water-based that is prescribed to keep the wound bed moist and prevent germs invasion and is often prescribed for the management of donor sites. Adverse reactions may include itching, red, hives, blisters, peeling skin, fever or not, tightness of the chest/throat, difficulty breathing, wheezing, swelling of mouth, tongue, lips, mouth, and throat. Priority teaching regarding the safe and effective use of biafine based on the client's medical history is avoiding the use of this topical medication for 4 hours after radiation therapy. Fuchsin, a dye to define the radiation markings and the lines, may be dissolved if the biafine is applied within 4 hours of radiation therapy

Which statement by a primigravid client about the amniotic fluid and sac indicates the need for further teaching? a. "The amniotic fluid helps to dilate the cervix once labor begins." b. "Fetal nutrients are provided by the amniotic fluid." c. "Amniotic fluid provides a cushion against impact of the maternal abdomen." d. "The fetus is kept at a stable temperature by the amniotic fluid and sac."

b. "Fetal nutrients are provided by the amniotic fluid." Nutrients are provided by the placenta

An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling." Which response would be most appropriate? a. "Hold him when he is fussy or crying." b. "Hold him as much as you want to hold him." c. "Try to hold him infrequently to avoid overstimulation." d. "You can hold him periodically throughout the day."

b. "Hold him as much as you want to hold him." According to Erikson, infants are in the trust vs. mistrust phase. Holding, talking to, singing to and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs.

The nurse provides care for a client who is newly prescribed interferon-beta for the treatment of multiple sclerosis (MS). Which client statement requires priority follow-up by the nurse? a. "I am worried about losing my hair." b. "I am currently taking bupropion." c. "My spouse will administer all future injections of this medication." d. "I will tell my dentist I am prescribed this medication prior to procedures."

b. "I am currently taking bupropion." Bupropion is a medication that is prescribed for the treatment of depression and to assist with smoking cessation; therefore, the nurse must determine why the client is prescribed the medication prior to administration. If bupropion is prescribed for the treatment of depression, the healthcare provider should be notified as this is a potential contraindication to the use of interferon-beta for the treatment of MS.

A primigravid client at 32 weeks' gestation is enrolled in a breastfeeding class. Which statements indicate that the client understands the breastfeeding education? select all that apply a. "My milk supply will be adequate since I have increased a whole bra size during pregnancy." b. "I can hold my baby several different ways during feedings." c. "If my infant latches on properly, I will not develop mastitis." d. "If I breastfeed, my uterus will return to prepregnancy size more quickly." e. "I need to feed my baby when I see feeding cues and not wait until she is crying."

b. "I can hold my baby several different ways during feedings." d. "If I breastfeed, my uterus will return to prepregnancy size more quickly." e. "I need to feed my baby when I see feeding cues and not wait until she is crying." Oxytocin release from the pituitary leading to a let-down reflex and uterine contractions for involution. Mastitis is an infectious process and is not influenced by latching on

A nurse is conducting health screenings at a statewide health fair and identifies several clients who require referral to a provider. Which of the following statements by a client indicates a barrier to accessing health care? a. "I don't drive, and my son is only available to take me places in the mornings." b. "I can't take off during the day, and the local after-hours clinic is no longer in operation." c. "Only one doctor in my town is a designated provider by my health maintenance organization." d. "I would like to schedule an appt with the local doctor in my town who speaks Spanish and English."

b. "I can't take off during the day, and the local after-hours clinic is no longer in operation." In the other options the patient has some access to care

A woman is diagnosed with complete molar pregnancy. The nurse understands that the woman requires more teaching when she makes which statement? a. "I need to make follow up appt to have my hormone levels checked." b. "I know the placenta caused problems, and my baby died in my uterus." c. "I plan to get pregnant again next year." d. "I understand I may develop a serious type of cancer."

b. "I know the placenta caused problems, and my baby died in my uterus."

The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? a. "I will need to take iron supplements now." b. "I may have anemia because my family is of Asian descent." c. "I am considered anemic if my Hgb is below 11 g/dL (110 g/L)." d. "The anemia increases the workload on my heart."

b. "I may have anemia because my family is of Asian descent." Iron deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the diet of the pregnant woman or both. Other thalassemia and sickle cell anemia, rather than iron deficiency anemia, can be associated with ethnicity but primarily in African or Mediterranean origin. Because RBC increase by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron deficiency anemia.

The nurse conducts disease management instructions to a client with an outbreak of herpes type 2 (HSV-2). Which client statement indicates that teaching has been successful? Select all that apply. a. "It is okay to have unprotected sex when no lesions are present." b. "I must avoid touching the lesions as the virus can spread." c. "I will use cool air to dry the lesions after having a bath or shower." d. "Sitz baths can provide relief of itching and burning." e. "When I have open lesions I will be sure to use a condom during sex."

b. "I must avoid touching the lesions as the virus can spread." c. "I will use cool air to dry the lesions after having a bath or shower." d. "Sitz baths can provide relief of itching and burning." All sexual contact should be avoided when lesions are present as the virus is transmitted through contact with the lesions. Barrier contraception (e.g. condoms) is not adequate to prevent transmission during an outbreak; additionally, this sexually transmitted infection can spread without lesions thus protection should be used with each sexual encounter.

After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic HTN about the need for frequent prenatal visits the nurse determines that the instructions have been successful when the client makes which statement? a. "I may develop hyperthyroidism because of my high BP." b. "I need close monitoring because I may have a small-for-gestational-age infant." c. "It is possible that I will have excess amniotic fluid and may need a C section." d. "I may develop placenta accreta, so I need to keep my clinic appts."

b. "I need close monitoring because I may have a small-for-gestational-age infant." Women with chronic HTN are at risk for complications such as preeclampsia, abruptio placentae, intrauterine growth retardation. Pregnant women with chronic HTN are not at an increased risk for hydramnios, an abnormally large amount of amniotic fluid. Clients with DM and multiple gestation are at risk for this condition. Placenta accreta, a placental abnormality refers to where the placenta abnormally adheres to the uterine lining.

The nurse in a health care clinic is instructing a pregnant client how to perform kick counts. Which statement by the client indicates a need for further instruction? a. "I will record the number of movements or kicks." b. "I need to lie flat on my back to perform the procedure." c. "If I count fewer than 10 kicks in a 2 hour period, it could be because my baby is sleeping." d. "I need to place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

b. "I need to lie flat on my back to perform the procedure." The client would need to sit or lie quietly on the side to perform kick counts. Lying flat on the back is not necessary, can cause discomfort and presenting a risk of vena cava syndrome.

A primiparous client who is bottle feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which response by the nurse would be most appropriate? a. "Your menstrual cycle will return in 3-4 weeks." b. "It will probably be 6-10 weeks before it starts again." c. "You can expect your menses to start in 12-14 weeks." d. "Your menses will return in 16-18 weeks."

b. "It will probably be 6-10 weeks before it starts again." For clients who are bottle feeding, the menstrual flow should return in 6-10 weeks, after a rise in the production of FSH by the pituitary gland. Nonlactating mothers rarely ovulate before 4-6 weeks postpartum. Therefore, 3-4 weeks is too early for the menstrual cycle to resume. For women who are breastfeeding, the menstrual flow may not return for 3-4 months or for the entire period of lactation because ovulation is suppressed

Which statement by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching? a. "BPD is an acute disease that can be treated with abx." b. "My baby may require long term respiratory support.'" c. "Bronchodilators can cure my baby's condition." d. "My baby may have seizures later on in life because of this condition

b. "My baby may require long term respiratory support.'" BPD is a chronic illness that may require prolonged hospitalization and permanent assisted ventilation. The disease typically occurs in compromised very low birth weight neonates who require oxygen therapy and assisted ventilation for treatment of respiratory distress syndrome. The cause is multifactorial and the disease has 4 stages. The neonate's activities may be limited by the disease. Abx may be prescribed and bronchodilators may be used, but will not cure the chronic disease state.

The nurse provides care for a client who experiences vaginal dryness due to menopause and the aging process. The client states, "It is so embarrassing to need a lubricant to have sex with my husband!" Which response by the nurse is best? a. "I wouldn't worry about it." b. "Tell me more about your embarrassment." c. "Dryness occurs due to the hormonal changes in your body." d. "A lot of women your age use lubricant during sexual intercourse."

b. "Tell me more about your embarrassment." While this response by the nurse is accurate, it does not address the client's embarrassment nor does it encourage the client to express thoughts and feelings as it provides an academic rationale for why vaginal dryness occurs. The client should be educated on why vaginal dryness is occurring; however, the use of medical terminology should be avoided.

A multigravid client admitted to the labor area is scheduled for a c section under spinal anesthesia. Which client statement indicates that teaching has been understood? a. "The medication will be administered while I am in prone position." b. "The anesthetic may cause a severe headache, which is treatable." c. "My BP may increase if I lie down too soon after the injection." d. "I can expect immediate anesthesia that can be reversed easily."

b. "The anesthetic may cause a severe headache, which is treatable." Spinal anesthesia is used less commonly today because of preference for epidural block anesthesia. One of the adverse effects of spinal anesthesia is a spinal headache caused by leakage of spinal fluid from the needle insertion. This can be treated by applying a cool cloth to the forehead, keeping the client in flat position or using a blood patch that can seal and clot off any further leakage. Spinal anesthesia is administered with the client in sitting position or side lying. Another adverse effect is hypotension caused by vasodilation. General anesthesia provides immediate anesthesia, whereas the full effects of spinal anesthesia may not be felt for 20-30 min. General anesthesia can be discontinued quickly when the anesthesiologist administers oxygen instead of nitrous oxide. Epidural anesthesia may take 1-2 hours to wear off

A client diagnosed with a urinary tract infection (UTI) is prescribed trimethoprim. Which client statement warrants the implementation of a nutritional assessment by the nurse? a. "I take the medication with grapefruit juice." b. "The medication causes me N/V." c. "I tried to take the medication with a full glass of water but I was gagging." d. "The medication causes me to have a loose, watery stool at least once a day."

b. "The medication causes me N/V." Side effects associated with the prescribed trimethoprim for the treatment of UTI may include diarrhea, nausea, upset stomach, and vomiting. The nurse should teach the client to take the medication with food to decrease GI upset; additionally, antiemetic medications may be prescribed to address this side effect. Persistent nausea and vomiting is likely to impair dietary intake thus increasing the client's risk for malnutrition; therefore, this finding warrants the implementation of a nutritional assessment.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports noticing a thin, colorless vaginal drainage. The nurse would make which statement to the client? a. "Come to the clinic immediately." b. "The vaginal discharge may be bothersome, but it is a normal occurrence." c. "Report to the ED at the maternity center immediately.: d. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

b. "The vaginal discharge may be bothersome, but it is a normal occurrence." Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout the pregnancy. If vaginal discharge is profuse, the client may use panty liners, but should not wear tampons because of the risk of infection.

The family of a dying client is distressed because they feel that loved one is becoming dehydrated. When the family asks about administering intravenous (IV) fluids, which response by the nurse is appropriate? a. "If we start IVF, your loved one may respond better to other life saving treatments." b. "We must consider your loved ones wishes when making decisions to administer IV hydration." c. "If IVF are started, your loved one could very quickly become overhydrated due to a decline in kidney function that occurs with the dying process." d. "The HCP will only prescribe artificial hydration to sustain the life of the client."

b. "We must consider your loved ones wishes when making decisions to administer IV hydration." It is important that clients, especially those who are at the end-of-life, discuss care that they want, or do not want, to sustain life (i.e., components of the living will) with family members. Dehydration is a natural occurrence at the end-of-life; therefore, the nurse must communicate this with the client's family. The nurse must advocate for the client's wishes (e.g., "We must consider the client's wishes when making decisions to administer IV hydration.") while supporting the family at end-of-life with the implementation of therapeutic communication techniques which enhance the nurse-client-family relationship. Appropriate interventions to address the symptoms associated with dehydration that occurs at end-of-life include providing oral care at least every 2 to 4 hours and offering ice chips or a moist cloth to keep the client's lips and mouth moist.

An older adult client who is diagnosed with sepsis becomes angry at the unlicensed assistive personnel (UAP) and refuses oral care. The UAP reports this incident to the registered nurse (RN). Which response by the RN is appropriate? a. "I will go check on the client and try to figure out what caused the episode." b. "We will go talk to the client about the issue together." c. "Why don't you talk with the client about the situation?" d. "I will talk to the nurse manager about floating you to another unit today."

b. "We will go talk to the client about the issue together." The client who is angry must be given an opportunity to openly express concerns; therefore, it is appropriate to approach the situation with an attitude of acceptance, openness, and unbiasedness.

The nurse would plan to make which statement to a pregnant client found to have a gynecoid pelvis? a. "Your type of pelvis has a narrow pubic arch." b. "Your type of pelvis is the most favorable for labor and birth." c. "Your type of pelvis is a wide pelvis, but it has a short diameter." d. "You will need a c section because this type of pelvis is not favorable for a vaginal delivery. "

b. "Your type of pelvis is the most favorable for labor and birth." An android pelvis would be unfavorable for labor because of the narrow pelvic planes. An antropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter but the anteroposterior diameter is short, making the outlet inadequate

After the nurse reinforces the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated BP, which client stateemnts would demonstrate udnerstnading of when to call the HCP's office? Select all that apply a. "If I feel dizzy when I get up quickly" b. "if I see any bleeding, even if I have no pain" c. "if I have a pounding headache that will not go away" d. "if I notice the veins in my legs getting bigger" e. "if the leg cramps at night are waking me up" f. "if the baby seems to be more active than usual"

b. "if I see any bleeding, even if I have no pain" c. "if I have a pounding headache that will not go away" f. "if the baby seems to be more active than usual" Vaginal bleeding with or w/o pain could signify placenta previa or abruptio placentae. Continuous or pounding HA could be elevated BP and change in strength or frequency of fetal movements could indicate that the fetus is in distress. Orthostatic hypotension can occur during pregnancy and can be alleviated by rising slowly. Leg veins may increase in size due to additional pressure from the increasing uterine size, while leg cramps may also occur and can commonly be decreased with calcium supplements

A nurse is reviewing dietary recommendations with a group of clients at a health fair. Which of the following information should the nurse include? a. "Fats should be 5-15% of daily calorie intake." b. "make protein 10-35% of total calories each day." c. "Consume 1,500 mL of water from liquids and solids daily." d. "The body needs 40 mg of iron each day."

b. "make protein 10-35% of total calories each day."

Which instruction should the nurse include when teaching a female client to collect a clean catch urine specimen? Select all that apply. a. "Cleanse the perineal area from back to front with soap and water." b. "open the labia using your non dominant pointer finger and thumb." c. "fill the specimen container until urine stream completely stopped." d. "Begin urinating before placing the container under your urine stream." e. "Wash your hands, open the specimen container, and place the lid upward."

b. "open the labia using your non dominant pointer finger and thumb." d. "Begin urinating before placing the container under your urine stream." e. "Wash your hands, open the specimen container, and place the lid upward."

A nurse is instructing a client on how to administer cyclic enteral feedings at home. Which of the following information should the nurse include? a. "Give a feeding every 6 hours." b. "set the feeding up before you go to bed." c. "Weight yourself daily." d. "flush the tube with a carbonated beverage to dislodge clogs." e. "Ensure your head is elevated to 15 degrees during administration."

b. "set the feeding up before you go to bed." c. "Weight yourself daily."

After suction and evaluation of a complete hydatidiform mole, the 28 y/o multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? a. 6 months b. 12 months c. 18 months d. 24 months

b. 12 months A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of hCG levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but these levels gradually begin to decline. Clients should have a pelvic exam and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate.

Which client should the nurse most encourage to receive the pneumococcal and flu vaccine? a. 30 y/o pregnant woman b. 75 y/o woman with diabetes c. 40 y/o man with BPH d. 50 y/o man with angina

b. 75 y/o woman with diabetes Clients with chronic illness, have serious illness, reside in LTC or 65 y/o or older are encouraged to get both vaccines.

When teaching a primiparous client about the growth and development of the neonate, the nurse should explain that most babies are able to drink from a sippy cup at what age? a. 5-7 months b. 8-10 months c. 12-14 months d. 15-16 months

b. 8-10 months

Which client is at the highest risk for developing a pressure injury while hospitalized? a. A client with paraplegia, PNA, temp of 101.5 F and WBC of 12,000/mm3 b. A client who is receiving a dopamine infusion, has a documented weight loss of 15 lbs in 21 days, a hx of HIV and critically low prealbumin level c. A client who is 5 days post appendectomy, has an indwelling urinary catheter, and a Hgb of 12 g/dL d. A client who is 1 day postop for a knee replacement, with Hgb of 10 g/dL, temp of 99F and WBC of 12,000/mm3

b. A client who is receiving a dopamine infusion, has a documented weight loss of 15 lbs in 21 days, a hx of HIV and critically low prealbumin level This client has two risk factors for pressure injury, including a comorbidity (i.e., paraplegia) and infection, exemplified by the elevated body temperature and an elevated WBC count. This client has four risk factors for pressure injuries. The risk factors include a comorbidity (e.g., HIV), poor perfusion (e.g., dopamine infusion for hypotension), poor nutrition (e.g., low serum prealbumin level), and weight loss (e.g., 15 lb [6.2 kg]) in the last month. This client has two risk factors for pressure injury (e.g., comorbidity [e.g, appendicitis] and the use of a medical device [e.g., indwelling urinary catheter]). This client has three risk factors for pressure injury (e.g., immobility, comorbidity [e.g., anemia], and infection [e.g., increased WBC count]).

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply a. Scarring is less severe in a child than in an adult b. A delay in growth may occur after a burn injury c. An immature immune system presents an increased risk of infection for infants and young children d. fluid resuscitation is unnecessary unless the burned area is more than 25% of the BSA e. The lower proportion of body fluid to body mass in a child increases the risk of CV problems f. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults

b. A delay in growth may occur after a burn injury c. An immature immune system presents an increased risk of infection for infants and young children f. Infants and young children are at increased risk for protein and calorie deficiency, because they have smaller muscle mass and less body fat than adults The higher proportion of body fluid to body mass in a child increases the risk of CV problems

The client has an IV and is experiencing tissue necrosis at the site of the IV. What drug might be causing this? a. Digoxin b. An alpha agonist c. A beta blocker d. A calcium channel blocker

b. An alpha agonist Alpha agonists cause vasoconstriction and can result in tissue necrosis if it extravasates at the IV site. The other drugs will not cause vasoconstriction nor do they cause tissue necrosis

The client is on a Class II anti-arrhythmic agent. What is one of these drugs? a. Calcium channel blocker b. Beta blocker c. Sodium channel blocker d. ACE inhibitor

b. Beta blocker A beta blocker is an example of a class II anti-arrhythmic drug. Calcium channel blockers is a class IV anti-arrhythmic medication and ACE inhibitors are not anti-arrhythmic agents. Sodium channel blockers are class I anti-arrhythmic drugs

A 4 y/o child is admitted to the hospital for abdominal pain. The parents report that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which lab result confirms the diagnosis? a. LP showing no blast cells b. Bone marrow biopsy showing blast cells c. plt ct of 350,000 mm3 d. WBC count of 4500 mm3

b. Bone marrow biopsy showing blast cells Leukemia is a malignant increase in the number of leukocytes in the bone marrow. The confirmatory test for leukemia is microscopic exam of the bone marrow obtained by aspirate and biopsy, which is considered positive if blast cells are present. Altered plt count occurs as a result of the disease but also may occur as a result of chemo and does not confirm the diagnosis. The WBC count may be normal, high or low .

The nurse provides care for a pregnant client who is 20 weeks' gestation who reports consuming large amounts of dirt over the last month. Which laboratory test should the nurse anticipate from the client's healthcare provider (HCP)? a. estrogen and progesterone levels b. CBC c. serum folate and B12 levels d. vitamin D and calcium levels

b. CBC During pregnancy, pica may indicate iron-deficiency anemia. Iron is needed to make hemoglobin in the blood; therefore, the nurse anticipates a CBC will be prescribed for this client based on the current data. Pica signifies that the client is trying to correct a nutritional deficiency. Correcting the deficiency will resolve the pica.

A client diagnosed with primary pulmonary HTN is admitted to hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? a. aminoglycosides b. CCB c. digoxin d. diuretics e. oxygen f. vasodilators

b. CCB c. digoxin d. diuretics e. oxygen f. vasodilators Digoxin can help the heart beat stronger and pump more blood. It can help control the heart rate if dysrhythmias are experienced. Oxygen therapy may be prescribed to treat pulmonary HTN, esp if the client lives at a high altitude or has sleep apnea

When planning a class for primigravid clients about the common physiologic changes of pregnancy, the nurse should include which information in the teaching plan? a. The temperature decreases slightly early in pregnancy b. CO increases by 25-50% during pregnancy c. The circulating fibrinogen level decreases as much as 50% during pregnancy d. The anterior pituitary gland secretes oxytocin late in pregnancy

b. CO increases by 25-50% during pregnancy Circulatory blood volume increases by about 30% The client may experience transient hypotension and dizziness with sudden position changes. Early in pregnancy, there is a slight increase in the temperature and clients may attribute this to a sinus infection or a cold. The client may feel warm, but this sensation is transient. The level of circulating fibrinogen increases as much as 50% during pregnancy, probably because of increased estrogen. Any calf tenderness should be reported because it may indicate a clot. Late in pregnancy, the posterior pituitary gland secretes oxytocin. The client may experience painful Braxton Hicks contractions or early labor symptoms

The client is taking a class IA anti-arrhythmic agent. What might be the drug the client is taking? Select all that apply. a. Metoprolol b. Disopyramide c. Procainamide d. Morcizine e. Quinidine

b. Disopyramide c. Procainamide e. Quinidine Disopyramide, procainamide, and quinidine are all class IA anti-arrhythmic medication. Metoprolol is a class II anti-arrhythmic and Morcizine is a class I antiarrhythmic

The client has a myocardial infarction and going into shock. What might be a medication to give to counteract shock in cases of myocardial infarction? a. Atropine b. Dopamine c. Digoxin d. Adenosine

b. Dopamine Dopamine is the drug of choice for shock associated with a myocardial infarction. Digoxin is used for CHF, atropine for bradycardia, and adenosine for supraventricular tachycardia.

The nurse is caring for several mother baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? a. G4, P1 client who is breastfeeding her infant b. G3, P3 client who is breastfeeding her infant c. G2, P2 C section who is bottle feeding her infant d. G3, P3 client who is bottle feeding her infant

b. G3, P3 client who is breastfeeding her infant The major reasons for after birth pains are breastfeeding, high arity, over distended uterus during pregnancy and uterus filled with blood clots. The intermittent contractions and relaxation of uterus are stronger in multigravida in order to maintain a contracted uterus. The release of oxytocin when breastfeeding also stimulates uterine contractions.

Before advising a 24 y/o client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? a. anemia b. HTN c. dysmenorrhea d. acne vulgaris

b. HTN Clients who have HTN, thrombophlebitis, obesity or family history of cerebral or CVA are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 y/o or have a history of pulmonary disease should be advised to use a different method. Iron deficiency anemia, dysmenorrhea and acne are not contraindications. Iron deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, providing a beneficial effect when used by clients w/ anemia. Low dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea. It is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne.

Which action by the client indicates an acceptance of his recent amputation? a. He verbalizes acceptance b. He looks at the operative site c. He asks for information regarding prosthesis d. He remains silent during dressing changes

b. He looks at the operative site Any time that there is a change in body image looking at the operative site is the best indicator of acceptance. Simply stating that he accepts the change in body image is not an accurate indicator, so answer A is incorrect. Answer C is incorrect because asking for information also is not an accurate indicator. Answer D is incorrect because remaining silent also is not an indicator.

The client is receiving a beta agonist. What adverse effect should the nurse look out for? a. Hypoglycemia b. Hyperglycemia c. Muscle weakness d. Parasthesias

b. Hyperglycemia Beta agonists cause the liver to break down glycogen into glucose so the blood glucose level may be increased. They cause tremor from muscle contraction and not muscle weakness. They do not cause paresthesias.

The client is being given a cardio-selective beta blocker because of which possible reasons? Select all that apply. a. Hypotension b. Hypertension c. Dysrhythmias d. Cardiac arrest e. Myocardial infarction

b. Hypertension c. Dysrhythmias e. Myocardial infarction

The nurse is assessing an elderly couple, both 80 years old, to determine if they can safely continue to live independently. They insist they are getting along fine but need help with grocery shopping and housekeeping. The nurse determines that they have difficulty in doing which of the following? a. ADL b. IADL c. milestones d. prevention

b. IADL

Stress reduction techniques include biofeedback and meditation. The nurse conducting classes on these methods knows that studies have shown a cause-and-effect relationship between stress and which of the following? Select all that apply a. Adverse medication effects b. Infectious diseases c. Traumatic injuries d. chronic illnesses

b. Infectious diseases c. Traumatic injuries d. chronic illnesses

The nurse is preparing to suction a client with an endotracheal tube. After ventilating, which is the correct sequence of actions for the nurse to follow during suctioning? a. Apply suction, insert a sterile catheter, and withdraw while rotating the catheter. b. Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw while rotating the catheter. c. Apply suction, insert a sterile catheter, and withdraw without rotating the catheter. d. Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw without rotating the catheter.

b. Insert a sterile catheter, begin to withdraw, apply suction, and continue to withdraw while rotating the catheter. The nurse would ventilate the client and insert the sterile catheter without applying suction. The nurse would then withdraw the catheter about 1 inch and apply suction while rotating the catheter.

Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a. It determines fetal lung matrutiy b. It is noninvasive using real time US c. It will correlate with the newborn's Apgar score d. It requires the client to have an empty bladder

b. It is noninvasive using real time US A noninvasive US assesses 5 parameters: HRF reactivity, fetal breathing movements, gross fetal body movements, fetal tone and amniotic fluid volume. FHR reactivity is determined by a nonstress test, the other 4 are determined by US. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. There is no correlation with the newborn's Apgar score. A score of 8-10 indicate fetal well being. Use of a US requires the mother to have a full bladder

Before surgery to repair an aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: a. anxiety b. LOC c. HA d. disorientation

b. LOC If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore LOC will be observed. A sudden LOC is a primary symptom of rupture and no blood flow to the brain

The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? a. Leukopenia with a shift to the left b. Leukocytosis with a shift to the left c. Leukopenia with a shift to the right d. Leukocytosis with a shift to the right

b. Leukocytosis with a shift to the left

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? a. Cleans the catheter proximally to distally with soap and water b. Maintains the urinary collection bag below the level of the bladder c. Removes a loose catheter anchor and puts a new anchor on the lower leg d. Uses the nondominant hand to bull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its original position

b. Maintains the urinary collection bag below the level of the bladder Any loose anchors need to be removed and replaced to ensure that the catheter tubing does not get pulled on. However, it needs to be placed on the upper thigh, not the lower bag

The critical care nurse is caring for a client with an arterial line (Aline). The nurse can utilize this line for which of the following? a. Monitoring blood pressure and heart rate, and infusing medications b. Monitoring blood pressure and heart rate, and obtaining blood gases and other laboratory samples c. Monitoring heart rate, obtaining blood gases and other laboratory samples, and infusing medications d. Obtaining blood gases and other laboratory samples, and infusing medications

b. Monitoring blood pressure and heart rate, and obtaining blood gases and other laboratory samples Arterial lines are used for monitoring blood pressure and heart rate, especially in clients requiring the use of vasopressor medications intravenously. They are also used for clients requiring frequent blood draws. The nurse may also draw arterial blood gases and other laboratory samples from the line, following the proper procedure. This saves the client from frequent arterial and venous draws.

A 3 month old child accompanies her parents to a seasonal flu clinic. Assuming that the child does not have a fever, can the nurse give the child a flu shot? a. Yes, if regular immunizations are up-to-date b. No, because the child is not old enough c. Yes, because then the child won't get sick later d. No, because it would interfere with regular immunizations

b. No, because the child is not old enough The minimum age to receive a flu shot is 6 months.

The nurse is giving the client digoxin for heart failure and recognizes that the drug has what type of effect on the heart? a. Negative inotropic, negative chronotropic effect b. Positive inotropic, negative chronotropic effect c. Negative inotropic, positive inotropic effect d. Positive inotropic, positive chronotropic effect.

b. Positive inotropic, negative chronotropic effect Digoxin strengthens the heart muscle, providing and inotropic effect and decreases the heart rate, having a negative chronotropic effect on the heart. The end result is an improvement in heart failure symptoms.

The nurse is administering a doxorubicin IV push to a client with breast cancer. Which of the following should the nurse explain is to be expected during therapy with this drug? a. Burning at the IV site during administration b. Red-colored urine c. Permanent alopecia d. Teeth discoloration

b. Red-colored urine

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which actions to correct the error in the MAR? select all that apply a. complete and file an occurrence report b. Right click on the entry and modify it to reflect the correct information c. document the correct information and end with the nurse's signature and title d. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg e. Document in a nurse's note in the client's record detailing the corrected information

b. Right click on the entry and modify it to reflect the correct information c. document the correct information and end with the nurse's signature and title d. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg e. Document in a nurse's note in the client's record detailing the corrected information

A first-time parent is discussing developmental milestones with the nurse. The nurse tells the client that she can reasonably expect her child to achieve which of the following by the time the child is 1 y/o? a. Walking b. Rolling from tummy to side c. Transferring toys from hand to hand d. Beginning to respond to words e. Vocalizing sounds

b. Rolling from tummy to side c. Transferring toys from hand to hand d. Beginning to respond to words e. Vocalizing sounds

A 23 y/o nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client? a. Check the cervical mucus to see if it is thick and sparse. b. Take her temperature at the same time every morning before getting out of bed. c. Document ovulation when her temperature decreases at least 1 F d. avoid coitus for 10 days after a slight rise in temperatures.

b. Take her temperature at the same time every morning before getting out of bed. Hyst before the day of, the temperature falls by 0.5F. At the time of ovulation, the temperature rises 0.4-0.8 F because of increased progesterone secretion in response to the LH. The temperature remains higher for the rest of menstrual cycle. There is no mucus for the first 3-4 days after menses and then thick, sticky mucus begins to appear. As estrogen increases, the mucus changes to clear, slippery and stretchy. Spinnbarkeit is present during ovulation. After ovulation, the mucus decreases in amount and becomes thick and sticky again until menses. Because the ovum typically survives about 24 hours and sperm can survive up to 72 hours, couples must avoid coitus when the cervical mucus is copious and for about 3-4 days before and after ovulation to avoid pregnancy.

The client is diagnosed by the ED HCP with an acute migraine. For which situation is it most important to have a discussion with the HCP before medication is prescribed? a. The HCP is considering dexamethasone to prevent reoccurrence, and the client has T2DM b. The HCP is considering SQ sumatriptan, and the client took ergotamine 3 hours ago c. The HCP is considering metoclopramide, and this is a first-time migraine for the client d. The HCP is considering prochlorperazine, and the client drove himself to the hospital.

b. The HCP is considering SQ sumatriptan, and the client took ergotamine 3 hours ago Intravenous metoclopramide and prochlorperazine and subcutaneous sumatriptan are recommended for adults who present with first-time onset of acute migraines. Sumatriptan should not be used if ergotamine, dihydroergotamine, or other triptan medication has been used in the past 24 hours because of the additive effect of narrowing of the blood vessels that could result in damage to major organs (e.g., stroke or myocardial infarction). Dexamethasone may cause increased glucose levels. Prochlorperazine can cause drowsiness.

The nurse develops a plan of care for a pediatric client who is newly diagnosed with human immunodeficiency virus (HIV). Which resource does the nurse include in the child's plan of care to provide primary health care services to this client? a. The Avert Organization: Global Information and Resources on HIV and AIDS b. The Ryan White Comprehensive AIDS Resources Emergency Act c. The ELizabeth Glaser Pediatric AIDS Foundation d. The Well Project: Women and HIV

b. The Ryan White Comprehensive AIDS Resources Emergency Act The Avert Organization: Global Information and Resources on HIV and AIDS is geared towards health care professionals to provide information important to providing the best care possible to individuals with an HIV or AIDS diagnosis. While there is information that is geared specifically toward the pediatric population, this resource does not fund primary health care or other services for persons with HIV. The Health Resources and Services Administration's (HRSA) Ryan White HIV/AIDS Program is the largest federal program focused specifically on providing HIV care and treatment services to low-income individuals living with HIV who are uninsured or underserved thus this is the resource the nurse includes in this child's plan of care as it funds primary health care and other services that may be needed by this client due to the diagnosis of HIV. The Elizabeth Glaser Pediatric AIDS Foundation is a nonprofit organization that is dedicated to preventing pediatric HIV infection and eliminating pediatric AIDS through advocacy, research, and prevention and treatment programs. This resource, however, does not fund primary health care and other services for persons with HIV. The Well Project is an organization that is committed to building agency and health literacy among women living with HIV by developing and providing access to culturally responsive, scientifically accurate, women-focused HIV information. This resource is not geared towards the pediatric population nor does it fund primary health care and other services for persons with HIV.

Which order should the nurse question? a. The addition of a loop diuretic with digoxin. b. The addition of a beta blocker with digoxin. c. A digoxin dose of 0.125 mg per day. d. The addition of an ACE inhibitor with digoxin.

b. The addition of a beta blocker with digoxin. Adding a beta blocker to digoxin can potentiate the bradycardic effect of the digoxin so the two should be used cautiously together. The normal dosage of digoxin is 0.125-0.25 mg per day. It does not interact with an ACE inhibitor or a loop diuretic.

The client is diabetic and is given a non-cardio-selective beta blocker. What might happen to the blood sugars? a. The blood sugars will increase because of breakdown of glycogen. b. The blood sugar drops due to impaired production of glucose from glycogen. c. It does not affect the blood sugar. d. The blood sugar drops due to increased cellular uptake of glucose.

b. The blood sugar drops due to impaired production of glucose from glycogen. The blood sugar will go down because the beta blocker impairs the production of glucose from glycogen in the liver. It does not affect glucose uptake by the cells and does not increase the breakdown of glycogen.

The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine. What are the general CI associated with receiving a live virus vaccine? Select all that apply a. The child has symptoms of a cold b. The child had a previous anaphylactic reaction to the vaccine c. The parent reports that the child is having intermittent episodes of diarrhea d. The parent reports that the child has not had an appetite and has been fussy e. the child has a disorder that caused a severely deficient immune system f. The parent reports that the child has recently been exposed to an infectious disease

b. The child had a previous anaphylactic reaction to the vaccine e. the child has a disorder that caused a severely deficient immune system

A nurse is discussing how the body processes food with a client during a a routine provider's visit. Which of the following states should the nurse include? a. Glycerol can be broken down into glucose for use by the body. b. The liver converts unused glucose into glycogen c. excess fatty acids are stored in the muscle tissue d. The body uses glycogen for fat before using available ATP

b. The liver converts unused glucose into glycogen

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special food from home." The nurse responds based on the understanding about which principle? a. Foods from home are generally discouraged on the postpartum unit b. The mother can bring the daughter any food that she desires c. This is permissible as long as the foods are nutritious and high in iron d. The client's HCP needs to give permission for the foods

b. The mother can bring the daughter any food that she desires

A client's red blood cell transfusion was discontinued due to an acute hemolytic transfusion reaction. Which of the following strategies should the nurse use to BEST minimize the risk of such a reaction? a. The nurse ensures the client's temperature does not increase more than 1.8º F during the transfusion. b. The nurse verifies all client-identifying information according to hospital protocol prior to hanging the unit of blood. c. The nurse administers meperidine for severe rigors. d. The nurse administers acetaminophen prior to the transfusion.

b. The nurse verifies all client-identifying information according to hospital protocol prior to hanging the unit of blood. The most common cause of an acute hemolytic transfusion reaction is the administration of ABO-incompatible blood. By verifying client-identifying information according to hospital policy, the nurse can minimize the risk of a client being transfused with ABO-incompatible blood. Administering meperidine may alleviate symptoms associated with a reaction but does not prevent it from developing. Administering acetaminophen may be indicated to prevent hypersensitivity reactions, but this action will not minimize the risk of an acute hemolytic transfusion reaction from taking place.

The nurse prepares to assess a client who is diagnosed with aortic stenosis. Which location does the nurse place the stethoscope to best hear a heart murmur? a. the second intercostal space to the left of the sternal border b. The second intercostal space to the right of the sternal border c. the third intercostal space to the left of the sternal border d. the fifth intercostal space at the midclavicular line

b. The second intercostal space to the right of the sternal border The aortic valve is best auscultated at the second intercostal space to the right of the sternal border; therefore, this is the location that nurse chooses to auscultate a heart murmur for the client with aortic stenosis.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation? a. Fetal development needs to be complete before testing. b. The volume of amniotic fluid needed for testing will be available by 15 weeks. c. Cells indicating hemophilia A are not produced until 15 weeks' gestation. d. Performing an amniocentesis prior to 15 weeks' gestation carries a greater infection rate.

b. The volume of amniotic fluid needed for testing will be available by 15 weeks. The volume of fluid needed for amniocentesis is 15 mL, usually available at 15 weeks' gestation. Cells necessary for testing for hemophilia A are available during the entire pregnancy but are not accessible by amniocentesis until 12 weeks' gestation.

The client is given a calcium channel blocker. Calcium channel blockers have what effect on the heart? a. They increase the preload on the heart. b. They decrease the velocity of electrical activity on the AV node. c. They block the sodium channels in the heart muscle. d. They cause vasoconstriction of coronary arteries.

b. They decrease the velocity of electrical activity on the AV node. Calcium channel blockers decrease the velocity of electrical activity on the AV node. They block calcium channels and not sodium channels. They cause vasodilatation of the blood vessels and not vasoconstriction. They do not increase the preload on the heart.

A 30 y/o multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which will occur regarding the client's insulin needs during the first trimester? a. They will increase b. They will decrease c. They will remain constant d. They will be unpredictable

b. They will decrease During the first trimester, it is not unusual for insulin needs to decrease due to N/V. Progressive insulin resistance is characteristic of pregnancy, esp in second half of pregnancy. It is not unusual for insulin needs to increase by as much as 4x the nonpregnant does after the24th week of gestation, caused by production of human placental lactogen called human chorionic somatotropin, by the placenta and by other hormones such as estrogen and progesterone which are insulin antagonists

A client is at 24 weeks' gestation. The nurse is reviewing the report of laboratory tests as noted below. Blood type A + Blood glucose 90 mg/dL VDRL Positive Rubella titer Immune The nurse should rerport which results to the HCP? a. blood type b. VDRL c. blood glucose d. rubella titer

b. VDRL The client must be treated for syphilis to prevent perinatal transmission of the disease.

Which prescription should the nurse clarify with the client's HCP (health care provider) prior to administration? a. Diazepam 5 mg PO for a client who is exhibiting signs of delirium tremens from alcohol withdrawal b. Ziprasidone 5 mg IM for a confused client who continually tries to ambulate without help c. Risperidone 1 mg PO for a client with schizophrenia who is becoming increasingly agitated and threatening to harm self and others d. Dexmedetomidine hydrochloride infusion for a client who is intubated

b. Ziprasidone 5 mg IM for a confused client who continually tries to ambulate without help It is not appropriate to administer an antipsychotic agent to a client who is attempting to get out bed. This is considered a chemical restraint and requires clarification prior to administration. This is an appropriate pharmacological prescription for the client who is mechanically ventilated; therefore, the nurse does not question this prescription.

A nurse caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? a. a client who has decreased vision b. a client who has PD c. a client who has poor dentition d. a client who has anorexia

b. a client who has PD This client is at risk of aspiration

Which client findings require the nurse's attention first? a. a gravida 2, para 1 at 39 weeks' gestation with spontaneous ROM 1 hour ago but no contractions b. a gravida 3, para 2 at 30 weeks' gestation with nausea, vomiting and epigastric pain c. a gravida 5, para 1 at 37 weeks' gestation with pink vaginal discharge and abdominal cramping d. a gravida 1, para 0 at 39 weeks' gestation with bruises on the arms and abdomen at various stages of healing

b. a gravida 3, para 2 at 30 weeks' gestation with nausea, vomiting and epigastric pain A woman presenting at 30 weeks with N/V and epigastric pain has signs of preeclampsia and requires the nurse's attention first. The client with spontaneous ROM but no contractions is not a priority. The client with pink discharge and abdominal cramping could be in early labor and is not a priority at this time. A client with bruises at various stages of healing could indicate that she is in an abusive relationship, but this is not a priority

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? a. an inflammation of the epidermis only b. a skin infection of the dermis and underlying hypodermis c. an acute superficial infection of the upper layers of the skin d. an epidermal and lymphatic infection caused by staph

b. a skin infection of the dermis and underlying hypodermis Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender and sometimes nodular. Erysipelas is an acute, superficial, infection affecting the upper layers of the skin. Cellulitis is not superficial and extends deeper than the epidermis

A public health nurse is planning interventions for children in the community. Which of the following topics should the nurse choose to target a major concern for school aged children? a. skin cancer dtection b. access to healthcare c. STI prevention d. cholesterol screening

b. access to healthcare

While performing an assessment, the nurse notes the infant's jaundice has moved from the nipple line to the umbilicus in the past 24 hours. How does the nurse interpret this physical finding? a. a decrease in bilirubin level is probable b. an increase in bilirubin level is probable c. no further assessment is necessary d. where jaundice is located on the baby is not indicative of bilirubin level

b. an increase in bilirubin level is probable jaundice progresses in a cephalocaudal manner. The jaundice increased from the nipple line to the umbilicus indicates the bilirubin levels are increasing in this infant

The triage nurse assesses clients who are brought to the hospital after experiencing chemical burns. The nurse hears audible stridor when assessing two of the clients. Which priority action should the nurse implement based on the current data? A. administer a breathing treatment for each client in respiratory distress b. apply PPE c. listen to the lungs of clients with stridor d. remove clothing and place the clients in the shower

b. apply PPE The priority action when providing care to a client who experiences a chemical burn is to don PPE. This action decreases the likelihood of cross-contamination.

The nurse assesses a client admitted to the intensive care unit (ICU) with diagnosis of traumatic brain injury (TBI) following a motor vehicle accident. Which action should the nurse implement to assess the client's cerebellum function? Select all that apply. a. monitor for a positive Brudzinski sign b. ask the client to perform rapid supination and pronation c. perform a Romberg test d. perform the finger to nose test e. perform shoulder shrug against resistance

b. ask the client to perform rapid supination and pronation c. perform a Romberg test d. perform the finger to nose test The cerebellum is responsible for coordination, equilibrium, and the smoothness of movement. Specific tests used to evaluate cerebellar function include assessment of gait and balance, pronator drift, the finger-to-nose test, rapid alternating action, and the heel-to-shin test. Assessment of cranial nerve X is performed to determine the client's ability to swallow; however, the nurse is assessing cerebellum function, or coordination thus this is not an appropriate action by the nurse.

A nurse is talking with a cleint who has a new diagnosis of T2DM and their caregiver. Which of the following sweeteners should the nurse include as a zero calorie sweetener option? select all that apply a. sucrose b. aspartame c. mannitol d. xylitol e. sucralose

b. aspartame e. sucralose

The nurse is caring for an elderly client with urinary incontinence. The nurse angrily tells the client, "If you can't stop making messes, I'm going to put in a catheter." The nurse's actions may be considered which type(s) of legal violation(s)? Select all that apply. a. battery b. assault c. malpractice d. intentional tort e. libel

b. assault d. intentional tort This answer is not correct because libel occurs when someone uses false written statements to defame another's character. The nurse's threatening statement is an example of assault, an intentional tort.

A client at 28 weeks' gestation presents to the ED with a "splitting HA." What actions are indicated by the nurse at this time? Select all that apply a. Reassure the client that HA are a normal part of pregnancy b. assess the client for vision changes or epigastric pain c. obtain a nonstress test d. assess the client's reflexes and presence of clonus e. determine if the client has a documented US for this pregnancy

b. assess the client for vision changes or epigastric pain c. obtain a nonstress test d. assess the client's reflexes and presence of clonus

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point? a. halfway between the client's symphysis pubis and umbilicus b. at about the level of the client's umbilicus c. between the client's umbilicus and xiphoid process d. near the client's xiphoid process and compressing the diaphragm

b. at about the level of the client's umbilicus At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus is typically over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approx 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approx 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Pressure on the diaphragm occurs late in pregnancy, so a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.

The nurse is caring for a postop client who is receiving demand dose hydromorphone via a PCA pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following VS: temp 97.2 F orally, pulse 52 bpm, BP 101/58 mmHg, RR 11 breaths per min and SpO2 of 93% on 3 L of O2 via NC. Which action would the nurse take first? a. document the findings b. attempt to arouse the client c. contact the PHCP d. check the medication administration history on the PCA pump

b. attempt to arouse the client

The nurse is teaching a client with PD about the nutritional modifications to make in the diet because the client is taking levodopa. The nurse should instruct the client to: a. increase amount of K in the diet b. avoid foods high in pyridoxine (vitamin B12) c. increase the amount of protein in the diet d. implement a 2 g sodium restricted diet

b. avoid foods high in pyridoxin (vitamin B12) Vitamin B12 interferes with the efficacy of the levodopa. The client should also avoid a high protein diet

At a preconception visit, a 24 y/o client is found to have malformation of the uterus. the nurse uses the figure below to explain which type of uterine malformation? a. septate uterus b. bicornuate uterus c. double uterus d. uterus didelphys

b. bicornuate uterus A bicornuate uterus has a Y shape and appears to be a double uterus but has only one cervix. A septate uterus contains a septum that extends from the fundus to the cervix, dividing the uterus into 2 separate compartments. A double uterus has two uteri, each of which has a cervix. A uterus didelphys occurs when both uteri of a double uterus are fully formed.

Which client is most critical and should be assessed by the RN? a. diabetic client being discharged and requiring discharge teaching b. cardiac client with a history of ventricular tachycardia c. client requiring IV medication d. comatose, terminally ill client

b. cardiac client with a history of ventricular tachycardia The cardiac client requires constant assessment with the possibility of immediate life support intervention should he have another run of ventricular tachycardia. Given the instability of the client's situation, the cardiac client is the most critical.

A nurse is caring for a client following an appendectomy who has a postop prescription that reads s/c NPO status: advance diet as tolerated. Which of the following are appropriate for the nurse to offer the client initially? Select all that apply a. applesauce b. chicken broth c. sherbet d. wheat toast e. cranberry juice

b. chicken broth e. cranberry juice

When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which problem? a. ectopic pregnancy b. choriocarcinoma c. multifetal pregnancies d. infertility

b. choriocarcinoma The client's hCG levels are monitored for 1 year. During this time, she should be advised not to become pregnant because this would be reflected in rising hCG levels.

A client with a PMH of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She has dyspnea with exertion and is very tired. Her VS are O2 98, pulse 80, RR 20, BP 116/72 mmHg. She has +2 pedal edema and clear breath sounds. The nurse determines the client's symptoms indicate which cardiac functional classification? a. class I b. class II c. class III d. class IV

b. class II She is symptomatic with increased activity (DOE). Class II clients have cardiac disease with a slight limitation in physical activity. When physical activity occurs, the client may experience angina, difficulty breathing, palpations and fatigue.

Which clients can be appropriately assigned to a newly graduated RN who has recently completed orientation? select all that apply a. Anxious client with chronic pain who frequently uses the call button b. client on the second postop day who needs pain medication before dressing changes c. client with AIDS who report HA and abdominal and pleuritic chest pain d. client with chronic pain who is to be discharged with a new surgically implanted catheter e. client who is reporting pain at the site of a peripheral IV line f. client with a kidney stone who needs frequent PRN pain medication

b. client on the second postop day who needs pain medication before dressing changes e. client who is reporting pain at the site of a peripheral IV line f. client with a kidney stone who needs frequent PRN pain medication The client who is second day postoperative, the client who has pain at the IV site, and the client with the kidney stone have predictable needs and require routine care that a new nurse can manage. The anxious client with chronic pain needs an in-depth assessment of the psychological and emotional components of pain and expert intervention. The client with acquired immune deficiency syndrome has complex issues that require expert assessment skills. The client pending discharge will need special and detailed instructions.

Which client is the best candidate for a vaginal birth after a caesarean (VBAC)? a. client who had an emergency c section because of fetal distress during her last birth and has a classic incision b. client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy c. client who dilated 6 cm in her last birth and failed to progress beyond this point despite 5 more hours of labor d. diabetic client whose last infant was over 10 lb. This infant is larger as seen on US

b. client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy

Which clients can be appropriately assigned to an LPN/LVN who will function under the supervision of an RN or team leader? Select all that apply a. Client who needs preop teaching about the PCA pump b. client with a leg cast who needs neuro-circ checks and PRN hydrocodone c. Client who underwent a toe amputation and has diabetic neuropathic pain d. client with terminal cancer and severe pain who is refusing medication e. client who reports abdominal pain after being kicked, punched and beaten f. client with arthritis who needs scheduled pain medications and heat applications

b. client with a leg cast who needs neuro-circ checks and PRN hydrocodone c. Client who underwent a toe amputation and has diabetic neuropathic pain f. client with arthritis who needs scheduled pain medications and heat applications The clients with the cast, toe amputation, and arthritis are in stable condition and need ongoing assessment and pain management that are within the scope of practice of an LPN/LVN under the supervision of an RN. The RN should take responsibility for preoperative teaching, and the client with terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication. The client with trauma needs serial assessments to detect occult trauma.

The nurse in a psychiatric unit receives the morning shift report on the following four clients. Which client should the nurse assess first? a. client with bipolar disorder with a lithium level of 1.0 mEq/L b. client with depression taking isocarboxazid with BP of 190/110 mmHg c. client with anxiety and RR of 12/mm requestion lorazepam d. client with psychosis and agitation due for a scheduled dose of haldol

b. client with depression taking isocarboxazid with BP of 190/110 mmHg the client is taking isocarboxazid, a monoamine oxidase inhibitor (MAOI), that has a risk of hypertensive crisis if taken with foods containing tyramine. The nurse should be alert to symptoms associated with hypertensive crises, including severely elevated blood pressure, a report of nausea, vomiting, chest pain, a severe headache, and increasing irritation. Hypertensive crisis can lead to stroke or myocardial infarction (MI).

A 21-year old female with severe acne has been prescribed the combination progestin and estrogen therapy, vestura. Which teaching should the nurse provide regarding this treatment option? a. this treatment is not effective as a contraceptive b. common side effects include weight gain and breast tenderness c. these drugs are not associated with an increased risk of cervical cancer d. the benefits of these drugs are seen almost immediately

b. common side effects include weight gain and breast tenderness These drugs are also associated with increased risk of cardiovascular problems, breast cancer, and cervical cancer. It may take several weeks for the client to see the benefits of this acne treatment option.

A nurse is completing a needs assessment and beginning analysis of data. Which of the following actions should the nurse take first? a. determine health patterns within collected data b. compile collected data into a database c. ensure data collection is complete d. identify health needs of the local community

b. compile collected data into a database

A multigravid client is admitted at 4 cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a BM. What should the nurse do first? a. have naloxone available in the birthing room b. complete a vaginal exam c. prepare for birth d. document the client's relief due to pain medication

b. complete a vaginal exam The feeling of needing to have a bm is commonly caused by pressure on the receptors low in the perineum when the fetus head is creaint pressure on them. This usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs by completing a vaginal exam to validate current effacement, dilation and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important.

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse would plan which intervention? a. Cover the bladder with petroleum jelly gauze b. cover the bladder with a nonadhering plastic wrap c. apply sterile distilled water dressings over the bladder mucosa d. keep the bladder tissue dry by covering it with dry sterile gauze

b. cover the bladder with a nonadhering plastic wrap The nurse should take care to protect the exposed bladder tissue from drying, while allowing the drainage of the urine. This is done best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze needs to be avoided because this type of dressing can dry out, adhere to the mucosa and damage the delicate tissue when removed. Dry sterile dressings and soaked in solutions that can dry out also damage the mucosa when removed

The long term care nurse is performing assessments on several of the residents. Which are normal age related physiological cahgnes the nurse would expect to note? Select all that apply a. increased HR b. decline in visual acuity c. decreased RR d. decline in long term memory e. increased susceptibility to UTI f. increased incidence of awakening after sleep onset

b. decline in visual acuity e. increased susceptibility to UTI f. increased incidence of awakening after sleep onset Although lung function may decrease, the RR usually remains unchanged. Short term memory may decline with age, but long term memory usually is maintained.

A multigravid client diagnosed with chronic HTN is now in preterm labor at 32 weeks gestation. The HCP has prescribed magnesium sulfate at 3 g/h. Which assessment finding indicates that the intended therapeutic effect has occurred? a. decrease in FHR accelerations b. decrease in the frequency and number of contractions c. decrease in maternal BP d. decrease in maternal RR

b. decrease in the frequency and number of contractions Magnesium sulfate may be used as an anticonvulsive or a tocolytic agent. The intended effect is to decrease the number and frequency of contractions. Even though this client has chronic hypertension, the first goal is to prevent birth in a 34 week gestation client. If the BP moves into the therapeutic range, that is a benefit for the client, but is not the major goal. Magnesium sulfate may decrease the accelerations as it decreases the ability of the infant to respond.

A 14-year-old boy has been prescribed amphetamine and dextroamphetamine for attention-deficit/hyperactivity disorder (ADHD). The nurse explains that the client should be alert for which of the following adverse drug effects? a. weight gain b. depression c. somnolence d. bradycardia

b. depression

When performing Leopold's maneuvers on a primigravid client at 22 weeks' gestation, the nurse performs the first maneuver to accomplish which action? a. locate the fetal back and spine b. determine what is in the fundus c. determine whether the fetal head is at the pelvic inlet d. identify the degree of fetal descent and flexion

b. determine what is in the fundus This first maneuver helps to determine the presenting part of the fetus. In the second maneuver, the palms of both hands are used to palpate the sides of the uterus and determine the location of the fetal back and spine. In the third maneuver, one hand gently grasps the lower portion of the abdomen just above the symphysis pubis to determine whether the fetal head is at the pelvic inlet. The fourth maneuver determines the degree of fetal descent and flexion into the pelvis.

The home health nurse is visitng a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several OTC meds that the client has been taking. Which intervention would the nurse take first? a. check for medication interactions b. determine whether there are medication duplications c. determine whether a family member supervises medication administration d. call the prescribing primary HCP and report polypharmacy

b. determine whether there are medication duplications

Which information would the nurse include in the teaching plan for a 32 y/o female client requesting information about using a diaphragm for family planning? a. douching with an acidic solution after intercourse is recommended. b. diaphragms should not be used if the client develops acute cervicitis c. The diaphragm should be washed in a weak solution of bleach and water. d. The diaphragm should be left in place for 2 hours after intercourse

b. diaphragms should not be is possible used if the client develops acute cervicitis Cervicitis is possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use w/ increased incidence of UTI. Douching after use is not recommended because pregnancy could occur. The diaphragm should be inspected and washed with mild soap and water after each use. It should be left in place for at least 6 hours but no longer than 24 hours after intercourse. Most spermicidal jelly or cream should be used if intercourse is repeated during this period.

A nurse is assessing a client who is postop from a gastric bypass and who jsut finished eating a meal. Which of the following findings are manifestations of dumping syndrome? Select all that apply a. bradycardia b. dizziness c. dry skin d. hypotension e. diarrhea

b. dizziness c. dry skin d. hypotension

The nurse caring for a child burned over 20% of her body assists the physician in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client? a. Gather equipment for the dressing change and explain the procedure to the child b. do a complete physical assessment and notify the physician of the findings c. administer appropriate analgesics and gather equipment for the dressing change d. offer the child an enticing distraction from pain, such as a video, music or toy

b. do a complete physical assessment and notify the physician of the findings The child may be suffering from an infection. The nurse recognizes that disorientation and fever are the first signs of sepsis in burn clients. It would be most appropriate to assess for the causes of fever and pain and notify the physician before proceeding.

A nurse is caring for a woman G1, P0 at 40 weeks' gestation in active labor. Assessments include cervix 5 cm dilated, 90% effaced, station 0, cephalic presentation, FHR baseline at 135 bpm and decrease to 125 bpm shortly after onset of five uterine returns to baseline before the uterine contraction ends. Based on this assessment, what action should the nurse take first? a. position the client on her left side and administer O2 via face mask b. document finding on the client's chart and continue to monitor labor progress c. perform vaginal exam to rule out umbilical cord prolapse d. notify the HCP immediately and prepare for emergency c section

b. document finding on the client's chart and continue to monitor labor progress The nurse would document these findings as early decels. Early decels are thought to be result of vagal nerve stimulation caused by compression of the fetal head during labor. They are considered normal physiologic response to labor and do not require any intervention. Early decels do not require position change or O2 as they are not a sign of fetal distress. Variable decels are thought to be due to umbilical cord compression. Early decels are not emergent and do not require immediate reporting to the HCP.

The nurse assesses the VS of a 12 month old infant with a respiratory infection and notes hat the RR is 35 breaths/min. On the basis of this finding, which action is most appropriate? a. administer oxygen b. document the findings c. notify the pediatrician d. reassess the RR in 15 min

b. document the findings The normal RR for a 12 month old is 20-40 breaths/min. The normal HR is 90-130 bpm and average BP is 90/56 mmHg.

The nurse provides care for a client who is diagnosed with anorexia nervosa and prescribed enteral nutrition by nasogastric tube. Which assessment finding indicates that the client is experiencing refeeding syndrome? Select all that apply. a. diarrhea b. dyspnea c. confusion d. weakness e. HTN

b. dyspnea c. confusion d. weakness e. HTN Symptoms associated with refeeding syndrome include the following: confusion; dyspnea; fatigue; heart issues, including failure and arrhythmia; hypertension; seizure activity; and weakness. If not identified and treated, coma and death can occur.

The community health nurse is creating a poster for an educational session for a group of community members and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer would the nurse list on the poster? Select all that apply. a. multiparity b. early menarche c. early menopause d. family history of breast cancer e. high dose radiation exposure to chest f. previous cancer of the breast, uterus or ovaries

b. early menarche d. family history of breast cancer e. high dose radiation exposure to chest f. previous cancer of the breast, uterus or ovaries

When performing Leopold's maneuvers, which action would the nurse ask the client to perform to ensure optimal comfort and accuracy? a. breathing deeply for 1 minute b. emptying her bladder c. drinking a full glass of water d. lying on her left side

b. emptying her bladder Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate.

An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? select all that apply a. coordinates the swallowing of feedings b. encourages sucking behaviors c. improves weight gain d. instills a calming effect e. improves digestion

b. encourages sucking behaviors c. improves weight gain d. instills a calming effect e. improves digestion Nonnutritive sucking has been seen in infants as early as 28 weeks and ultrasound exams have shown thumb sucking in utero even earlier. It encourages sucking behaviors that help a baby to maintain the sucking reflex needed for subsequent breast or bottle feedings. It promotes digestion by stimulating secretions of GI peptides that help with gastric emptying. It has a calming effect that improves physiological stability. When it takes place during tube feedings it helps the newborn make the association that it has a full stomach.

Which clinical manifestation does the nurse anticipate when assessing a child who is diagnosed with intussusception? Select all that apply. a. a small oval mass found in the abdomen upon palpation b. episodes of sudden, crampy abdominal pain c. inconsolable periods of crying d. mucous and melena in stool e. severe vomiting of bile

b. episodes of sudden, crampy abdominal pain c. inconsolable periods of crying d. mucous and melena in stool e. severe vomiting of bile an abdominal mass is not indicative of intussception; however, this finding may indicate wilms tumor

The HCP prescribes intermittent HFR monitoring for a 20 year old obese primigravid client at 40 weeks' gestation in the first stage of labor. The nurse should monitor the client's FHR pattern at which interval? a. every 15 min during the latent phase b. every 30 min during the active phase c. every 60 min during the pushing phase d. every 2 hours during the transition phase

b. every 30 min during the active phase The first stage of labor is categorized into 3 phases: latent, active and transition. During the active stage, intermittent fetal monitoring is performed every 30 min to detect changes in FHR such as bradycardia, tachycardia or decels in a low risk labor. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring is usually performed every 1 hour because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 min because the client is getting closer to the birth of the baby. Pushing occurs in stage II of labor, and monitoring continues to occur every 5-15 min

A client who recently underwent a laryngectomy asks about learning esophageal speech. The nurse can explain this communication technique involves: a. providing an access route from the trachea to the esophagus b. filling the esophagus with air c. holding an electronic instrument against the esophagus d. replacing the larynx with scar tissue

b. filling the esophagus with air Esophageal speech requires filling the esophagus with air and allowing it to vibrate out. An artificial larynx is a handheld speech aid placed against the neck. It produces a buzzing sound that can be turned into speech by the tongue and mouth. An access route from the trachea to the esophagus is required for trachesophageal shunting. This provides pulmonary power to the pharyngeal sphincter that provides vibrations for a pseudovoice

When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, the nurse would anticipate administering IV which therapeutic agent if the client develops DIC? a. Ringer's lactate solution b. fresh frozen platelets c. 5% dextrose solution d. warfarin

b. fresh frozen platelets IV infusion of whole blood, fresh frozen plasma or platelets are used to replace depleted maternal coagulation factors. Normal saline must be used.

The nurse is checking the chart of a postpartum client who delivered at 12 am. Which of the following contributing factors indicate that client has a high risk of early postpartum hemorrhage? select all that apply a. drug free labor and delivery b. grand multiparity c. infant birth weight of 9 lb, 2oz d. labor lasting 12 hours e. third stage of labor lasting 1 hour

b. grand multiparity c. infant birth weight of 9 lb, 2oz e. third stage of labor lasting 1 hour Uterine atony causes 80% of postpartum bleeding occurring within the first 24 hours after delivery. Contributing factors include uterine overdistention, uterine fatigue (prolonged labor), grand multiparity, use of uterine relaxants or anesthesia. Labor lasting 12 hours is within the vaginal delivery reference range (</= 24 hours). The third stage of labor is usually < 30 min.

The nurse assist the HCP with a LP on a postterm neonate with signs of sepsis. What should the nurse do to assist in this procedure? Select all that apply a. administer the IV Bx b. hold the neonate steady in the correct position c. ensure a patent airway d. maintain a sterile field e. obtain a serum glucose level

b. hold the neonate steady in the correct position c. ensure a patent airway d. maintain a sterile field The neonate is usually held in a C position to open the spaces between the vertebral column. This position puts the neonate at risk for airway obstruction, thus ensuring the patency of the airway is the first priority and the nurse should observe the neonate for adequate ventilation.

A client with AF who is receiving maintenance therapy of warfarin sodium has a PT time of 35 seconds. On the basis of these lab values, the nurse anticipates which prescription? a. adding a dose of heparin sodium b. holding the next dose of warfarin c. increasing the next dose of warfarin d. administering the next dose of warfarin

b. holding the next dose of warfarin The normal PT is 11-12.5 sec. A therapeutic PT level is 1.5-2 x higher than normal level. Because the value of 35 sec is high, the nurse would anticipate that the client would not receive further doses at this time.

The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication? a. leg cramps b. hot flashes c. urinary frequency d. cold extremities

b. hot flashes This drug is in the same category as the chemotherapeutic agent tamoxifene (Novaldex) used for breast cancer. In the case of Evista, this drug is used to treat osteoporosis. Notice that the E stands for estrogen. This drug has an agonist effect, so it binds with estrogen and can cause hot flashes.

The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which topic would be important for the nurse to include in the teaching plan? a. decreased plasma volume b. increased risk for UTI c. increased peripheral vascular resistance d. increased hgb levels

b. increased risk for UTI During pregnancy, UTI are more common because of urinary stasis. Clients need instructions about increasing fluid volume intake. The increase in plasma volume is more pronounced and occurs earlier than does the increase in RBC mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable BP. Hgb levels decrease during pregnancy even though there is an increase in blood volume

Which finding in FHR during a nonstress test would indicate to the nurse that a potential problem for the fetus may exist? a. increases 30 bpm for 20 sec with fetal movement b. increases 8 bpm for 10 sec with fetal movement c. remains unchanged with maternal movement d. increases 5 bpm for 30 sec with maternal movement

b. increases 8 bpm for 10 sec with fetal movement nonreactive test is when FHR accelerates less than 15 bpm above baseline. This may indicate fetal compromise

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? select all that apply? a. bites from ticks or deer flies b. inhalation of bacterial spores c. through a cut or abrasion in the skin d. direct contact with an infected individual e. sexual contact with an infected individual f. ingestion of contaminated undercooked meat

b. inhalation of bacterial spores c. through a cut or abrasion in the skin f. ingestion of contaminated undercooked meat

The nurse is taking care of an adult client with a long-bone fracture. The nurse encourages the client to move fingers and toes hourly, to change positions slightly every hour, and to eat high-iron foods as part of a balanced diet. Which of the following foods or beverages should the nurse advise the client to avoid while on bed rest? a. fruit juices b. large amounts of milk or milk products c. cranberry juice cocktail d. no need to avoid any foods while on bed rest

b. large amounts of milk or milk products Too much milk increases the demand on the kidneys to excrete calcium and can lead to kidney stones

The nurse is assessing fetal position for a 32 y/o client in her 8th month of pregnancy. As shown below, the fetus is in which position? a. left occipital transverse b. left occipital anterior c. right occipital transverse d. right occipital anterior

b. left occipital anterior The occiput faces the left anterior segment of the woman's pelvis. In left occipital transverse lie, the occiput faces the woman's left hip. In right occipital transverse lie, the occiput faces the woman's right hip. In right occipital anterior lie, the occiput faces the right anterior segment of the woman's pelvis

A client returns to the clinic for f/u treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse recognizes that melanoma has which characteristics? select all that apply a. lesion is painful to touch b. lesion is highly metastatic c. lesion is a nevus that has changes in color d. skin under the lesion is reddened and warm to touch e. lesion occurs in body areas exposed to outdoor sunlight

b. lesion is highly metastatic c. lesion is a nevus that has changes in color Although sun exposure increases the risk of melanoma, lesions may occur any place on the body, especially where birthmarks or new moles are present

At a home visit, the nurse assess a neonate born vaginally at 41 weeks' gestation 5 days ago. Which of these findings warrants further assessment? a. frequent hiccups b. loose, watery stool in diaper c. pink papular vesicles on the face d. dry, peeling skin

b. loose, watery stool in diaper A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate. Frequent hiccups are considered normal. Pink papular vesicles (erythema toxicum) on the face are normal.

The nurse creates a plan of care for a birthing parent with HIV infection and the newborn. The nurse would include which intervention in the plan of care? a. Monitoring the newborn's VS routinely b. maintaining standard precautions at all times while caring for the newborn c. initiating referral to evaluate for blindness, deafness, learning problems or behavioral problems d. instructing the breastfeeding parent regarding the treatment of the nipples with nystatin ointment

b. maintaining standard precautions at all times while caring for the newborn An infant born to a birthing parent infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn

The novice nurse is assigned to care for a client who is diagnosed with a paralytic ileus. The client has a nasogastric (NG) tube with continuous suction. Which action by the novice nurse requires intervention by the nurse preceptor? Select all that apply. a. discontinues suction when checking BS b. measures gastric residual every 4 hours c. places a cap on the air vent d. places client on the left side e. places client's head of bed at 30-45 degree angle

b. measures gastric residual every 4 hours c. places a cap on the air vent d. places client on the left side A paralytic ileus may be caused by abdominal or pelvic surgery; additionally, this condition is also associated with bacterial and viral infections of the GI tract. A paralytic ileus typically resolves without surgical intervention; however, if the blockage persists surgical intervention may be required. Medical treatment for a client with this diagnosis includes a nothing-by-mouth (NPO) status and decompression of the stomach via a NG tube with continuous suction. It is important that the client not be placed on the left-side for long periods of time as this can result in complications, including the tube adhering to the client's inner abdominal wall. Additionally, the cap should remain vented to decrease the risk for this complication.

What infectious signs and symptoms would an immunocompromised client most likely exhibit? (Select all that apply) a. erythema b. mild leukocytosis c. low grade fever d. pain at infection site e. local edema

b. mild leukocytosis c. low grade fever

The nurse has create da plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? a. providing comfort measures b. monitoring the FHR c. changing the client's position frequently d. keeping the significant other informed of the progress of labor

b. monitoring the FHR

The nurse educator is preparing to conduct a teaching session about school-age children regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply a. Individual move through all six stages in a sequential fashion b. moral development progresses in relationship to cognitive development c. a person's ability to make moral judgments develops over a period of time d. the theory provides a framework for understanding how individuals determine a moral code to guide their behavior e. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society f. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned

b. moral development progresses in relationship to cognitive development c. a person's ability to make moral judgments develops over a period of time d. the theory provides a framework for understanding how individuals determine a moral code to guide their behavior f. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned

The nurse is reviewing results for clients who are having antenatal testing. The assessment data from which client warrant prompt notification of the HCP and a further plan of care? a. primigravida who reports fetal movement 6 times in 2 hours b. multigravida who had a positive oxytocin challenge test c. primigravida whose infant has a biophysical profile of 9 d. multigravida whose infant has a moderate variability on a nonstress test

b. multigravida who had a positive oxytocin challenge test Late decel during an oxytocin challenge test indicate that the infant is not receiving enough oxygen during contractions and is exhibiting signs of uteroplacental insufficiency. Fetal movement 6 x in 2 hours is adequate and biophysical profile of 9 indicates that the risk of fetal asphyxia is rare. A normal nonstress test report shows that the FHR is b/w 110 and 160 with moderate variability with 2 FHR accel of 15 beats per min above baseline and lasting for 15 secs within 20 min period and no decels.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 bpm. On the basis of this finding, what is the priority nursing action? a. document the finding b. notify the OB c. check the mother's HR d. tell the client that the FHR is normal

b. notify the OB The FHR depends on gestational age and ranges from 160-170 bpm in the first trimester but slows with fetal growth to 110-160 bpm. If the FHR is less than 110 or more than 160 bpm with the uterus at rest, the fetus may be in distress.

A public health nurse is planning several initiatives for a city. Which of the following interventions should the nurse include as part of a public health assurance? a. Meeting with city officials to propose changes to health laws b. partnering with a laboratory company to provide free HIV screenings for the public. c. reviewing data for incidence of influenza over a 25-year span d. providing medical facilities with information accidental injury rates

b. partnering with a laboratory company to provide free HIV screenings for the public. Assurance tasks are those that promote the accomplishment of public health goals.

The lab results show that a mother has a blood type of O + and her infant has the blood A-. As part of the plan of care, the nurse should assess the infant for which condition? a. breast milk jaundice b. pathologic hyperbilirubinemia c. physiologic hyperbilirubinemia d. Rh incompatibility

b. pathologic hyperbilirubinemia There is potential for ABO blood Ab antigen reaction. The infant's A antigen enters the mother, the mother produces Ab, the Ab then reenter the infant causing hemolysis and hyperbilirubinemia.

The client who has had renal transplant should be instructed to avoid which of the following? a. salt b. pepper c. lemon d. lime

b. pepper The client with a renal transplant is maintained on immunosuppressants. Pepper is unprocessed and contains bacteria, so it should be avoided. Notice the opposites in the choices. Salt is another type of seasoning but is allowed. Lemon and lime are also allowed. The testing strategy is to look for opposite answers.

A client is admitted to the intensive care unit (ICU) with a new diagnosis of supraventricular tachycardia. The client's current heart rate is 180 BPM. The client is awake, alert without altered mentation. Which action should the nurse implement first? a. notify the HCP immediately b. place a bag of ice on the bridge of the client's nose c. prepare to give adenosine 6 mg rapidly by IVP d. perform immediate synchronized cardioversion

b. place a bag of ice on the bridge of the client's nose Initial treatment of SVT is the utilization of vagal maneuvers, such as the act of bearing down. The vagal maneuver works by increasing intrathoracic pressure and stimulating the vagus nerve. The vagus nerve supplies parasympathetic nerve fibers to the heart and when stimulated, results in slower electrical conduction. The vagal maneuver can be replicated in additional ways in the client that is unable to "bear down," such as placing ice on the bridge of the client's nose. If this intervention is not successful, the nurse then prepares to administer pharmacotherapy appropriate for SVT. If pharmacotherapy is not successful, the nurse then prepares the client for cardioversion. Rationales

The nurse is performing an assessment on a 39 week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? select all that apply a. one artery and one vein in the umbilical cord b. plantar creases up the entire sole c. skin on the nose blanches to a yellowish hue d. toes fan outward when the lateral sole surface is stroked e. white pearl like cysts on gum margins

b. plantar creases up the entire sole d. toes fan outward when the lateral sole surface is stroked e. white pearl like cysts on gum margins The more creases over the greater proportion of the foot, the more mature the neonate. Epstein's pearls are white, pearl like epithelial cysts on gum margins and the palate. They are benign and usually disappear within a few weeks. Jaundice first appears on the face and extends to the trunk and eventually the entire body. Jaundice within the first 24 hours is pathological. Jaundice after 24 hours is referred to as physiological jaundice and is related to the increased amount of unconjugated bilirubin in the system.

The parent of a 6 year old child arrives at a clinic because the child has been experiencing itchy, red, swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the lab for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? a. possible trauma b. possible sexual abuse c. presence of an allergy d. presence of a respiratory infection

b. possible sexual abuse A diagnosis of chlamydial conjunctivitis in a child who is not sexually active would signal for possible sexual abuse.

A rubella titer of a 1 day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply a. Breast/chest feeding needs to be stopped for 3 months b. pregnancy needs to be avoided for 1 to 3 months c. the vaccine is administered by the SC route d. Exposure to immunosuppressed individuals need to be avoided e. A hypersensitivity reaction can occur if the client has an allergy to eggs f. the area of the injection needs to be covered with a sterile gauze for 1 week

b. pregnancy needs to be avoided for 1 to 3 months c. the vaccine is administered by the SC route d. Exposure to immunosuppressed individuals need to be avoided e. A hypersensitivity reaction can occur if the client has an allergy to eggs

Before surgery to remove an ectopic pregnancy and the fallopian tube, which sign or symptom would alert the nurse to the possibility of tubal rupture? a. amount of vaginal bleeding and discharge b. profuse sweating c. slow, bounding pulse rate of 80 bpm d. marked abdominal edema

b. profuse sweating Diaphoresis indicates shock, which occurs if the tube ruptures. Other symptoms include severe knife like lower quadrant abdominal pain, referred shoulder pain and falling BP. The amount of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding is common. A rapid, thready pulse, a symptom of sock is more common than a slow, bounding pulse. Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy

The nurse is providing care to a 5 y/o client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? a. encourage the client to talk about the pain b. provide distraction by turning on the TV c. contact the primary HCP for a pain medication prescription d. request that the parents leave the room

b. provide distraction by turning on the TV Distraction and other techniques should be used before pain medication

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next? a. tell the client to push between contractions b. provide gentle support to the fetal head c. apply gentle upward traction on the neonate's anterior shoulder d. massage the perineum to stretch the perineum tissues

b. provide gentle support to the fetal head During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent too rapid of emergence leading in injury. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying Downard traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder.

A nurse is reviewing information about the local health department to prepare for an interview. Which of the following services should the nurse expect the local health dpartment to provide? select all that apply a. managing the WIC program b. providing education to achieve community health goals c. coordinating directives from the state personnel d. reporting communicable diseases to the CDC e. licensing of RNs

b. providing education to achieve community health goals c. coordinating directives from the state personnel

The nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? select all that apply a. peas b. raisins c. potatoes d. cantaloupe e. cauliflower f. strawberries

b. raisins c. potatoes d. cantaloupe f. strawberries Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries and tomatoes. Peas and cauliflower are high in magnesium

A woman at 22 weeks' gestation has right upper quadrant pain radiating to her back. She rates the pain as 9 on a scale of 1 to 10 and says that it has occurred 2 times in the last week for about 4 hours at a time. She does not associate the pain with food. Which nursing measure is the highest priority for this client? a. Educate the client concerning changes occurring in the gallbladder as a result of pregnancy b. refer the client to her HCP for evaluation and treatment of the pain c. discuss nutritional strategies to decrease the possibility of heartburn d. Support the client's use of APAP to relieve pain

b. refer the client to her HCP for evaluation and treatment of the pain Referral would allow more definitive diagnosis and medical intervention that may include surgery. Referral would occur because of her high pain rating as well as other symptoms, which suggest gallbladder disease. During pregnancy, the gallbladder is under the influence of progesterone, which is a smooth muscle relaxant. Because bile doesn't move through the system as quickly during pregnancy, bile stasis and gallstone formation can occur. It is not appropriate for the nurse to diagnose pain as heartburn. APAP is acceptable during pregnancy but should not be used on a regular basis.

A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client has a warm, red, painful breast, a temp of 100 F, and flu like symptoms. What should the nurse do? a. Encourage the client to breastfeed her infant using the unaffected breast b. refer the woman to her HCP c. inform the client that she needs to discontinue breastfeeding d. instruct the woman to apply warm compresses to the affected breast

b. refer the woman to her HCP The client is exhibiting sings of mastitis. The nurse should instruct her to contact her HCP, who will likely prescribe a prescription for abx. She should continue to breastfeed the infant from both breasts. Frequent breastfeeding is encouraged rather than d/c the process. Applying warm compresses may relieve pain, but the underlying infection indicates that additional treatment will be needed

The nurse provides care for a mechanically ventilated client who has a prescription for an arterial blood gas (ABG). Which action should the nurse perform when preparing to implement the prescription? a. Administer 100% O2 to the client and position the HOB at 45 degrees b. refrain from suctioning the client until after the blood sample is drawn c. decrease the rate of the client's propofol infusion d. move the client from the bed to the chair for easy access to radial artery

b. refrain from suctioning the client until after the blood sample is drawn Oxygenation and elevating the head of the bed can generate inaccurate ABG results and should be avoided immediately before drawing the blood sample for the prescribed test; therefore, this is not an appropriate action by the nurse. Suctioning within 20 minutes prior to an ABG draw could cause inaccurate results; therefore, this is the appropriate action by the nurse prior to implementing the prescription for the client. A reduction in propofol would reduce sedation and further increase the client's activity level. An increased activity level could negatively affect the ABG results; therefore, this is not an appropriate action by the nurse. Client activity, including moving the client to a chair, negatively impacts the client's ABG levels; therefore, this action should be avoided by the nurse.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preop period? a. test the urine for protein b. reposition the infant frequently c. provide a stimulating environment d. assess BP every 15 min

b. reposition the infant frequently Hydrocephalus occurs as a result of an imbalance of CSF absorption or production that is caused by malformations, tumors, hemorrhage, infections or trauma. It results in head enlargement and increased ICP. In infants with hydrocephalus, the head grows at an abnormal rate and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of head.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply a. respirations that are shallow b. respirations that are increased in rate c. respirations that are abnormally deep d. respirations that are abnormally slow e. respirations that cease of several seconds

b. respirations that are increased in rate c. respirations that are abnormally deep Kussmaul's respirations are abnormally deep and increased in rate due to compensation by the lungs.

The nurse assesses a client's surgical incision for signs of infection. Which ifnding by the nurse would be interpreted as a normal finding at the surgical site? a. hard reddened skin b. serous drainage c. purulent drainage d. warm, tender skin

b. serous drainage

A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. Which FHR pattern would the nurse find is most concerning? a. early decel b. sinusoidal pattern c. variable decel d. late decel

b. sinusoidal pattern A sinusoidal pattern is an ominous sign that reflects an absence of autonomic nervous control over the FHR resulting from severe hypoxia. Sinusoidal patterns, while rare are associated with Rh sensitization, fetal hydrops and anemia. The client will most likely require a c section to improve fetal outcome.

The nurse is preparing to assist the HCP with a cervical check for a client whose membranes have ruptured. What equipment should the nurse have ready for the HCP? Select all that apply a. sterile speculum b. sterile gloves c. sterile lubricant d. amnio hook e. cervical dilators

b. sterile gloves c. sterile lubrican

Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy? a. take at bedtime b. take the medication with juice c. report changes in appetite d. avoid the sunshine while taking

b. take the medication with juice Lugol's solution is a soluble solution of potassium iodine and should be given with juice because it is bitter to taste. In answer A the medication can be taken at another time, so it is incorrect. Reporting changes in appetite is unnecessary, so answer C is incorrect. Answer D is incorrect because it is also unnecessary.

A nurse at a community center is providing nutrition counseling for a group of older adult clients. Which of the following information should the nurse include? select all that apply a. increase protein to 50% of daily calories b. the need for vitamins and minerals can increase c. up to 35% of daily calories should come from fat d. at least 45% of daily calories should come from carbs e. fruits and vegetables should make up 1/3 of each meal

b. the need for vitamins and minerals can increase c. up to 35% of daily calories should come from fat d. at least 45% of daily calories should come from carbs fruits and vegetables should make up one half of each meal

The nurse is caring for a client who is about to be discharged. The client expresses uncertainty about being able to perform required dressing changes at home, and the nurse promises to help the client understand the process. Which action(s) best illustrate(s) the ethical principle of fidelity? Select all that apply. a. The nurse ensures that the client has the supplies necessary for dressing changes at home b. the nurse provides the client with written handout with step by step instructions c. the nurse offers to demonstrate the process again before the client leaves d. the nurse encourages the client to ask specific questions about the process e. the nurse requests that the HCP order home health nursing for the client

b. the nurse provides the client with written handout with step by step instructions c. the nurse offers to demonstrate the process again before the client leaves d. the nurse encourages the client to ask specific questions about the process This answer is not correct because the nurse has promised to ensure that the client understands the dressing change process. Ensuring that the client has supplies for home use does not directly facilitate comprehension of the task.

A newly postpartum primiparous client asks the nurse, "Can my baby see?" Which statement about neonatal vision should the nurse include in the explanation? a. Neonates primarily focus on moving objects b. they can see objects up to 12 inches away c. usually they see clearly by about 2 days after birth d. neonates primarily distinguish light from dark

b. they can see objects up to 12 inches away The neonate has immature oculomotor coordination, an inability to accommodate for distance and poorly developed eyes, visual nerves and brain. However, the normal neonate can see objects clearly within a range of 9-12 inches, whether or not the neonate is moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark

A client in labor received an epidural for pain management. Before receiving the epidural, the client's BP was 124/76 mmHg. Ten minutes after receiving the epidural, the client's BP is 98/56 mmHg, and the mother is vomiting. Before calling the HCP, what should the nurse do? a. decrease the IVF rate b. turn the client to her side c. catheterize the client d. perform a vaginal exam

b. turn the client to her side IVF rate would be increased. There are no information indicating the client has a full bladder or requires a vaginal exam.

The nurse explains the complications of pregnancy that occur with diabetes to a primigravid client at 10 weeks' gestation who has a 5 year history of insulin dependent diabetes. Which complication if stated by the client indicates the need for additional teaching? a. Candida albicans infection b. twin to twin transfusion c. polyhydramnios d. preeclampsia

b. twin to twin transfusion Clients who have diabetes are not at greater risk for multifetal pregnancy and subsequent twin to twin transfusion unless they have undergone fertility treatments.

A nurse is reviewing the various roles of a community health nurse. Which of the following actions is an example of a nurse functioning as a consultant? a. advocating for federal funding of local health screening programs b. updating state officials about health needs of the local community c. facilitating discussion of a client's ongoing needs with an interprofessional team d. performing health screenings for high BP at a local health fair

b. updating state officials about health needs of the local community

The nurse is evaluating the developmental level of a 2 y/o. Which does the nurse expect to observe in this child? a. uses a fork to eat b. uses a cup to drink c. pours own milk into a cup d. uses a knife for cutting food

b. uses a cup to drink By 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3-4 years, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting

Epiglottitis

bacterial form of croup, inflammation of the epiglottis occurs and is most commonly caused by Hib. Considered an emergency because it can progress rapidly to complete airway obstruction

chroioamnionitis

bacterial infection of the amniotic cavity, can be from PROM or prolonged ROM, vaginitis, amniocentesis or intrauterine procedures

eczema interventions

baths and moisturizers, oatmeal baths. Limit baths to 5-10 min and moisturize immediately. apply topical meds within 3 min of baths. CS, abx if secondary infections. Avoid irritants. Cool wet compresses may help soothe skin and alleviate itching. Prevent scratching. Monitor for infection

Abortion intervention

bed rest, VS, monitor for cramping and bleeding, count and weigh perineal pads, IVF and monitor for hemorrhage, prepare for dilation and curettage, Rhogam if needed

incompetent cervix interventions

bed rest, hydration, tocolysis, prepare for cervical cerclage where a band of fascia or nonabsorbable ribbon is placed around cervix

Erythema infectiosum assessment

before rash: asymptomatic or mild fever, malaise, HA, runny nose stages of rash: erythema of the face (slapped cheek appearance) develops and disappears by 1-4 days. About 1 day after the rash appears on the face, maculopapular red spots appear, symmetrically distributed on the extremities, the rash progresses from proximal to distal surfaces and may last a week or more. The rash subsides but may reappear if the skin becomes irritated by the sun, heat, cold, exercise or friction

enoxaparin ADR

bleeding, bruising, injection site hematoma, injection site ecchymosis, increase in AST/ALT

rivaroxaban ADR

bleeding, bruising, pruritus, syncope, nausea, hematoma, elevated bilirubin, elevated ALT/AST

alteplase ADR

bleeding, dysrhythmia, allergic responses, nausea, vomiting, fever, ecchymosis, hypotension, bleeding at puncture site

apixaban ADR

bleeding, hypersensitivity reactions, thrombocytopenia, increased liver enzymes

B Thalessemia major interventions

blood transfusion, monitor for iron overload, chelation therapy with deferasirox may be used to treat iron overload and prevent organ damage from elevated levels of iron caused by multiple transfusion therapy.

osteosarcoma

bone cancer usually in long bones of lower extremities. Symptoms in earliest stage almost always attributed to extremity injury or normal growing pains. Treatment may include surgical resection to save a limb or remove affected tissue or amputation. Can use chemo

Contraceptive ADR

breakthrough bleeding, excessive formation of cervical mucus, breast tenderness, HTN, N/V

topical GC ADR

burning, dryness, itching, thinning of skin, striae, purpura, telangiectasis (threadlike red lines on skin), skin atrophy, acneiform eruptions, hypopigmentation, overgrowth of bacteria, fungi and viruses. Growth retardation in children, adrenal suppression, Cushing's, ocular (glaucoma and cataracts)

A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when she makes which statement? a. "The baby needs to have as much of the nipple and areola in the mouth as possible to prevent sore and cracked nipples" b. "I can put breast milk on my nipples to heal the sore areas." c. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." d. 'Feeding the baby for a half a hour on each side will not make my breasts sore

c. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk. As much of the mother's nipple and areola as possible need to be in the infant's mouth in order to establish a latch that doesn't cause nipple cracks or fissures. Having the nipple and the areola deep in the infant's mouth decreases the stress on the end of the nipple, decreasing pain, cracking and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding.

The nurse provides care for a client who is prescribed methotrexate for the treatment of rheumatoid arthritis (RA). The client reports extreme fatigue that interferes with activities of daily living (ADLs). Which is the best response by the nurse? a. "Are you having trouble sleeping?" b. "This is an expected side effect to your medication." c. "Do your gums bleed when you brush your teeth?" d. "You should avoid the use of electronics for one hour prior to bed."

c. "Do your gums bleed when you brush your teeth?" The client's prescribed medication increases the client's risk for anemia due to bleeding caused by thrombocytopenia; therefore, the nurse should assess the client for symptoms indicative of bleeding.

Which instruction should the nurse provide to a pregnant client who is 36 weeks' gestation who is planning to book a flight out of state to visit her grandparents? Select all that apply. a. "Avoid moving about in the cabin to minimize exposure to other travelers." b. "Apply the lap belt above the abdomen and across the hips when sitting." c. "Have on hand a written or electronic coy of your most recent prenatal records." d. "Limit fluid intake to minimize having to use the restroom while in flight." e. "wear loose fitting clothes during travel."

c. "Have on hand a written or electronic coy of your most recent prenatal records." e. "wear loose fitting clothes during travel." Client education regarding safe travel is imperative for the pregnant client. Education should include the following: Try not to fly during the last month of pregnancy; if a flight cannot be avoided, comfortable, non-binding clothing should be worn; frequent bathroom trips should be maintained to decrease the risk of infection due to urinary stasis and enhance movement to decrease the risk of deep vein thrombosis (DVT); and a medical waiver may be needed by the airline, although most airlines allow pregnant women to fly up to 36 weeks' gestation. Additionally, the nurse should instruct the client to have the most recent prenatal data available in case complications occurs and treatment is required. The lap belt should be placed below the abdomen, touching the thighs, and low and snug on the hip bones; therefore, this instruction is not appropriate for this client based on the current data

The nurse monitors a client who is one-day postoperative for cataract surgery. Which client statement is concerning to the nurse? Select all that apply. a. "I am terribly sensitive to bright light right now." b. "I am taking 650 mg of APAP for eye pain." c. "I have not had a BM in 6 days." d. "I noticed blurry vision after I removed the eye patch." e. "I have been using pillows to prop me up when I sleep."

c. "I have not had a BM in 6 days." Constipation is very concerning because this could cause the client to strain during bowel movements which is contraindicated in the postoperative period of care. A stool softener could be given before surgery and continued during the postoperative period to avert this issue. Elevation of the head on pillows is appropriate to help decrease intraocular pressure in the postoperative period of care following cataract surgery.

The nurse is conducting a home visit with a client who has a history of angina. Which of the following BEST demonstrates that further teaching about nitroglycerin therapy is required? a. "I take a tablet about 10 minutes before I walk up the stairs." b. "I take no more than 3 doses in a 15-minute period of time." c. "I keep the tablets in a glass dish on the windowsill so they are readily available." d. "I will call my doctor immediately if I experience blurred vision."

c. "I keep the tablets in a glass dish on the windowsill so they are readily available."

After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which client statement indicates the need for further teaching? a. "I can safety store freshly expressed breast milk at room temp for 8 hours." b. "I will be sure to label the breast milk with the date, time and amount." c. "I must discard any breast milk stored for more than 3 days in the refrigerator d. "I can keep the breast milk in a deep freezer in clean glass bottles for up to 1 year."

c. "I must discard any breast milk stored for more than 3 days in the refrigerator fresh milk can be kept in the refrigerator for 5-7 days. Storage recommendations for frozen breast milk vary per type of freezer. In a chest or upright deep freezer at -4F, breast milk can be stored for 12 months. Breast milk should be stored in glass containers because immunoglobulin tends to stick to plastic bottles.

Parents bring their 2 week old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder? a. "Treatment needs to be started as soon as possible." b."I realize my infant will require follow up care until fully grown." c. "I need to bring my infant back to the clinic in 1 month for a new cast." d. "I need to come to the clinic every week with my infant for the casting."

c. "I need to bring my infant back to the clinic in 1 month for a new cast."

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which client statement indicates the need for additional teaching? a. "I should ask my HCP about using a stool softener." b. "Analgesic sprays and witch hazel pads can relieve the pain." c. "I should lie on my back as much as possible to relieve the pain." d. "I should drink lots of water and eat foods that have a lot of roughage."

c. "I should lie on my back as much as possible to relieve the pain." The client should lie in Sims position as much as possible to aid venous return to the rectal area and reduce discomfort.

After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which client statement would indicate the need for additional teaching? a. "I should avoid being near people who have a cold." b. "I may be given abx during my pregnancy." c. "I should reduce my intake of protein in my diet." d. "I should limit my salt intake at meals."

c. "I should reduce my intake of protein in my diet." Client needs a diet that is high in protein and calories to prevent anemia, which can put additional strain on the cardiac system. The client should avoid contact with people with infections because of the increased risk of developing endocarditis.

The nurse is providing discharge instructions to a client going home on enoxaparin. Which of the following responses by the client indicates to the nurse that the teaching was effective? a. "Prior to injection, I will rub the site with an alcohol wipe." b. "I will use the same site for each injection." c. "I will not pull back the plunger after inserting the needle into the site." d. "After injection, I will massage the site to increase absorption."

c. "I will not pull back the plunger after inserting the needle into the site." The area would be cleansed with an alcohol wipe, with care not to rub. Rubbing may cause damage to the skin and could contribute to formation of a hematoma Aspiration, or pulling back the plunger after needle insertion, can cause damage to small capillaries and blood vessels and can lead to hematoma formation and bleeding.

The nurse knows that the client with PVD understands her instructions in ways to improve circulation if the client states: a. "I will massage my legs TID." b. "I will elevate the foot of my bed on blocks." c. "I will take a brisk walk for 20 minutes each day." d. "I will prop my feet up when I sit to watch TV."

c. "I will take a brisk walk for 20 minutes each day." Answer A is totally wrong. If this is done, a clot may be present that can become a pulmonary emboli. Answers B and D are similar, but they both can be eliminated because they assist in returning blood to the heart, but not increasing circulation to the extremities.

The client with a UTI is given a rx for trimethoprim. Which statement indicates that the client understands how to take the medication? a. "I'll take the pills until I feel better and keep the rest for recurrences." b. "I'll take all the pills and then have the prescription renewed once." c. "I'll take all the pills and then return to my doctor." d. "I'll take all the pills until the symptoms go away and then reduce the dose to one pill a day."

c. "I'll take all the pills and then return to my doctor." A urine culture should be done after the course of abx to ensure that the urine is bacteria free. Tapering the dose is inappropriate with abx because it lowers the therapeutic blood level

A primigravid client at 15 weeks' gestation has received teaching about concerning signs and symptoms to report following an amniocentesis. Which statement indicates that the client needs further teaching? a. "I need to call if I start to leak fluid from my vagina." b. "If I start bleeding, I will need to call back." c. "If my baby does not move, I need to call my HCP." d. "If I start running a fever, I should let the office know."

c. "If my baby does not move, I need to call my HCP." Quickening typically occurs between 18 and 20 weeks' gestation for a primipara and between 16-18 weeks' gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a ROM. Bleeding and a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy.

A nurse is completing an ecomap as part of a family assessment. Which of the following questions should the nurse plan to ask to gather appropriate data? a. "Do you have a family history of heart disease?" b. "What kinds of foods does your family eat?" c. "Is your family involved in any community organizations?" d. "How does your family cultural beliefs influence your health values?"

c. "Is your family involved in any community organizations?" An ecomap studies the family's relationships with groups and organization such as work, faith communities and school

The nursing instructor teaches a group of students about fetal circulation and then asks a student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? a. "It connects the pulmonary artery to the aorta." b. "It is an opening between the right and left atria." c. "It connects the umbilical vein to the inferior vena cava." d. "It connects the umbilical artery to the inferior vena cava."

c. "It connects the umbilical vein to the inferior vena cava." The foramen ovale is the temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery

The nurse is conducting a prenatal class on the reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? a. "It promotes the fertilized ovum's chances of survival." b. "It promotes the fertilized ovum's exposure to estrogen and progesterone." c. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." d. "It promotes the fertilized ovum's exposure to LH and FSH."

c. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube, which promotes its normal implantation in the fundal portion of the uterine corpus.

The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? a. "It is extremely contagious." b. "It is most common in humid weather." c. "Lesions most often are located on the arms and chest." d. "It might show up in an area of broken skin, such as an insect bite."

c. "Lesions most often are located on the arms and chest." Lesions are usually around the mouth and nose but may be present on the hands and extremities

The nurse teaches a client about using medroxyprogesterone as a birth control method. Which client statement indicates effective teaching? a. "This method of family planning requires monthly injections." b. "I should have my first injection during my menstrual cycle." c. "One possible adverse effect is absence of a menstrual period." d. "This drug will be given by SQ injections."

c. "One possible adverse effect is absence of a menstrual period." Other adverse effects include weight gain, breakthrough bleeding, HA and depression. This method requires deep IM injections q3months. The first injection should occur within 5 days after menses.

A primigravid client at 28 weeks' gestation tells the nurse that she and her husband wish to drive to visit relatives who live several hours away. Which recommendation by the nurse would be best? a. "Try to avoid traveling anywhere in the car during your third trimester." b. "Limit the time you spend in the car to a maximum of 4-5 hours." c. "Taking the trip is okay if you stop every 1 to 2 hours and walk." d. "Avoid wearing your seat belt in the car to prevent injury to the fetus."

c. "Taking the trip is okay if you stop every 1 to 2 hours and walk."

The nurse is working with a middle-aged female after a knee injury. Ambulation is still difficult for the client, and the physical therapist has suggested the client use a cane. The nurse states which of the following with respect to using a cane rather than a walker for this injury? a. "The cane is just a reminder to use good posture." b. "The cane can be more dangerous than helpful, and another type of assistive device should be considered for this client." c. "The cane will help with fatigue while assisting the client with balance and support." d. "A cane does not offer any relief on weight-bearing joints."

c. "The cane will help with fatigue while assisting the client with balance and support." A cane offers support and can give the client relief of joint pain and fatigue, and promote a safe way to ambulate when a lower extremity is injured.

The client is 40 y/o and pregnant with her first child. Her obstetrician has asked the nurse to schedule her for an amniocentesis. The client inquires why she needs that test. The nurse says which of the following as an explanation? a. "We routinely do an amniocentesis on all our clients to check the child's gender." b. "An amniocentesis is not invasive, so there is less risk than doing an US." c. "The standard for doing an amniocentesis is motherhood over age 35." d. "If we know the baby's size, you can better count on having a vaginal birth."

c. "The standard for doing an amniocentesis is motherhood over age 35." After age 35, the risk of infant chromosomal abnormality is greater than the risk associated with the procedure.

The nurse provides care for a pediatric client who experiences sudden cardiac death. The child's family practices orthodox Judaism. Which question by the nurse is appropriate when planning postmortem care for the child? Select all that apply. a. "Would you like me to call a priest?" b. "Would you like your child to receive last rites?" c. "Would you like to assist with washing your child?" d. "Is there anyone who cannot be involved in providing care to your child?" e. "Is there anyone you would like me to call to be with your family and child?"

c. "Would you like to assist with washing your child?" e. "Is there anyone you would like me to call to be with your family and child?" For the family who identifies with orthodox Judaism, it is often customary to participate in the ritual of washing the body after death; additionally, the family and close friends remain with the deceased for a period of time. Based on this information, the nurse should ask the family the following questions prior to the initiation of postmortem care: "Would you like to assist with washing your child?" "Is there anyone you would like me to call to be with your family and child?" Last rites is a ritual that is performed for those who identify themselves as Catholic, not orthodox Judaism; therefore, this is not an appropriate question for the nurse to ask when providing care for a family of a child who experienced sudden cardiac death. The Hindu, not orthodox Judaism faith is more likely to have rules regarding who can touch the child's body after death; therefore, this is not an appropriate question for the nurse to ask when providing care for a family of a child who experienced sudden cardiac death. A rabbi, not a priest, is more appropriate for this family as they identify with orthodox judaism; therefore, this is not an appropriate question for the nurse to ask when providing care for the family of a child who experienced sudden cardiac death.

A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? a. "You will lay on your right side during the procedure." b. "You should not eat anything for 24 hours prior to the procedure." c. "You should empty your bladder prior to the procedure." d. "The test is done to determine gestational age."

c. "You should empty your bladder prior to the procedure." Assist the client into a supine position, place a wedge under the right hip to displace the uterus off the vena cava

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) nonreactive Prenatal vitamins Weight 135 lb (61 kg) Rubella immune Positive Goodell and Chadwick Rh positive, type O a. "You need to avoid all school-age children during pregnancy." b. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." c. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." d. "Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."

c. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the first trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction? a. 1000 b. 1100 c. 1700 d. 2400

c. 1700 Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

A nurse is transferred from the oncology unit to the neurology unit. Which is the best patient assignment for the nurse? a. A 75-year-old patient with an intracranial pressure monitor on a ventilator 2 days post fall. b. A 50-year-old patient with a recent stroke experiencing left-sided weakness. c. A 40-year-old patient recovering from an esophagogastroduodenoscopy with variceal banding. d. A 30-year-old patient with a history of migraines complaining of blurred vision.

c. A 40-year-old patient recovering from an esophagogastroduodenoscopy with variceal banding. The nurse who is floating to another unit should be given a non-unit specific patient since patients go to certain units to receive specialized care from providers trained accordingly. During an esophagogastroduodenoscopy, the doctor uses an endoscope to place elastic rings around enlarged vessels.

The home care nurse reviews the patient list in order to prioritize home visitations. Which patient should the nurse see first? a. A 65-year-old patient with chronic obstructive pulmonary disease on supplemental oxygen. b. A 40-year-old patient diagnosed with type 2 diabetes reporting poor sensation in his feet. c. A 45-year-old reporting a cough 3 days post hysterectomy. d. A 50-year-old complaining of tenderness at the incision site 2 days post inguinal hernia repair

c. A 45-year-old reporting a cough 3 days post hysterectomy. Patients are at a high risk for pulmonary embolism after hysterectomy surgery. Shortness of breath, cough, and chest pain are common signs. Atelectasis-induced pneumonia is also a risk. The COPD and diabetes patients are experiencing expected complications of non-acute diseases. Although the inguinal hernia is an acute problem, it is an expected finding and can be prioritized

Which laboratory result should the nurse report immediately to the client's healthcare provider (HCP)? Select all that apply. a. INR of 2.5 for a client prescribed warfarin therapy for a DVT b. a client who is diagnosed with pneumonia and chronic, end stage emphysema with a PaCO2 of 0 mmHg and PaO2 of 88% c. A client who is diagnosed with MI with an aPTT of 110 sec d. A client who is diagnosed with HF and prescribed furosemide with a serum K level of 5.1 meq/L e. A client who is newly diagnosed with a complicated UTI with a WBC count of 14,500/mm3

c. A client who is diagnosed with MI with an aPTT of 110 sec An INR of 2.5 for a client who is prescribed warfarin therapy for DVT is considered within normal range of 2 to 3; therefore immediate reporting to the HCP is not necessary. A PaCO2 of 60 mm Hg and PaO2 of 88% for a client who is diagnosed with pneumonia and chronic, end-stage emphysema is considered normal. The normal PaCO2 range for non-emphysemic client is 33-45 mm Hg but since emphysema clients air-trap, respiratory acidosis is expected; additionally, many clients who are diagnosed with emphysema have a "normal" PaO2 of 88%; therefore, this data does not require immediate HCP notification. The normal reference range for aPTT is 25-35 seconds and the goal of anticoagulation therapy for MI is an aPTT 1.5 to 2 times the normal range. An aPTT greater than 75 seconds indicates the client will have clotting issues increasing the risk for spontaneous bleeding and hemorrhage; therefore, an aPTT of 110 seconds is very dangerous and requires immediate HCP notification. A potassium level of 5.1 mEq/L for a client who is diagnosed with heart failure and prescribed diuretic therapy is at risk for hypokalemia. The current data indicates a slightly elevated serum potassium level (hyperkalemia); therefore, this data does not require immediate HCP notification. A WBC count of 14,500/mm3 for a client who is newly diagnosed with a complicated UTI is not an unexpected finding. While the WBC count is higher than the normal range, this is likely due to the diagnosis; therefore, immediate HCP notification is not required.

Which client should receive a private room? a. a client with diabetes b. a client with Cushing's disease c. A client with Grave's disease d. A client with gastric ulcers

c. A client with Grave's disease These clients have insomnia and any noise will wake them. Lack of sleep makes their condition worse. Answer B is a good choice, but if you answered B you are reading into the question because the question does not say that the client should be placed in a room with any client who is infected with any microorganism. Answers A and D are vague answers; stay away from vague answers. The answer does not tell us if they are in the hospital for diagnostic studies or for complications of their diseases.

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care would the nurse review with the client's primary health care provider? a. A decreased dosage of levothyroxine b. An increased dosage of levothyroxine c. A decreased dosage of warfarin sodium d. An increased dosage of warfarin sodium

c. A decreased dosage of warfarin sodium Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin would be reduced.

A 20 y/o client has just given birth. The baby looks healthy, with the exception of giving a grimace instead of a cry. Which of the following would the nurse expect the obstetrician to say? a. An APGAR score of 3 b. An APGAR score of 6 c. An APGAR score of 9 d. An APGAR score of 12

c. An APGAR score of 9 An APGAR score of 3 indicates a baby in poor health. An APGAR score of 6 indicates a less healthy baby. CORRECT: In 4 of the 5 categories of rating, the baby scored a 2. In the category of reflex irritability, the baby scored a 1, for a total APGAR score of 9. An APGAR score of 12 does not exist; the highest score is 10.

A 19 y/o nulligravid client visiting the clinic for a routine examination asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which information would the nurse expect to include in the client's teaching plan? a. About midway through the menstrual cycle, cervical mucus is thick and sticky b. During ovulation, the cervix remains dry without any mucus production c. As ovulation approaches, cervical mucus is abundant and clear d. cervical mucus disappears immediately after ovulation, resuming with menses

c. As ovulation approaches, cervical mucus is abundant and clear During the luteal phase of the cycle, which occurs after ovulation, the cervical mucus is thick and sticky, making it difficult for sperm to pass. Changes in the cervical mucus are related to influences of estrogen and progesterone. Cervical mucus is always present.

A client, approximately 11 weeks pregnant and her husband are seen in the antepartal clinic. The client's husband tells the nurse that he has been experiencing nausea and vomiting and fatigue along with his wife. The nurse interprets these findings as suggesting that the client's husband is experiencing which complication? a. ptyalism b. mittelschmerz c. Couvade syndrome d. pica

c. Couvade syndrome Couvade syndrome refers to the situation in which the expectant father experiences some of the discomforts of pregnancy along with the pregnant woman as a means of identifying with the pregnancy. Ptyalism is the term for excessive salivation. Mittelschmerz is the lower abdominal discomfort felt by some women during ovulation.

A client's opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? a. Fever b. Nausea c. Diaphoresis d. Abdominal cramps

c. Diaphoresis Diaphoresis is one of the early signs that occurs between 6 and 12 hours after withdrawal. Fever, nausea, and abdominal cramps are late signs that occur between 48 and 72 hours after withdrawal.

A client with known heparin-induced thrombocytopenia (HIT) is undergoing chemotherapy and is having a central venous access device placed. Which of the following types of central venous access device does the nurse know BEST minimizes the risk of HITrelated complication? a. Hickman b. Broviac c. Groshong d. Port

c. Groshong A Groshong is a valved catheter that does not require heparin flushing.

A client is admitted with sickle-cell anemia and voices concerns about becoming addicted to pain medicine. The nurse explains the difference between physical dependence, tolerance, and addiction. Which of the following symptoms or behaviors does the nurse know is BEST associated with addiction? a. Withdrawal symptoms when the drug is abruptly stopped b. Withdrawal symptoms when the drug dose is reduced c. Habitual and compulsive use of a drug d. A state of adaptation

c. Habitual and compulsive use of a drug

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? a. Bradycardia and hyperactivity b. Decreased respiratory rate and depth c. Headache, restlessness, and confusion d. Bradypnea, dizziness, and paresthesias

c. Headache, restlessness, and confusion

A 10 y/o child with hemophilia A has slipped on the ice and bumped the knee. The nurse would prepare to administer which prescription? a. injection of factor X b. intravenous infusion of iron c. IV factor VIII d. IM injection of iron using the Z track method

c. IV factor VIII

A client is admitted with severe back pain and is requesting pain medication. During her assessment, the nurse notes the client has been taking acetaminophen 650 mg every 4 hours at home with minimal relief. Based on this information, which of the following PRN-ordered drug(s) should the nurse consider administering? a. Hydrocodone with acetaminophen b. Acetaminophen c. Ibuprofen d. Acetaminophen with oxycodone

c. Ibuprofen Hydrocodone with acetaminophen would increase the client's intake of acetaminophen. The maximum recommended dose of acetaminophen in a 24 hour period is 4 g. Giving the client more acetaminophen would increase intake above the maximum recommended dose of 4 g in a 24-hour period. CORRECT: Ibuprofen is the only pain relief medication listed that does not contain acetaminophen.

The nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. a. Provide a cool environment for the client. b. Instruct the client to consume a high-fat diet. c. Instruct the client about thyroid replacement therapy. d. Encourage the client to consume fluids and high-fiber foods in the diet. e. Inform the client that iodine preparations will be prescribed to treat the disorder. f. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

c. Instruct the client about thyroid replacement therapy. d. Encourage the client to consume fluids and high-fiber foods in the diet. f. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur. The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.

The nurse is assessing an irritable 6-month-old infant during a well baby checkup. The infant's weight is 19 lb., 6.4 oz. (8.8 kg). The infant does not have an elevated temperature, the heart rate is 102, and the respiratory rate is 32. The mother states that the infant wakes every hour or two throughout the night. The infant wants a bottle, and falls asleep while eating, but doesn't stay asleep. Which of the following instructions should the nurse give the parents? a. Instruct the parents to offer acetaminophen 325 mg orally for comfort, and diphenhydramine 25 mg orally for sleep. b. Instruct the parents to offer high-calorie solid foods during daytime hours so the infant does not wake up hungry during the night. c. Instruct the parents to offer the last feeding as late as possible, and put the infant to bed awake without a bottle. d. Suggest using pacifiers, taking the infant to the parent's bed, or rocking the infant to sleep.

c. Instruct the parents to offer the last feeding as late as possible, and put the infant to bed awake without a bottle. Tylenol may be appropriate for teething pain, and Benadryl is an antihistamine that may cause drowsiness, but the doses as given are for adults. The infant's weight is within normal limits, so high-calorie foods may not be appropriate. The infant is having sleep disturbances related to nighttime feeding. Feeding late and putting the infant to bed awake help the infant learn to recognize bedtime and to self-soothe to fall asleep. The Academy of Pediatrics does not promote putting infants to bed with parents. Rocking the infant will not help learning to selfsoothe. 2.

A woman who gave birth to her last infant by c section is admitted to the hospital at term with contractions every 5 minutes. The HCP intends to have her undergo a trial labor. What does the nurse explain to the client that trial of labor means? a. Labor will be stimulated with exogenous oxytocin until birth b. The HC needs more information to determine the presence of true labor c. Labor progress will be evaluated continually to determine appropriate progress for a vaginal birth d. Labor will be arrested with tocolytic agents after a 2 hour period even if no fetal distress is noted

c. Labor progress will be evaluated continually to determine appropriate progress for a vaginal birth A trial labor means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to birth. If there are indications that labor is not progressing, other means of birth are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicate true labor. If fetal distress is noted and an emergency c section cannot be done immediately, tocolytic agents may be considered to stop contractions

The client is taking a class IB anti-arrhythmic drug. What drug might that be? a. Lidocaine b. Procainamide c. Mexiletine d. Metoprolol

c. Mexiletine Mexiletine is a class IB anti-arrhythmic drug. Lidocaine and procainamide are class II medications. Metoprolol is a class II antiarrhythmic.

A 65-year-old man with metastatic colon cancer has been prescribed hydromorphone PO/PRN to help manage his pain. The nurse knows that the rectal route of administration is contraindicated when which of the following is present? a. Nausea and vomiting b. Difficulty swallowing c. Neutropenia d. Fever

c. Neutropenia The rectal route of administration should NOT be used in clients who have anal or rectal lesions, mucositis, thrombocytopenia, or neutropenia.

Which information would be important to include in the teaching plan for the client who wants more information on ovulation and fertility management? a. The ovum survives for 96 hours after ovulation, making conception possible during this time. b. The basal body temperature falls at least 0.2F after ovulation has occurred c. Ovulation usually occurs on day 14 plus or minus 2 days, before the onset of the next menstrual cycle d. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus

c. Ovulation usually occurs on day 14 plus or minus 2 days, before the onset of the next menstrual cycle For a client with typical menstrual cycle of 28 days, ovulation usually occurs on day 14, plus or minus 2 days. Menstrual period begins about 2 weeks after ovulation has occurred. The ovum survives for about 12-24 hours after ovulation. The basal body temperature rises 0.5 F-1 . Although some women experience some pelvic discomfort (mittelschmerz), severe or unusual pain is rare. After ovulation, the cervical mucus is thin and copious.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse would plan to provide which instruction to the client? a. Use nail polish to protect the nail beds from injury. b. Wear gloves for all activities involving the use of both hands. c. Stop smoking because it causes cutaneous blood vessel spasm. d. Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

c. Stop smoking because it causes cutaneous blood vessel spasm.

Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps? a. change positions frequently throughout the day b. Alternately flex and extend the legs c. Straighten the knees, and flex the toes toward the chin d. Lie prone in bed with the legs elevated

c. Straighten the knees, and flex the toes toward the chin Leg cramps are thought to result from excessive amounts of phosphorous absorbed from milk products. Straightening the knee and flexing the toes toward the chin is effective to relieve leg cramps. Also, decreasing milk intake and supplementing with calcium lactate may help to reduce the cramping. Keeping the legs warm and elevating them are good preventive measures. Changing positions frequently aids venous return but is not helpful in relieving leg cramps. Lying prone in the bed is a difficult position for a client at 37 weeks' gestation to achieve and maintain because of the increase in abdominal size and therefore is not considered helpful.

The client is on dobutamine. Adverse effects 0f Dobutrex (dobutamine) include the following: Select all that apply. a. Heart failure b. Bradycardia c. Tachycardia d. Respiratory distress e. Ventricular ectopy

c. Tachycardia e. Ventricular ectopy It does not cause respiratory distress but can cause chest pain.

The nurse reviews the electrolyte result of client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab value? a. ST depression b. Prominent U wave c. Tall peaked T waves d. Prolonged ST segment e. Widened QRS complexes

c. Tall peaked T waves e. Widened QRS complexes

The following clients have a head injury. Which clients should the nurse question administering the medication mannitol? Select all that apply. a. The 34- year- old client who is HIV positive. b. The 84- year- old client who has glaucoma. c. The 68- year- old client who has cor pulmonale. d. The 16- year- old client who has cystic fi brosis. e. The 58- year- old client with congestive heart failure (CHF).

c. The 68- year- old client who has cor pulmonale. e. The 58- year- old client with congestive heart failure (CHF). Cor pulmonale is right- sided heart failure, often secondary to chronic obstructive pulmonary disease. Because mannitol pulls fl uid off the brain, it may lead to a circulatory overload, which the heart with right- sided failure could not handle. This client would need an order for a loop diuretic to prevent serious cardiac complications. Because the osmotic diuretic mannitol (Osmitrol) pulls fl uid off the brain, it may lead to a circulatory overload, which the client in CHF could not handle. This client would need an order for a loop diuretic to prevent serious cardiac complications.

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? a. The informed consent does not need to be obtained. b. The informed consent would be obtained from the family. c. The informed consent needs to be obtained from the client. d. The primary health care provider will provide the informed consent.

c. The informed consent needs to be obtained from the client. Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.

The nurse is caring for a heart client on digoxin and notes a potassium level of 2.5. What is the appropriate priority nursing intervention? a. Do nothing as this is a normal potassium level. b. The potassium level is low so the nurse asks for an order for potassium. c. The nurse asks to check the digoxin level as low potassium can increase digoxin toxicity d. The nurse stops the digoxin.

c. The nurse asks to check the digoxin level as low potassium can increase digoxin toxicity The potassium is low and this can cause digoxin toxicity so a digoxin level should be checked as a priority. A secondary priority item is to ask for an order for potassium replacement. The digoxin shouldn't be stopped unless the digoxin level is toxic.

The nurse is providing instructions to the AP regarding care of an older client with hearing loss. What would the nurse tell the AP about older clients with hearing loss? a. The yare often distracted b. They have middle ear changes c. They respond to low pitched tones d. They develop moist cerumen production

c. They respond to low pitched tones

The nurse in an outpatient clinic has received an order from the physician to remove the client's sutures. The nurse should do which of the following? a. Use gloves when removing sutures. b. Apply hydrogen peroxide gauze pads to cleanse the area first, then remove the sutures. c. Use sterile technique when removing sutures. d. Nothing, suture removal is outside of the nurse's scope of practice.

c. Use sterile technique when removing sutures.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? a. lub-dub sounds b. scratchy, leathery heart noise c. a blowing or swooshing noise d. abrupt, high pitched snapping noise

c. a blowing or swooshing noise A pericardial friction rub is described as a scratchy, leathery heart sound. A click is described as an abrupt, high pitched snapping sound

Several pregnant clients are waiting to be seen in the triage area of the obstetrical unit. What client should the nurse see first? a. a client at 13 weeks' gestation who is experiencing nausea and vomiting 3 times a day with +1 ketones in her urine b. a client at 37 weeks' gestation who is an insulin dependent diabetic and experiencing 3 to 4 fetal movements per day c. a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and returning for evaluation of epigastric pain d. a client at 17 weeks' gestation who is not feeling fetal movement at this point in her pregnancy

c. a client at 32 weeks' gestation who has preeclampsia and +3 proteinuria and returning for evaluation of epigastric pain A preeclamptic client with +3 proteinuria and epigastric pain is t risk for seizing, which would jeopardize the mother and the fetus. The client at 13 weeks' gestation with N/V is a concern because the presence of ketones indicates that her body does not have glucose to break down. However, this situation is a lower priority than the preeclamptic client or the diabetic. The insulin dependent diabetic is a high priority, but fetal movement indicates that the fetus is alive but may be ill. As few as 4 fetal movements in 12 hours is considered normal. The client who is at 17 weeks' gestation may be too early in her pregnancy to experience fetal movement and would be the last to be seen.

The RN in charge of assignments, with limited available staff, must assign the following four clients. Which client would be most appropriate for the UAP? a. a recent postsurgical TURP b. a head injury client with stable ICP c. a client with HF d. a client with acute pancreatitis

c. a client with HF The TURP client (1) must be assessed for hemorrhage; the head-injury client (2) must be monitored for a change in ICP; and the client with acute pancreatitis (4) requires vital signs, monitoring every 15 minutes, and frequent assessment for complications.

The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the AP to use an electric razor for shaving? Select all that apply a. A client with leukocytosis b. a client with thrombocytosis c. a client with thrombocytopenia d. A client receiving an antiplatelet medication e. A client receiving APAP as needed for mild pain

c. a client with thrombocytopenia d. A client receiving an antiplatelet medication

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? a. pallor b. hyperactivity c. activity intolerance d. GI disturbances

c. activity intolerance Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the LV, decreased CO, LV hypertrophy and pulmonary vascular congestion. A child with aortic stenosis shows signs of activity intolerance, chest pain and dizziness when standing for long periods. Pallor may be noted but is not specific to this type of disorder.

Which clients would the nurse monitor for the development of hypovolemic shock? select all that apply a. having an allergic reaction from multiple wasp stings b. post operative cervical spinal cord surgery c. addisonian crisis d. Partial thickness burns over 50% TBSA e. T2DM with HHNK

c. addisonian crisis d. Partial thickness burns over 50% TBSA e. T2DM with HHNK A client in Addisonian crisis loses sodium and water and can have hypovolemic shock

At 32 weeks' gestation, a 15 y/o primigravid client who is 5 feet, 2 inches has gained a total of 20 lb, with a 1 lb gain in the last 2 weeks. UA reveals negative glucose and a trace of protein. The nurse should advise the client that which factor increases her risk for preeclampsia? a. total weight gain b. short stature c. adolescent age group d. trace proteinuria

c. adolescent age group Clients with increased risk for preeclampsia include primigravid clients younger than 20 or older than 40 years, clients with 5 or more pregnancies, with DM or heart disease and women with hydramnios. A total weight gain of 20 lb at 32 weeks with a 1 lb weight gain in the last 2 weeks is within normal. A trace amount of proteinuria is common, but protein amounts of 1+ or more may be a symptom of pregnancy induced HTN.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? a. a stage 1 ulcer b. a vascular ulcer c. an arterial ulcer d. a venous stasis ulcer

c. an arterial ulcer Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse is managing care of a primigravida at full term who is in active labor. What should be included in the plan of care for this client? a. oxygen saturation monitoring every half hour b. supine positioning on back, if comfortable c. anesthesia/pain level assessment every 30 minutes d. vaginal bleeding, ROM assessment every shift

c. anesthesia/pain level assessment every 30 minutes The nurse should monitor anesthesia/pain levels every 30 minutes during active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client. When in active labor, SaO2 is not monitored unless there is a specific need, such as heart disease. The client should not be on her back but wedged to the right or let side to take the pressure off the vena cava. When lying on the back, the fetus compresses the major blood vessels. Vaginal bleeding in active labor should be monitored every 30 min to an hour

A client admitted for placement of heart stents was started on clopidogrel. The nurse knows that a daily assessment of this client should include what data? Select all that apply a. monitoring I&O b. check daily LFT c. assess stools for tarry appearance d. monitor daily plt count e. assess for new ecchymosis

c. assess stools for tarry appearance d. monitor daily plt count e. assess for new ecchymosis The action of clopidogrel inhibits plt aggregation

While the nurse is caring for a multiparous client in active labor at 36 weeks' gestation, the client tells the nurse, "I think my water just broke." What should the nurse do first? a. turn the client to the right side b. assess the color, amount and odor of the fluid c. assess the FHR pattern d. check the client's cervical dilation

c. assess the FHR pattern After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the birth canal. Sudden decels of the FHR commonly signifies cord compression or prolapse of the cord. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged. Turning the client to the right side is not a priority, but would be appropriate if variable decels are present.

The nurse has obtained a urine specimen from a multiparous client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? select all that apply a. assisting her to the bathroom b. applying an external fetal monitor to obtain FHR c. assessing her stage of labor d. asking if she had back labor pains like this with any of her other birth experiences e. Allowing her support person to take her to the bathroom to maintain privacy f. checking the degree of fetal descent

c. assessing her stage of labor f. checking the degree of fetal descent The pressure from the fetus descending into the birth canal can cause the client to feel she needs to move her bowels and could be near birth. Failure to assess the stage of labor and degree of fetal descent before allowing the client to go to the bathroom may lead to progression of labor and could result in a birth in the bathroom. Applying fetal monitor may reassure the nurse that the fetus is doing well but it doesn't tell whether the fetus is ready to be born. Regardless of prior experience with back labor pain, the fetus moving lower into the birth canal causes pressure in the lower back area similar to the feeling of passing a bowel movement.

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which of the following actions should the nurse include in the pla of care? Select all that apply a. thicken liquids to honey consistency b. educate the client about the use of NG tube c. assist the client to use a straw to drink liquids d. ensure that the client receives ground meats e. encourage intake of fluids between meals

c. assist the client to use a straw to drink liquids e. encourage intake of fluids between meals

During the administration of 40 mg intravenous furosemide, in which way will the nurse administer the medication to reduce the risk of the client developing ototoxicity? a. over 4 min b. over 2 min c. at rate of 4 mg/min d. 10 mg each hr for 4 hours

c. at rate of 4 mg/min This answer is correct because furosemide can lead to reversible ototoxicity. To avoid this complication it is recommended to provide the medication at the rate of 4 mg/minute.

The client is diagnosed with benign fibrocystic breast disease. Interventions to reduce discomfort from this disease include teaching the client to: a. wear tight supporting garments b. increase her activity level c. avoid caffeine d. obtain estrogen therapy from the HCP

c. avoid caffeine

While a client is being admitted to the birthing unit she states, "my water broke last night but my labor started 2 hours ago." Which findings are a concern? select all that apply a. maternal VS T 99.5 F, HR 80, R 24, BP 130/80 mmHg b. blood and mucus on perineal pad c. baseline FHR of 140 bpm with a range b/w 110 and 160 with contractions d. peripad stained with green fluid e. client stating, "This baby wants out - he keeps kicking me"

c. baseline FHR of 140 bpm with a range b/w 110 and 160 with contractions d. peripad stained with green fluid e. client stating, "This baby wants out - he keeps kicking me" The range of FHR fluctuating more than 25 bpm could indicate fetal distress. Increased fetal activity during labor may also indicate distress

In which maternal locations would the nurse place the US transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position? a. near the symphysis pubis b. 2 inches above the umbilicus c. below the umbilicus on the left side d. at the level of the umbilicus

c. below the umbilicus on the left side If the fetal back is near the symphysis pubis, the fetus is presenting as a transverse lie. If the fetus is in a breech position, the fetal back may be at or above the umbilicus

A client, with a family history of breast cancer, is hesitant to take hormone replacement therapy (HRT) to address hot flashes caused by menopause. Which vitamin or herbal preparation is a potential alternative to HRT to address the client's hot flashes? a. garlic b. saw palmetto c. black cohosh d. niacin

c. black cohosh Clients have found relief from hot flashes that are associated with menopause through use of black cohosh, a herbal root remedy; therfore, this is an appropriate alternative to HRT for clients experiencing hot flashes.

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color? a. yellow b. white c. blue d. red

c. blue An alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for ROM is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under the microscope. Dried amniotic fluid will form a fern pattern.

An antenatal G2, T1, P0, A0, L1 client is discussing her postpartum plans for birth control with her HCP. In analyzing the available choices, which factor has the greatest impact on her birth control options? a. satisfaction with prior methods b. preference of sexual partner c. breast or bottle-feeding plan d. desire for another child in 2 years

c. breast or bottle-feeding plan Maternal milk supply must be well established prior to the initiation of most hormonal birth control methods except for low dose oral contraceptives. use of estrogen/progesterone based pills and are commonly initiated from 4-6 weeks postpartum because the milk supply is well established by this time.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? a. Insert an airway to improve oxygenation b. note the time when the seizure begins and ends c. call for immediate assistance d. turn the client to her left side

c. call for immediate assistance

The HCP verbally prescribed carboprost tromethamine 0.25 mg IM stat for a client experiencing a postpartum hemorrhage. The nurse administers the medication, but later finds that the HCP has written a prescription for 0.25 mg carboprost tromethamine IV stat. How should the nurse respond? a. ask the charge nurse to have a discussion with the HCP about the prescription b. initiate an incident report c. call the HCP, discuss the prescription and request revision if heard correctly d. wait until the HCP returns to the unit, and discuss the situation in person

c. call the HCP, discuss the prescription and request revision if heard correctly

A 20 y/o nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which information would the nurse include in the teaching plan? a. This method has a 50% failure rate during the first year of use. b. couples must abstain from coitus for 5 days after the menses. c. cervical mucus is carefully monitored for changes d. The male partner uses condoms for significant effectiveness.

c. cervical mucus is carefully monitored for changes The symptothermal depends on knowing when ovulation has occurred. It requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. This relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period. Typically, the failure rate for this method is between 10-20%.

Which information would be included in the teaching plan about pregnancy-related breast changes for a primigravid client? a. growth of the milk ducts is greatest during the first 8 weeks of gestation b. enlargement of the breasts indicates adequate levels of progesterone c. colostrum is usually secreted by about the 16th week of gestation d. darkening of the areola occurs during the last month of pregnancy

c. colostrum is usually secreted by about the 16th week of gestation Growth of the milk ducts is greatest in the last trimester, not in the first 8 weeks of gestation. Enlargement of the breasts is usually caused by estrogen, not progesterone. Darkening of the areola can occur as early as the 6th week of gestation

A nurse is caring for an 80 year old client with a total hip arthroplasty 8 hours ago. Which nursing postop intervention has priority for an elderly client? a. reorient to time and place b. position in an abduction pillow c. coughing and deep breathing exercises Q2h d. turn the client toward the unaffected side

c. coughing and deep breathing exercises Q2h increased stiffness of the lung tissue is a normal physiological change with the elderly. It will increase the risk of postop pulmonary complications.

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week, and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? a. abruptio placentae b. HELLP syndrome c. disseminated intravascular coagulation d. threatened abortion

c. disseminated intravascular coagulation A fetus that has died and is retained in utero places the mother at risk for DIC because the clotting factors within the maternal system are consumed when the nonviable fetus is retained. This client has no RF, history or signs that put her at risk for abruptio placentae such as sharp pain and woody firm consistency of the abdomen. HELLP syndrome is a complication of preeclampsia that does not occur before 20 weeks' gestation unless a molar pregnancy is present. There is no evidence that she is threatening to abort as she has no cramping or vaginal bleeding

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? a. apply gentle pressure b. reinforce the dressing c. document the findings d. contact the PHCP

c. document the findings The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours and this is normal part of healing. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated and the nurse would notify the PHCP

A client who is diagnosed with type 1 diabetes mellitus (DM) is prescribed NPH insulin at breakfast and supper. The client, who monitors serum glucose levels as instructed, documents a fasting blood glucose averaging 60 mg/dL over the past couple weeks. Although the client reports, "feeling fine" which action should the nurse advise based on the current data? a. Add more bread and grains to each meal consumed b. test for ketones in the urine c. eat a snack of cheese and crackers before at bedtime d. discontinue the dinner dose of NPH

c. eat a snack of cheese and crackers before at bedtime Carbohydrates lead to persistent hyperglycemia; therefore, this is not recommended for the client diagnosed with type 1 DM. Clients who are prescribed NPH insulin are at risk for hypoglycemia. Preventative intervention may include recommending a snack before bed; specifically, a complex carbohydrate that is paired with a protein which provides a slow and sustained release of glucose; therefore, this action decreases the likelihood of decreased serum glucose levels.

The nurse instructs a primigravid client about the importance of sufficient vitamin A in her diet. The nurse knows that the instructions have been effective when the client indicates that she should include which foods in her diet? a. buttermilk and cheese b. strawberries and broccoli c. egg yolks and squash d. oranges and tomatoes

c. egg yolks and squash Buttermilk and cheese are good sources of calcium. Strawberries, broccoli, citrus fruits and tomatoes are good sources of vitamin C

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? select all that apply a. discourage reminiscing b. make the decisions for the family c. encourage expression of feelings, concerns and fears d. explain everything that is happening to all family members e. touch and hold the client's or family member's hand if appropriate f. Be honest and let the client and family know that they will not be abandoned by the nurse

c. encourage expression of feelings, concerns and fearse. touch and hold the client's or family member's hand if appropriate f. Be honest and let the client and family know that they will not be abandoned by the nurse The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know.

The primigravid client is at +1 station and 9 cm dilated. Based on these data, what should the nurse do first? a. ask the anesthesiologist to increase epidural infusion rate b. assist the client to push if she feels the need to do so c. encourage the client to breathe through the urge to push d. support family members in providing comfort measures

c. encourage the client to breathe through the urge to push The urge to push is often present when the fetus reaches + stations. The client does not have a cervix that is completely dilated and pushing may tear the cervix. Encouraging the client to breathe through the urge to push is the most appropriate and allows the cervix to dilate before pushing. Increasing the level of epidural is inappropriate as nursing would like to have the client be able to push when she is fully dilated.

The nurse monitors clients' medications in a day program for clients with disabilities. The nurse notices a teenage client who is frequently alone and often quiet. It would be MOST appropriate for the nurse to take which of the following actions? a. allow the client alone time since the client seems to prefer this. The client has the right to make that choice b. make an effort to interact with the client periodically c. encourage the client to join a youth group d. encourage other clients in the program to interact more frequently with the client

c. encourage the client to join a youth group Participating in a youth group can help a teenage client with a disability develop social skills, use support systems, and feel more like a typical teenager.

The postpartum nurse is assessing a client who delivered a healthy infant by c section for signs of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? a. paleness of the calf area b. coolness of the calf area c. enlarged, hardened veins d. palpable dorsalis pedis pulses

c. enlarged, hardened veins Thrombosis of superficial veins usually is accompanied signs of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk.

A 16 y/o primigravid client at 37 weeks' gestation with severe preeclampsia is in early active labor. The client's BP is 164/110 mmHg. Which finding would alert the nurse that the client may be about to experience a seizure? a. decreased contraction intensity b. decreased temperature c. epigastric pain d. hyporeflexia

c. epigastric pain This is thought to be related to liver ischemia. Decreased contraction intensity is unrelated. Typically, the client's temperature increases due to increased cerebral pressure.

A 36 y/o multigravid client is admitted to the hospital with possible ruptured ectopic pregnancy. When obtaining the client's history, which finding would be most important to identify as a predisposing factor? a. UTI b. marijuana use during pregnancy c. episodes of PID d. use of estrogen progestin contraceptives

c. episodes of PID Anything that causes a narrowing or constriction in the fallopian tubes so that a fertilized ovum cannot be properly transported to the uterus for implantation predisposes an ectopic pregnancy. PID is the most common cause of constricted or narrow tubes. Developmental defects are other possible causes. Ectopic pregnancy is not related to UTI. Use of marijuana during pregnancy is not associated but can result in cognitive reduction if the mother's use during pregnancy is extensive. Progestin only contraceptives and intrauterine devices have been associated with ectopic pregnancy

A public health nurse is reviewing the outcomes of an exercise program at various locations. Which of the following aspects of care does this finding evaluate? a. timeliness b. client centered c. equity d. safety

c. equity There was no difference in client outcomes across geographic locations, this helps to validate that the program was equitable. Also examine data based on gender, ethnicity and socioeconomic status to check for equity across those variables.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? a. apply an ice cube to the nipples b. rub the nipples gently with lanolin cream c. express a small amount of breast milk d. offer the neonate a small amount of formula

c. express a small amount of breast milk Expressing a little milk before nursing, massaging the breasts gently or taking a warm shower before feeding also may help to improve milk flow. Applying ice to the nipples does not relieve breast engorgement, but may temporarily relieve the discomfort associated with breast engorgement. Use of lanolin may cause sensitivity and irritation.

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the UAP? a. obtain a urine sample from an infant b. empty a NG tube canister for client with ileus c. feed a child with bilateral burns of hands d. change an ostomy appliance on child with stoma e. ambulate an adolescent two days post appendectomy

c. feed a child with bilateral burns of hands e. ambulate an adolescent two days post appendectomy Obtaining a urine sample is too complex for a UAP. The two methods used for collecting this urine sample is either straight catheterization of the infant or use a wee bag. Neither can be performed by a UAP

A primiparous client, 20 hours after birth, asks the nurse about starting postpartum exercises. Which instruction would be most appropriate to include in the plan of care? a. start in a sitting position, then lie back, and return to a sitting position, repeating this 5 times b. assume a prone position, and then do pushups by using the arms to lift the upper body c. flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles d. flex the knees while supine, and then bring chin to chest while exhaling and reach for knees by lifting the head and shoulders while inhaling

c. flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit ups and pushups are ordinarily too strenuous for the first postpartum day. Sit ups may be done later in the postpartum period after approx 3-6 weeks

A 24 y/o primipara who has given birth to a healthy neonate plans to bottle feed her neonate. What information regarding normal weight gain should the nurse include in the teaching plan? a. A baby normally loses 15% of weight before beginning to gain weight b. adding rice cereal to the bottle is a good way to increase calories if weight gain is slow c. gaining 30 g/day is normal weight gain pattern d. babies typically double birth weight by 3 months

c. gaining 30 g/day is normal weight gain pattern Initial weight loss that exceeds 10% of birth weight is abnormal. Adding rice cereal to a bottle without a medical indication increases the risk of aspiration and may promote obesity. Doubling the birth weight is typical at 5 months

The nurse provides care for a client who is diagnosed with diabetes mellitus with delayed gastric emptying (i.e., gastroparesis). Which clinical finding requires healthcare provider (HCP) notification prior to administering the next prescribed dose of metoclopramide through the peripherally inserted central catheter (PICC) line? a. abdominal discomfort b. frequent flatulence c. hand wringing d. watery bowel movement

c. hand wringing Abdominal discomfort is a symptom of gastroparesis which is why the metoclopramide is prescribed; therefore, this finding does not HCP notification prior to medication administration. Frequent flatulence is an indication that the medication is effective; therefore, this finding does not require HCP notification. Hand wringing is a clinical indicator of tardive dyskinesia (TD), a serious complication associated with the prescribed medication that may become permanent if the medication is continued; therefore, this is the finding must be reported to the HCP prior to administering the prescribed metoclopramide. Watery bowel movements is often a clinical manifestation associated with gastroparesis; therefore, this finding does not require HCP notification.

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in ROP position. The nurse should place the client in which position for pain relief? a. lithotomy b. right lateral position c. hands and knees d. tailor sitting

c. hands and knees placing the client in the hands and knees pulls the fetal head away from the sacral promotory and facilitates rotation of the fetus to the anterior positon.

A client with leukemia is receiving oral prednisolone (Prednisone). An expected side effect of this medication is: a. weight loss b. decreased appetite c. hirsutism d. integumentary bronzing

c. hirsutism Answers A, B, and D are symptoms of Addison's disease. Answer C is the answer that is different from the rest. Hirsutism, or facial hair, is a side effect of cortisone therapy or Cushing's disease.

The nurse is caring for a client with HF who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia? a. muscle twitches b. decreased UOP c. hyperactive bowel sounds d. increased SG of the urine

c. hyperactive bowel sounds

A client arrives at a birthing center in active labor. After examination, it is determined that the client's membranes are still intact and the client is at -1 station. The PHCP prepares to perform an amniotomy. What will the nurse tell to the client as the most likely outcomes of the amniotomy? select all that apply a. less pressure on the cervix b. decreased number of contractions c. increased efficiency of contractions d. The need for increased maternal BP monitoring e. The need for frequent fetal heart rate monitoring to detect the presence of prolapsed cord

c. increased efficiency of contractions e. The need for frequent fetal heart rate monitoring to detect the presence of prolapsed cord Amniotomy can be used to induce labor when the condition of the cervix is favorable r to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contraction.

The nurse is assessing a client who is 6 hours postpartum after delivering a full term healthy newborn. The client complains to the nurse of feelings of dizziness. Which nursing action is most appropriate? a. raise the head of the bed b. obtain Hgb and Hct levels c. instruct the client to request help when getting out of bed d. inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided

c. instruct the client to request help when getting out of bed Orthostatic hypotension may be evident during the first 8 hours after birth. The nurse would advise the client to get help the first few times getting out of bed. Option 1 is not helpful and would not relieve the symptoms. Option 2 requires a prescription

A 19 y/o primigravid client at 38 weeks' gestation is 7 cm dilated and the presenting part is at +1 station. The client tells the nurse, "I need to push1" What should the nurse do next? a. Use the McDonald procedure to widen the pelvic opening b. Increase the rate of oxygen and IV fluids c. instruct the client to use pant-blow pattern of breathing d. tell the client to push only when absolutely necessary

c. instruct the client to use pant-blow pattern of breathing Pushing during the first stage of labor when the urge is felt but the cervix is not completely dilated, may produce cervical swelling, making labor more difficult. The client should be encouraged to use a pant-blow (or blow-blow) pattern to help overcome the urge to push. McDonald procedure is used for cervical cerclage for an incompetent cervix and is inappropriate. Increasing the rate of O2 and IVF will not alleviate the pressure. The client should not push even if she feels the urge to do so.

The health care provider determines that outlet forceps are needed to assist in the birth a primigravid client in active labor with a large for gestational size fetus The nurse understands that the fetus' skull must be at what point before the procedure can take place? a. it is engaged past the inlet b. it is at +1 station c. it is visible at the perineal floor d. It has reached the level of the ischial spine

c. it is visible at the perineal floor When the fetal skull is on the perineum with the scalp visible at the perineal floor or vaginal opening, this is considered outlet forceps application.When the head is higher in the pelvis but engaged and its greatest diameter has passed the inlet, the operation is termed midforceps. Midforceps birth are not recommended because they are extremely dangerous for the mother and fetus because of the possibility of uterine rupture. If the head is not engaged, at -1 station, this is termed high forceps. High forceps births are also exceedingly dangerous for both the mother and the fetus. The fetus head at station +2 or lower is termed lower forceps

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use? a. deep kneading of superficial muscles b. secure grasping of muscular tissues c. light stroking of the skin surface d. prolonged pressure on specific areas

c. light stroking of the skin surface Light abdominal massage with just enough pressure to avoid tickling is thought to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically associated with relaxation massages to relieve stress. Prolonged pressure on specific sites is associated with acupressure

When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, the nurse would include which information? a. fetal macrosomia b. decreased fetal insulin c. maternal infection d. gestational HTN

c. maternal infection Maternal infection is the most common cause of maternal hyperglycemia and can lead to ketoacidosis, coma and death. Fetal macrosomia results from maternal hyperglycemia but does not cause it. Fetal insulin production increases as maternal glucose crosses the placenta, which helps control glucose in the fetus but has no bearing on maternal glucose levels

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which medication may be prescribed? a. progestin contraceptives b. medroxyprogesterone c. methotrexate d. dyphylline

c. methotrexate Because the fallopian tube has not yet ruptured, methotrexate may be given followed by leucovorin. This chemotherapeutic agent attacks the fast growing zygote and trophoblast cells. RU-486 is also effective. A hysterosalpingogram is usually performed after chemotherapy to determine whether the tube is still patent. Progestin only contraceptives and medroxyprogesterone are ineffective in clearing the fallopian tube. Dyphylline is a bronchodilator and is not used

Which is a priority nursing intervention in the provision of care for a pediatric client who is diagnosed with Kawasaki disease? a. applying cool compresses to the child's hands and feet b. Encouraging a quiet, calm and dark environment at night c. monitoring for extra heart sounds and low UOP d. supplying soft foods and increased amounts of clear liquids

c. monitoring for extra heart sounds and low UOP Application of cool compresses to the hands and feet could give comfort to the client in the acute phase of KD; however, this is not a priority over monitoring for complications associated with KD. Encouraging a quiet, calm, and dark environment at night is an appropriate nursing intervention for the child diagnosed with KD who is irritable and febrile; however, this is not a priority nursing intervention for this child. Extra heart sounds and low urine output could indicate poor myocardial function and poor kidney perfusion; therefore, this is the priority nursing intervention for this child Supplying soft foods and increased amounts of clear liquids will help the mouth discomfort associated with KD. While this is an appropriate nursing intervention, this is not the priority. Kawasaki disease (KD) is a disease process that causes inflammation (e.g., swelling and redness) in blood vessels throughout the body. There are three phases of KD with a fever often being the first symptom experienced by the child Kawasaki disease is a vasculitis that affects children. Although the symptoms themselves are not usually serious, KD can lead to long-term heart problems. Symptoms can recur so parents are taught the early symptoms so treatment can occur as soon as possible. The goal is to treat the condition before acute inflammation of the vessels of the body cause serious complications of the heart. Poor myocardial function can produce arrhythmias and poor kidney perfusion leading to extra heart sounds and low urine output

A newly diagnosed pregnant client tells the nurse, "If I am going to have all of these discomforts, I am not sure I want to be pregnant!" The nurse interprets the client's statement as an indication of which perception? a. fear of pregnancy outcome b. rejection of the pregnancy c. normal ambivalence d. limited self-care abilities

c. normal ambivalence The nurse should become concerned and contact a SW if the client expresses ambivalence in the third trimester.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the initial nursing action? a. record the findings b. massage the fundus c. notify the OB d. place the client in Trendelenburg position

c. notify the OB If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus would not assist in controlling the bleeding. Trendelenburg position would need to be avoided because it may interfere with cardiac and respiratory function.

The nurse is reviewing the PHCP's prescriptions for a client admitted for PROM. Gestational age of the fetus is determined to be 37 weeks. Which prescription would the nurse question? a. monitor HFR continuously b. monitor maternal VS frequently c. perform a vaginal exam every shift d. administer an abx per prescription and agency protocol

c. perform a vaginal exam every shift vaginal examinations should not be done routinely due to risk of infection

The PHP prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? a. offer the client frequent high calorie snacks b. check the apical pulse before each dose c. perform or assist with oral hygiene every shift d. give the medication 30 minutes prior to meal

c. perform or assist with oral hygiene every shift Phenytoin is an anticonvulsant. It works by slowing down impulses in the brain that cause seizures. A major side effect is gingival hyperplasia. Oral hygiene is important for decreasing this complication.

A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? select all that apply a. avoid any lifting b. perform Kegel exercises twice a day c. perform the pelvic rock exercise every day d. use proper body mechanics e. avoid constrictive clothing

c. perform the pelvic rock exercise every day d. use proper body mechanics

The nurse provides care for a toddler-age client who presents with sore throat, inspiratory stridor, and a fever of 103.1 F ( 39.5 C). Which is the nurse's priority action? a. Insert an IV catheter for med and fluid adminstration b. obtain an accurate temp with a rectal thermometer c. place the child in a tripod position on the parent's lap d. visually examine the child's throat for evidence of any drainage or exudate

c. place the child in a tripod position on the parent's lap This is the priority nursing action as the tripod position opens the child's airway and helps air flow. Allowing the child to assume this position in the parent's lap will also decrease anxiety. Invasive procedures, such as the initiation of IV access, should be delayed as this action by the nurse is likely to cause the child to cry which further compromises airway patency. A rectal temperature requires that the child be placed in a side-lying position which is likely to further exacerbate the child's airway issues. Visual examination of the client's throat is contraindicated for a child with a differential diagnosis of epiglottitis as this action will further exacerbate the child's airway issues. Examination of the child's throat is performed by the healthcare practitioner with emergency equipment available to address airway obstruction that may occur.

A community health nurse is educating the public on the agents of bioterrorism. Which of the following agents should the nurse include as Category A biological agents? Select all that apply a. Hantavirus b. typhus c. plague d. tularemia e. botulism

c. plague d. tularemia e. botulism Hantavirus is a Category C biological agent Typhus is a Category B biological agent

Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client has severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in which position? a. breech b. transverse c. posterior d. anterior

c. posterior When a client has severe back pain during labor, the fetus is most likely in an occipitoposterior position. This means that the fetal head presses against the client's sacrum, causing marked discomfort during contractions. These sensations may be so intense that the client requests medication for relief of the back pain rather than the contractions. Breech presentation and transverse lie are usually known prior to 8 cm dilation and a c section is performed. Fetal occiput anterior position doesn't increase the pain during labor.

The nurse discovers a hospice client has expired. The family members are regrouping in the facility's waiting room. Which of the following actions by the nurse would be the MOST appropriate? a. tell the family it would not be in their best interest to see their loved one b. encourage the family to view the body to help accept the situation c. provide condolences to the family and offer them viewing time d. tell the family, "I will give you some time to spend with your loved one. Let me know if you need anything."

c. provide condolences to the family and offer them viewing time The nurse acknowledges the loss, expresses sympathy, and offers the viewing opportunity.

Approximately 15 minutes after birth of a viable term neonate, a multiparous client has chills. What should the nurse do next? a. assess the client's pulse rate b. decrease the rate of IVF c. provide the client with a warm blanket d. assess the amount of blood loss

c. provide the client with a warm blanket A chill after birth is common. Warm blankets can help provide comfort for the patient.

When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, the nurse should discuss which type of diet? a. high-residue diet b. low-sodium diet c. regular diet d. high-protein diet

c. regular diet For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased.

Trimethoprim has been prescribed for a client for a UTI. The nurse should instruct the client to: a. take the medication with meals b. return to the office in 3 days so that a urine culture can be obtained c. report any unusual bleeding or bruising d. take the medication until symptoms subside

c. report any unusual bleeding or bruising Trimethoprim can cause thrombocytopenia so they should be instructed to report any unusual bleeding or bruising. Periodic blood counts should be conducted while the client is on this medication

A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, is bright red and is trickling from the vagina. The nurse locates the fundus at the umbilicus, it is firm and midline with no palpable bladder. The client's VS remain at their baseline. Based on this information, the nurse would implement which action? a. increase the IV rate b. recheck the admission hct and hgb levels c. report the findings to the HCP d. document the findings as normal

c. report the findings to the HCP At any point in the postpartum period, the lochia should be dark in color rather than bright red. The volume should not be great enough to trickle or run from the vagina. The fundus being firm, midline and at umbilicus are expected outcomes. These findings indicate bleeding is not from the uterus or uterine atony. The bladder is not palpable, which indicates that bleeding is not related to a full bladder. The most likely etiology is cervical or vaginal lacerations or tears.

A multigravida in active labor is 7 cm dilated. The FHR baseline is 130 bm with moderate variability. The client begins to have variable decels to 100-110 bpm. What should the nurse do next? a. perform a vaginal examination b. notify the HCP of the decels c. reposition the client and continue to evaluate FHR d. administer oxygen via mask at 2 L/min

c. reposition the client and continue to evaluate FHR The cause of variable decel is cord compression which may be relieved by moving the client to one side or another.

A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse make? a. shake the bag to mix the fat b. turn the bag upside down one time c. return the bag to the pharmacy d. administer the bag of solution as is

c. return the bag to the pharmacy Cracking has occurred and the bag should not be used

A client who is diagnosed with infective endocarditis (IE) is admitted to the nursing unit for observation. Which assessment data should the nurse report immediately to the client's healthcare provider (HCP)? Select all that apply. a. WBC of 12,400/mm3 b. fingers that appear clubbed c. right extremity paralysis d. pain and coolness to left foot e. temp of 101.9 F

c. right extremity paralysis d. pain and coolness to left foot A slightly elevated WBC count is expected for a client who is diagnosed with infective endocarditis. Clubbing of the fingers is associated with long-term hypoxemia; therefore, this is not an acute problem thus it does not require immediate HCP notification. Right extremity paralysis could indicate emboli from the IE has migrated to the right extremity; therefore, this data should be reported to the client's HCP immediately for further evaluation. Pain and coolness to left foot could indicate emboli from the IE has migrated to the left foot; therefore, this assessment data is reported immediately to the client's HCP for additional evaluation. A temperature of 101.9 F (38.8 C) is an expected finding for a client who is diagnosed with IE; therefore, this assessment data does not require immediate HCP notification

The nurse provides care for a client who is prescribed the following medications: torsemide 10 mg PO daily, atenolol 50 mg PO daily, cyclobenzaprine XL 5 mg po daily, and oxycodone 40 mg PO every 6 hours prn pain. Based on the client's medications, which is the priority nursing diagnosis to include in the plan of care? a. chronic pain b. risk for acute confusion c. risk for injury d. urinary frequency

c. risk for injury Oxycodone that is prescribed in conjunction with cyclobenzaprine, atenolol, and torsemide increases the client's risk for injury due to a fall. Therefore, this is the priority nursing diagnosis for this client.

The nurse working in a community outreache program for foster children plans care, knowing that which health conditions are common in this populaton? Select all that apply a. asthma b. claustrophobia c. sleep problems d. bipolar disorder e. aggressive behavior f. ADHD

c. sleep problems d. bipolar disorder e. aggressive behavior f. ADHD

The HCP has prescribed prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which finding indicates that the client has had a therapeutic response to the medication? a. resting period of 2 min between contractions b. decreasing nausea in labor c. softening of the cervix and beginning of effacement d. leaking of clear amniotic fluid in small amounts

c. softening of the cervix and beginning of effacement Prostaglandin gel may be used for cervical ripening before the induction of labor with oxytocin. It is usually administered by catheter or suppository or by vaginal insertion. Two or three doses are usually needed to begin the softening process. Common ADR include N/V. fever and diarrhea. Continuous FHR monitoring and close monitoring of maternal VS are necessary to detect subtle changes or ADR.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? a. taking in b. taking on c. taking hold d. letting go

c. taking hold The client is in the taking hold phase with demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase. Letting go is the process beginning about 6 weeks postpartum when the other may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process

A community health nurse is developing strategies to prevent or improve mental health issues in the local area. In which of the following situations is the nurse implementing a tertiary prevention strategy? a. providing support programs for new parents b. screening a client whose partner recently died for suicide risk c. teaching a client who has schizophrenia about medication interactions d. discussing stress reduction techniques with employees at an industrial site

c. teaching a client who has schizophrenia about medication interactions

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? select all that apply a. The contractions are regular b. the membranes have ruptured c. the cervix is dilated completely d. the client begins to expel clear vaginal fluid e. the Ferguson reflex is initiated from perineal pressure

c. the cervix is dilated completely e. the Ferguson reflex is initiated from perineal pressure The client has a strong urge to push in stage 2 when the Ferguson reflex is activated

The HCP has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate which other client finding within the next week? a. The client will develop preeclampsia b. the fetus will develop mature lugns c. the client will not develop preterm labor d. the fetus will not develop gestational diabetes

c. the client will not develop preterm labor The absence of fetal fibronectin in a vaginal swab between 22=37 weeks 'gestation indicates there is < 1% risk of developing preterm labor in the next week. Fetal fibronectin is extracellular protein normally found in fetal membranes and decidua and has no correlation with preeclampsia, fetal lung maturation or gestational diabetes

When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown below. Which maneuver is the nurse performing? a. first maneuver b. second maneuver c. third maneuver d. fourth maneuver

c. third maneuver The third maneuver invovles grasping the lower porition of the abdomen just above the symphysis pubis between the thumb and index finger. This maneuver determines whether the fetal presenting part is engaged. The first maneuver involves facing the woman's head and using the tips of the fingers to palpate the uterine fundus. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. The second maneuver involves placing the palms of each hand on either side of the abdomen to locate the back of the fetus. The fourth maneuver involves placing the fingers on both sides of the uterus and pressing downward and inward in the direction of the birth canal. This maneuver is done to determine fetal attitude and degree of extension and should only be done if the fetus is in the cephalic presentation

A client has had a total abdominal hysterectomy. The nurse should specifically assess the client for which potential complication related to this surgery? a. infection b. bleeding c. thrombophlebitis d. atelectasis

c. thrombophlebitis Extensive pelvic surgery removes lymph nodes from pelvis and results in circulatory congestion from edema and stasis.

A nurse is preparing an education program on disease transmission for employees at a local day care facility. Wehn discussing the epidemiological triangle, the nurse should include which of the following factors as agents? Select all that apply a. resource availability b. ethnicity c. toxins d. bacteria e. altered immunity

c. toxins d. bacteria Altered immunity is host factor

The nurse is performing an assessment on a client with a history of chronic venous insufficiency and observes 2+ pitting edema to bilateral lower extremities with discolored ankles and thickened, overgrown toenails. Which action is most important for the nurse to take? a. help the client stand and remain upright for 15 min b. apply tight fitting nonslip footwear to the client's feet c. use pillows to elevate the client's lower extremities d. trim the client's toenails carefully with sterile clippers

c. use pillows to elevate the client's lower extremities This answer is not correct because standing for 15 minutes would likely exacerbate the client's edema. While movement in the form of exercise can help to promote better blood flow, prolonged periods of standing should be avoided. This answer is not correct because while the thickened toenails that this client displays are consistent with the client's history of chronic venous insufficiency, the nurse should never trim the client's toenails. Doing so could increase the client's risk for injury and infection.

The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. What prescription would the nurse anticipate from the HCP? a. frequent assessments of cervical dilation b. IV oxytocin administration c. vaginal cultures for Neisseria gonorrhoeae d. sonogram for amniotic fluid volume index

c. vaginal cultures for Neisseria gonorrhoeae Because an intrauterine infection may occur when membranes have ruptured, vaginal cultures for N. gonorrhoeae, group B strep and chlamydia are usually taken. Prophylactic abx may be prescribed to reduce the risk of infection in the newborn. Frequent vaginal exam should be avoided because they can further increase the risk for infection. IV oxytocin may be used if an infection occurs. Bed rest can prolong the pregnancy and prevent a preterm birth. A sonogram may be used to validate rupture of the membranes with an amniotic fluid index, but is not needed if HCP has confirmed the rupture

A community health nurse is assessing a client who reports numbness of the hands and feet for the past 2 weeks. This finding is associated with which of the following nutritional deficiencies? a. folic acid b. potassium c. vitamin B12 d. iron

c. vitamin B12

What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? Select all that apply a. thick, white sputum b. crackles that clear with coughing c. wheezing d. orthopnea e. apical pulse 88/min f. S3 gallop

c. wheezing d. orthopnea f. S3 gallop

Poison ivy treatment

calamine lotion and commercial products that soothe lesions, wet compresses and solutions that are astringent and antiseptic, and colloidal oatmeal baths to relieve discomfort. Topical CS to prevent or relieve inflammation esp when used before blisters form. Oral CS for severe reactions, and antihistamine to promote sleep such as benadryl

medications to treat poison ivy

calamine lotion, hydrocortisone (local), prednisone (systemic), pramoxine, zinc acetate, isopropanol, benzyl alcohol

Phytonadione ADR

can cause hyperbilirubinemia

Actinic keratoses

caused by prolonged exposure to sun and appear as rough, scaly, red or brown lesions, usually on face, scalp, arms and back of hands

Hodgkin's disease interventions

chemo or radiation. Monitor for medication induced pancytopenia and abnormal depression of all cellular components of the blood, which increase risk for infection, bleeding and anemia. Monitor for infection and bleeding, N/V.

signs of transfusion reaction

chest pain, hives or skin rash, hypotension/HTN, fever, chills, anxiety, wheezing, HA or muscle pain w/ fever, flushing, back pain, dizziness, itching, urticaria, tachycardia, tachypnea, dyspnea, N/V

Allergic rhinitis

children are sensitive to environmental allergens

endometritis assessment

chills and fever, increased pulse, decreased appetite, HA, backache, prolonged severe afterpains, tender large uterus, foul lochia or reddish brown lochia, ileus, elevated WBC

Rheumatic fever assessment

chorea (involuntary movements of extremities and face, affects speech), fever, carditis, erythema marginaturm (red skin lesions starting on the trunk spreading peripherally), abdominal pain, SC nodules, polyarthritis. Elevated anti-streptolysin O titer, elevated ESR and CRP. Aschoff bodies (lesions) found in heart, blood vessels, brain, serous surfaces of the joints and pleura

psoriasis

chronic inflammatory disorder that has varying degrees of severity. Treatment is based on severity and aims to suppress proliferation of keratinocytes or suppress activity of inflammatory cells

Erythromycin interventions

clean eyes before instilling, don't flush eyes after

Thrombophlebitis

clot forms in vessel wall as result of inflammation of vessel wall, most common in legs and can be superficial or deep. concern for PE. increased blood clotting factors in postpartum place client at risk, early ambulation is preventative

Hepatitis D

coinfection with HBV, more severe than HBV and can lead to cirrhosis Children with heophilia are more likely to be infected, as well as IVDU

intussception assessment

colicky abdominal lain that causes the child to scream and draw knees to abdomen, similar to fetal position. vomiting of gastric contents or bile stained fecal emesis. Currant jelly like stools containing blood and mucus. Hypoactive or hyperactive bowel sounds. Tender distended abdomen, possibly w/ palpable sausage shaped mass in upper right quadrant

rupture of vagina

complete or incomplete separation of uterine tissue as result of tear in the wall of uterus from the stress of labor

Legg-Calve-perthes disease

condition affecting the hip where the femur and pelvis meet in the joint. Blood supply is temporarily interrupted to the head of the femur, and the bone dies and stops growing

Encopresis

constipation with fecal incontinence, children often complain that soiling is involuntary and occurs without warning. Usually result of fecal impaction and an enlarged rectum caused by chronic constipation

scarlet fever intervention

contact and droplet precautions until 24 hours after abx. Supportive therapy, bed rest

impetigo interventions

contact isolation, topical abx ointments. Can be contagious beyond 24 hour after abx treatment. cover lesions with gauze to prevent spreading of infection. warm compresses to lesions and mild soap and water to soften crusts for removal and healing.

impetigo

contagious bacterial infection caused by group A strep and staph aureus. Occurs due to poor hygiene, can be primary or secondary infection at an insect bite, rash, such as atopic dermatitis, poison ivy or poison oak. Most common on face and around mouth, hands, neck and extremities. Begin as vesicles or pustules surrounded by edema and redness. Progress to exudative and crusting stage. After the crusting of the lesions the initially serous vesicular fluid becomes cloudy, and the vesicles rupture, leaving honey colored crusts covering ulcerated bases. Blisters and honey colored crusts, erythema, pruritus, burning, secondary lymph node involvement

rheumatic fever interventions

control pain with massage and alternating hot and cold applications, bed rest during acute febrile phase. Abx, salicylates and antiinflammatory agents. Seizure precautions if experiencing chorea. Need for abx prophylaxis for dental work

strasbismus interventions

corrective lenses, patching of good eye to strengthen the weak eye. Surgery to realign the weak muscle if nonsurgical interventions are not successful

Pregnancy cardiac disease assessment

cough and respiratory congestion, dyspnea and fatigue, palpitation and tachycardia, peripheral edema, chest pain, signs of respiratory infection, signs of HF and pulmonary edema

strasbismus assessment

crossed eyes, squinting, tilts the head or closes one eye to see, loss of binocular vision, impairment of depth perception, frequent HA, diplopia, photophobia

A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? a. "Obtain an immunization against rubella early in pregnancy." b. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." c. "A client should avoid crowded places during pregnancy." d. "A client should avoid consuming undercooked meat while pregnant."

d. "A client should avoid consuming undercooked meat while pregnant." Toxoplasmosis, a TORCH infection, is contracted by consuming undercooked meat.

After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client makes which statement? a. "A total weight gain of approx 20 lb is recommended." b. "A weight gain of 6.6 lb in the second and third trimesters is considered normal." c. "A weight gain of about 12 lb every trimester is recommended." d. "Although it varies, a gain of 25 to 35 lb is about average."

d. "Although it varies, a gain of 25 to 35 lb is about average." Typically, women should gain 3.5 lb during the first trimester and then 1 lb/week during the remainder of the pregnancy for a total of about 27-28 lb. In addition, nausea and vomiting during the first trimester can contribute to a lack of appetite and smaller weight gain during this trimester

A woman with asthma controlled through the consistent use of medication is now pregnant for the first time. Which client statement concerning asthma during pregnancy indicates the need for further instruction? a. "I need to continue taking my asthma medication as prescribed." b. "It is my goal to prevent or limit asthma attacks." c. During an asthma attack, oxygen needs to continue to be high for mother and the fetus." d. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

d. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions would include which statement? a. "Your hair will need to be shaved." b. "You will receive spinal anesthesia." c. "You will need to ambulate after surgery." d. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery."

d. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site.

A nurse is discussing preterm labor in a prenatal class. After class, a client asks the nurse to identify again the nursing strategies to prevent preterm labor. The client needs further instructions when she makes which statement? a. "I need to stay hydrated all the time." b. "Even dental infections can lead to preterm labor." c. "I should include frequent rest breaks if I travel." d. "Cutting back on my smoking will not help my baby."

d. "Cutting back on my smoking will not help my baby." Smoking is a major RF for preterm labor and decreased fetal weight. Dehydration is a RF for preterm labor as is prolonged standing and remaining in one position. Infection anywhere in the body can lead to preterm labor through the inflammation pathway. While taking trips, frequent emptying of the bladder prevents infection and ambulates the woman.

Which is the priority action by the nurse when responding to a parent of a toddler-age client who calls and reports finding the child in the bathroom with a cough medicine bottle that is empty? a. "You should call and schedule an appt with your child's pediatrician." b. "Give your child a bottle of gatorade to flush the cough medicine out of the system." c. "Do you have a pen to write down the phone number for poison control?" d. "Describe exactly how your child is behaving right now."

d. "Describe exactly how your child is behaving right now." When faced with any clinical scenario, the nurse implements the steps of the nursing process. The first step of this process is assessment. Therefore, the nurse asks the toddler's parent to, "Describe exactly how your child is behaving right now." This response allows the nurse to gather data to determine next steps that are required to enhance the toddler's safety. While the other responses may be appropriate, they are not the first action when implementing the nursing process; therefore, are not considered the priority response by the nurse.

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? a. "Wait until you have breastfed for at least 4 months." b. "Eliminate the baby's favorite feeding times first." c. "Plan to omit the daytime feedings last." d. "Gradually eliminate one feeding at a time."

d. "Gradually eliminate one feeding at a time." The baby can be weaned to a bottle anytime the mother desires, she doesn't have to breastfeed for 4 months. Most infants develop a favorite feeding time so it should be eliminated last.

An 8-year-old girl is discharged from the hospital with a new tracheostomy. The parents have received initial teaching in the hospital, and the home health nurse will reinforce this teaching. Per report, the parents are willing to learn and are grasping the concepts well. The home health nurse would expect the parents to verbalize and demonstrate which of the following? a. "The cleansing and dressing of the stoma will be done at least every 24 hours." b. "It is not always necessary to suction before tracheostomy care." c. "The inner cannula should be changed by the physician or home health nurse." d. "Hydrogen peroxide is used to cleanse the stoma area."

d. "Hydrogen peroxide is used to cleanse the stoma area." Hydrogen peroxide-soaked gauze pads or cotton-tipped applicators are used to clean the stoma area, followed by the use of sterile water-soaked gauze pads and cotton-tipped applicators to remove the hydrogen peroxide. The stoma area would then be dried using sterile gauze pads to reduce the risk of infection and irritation

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? a. "I need to be sure not to go barefoot around the house." b. "If I cut my toenails, I need to be sure that I cut them straight across." c. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." d. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

d. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, needs to avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements and indicate that the teaching has been effective.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? a. "I need to increase my sodium intake during pregnancy." b. "I need to lower my blood volume by limiting my fluids." c. "I need to maintain a low calorie diet to prevent any weight gain." d. "I need to drink adequate fluids and increase my intake of high fiber foods."

d. "I need to drink adequate fluids and increase my intake of high fiber foods." Constipation can cause the client to use the Valsalva maneuver. It needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by addition of fluids and high fiber foods. A low calories diet is not recommended during pregnancy because it could be harmful to the fetus.

A client with coronary artery disease is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? a. "It will really hurt when the catheter is first put in." b. "I will receive general anesthesia for the procedure." c. "I will have to go to the operating room for this procedure." d. "I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

d. "I probably will feel tired after the test from lying on a hard x-ray table for a few hours." It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? a. "I will handle the area gently." b. "I will wear loose-fitting clothing." c. "I will avoid the use of deodorants." d. "I will limit sun exposure to 1 hour daily."

d. "I will limit sun exposure to 1 hour daily." The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement? a. "I will need more frequent appt during the remainder of the pregnancy." b. "Signs of any type of infection must be reported immediately." c. "At the earliest signs of a crisis, I need to seek treatment." d. "I will need to take an iron supplement even if my lab values are normal."

d. "I will need to take an iron supplement even if my lab values are normal." This type of anemia is not caused by lack of iron in the diet. Iron supplementation is needed only if there is lab evidence of iron deficiency anemia.

A client gave birth 2 days ago and has been given instructions on breast care for bottle feeding mothers. Which statement indicates that the nurse should reinforce the instructions to the client? a. "I will wear a sports bra or a well fitting bra for several days." b. "When showering, I will direct water onto my shoulders." c. "I will use only water to clean my nipples." d. "I will use a breast pump to remove any milk that may appear."

d. "I will use a breast pump to remove any milk that may appear." The use of a breast pump to remove milk is contraindicated in bottle feeding mothers. Nipple and breast stimulation and emptying the breasts produce milk rather than eliminate milk production. The bottle feeding client is discouraged from stimulating the breasts in any way.

The nurse instructs a preeclamptic client about monitoring the movements of her fetus to determine fetal well being. Which statement by the client indicates that she needs further instruction about when to call the HCP concerning fetal movement? a. "If the fetus is becoming less active than before." b. "If it takes longer each day for the fetus to move 10 times." c. "If the fetus stops moving for 12 hours." d. "If the fetus moves more often than 3 times an hour."

d. "If the fetus moves more often than 3 times an hour."

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? a. "It is used to stimulate uterine contractions." b. "It will decrease the incidence of uterine contractions." c. "It lulls the fetus to sleep." d. "It awakens a sleeping fetus

d. "It awakens a sleeping fetus

During a routine clinic visit, a 25 year-old multigravid client who initiated prenatal care at 10 weeks' gestation and is now in her third trimester states, "I've been having strange dreams about the baby. Last week I dreamed he was covered with hair." What should the nurse tell the mother? a. "Dreams like the ones that you describe are very unusual. Please tell me more about them." b. "Commonly when a mother has these dreams, she is trying to cope with becoming a parent." c. "Dreams about the baby late in pregnancy usually mean that labor is about to begin soon." d. "It is not uncommon to have dreams about the baby, particularly in the third trimester."

d. "It is not uncommon to have dreams about the baby, particularly in the third trimester."

The nurse is caring for a G2, T1, P0, A0, L1 client at term. The client is completely effaced, dilated to 2 cm, with contractions every 3 minutes lasting 45 seconds. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse. a. "We cannot give epidurals until you are 5-6 cm dilated. There is IV medication available if you would like it now." b. "You cannot have an epidural until your membranes have ruptured." c. "Your contraction pattern is slow at this point and iwll need to accelerate before you can have your epidural." d. "It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1-2 cm more."

d. "It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1-2 cm more." Epidurals are given when labor is established, usually at 3-4 cm dilation. The effect of the epidural should be that labor will continue and not be slowed down by the epidural. The use of an epidural is not correlated with ROM. The contraction pattern for this client is adequate, not slow and considered normal for 2 cm dilation. Epidurals are given at 3-4 cm dilation and if there is medication available, it can be given to make that client comfortable until an epidural can be given.

A client arrives at the crisis center and reports stopping daily lithium because of the pregnancy. What response by the nurse is most accurate? a. "Are you positive that you are actually pregnant?" b. "Lithium is perfectly safe throughout pregnancy." c. "The psychiatrist can change you to another medication that is safe." d. "It may be worse to suddenly stop the medication than to take the medication."

d. "It may be worse to suddenly stop the medication than to take the medication." Lithium is most often used to treat manic-depression. Suddenly stopping the medication could cause the client to relapse, experiencing worse symptoms than previously. It may also be more difficult to get those symptoms under control again if the client has stopped this drug suddenly. The client and PHP would need to weigh the benefits of this medication vs. the possible birth defects. There are very few medications for bipolar disorder that would be completely safe during pregnancy

A birthing parent with HIV infection brings a 10 month old infant to the clinic for a routine checkup. The pediatrician has documented that the infant is asymptomatic for HIV infection. After the checkup the parent tells the nurse about being so pleased that the infant will not get HIV infection. The nurse would make which most appropriate response to the parent? a. "I am so pleased also that everything has turned out fine." b. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection." c. "Everything looks great, but be sure to return with your infant next month for the scheduled visit." d. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

d. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

The nurse has completed an educational course about first-degree heart block. Which statement by the nurse indicates that teaching has been effective? a. "Presence of Q waves indicates first-degree heart block." b. "Tall, peaked T waves indicate first-degree heart block." c. "Widened QRS complexes indicate first-degree heart block." d. "Prolonged, equal PR intervals indicate first-degree heart block."

d. "Prolonged, equal PR intervals indicate first-degree heart block." Prolonged and equal PR intervals indicate first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An electrocardiogram (ECG) taken during a pain episode is intended to capture ischemic changes, which also include ST segment elevation or depression.

The nurse provides teaching to the parents of an infant who is diagnosed with acute otitis media (AOM) and prescribed a 10 day course of azithromycin. Which statement should the nurse include in the teaching session? a. "Give PSE 30 mg by mouth every 6 hours for relief of ear pressure and pain." b. "If your child develops a rash, give 10 mg of benadryl by mouth every 12 hours." c. "If your child develops diarrhea make sure to hold the abx for that day and give fluids." d. "Schedule an appt with your child's pediatrician if symptom improvement does not occur within 72 hours."

d. "Schedule an appt with your child's pediatrician if symptom improvement does not occur within 72 hours." The antibiotic should be stopped immediately and the healthcare provider consulted if a rash develops. Anaphylaxis can occur from an allergic reaction to antibiotics so the practitioner should be consulted immediately prior to the implementation of interventions. Acute otitis media (AOM) is an infection of the inner ear from a virus or bacteria. Medical treatment is antibiotics, including a 10 day course of azithromycin. If improvement of symptoms is not achieved within 72 hours, the healthcare provider should be consulted.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about yellow and seedy stools that the infant has had since they were discharged home from the hospital. What is the best reply by the nurse? a. "This type of stool indicates the infant may have diarrhea and should be seen in the office today." b. "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." c. "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." d. "Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."

d. "Soft, seedy, unformed stools with each feeding are normal for this age infant and will continue through breastfeeding."

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? a. "This form of therapy can be applied to new situations." b. "An advantage of this technique is that change is likely to last." c. "Talking to oneself is a basic component of this form of therapy." d. "This form of therapy provides a negative reinforcement when the stimulus is produced."

d. "This form of therapy provides a negative reinforcement when the stimulus is produced." Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I am really in labor?" What should the nurse tell the participant about true labor contractions? a. "Walking around helps to decrease true contractions." b. "True labor contractions may disappear with ambulation, rest or sleep." c. "The duration and frequency of true labor contractions remain the same." d. "True labor contractions are felt first in the lower back, then the abdomen."

d. "True labor contractions are felt first in the lower back, then the abdomen." They gradually increase in frequency and duration and does not disappear with ambulation, rest or sleep. In true labor, the cervix dilates and effaces. Walking tends to increase contractions. False labor contractions disappear with ambulation, rest or sleep. They commonly remain same in duration and frequency. Clients in false labor may have pain, even though the contractions are not very effective

When providing culturally competent care to a African American family with an infant recently diagnosed with colic, which question is best for the nurse to ask during the assessment process? a. "Did your other children have colic as babies?" b. "How do you respond when your baby cries?" c. "How many times per day do you feed the baby?" d. "What do you think caused your baby's colic?"

d. "What do you think caused your baby's colic?" This question allows the nurse to assess the parents' beliefs regarding the cause of their child's colic and will facilitate the development of culturally sensitive and appropriate care and teaching; therefore, it is the most relevant question for the nurse to ask the caregiver

A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client? a. "You should wait until 4 weeks after conception to be tested." b. "You should be off any medications for 24 hours prior to the test." c. "You should be NPO for at least 8 hours prior to the test." d. "You should collect urine from the first morning void."

d. "You should collect urine from the first morning void."

The nurse is reviewing discharge instructions with a postpartum breatfeeding client who is going home. She has chosen depot medroxyprogesterone acetate (DMPA) injections as birth control. Which statement by the client idetnifies that she needs further instruction concerning birth control? a. "I will wait for my 6 week checkup to get my first birth control injection." b. "Depot injections last for 90 days." c. "My milk supply should be well established before receiving a birth control injection." d. "You will give me my first depot injection before I leave today."

d. "You will give me my first depot injection before I leave today." Depot medroxyprogesterone acetate is an injectable progestin contraceptive that can reduce the initial production of breast milk. It is given to a breastfeeding woman when she returns for the 6 week postpartum checkup. By this time, the milk supply is well established and will remain at that level. DMPA is effective for 90 days and can be given within 5 days of birth only if a mother is not breastfeeding

A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with 2 beats of ankle clonus present. How does the nurse document the patellar reflexes? a. 1+ b. 2+ c. 3+ d. 4+

d. 4+ 1+ indicates a diminished response, 2+ indicates a normal response, 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are 2 movements

The charge nurse prepares for the admission of a client from the postanesthesia care unit (PACU). Which semi-private room assignment is most appropriate for this client? a. A client with cellulitis of the arm secondary to an insect bite with an elevated WBC count b. A client with ESRD on HD and elevated BG c. A client who is diagnosed with AIDS who reports feeling under the weather for a few days now d. A client with severe epistaxis after a traumatic fall who has a plt count of 72,000/mm3

d. A client with severe epistaxis after a traumatic fall who has a plt count of 72,000/mm3 Client with elevated serum glucose levels and end-stage renal disease have compromised immune defenses and are at risk for developing infections as a result. Due to this client's increased risk for infection, this is not the best choice to be paired with an immediate post-op client with new surgical incisions. This client does not display any signs or symptoms of any infectious disease and may be safely paired in a semi-private room with an immediate post-op client without increasing the surgical client's risk for infection.

The nurse has several tasks to perform this afternoon. Which of the following should the nurse delegate to the CNA? a. Assessing the breath sounds of a patient with shortness of breath. b. Removing a pressure ulcer dressing in anticipation of the rounding physician. c. Performing a rectal temperature on a febrile patient receiving Tylenol. d. Administering tube feedings through the Dobhoff of a patient with increased intracranial pressures.

d. Administering tube feedings through the Dobhoff of a patient with increased intracranial pressures. In most states CNA's are not allowed to perform invasive procedures like rectal temperatures, apply or remove dressings, or perform assessments, especially when a change in the patient's conditions requires advanced nursing skill. Administering tube feedings is acceptable despite the increased ICP. As long as the tube is already in place and it's appropriate position confirmed and the CNA is following orders closely, they are practicing within their guidelines and in no threat of increasing the ICP any further.

A client with a 3 day history of nausea and vomiting and suspected gastroenteritis presents to the ED. The client is hypoventilating and has a RR of 10 breaths per minutes. The ECG monitor displays tachycardia, with HR of 120 bpm. ABG are drawn, and the nurse reviews the results, expecting to note which finding? a. A decreased pH and increased PaCO2 b. An increased pH and decreased PaCO2 c. decreased pH and decreased HCO3- d. An increased pH and an increased HCO3-

d. An increased pH and an increased HCO3- Clients w/ N/V would most likely present w/ metabolic alkalosis, causing pH and HCO3 would increase.

The nurse is assigned a group of clients on a medical-surgical unit. Which client requires priority action by the nurse? a. a client, diagnosed with a blood clotting disorder, who did not receive a prescribed dose of rivaroxaban b. a client with colostomy that is full half of dark brown stool c. a client, diagnosed with emphysema, who reports DOE with a pulse ox of 89% on RA d. An older client with new onset hematuria and bloody stools who is receiving IV abx for UTI

d. An older client with new onset hematuria and bloody stools who is receiving IV abx for UTI An older adult client being treated for a UTI who develops hematuria and bloody stools may be experiencing disseminated intravascular coagulation (DIC), a life-threatening complication; therefore, this is the client that requires priority action by the nurse to prevent potential complications related to abnormal clotting and bleeding.

The team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN/LVN? a. Calling the HCP to report SBAR. b. Giving naloxone and evaluating response to therapy c. Monitoring the respiratory status for the first 30 minutes d. Applying O2 per NC as ordered

d. Applying O2 per NC as ordered The LPN/LVN is well trained to administer oxygen per nasal cannula. This client is considered unstable; therefore, the RN should take responsibility for administering drugs and monitoring the response to therapy, which includes the effects on the respiratory system. The RN should also take responsibility to communicate with the HCP for ongoing treatment and therapy.

An inexperienced graduate nurse is reviewing the MAR for a client who has a PCA pump for pain management. The new nurse compares the MAR and the HCP's prescription, and both indicate that larger doses are prescribed at night compared with doses throughout the day. Which member of the health care team should the new nurse consult first? a. Ask the client if he typically needs extra medication in the evening b. Ask the HCP to verify that the larger amount is the correct dose c. Ask the pharmacist to confirm the dosage on the original prescription d. Ask the charge nurse if this is a typical dosage for nighttime PCA

d. Ask the charge nurse if this is a typical dosage for nighttime PCA The nurse has taken the first correct step and compared the MAR to the HCP's original prescription. Because the nurse is new, the charge nurse would be the best resource. In fact, larger PCA doses are given at night to increase the interval between doses. This helps the client to rest and sleep. The nurse can contact the other members of the health care team at any time if the charge nurse is unable to help

The nurse assesses the peripheral IV site of a client receiving a doxorubicin infusion and suspects extravasation. After stopping the infusion and disconnecting the IV tubing, which of the following should the nurse do next? a. Apply a hot compress to the IV site. b. Apply a cold compress to the IV site. c. Elevate the affected extremity. d. Attempt to aspirate the residual drug.

d. Attempt to aspirate the residual drug. Although a cold compress is recommended in an doxorubicinassociated extravasation, it should not be applied until residual drug removal has been attempted. Although elevating the arm for 48 hours is recommended, this should not be done until after the residual drug has been removed.

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? a. Checking for normal serum electrolyte levels b. Checking for normal pH of the gastric aspirate c. Checking for proper nasogastric tube placement d. Checking for the presence of bowel sounds in all four quadrants

d. Checking for the presence of bowel sounds in all four quadrants Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.

The client is taking Flecainide for arrhythmias. What type of antiarrhythmic medication is this: a. Class IB b. Class II c. Class IB d. Class IC

d. Class IC Flecainide is a class IC anti-arrhythmic drug.

The HCP has ordered a placebo for a client with chronic pain. The newly hired nurse feels very uncomfortable administering the medication. What is the first action that the new nurse should take? a. Prepare the medication and hand it to the HCP b. Check the hospital policy regarding the use of a placebo c. Follow a personal code of ethics and refuse to participate d. Contact the CSN for advice and suggestions

d. Contact the CSN for advice and suggestions Administering placebos is generally considered unethical. (There are circumstances, such as clinical drug research where placebos are used, but clients are aware of that possibility.) The charge nurse is a resource person who can help clarify the situation and locate and review the hospital policy. If the HCP is insistent, suggest that he or she could give the placebo.

A parent brings a 4 month old infant to a well-baby clinic for immunizations. The child is up to date with the immunization schedule. The nurse should prepare to administer which immunizations to this infant? a. varicella, Hep B b. DTaP, MMR, IPV c. MMR, Hib, DTaP d. DTaP, Hib, IPV, PCV and RV

d. DTaP, Hib, IPV, PCV and RV

The nurse is reviewing the client's medication list. Calcium channel blockers have a significant drug-drug interaction with what? a. Digoxin b. Theophylline c. Hydrochlorothiazide d. Fentanyl

d. Fentanyl The giving of Fentanyl with calcium channel blockers can bring about severe hypotension.

A multigravid client in active labor at term is diagnosed with polyhydramnios. The HCP has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that it is associated with which problem in the fetus or neonate? a. renal dysfunction b. IUGR c. pulmonary hypoplasia d. GI disorders

d. GI disorders Polyhydramnios is associated with GI disorders (tracheoesophageal fistula). It is also associated with maternal illnesses such as DM and anemia. Other disorders associated with this condition include congenital anomalies of the CNS (anencephaly), upper GI obstruction and macrosomia.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What would the nurse plan to teach the client about this type of angina? a. It is most effectively managed by beta-blocking agents. b. It has the same risk factors as stable and unstable angina. c. It can be controlled with a low-sodium, high-potassium diet. d. Generally it is treated with calcium channel-blocking agents.

d. Generally it is treated with calcium channel-blocking agents. Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium channel blockers. Beta blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.

The charge nurse is reviewing the records of clients who were assigned to a newly graduated RN. The RN has correctly documented dose and time of medication, but there is no documentation regarding nonpharmaceutical measures. What action should the charge nurse take first? a. Make a note in the nurse's file and continue to observe clinical performance b. Refer the new nurse to the in-service education dept. c. Quiz the nurse about knowledge of pain management and pharmacology d. Give praise for documenting dose and time and discuss documentation deficits

d. Give praise for documenting dose and time and discuss documentation deficits In supervision of the new RN, good performance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an option; however, it would be a more indirect and time-consuming approach. Making a note and watching do not help the nurse to correct the immediate problem. In-service training might be considered if the problem persists.

A client with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse's initial action? a. Check the MAR for the past several days. b. Ask the nurse educator to provide in-service training about pain management c. Perform a complete pain assessment on the client and take a pain history d. Have a conference with the staff nurses to assess their care of this patient.

d. Have a conference with the staff nurses to assess their care of this patient. The CSN must assess the performance and attitude of the staff in relation to this client. After data are gathered from the nurses, additional information can be obtained from the recrods and the client as necessary. The educator may be of assistance if a knowledge deficit or need for performance improvement is the problem.

The nurse assesses a client with a diagnosis of parathyroid disease. The client is having abdominal cramping, positive Chovstek's and Trousseau's signs, and tingling in the extremities. The nurse knows that these findings could be signs and symptoms of which of the following? a. Hypermagnesemia b. Hypomagnesemia c. Hypercalcemia d. Hypocalcemia

d. Hypocalcemia Hypocalcemia can be demonstrated by abdominal cramping, tingling of the extremities, and tetany. Chovstek's sign refers to an abnormal reaction to the stimulation of the facial nerve such that, when tapped at the masseter muscle, the facial muscles on the same side of the face contract, causing a brief twitching of the nose or lips. Chovstek's sign can be seen in hypomagnesemia and hypocalcemia. Trousseau's sign of latent tetany is more sensitive than Chovstek's sign in hypocalcemia, and may be positive before gross manifestations of hypocalcemia, specifically tetany and hyperreflexia. A blood pressure cuff is inflated to a pressure greater than the systolic pressure and held in place for 3 minutes. This causes the occlusion of the brachial artery, and the hypocalcemia and subsequent neuromuscular irritability will induce a muscle spasm of the client's hand and forearm.

A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low sodium, 1800 cal diet. Which instruction should the nurse give the client? a. Avoid folic acid supplements to prevent megaloblastic anemia b. severely restrict sodium intake throughout the pregnancy c. Take iron supplements with milk to enhance absorption d. Increase caloric intake to 2200 calories daily to promote fetal growth

d. Increase caloric intake to 2200 calories daily to promote fetal growth The client can continue a low sodium diet but should increase the caloric intake to provide adequate nutrients to support fetal growth and development.

The client is taking a class I anti-arrhythmic medication. How does this type of medication work? a. It blocks the calcium channels in the heart b. It increases the conduction through the AV node c. It decreases the excitability of the SA node d. It blocks the sodium channels in the heart

d. It blocks the sodium channels in the heart Class I anti-arrhythmic drugs act by blocking the sodium channels in the heart. They slow conduction through the atria, ventricles, and His-Purkinje fibers. They do not act on the SA node nor do they block calcium channels in the heart.

A child with T1DM is brought to the ED by the parents, who state that the child has been complaining of abodminal pain and has been lethargic. DKA is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of IVF? a. K infusion b. NPH insulin infusion c. 5% dextrose infusion d. NS infusion

d. NS infusion DKA is complication of DM that develops when a severe insulin deficiency occurs. Rehydration is the initial step in resolving DKA. NPH insulin is never administered IV route.

A pediatrician prescribes lab studies for the infant of a birthing parent positive for HIV. The nurse anticipates that which lab study will be prescribed for the infant? a. CXR b. western blot c. CD4+ cell count d. P24 antigen assay

d. P24 antigen assay Infants born to HIV infected mothers need to be screened for the HIV antigen, confirmed by a p24 antigen assay or polymerase chain reaction. A western blot test confirms the presence of HIV antibodies.

A primigravid near birth is experiencing a prolonged second stage of labor with a fetus suspected of weighing over 4 kg. Which intervention is most important? a. preparing for a vacuum assisted birth b. administering an IVF bolus c. preparing for an emergency c section d. Performing the McRoberts maneuver

d. Performing the McRoberts maneuver A prolonged second stage of labor with a large fetus could indicate a shoulder dystocia at birth. Immediate nursing actions include suprapubic pressure and the McRoberts maneuver. If after interventions for vaginal birth fail, an emergency c section may be needed but not at this time.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL. Which patterns would the nurse watch for on the ECG? Select all that apply a. Peaked T wave b. Widened T wave c. prominent U wave d. Prolonged QT interval e. Prolonged ST segment

d. Prolonged QT interval e. Prolonged ST segment

The nurse is caring for a child who had an adenoidectomy and tonsillectomy 10 hours ago. The parents are in the room and preparing the child for bedtime. Which of the following nursing interventions would be helpful to promote rest and sleep for this client? a. Provide a cool water rinse, adjust the head of the bed to a 30-45-degree angle, and offer an ice collar for comfort. b. Encourage the parents to leave so the child can sleep c. Suction vigorously before the child falls asleep to ensure the child has a patent airway. d. Provide a water rinse, offer an ice collar for discomfort, and assist the child in finding a position of comfort while promoting a patent airway for sleep

d. Provide a water rinse, offer an ice collar for discomfort, and assist the child in finding a position of comfort while promoting a patent airway for sleep Assist the child in finding a position of comfort. This may be prone, semi-prone, or semi-Fowler's. An ice collar and a cool oral rinse will also aid in comfort.

The nurse gives a 35 year old primigravida client a RhoGAM injection in her 28th week of pregnancy. Which of the following client situations requires the nurse to take this action? a. Rh-positive mother and Rh-negative father b. Rh-positive mother and Rh-positive father c. Rh-negative mother and Rh-negative father d. Rh-negative mother and Rh-positive father

d. Rh-negative mother and Rh-positive father

The nurse is taking care of a quadriplegic young man who suffers from a C2-C3 fracture after an auto accident 3 months prior. He has a tracheotomy, is ventilator-dependent, and has been discharged to home with skilled home nursing care. The nurse knows that this client is at risk for autonomic dysreflexia. Which of the following measures should this nurse take to keep the client comfortable, manage his elimination needs, and prevent common causes of autonomic dysreflexia? a. Turn the client at least every two hours and look for skin breakdown. b. Allow the client to sleep 8-10 hours without interruption each night to promote rest. c. Offer appetizing fluids at least every two hours during the day to promote hydration. d. Straight catheterize the client to prevent bladder distention and maintain a regular bowel program to prevent impaction

d. Straight catheterize the client to prevent bladder distention and maintain a regular bowel program to prevent impaction Bladder distension and bowel impaction can result in autonomic dysreflexia, causing a critical increase in blood pressure.

When preparing a prenatal class about endocrine changes that normally occur during pregnancy, the nurse should include information about which subject? a. Human placental lactogen maintains the corpus luteum b. progesterone is responsible for hyperpigmentation and vascular skin changes c. Estrogen relaxes smooth muscle in the respiratory tract d. The thyroid enlarges with an increase in BMR

d. The thyroid enlarges with an increase in BMR Human placental lactogen enhances milk production. Estrogen is responsible for hyperpigmentation and vascular skin changes. Progesterone relaxes smooth muscle in the respiratory tract

The home health nurse is interviewing an older client with a hx of mild HF and RA. The client reports "feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed." Which member of the health care team would be the most appropriate to aid in the client's report of pain? a. HCP to review the dosage and frequency of pain medication b. PT for evaluation of function and possible exercise therapy c. SW to locate community resources for complementary therapy d. UAP to help client with a warm shower in the morning

d. UAP to help client with a warm shower in the morning One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A nonpharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions.

The client with a head injury is experiencing increased intracranial pressure. The neurosurgeon prescribes mannitol. Which intervention should the nurse implement when administering this medication? a. Monitor the client's ABGs during administration b. do not administer if the client's BP is < 90/60 c. Ensure that the client's cardiac status is monitored by telemetry d. Use a filter needle when administering the medication

d. Use a filter needle when administering the medication crystals may form in the solution and syringe and be inadvertently injected into the client if a fi lter needle is not used.

An adult diagnosed with pancreatic cancer is having a consultation with the nurse about nutrition and hydration. Which of the following suggestions might the nurse include when providing education to this client? a. Drink clear water, progress diet rapidly as tolerated, and weigh daily. b. Puree foods, choose low-protein foods for easier digestion, and weigh weekly. c. Take herbal therapies, avoid vitamins, and don't monitor weight. d. Use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but frequent high-protein and high-carbohydrate meals.

d. Use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but frequent high-protein and high-carbohydrate meals. It is more appropriate to progress the diet slowly to avoid nausea and vomiting. Pureed foods may cause nausea and gagging, low-protein foods do not offer enough nutrients, and daily weights are the norm. Herbal therapies have not been researched enough to be certain that they would not interfere or compromise cancer treatments when ingested. Topical herbal treatments may be of use for comfort. CORRECT: Flavored foods high in both protein and carbohydrates will help to increase calorie intake. Foods that have less odor, and small, frequent meals help ward off nausea.

The medical floor nurse receives report from the Emergency Department on a 42-year-old client who is admitted to the hospital for hyperphosphatemia related to end-stage renal disease. The client receives continuous ambulatory peritoneal dialysis (CAPD), and the physician has ordered continuation of treatment during hospitalization. The nurse should do which of the following? a. Maintain a permanent peritoneal catheter with flushes of 0.9% normal saline (0.9% NS) every 4-6 hours. b. Obtain a pump in preparation for dialysate infusion. c. Ensure the dialysate is refrigerated until ready to infuse, and obtain a warming pad or a warming machine to warm the dialysate to body temperature prior to exchange. d. Weigh the client at the same time every day, and use sterile technique while working with a permanent peritoneal catheter.

d. Weigh the client at the same time every day, and use sterile technique while working with a permanent peritoneal catheter.

The labor and birth nurse is assigned to triage for the day. There are 4 clients already in rooms and reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first? a. a primipara in active labor at 5 cm asking to be admitted and wanting an epidural b. a primipara who is 100% effaced, 8 cm dilated and +2 station with nausea c. a client with no prenatal care, occasional contractions, BP 148/90 mmHg and swollen feet d. a client who is at 42 weeks' gestation with bloody show, no contractions, ROM 1 hour ago leaking green fluid

d. a client who is at 42 weeks' gestation with bloody show, no contractions, ROM 1 hour ago leaking green fluid Bloody show is a normal sign of impending labor as the cervix maybe beginning to dilate. Not having contractions after ROM is not unusual within a 1 hour time frame. Green amniotic fluid indicates that fetal distress has recently occurred to the point that the fetus had a BM in utero. This occurrence, along with the 42 week gestation, places this fetus at greatest risk. The nurse can see the primipara in active labor at 5 cm dilation last, this client is in pain but nothing about her situation indicates anything but a normal birthing process. The client who is completely effaced, 8 cm dilated and at +2 station is also a primipara and will move through labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected situation as a laboring client enters transition. The client with no prenatal care is a cause for concern because the nurse knows nothing about her background. Her BP is elevated an indicator of mild preeclampsia but there are no other indications of worsening preeclampsia such as HA, visual disturbances or epigastric pain.

The nurse is assigned care for several clients on the medical-surgical unit. Which client should be assessed first by the nurse? a. A client with history of Roux-n-y gastric bypass who is admitted for a barium enema to check for pouch abnormalities b. a client with a PMH of aspiration pneumonia admitted for an upper endoscopy to rule out GERD c. a client with suspected peritoneal cancer with new onset ascites who is awaiting a diagnostic paracentesis d. a client with hematochezia, pain in the abdomen, and history of UC awaiting diagnostic radiology

d. a client with hematochezia, pain in the abdomen, and history of UC awaiting diagnostic radiology While this client may require surgical intervention based on the identification of pouch abnormalities, priority assessment of this client is not warranted prior to the diagnostic procedure. Gastroesophageal reflux disease is the reflux of gastric secretions which can be aspirated into the lungs. There is no indication of respiratory distress in the client who has a past history of aspiration pneumonia; therefore, this client does not require priority assessment at the start of the shift. Ascites is the abnormal buildup of fluid in the abdomen; however, in the absence of other findings this client does not require priority assessment as there is no indication that the client is in distress. Hematochezia and abdominal pain is cause for concern as it can indicate an ulcerative colitis flare-up which can lead to complications such as hypotension and infection, which can both be life-threatening; therefore, this client requires priority assessment by the nurse.

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? select all that apply a. an irregularly shaped lesion b. a small papule with a dry, rough scale c. a firm, nodular lesion topped with crust d. a pearly papule with a central crater and a waxy border e. location in the bald spot atop the head that is exposed to outdoor sunlight

d. a pearly papule with a central crater and a waxy border e. location in the bald spot atop the head that is exposed to outdoor sunlight A melanoma is an irregularly shaped pigmented papule or plaque with a red, white or blue toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis? a. the presence of 1 mL of gastric residual before a gavage feeding b. jaundice appearing on the face and chest c. an increase in bowel peristalsis d. abdominal distention

d. abdominal distention Indications of NC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis and unstable temperature.

During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to FHR assessment, the nurse should monitor the client for symptoms of which complication? a. placenta previa b. ruptured uterus c. maternal hypotension d. abruptio placentae

d. abruptio placentae Dramatic vasoconstriction occurs as a result of smoking crack cocaine. This can lead to increased RR and cardiac rates and hypotension. It can severely compromise placental circulation, resulting in abruptio placentae and preterm labor and birth. Infants of these women can experience intracranial hemorrhage and withdrawal symptoms of tremulousness, irritability and rigidity.

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the HCP if which finding is noted? a. bronze colored skin b. maculopapular chest rash c. urine specific gravity of 1.018 d. absent Moro reflex

d. absent Moro reflex An absent Moro reflex, lethargy, opisthotonos and seizures are symptoms of bilirubin encephalopathy can be life-threatening. Bronze discoloration of the skin and maculopapular chest rash are normal and are caused by the phototherapy. Urine specific gravity is 1.001 to 1.020 is normal.

The nurse caring for a refugee considers which health care need a priority for this client? a. access to housing b. access to clean water c. access to transportation d. access to mental health services

d. access to mental health services Specific needs to the population

A client is admitted to the hospital due to DVT. Which intervention should the nurse initiate? a. ambulate client around room q2hr b. assess Homan's sign every 8 hours c. place SCD on both legs d. apply intermittent warm, moist soaks to the affected area

d. apply intermittent warm, moist soaks to the affected area to decrease edema and ease the discomfort. The client is placed on bedrest with gradual increase in ambulation to allow time for clot to adhere to the vessel wall which will prevent embolization

The nurse on the inpatient psychiatric ward is caring for a client with known suicidal ideation. The 24-hour observer calls the nurse to report that the client took off down the hall. The nurse is unable to immediately locate the client. Arrange the following actions by the nurse in the order that is MOST appropriate. All options must be used. a. notify security that the client has eloped, and provide a description of the client b. notify the nurse manager c. notify other staff on the unit d. ask the observer in what direction the client headed

d. ask the observer in what direction the client headed c. notify other staff on the unit a. notify security that the client has eloped, and provide a description of the client b. notify the nurse manager Security is the third step because, although they are not immediately on hand, they can have multiple people search from different directions. Notifying your nurse manager is the last step, because the manager may not be readily available. Your priority is locating client and ensuring the client's safety. Notifying other staff is the second step because they know the client and are readily available to search locally. Asking the observer which direction the client headed is the first step. This enables the nurse to give accurate information to staff, and if necessary, security to help locate the client.

2 hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, she is experiencing N/V, a slight chill with perspiration beads on her lip and extreme irritability. What should the nurse do first? a. Warm the temperature of the room by a few degrees b. increase the rate of IVF administration c. obtain a prescription for a IM antiemetic d. assess the client's cervical dilation and station

d. assess the client's cervical dilation and station The client's symptoms are indicative of the transition phase of labor. Multiparous clients can proceed 5-9 cm/h during the active phase. Increasing the IVF rate is not warranted unless the client is dehydrated. Administration of an antiemetic at this point in labor is not warranted and may result in neonatal depression.

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area? a. acme of one contraction to the beginning of the next contraction b. beginning of one contraction to the end of the next contraction c. end of one contraction to the end of the next contraction d. beginning of one contraction to the beginning of the next contraction

d. beginning of one contraction to the beginning of the next contraction The acme identifies the peak of a contraction

The cervix of a primigravid client in active labor who received epidural anesthesia 4 hours ago is now completely dilated. What is most important for the nurse to assess before the client begins to push? a. FHR variability b. cervical dilation again c. status of membranes d. bladder status

d. bladder status A full bladder can impede the progress of labor and slow fetal descent. Because she has had an epidural anesthetic, it is most likely that she is receiving IVF, contributing to a full bladder. The client also does not feel the urge to void because of the anesthetic. Although it is important to monitor membrane status and FHR variability throughout the labor, this does not affect the client's ability to push.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented? a. watery diarrhea b. ribbon-like stools c. profuse projectile vomiting d. bright red blood and mucus in the stools

d. bright red blood and mucus in the stools

A nurse is teaching a client who has constipation about a high fiber, low fat diet. Which of the following food choice by the client indicates understanding of the teaching? a. peanut butter b. peeled apples c. hardboiled egg d. brown rice

d. brown rice

An Orthodox Jewish client receives the following lunch tray. What is the nurse's priority action? Lunch menu: spaghetti and meatball in sauce tossed salad with vinegrette dressing hot rolls with butter dessert: fruit cocktail or cookie milk - coffee available a. nothing, since this is a healthy and acceptable lunch b. ask the client to eat the lunch so food is not wasted c. remove the tossed salad so the client can eat other foods provided d. call dietary to immediately make a new tray for the client

d. call dietary to immediately make a new tray for the client One Jewish religious belief contends that dairy and meat cannot be served or eaten at the same meal. The tray includes meatballs in the spaghetti and milk served with the meal. Nothing on this tray could be consumed by the client, and an entirely new tray must be prepared immediately.

An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe SOB, a petechial rash on his chest and BP: 88/50, P 122 R21. What should the nurse do first? a. decrease rate of IVF b. neurovascular checks on the affected leg c. elevate HOB d. call the RRT

d. call the RRT The client is exhibiting symptoms of fat embolism, particularly with the petechial rash on his chest and severe SOB. Due to his age, high risk behaviors with contact sports, and large long bone fracture.

The nurse is working with 4 clients on the obstetrical unit. Which client will be the highest priority for a c section? a. client at 40 weeks' gestation whose fetus weighs 8 lb by US estimate b. client at 37 weeks' gestation with fetus in the right occiput posterior (ROP) position c. client at 32 weeks' gestation with fetus in breech position d. client at 38 weeks' gestation with active herpes lesions

d. client at 38 weeks' gestation with active herpes lesions The client carrying an infant weighing 8 lb will be given a trial of labor before a c section. The client with a fetus in the ROP position will have a slow labor with increased back pain but can give birth vaginally. The fetus in a breech position still has many weeks to change positions before being at term.

After conducting a presentation to a group of adolescent parents on the topic of adolescent pregnancy, the nurse determines that one of the parents needs further instruction when the parent says that adolescents are at greater risk for which complication? a. denial of the pregnancy b. low birth weight infant c. cephalopelvic disproportion d. congenital anomalies

d. congenital anomalies

A 28 y/o multigravid client at 28 weeks' gestation is diagnosed with acute pyelonephritis is receiving IVF and abx. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which complication? a. preterm labor b. maternal sepsis c. IUGR d. congenital fetal anomalies

d. congenital fetal anomalies

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor? a. a decrease in vaginal glycogen stores b. development of a STI c. prevention of expulsion of the cervical mucus plug d. control of the growth of pathologic bacteria

d. control of the growth of pathologic bacteria Vaginal secretions increase because of the influence of estrogen secretion and increased vaginal and cervical vascularity. The acidity is caused by the action of Lactobacillus acidophilus, which increases the lactic acid content of the secretions, which make the vagina resistant to bacterial growth. During pregnancy, estrogen secretions fosters a glycogen rich environment. The glycogen rich and acidic environment fosters the development of yeast (Candida albicans) infections, manifested by itching, burning and cheese like vaginal discharge. The mucus plug is held in place by the cervix until the cervix becomes ripe.

The nurse is giving a bed bath to an assigned client when an AP enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. What is the most appropriate nursing action? a. Finish the bed bath and then administer the pain medication to the other client b. ask the AP to find out when the last pain medication was given to the client c. Ask the AP to tell the client in pain that the medication will be administered as soon as the bed bath is complete d. cover the client, raise the side rails, tell them that you will return shortly and administer the pain medication to the other client.

d. cover the client, raise the side rails, tell them that you will return shortly and administer the pain medication to the other client.

What information should the nurse include in teaching an oncology client the purpose of taking epoetin? a. emergency treatment of anemia b. improves QOL c. used for prevention of pure red cell aplasia d. decreases the need for transfusion

d. decreases the need for transfusion Epoetin is used to treat a lower number of RBC caused by CKD in clients with dialysis, in HIV clients receiving zidovudine and in cancer clients receiving chemo that develop anemia. Epoetin stimulates the bone marrow to produce more RBC

A 30 y/o G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is postterm. The nurse notes late decels. The client is wedged to her side while lying in bed and is approximately 6 cm dilated and 100% effaced. What should the nurse do first? a. continue to observe the fetal monitor b. anticipate ROM c. prepare for fetal oximetry d. discontinue the oxytocin infusion

d. discontinue the oxytocin infusion The first intervention would be to turn off the oxytocin because the medication is causing the contractions. The stress caused by the contractions demonstrates that the fetus is not being perfused during the entire contraction. There is no time to continue to observe, intervention is priority. The client is attached to an internal fetal monitor, which would be possible only if her membranes had already ruptured. If the fetus continues to experience stress, fetal oximetry may be initiated

A 68 y/o client with history of angina presents to the ED reporting flu like symptoms progressively worsening over the 24 hours. What action is most important for the nurse to initiate? VS P 132 bpm, R 26 breaths/min, BP 94/60 mmhg, T 101.3F, cap refill 4 sec prescriptions rapid influenza diagnostic test NS 1 L at 250 mL/hr, then NS at 100 mL/hr CXR APAP 500 mg PO now CC: "I have the flu. I have been vomiting every coule of hours, running a fever and my chest hurts." a. administer APAP b. initiate IV NS at 250 mL/hr c. notify radiology lab or diagnostic test prescriptions d. discuss IV prescription with PHP

d. discuss IV prescription with PHP client is elderly and has a history of cardiac problems. Giving NS rapidly could throw heart into pulmonary edema

Which discharge instruction should the nurse provide for a client who is newly diagnosed left-sided Bell palsy? Select all that apply. a. call for assistance when moving b. cover both eyes with patches during sleep c. do not drive a vehicle for 4-6 weeks d. eat a soft diet and chew on the unaffected side of the mouth e. instill artificial tears to the impacted eye every 4 hours

d. eat a soft diet and chew on the unaffected side of the mouth e. instill artificial tears to the impacted eye every 4 hours Bell palsy is caused by swelling and compression of cranial nerve VII which causes temporary unilateral paralysis and altered sensation of the facial muscles. Clients are taught strategies to manage chewing and swallowing dysfunction as well as eye care due to the inability of the eyelids to shut properly during exacerbations. The nurse should teach the client to eat soft foods, chew on the unaffected side, and to use artificial tears to prevent eye dryness in the affected eye. It is not necessary to cover both eyes at night when sleeping as this condition affects one side of the client's face. Vision is not affected in clients who are diagnosed with Bell palsy; therefore, driving restrictions are not necessary.

The parent of an 8 year old child being treated for right lower lobe PNA at home calls the clinic nurse. The parent tells the nurse that the child complains of discomfort on the right side and that ibuprofen is ineffective. Which instruction would the nurse provide to the parent? a. increase the dose of ibuprofen b. increase the frequency of ibuprofen c. encourage the child to lie on the left side d. encourage the child to lie on the right side

d. encourage the child to lie on the right side

The nurse is receiving shift report on four clients on an antenatal unit. The four clients are 1. a 35 week gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hour ago, 2. a 3-0 week gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hours, 3. a hyperemesis client with emesis 4 times in the past 12 hours, and 4. a 33 week gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first? a. Evaluate the client with preeclampsia for maternal and fetal tolerance of magnesium sulfate and the labor pattern b. assess the client with preterm labor for tolerance of tocolytics and the labor pattern c. assess the client with hyperemesis for nausea, further emesis or dehydration d. evaluate the client with placenta previa without an exam

d. evaluate the client with placenta previa without an exam The pelvic pressure may be caused by a fetal head creating pressure in the pelvis indicating a potential birth. The second action would be to complete an assessment on the client with preeclampsia and her fetus to evaluate for tolerance and effectiveness of the magnesium sulfate. The hyperemesis client needs to be evaluated for hydration status and for medication. The preterm labor client is stable on oral medication and should be seen last

A home health nurse is planning care for a client following a stroke. The nurse plans to interview each member of the family to see how they might help the client progress towards recovery. The nurse is using which of the following approaches to family health? a. family as a component of society b. family as a system c. family as a client d. family as a context

d. family as a context The client is the focus, and members are viewed as a source of support for the client. When using the family as a system approach, question how one change in the family impacts all members. Ask individual family members how their life has changed following the client's stroke.

After the nurse reviews the HCP's explanation of amniocentesis with a multigravid client, which complication, if stated by the client, indicates that she needs more teaching about the procedure? a. risk of infection b. possible miscarriage c. risk of club foot d. fetal organ malformations

d. fetal organ malformations

A client presenting at the clinic has a history of SLE. Which finding would indicate to the nurse that the client is having a flare up of the disease? a. alopecia b. arthritis of hands c. weight gain d. fever

d. fever

The clinic nurse reviews the record of an infant and notes that the PHCP has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the parent to seek health care for the infant? a. diarrhea b. projectile vomiting c. regurgitation of feedings d. foul smelling ribbon like stools

d. foul smelling ribbon like stools

contact precautions are initiated for a client with a nosocomial infection caused by MRSA. The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? a. gloves and gown b. gloves and goggles c. gloves, gown and shoe protectors d. gloves, gown, goggles, and a mask or face shield

d. gloves, gown, goggles, and a mask or face shield

An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication? a. preterm labor b. twin-to-twin transfusion c. anemia d. group B streptococcus

d. group B streptococcus Group B streptococcus is a RF for all pregnant women and not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor is more likely with twin gestation. The normal uterus is only able to distend to a certain point, and when that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestations. The donor twin may become growth restricted and can have oligohydramnios, while the recipient twin may become polycythemic with polyhydramnios and develop HF. Anemia is common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium and iron to supply her needs and those of the fetuses.

A primigravid client is at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes and clusters of vesicles on her vagina. The nurse refers the client to a HCP because the nurse suspects which STI? a. gonorrhea b. Chlamydia trachomatis infection c. syphilis d. herpes genitalis

d. herpes genitalis Some women have no symptoms of gonorrhea. Others may experience vaginal itching and a thick, purulent vaginal discharge. C. trachomatis infection in women is commonly asymptomatic, but symptoms may include a yellowish discharge and painful urination. The first symptom of syphilis is a painless chancre

A 24 y/o client, G3, T1, P1, A1, L1 at 32 weeks' gestation, is admitted to the hospital because of vaginal bleeding. After reviewing the client's history, which factor might lead the nurse to suspect abruptio placentae? a. several hypotensive episodes b. previous low transverse cesarean birth c. one induced abortion d. history of cocaine use

d. history of cocaine use possible contributing factors include excessive intrauterine pressure caused by hydramnios or multiple pregnancy, cocaine use, cigarette smoking, alcohol ingestion, trauma, increased maternal age and parity and amniotomy. A history of HTN is associated with an increased risk of abruptio placentae. A previous low transverse c section and a history of one induced abortion are associated with increased risk of placenta previa.

The nurse admits a child with a history of CF with vomiting for 3 days, HA and unusual behavior. What does the nurse anticipate the lab values will show? a. hypernatremia b. hypercalcemia c. hypocalcemia d. hyponatremia

d. hyponatremia CF kids are always losing sodium.

The postpartum nurse is taking the VS of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? a. document the findings b. notify the obstetrician c. retake the temperature in 15 minutes d. increase hydration by encouraging oral fluids

d. increase hydration by encouraging oral fluids The client's temperature would be taken every 4 hours while awake. Temperatures up to 100.4 F in the first 24 hours after birth are related to dehydrating effects of labor.

A parent arrives at a clinic with a toddler and tells the nurse how difficult it is to get the child to go to bed at night. What measure is most appropriate for the nurse to suggest to the parent? a. allow the child to set bedtime limits b. allow the child to have temper tantrums c. avoid letting the child nap during the day d. inform the child of bedtime a few minutes before it is time for bed

d. inform the child of bedtime a few minutes before it is time for bed Toddlers often resist going to bed. Bedtime protests may be reduced by establishing a consistent before bedtime routine and enforcing consistent limits regarding the child's bedtime behavior. Informing the child of bedtime a few minutes before it is time for bed is the most appropriate option. Most toddlers take an afternoon nap and until their second birthday, also may require a morning nap. Firm consistent limits are needed for temper tantrums or when toddlers try stalling tactics

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure? a. placement of the neonate on a ventilator b. administration of bronchodilators through the nares c. suctioning of the neonate's nares with wall suction d. insertion of a chest tube into the neonate

d. insertion of a chest tube into the neonate The data supports the diagnosis of pneumothorax, which would be confirmed with a CXR. Pneumothorax is an accumulation of air in the thoracic cavity between the parietal and visceral pleurae and requires immediate removal of accumulated air. Resolution is initiated with insertion of a chest tube connected to continuous negative pressure.

The nurse provides care for a pediatric client who experiences a high fever due to infection. Which nonpharmacologic intervention should the nurse implement to improve this child's comfort? a. administer the prescribed antipyretic medication b. give the prescribed analgesic medication c. provide cool mist humidification d. keep linens and clothing dry

d. keep linens and clothing dry The use of a cool mist humidifier is a nonpharmacologic strategy that decreases discomfort associated with a sore throat, not fever. The pediatric client who has a fever will likely experience diaphoresis, which is uncomfortable. It is not uncommon for the child to soak through clothing and bedding with diaphoresis; therefore, the nurse should ensure that clothing and linens are clean in dry as a nonpharmacologic strategy to enhance this child's comfort.

A client is receiving a continuous intravenous infusion of heparin sodium to treat DVT. The client's aPTT is 65 sec. The nurse anticipates that which action is needed? a. discontinuing the heparin infusion b. increasing the rate of the heparin infusion c. decreasing the rate of the heparin infusion d. leaving the rate of the heparin infusion as is

d. leaving the rate of the heparin infusion as is The normal aPTT is between 30-40 sec. The therapeutic dose of heparin for treatment of DVT is to keep the aPTT between 1.5 x (45-60) and 2.5 x (75-100) normal. The client's value should not be less than 45 sec or greater than 100 sec.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? a. milk b. chicken c. broccoli d. legumes

d. legumes Thiamine is present in a variety of foods plant and animal origin. Other good food sources include nuts, whole grain cereals and pork. Milk contains vitamins A, D and B2. Poultry contains niacin. Broccoli contains vitamins C E K and folic acid.

A multigravid client at 32 weeks gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluation obtained from which source? a. placental blood b. amniotic fluid c. fetal blood d. maternal blood

d. maternal blood For the Rh-negative client who may be pregnant with an Rh-positive fetus, an indirect Coombs test measures antibodies in the maternal blood. Titers should be performed monthly during the first and second trimesters and biweekly during the third trimester and the week before the due date.

The nurse plans care for a postpartum client after a vaginal birth. Which risk factor is more likely to cause the new mother to have postpartum hemorrhage (PPH)? a. maternal blood loss of approx 400 mL b. prolonged labor lasting 24 hours c. newborn weight of 5 lb, 4 oz d. newborn weight of 11 lb, 8 oz

d. newborn weight of 11 lb, 8 oz A woman experiencing PPH will exhibit clinical manifestations similar to any client who is hemorrhaging. Clinical manifestations indicative of PPH include changes in the complete blood count (CBC), a decreased blood pressure, an increased heart rate and respirations, lethargy, and changes in levels of consciousness (LOC). Causes of PPH include uterine atony, birth trauma, retained placenta (or placental abnormalities), and coagulopathy. Risk factors for PPH include neonatal macrosomia, prolonged labor, multiparity, multiple gestation, placenta previa, placental abruption, and blood dyscrasias. The nurse must monitor the amount of postpartum bleeding, including a peri-pad count. Saturating more than one saturated pad every hour is often an indicator of PPH.

A 34 y/o multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret the finding? a. the possibility that the client is carrying twins b. unusual because most multiparous clients do not experience quickening until 30 weeks' gestation c. evidence that the client's estimated date of birth is probably off by a few weeks d. normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation.

d. normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation. Although most multiparous women experience quickening at about 17 1/2 weeks' gestation, some women may perceive it between 14 and 20 weeks' gestation because they have been pregnant before and know what to expect.

What would be the priority when caring for a primigravid client whose cervix is dilated at 8 cm when the fetus is at 1+ station and the client has had no analgesia or anesthesia? a. giving frequent sips of water b. applying extra blankets for warmth c. providing frequent perineal cleansing d. offering encouragement and support

d. offering encouragement and support The client is in the transition phase of the first stage of labor. The client needs encouragement and support because this is a difficult and painful time, when contractions are especially strong. Usually, the client finds it difficult to maintain self-control. Everything else seems secondary to her as she progresses into the second stage of labor. Although ice chips may be given, typically the client does not desire sips of water. Generally, the client is perspiring and does not desire additional warmth. Frequent perineal cleansing is not necessary unless there is excessive amniotic fluid leaking

A 21 y/o primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which is a priority nursing problem? a. urinary retention b. hyperventilation c. ineffective coping d. pain

d. pain During transition, contractions are increasing in frequency, duration and intensity. The most appropriate nursing problem is pain related to strength and duration of the contraction.

The nurse is teaching a young male client to recognize the most common early sign of testicular CA. The nurse emphasizes the fact that he should be aware of which of the following? a. lumbar pain b. Urinary frequency c. urinary urgency d. painless testicular enlargement

d. painless testicular enlargement Among other serious causes, lumbar pain could be a sign of metastasis

The nurse provides care for a pediatric client with a differential diagnosis of Duchenne muscular dystrophy (DMD). Which assessment data supports the child's differential diagnosis? Select all that apply. a. An extra gluteal fold with a positive Ortolani sign b. sudden jerking and rigidity in the extremities is noted c. morning pain and stiffness of the knees and elbows d. parental report that the client falls often e. parental report that client ambulates using tiptoes and has significantly large calves f. uses hands on thighs to push up while trying to stand

d. parental report that the client falls often e. parental report that client ambulates using tiptoes and has significantly large calves f. uses hands on thighs to push up while trying to stand An extra gluteal folds with a positive Ortolani sign is associated with hip dysplasia, not DMD Sudden jerking and rigidity in the extremities is most associated with seizure activity, not DMD Joint pain and stiffness in the morning is most associated with juvenile idiopathic arthritis, not DMD.

After instructing participants in a birth education class about methods for coping with discomforts in the first stage of labor, the nurse determines that one of the pregnant clients needs further instruction when she says that she has been practicing which technique? a. biofeedback b. effleurage c. guided imagery d. pelvic tilt exercises

d. pelvic tilt exercises Pelvic tilt exercises are useful in alleviating backache during pregnancy and labor but are not useful for pain from contractions

The nurse is caring for a full term, nonmedicated primiparous client who is in transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" Her last vaginal exam 1 hour ago showed that she was 8 cm dilated +1 station, and what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client? a. Help the client through contractions until a narcotic can be given b. Palpate the bladder to see if it has become distended c. Ask the client for suggestions to make her more comfortable d. perform a vaginal exam to determine if the client is fully dilated

d. perform a vaginal exam to determine if the client is fully dilated Transition is the most difficult period of the labor process, and often when clients are tired, pain becomes more intensified. Clients during this stage verbalize anger and are outspoken and difficult to comfort. The most logical next step would be to determine if the client has completed transition and is ready to begin pushing. The use of narcotics is discouraged as they can lead to respiratory depression in the neonate. Palpating the bladder is important but not the highest priority as it was done less than an hour ago.

3 hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? a. retained placental tissue b. uterine inversion c. bladder distention d. perineal lacerations

d. perineal lacerations A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client has retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case, the fundus would be soft, possibly boggy, and displaced from midline

The nurse administers erythromycin ointment to the eyes of a newborn, and the birthing parent asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? a. protects the newborn's eyes from possible infections acquired while hospitalized b. prevents cataracts in the newborn born to a parent who is susceptible to rubella c. minimizes the spread of microorganisms to the newborn from invasive procedures during labor d. prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a parent with an untreated gonococcal infection

d. prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a parent with an untreated gonococcal infection

Which is the best nursing intervention for a school aged client, diagnosed with Asperger syndrome who is hospitalized for diagnostic testing? a. making sure the child is medicated before all tests b. disregarding any emotional outbursts by the child c. making time for the child has a favorite game and an accessible TV d. providing the child with a calendar of scheduled daily events

d. providing the child with a calendar of scheduled daily events Asperger syndrome (AS) is a neurodevelopmental disorder that is characterized by significant difficulties in social interaction and nonverbal communication. Additionally, a child who is diagnosed with AS experiences restricted and repetitive patterns of behavior and interests.Hospitalization of pediatric clients who are diagnosed with AS should be focused on structured routines and consistency to decrease anxiety. Feedback from the parents about usual patterns is helpful to maintain this consistency. A nursing diagnosis of impaired social interaction is appropriate due to the unresponsiveness towards people. To avoid overstimulation, limiting visitors to trusted caregivers is essential. The priority nursing intervention for this child is as follows: providing the child with a calendar of scheduled daily events.

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system? a. urinary b. GI c. CV d. pulmonary

d. pulmonary The test is based on the fact that surfactant foams when mixed with ethanol. The more stable the foam, the more mature the fetal pulmonary system. A lecithin/sphingomyelin ratio is usually determined in conjunction with the shake test. Amniotic fluid volumes are used to evaluate the GI and urinary systems. US to evaluate the CV system

A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's BP before surgery, which facto is most important for the nurse to assess? a. uterine cramping b. abdominal distention c. hemoglobin and hematocrit d. pulse rate

d. pulse rate Fallopian tube rupture is an emergency situation because of extensive bleeding into the peritoneal cavity. Shock soon develops if precautionary measures are not taken. The nurse should be prepared to administer fluids, blood or plasma expanders as necessary through an IV line that should already be in place. Because the fertilized ovum has implanted outside the uterus, uterine cramping is unlikely. However, abdominal tenderness or knife like pain may occur. Abdominal fullness may be present but abdominal distention is rare unless peritonitis has developed. Although Hgb and Hct may be checked routinely before surgery, the lab results may not truly reflect the presence or degree of acute hemorrhage

Which diagnostic test would be the most important for a 40-year-old primigravid client to have in the second trimester of her pregnancy? a. beta strep screening b. chorionic villus sampling c. US testing d. quad screen

d. quad screen A maternal quad screen testing is done to screen for genetic and neural tube abnormalities between the 15th and 18th weeks of gestation. The 4 tests are alpha fetoprotein (AFP), human chorionic gonadotropin, estriol and inhibin A. Low levels of AFP may indicate trisomy 21. Beta strep testing is done during 3rd trimester. CVS is done as early as 10 weeks' to determine anomalies. US may be done in the first trimester to determine fetal viability and in the 3rd trimester to determine pelvic adequacy and fetal or placental position

Which information should the nurse include in a postop teaching plan for a client with laryngectomy? a. instruct the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin b. tell the client to speak by covering the stoma with a sterile gauze pad c. instruct the client to avoid coughing until the sutures are removed d. reassure the client that normal eating will be possible until healing has occurred

d. reassure the client that normal eating will be possible until healing has occurred coughing is essential to keep the airway patent. Because the larynx has been removed, the ability to speak is lot. swallowing is usually not affected nor is the ability to control oral secretions

During a scheduled c section of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the OR. The nurse explains to the client that the neonatologist is present because neonates born by c section tend to have an increased incidence of which problem? a. congenital anomalies b. pulmonary HTN c. meconium aspiration syndrome d. respiratory distress syndrome

d. respiratory distress syndrome During a vaginal birth, pressure is exerted on the fetal chest, which aids in the fetal inhalation and exhalation of air and lung expansion. This pressure is not exerted on the fetus with a c section.

The nurse caring for a child diagnosed with rubeola notes that the pediatrician has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected? a. Pinpoint petechiae noted on both legs b. whitish vesicles located across the chest c. petechiae spots that are reddish and pinpoint on the soft palate d. small blue-white spots with a red base found on the buccal mucosa

d. small blue-white spots with a red base found on the buccal mucosa

A primigravid client is in the second stage of labor feels the urge to push. The client has had no analgesia or anesthesia. Anatomically what would be the best position for the client to assume? a. dorsal recumbent b. lithotomy c. hands and knees d. squatting

d. squatting This enhances the pelvic diameters and allows gravity to assist the expulsion stage of labor. This position also provides for natural pressure anesthesia as the fetal presenting part presses on the stretched perineum. If the client is extremely fatigued from a lengthy labor process, she may prefer the dorsal recumbent position. However, this position is not considered the best anatomically. The lithotomy position may be ineffective and uncomfortable for a client who is ready to push. The hands and knees position may help to alleviate some back pain but can cause discomfort to the arms and wrists and is tiring over a long period of time

A client at 15 weeks' gestation presents at the obstetrical triage unit with dark brown vaginal bleeding and continuous nausea and vomiting. Her BP is 142/98 mmHg, and fundal height is 19 cm. Which prescription is most important for the nurse to request from the PCP? a. a transfer to the antenatal unit b. NPO status for 24 hours c. IV Mag sulfate d. stat US

d. stat US Elevated BP could indicate chronic HTN as well as hydatidiform mole. The fundal height of 19 cm is higher than typically found at 15 weeks' gestation and is indicative of a molar pregnancy. The dark brown vaginal bleeding in isolation could indicate an abortion but when placed in context of other symptoms is likely related to a hydatidiform mole. The continuous nausea and vomiting is abnormal and can be result of high levels of progesterone from a molar pregnancy. There is no fetus involved, the BP elevation and continuous N/V will resolve with evacuation of the mole, negating the need for Mag sulfate and placing the client on NPO status. Transferring the client to the antenatal unit is premature before a diagnosis has been made

At 38 weeks' gestation, a primigravid client with poorly controlled diabetes and severe preeclampsia is admitted for a c section. The nurse explains to the client that birth helps to prevent which complication? a. neonatal hyperbilirubinemia b. congenital anomalies c. perinatal asphyxia d. stillbirth

d. stillbirth Stillbirths caused by placental insufficiency occur with increased frequency in women with diabetes and severe preeclampsia. Clients with poorly controlled diabetes may experience unanticipated stillbirth as result of premature aging of the placenta. Therefore, labor is commonly induced in these clients before term. If induction of labor fails, a C section is necessary.

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment? a. hgb 12.1 g/dL b. WBC 15,000 mcL c. pulse of 60 beats/min d. temp of 100.8 F

d. temp of 100.8 F Within the first 24 hours of postpartum, maternal temp may increase to 100.4 F, a normal postpartum finding attributed to dehydration. A temp above 100.4 F indicates a potential for infection. WBC is normally elevated as a response to the inflammation, pain and stress of the birthing process.

A primigravid client at 30 weeks' gestation has been admitted to the hospital with PROM without contractions. Her cervix is 2 cm dilated and 50% effaced. Which factor is the most important for the nurse to assess next? a. RBC count b. degree of discomfort c. urinary output d. temperature

d. temperature PROM are commonly associated with chorioamnionitis or an infection. Temperature elevation may indicate infection. Lethargy and elevated WBC also indicate an infection. the RBC count would provide information related to anemia, not infection.

The nurse assigns an UAP to the care of a client who has just returned from surgery for repair of fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting: a. the client is feeling heat from the plaster cast b. results of hourly neurovascular assessments c. I&O for the shit d. the client cannot move the fingers on the right hand

d. the client cannot move the fingers on the right hand The UAP should report immediately to the nurse any sign that the client cannot move the fingers on the casted arm, numbness or tingling or feelings of tightness because these may indicate impaired neurovascular status. It is normal for the client to feel heat immediately after application of a plaster cast.

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? select all that apply a. presence of striae b. palpable radial pulses c. absence of any ecchymosis on the extremities d. thinner reddish papules and decrease in their number e. scarce amount of silvery white scaly patches on the arms

d. thinner reddish papules and decrease in their number e. scarce amount of silvery white scaly patches on the arms

A 36 y/o primigravid client at 22 weeks' gestation without any complications to date is being seen in the clinic for a routine visit. Why does the nurse need to assess the client's fundal height? a. to determine the level of uterine actvitiy b. to identify the need for increased weight gain c. to assess the fetal position d. to estimate the fetal growth

d. to estimate the fetal growth

A community health nurse is developing an education program on substance use disorders for a group of adolescents. Which of the following information should the nurse include when discussing nicotine and smoking? a. smoking is the 5th most preventable cause of death in the US b. nicotine is a CNS depressant c. withdrawal effects from smoking are minimal d. tolerance to nicotine develops quickly

d. tolerance to nicotine develops quickly

The nurse attends a school picnic when an older adult participant suddenly reports feeling faint, fatigued and nauseated. Upon assessment the client is diaphoretic and has a heart rate of 115 BPM. Which action does the nurse implement next? a. immediately instruct a bystander to call the emergency medical services b. call the emergency contact listed in the client's wallet c. assess the client's mental status and LOC d. transport the client to a cool area and give him water

d. transport the client to a cool area and give him water First aid for a client who exhibits symptoms of heat exhaustion (e.g., fatigue, lethargy, nausea, tachycardia) includes moving the client to a cooler environment and providing oral fluids (e.g., water or an electrolyte solution is preferred). This action assists in cooling the client's body temperature while addressing the fluid volume deficit that is caused by profuse sweating with heat exhaustion; therefore, this is the next action the nurse implements. Assessment is not appropriate when the nurse has collected enough data to treat the client's current condition, which is heat exhaustion. Postponing intervention for additional client assessment increases the risk for heat stroke, a potentially life-threatening condition.

A nurse is preparing to administer oxytocin to induce labor in a client. The nurse recognizes that the oxytocin infusion can lead to which of the following? a. decreased postpartum hemorrhage b. delayed milk production c. high risk placenta previa d. unnecessary cesarean birth

d. unnecessary cesarean birth Contractions can become too strong after oxytocin is used and lead to reduced placental blood flow. Reduced placental blood flow can result in non-reassuring FHR patterns such as late decels, fetal bradycardia, tachycardia or minimal variability, which may necessitate emergency c section. After birth, the nurse should observe for postpartum hemorrhage, esp if the client received oxytocin for a long period. The uterine muscles become fatigued and ma y not contract effectively to compress vessels at the placental site . Oxytocin is a hormone secreted by the pituitary that triggers the milk ejection/let down reflex. Prolactin is the pituitary hormone that regulates milk production. Greater uterine activity from oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa is abnormal implantation and is unrelated to oxytocin infusion

Following an eclamptic seizure, the nurse should assess the client for which complication? a. polyuria b. facial flushing c. hypotension d. uterine contractions

d. uterine contractions The client commonly falls ito a deep sleep or coma. The nurse should continually monitor for signs of impending labor because the client is unable to verbalize that contractions are starting.

A nurse is caring for a client following a forceps assisted birth. The client reports several vaginal pain and fullness. On assessment the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? a. cervical laceration b. inversion of the uterus c. uterine atony d. vaginal hematoma

d. vaginal hematoma A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. They are more likely to occur following a forceps or vacuum assisted birth or episiotomy. The client will report persistent severe vaginal pain or feeling of fullness. Vaginal bleeding will be unchanged. The uterus will be firm and at midline upon palpation. If the hematoma is large, the Hgb and VS can change significantly.

In preparation for discharge, the nurse discusses sexual issues with a multiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse? a. in 6 weeks when the episiotomy is completely healed b. after a postpartum check by the HCP c. whenever the client is feeling amorous and desirable d. when lochia flow and episiotomy pain have stopped

d. when lochia flow and episiotomy pain have stopped For most clients, sexual intercourse can be resumed when the lochia has stopped flowing and episiotomy pain has ceased, usually about 3 weeks postpartum. Sexual intercourse may be painful until episiotomy has healed. The client also needs instructions about the possibility that pregnancy may occur before the return of the client's menstrual flow. The postpartum check by the HCP typically occurs 4-6 weeks after birth, and most women have already had intercourse by this time. Typically new mothers are exhausted and may not feel amorous or desirable for quite a while.

At a postpartum checkup 11 days after birth, the nurse asks the client about the color of her lochia. What color is expected? a. dark red b. pink c. brown d. white

d. white On about 11th postpartum day, the lochia should be lochia alba, clear or white in color. Lochia rubra, which is dark red to red, may persist for the first 2-3 days postpartum. From day 3-10, lochia serosa, which is pink or brown, is normal

fetal distress interventions

d/c oxytocin, tocolytic if fetal distress from contractions persists, lateral position, O2 8-10 L/min, IVF

abruptio placentae assessment

dark red vaginal bleeding, uterine pain or tenderness, uterine rigidity, severe abdominal pain, signs of fetal distress

aplastic anemia

deficiency of circulating erythrocytes and all other formed elements of blood, resulting from arrested development of cells within bone marrow, pancytopenia, deficiency of erythrocytes, leukocytes and thrombocytes

Indomethacin pregnancy use

delays preterm delivery

uterine inversion assessment

depression in fundal area of uterus, interior of uterus may be seen through the cervix or protruding through the vagina, severe pain, hemorrhage, signs of shock

actinic keratoses treatment

diclofenac: NSAID topical, ADR include dry skin, itching, redness and rash fluorouracil: topical med that affects DNA and RNA synthesis and cause sequence of responses that result in healing. ADR include itching, burning, inflammation, rash, increased sensitivity to sunlight imiquimod cream: treat veneral warts, ADR include redness, skin swelling, itching, burning, sores, blisters, scabbing, and crusting of skin ingenol mebutate: risk of severe allergic reaction and development of herpes zoster. ADR include skin reactions, erythema, flaking/scaling, crusting, swelling, posotulation and erosion/ulceration, allergic reactions, herpes zoster

Dystocia

difficult labor that is prolonged or more painful due to problems caused by uterine contractions, fetus or bones and tissues of the pelvis. The fetus may be large, malpositioned or abnormal presentation. Contractions may be hypotonic or hypertonic. Hypotonic contractions are short, irregular and weak, amniotomy and oxytocin may be used. Hypertonic contractions are painful, frequent and uncoordinated. Can result in dehydration, infection, fetal injury or death.

phenylkentonuria assessment

digestive problems and vomiting, seizures, musty odor of the urine, intellectual ability. In older children, eczema, hypertonia, hypopigmentation of the hair, skin and irises. Behavioral abnormality including hyperactivity and bizarre or schizoid behavior

aplastic crisis in sickle cell crisis

diminished production and increased destruction of RBC, triggered by viral infection of depletion of folic acid. profound anemia and pallor

cerebral palsy

disorder characterized by mipaired movement, posture and muscle tone resulting from abnormality in the extrapyramidal or pyramidal motor system.

Marfan's syndrome

disorder of CT that primarily affects the skeletal, CV and ocular systems. Caused by defects in the fibrillin 1 gene, which serves as a building block for elastic tissue in the body. There is no cure

meloxicam ADR

dizziness, GI upset, N/V, URI, flulike sx

tramadol ADR

dizziness, confusion, HA, orthostatic hypotension, abnormal EKG, visual disturbances, N/V, GI bleeding, urinary retention/frequency, rash, respiratory depression

diphenhydramine ADR

dizziness, drowsiness, palpitations, hypotension, blurred vision, N/D, dysuria, urinary retention, thrombocytopenia, photosensitivity, chest tightness, wheezing

hydrocodone/acetaminophen ADR

dizziness, drowsiness, sedation, constipation, N/V, respiratory depression, impairment of mental and physical performance, rash, pruritus, palpitations

apixaban nursing considerations

do not give to clients with bleeding potential, CI in aneurysm, active bleeding, hemorrhage, blood dyscrasias, hemophilia, HTN, pericardial effusions, pericarditis. Older adult clients may require lower doses. Use with caution in severe diabetes, kidney impairment, severe trauma, ulcerations, vasculitis, pregnancy. Avoid in breastfeeding due to increased risk of bleeding in infants (vitamin K deficiency). Stop med before surgery, Rx

nephroblastoma interventions

do not palpate abdomen, measure girth.

Mumps interventions

droplet and contact precautions, soft foods, hot or cold compresses to the neck

fexofenadine ADR

drowsiness, HA, dizziness, diarrhea, vomiting, rash, itching, hoarseness, urinary retention

cetirizine ADR

drowsiness, dry mouth, HA, constipation

Hydroxyzine ADR

drowsiness, oropharyngeal dryness, dizziness, HA, chest congestion

hydromorphone ADR

drowsiness, sedation, GI disturbance, anorexia, respiratory depression, orthostatic hypotension, confusion, HA, rash

Oxycodone ADR

drowsiness, sedation, N/V, anorexia, respiratory depression, constipation, confusion, HA, rash, euphoria, urinary retention, orthostatic hypotension, palpitations

methadone ADR

drowsiness, sedation, N/V, anorexia, respiratory depression, constipation, cramps, orthostatic hypotension, confusion, HA, rash, dysrhythmias, agitation

codeine ADR

drowsiness, sedation, N/V, anorexia, respiratory depression, constipation, orthostatic hypotension, dysuria, dyspnea, seizures, bradycardia

buprenorphine/naloxone ADR

drowsiness, sleepiness, itching, rash, blurred vision, palpitations, tachycardia, HA, mental changes, hepatotoxicity, respiratory depression

Methylergonovine CI

during pregnancy and those w/ significant CVD, PVD or HTN

dabigatran ADR

dyspepsia, abdominal discomfort, epigastric pain, GI hemorrhage, bleeding

propofol ADR

dystonic or choreiform movements, bradycardia, hypotension, hypertension, decreased CO, hyperlipidemia, increased serum TG levels ,apnea, respiratory acidosis, rash, pruritus, burning or stinging at injection site

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the nurse would indicate to the nurse that the client understands the prescribed low oxalate diet? a. spinach b. raspberries c. almonds d. 100% bran cereal e. bananas f. raisins

e. bananas f. raisins Many fruits are considered low oxalate, including bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums and nectarines. Canned fruits including peaches, pears and dried fruits such as raisins are also low in oxalate

Capput Succedaneum

edema of newborn scalp that crosses the suture lines

prolapsed umbilical cord interventions

elevate fetal presenting part that is lying on the cord using gloved finger place mom into extreme trendelenburg or knee chest admin O2 8-10L monitor FHR prepare for immediate birth

Rhogam ADR

elevated temp, tenderness at injection site

neuroblastoma interventions

emotional support, postop monitoring complications

GDM intervention

employ diet, exercise and glucose determinations QID, referral, signs of hyperglycemia and hypoglycemia, calorie intake, signs of complications, signs of infection, instruct to report signs of UTI, fetal monitor for signs of distress, regulate insulin and glucose. During postpartum, monitor for hypoglycemia

precipitous labor interventions

ensure precipitous delivery tray is available (hemostats, scissors, cord clamp), pant b/w contractions, emotional support, stay w/ client, prepare for ROM when head crowns. If delivery needs to be done before PHCP comes, apply gentle pressure to fetal head up toward vagina to prevent damage, support perineal area (Ritgen maneuver), support infant's body, check for cord around neck, restitution to deliver posterior shoulder, use gentle down pressure to move anterior shoulder under the pubic symphysis, bulb suction mouth and nares, dry and cover infant, allow placenta to separate naturally.

diphtheria intervention

ensure strict isolation, Administer diphtheria antitoxin, bed rest, abx, suction and humidified oxygen

poliomyelitis interventions

enteric and contact precautions, supportive treatment, bed rest, monitor for resp paralysis, PT

poliomyelitis

enteroviruses incubation 7-14 days, virus is present in throat and feces shortly after infection and persists for about 1 week in the throat and 4-6 weeks in the feces. Oropharyngeal secretions and feces of the infected person. Direct contact with infected person, fecal-oral and oropharyngeal routes

von willebrand disease assessment

epistaxis, gum bleeding, easy bruising, excessive menstrual bleeding

Erysipelas and cellulitis

erysipelas is an acute, superficial infection affecting the upper layers of skin caused by group A strep, which enters the tissue via abrasion, bite, trauma or wound. Cellulitis is infection of the dermis and underlying hypodermis, the causative organism is usually group A strep or staph

Anaphylactoid syndrome of pregnancy

escape of amniotic fluid into the maternal circulation, the debris deposits in pulmonary arterioles, causing anaphylactic like reaction fatal to client.

hydatidiform mole interventions

evacuation (vacuum aspiration, oxytocin), monitor for hemorrhage, tissue to lab, monitor HCG for a year

encopresis assessment

evidence of soiling of clothing, scratching or rubbing of the anal area, fecal odor, social withdrawal

GDM assessment

excessive thirst, hunger, weight loss, frequent urination, blurred vision, recurrent UTI or yeast infections, glycosuria and ketonuria, signs of gestational HTN or preeclampsia, polyhydramnios, large for gestational age fetus

cerebral palsy assessment

extreme irritability and crying, feeding difficulties, abnormal motor performance, alterations of muscle tone, stiff and rigid arms and legs, delayed developmental milestones, persistence of primitive infantile reflexes (moro, tonic neck) after 6 months (usually goes away by 3-4 months). seizures may occur

imperforate anus assessment

failure to pass meconium stool, absence or stenosis of the anal rectal canal, presence of an anal membrane, external fistula to the perineum

celecoxib ADR

fatigue, anxiety, depression, nervousness, N/V, anorexia, dry mouth, constipation, dyspnea, back pain, tachycardia, dysuria, palpitations

prolapsed umbilical cord assessment

feeling of something coming through vagina, visible or palpable umbilical cord, irregular and slow and FHR, variable decels or bradycardia after ROM.

mumps assessment

fever, HA and malaise, anorexia, jaw or ear pain aggravated by chewing, followed by parotid glandular swelling. Orchitis or oophoritis may occur. Deafness may occur. Aseptic meningitis may occur.

otitis media assessment

fever, acute onset of ear pain, crying, irritability, lethargy, loss of appetite, rolling of head from side to side, pulling on or rubbing the ear, purulent ear drainage , red opaque, bulging, immobile tympanic drums, signs of hearing loss

bronchitis assessment

fever, dry hacking, non productive cough worse at night and becomes productive in 2-3 days.

mononucleosis assessment

fever, malaise, HA, fatigue, nausea, abdominal pain, sore throat, enlarged red tonsils, lymphadenopathy and hepatosplenomegaly. Discrete macular rash most prominent over the trunk may occur

poliomyelitis assessment

fever, malaise, anorexia, nausea, HA, sore throat, abdomen pain followed by soreness and stiffness of the trunk, neck and limbs that may progress to CNS paralysis

Rocky mountain spotted fever assessment

fever, malaise, anorexia, vomiting, HA, myalgia. Maculopapular or petechial rash primarily on the extremities (ankles and wrists) but may spread to other areas, characteristically on the palms and soles

rubeola assessment

fever, malaise, the 3 Cs (coryza, cough, conjunctivitis), rash appears as red, erythematous maculopapular eruption starting on the face and spreading down to the feet. Blanches easily with pressure and gradually turns a brownish color (lasts 6-7 days), may have desquamation. Koplik's spots" small red spots with a bluish white center and a red base, located on the buccal mucosa and lasts 3 days

Vasoocclusive crisis

fever, painful swelling of hands, feet, joints, and abdominal pain

Which nursing intervention is appropriate when providing care to a client who's internal radiation implant becomes dislodged and is found on the pillow during a routine assessment? Select all that apply. a. fill out an incident report b. call the HCP c. notify the radiation safety officer d. immediately reinsert the implant and notify the HCP e. remove the client from the source of radiation f. use forceps to place the implant in the appropriate lead container

fill out an incident report b. call the HCP c. notify the radiation safety officer e. remove the client from the source of radiation f. use forceps to place the implant in the appropriate lead container

neuroblastoma assessment

firm, nontender, irregular mass in abdomen that crosses the midline. urinary frequency or retention from compression of the kidney, ureter or bladder. Lymphadenopathy esp in cervical and supraclavicular areas. Bone pain if skeletal involvement. Supraorbital ecchymosis, periorbital edema, and exophthalmos due to invasion of retrobulbar soft tissue. Pallor, weakness, irritability, anorexia, weight loss. Signs of resp impairment (horacic lesion), signs of neuro impairment (intracranial lesion), paralysis from compression of spinal cord

B Thalessemia assessment

frontal bossing, maxillary prominence, wide set eyes with flattened nose, greenish yellow skin tone, hepatosplenomegaly, severe anemia, microcytic, hypochromic RBC

Esophageal atresia and tracheoesophageal fistula assessment

frothy saliva in mouth and nose and excessive drooling, 3 C's - coughing and choking during feedings and unexplained cyanosis, regurgitation and vomiting, abdominal distention, increased respiratory distress during and after feeding

propofol purpose

general anesthesia and monitored anesthesia care (MAC), sedation of intubated ICU clients

middle adulthood psychosocial crisis

generativity vs. stagnation

Phenylkenoturia

genetic disorder results in CNS damage from toxic levels of phenylalanine > 20 mg/dL

alteplase nursing considerations

give by IV infusion. Use with caution after surgery or trauma. Numerous interactions with other meds. Monitor VS carefully. Observe for bleeding. Do not use in pregnancy (except in life threatening situations). use with caution in breastfeeding. Rx

Rubella vaccine

given SC before d/c to nonimmune postpartum client if rubella titer < 1:8

celiac disease interventions

gluten free diet, mineral and vitamin supplements such as iron, folic acid, and fat soluble vitamins ADEK

celiac disease

gluten intolerance, protein component of wheat, barley, rye and oats. Results in accumulation of amino acid glutamine, which is toxic to intestinal mucosal cells. Intestinal villous atrophy occurs, which affects absorption of ingested nutrients.

GTPAL

gravida, term births (longer than 37 weeks), preterm births (before 37 weeks), abortions, living children

Hemophilia

group of bleeding disorders from deficiency of specific coagulation proteins. X linked recessive. Primary treatment is replacement of missing clotting factor, additional medications such as agents to relieve pain or CS

Nifedipine pregnancy use

halt preterm labor contractions

Magnesium sulfate CI

heart block, myocardial damage or kidney failure. Use in caution iwth renal impairment

hemolytic uremic syndrome interventions

hemodialysis or PD if renal status worsens. Strict monitoring of fluid balance. Prevent infection. Blood products to treat anemia

warfarin ADR

hemorrhage, diarrhea, rash, fever, angina syndrome, anemia, dermatitis, jaundice, elevated liver enzymes, anaphylactic reactions

Von Willebrand Disease

hereditary bleeding disorder due to deficiency or defect in protein named von Willebrand. It causes plt to adhere to damaged endothelium, increased tendency to bleed from mucous membranes

Omphalocele

herniation of abdominal contents though umbilical ring, usually with intact peritoneal sac. protrusion is covered by a translucent sac that may contain bowel or other abdominal organs. Rupture of the sac results in evisceration of the abdominal contents. Immediately after birth, the sac is covered with sterile gauze soaked in normal saline to prevent drying of abdominal contents, a layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss. monitor VS q2-4 hours esp temp because infant can lose heat through the sac.

Gastroschiisis

herniation of intestine is lateral to the umbilical ring. No membrane covers the exposed bowel. The exposed bowel is covered loosely in saline soaked pads and abdomen is loosely wrapped in plastic drape. Wrapping directly around the exposed bowel is contraindicated because if the exposed bowel expands, wrapping could cause pressure and necrosis.

Epiglottitis assessment

high fever, sore, red and inflamed throat (large, cherry red, edematous epiglottis) and pain on swallowing. Absence of spontaneous cough. Dysphonia (muffled voice), dysphagia, dyspnea, and drooling, agitation, retractions as the child struggles to breathe, inspiratory stridor aggravated by the supine position, tachycardia, tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia, respiratory acidosis, decreased LOC). Tripod positioning

Reye's syndrome assessment

history of systemic viral illness 4-7 days before onset of sx, fever, N/V, signs of altered hepatic function such as lethargy, progressive neuro deterioration, increased blood ammonia levels

fluticasone ADR

hoarseness, oropharyngeal fungal infections, HA, nasal congestion, cold symptoms, N/V/D, epistaxis, nasal irritation, dyspnea

Beclomethasone ADR

hoarseness, oropharyngeal fungal infections, HA, sore throat, dyspepsia, rhinitis, cough, angioedema

Rubella vaccine CI

hypersensitivity to eggs

hypertrophic pyloric stenosis

hypertrophy of circular muscles of pylorus causes narrowing of the pyloric canal between the stomach and duodenum, causing projectile vomiting, dehydration, metabolic alkalosis and failure to thrive.

preterm labor interventions

identify and treat infection, restrict activity, ensure hydration, lateral position, medications such as tocolytics, 17P injection to decrease risk of preterm delivery

adolescence psychosocial crisis

identity vs. role confusion

Ginko

improves memory and treat depression, improves circulation. Should not be taken with MAOI, anticoagulants, antiplatelets. Increases bleeding time with NSAIDs, cephalosporins and valproic acid

preoperational stage

in Piaget's theory, the stage (from about 2 to 6 or 7 years of age) during which a child learns to use language but does not yet comprehend the mental operations of concrete logic

sensorimotor stage

in Piaget's theory, the stage (from birth to about 2 years of age) during which infants know the world mostly in terms of their sensory impressions and motor activities

concrete operational stage

in Piaget's theory, the stage of cognitive development (from about 6 or 7 to 11 years of age) during which children gain the mental operations that enable them to think logically about concrete events

formal operational stage

in Piaget's theory, the stage of cognitive development (normally beginning about age 12) during which people begin to think logically about abstract concepts

Imperforate anus

incomplete development or absence of the anus in its normal position in the perineum. A membrane is noted over the anal opening with a normal anus just above the membrane. There is complete absence of the anus (anal agenesis) with a rectal pouch ending some distance above. Or rectum ends blindly or has a fistula connection to the perineum, urethra, bladder or vagina

subinvolution

incomplete involution or failure of uterus to return to its normal size and condition

Betamethasone and dexamethasone

increase production of surfactant to accelerate fetal lung maturity and decrease incidence or severity of respiratory distress syndrome. Use for client in preterm labor between 28-32 weeks whose labor can be inhibited for 48 hours without jeopardizing the pregnant client or fetus

Rubeola (measles)

incubation 10-20 days, communicable period from 4 days before 5 days after rash appears, mainly during the prodromal stage. Respiratory secretions, blood or urine. Airborne particles, dire ct contact with infectious droplets or transplacental trasmission

mumps

incubation 14-21 days, communicable period immediately before and after parotid gland swelling begins. Saliva of infected person and possibly urine. Transmission direct contact or droplet spread from an infected person.

indomethacin ADR

indigestion, vaginal bleeding. In fetus, reduced UOP (amniotic fluid may be reduced), ductus arteriosus, at risk for NEC, intraventricular hemorrhage, periventricular leukomalacia (type of brain injury)

school age psychosocial crisis

industry vs inferiority

SIDS assessment

infant is apneic, blue and lifeless, frothy blood tinged fluid is in nose and mouth. Infant may be found in any position but typically s found in disheveled bed, with blankets over the head and huddled in corner. Diaper may be wet and full of stool

Esophageal atresia and tracheoesophageal fistula interventions

infant may be placed in radiant warmer where humidified O2 is administered, NPO, IVF, resp status, suction accumulated secretions from the mouth and pharynx. Maintain supine position at least 30 degrees to maintain drainage and prevent aspiration of gastric secretions. Keep blind pouch empty of secretions through suctioning. If gastrostomy tube is inserted, it may be left open so that air entering the stomach through the fistula can escape. Abx for high risk of aspiration pneumonia. I&Os. Prepare esophagogram before oral feedings and removal of chest tube. Elevate the gastrostomy tube and secure above stomach to allow gastric secretions to pass to duodenum and swallowed air to escape before feeding. Administer feedings with sterile water and frequent small feedings of formula. Provide nonnutritive sucking, using pacifier for NPO

SIDS prevention and interventions

infants would be placed in supine.

endometritis

infection of the lining of the uterus occurring in the postpartum period, caused by bacteria that invade the uterus at the placental site

leukemia assessment

infiltration of bone marrow by malignant cells cause fever, pallor, fatigue, anorexia, hemorrhage and bone and joint pain. Pathological fracture can occur. Infection due to neutropenia. Hepatosplenomegaly and lymphadenopathy. Normal, elevated or low WBC count, decreased Hgb and Hct, plt. Positive bone marrow biopsy specimen. Signs of increased ICP due to CNS involvement. Signs of CN VII (facial nerve) or spinal nerve. Invasion of leukemic cells to kidneys, testes, prostate, ovaries, GI tract and lungs.

adenoiditis

inflammation and infection of adenoids (pharyngeal tonsils) on the posterior wall of the nasopharynx. Enlarged tonsils and adenoids may lead to OSA in children, manifested by snoring and periods of sudden waking and fragmented sleep. Can be result of viral, bacterial or fungal. Commonly group A strep (strep throat)

tonsillitis

inflammation and infection of tonsils which is lymphoid tissue in the pharynx

otitis externa

inflammation of external auditory canal which can be w/ or w/o ifnection, swimmer's ear

PNA

inflammation of pulmonary parenchyma or alveoli or both, caused by virus, mycoplasmal agents, bacteria, or aspiration of foreign bodies. Causative agent introduced into lungs through inhalation or from blood. Viral PNA more frequent. Bacterial PNA more serious. Aspiration PNA when food, secretions, liquids or other materials enter the lung and cause inflammation and chemicals.

Laryngotracheobronchitis (croup)

inflammation of the larynx, trachea and bronchi, most common type of croup, may be viral or bacterial. Most common parainfluenza virus types 2 and 3, RSV, Mycoplasma pneumoniae and influenza A and B. Characterized by gradual onset that may be preceded by URTI

pleurisy

inflammation of the pleura can be associated with URTI, PE, thoractomy, chest trauma or cancer. Sx include sharp pain on inspiration, chills, fever, cough, dyspnea. CXR reveals presence of air in the pleural sac.

Bronchitis

inflammation of trachea and bronchi, usually associated with URTI, usually mild, causative agent is most ofen viral

Rheumatic fever

inflammatory autoimmune disease that affects the CT of heart, joints, skin, blood vessels and CNS. The most serious complication is rheumatic heart disease, which affects the cardiac valves, particularly the mitral valve. It manifests 2-6 weeks after untreated or partially treated group A strep of upper respiratory tract.

Otitis media

inflammatory disorder usually caused by infection of middle ear, occurring as result of blocked eustachian tube, which prevents normal drainage, can be acute or chronic. Common complication of acute respiratory infection (RSV, flu or group A strep). Infants and children have eustachian tubes that are shorter, wider and straighter, which makes them more prone.

glomerulonephritis

inflammatory injury in the glomerulus caused by immunological reaction. Results in proliferative and inflammatory changes within the glomerular structure. Causes include immunological diseases, autoimmune diseases, group A beta hemolytic strep infection of pharynx or skin, hx of pharyngitis or tonsillitis or hx of infection of skin 3-6 weeks before symptoms

RSV assessment

initial: rhinorrhea, eye or ear drainage, pharyngitis, coughing, sneezing, wheezing, intermittent fever increased coughing and wheezing, signs of air hunger, tachypnea and retractions, periods of cyanosis severe illness: tachypnea of more than 70 breaths/min, decreased breath sounds and poor air exchange, listlessness, apneic episodes

late childhood psychosocial crisis

initiative vs. guilt

vaginal ring

inserted into vagina, left in place for 3 weeks and removed for 1 week

lung surfactant interventions

instill through catheter inserted into endotracheal tube, avoid suctioning for at least 2 hours after. Monitor for bradycardia and decreased O2, resp status and lung sounds

later adulthood psychosocial crisis

integrity vs. despair

early adulthood psychosocial crisis

intimacy vs. isolation

opioid withdrawal in babies

irritability, excessive crying, tremors, hyperactive reflexes, fever, vomiting, diarrhea, yawning, sneezing and seizures

pertussis interventions

isolate during catarrhal stage, droplet and contact precautions. Antimicrobial therapy. Reduce environmental factors that cause coughing spasms such as dust, smoke and sudden changes in temp. Adequate hydration and nutrition. Suction and humidified oxygen.

herpes zoster interventions

isolate, contact precautions as long as vesicles are present. Neurovascular status and Bell's palsy common complication. Keep environment cool, warmth and touch aggravate the pain. Antiviral therapy, vaccination recommended after 50 years of age.

conjunctivitis assessment

itching, burning, scratchy eyelids, redness, edema, discharge

eczema assessment

itching, redness, scaliness, minute papules (firm, elevated, circumscribed lesions < 1 cm in diameter) and vesicles (similar to papules but fluid filled), weeping oozing and crusting of lesions on scalp and face, creases of elbows and knees, neck, wrists and ankles. Uncommon in axillary, gluteal or groin area

allergic rhinitis assessment

itchy and watery eyes, runny nose, itchy throat, may be a family history of atopic disease. Dark circles under eyes, cobblestoning of the conjunctiva, pale nasal mucosa, clear nasal drainage, nasal polyps, fluid in middle ear, cobblestoning of posterior pharynx, wheezes, rhonchi, eczema, hives, angioedema

myringotomy interventions

keep ears dry, wear earplugs while bathing, shampooing and swimming (diving and submerging underwater are not allowed), Analgesic , should not blow nose for 7-10 days. Tubes usually fall out 6-12 months

Hirschprung's disease

known as congenital aganglionosis or agnglionic megacolon. Result of absence of ganglion cells in the rectum and other parts of the intestine. Mechanical obstruction results due to inadequate motility in the intestine. The most serious complication is enterocolitis, which include fever, severe prostration, GI bleeding and explosive watery diarrhea. Treatment for mild to moderate is based on relieving the chronic constipation with stool softeners and rectal irrigations, mut many children require surgery.

precipitous labor

labor lasting less than 3 hours

Pediculosis capitis

lice, occipital area behind ears and nape of neck, eyebrows and eyelashes. lice can survive for 48 hours away from host, shed and can hatch in 7-10 days. They reproduce only on humans and transmitted by direct and indirect contact. Excessive head scratching, pruritus, nits, small tan or grayish specks

Hepatitis B pregnancy interventions

limit number of vaginal exams, remove parent's blood from neonate immediately after birth, suction fluids from neonate, bathe before invasive procedures, clean and dry face and eyes of neonate before eye prophylaxis, immune globulin and vaccine after birth

Legg-Calve-Perthes disease assessment

limping, pain or stiffness in the hip, groin, thigh or knee, limited ROM in the affected joint

Mastitis assessment

localized heat and swelling, pain, tender axillary lymph nodes, elevated temp, flu like sx

osteosarcoma assessments

localized pain at affected site may be attributed to trauma or growing pains. Pain relieved by flexed position, palpable mass, limping if weight bearing limb affected. Progressive limited ROM and curtailing of physical activity. May be unable to hold heavy objects because of their weight and resultant pain in extremity. Pathological fractures

Intrauterine fetal demise assessment

loss of fetal movement, absence of fetal heart tones, maternal weight loss, lack of fetal growth or decrease in fundal height, no evidence of fetal cardiac activity, DIC, low Hgb and Hct, plt, prolonged PT, bleeding from puncture sites

Hirschsprung's disease interventions

low fiber, high calorie, high protein diet, parenteral nutrition may be necessary. Stool softeners, daily rectal irrigations with prescribed fluid to promote adequate elimination and prevent obstruction. Surgical: assess bowel sounds and function, bowel prep, NPO, hydration and electrolytes, abx or colonic irrigations with antibiotic, I&Os, daily weight, abdominal girth

rubella assessment

low grade fever, malaise, pinkish red maculopapular rash that begins on the face and spreads to the entire body within 1-3 days. Petechiae may occur on the soft palate.

diphtheria assessment

low grade fever, malaise, sore throat, foul smelling mucopurulent nasal discharge, dense pseudomembrane formation in the throat that may interfere with eating, drinking and breathing. Lymphadenitis, neck edema, bull neck

encopresis intervention

maintain diet high in fiber and fluids to promote bowel elimination, select fiber foods, monitor treatment regimen for severe encopresis for 3-6 months. Decrease sugar and milk intake. Administer enemas as prescribed until impaction is cleared. monitor for hypernatremia or hyperphosphatemia with enemas (hypernatremia include increased thirst, dry sticky mucous membranes, flushed skin, increased temperature, nausea and vomiting, oliguria, lethargy. signs of hyperphosphatemia tetany, muscle weakness, dysrhythmia and hypotension)

Hodgkin's disease

malignancy of lymph nodes that originates in a single lymph node or single chain of nodes. The disease metastasizes to nonnodal or extralymphatic sites, esp spleen, liver, bone marrow, lungs and mediastinum. Presence of reed-sternberg cells inlymph node biopsy. Peak in midadolescence possibly due to viral infections and previous exposure to alkylating chemical agents.

Leukemia

malignant increase in number of leukocytes usually at immature stage in the bone marrow, causing depression of the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia and bleeding from decreased plt production. Acute lymphocytic leukemia most frequent in children. The phases of chemo include induction, which achieves a complete remission or disappearance of leukemic cells, intensification or consolidation therapy, which decreases the tumor burden further, CNS prophylactic therapy, which prevents leukemic cells from invading the CNS and maintenance, which serves to maintain the remission phase

Celecoxib purpose

management of acute chronic arthritis pain, relief of primary dysmenorrheal pain within 60 minutes

aspirin purpose

management of mild to moderate pain or fever and TIA; prophylaxis of MI, ischemic stroke, and angina

tramadol purpose

management of moderate to severe pain and chronic pain

loratadine purpose

management of seasonal rhinitis

buprenorphine/naloxone purpose

management of severe pain, treatment of opioid dependence

uterine atony inerventions

massage uterus until firm, empty bladder by voiding or catheterization. Notify OB or PHCP if interventions do not resolve atony, this can indicate hemorrhage

nephrotic syndrome

massive proteinuria, hypoalbuminemia, hyperlipidemia and edema. Reduce excretion of urinary protein, maintain protein free urine and minimize complications

Corticosteroid ADR

may decrease resistance to infection, pulmonary edema secondary to sodium and fluid retention. elevated glucose levels

hyperemesis gravidarum interventions

medication, fluid, electrolyte replacement, VS, I&Os, weight and calorie, lab data, monitor for ketonuria, FHR, encourage intake of small portions of food with low fat, easily digestible carbs, encourage intake of liquids, sit upright after meals

ectopic pregnancy assessment

missed period, abdominal pain, vaginal spotting to bleeding dark red or brown. In rupture, increased pain, referred shoulder pain

dermatitis treatment

moisturizer and topical GC, systemic immunosuppressants if topical treatment is ineffective or systemic exposure. Topical immunosuppressants: tacrolimus and pimecrolimus creams. ADR include redness, burning, itching, sensitization to sunlight. Tacrolimus increase risk of varicella zoster in children, may increase risk of developing skin cancer and lymphoma

pregnancy HTN and preeclampsia interventions

monitor BP and weight, fetal activity, frequent rest periods, medications, fluids, I&Os, neuro status, DTR, HELLP syndrome, renal function, mag sulfate for prevention, signs of mg toxicity

GS interventions

monitor VS and lung sounds and edema, signs of infection, WBC count, glucose levels, administer by deep IM injection

postpartum infection interventions

monitor VS and temp q2-4 hours, position client to promote vaginal drainage, keep client warm if chilled. Isolate newborn only if infectious. high calorie, high protein diet, fluids to 3-4 L/day. monitor I&Os, C&S, antipyretics and analgesics, abx

Methylergonovine interventions

monitor VS, BP contractions, chest pain, HA, SOB, itching, pale or cold hands or feet, N/D and dizziness. Assess extremities for color, warmth, movement and pain, vaginal bleeding. Administer analgesics as needed because it can cause painful uterine contractions

Prostaglandin interventions

monitor VS, FHR, status of pregnancy including indications for cervical ripening or induction of labor. Void before and maintain supine with lateral tilt or side lying position for 30-60 min up to 2 hour after. Treatment d/c when Bishop score >/= 8 or signs of ADR. Oxytocin may be used if needed 6-12 hours after d/c of prostaglandin therapy

hemophilia interventions

monitor for bleeding and bleeding precautions. Prepare to administer factor VIII concentrates, DDAVP, synthetic form of vasopressin may be prescribed for mild hemophilia. Monitor for joint pain, immobilize affected extremity. Assess neuro status (risk for intracranial hemorrhage), hematuria, control joint bleeding by immobilization, elevation and application of ice. Protective gear for sports and activities

uterine inversion interventions

monitor for hemorrhage and shock, treat shock, return uterus to correct position, laparotomy if unsuccessful

Marfan's syndrome interventions

monitor for vision problems, curvature of the spine, cardiac meds, avoid competitive sports to avoid injuring heart. Abx prophylaxis before dental work.

Kawasaki disease interventions

monitor temp, heart, I&Os, soft foods and liquids that aren't too hot or cold, weight daily, acetylsalicylic acid , immunoglobulin

Nephroblastoma (wilm's tumor)

most common intraabdominal and kidney tumor of childhood associated with genetic and congenital anomalies. Surgery, chemo and radiation

Kawasaki disease

mucocutaneous lymph node syndrome is acute systemic inflammatory disease. The cause is unknown but may be associated with infection. Cardiac involvement is most serious complication, aneurysms can develop

beclomethasone nursing considerations

nasal spray onset 5-7 days up to 3 weeks in some clients, peak up to 3 weeks. Inhaler onset 10 min. use regular PF monitoring to determine respiratory status. Rinse mouth after each use to prevent oral fungal infections. Rx

hyperemesis gravidarum assessment

nausea most pronounced on arising, persistent vomiting, weight loss, dehydration, F&E imbalances

Methylergonovine ADR

nausea, uterine cramping, bradycardia, dysrhythmias, MI and severe HTN. High doses are associated with peripheral vasospasm or vasoconstriction, angina, miosis, confusion, respiratory depression, seizures or unconsciousness, uterine tetany can occur

allergic rhinitis interventions

need to be tested for environmental allergies, food allergies, atopic dermatitis and asthma. Avoid triggers, antihistamines, nasal CS, inhalers

brain tumor interventions

neuro assessment, seizure precautions, monitor temp which may be elevated because of hypothalamus or brainstem involvement, maintain a cooling blanket. Monitor for resp infection, meningitis, increased ICP, hemorrhage, pupillary response, colorless drainage. Prevent vomiting, quiet environment, analgesics

Hirschspuring's disease assessment

newborns: failure to pass meconium stool, refusal to suck, abdominal distention, bile stained vomitus children: failure to gain weight and delayed growth, abdominal distention, vomiting, constipation alternating with diarrhea, ribbon like and foul smelling stools

hydatidiform mole assessment

no FHR, hyperemesis, vaginal bleeding bright red or dark brown, signs of preeclampsia before 20th week, fundal height greater than expected, elevated HCG, snowstorm pattern on US

hydrocele

noncommunicating hydrocele has no connection to the peritoneum, fluid comes from mesothelial lining of the tunica vaginalis. Hydrocele usually disappears by age 1 years as the fluid is reabsorbed. Communicating hydrocele is associated with a hernia that remains open from the scrotum to the abdominal cavity. Assessment includes a bulge in the inguinal area or scrotum that increases with crying or straining and ecrease at rest.

erythema infectiosum interventions

not usually hospitalized, antipyretics, analgesics and antiinflammatory

loratadine nursing considerations

onset 1-3 hours, peak 8-12 hours, duration at least 24 hours. Avoid alcohol, CNS depressants. take on empty stomach 1 hour ac or 2 hours pc. OTC, rx

ibuprofen nursing considerations

onset 30 min, peak 1-2 hours, used in RA, osteoarthritis, primary dysmenorrhea, gout, dental pain, MSK disorders, fever. Take with food or milk to decrease GI symptoms. Contact provider if ringing/roaring in ears (may indicate toxicity). Contact provider if changes in urinary pattern, increased weight, edema, increased joint pain, fever or blood in urine (may indicate kidney damage). use sunscreen to prevent photosensitivity. Avoid use with anticoagulants, aspirin, NSAIDs, alcohol (may precipitate GI bleeding). OTC, Rx

erysipelas and cellulitis assessment

pain and tenderness, erythema and warmth, fever, edema

Hodgkin's disease assessment

painless enlargement of lymph nodes, enlarged, firm, nontender, movable nodes in supraclavicular or cervical area. Sentinel node located near left clavicle may be the first enlarged node. Nonproductive cough due to mediastinal lymphadenopathy. Abdominal pain due to enlarged retroperitoneal nodes. Advanced lymph node and extralymphatic involvement that may cause systemic involvement such as low grade or intermittent fever, anorexia, nausea, weight loss, night sweats and pruritus.

supine hypotension birth assessment

pallor, faintness, dizziness, breathlessness, tachycardia, hypotension, sweating, cool and damp skin, fetal distress

Thrombophlebitis assessment

palpable thrombus that feels bumpy and hard, tenderness and pain in affected extremity, warm and pinkish red color over thrombus area, malaise, chills and fever, diminished peripheral pulses, shiny white skin over affected area, pain, stiffness and swelling of affected extremities

scabies

parasitic skin disorder caused by Sarcoptes scabiei, endemic among schoolchildren and institutionalized populations due to close contact. pruritic papular rash, burrows into the skin (fine grayish red lines that may be difficult to see)

croup interventions

patent airway, assess resp status, pallor and cyanosis, elevate HOB. Humidified O2. Fluid intake, IVF, analgesics. Avoid cough medicines which may dry and thicken secretions. CS, abx, Heliox, nebulized racemic epinephrine.

epiglottitis interventions

patent airway, resp status and breath sounds, nasal flaring, use of accessory muscles, retractions and stridor. Do not measure oral temp. Pulse ox, prepare for lateral neck films to confirm diagnosis, avoid placing in supine position, NPO. IVF, abx, analgesics and antipyretics, CS. Heliox (helium and oxygen) may be prescribed, reduces the work of breathing, reduce airway turbulence and helps relieve airway obstruction. Cool mist oxygen, high humidification.

lice interventions

pediculicide product, use for over age 6 months. Lindane shampoo should not be used younger than 2 years due to neurotoxicity and seizures. Daily removal of nits with extra fine tooth comb after the product. Hairbrushes or combs soaked in boiling water for 10 min. Clothing and bedding should be laundered in hot water for 20 min. Or store in tightly sealed plastic bag for 2 weeks and then washed.

glomerulonephritis assessment

periorbital and facial edema more prominent in morning, anorexia, decreased UOP, cloudy, smoky, cola colored urine, pallor, irritability, lethargy older child: HA, abdominal or flank pain, dysuria HTN, proteinuria that produces a persistent and excessive foam in the urine, azotemia, increased BUN and Cr, increased anti-streptolysin O titer

tonsillitis/adenoiditis assessment

persistent or recurrent sore throat, enlarged, bright red tonsils that may be covered with white exudate, difficulty swallowing, mouth breathing and unpleasant mouth odor, fever, cough, enlarged adenoids may cause nasal quality of speech, mouth breathing, hearing difficulty, snoring or OSA

conjunctivitis

pink eye, inflammation of the conjunctiva usually caused by allergy, infection or trauma.

splenic sequestration in sickle cell crisis

pooling and clumping of blood in spleen. Profound anemia, hypovolemia and shock

uterine atony

poorly contracted uterus that does not adequately compress large open vessels at the placental site, this can result in hemorrhage

tocolytic medication interventions

position on side to enhance placental perfusion and reduce pressure on cervix. Monitor VS, fetal status, ADR, daily weight and I&Os, comfort measures

supine hypotension birth interventions

position on side to shift the weight of fetus off vena cava

intrauterine fetal demise interventions

prepare for birth, religious and spiritual beliefs, monitor for maternal infection or DIC, IVF, meds and blood products

premature ROM assessment

presence of fluid pooling in vaginal vault, + nitrazine test

fertility medications CI

presence of primary ovarian dysfunction, thyroid or adrenal dysfunction, ovarian cysts, pregnancy or idiopathic uterine bleeding. Should be used with caution in those with thromboembolic or respiratory disease

feverfew

prevent and treat migraines, arthritis and fever. Prolongs bleeding

enoxaparin purpose

prevention and treatment of deep vein thrombosis

heparin purpose

prevention and treatment of deep vein thrombosis and pulmonary embolism

warfarin purpose

prevention and treatment of deep vein thrombosis and pulmonary embolism, treatment of atrial fibrillation

Rhogam

prevention of anti-Rh ab formation is most successful if administered twice at 28 weeks' and again within 72 hours of delivery. Must be given with each subsequent exposure. Used to prevent isoimmunization in Rh negative clients who are negative for Rh ab and exposed to Rh + RBC by amniocentesis, CVS, transfusion ,termination of pregnancy, abdominal trauma, or bleeding during pregnancy or birthing process.

apixaban purpose

prevention of clots, treatment of pulmonary embolism, deep vein thrombosis, DIC, unstable angina, MI, atrial fibrillation, heparin induced thrombocytopenia, and heparin induced thrombosis

dabigatran purpose

prevention of stroke in patients with nonvalvular atrial fibrillation

otitis media interventions

prevention: feed in upright position, encourage breastfeeding, exposure to tobacco smoke and allergens. Encourage fluid intake, avoid chewing, local heat or cold for discomfort, lie with affected ear down. Clean drainage w/ sterile swabs or gauze, Administration of analgesics or antipyretics, abx, screening for hearing loss

Erythromycin

preventive eye treatment against ophthalmia neonatorum in newborn prophylaxis against Neisseria gonorrhoeae and Chlamydia.

topical GC CI

previous sensitivity to CS, current systemic fungal, viral or bacterial infections. Current complications related to GC.

Tocolytics

produce uterine relaxation and suppress uterine activity to halt uterine contractions and prevent preterm birth

Phytonadione interventions

protect med from light, administer by IM in vastus lateralis, monitor for bruising at injection site and bleeding for cord. Jaundice, monitor bilirubin level.

fertility medications interventions

provide a calendar of treatment days and instructions on when sex should occur to increase therapeutic effectiveness. Notify if signs of ovarian overstimulation occur

otitis externa assessment

rapid onset of sx within 48 hours, otalgia, pruritus, fullness, drainage, impaired hearing, low grade fever, tenderness on manipulation of the pinna and tragus. may have regional lymphadenopathy

cerebral palsy interventions

recognize the disorder early and maximize abilities. PT, OT, ST, education and recreation. mobilizing devices. Position upright after meals, meds for muscle spasm which cause intensive pain

Diphenhydramine use

relief of allergy symptoms, rhinitis, and motion sickness, treatment of insomnia

fentanyl purpose

relief of moderate to severe pain

cetirizine nursing considerations

relief of perennial allergic rhinitis caused by molds, animal dander and other allergens, avoid alcohol, call provider immediately for difficulty breathing or swallowing, hydroxyzine allergy, OTC

cetirizine use

relief of seasonal allergic rhinitis symptoms

DIC interventions

remove underlying cause, monitor VS, assess for bleeding and signs of shock, oxygen, volume replacement, blood therapy, heparin therapy, monitor for complications associated with fluid, blood and heparin therapy. monitor UOP

lung surfactants

replenish surfactant and restore surface activity to lungs to prevent and treat respiratory distress syndrome. Given intratracheal route to newborn to prevent or treat RDS in premature newborns

fentanyl ADR

respiratory and circulatory depression, coma, seizures and sedation, dysphoria/euphoria, depression, agitation, faintness, weakness, visual disturbances, dizziness, biliary colic, GI disturbance, urinary retention/frequency

Magnesium sulfate ADR

respiratory depression, depressed reflexes, flushing, hypotension, extreme muscle weakness, decreased UOP, pulmonary edema and elevated Magnesium (> 7.5 mEq/L). High dose can cause loss of DTR, heart block, respiratory paralysis and cardiac arrest

morphine ADR

respiratory depression, sedation, euphoria, orthostatic hypotension, bradycardia, diaphoresis, urticaria

acute respiratory distress syndrome (ARDS)

respiratory failure as a result of disease or injury

erysipelas and cellulitis interventions

rest of affected area, apply warm compresses to promote circulation and decrease discomfort, erythema and edema, antibacterial treatment

Prostaglandins

ripen the cervix, making it softer and causing it to begin to dilate and efface, stimulate uterine contractions, administered vaginally. Used in preinduction cervical ripening (when Bishop score </= 4), induction of labor, induction of abortion. misoprostol and dinoprostone

Fertility medications ADR

risk of multiple births and birth defects, ovarian overstimulation (abdominal pain, distention, ascites, pleural effusion), HA, irritability, fluid retention and bloating, N/V, uterine bleeding, ovarian enlargement, gynecomastia, rash, orthostatic hypotension, febrile reactions

phenylketonuria intervention

screening, restrict phenylalanine intake, high protein foods and aspartame avoided. Monitor physical, neuro and intellectual development. Use of special prep formulas

tocolytics CI

severe preeclampsia and eclampsia, active vaginal bleeding, intrauterine infection, cardiac disease, placental abruption or poorly controlled DM. For fetal, estimated gestational age > 37 weeks, cervical dilation > 4 cm, fetal demise, lethal fetal anomaly, chorioamnionitis, acute fetal distress and chronic IUGR

indomethacin intervention

should not be used for more than 2-3 days at a time. Avoided in those > 32 weeks pregnant due to risk of ductus arteriosus in fetus. Avoid in those w/ hx of ulcers, bleeding disorders or kidney/liver disease. Monitor amniotic fluid levels regularly by US, will return to normal once indomethacin is d/c'ed. US of fetal heart if taken for more than 2 days

imperforate anus post op interventions

side lying prone with hips elevated or supine position with legs suspended at 90 degrees to the trunk to reduce edema and pressure on the surgical site. NPO and NG tube. May have colostomy

Brain tumor

signs depend on location and size and age. Surgery, radiation or chemo

intussception interventions

signs of monitor for signs of perforation and shock as evidenced by fever, increased HR, changes in LOC or BP and respiratory distress. Abx, IVF and decompression via NG tube. Monitor for passage of normal brown stool. Prepare for hydrostatic reduction as prescribed. air or fluid is used to exert pressure on area involved to lessen, diminish or resolve the prolapse.

von willebrand disease interventions

similar to hemophilia including administration of clotting factors

MRSA

skin or wound infected with MRSA. Clients with positive cultures or history of positive culture are isolated. Folliculitis is superficial infection of follicle caused by staph and presents as a raised red rash and pustules, furuncles also caused by staph and occur deep in the follicle.

chicken pox assessment

slight fever, malaise, anorexia followed by macular rash that first appears on the trunk and scalp and moves to the face and extremities. Lesions become pustules, begin to dry and develop a crust. Lesions may appear on the mucous membranes of the mouth, the genital area and the rectal area

umbilical hernia assessment

soft swelling or protrusion around the umbilicus that is usually reducible with a finger. swelling may disappear during periods of rest and is most noticeable when the infant cries or coughs. Incarcerated hernia occurs when the descended portion of the bowel becomes tightly caught in the hernial sac, compromising blood supply. This represents a medical emergency requiring surgical repair. Assessment findings include irritability tenderness at site, anorexia, abdominal distention and difficulty defecating. The protrusion cannot be reduced and complete intestinal obstrucion and gangrene may occur

heparin ADR

spontaneous bleeding, tissue irritation/pain at injection site, increased AST/ALT, anemia, thrombocytopenia, fever, rash

Abortion assessment

spontaneous vaginal bleeding, low uterine cramping, blood clots or tissue through the vagina

Strasbismus

squint or cross eye, in which the eyes are not aligned because of lack of coordination of the extraocular muscles. It most often results from muscle imbalance or paralysis of extraocular muscles, but it also may result from a congenital defect or poor vision. Amblyopia (reduced visual acuity) may occur if not treated early because the brain receives 2 messages as a result of the nonparallel visual axes.

Croup assessment

stage I: low fever, hoarseness, seal bark and brassy cough, inspiratory stridor, fear, irritability and restlessness stage II: continuous respiratory stridor, retractions, use of accessory muscles, crackles and wheezing, labored respirations stage III: continued restlessness, anxiety, pallor, diaphoresis, tachypnea, signs of anoxia and hypercapnia stage IV: intermittent cyanosis progressing to consistent cyanosis, apneic episodes progressing to cessation of breathing

oxytocin

stimulates the smooth muscle of uterus and increase the force, frequency and duration of contractions. Also promotes milk letdown. Used for induction of labor, by IV. If IM, aspiration is necessary to avoid injection into a blood vessel. Used for inducing or augmenting labor, controlling postpartum bleeding, managing an incomplete abortion

Steps on nonreassuring FHR on oxytocin

stop infusion, turn to side, stay w/ client and ask another staff to let HCP know. Increase IVF that doesn't contain oxytocin, administer O2 8-10 L/min

Pulmonary embolism assessment

sudden dyspnea and chest pain, tachypnea and tachycardia, cough and lung crackles, hemoptysis, feeling of impending doom

roseola assessment

sudden high >102 F fever of 3-5 days duration in a child who appears well, followed by a rash (rose-pink macules that blanch with pressure), febrile seizures may occur. Rash appears several hours to 2 days after the fever subsides and lasts 1-2 days

placenta previa assessment

sudden onset of painless, bright red vaginal bleeding in last half of pregnancy, soft, relaxed and nontender uterus, fundal height may be more than expected

dermatitis

superficial inflammatory process involving primarily the epidermis

Mononucleosis interventions

supportive care, monitor for splenic rupture.

Myringotomy

surgical incision into tympanic membrane to provide drainage of purulent middle ear fluid, may be done by laser assisted procedure. Tympanoplasty tubes may be inserted to allow continued drainage and equalize pressure

Nephroblastoma assessment

swelling or mass within the abdomen (firm, nontender, confined to one side and deep within the flank). Urinary retention or hematuria, anemia caused by hemorrhage within the tumor, pallor, anorexia and lethargy from anemia. HTN due to secretion of renin by tumor, weight loss and fever, symptoms of lung involvement such as dyspnea, SOB and pain in chest after metastasis

Pertussis assessment

symptoms of respiratory infection followed by increased severity of cough, with a loud whooping inspiration. May experience cyanosis, respiratory distress, tongue protrusion, listlessness, irritability, anorexia

medications to treat dermatitis

systemic immunosuppressants: azathioprine, cyclosporine, methotrexate, oral GC topical immunosuppressants: pimecrolimus cream, tacrolimus

nifedipine ADR

tachycardia, hypotension, dizziness, HA, nervousness, facial flushing, fatigue, nausea. In fetus, may cause vascular dilation

Marfan's syndrome assessment

tall and thin body structure: slender fingers, long arms and legs, curvature of the spine, presence of visual problems, presence of cardiac problems

Intussusception

telescoping of one portion of the bowel into another portion, results in obstruction to passage of intestinal contents

premature ROM interventions

tests to assess gestational age, avoid vaginal exams, monitor maternal and fetal status, abx

thrombophlebitis interventions

therapies depending on location. Assess lower extremities for edema, tenderness, varices and increased skin temp. Implement bed rest, gradual ambulation. Elevate affected leg

otitis externa interventions

topical abx and may include neomycin w/ or w/o polymyxin B or fluoroquinolone prep

scabies interventions

topical scabicide, use only neck down. Permethrin is applied to cool, dry skin at least 30 min after bathing, massaged thoroughly into all skin surfaces, left on for 8-14 hours and removed by bathing. All clothing, bedding and pillowcases need to be washed in hot water for at least 1 week, nonwashable toys can be in sealed plastic bags for at least 4 days.

lung surfactant ADR

transient bradycardia and Oxygen desat, pulmonary hemorrhage, mucous plugging, endotracheal tube reflux. Caution in newborns at risk for circulatory overload

Rubella vaccine ADR

transient rash, hypersensitivity

Ma Huang

treat asthma and hay fever, weight loss and increase energy levels, Increases effect of MAOIs, sympathomimetics, theophylline and cardiac glycosides

Echinacea

treat cold, fever and UTI. May interfere with immunosuppressive agents, methotrexate and ketoconazole

Kava-kava

treat insomnia and mild muscle aches and pains. Increases effect of CNS suppressants and decrease effects of levodopa. Increase effect of MAOIs

St. John's Wort

treat mild to moderate depression, increase adverse CNS effects with alcohol or antidepressants

rupture of vagina interventions

treat signs of shock (O2, IVF and blood products), prepare for C-section

RSV interventions

treat sx and airway maintenance, cool humidified air and oxygen, fluid intake and medications. Contact, drop and SP. 30-40 degree angle with neck slightly extended. Fluids, suctioning if nasal secretions are copious. Antivirals

bronchitis interventions

treat sx as necessary, monitor for resp distress, cool humidified air. Fluid intake, antipyretics, cough suppressant

rivaroxaban purpose

treatment and prevention of deep vein thrombosis and pulmonary embolism, prevention of stroke in patients with nonvalvular atrial fibrillation

alteplase purpose

treatment of MI, stroke, PE and peripheral vascular occlusion; patency restoration of thrombosed grafts and IV access devices

Fluticasone purpose

treatment of chronic asthma and of seasonal and perennial rhinitis

beclomethasone purpose

treatment of chronic asthma and of seasonal and perennial rhinitis, prevention of recurrence of nasal polyps after surgical removal

MOMETASONE: Purpose

treatment of chronic asthma and of seasonal or perennial rhinitis

Triamcinolone purpose

treatment of chronic asthma and of seasonal or perennial rhinitis

acetaminophen purpose

treatment of mild pain or fever

Ibuprofen purpose

treatment of mild to moderate pain, reduction of inflammation

naproxen purpose

treatment of mild to moderate pain, reduction of inflammation

codeine purpose

treatment of moderate to severe pain and of nonproductive cough

hydromorphone purpose

treatment of moderate to severe pain and of nonproductive cough

MELOXICAM: Purpose

treatment of pain or inflammation caused by arthritis

morphine purpose

treatment of severe pain

methadone purpose

treatment of severe pain, detoxification/management of narcotic addiction

infancy psychosocial crisis

trust vs. mistrust

Neuroblastoma

tumor from embryonic neural crest cells that give rise to adrenal medulla and sympathetic ganglia. Most presenting signs from tumor compressing adjacent normal tissue and organs. Surgery, radiation, chemo

umbilical hernia and hydrocele

umbilical hernia is a protrusion of bowel through an abnormal opening in the abdominal wall. A hydrocele is the presence of abdominal fluid in the scrotal sac

DIC assessment

uncontrolled bleeding, bruising, purpura, petechiae, ecchymosis, presence of occult blood, hematuria, hematemesis, vaginal bleeding, signs of shock, decreased fibrinogen level, plt ct and hct, increased PT and PTT, clotting time, fibrin degradation products

SIDS

unexpected death of apparently healthy infant younger than 1 year. High risk prone position, use of soft bedding, sleeping in noninfant bed such as sofa, overheating, cosleeping, birthing parent who smoked cigarettes or abused substances, exposure to smoke after birth.

Herpes zoster assessment

unilaterally clustered skin vesicles along peripheral sensory nerves on the trunk, thorax or face, fever, malaise, burning and pain, paresthesia, pruritus

Vesicoureteral reflux (VUR)

urine flow is abnormal and flows from bladder back up into ureters and kidneys, causing infection and kidney damage. Cause is most likely due to abnormal flap valve where the ureter joins the bladder, allowing the backflow of urine. Secondary vesicoureteral reflux could also be a cause, referring to a blockage at the bladder that causes the urine to backflow into the ureters from the bladder.

hydrocodone/acetaminophen nursing considerations

use with CNS depressants and alcohol may result in additive CNS depression. Use with caution in clients with pulmonary considerations. May be habit forming. Avoid alcohol during treatment. Rx CIII

Nifedipine interventions

use with Mg sulfate avoided due to severe hypotension.

preterm labor assessment

uterine contractions (painless or painful)., low back pain, abdominal cramping, pelvic pressure, change in discharge, rupture of amniotic membranes, presence of fetal fibronectin in cervical canal, shortening of cervical length

subinvolution assessment

uterine pain on palpation, uterus larger than expected, more than normal vaginal bleeding, prolonged lochia rubra

chorioamnionitis assessment

uterine tenderness and contractions, elevated temperature, client or fetal tachycardia, foul odor to amnioic fluid, leukocytosis

uterine inversion

uterus completely or partly turns inside out

incompetent cervix assessment

vaginal bleeding, fetal membranes visible through cervix

chicken pox (varicella)

varicella zoster virus incubation 14-16 days. Communicable from 1-2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Respiratory tract secretions of infected person, skin lesions. Direct contact, airborne, droplet spread and contaminated objects

Rocky mountain spotted fever interventiions

vigorous supportive care, abx

PNA assessment

viral: acute or insidious, mild fever, slight cough, malaise to high fever, severe cough, diaphoresis. Nonproductive or productive cough of small amounts of whitish sputum. Wheezes or fine crackles primary atypical: acute or insidious, fever (lasting several days to 2 weeks), chills, anorexia, HA, malaise, and myalgia, rhinitis, sore throat, and dry hacking cough. Nonproductive cough initially, progressing to production of seromucoid sputum that becomes mucopurulent or bleed streaked bacterial: acute, infant: irritability, lethargy, poor feeding, abrupt fever may be accompanied by seizures, respiratory distress. Older child: HA, chills, abdominal pain, chest pain, meningeal symptoms (meningism), hacking nonproductive cough, diminished breath sounds or scattered crackles, cough becomes more productive and expectorates purulent sputum, coarse crackles and wheezing

PNA interventions

viral: symptomatic treatment, O2 with cool humidified air, increase fluid intake antipyretics, chest physiotherapy primary atypical: symptomatic, recovery generally 7-10 days bacterial: C&S, abx, O2, cool mist tent or humidified O2 through NC, suction, chest physiotherapy and postural drainage q4h, bed rest, lie on affected side to splint the chest and reduce discomfort of pleural rubbing. Fluid intake, antipyretic, monitor for fever and febrile seizures. Isolation precautions, cough suppressant, closed chest drainage may be necessary if purulent fluid. Thoracentesis of fluid accumulation

conjunctiva interventions

viral: usually resolve in 7-10 days, can take 2=3 weeks or more. Antiviral medications in more serious caused by HSV or varicella zoster virus. Bacterial: abx may be prescribed to shorten the length of infection, reduce complications or infection. Allergic: remove allergen, allergy medications education on administration of medication, d/c wearing contact lenses and obtain new ones to eliminate the chance of reinfection

Hypertrophic pyloric stenosis assessment

vomiting progresses from mild regurgitation to forceful and projectile vomiting, usually after a feeding. Vomitus contains gastric contents such as milk or formula and may contain mucus, blood tinged and doesn't contain bile. Hunger and irritability. Peristaltic waves are visible from left to right during or immediately after. Olive shaped mass in epigastrium just right of umbilicus. Signs of dehydration and malnutrition. Electrolyte imbalances, metabolic alkalosis

hemolytic uremic syndrome assessment

vomiting, irritability, lethargy, marked pallor, hemorrhagic manifestations: bruising, petechiae, jaundice, bloody diarrhea. oliguria or anuria. CNS sx: seizures, stupor, coma. Proteinuria, hematuria and presence of urinary casts. BUN and SCr elevated, Hgb and Hct decreased, increased reticulocyte count

topical GC interventions

wear gloves, wash the area just before application to ensure cleanliness and increase medication penetration. Apply sparingly in thin film. Avoid use of dry occlusive dressing unless prescribed.

nephrotic syndrome assessment

weight gain, periorbital and facial edema most prominent in morning, leg, ankle, labial or scrotal edema, decrease in UOP, urine dark and frothy, ascites, BP normal or decreased, lethargy, anorexia and pallor, massive proteinuria, hypoproteinemia and hyperlipidemia

contraceptive patch

worn for 3 weeks and removed for 1 week. If the patch falls off and remains off for less than 24 hours, can be reapplied if still sticky or replaced with new patch. If the patch is off for more than 24 hours, a new 4 week cycle must be started immediately