NCLEX Saunder 8th edition pt 3

The student nurse is working with a registered nurse (RN) in the clinic. The RN is educating the student nurse on dysfunction in the area of the semicircular canals of the ear. Which statement by the student nurse indicates that the teaching has been effective?

"Disturbance in balance occurs." The semicircular canals function to aid the client's sense of balance. These canals do not relate to hearing function or the presence of tinnitus.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected?

"Being respectful and concerned will ensure that I'm attentive to my clients' rights."

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan?

Maintain activity level as prescribed. Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed.

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply.

Client report of severe, deep, unrelenting pain. Client report of pain as nurse assesses finger movement. Client report of numbness and tingling sensation in the fingers.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

Confront the AP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem.

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?

The major bronchi. Bronchovesicular breath sounds are heard over major bronchi. The upper sternum area is where major bronchi are located. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Vesicular breath sounds are heard over the peripheral lung fields.

The nurse notes that a client is taking lansoprazole. Which question by the nurse helps to determine that this medication is effective?

"Are you experiencing any heartburn?" Lansoprazole is a gastric acid proton pump inhibitor that is used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD).

The home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin. Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which statement?

"I feel stronger and have a much better appetite." yanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly.

The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction?

"I should sit in my recliner when I get home." After total hip replacement, the client should be instructed to sit on a high, firm chair. The client should be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

"I should sleep on my left side." After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?

"I will flush the eyes after instilling the ointment." Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication.

The nursing instructor is reviewing the plan of care with a nursing student who is caring for a client with an immune disorder, and they discuss the classes of human antibodies. Which statement by the nursing student indicates a need for further teaching?

"Immunoglobulin G (IgG) is the minor serum antibody." The major serum antibody is IgG, which constitutes about 70% of the total circulating antibodies. It is antiviral, antibacterial, and effective against toxins. IgM is the first antibody produced in response to antigen and makes up about 7% of the total serum antibodies. IgE accounts for only about 0.5% of the total antibody level in the blood.

A client with lung cancer is receiving a high dose of methotrexate. A primary health care provider also prescribes leucovorin to the client. The nurse should explain to the client that leucovorin is prescribed for which reason?

"It helps to preserve normal cells." High concentrations of methotrexate harm and damage normal cells. To save normal cells, leucovorin is given; this is known as leucovorin rescue. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. Note that leucovorin rescue is potentially hazardous. Failure to administer leucovorin in the right dose at the right time can be fatal.

The primary health care provider (PHCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed?

"It is an antibody found on the surface of the red blood cell."

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

"It is okay to share towels and washcloths." Conjunctivitis is an inflammation of the conjunctiva. Bacterial conjunctivitis is highly contagious, and the nurse should teach infection control measures. These include good hand washing and not sharing towels and washcloths.

The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful?

"My nails may become clubbed." A client with COPD will have clubbing of the nails, described as an angle between the nail plate and the proximal nail fold exceeding 180 degrees. Psoriasis is represented by multiple small pits in the nail bed. Flattening of the nail plate is caused by several conditions, such as iron deficiency anemia and poorly controlled diabetes for greater than 15 years. Horizontal depression across the nail beds is caused by medical problems, such as acute, severe illness and isolated periods of severe malnutrition.

A client who was receiving enteral feedings in the hospital has been started on a regular diet and is almost ready for discharge. The client will be self-administering supplemental tube feedings between meals for a short time after discharge. The client expresses concern about performing this procedure at home. What is the nurse's bestresponse?

"Tell me more about your concerns about going home."

Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?

"The UV light treatments are given on consecutive days."

The nurse has given the client with atrial fibrillation instructions to take 1 aspirin daily. The client says to the nurse, "Why do I need to take this? I don't get any pain with my heart rhythm. "Which response by the nurse is the most appropriate?

"This will help prevent clot formation in your heart as a result of your heart's rhythm." Atrial fibrillation puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the atrial kick. In atrial fibrillation, the primary health care provider may prescribe a daily aspirin. This will prevent clot formation along the walls of the atria and resultant embolus. Aspirin will not prevent chest pain or keep a client from ever having a heart attack.

The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?

"When I'm feeling better, I'm returning to the soccer team." Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

The primary health care provider prescribes ketorolac 15 mg intravenous push. The medication vial states "30 mg/mL." How many milliliters will the nurse administer? Fill in the blank.

0.5 mL. 15 mg/30 mg x 1 mL= 0.5 mL

A client with hypertension has a new prescription for a medication called moexipril. The nurse plans to provide written directions that tell the client to take the medication at which time?

1 hour before meals. Moexipril is an angiotensin-converting enzyme (ACE) inhibitor. The client should be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that should be taken 1 hour before meals is captopril.

The nurse is reviewing the electrolyte panel results for an assigned client who is taking a potassium supplement. The nurse should determine that a therapeutic effect is present if which value is noted?

4.0 mEq/L (4.0 mmol/L). The normal serum potassium level for an adult client is approximately 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

A client who requires urine specimen collections. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures.

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 should the nurse review with the client's primary health care provider?

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 should be reduced.

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?

A structured program of activities in which the client can participate. A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem.

The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first?

A victim experiencing airway obstruction. Client needs related to maintaining a patent airway are always the priority. Therefore, the nurse would attend to the victim experiencing airway obstruction first. Care to the other victims follows.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which finding should the nurse interpret as a sign or symptom of portal hypertension?

Abdominal distention. With portal hypertension, proteins shift from the blood vessels via the larger pores of the sinusoids (capillaries) into the lymph space. When the lymphatic system is unable to carry off the excess proteins and water, they leak through the liver capsule into the peritoneal cavity. This is called ascites, and abdominal distention would be the consequence. Increased portal pressure can lead to findings associated with right-sided heart failure, such as distended jugular veins. Thrombocytopenia, leukopenia, and anemia are caused by the splenomegaly that results from backup of blood from the portal vein into the spleen (portal hypertension).

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted.

A client has a tumor that is interfering with the function of the hypothalamus. The nurse should monitor for signs and symptoms related to which imbalance?

Antidiuretic hormone (ADH) excess or deficit. The hypothalamus exerts an influence on both the anterior and the posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The pineal gland is responsible for melatonin production. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

Permethrin is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?

Apply the lotion to cool, dry skin at least 30 minutes after bathing. Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The child should be clothed during the 8 to 14 hours of treatment contact time.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made?

Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg. After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

Insulin glargine is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time?

At bedtime every day. Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day at the same time, usually at bedtime.

A client has a prescription to receive valproic acid daily. To ensure the client's safety, when is the best time for the nurse to schedule the administration of this medication?

At bedtime. Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. The medication also should be administered at the same time each day.

A client has been prescribed dextroamphetamine. The client complains to the nurse that the client cannot sleep well at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which proper time schedule?

At least 6 hours before bedtime. Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent sleep disturbance.

Cyclosporine is prescribed for the client following allogenic kidney transplantation. The nurse should provide which instruction to the client regarding the medication?

Blood levels of the medication will need to be measured periodically. Cyclosporine is an immunosuppressant. To avoid toxicity from high medication levels and to avoid organ rejection from low medication levels, blood levels of cyclosporine should be measured periodically. In the organ transplant client, an immunosuppressant will need to be taken for life.

The nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student. Which intervention on the student written plan of care requires correction?

Blood transfusion of packed red blood cells. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Blood product transfusion is not the treatment of choice over administering recombinant factors intravenously. Measuring circumference of injured joints is appropriate to assess for enlarging hematomas or bleeding under the skin. The nurse should avoid taking rectal temperatures to decrease the risk for injury.

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

Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L). Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female is 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L).

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Bring the infant to the clinic. Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify the primary health care provider (PHCP). If these symptoms occur, antibiotics may be necessary.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

Broth. Coffee. Gelatin. A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea.

The nurse is providing dietary instructions to a client about food items that are high in vitamin C. Which food item does the nurse recommend as being highest in vitamin C?

Cabbage. Cabbage, tomatoes, potatoes, and strawberries are some of the foods that are high in vitamin C. Milk contains vitamins A and D and some B vitamins. Eggs contain B vitamins. Liver contains vitamins B6 (pyridoxine), B9 (folic acid), and K.

The nurse manager is reviewing documentation describing a client's progress in terms of a critical path (Care Map) for postoperative colon resection recovery. The nurse manager notes that, although the documentation is complete, the client has made minimal progress in the areas of mobility and pain control during the prior 48 hours. Who should the nurse manager contact next?

Case manager, to determine whether the predicted variance has been negotiated with the health insurer.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply.

Check the drain for patency. Observe for bright red bloody drainage. Maintain aseptic technique when emptying the drain.

A child with acquired immunodeficiency syndrome is hospitalized for the treatment of Pneumocystis jiroveci pneumonia. The child will be receiving nebulizer treatments at home when discharged. The nurse instructs the mother regarding the maintenance of the nebulizer equipment. What should the nurse tell the mother to do?

Clean the nebulizer pieces with warm water after each treatment and allow to air dry. Nebulizer pieces are cleaned with warm water after each treatment and allowed to air dry. They are soaked in white vinegar and water for 30 minutes at the end of each day.

A client who has been taking phenytoin for seizure control has a serum phenytoin level of 8 mcg/mL (35.71 mmol/L). On the basis of this finding, which note should the nurse enter in the client's health record?

Client has an inadequate medication level. The therapeutic serum level range for phenytoin is 10 to 20 mcg/mL (40 to 79 mmol/L). A laboratory value of 8 mcg/mL is below the therapeutic range, indicating an inadequate medication level, so this should be noted in the health record and the primary health care provider should be notified.

A client diagnosed with an anxiety disorder is prescribed buspirone orally. The client tells the nurse that it is difficult to swallow the tablets. Which is the best instruction to provide the client?

Crush the tablets before taking them. Buspirone may be administered without regard to meals, and the tablets may be crushed. Mixing the tablet uncrushed in apple sauce will not ensure ease in swallowing. This medication is not available in liquid form.

A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action?

Determine if there are any disconnections in the ventilator tubing. The low-pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. High-pressure alarms can be triggered by increased airway resistance, which can occur with excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate?

Document the findings. The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths per minute. The normal apical heart rate is 90 to 130 beats per minute, and the average blood pressure is 90/56 Hg. The nurse would document the findings.

A client is taking cetirizine. The nurse should inform the client of which side effect of this medication?

Drowsiness. Cetirizine is an antihistamine; frequent side effects are drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating.

The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom should the nurse anticipate the client may report?

Dull abdominal pain exacerbated by walking. Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking and dark red- or mahogany-colored blood mixed in the stool.

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primarycharacteristics of bulimia?

Eating a lot of food in a short period of time and misuse of laxatives. Eating binges and purging are the characteristic that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.

A child is sent to the school nurse by the teacher. On assessment of the child, the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding?

Erythema on the face, giving a "slapped cheeks" appearance. The classic rash of erythema infectiosum, or fifth disease, affects the face. The discrete rose-pink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish-red maculopapular rash is the rash of rubella (German measles).

A child with severe seborrheic dermatitis is receiving treatments of topical corticosteroid applied over an extensive area of the body, followed by the application of an occlusive dressing. The nurse should monitor the child closely, knowing that which systemic effect can occur as a result of this treatment?

Growth retardation. Topical corticosteroid can be absorbed in sufficient amounts to produce systemic toxicity. Principal concerns are growth retardation (in children) and adrenal suppression (in all age groups). Systemic toxicity is more likely under extreme conditions of use, such as with prolonged therapy in which extensive surfaces are treated with high doses of high-potency agents in conjunction with occlusive dressings.

The nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag?

Hanging the medication bag higher than the primary IV bag. For an intermittent IV infusion that is piggybacked to the primary IV line, the bag for the intermittent infusion is placed higher than the primary solution bag. This allows gravity to assist in infusing the medication.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition?

Heart failure. Nursing care initially centers on observing for signs of heart failure. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distension.

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?

Hematuria. The most common sign in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms of a bladder infection

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin. During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium. The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study?

Liver function studies. Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations.

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

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

A client newly diagnosed with diabetes mellitus is instructed by the primary health care provider to obtain glucagon for emergency home use. The client asks the home care nurse about the purpose of the medication. The nurse should instruct the client that the purpose of the medication is to treat which problem?

Hypoglycemia from insulin overdose. Glucagon is used to treat hypoglycemia resulting from insulin overdose. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of glucagon injection. Once consciousness has been regained, oral carbohydrates should be given. Lipoatrophy and lipohypertrophy result from insulin injections.

The nurse is working at a computer in the nurses' station when the charge nurse from another nursing unit approaches and asks about the condition of the client in room 432, stating, "The client is my neighbor and I want to check on her." The nurse should make which most appropriateresponse?

I'm sorry, I cannot tell you."

The mother of a toddler informs the nurse that her child has frequent temper tantrums. The nurse should instruct the mother to implement which measure to deal with the temper tantrums?

Ignore the behavior. During temper tantrums the mother should ignore the behavior, providing that the behavior is not injurious to the child, such as banging the head on the floor. The mother should continue to be present to provide a feeling of control and security to the child once the tantrum has subsided.

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room.

The nurse is teaching chest compressions for cardiopulmonary resuscitation (CPR) to a group of lay clients. Which behavior by one of the participants indicates a need for further teaching?

Letting the right and left fingers rest on the chest. To maximize the effectiveness of chest compressions, the rescuer avoids letting the fingers rest on the chest. This also helps prevent accidental injury to internal organs.

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing?

Liquefaction necrosis. Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury.

The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?

Lung sounds.

Betaxolol eye drops have been prescribed for a client with glaucoma. The home health nurse preparing to visit the client develops a plan of care that includes monitoring for the side/adverse effects of this medication by taking which assessment action?

Monitoring body weight. This medication is an antiglaucoma medication and a beta-adrenergic blocker. The nurse assesses for evidence of heart failure manifested by dizziness, night cough, peripheral edema, and distended neck veins. Intake greater than output, weight gain, and decreased urine output also may indicate heart failure. Hypotension (manifested as dizziness), nausea, diaphoresis, headache, fatigue, and constipation or diarrhea also are potential systemic effects of the medication. Nursing interventions include monitoring body weight; periodically evaluating blood pressure for hypotension; and assessing the apical or radial pulse for strength, weakness, irregular heart rate, and bradycardia.

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate?

Naloxone. Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.

A client admitted to the hospital is taking zidovudine. The nurse monitors the client for which adverse effect of the medication?

Neurotoxicity. Zidovudine is a nucleoside reverse transcriptase inhibitor that is used in combination with other antiretroviral agents to treat human immunodeficiency virus (HIV) infections. Adverse effects include anemia, granulocytopenia, and neurotoxicity as evidenced by ataxia, fatigue, lethargy, and nystagmus.

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Notify the primary health care provider (PHCP). Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The PHCP must be notified.

The nurse caring for a client immediately after transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. Which is the prioritynursing action for this client?

Notify the primary health care provider (PHCP). The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If the solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse should notify the PHCP of these symptoms.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Oranges. Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins.

The nurse monitoring an oncological client assesses for which early sign of vena cava syndrome?

Periorbital edema. Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms.

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed?

Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed.

The nurse is assisting a primary health care provider (PHCP) with the insertion of a Miller-Abbott tube. The nurse understands that the procedure places the client at risk for aspiration and should therefore implement which action to decrease this risk?

Place the client in a semi-Fowler's to high-Fowler's position. The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine, as in correcting a bowel obstruction. Initial insertion of the tube is an PHCP responsibility. The tube is inserted with the balloon deflated in a manner similar to the proper procedure for inserting a nasogastric tube. The client is usually given water to drink to facilitate passage of the tube through the nasopharynx and esophagus. A semi-Fowler's to high-Fowler's position decreases the risk of aspiration if vomiting occurs.

The primary health care provider prescribes patching for a child with strabismus of the right eye, and the nurse instructs the mother regarding this procedure. What should the nurse include in the instructions?

Place the patch on the left eye. Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the better-functioning eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

The nurse should be prepared to institute bleeding precautions in the client receiving antineoplastic medication if which result was reported from the laboratory?

Platelet count 50,000 mm3 (50 × 109/L). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). Bleeding precautions should be instituted when the platelet count drops to a low level, as defined by agency policy. Bleeding precautions include avoiding all trauma, such as rectal temperatures or injections. The normal clotting time is 8 to 15 seconds. The normal ammonia value is 10 to 80 mcg/dL (6 to 47 mcmol/L). The normal WBC count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the WBC count drops, neutropenic precautions should be implemented.

A client with previously well-controlled diabetes mellitus has had fasting blood glucose levels ranging from 180 to 200 mg/dL. The client takes glyburide 5 mg orally daily. In reviewing the client's medication list, the home health care nurse suspects that which newly added medications could be contributing to the elevated blood glucose levels?

Prednisone. Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, thus causing hyperglycemia

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is mostsignificant to review?

Prothrombin time. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. Creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.

A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription?

Question the primary health care provider about whether a portable chest radiograph may be obtained.

The nurse has called a client's primary health care provider (PHCP) to clarify a medication prescription. The PHCP gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time?

Read the prescription back to the PHCP after writing it on the prescription sheet. The Joint Commission (TJC) requires a verification process, such as reading back the prescription to the prescriber, when the nurse takes either telephone or verbal prescriptions. This verification acts to promote accuracy and reduce errors.

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action should the nurse include in the client's plan of care to ensure safety?

Remove all metal-containing objects from the client. In MRI, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices such as orthopedic hardware, pacemakers, or shrapnel.

The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

Shortness of breath. Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action?

Stop the irrigation temporarily. If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. Increasing the height of the irrigation will cause further discomfort.

The nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. Which immune disorder should the nurse primarilyanticipate?

Systemic lupus erythematosus (SLE). A Lupus erythematosus (LE) cell test is a blood test that measures the presence of a special cell found mostly in individuals with systemic lupus erythematosus. The LE cell prep (lupus erythematosus cell preparation) may be performed in a client suspected of having SLE. It also may be used to screen for progressive systemic sclerosis but is used primarily to screen for SLE.

What early signs and symptoms should the nurse assess for in a client with a suspected pulmonary embolism? Select all that apply.

Tachypnea. Restlessness. Feeling of impending doom. Signs and symptoms of a pulmonary embolism include the sudden onset of dyspnea, apprehension and restlessness, a feeling of impending doom, cough, hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a decreased arterial oxygen saturation. If suspected, the nurse immediately notifies the Rapid Response Team and primary health care provider. The nurse stays with the client, reassures the client, and elevates the head of the bed. The nurse prepares to administer oxygen and obtains the vital signs and checks lung sounds.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion. An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy?

Tarry stools. Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood.

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is probably hyperventilating. The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis.

A client with acquired immunodeficiency syndrome (AIDS) has a respiratory infection from Pneumocystis jiroveci and has been experiencing difficulty breathing and resultant problems with gas exchange. Which finding indicates that the expected outcome of care has yet to be achieved?

The client limits fluid intake. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. The status of the client with a problem concerning gas exchange would be evaluated against the standard outcome criteria for a P. jiroveci infection

The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.

The client who 24 hours earlier gave birth to her second child by caesarean delivery. The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis. The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker. The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation. The client who remains febrile with peritonitis and the client who has continuing rhonchi with heart failure need to be monitored on an ongoing basis.

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply.

The client will keep scheduled appointments. The client's physical wounds will begin to heal properly. The client will verbalize feelings about the abusive event. The client will participate in the various aspects of the treatment plan. Resolving feelings triggered by the event will take time and therapy, so it is considered a long-term goal.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis. When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance.

A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure?

The use of Montgomery straps. The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. They limit the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin, fragile skin; clients whose skin is sensitive to standard tape; and clients who require less frequent dressing changes.

The client who is seropositive for human immunodeficiency virus (HIV) has been taking ritonavir. The nurse tells the client that which follow-up laboratory study will be necessary while taking this medication?

Triglyceride level. Ritonavir is an antiretroviral (protease inhibitor) used in combination with other antiretroviral medications in the management of HIV infection. It can increase triglyceride levels; therefore, the client's triglyceride levels should be monitored.

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration?

Upright in a chair. It is best to assist the client who is at risk for aspiration and is dysphagic to sit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents.

A client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/minute range. The client is also complaining of nausea. Which cranial nerve damage should the nurse expect that the client is experiencing?

Vagus (CN X). The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It is also responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two-thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement.

The nurse should anticipate that the primary health care provider (PHCP) will prescribe which treatment for a client with pernicious anemia?

Vitamin B12 injections. A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Iron is used for anemia that results from a lack of iron. Blood transfusions are not needed for pernicious anemia because a lack of red blood cells is not the problem.

The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

Withdraws the NPH insulin first. When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type.