Nclex study set 4

This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response? A. Decreased mood lability B. Steady gait C. Urinary continence D. Increased bone mass

Choice A is correct. Carbamazepine is indicated for the prevention of seizures—neuropathic pain. And the treatment of certain mood disorders. The client demonstrating decreased mood lability would be the desired outcome. Choices B, C, and D are incorrect. Increased bone mass, urinary continence, and steady gait are all outcomes irrelevant to carbamazepine. Additional Info ✓ Mood stabilizers (lithium, carbamazepine, quetiapine, risperidone) are considered the drug of choice for clients with bipolar disorder (including acute mania and mixed episodes associated with bipolar disorder (i.e., bipolar I disorder). ✓ Carbamazepine is not as widely used compared to oxcarbazepine which has a decreased side effect profile. ✓ Carbamazepine may cause blood dyscrasias and monitoring of the client's CBC during therapy is essential. ✓ Treatment consists of mood-stabilizing medication(s), with some clients requiring psychotherapy. ✓ Females of childbearing age will need to be educated on avoiding pregnancy or utilizing the appropriate contraceptive methods while taking this medication, as carbamazepine use increases the risk of neural tube defects.

The nurse is helping the unlicensed assistive personnel pass meal trays. When providing a meal tray for a client diagnosed with pheochromocytoma, which dietary item should the nurse remove? A. Macaroni and cheddar cheese B. Watermelon slices C. Caffeine free cola D. Baked chicken

Choice A is correct. Pheochromocytoma is caused by a tumor on top of the adrenal medulla, causing a surge in catecholamines to be released, thus causing the client to experience headaches, hypertension, hyperglycemia, tremor, and unintentional weight loss. A client with pheochromocytoma is advised to modify their diet so that it does not increase blood pressure. Cheddar cheese contains tyramine and should not be included in the client's diet. Other dietary modifications include limitations of caffeinated beverages which may also raise blood pressure. Choices B, C, and D are incorrect. These food items are allowed because they would not contribute to raising the client's blood pressure.

The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question? A. citalopram B. pantoprazole C. phenytoin D. risperidone

Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client takes an anticonvulsant, like phenytoin, this will increase the seizure threshold and may attenuate the efficacy of ECT. Benzodiazepines and anticonvulsants should therefore be avoided in clients receiving ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as sertraline, fluoxetine, and citalopram) and antipsychotics (such as risperidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as pantoprazole) are typically given on the day of treatment to prevent gastric reflux and aspiration.

A nurse at the family clinic is educating the mother of a 13-year-old regarding how to avoid acute asthma attacks. Which statement, if made by the mother, indicates effective teaching? A. "Dogs and cats would be okay to have as a family pet." B. "I can take my daughter to the mountains to ski." C. "Swimming would be a good exercise for my daughter." D. "Cold weather may make symptoms better."

Choice C is correct. This statement made by the mother indicates effective teaching. Exercise is not contraindicated for those with asthma. Acceptable forms of exercise include low-intensity activities such as swimming, walking, and hiking. Choices A, B, and D are incorrect. Animal dander can trigger asthma attacks. The client must be reeducated to avoid pets, including, but not limited to, dogs, cats, and birds. Turtles, fish, and other pets without dander can be acceptable pets for children with asthma. Extreme cold is considered a nonallergenic trigger for an acute asthma attack. Snow skiing exposes the child to extreme cold, placing the child at risk for a severe asthma attack.

The nurse understands that which of the following benefits can be attributed to delayed cord clamping in a newborn? Increased blood volume Decreased brain hemorrhages Decreased risk of polycythemia Decreased jaundice Increased iron stores

Choices A, B, and E are correct. Potential benefits of delayed cord clamping in the newborn include increased blood volume, decreased risk of brain hemorrhages, increased blood pressure, lower risk of necrotizing enterocolitis, decreased anemia, and improved neurodevelopmental outcomes. Delayed cord clamping allows more blood to flow from the placenta to the baby, which can increase the baby's iron stores (Choice E) and reduce the risk of iron deficiency anemia. Current research indicates that cord clamping can be delayed for 30-60 seconds in vigorous newborns as long as the team manages the newborn's temperature to keep the infant warm. Choices C and D are incorrect. Delayed cord clamping does not decrease the risk of polycythemia or jaundice. Potential adverse effects of delayed cord clamping include an increased risk of polycythemia and jaundice and possible delay in resuscitation efforts for at-risk newborns.

The nurse is observing a newly hired nurse insert a nasogastric tube (NGT). Which action by the newly hired nurse requires follow-up? A. Advances the tube during the client's inspiration. B. Hands the client a cup of water and straw. C. Positions the client's head-of-bed at 90 degrees. D. Washes the client's bridge of nose with soap and water.

Choice A is correct. This observation requires follow-up because it will likely enter the respiratory tract if the nasogastric tube ( NGT) is advanced as the client takes a breath. The preferred method is gently advancing the NGT each time the client swallows until the desired length is reached. One can feel the characteristic tug on the tube as the epiglottis closes during swallowing. During the advancement of the tube, if the client begins coughing or becomes cyanotic, the nurse should pull the tube back until the client breathes normally again. Cyanosis and severe coughing during tube insertion can indicate accidental positioning of the tube in the respiratory tract ( trachea and bronchi). Choices B, C, and D are incorrect. These actions are appropriate and do not require follow-up. A cup of water and straw are supply items utilized to insert an NGT. The client is instructed to take short sips of water and swallow during the tube insertion. This facilitates the passage of the tube. The head-of-bed ( HOB) should be positioned at 90 degrees with the pillow behind the shoulders to allow neck flexion and extension. Washing the bridge of the nose with soap and water (or alcohol) is recommended because this removes skin oils and promotes adherence to the tape to the nose. Additional Info A nasogastric tube (NGT) should be measured from the tip of the nose to the earlobe to the xiphoid process of the sternum. Once this is established, a small piece of tape should be placed around the tube. An NGT is used to decompress the stomach, feed a client, administer medications, and irrigate the stomach.

The nurse receives a prescription from the primary healthcare provider (PHCP) for metoprolol 5 mL intravenous (IV) push x 1 dose. The nurse should take which priority action before administering the medication? A. Clarify the prescription with the primary healthcare provider (PHCP) B. Assess vital signs C. Obtain a 5 mL syringe D. Assess the client's allergies

Choice A is correct. This prescription is inaccurate and requires clarification with the PHCP before moving forward. This medication was prescribed as a volume of 5 mL, not the precise dosage amount to be administered (for example, it is okay to be prescribed 5 mg of metoprolol, not 5 mL). The nurse needs an accurate prescription that is complete before executing other steps in the medication administration process. Choices B, C, and D are incorrect. These actions are all correct to perform if the nurse has an accurate prescription. The prescription of metoprolol is incomplete because the actual dose was not provided. Metoprolol is a beta-blocker indicated in treating hypertension and specific dysrhythmias such as atrial fibrillation. Additional Info The nurse must clarify any inaccurate or incomplete prescriptions to maintain client safety. Components of a medication order include the name of the drug, dosage, route, and frequency.

The RN is discussing the signs and symptoms of postpartum thrombophlebitis with an expectant mother. The client should be instructed to monitor for which of the following symptoms? +2 pulses Bilateral redness. Edema in one leg. Tenderness. Unilateral cyanosis. Hypotension.

C is correct. The client should be advised to monitor for edema in one leg as a sign of postpartum thrombophlebitis. If swelling is noted, the nurse should measure both lower extremities and compare the circumference of the affected with the unaffected. D is correct. The client should be advised to monitor for tenderness in one leg as a sign of postpartum thrombophlebitis. Edema, pain, and redness would be expected findings in whichever leg the clot is occluding. Choice A is incorrect. +2 pulses are healthy, intense pulses. In postpartum thrombophlebitis, the nurse would expect to see weak pulses in the affected leg due to decreased blood flow at the site of the clot. Choice B is incorrect. The nurse would expect unilateral redness in a client with postpartum thrombophlebitis, so this mother would not be advised to monitor for bilateral redness. The edema, pain, redness, and tenderness are all unilateral, relating to the clot in one leg. Choice E is incorrect. Cyanosis (bluish discoloration of the skin) or coolness in one limb is a sign of venous obstruction, not thrombosis. Instead, when monitoring for signs of postpartum thrombophlebitis, the client should be instructed to report signs of inflammation such as warmth, swelling, or redness. Choice F is incorrect. Hypotension is not a sign of thrombophlebitis. Symptoms that indicate excessive bleeding, such as hypotension, tachycardia, and blood in the stool/urine, would be important to monitor if the client is on anticoagulant therapy, but are not associated with thrombophlebitis. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery Additional Info ✔︎Thrombophlebitis occurs when a blood clot develops and causes occlusion of one or several veins. This inflammatory process usually occurs in the lower extremities and affects only one side. ✔︎Interventions to reduce the risk of postpartum thrombophlebitis include early ambulation after delivery, anticoagulant agents, intermittent compression devices, and graduated compression stockings.

The nurse is caring for a female client who is receiving prescribed isotretinoin. Which laboratory data is essential prior to the initiation of this therapy? A. Pregnancy test B. C-Reactive Protein C. BUN and Creatinine D. Prothrombin time (PT)

Choice A is correct. Isotretinoin is indicated in the treatment of moderate to severe acne vulgaris. This medication is highly teratogenic, and a negative pregnancy test is essential prior to the initiation of therapy. Choices B, C, and D are incorrect. A C-Reactive Protein, BUN and Creatinine, and Prothrombin time (PT) are all laboratory data not relevant to isotretinoin. This medication is highly hepatotoxic, and the liver function tests are laboratory data that should be monitored before and during the course of treatment. Additional Info Isotretinoin may also be utilized in the treatment of moderate to severe acne vulgaris as it has demonstrated its ability to shrink the sebaceous glands. This medication is highly teratogenic, and the client should be counseled on reliable contraception. A negative pregnancy test is required prior to the start of treatment. Laboratory monitoring of the client's liver function tests and triglycerides is essential. This medication may cause a liver injury and raise triglyceride levels.

The nurse is caring for a client who had a thoracentesis two hours ago. Which assessment finding requires follow-up? A. persistent cough B. soreness at the needle site C. urine output of 200 mL D. scant bloody drainage

Choice A is correct. The most immediate postoperative risk factor is pneumothorax. Thoracentesis is when a needle is inserted into the pleural space between the lungs and the chest wall. This procedure removes pleural effusion (excess fluid) from the pleural space to help ease breathing. The risks of this procedure may include air in the area between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare). Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and frequent coughing. Choice B is incorrect. Soreness at the needle site is common and usually resolves in several hours. Choice C is incorrect. A urine output following this procedure of 200 mL is irrelevant and does not require follow-up. Choice D is incorrect. Scant bloody drainage at the needle site is expected and not a finding that requires follow-up.

The nurse is precepting a newly hired nurse administer an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up? A. Prepares to administer the medication in the dorsogluteal. B. Prepares to insert the needle at a 90-degree angle. C. Uses isopropyl alcohol to clean the area prior to injection. D. Washes their hands before and after the procedure.

Choice A is correct. This action requires follow-up as the dorsogluteal site is not recommended. The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. Choices B, C, and D are incorrect. These are correct actions and do not require follow-up. Intramuscular injections should be given at a 90-degree angle. Prior to injecting the medication, the nurse should appropriately clean the skin with isopropyl alcohol. Standard precautions are utilized for an injection which requires the use of thorough hand hygiene. For adults, potential intramuscular sites include the ventrogluteal, vastus lateralis, and deltoid. ✓ The dorsogluteal site is not recommended because of potential damage to nearby nerves and blood vessels. ✓ A normal, well-developed adult patient tolerates 3 mL of medication into a larger muscle without severe muscle discomfort. ✓ Larger volumes of medication (4-5 mL) are unlikely to be absorbed properly. ✓ Children, older adults, and clients who are thin tolerate only 2 mL of an IM injection. ✓ Do not give more than 1 mL to small children and older infants, and do not give more than 0.5 mL to smaller infants

The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate? A. Dextrose 5% in water (D5W) B. 3% saline C. Lactated ringers D. 0.9% Saline

Choice A is correct. This client has hypernatremia (sodium > 145 mEq/L) and should avoid additional sodium-containing fluids. Dextrose 5% in water is used to replace water losses due to hypernatremia. It would be an appropriate maintenance fluid for this client because it contains free water with no added sodium or other electrolytes and promotes renal solute excretion. Choices B, C, and D are incorrect. 3% saline is a hypertonic fluid and should be avoided in this client because of their hypernatremic state. This would further increase the sodium. This client should avoid any additional sodium-containing fluids at this time. Lactated Ringer's solution treats mild metabolic acidosis and water loss from burns or lower gastrointestinal tract issues. It would not provide free water to promote renal excretion of excess sodium. Dextrose has no additional sodium and will correct the sodium faster. 0.9% saline is an isotonic solution used to expand the intravascular volume and replace extracellular fluid losses. It contains sodium and chloride, which may result in intravascular overload or hyperchloremic acidosis.

After reviewing information related to advanced directives with a patient, which statement by the patient indicates the need for further discussion and education? A. "A living will designates a person that can make decisions about my medical care if I can't do that myself." B. "The person who I choose to make decisions about my medical care if I cannot on my own is named as the durable power of attorney." C. "I can refuse to be intubated or placed on mechanical ventilation as part of a living will." D. "If I change my mind, I can revoke an advanced directive any time, just by verbally saying so."

Choice A is correct. This statement indicates that the patient requires further teaching. A 'living will' provides specific instructions to health care providers regarding the patient's preferences about life-sustaining interventions, eg: cardiopulmonary resuscitation (CPR), mechanical ventilation, dialysis, tube feeding, organ and tissue donations, body donation, and comfort care. An advance directive in which a person is designated to make decisions for the patient when he/she is unable to do so is called a durable power of attorney or a healthcare proxy and is not a part of a living will. Choice B is incorrect. This statement indicates the patient understands the purpose of a durable power of attorney. A 'living will' differs from the durable power of attorney for health care because life will delineate the patient's wishes precisely. In contrast, a power of attorney allows the patient's designated agent to make health care decisions for the patient. Choice C is incorrect. This statement indicates the patient understands the purpose of the living will. Choice D is incorrect. This statement indicates that the patient understands that they can revoke an advanced directive at any time and that this can be done either verbally or in writing.

The nurse has instructed a client who is being discharged with crutches about using stairs. Which statement by the client would indicate a correct understanding of the teaching? A. "I should hold the handrail for support with one hand." B. "Going up the stairs, I should lead with my crutches and weaker leg." C. "Going down the stairs, I should lead with my crutches and strong leg." D. "I should remove the rubber tip when going up and down the stairs."

Choice A is correct. This statement is correct and indicates an understanding of using crutches. The client should place both crutches on the side away from the handrail and then hold the handrail for support with one hand. The client should lead with their affected leg and crutch as they descend the stairs. Choices B, C, and D are incorrect. These statements are incorrect and require follow-up. When a client is ascending stairs, the client leads with the stronger leg. When the client is descending the stairs, the client should lead with the affected leg. The client must always have a rubber tip on the crutch to ensure appropriate traction. Additional Info When a client is using crutches and has to use stairs, the nurse should emphasize the following points: Have the client hold the handrail for support with one hand, and their strong leg should be next to the railing. The client places a crutch under the axilla of the affected side. Have the client transfer body weight to the crutch while holding the handrail with one hand. Then, have the client support the weight evenly between the handrail and crutch. Next, the client places some weight on the crutch and then steps up the first step with an unaffected leg. Have the client balance by leaning forward with the weight on the unaffected leg. Then ask the client to straighten the good knee, push down on crutches and lift body weight, bringing the affected leg and then the crutch up the stair. The crutch tip is entirely on the stair.

While the nurse uses Nagele's rule to determine the prenatal clients' estimated due date (EDD), they know that their calculations are limited by the fact that they assume: A. Ovulation occurs on day 14 B. Pregnancy lasts 9 months C. Amenorrhea is the first sign of pregnancy D. Cycles are 30 days in length

Choice A is correct: Naegele's rule is limited in calculating the EDD as it assumes that all women ovulate around day 14 of their menstrual cycle. Women all vary biologically and may ovulate on varying days within their cycle. Naegele's rule also incorrectly assumes that all women have cycles that last 28 days. Choice B is incorrect: Pregnancy lasts 40 weeks. The term "month" assumes four weeks. 9 months would roughly equal 36 weeks. This is not how pregnancy is calculated. The average pregnancy lasts for 282 days which equals 40 weeks. Choice C is incorrect: Naegele's rule in factoring the estimated due date does not have to do with what the first sign of pregnancy was in the woman. Amenorrhea is not always the first symptom women experience when they become pregnant. Each individual client experiences different pregnancy symptoms. What is essential to know when calculating Naegele's rule is to understand the first day of the last menstrual period. Choice D is incorrect: Naegele's rule is based on a cycle that lasts 28 days, not 30 days.

Pain of short duration with an identifiable cause is referred to as: A. Chronic pain B. Acute pain C. Complex pain D. Neuropathic pain

Choice B is correct. Acute pain is of short duration. There are several terms used to describe the pain. Definitions of illness emphasize that it is an unpleasant experience. Since pain can be so damaging, it is essential to understand how it is created. Acute pain is meant to warn the body that some type of insult or injury has occurred, whereas chronic pain lasts beyond the average healing period and has no useful role. Choice A is incorrect. Chronic pain lasts more than 3 to 6 months. Choice C is incorrect. Complex regional pain syndrome can develop from acute pain, which is undertreated. Choice D is incorrect. Neuropathic pain results from injury to a nerve related to trauma or diseases (such as diabetes).

A client is receiving allopurinol and asks what they should know about taking this medicine. The nurse would be most correct in stating which of the following? Correct A. "Facial swelling is expected in the first few days of therapy." B. "Drink at least 3000 mL of water per day." C. "Do not eat while taking this medication." D. "This medication begins working immediately."

Choice B is correct. Allopurinol is prescribed to patients with gout or kidney stones and works by reducing the amount of uric acid produced by the body. Patients taking this medication should be encouraged to drink plenty of water, at least 3,000 mL per day. Choice A is incorrect. Facial swelling is not normal and may indicate an emergency reaction. Patients who experience swelling should seek medical attention as soon as possible. Choice C is incorrect. Eating with this medication is appropriate. Choice D is incorrect. This medication does not work immediately and may take a few months to reach full effectiveness.

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient's chart. Which is the appropriate nursing action? A. Notify the physician about the need for a living will to validate this order. B. Verify that the physician consulted with the patient and/or family. C. Accept the order as written, no other documentation is needed. D. Notify the nurse supervisor and risk management about the DNR order.

Choice B is correct. Documentation that the physician has consulted with the patient and family is required before a do not resuscitate order is entered on the patient's chart. Choice A is incorrect. It is not necessary to have a living will on the patient's chart, but there must be documentation that the issue was discussed with the patient/family. Choice C is incorrect. There must be documentation noting that the DNR order was discussed with the patient and family. Choice D is incorrect. It is not necessary to notify the nursing supervisor and risk management about this order.

The nurse is caring for a client with epistaxis. The nurse should perform which appropriate action? A. Position the client upright and leaning forward while gently pinching their nose intermittently B. Position the client upright and leaning forward while gently pinching their nose continuously C. Ask the client to blow their nose and then put lateral pressure on the nose D. Instruct the client to hold their nose while bending forward at the waist

Choice B is correct. During epistaxis, the nurse should position the client upright while leaning slightly forward and pinching the nasal alae together. This position prevents blood from entering the larynx, thereby decreasing the likelihood of possible aspiration. Choices A, C, and D are incorrect. Continuous pressure for at least ten minutes is recommended to treat epistaxis. Intermittent pressure would not achieve the same results because of the alleviation of the pressure. Blowing the nose would increase the risk of dislodging any clotting that has occurred, thereby increasing the client's bleeding. Having the client blow their nose would increase the risk of dislodging any clotting that has formed. Instructing the client to bend at the waist would increase the vascular pressure within the client's nose, potentially dislodging any previously formed clots. Both of these interventions would lead to increased bleeding in any client experiencing epistaxis.

The parents of a toddler report that the client is having poor sleeping, intense perianal itching, and scratching. The nurse understands that this client is at the highest risk for which condition? A. Anal fissure B. Enterobiasis C. Giardiasis D. Celiac disease

Choice B is correct. Enterobiasis is an intestinal infestation by the pinworm Enterobius vermicularis, usually in children, but adult members of their household and caregivers are also at risk. The primary symptom is perianal itching due to female pinworms leaving the intestine through the anus and depositing their eggs on the surrounding skin while the infected individual sleeps. Most cases are in school-aged and young children, with thumb-sucking being a primary risk factor. Choices A, C, and D are incorrect. An anal fissure is an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation. Diagnosis is by inspection. Giardiasis is one of the most common causes of waterborne disease worldwide (especially in areas of poor sanitation) caused by the protozoan Giardia duodenalis. Symptoms include watery malodorous diarrhea, abdominal cramps and distention, flatulence, eructation, intermittent nausea, epigastric discomfort, and sometimes low-grade malaise, fatigue, anorexia, and/or failure to thrive. Celiac disease is a hereditary disorder in genetically susceptible people caused by intolerance to gluten, resulting in mucosal inflammation and villous atrophy, which causes malabsorption. Symptoms usually include diarrhea and abdominal discomfort. Diagnosis occurs via small-bowel biopsy and resolves with a strict gluten-free diet.

The patient is admitted to the ICU following a motor vehicle accident in which he sustained multiple fractures. He is scheduled to go to surgery for repair of his fractured femur. The physician has ordered famotidine 20 mg IV as one of the preoperative medications. The nurse knows that this medication will: A. Decrease pain B. Help prevent ulcers C. Promote post-op healing D. Treat nausea

Choice B is correct. Famotidine is a histamine antagonist often referred to as an H2-blocker. This class of drugs treats and prevents duodenal and gastric ulcers caused by increased acid production in the stomach. In the pre-operative setting, it can also be used to reduce the risk of aspiration pneumonitis that can be caused by reflux from increased stomach acid. As the histamine antagonist name suggests, famotidine blocks the action of histamine in the cells of the stomach, which reduces the secretion of acid into the stomach. Choices A, C, and D are incorrect. This class of medications does not decrease pain, treat nausea, or promote post-operative healing.

The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan? A. Place an eye patch over the affected eye B. Instruct the client to turn their head from side to side C. Speak slowly, clearly, and in a deeper voice D. Provide the client with ear plugs to promote rest

Choice B is correct. Homonymous hemianopia (HH) is vision loss on the same side of the visual field in both eyes. It is appropriate for the nurse to teach the client to scan the room. Scanning the room will expand the visual field because the same half of each eye is affected. Choices A, C, and D are incorrect. An eye patch is an appropriate intervention for a client with double vision (diplopia). HH is not a problem with hearing and changing the approach to speaking to a client and providing ear plugs is irrelevant to this disorder. Additional Info Homonymous Hemianopia is characterized by vision loss on the same side of the visual field in both eyes. This is usually caused by a stroke, tumors, or epilepsy. Visual field loss is indicative of a lesion involving the visual pathway posterior to the chiasm.

The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad? A. hypotension, jugular venous distention, and muffled heart tones B. irregular respirations, bradycardia, and widening pulse pressure C. fixed pupils, hypotension, and bradycardia D. bradycardia, hypotension, and bradypnea

Choice B is correct. Irregular respiration, bradycardia, and widened pulse pressure are the three symptoms that makeup Cushing's triad. Cushing's triad occurs when the intracranial pressure in the skull has increased, thus causing these symptoms to happen. These manifestations are a late sign of increased intracranial pressure, where headache and altered level of consciousness are early signs. Choices A, C, and D are incorrect. Hypotension, jugular venous distention, and muffled heart tones are classic manifestations of Beck's triad, which is found with cardiac tamponade. Fixed pupils are an extremely late sign of increased intracranial pressure and are not found in Cushing's triad. The rest of the options are not reflective of this triad. Cushing's triad is a late manifestation of increased intracranial pressure (ICP) ✓ The normal ICP is 10-15 mm Hg, with any value over 20 mm Hg being increased ✓ Early manifestations of increased ICP include Decreased level of consciousness (LOC) (earliest sign) Behavior changes: restlessness, irritability, and confusion Headache Nausea and vomiting (may be projectile) ✓ Late manifestations of increased ICP include Cushing's triad Abnormal posturing

A 15-year-old admitted for status asthmaticus has been stabilized. Which activity would be most appropriate for the client? A. Completing a jigsaw puzzle B. Talking on the phone with friends C. Watching basketball on television D. Putting together a necklace

Choice B is correct. Peer groups play a significant role in the socialization of adolescents. Teenagers need an opportunity to interact with their peers during sickness to allow them an outlet to express their concerns. Allowing teenage clients to speak with friends over the phone enables the teenage client to accomplish these needs. Additionally, it is important to note that this activity is being encouraged following the stabilization of the client. Choice A is incorrect. Since peer groups play such a significant role in the socialization of adolescents, teenagers should be provided an opportunity to interact with peers during their times of sickness to facilitate an outlet to express their concerns. Assembling a jigsaw puzzle would not provide the teenager with an opportunity to accomplish this. Choice C is incorrect. Watching television would not provide this teenage client with an opportunity to interact with members of their peer group. Choice D is incorrect. Even during times of sickness, teenagers need an outlet to express their concerns and interact with their peer group. Assembling a necklace (or other arts and crafts) would not provide this teenage client an opportunity to socialize with their peer group. Learning Objective Recognize the importance of a teenage client's peer group in the client's social structure. Additional Info Peers serve as credible sources of information, serve as role models of social behaviors, and provide sources of social reinforcement. Socialization with peers should be strongly encouraged.

The nurse teaches a group of students about phenytoin. Which of the following statements would indicate understanding? "Phenytoin is a selective serotonin reuptake inhibitor (SSRI) commonly used for epilepsy." B. "The therapeutic range of phenytoin is 10-20 mcg/mL, and levels above this range can lead to toxicity." C. "Phenytoin is contraindicated in clients with Parkinson's disease due to potential exacerbation of symptoms." D. "Phenytoin is primarily metabolized by the liver and has no significant drug interactions."

Choice B is correct. Phenytoin has a narrow therapeutic range, and maintaining drug levels within the 10-20 mcg/mL range is essential for effective seizure control. Levels above the therapeutic range can result in phenytoin toxicity, characterized by symptoms such as nystagmus, ataxia, and confusion. Choice A is incorrect. Phenytoin belongs to the class of antiepileptic drugs known as hydantoins and works by stabilizing neuronal membranes and decreasing seizure activity. Choice C is incorrect. Phenytoin is not contraindicated in clients with Parkinson's disease. However, it may have some extrapyramidal side effects and can potentially worsen Parkinson's symptoms in some individuals. Choice D is incorrect. Phenytoin is extensively metabolized by the liver, primarily through the CYP450 enzyme system. It is known to have numerous drug interactions, Additional Info ✓ Phenytoin has been used as a first-line drug for many years, it is indicated for the management of tonic-clonic and partial seizures. ✓ Phenytoin has many advantages for long-term therapy. It is usually well tolerated, highly effective, and relatively inexpensive. It can also be given intravenously if needed. Most often, however, phenytoin is taken orally. ✓ Teach the client and family that serum drug levels are checked every 6 to 12 hours after the loading dose and then 2 weeks after oral phenytoin has started. The desired serum therapeutic range is 10 to 20 mcg/mL

The nurse reviews newly prescribed laboratory tests and medications for the following clients. Which of the laboratory tests and prescriptions should the nurse question? A. Liver function tests (LFTs) for a client prescribed atorvastatin B. International normalized ratio (INR) for a client prescribed rivaroxaban C. Serum creatinine level for a client prescribed lisinopril D. Glycosylated hemoglobin (HgbA1C) level for a client prescribed olanzapine

Choice B is correct. Rivaroxaban is advantageous because it does not require frequent laboratory monitoring. International Normalized ratio (INR) monitoring is required for a client receiving selected anticoagulants such as warfarin. Rivaroxaban and apixaban (direct factor Xa inhibitors) may increase prothrombin time (PT) and INR. However, these tests are not reliable in assessing the anticoagulation effects of these agents. Therefore, INR monitoring is not recommended for clients on prescribed rivaroxaban. The nurse should question this because it is unnecessary. Choices A, C, and D are incorrect. All these laboratory tests are appropriate for the prescribed medication. LFTs are necessary to trend while a client is on statin therapy because of the risk of hepatic injury (choice A). ACE inhibitors such as lisinopril may be nephrotoxic if exposure is prolonged and at high doses. While ACE-I may be nephroprotective, monitoring the creatine is a clinical standard while a client is on ACE-I (choice C). Olanzapine is an atypical antipsychotic and may cause some of the worst metabolic derangements, such as dyslipidemia, elevations in blood glucose, and weight gain. These metabolic abnormalities may lead the client to develop diabetes mellitus. The antipsychotic -pines are the worst metabolically (clozapine, olanzapine, quetiapine). Therefore, HgbA1C monitoring is warranted for the clients taking these medications. Additional Info Recognize that direct factor Xa inhibitors do not require INR monitoring. While they may prolong the INR, the INR test is unreliable in assessing their anticoagulation effects. Rivaroxaban causes inhibition of factor Xa, which leads to an anticoagulant effect ➢ This medication is indicated for pulmonary embolism, venous thromboembolism, and venous thromboembolism prophylaxis ➢ This medication is commonly prescribed for those with atrial fibrillation to prevent stroke ➢ Therapeutic monitoring is not required for this medication ➢ Andexanet is the approved reversal agent for this medication

The nurse is talking to an elderly client with osteomalacia regarding ways to strengthen his bones. Which statement by the client would necessitate further teaching by the nurse? A. "I've started to walk more frequently under the sun." B. "I don't like dairy products so I've stopped eating them." C. "I've enrolled myself in an exercise program for seniors at the community center." D. "I've been taking Vitamin D supplements lately."

Choice B is correct. The client needs to be reinforced regarding a calcium-rich diet and calcium-rich foods. Milk and dairy products are some of the most common sources of dietary calcium. If the client does not like milk or any other dairy product, the nurse should talk to him about different foods that are rich in calcium. Choice A is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Walking under the sun stimulates vitamin D production in the body. Choice C is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Enrolling in an exercise program indicates that the client understands the treatment regimen for osteomalacia. Choice D is incorrect. Clients with osteomalacia need vitamin D to stimulate calcium absorption and mineralization. Vitamin D, exercise, and a calcium-rich diet are recommended. Taking vitamin D supplements indicates that the client understands the treatment regimen for osteomalacia. Add'l info: Osteomalacia is a medical condition characterized by the softening of the bones, primarily due to a deficiency in vitamin D or problems with its metabolism. ✓ Osteomalacia is more commonly observed in adults, while a similar condition in children is referred to as rickets. ✓ The most common cause of osteomalacia is a lack of vitamin D, which is essential for the proper absorption of calcium and phosphorus from the diet. ✓ Vitamin D deficiency can occur due to: Inadequate sunlight exposure Inadequate dietary intake Malabsorption issues Chronic kidney disease

The nurse received a prescription for a continuous infusion of weight-based heparin for a client with acute coronary syndrome. Prior to administering the medication, the nurse should A. obtain a blood specimen to measure the creatinine. B. weigh the client. C. obtain a blood specimen to measure the international normalized ratio (INR). D. verify that the client has a 20-gauge peripheral venous access device (VAD).

Choice B is correct. The client needs to be weighed for prescribed a weight-based heparin infusion. It is inappropriate for the nurse to rely on the client's stated or estimated weight because this could lead to a severe dosing error. An accurate weight, along with a baseline activated partial thromboplastin time (aPTT) and platelet count, should be obtained prior to the start of the infusion. Choices A, C, and D are incorrect. Serum creatinine level is not required because kidney function does not affect heparin dosing. This is not true if the client were prescribed a low molecular weight-based heparin such as enoxaparin which is excreted by the kidneys; their biological half-life may be prolonged in clients with kidney failure. INR does not need to be obtained. This laboratory parameter is monitored when a client is receiving warfarin. Heparin does not require a 20-gauge peripheral vascular access device. This is a true statement for a client receiving a unit of packed red blood cells but not heparin. Additional Info ✓ Unfractionated heparin is an anticoagulant that may be administered for a client with acute coronary syndrome, venous thromboembolism, and pulmonary embolism ✓ Heparin is a high-risk medication requiring a double-check with another nurse to ensure that it is an accurate dose ✓ An accurate weight is needed as most (not all) protocols require a weight-based dosing structure ✓ Heparin is advantageous because it has a rapid onset of action and offset of action in the event the client needs surgery

The nurse is teaching a postpartum client about caring for her episiotomy. Which of the following statement by the client would indicate a correct understanding of the teaching? A. "I can expect to have pain and urgency with urination." B. "I should increase my fluid and fiber intake." C. "I will clean the area with hot, soapy water." D. "I should wipe in a continuous motion using a washcloth."

Choice B is correct. The client should be instructed to increase their fluid and fiber intake to prevent constipation because constipation may cause a client to experience significant pain at the episiotomy site during defecation. If the client is still experiencing constipation as they recover from an episiotomy, the primary healthcare provider (PHCP) may prescribe a stool softener. Choices A, C, and D are incorrect. Pain and urgency with urination are concerning symptoms of cystitis. The client should report this to the PHCP. Stinging with urination may occur but should not be painful or have an increased urgency. The client should be instructed to clean the area with a peri bottle and pat it dry. For the first 12 hours following an episiotomy, the nurse should advise the client to apply a cold compress for the first 12 hours, followed by a warm compress afterward. The client should not use a continuous motion when wiping, nor should they use a washcloth which may cause trauma to the area. Patting dry with toilet paper or using a sitz bath or peri bottle could be helpful. Additional Info ✓ An episiotomy is an incision into the perineum right before birth ✓ Indications for an episiotomy include resolution of shoulder dystocia, breech delivery, macrosomic fetus, and birth assisted with a vacuum or forceps. ✓ Infection is the main risk following an episiotomy. ✓ Fever should be reported along with foul-smelling drainage. ✓ Cold applications are applied for at least the first 12 hours, followed by warm perineal applications after 12 hours. ✓ The client should increase their fluids and fiber to prevent constipation which may aggravate their pain. ✓ It is also recommended that the client pat dries with toilet paper and irrigate the peri area with warm water.

The nurse is preparing to administer prescribed bumetanide to a client. Which clinical finding would indicate the desired outcome? A. Increase in central venous pressure B. Reduced cardiac preload and wall tension C. Decreased glomerular filtration rate D. Increase in systemic vascular resistance

Choice B is correct. The desired outcome for a loop diuretic is the following - Reduction of blood pressure Reduction of pulmonary vascular resistance Reduction of systemic vascular resistance Reduction of central venous pressure Reduction of left ventricular end-diastolic pressure Choices A, C, and D are incorrect. It is not desired for a diuretic to increase CVP. CVP is the measurement of right ventricular end-diastolic pressure. Diuretics reduce blood volume, thereby reducing this pressure. The goal of a diuretic is to reduce the CVP. It is not desired for a client to have their GFR reduced. The goal for all clients is to have a high GFR, as this is an indicator of renal health. Prolonged exposure to loop diuretics may reduce the GFR, especially at aggressive doses. An increase in systemic vascular resistance is also not the desired effect of diuretics. SVR is the amount of force exerted on circulating blood by the body's vasculature. Less blood volume by the diuretic = a decrease in SVR.

The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take? A. Obtain baseline platelet count B. Verify ABO compatibility C. Infuse over two to four hours D. Obtain a 12-lead electrocardiogram

Choice B is correct. When infusing fresh frozen plasma (FFP), the nurse should ensure that the FFP is ABO compatible with the recipient. Choices A, C, and D are incorrect. A baseline platelet count is not needed because FFP is utilized to correct coagulopathy - not thrombocytopenia. Baseline coagulation studies may be obtained, such as the internationalized normalized ratio (INR) or activated partial thromboplastin time (aPTT). FFP is infused over fifteen to thirty minutes, whereas packed red blood cells are administered over two to four hours. An electrocardiogram is not indicated prior to any blood product transfusion. Additional Info ✓ FFP is indicated for deficiency of certain clotting factors. ✓ This blood product may also be used for warfarin toxicity and Vitamin K. ✓ FFP may also provide some volume resuscitation; however, its primary purpose is to assist with clotting. ✓ FFP is administered to a client over 15-30 minutes.

You are caring for a client who is complaining of phantom limb pain after a below-the-knee amputation. What type of pain is this client most likely experiencing? A. Perceived pain B. Somatic pain C. Peripheral neuropathic pain D. Peripheral nociceptive pain

Choice C is correct. A client who is complaining of phantom limb pain after a below-the-knee amputation (BKA) is most likely experiencing peripheral neuropathic pain. Peripheral neuropathic pain, such that occurs with neuralgia, phantom limb pain, and carpal tunnel syndrome, is described as a burning, sharp and shooting pain, and it is often chronic. Choice A is incorrect. Although a client who is complaining of phantom limb pain after a below-the-knee amputation is feeling and perceiving pain, this pain after a below-the-knee amputation is not referred to as perceived pain. Choice B is incorrect. A client who is complaining of phantom limb pain after a below-the-knee amputation is not likely to be experiencing somatic pain. Somatic pain is a type of nociceptive pain that results from damage to the bones, skin, and muscles. Choice D is incorrect. A client who is complaining of phantom limb pain after a below-the-knee amputation is not experiencing peripheral nociceptive pain. Nociceptive pain is classified as bodily nociceptive pain and visceral nociceptive pain, not peripheral nociceptive pain.

The nurse is assessing a child with glomerulonephritis. Which assessment finding requires follow-up by the nurse? A. Periorbital edema B. Decreased urine output C. Headache D. Hematuria

Choice C is correct. A complication of glomerulonephritis is encephalopathy caused by severe hypertension associated with the disease process. A client's report of a headache should clue the nurse into checking the client's blood pressure. The client should be monitored for this potential complication, which can be avoided by closely monitoring the client's blood pressure. Choices A, B, and D are incorrect. These manifestations are associated (and expected) with glomerulonephritis and do not require follow-up. Additional Info AGN is a serious condition secondary to many infectious processes such as streptococcal infections, mononucleosis, and hepatitis. Nursing care aims to prevent the most common complications, including fluid volume overload and hepatic encephalopathy. The client may have dietary restrictions such as fluid, sodium, and potassium. The nurse should monitor the client's intake and output, weight, and blood pressure.

The nurse is anticipating a client arriving at the emergency department (ED) exposed to inhalation anthrax. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Acyclovir B. Zidovudine C. Ciprofloxacin D. Oseltamivir

Choice C is correct. Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin. Inhaled anthrax is most effectively treated with a combination of ciprofloxacin and another antibiotic (i.e. penicillin, clindamycin, chloramphenicol). Antibiotics are usually given for 60 days because it takes that long for spores to germinate. Choices A, B, and D are incorrect. Acyclovir is an antiviral used to treat herpes. Antiviral medications do not affect anthrax, which is a bacterial infection. Zidovudine is an anti-retroviral medication that is used for the treatment of HIV/AIDS. Antiviral drugs do not affect anthrax, which is a bacterial infection. Oseltamivir is an antiviral drug used to treat influenza. Antiviral medications do not affect anthrax, which is a bacterial infection. Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. ✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. ✓ Standard precautions are used for a client with inhalation anthrax. ✓ Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

While working on a pediatric floor, you have a patient diagnosed with pertussis. Which image below indicates the correct precautions the nurse needs to place the patient on?

Choice C is correct. Droplet precautions are necessary for the patient with pertussis. This means that the client needs a private room, or a room shared only with another client with pertussis. Staff should and visitors must wear a mask when entering the room. A mask must be placed on the client if they need to leave the room. Choices A, B, and D are incorrect. These types of precautions are not applicable to patients with pertussis.

After presenting with acute myocardial ischemia, a client was given 324 mg PO aspirin, three doses of 0.4 mg SL nitroglycerin tablets (taken five minutes apart), and oxygen via nasal cannula at 2L/minute. Which ECG change would indicate these interventions have been effective? A. Widening of the QRS complex B. Decrease in ectopic heartbeats C. ST-segment has returned to the baseline D. Reduction of the significant Q-wave

Choice C is correct. In myocardial ischemia, the ST-segment may appear elevated or depressed. In the presence of acute myocardial ischemia, ST-segment changes result from lack of oxygen to a specific region of the cardiac muscle. If treatment has been successful, the ST-segment will return to baseline. Choice A is incorrect. A widening of the QRS complex is not directly associated with myocardial ischemia. Choice B is incorrect. Ectopic heartbeats are changes in an otherwise normal heart rate leading to extra or skipped heartbeats. Although common, the cause of ectopic heartbeats is often idiopathic. The two most common types of ectopic heartbeats are premature ventricular contractions (PVCs) and premature atrial contractions (PACs). Overall, ectopic heartbeats are not directly associated with myocardial ischemia. Choice D is incorrect. The presence of a Q-wave is not directly associated with myocardial ischemia.

The nurse is performing community health screenings. A client tells the nurse that they smoke two packs a day of cigarettes and have smoked for six years. The nurse should document this finding as how many pack years? A. 3.5 pack years B. 3 pack years C. 12 pack years D. 6 pack years

Choice C is correct. Pack-years are calculated by multiplying the number of packs smoked per day by the years the client has smoked. Pack-years (PY) = number of packs of cigarettes per day (P) x number of years of smoking (Y) In this client, twelve is the correct amount of pack-years. The client has smoked two packs of cigarettes for six years (PY = two packs x six years = twelve pack-years). Choices A, B, and D are incorrect. None of these calculations are accurate when two is multiplied by six. Learning Objective Understand that "pack-year" is a terminology used to quantify lifelong smoking. It is a value obtained by multiplying the number of cigarette packs/day by the number of years. Additional Info ✓ The smoking history should include the number of cigarettes smoked daily, the duration of the smoking habit, and the client's age when smoking started, even for clients who are not current smokers. ✓ Record the smoking history in pack-years (the number of packs smoked per day multiplied by the number of years the client has smoked). ✓ For example, one pack year equals smoking one pack per day for one year, two packs per day for half a year, and so on. ✓ An occasional smoker's risk profile differs from a lifelong, heavy smoker. ✓ Some clients may have smoked heavily but later quit or cut back on smoking. Without using common terminology to quantify the "lifelong" use, it is difficult to estimate the client's risk for lung problems. ✓ Screening for smoking in "pack years" helps healthcare providers with a common terminology to quantify lifelong smoking.

The nurse is working with an advocacy group to raise awareness about cystic fibrosis. Which statement best explains the condition? A. "It is an inherited disease that causes inflammation and hypersensitivity of the airway." B. "It is an infectious disease causing inflammation and fluid accumulation in the alveoli of the lungs." C. "It is an inherited disease causing excessive, thick mucus to build up in the body and cause blockages." D. "It is an acquired disease that causes inflammation and swelling of the epiglottis."

Choice C is correct. This statement correctly describes cystic fibrosis as an inherited disease causing excessive, thick mucus to build up in the body and cause blockages. Choice A is incorrect. Cystic fibrosis is NOT an inherited disease that causes inflammation and hypersensitivity of the airway. A disease that causes inflammation and hypersensitivity of the airway is asthma, not CF. Choice B is incorrect. Cystic fibrosis is NOT an infectious disease that causes inflammation and fluid accumulation in the alveoli of the lungs. Pneumonia is an infectious disease that causes inflammation and fluid accumulation in the alveoli of the lungs. Choice D is incorrect. Cystic fibrosis is NOT an acquired disease that causes inflammation and swelling of the epiglottis. Epiglottitis is a disease that causes inflammation and swelling of the epiglottis.

A 15-year-old female comes into the gynecology clinic asking for an oral contraceptive pills prescription. Fifteen minutes later, her mother comes in and scolds the teenager about her decision. She tells the doctor not to give her daughter the pills because she is still too young. What should be the most appropriate action by the nurse? A. Withdraw the prescription for contraceptive pills. B. Call Child Protective Services. C. Explain to the mother that in cases of birth control services, her daughter has the right to give consent on her own. D. Explain to the teenager that her mother still has consenting authority over her decisions.

Choice C is correct. When the minor is seeking birth control treatments, the minor's consent is sufficient and does not warrant the permission of her parents. Choice A is incorrect. Parental or guardian consent should be obtained before treatment is initiated for a minor except in an emergency. There are certain situations in which the permission of the minor is sufficient enough, i.e. birth control treatments. Choice B is incorrect. There is no sign of abuse; the nurse does not need to call child protective services. Choice D is incorrect. The mother no longer has consenting authority over her child when it comes to birth control treatments.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding? A. Decreased pulse oximetry (SpO2) B. Hyperarousal C. Bradycardia D. Headache

Choice D is correct. CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death. Choices A, B, and C are incorrect. A common misconception about CO poisoning is that it causes a decrease in SpO2. This is not accurate because pulse oximetry does not differentiate COHb from oxyhemoglobin. It is entirely plausible and likely that the client has a normal SpO2. CO poisoning would not cause hyperarousal. Instead, it would cause the client to experience dizziness and lethargy. Tachycardia is commonly seen as a compensatory mechanism from the falling cardiac output, not bradycardia. Additional Info ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? A. Packed red blood cells (PRBCs) B. Platelets C. Granulocytes D. Fresh frozen plasma (FFP)

Choice D is correct. FFP would be prescribed because this client is experiencing bleeding related to the prescribed warfarin. The client's INR is grossly elevated (therapeutic for VTE prophylaxis is 2-3), and FFP includes the Vitamin K-dependent clotting factors (factors II, VII, IX, X, proteins C, and S) that need to be replaced to stop the bleeding. Vitamin K may be prescribed, but the efficacy takes six to eight hours. FFP can treat the bleeding almost immediately. Choices A, B, and C are incorrect. PRBCs are indicated to treat anemia. Platelets would be prescribed to treat thrombocytopenia. Granulocytes are rarely prescribed, but if they are prescribed, they are indicated for severe aplastic anemia, neutropenia, and neonatal sepsis.

The nurse is providing health education to a client with dumping syndrome. Which teaching point about drinking fluids is accurate? A. The client should drink fluids immediately before meals. B. The client must only drink fluids with meals. C. The client must drink fluids before and during meals. D. The client should avoid drinking fluids for at least half an hour after meals.

Choice D is correct. Fluids should be avoided for at least 30 minutes to one hour after consuming meals to decrease the likelihood of dumping syndrome. Fluids fill up the stomach quickly and will move food more quickly into the small intestine. Therefore, the client should be educated to wait 30-60 minutes after a meal before consuming fluids. Choice A is incorrect. Consuming fluids before meals increase the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids within a half hour before eating. Choice B is incorrect. Consuming fluids with meals increases the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids with their meals. Choice C is incorrect. Consuming fluids before and during meals increases the speed of gastric emptying, subsequently increasing the likelihood of dumping syndrome. Clients should be advised to avoid drinking fluids 30 minutes before meals, during meals, and 30-60 minutes after meals to decrease the likelihood of experiencing dumping syndrome symptoms. Learning Objective When providing nursing education regarding fluid consumption to a client with dumping syndrome, identify "the client should drink fluids at least half an hour after meals" as the accurate statement. Additional Info Dumping syndrome is a collection of symptoms that occur when the contents of the stomach empty too rapidly into the small intestine. A large percentage of dumping syndrome cases are associated with gastric surgery, with an estimated 20-50% of clients who undergo surgery to remove or bypass the stomach (e.g., gastrectomy, gastric bypass surgery, gastric sleeve surgery, etc.) ultimately developing symptoms of dumping syndrome. Rapid gastric emptying causes large amounts of undigested food to empty rapidly into the small intestine, causing the client to experience nausea, abdominal cramping, diarrhea, and/or rapid blood glucose responses.

A 14-year-old is admitted to the medical ward for status asthmaticus. He was put on IV theophylline. Which manifestation would the nurse consider as a side effect of the drug? A. Grand mal seizures B. Severe palpitations C. Hypotension D. Headache

Choice D is correct. Headache is one of the most common side effects of theophylline. It is essential to understand the difference between a side effect and drug toxicity- a side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity (adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range. Common side effects of theophylline include headache, restlessness, nausea, and sleeplessness. On the other hand, the clinical manifestations of theophylline drug toxicity/ theophylline poisoning include cardiac dysrhythmias (presenting as palpitations, cardiac arrest), hypotensive shock, seizures/ status epilepticus, and refractory vomiting. Choice A is incorrect. Seizures are a sign of toxicity from theophylline, not just a common side effect. Choice B is incorrect. Palpitations and arrhythmias are a sign of theophylline drug toxicity as well. Choice C is incorrect. Hypotension and shock are seen with theophylline overdose/ drug toxicity and is not common side effect.

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

Choice D is correct. Risperidone is an atypical (second generation) antipsychotic indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect. Choices A, B, and C are incorrect. Risperidone increases prolactin levels and weight. Atypical antipsychotics, unfortunately, carry this consequential effect that may induce metabolic syndrome. Risperidone would assist in providing mood stability - not increased lability. Adversely, risperidone may cause extrapyramidal side effects causing gait disturbances.

The nurse has received an assignment of four patients on the Medical-Surgical floor. Which patient should she/he check on first? A. A 61-year-old male patient who is one day post-op from hernia repair with complaints of pain at the incision site. B. A 68-year-old female patient with type II diabetes who is complaining of stomach discomfort. C. A 72-year-old male patient with emphysema and a history of uncontrolled hypertension who is complaining of a headache. D. A 70-year-old female patient who is two days post-op from ankle surgery who complains of feeling some shortness of breath.

Choice D is correct. The ABCs identify the patient's airway, breathing, and cardiovascular status as the highest of all priorities in that sequential order. Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the requirements for self-esteem and esteem by others, and the self-actualization needs in that order of priority. Examples of each of these needs, according to Abraham Maslow's Hierarchy of Needs, include: Physical and Biological Needs: Some physical needs include the need for the ABCs of the airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene, and elimination. Safety and Psychological Needs: Psychological or emotional, safety and security needs include needs like low-level stress and anxiety, emotional support, comfort, environmental and medical protection, and emotional and physical security. Love and Belonging: The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others. Self-Esteem and Esteem by Others: All people need to be recognized and respected as valued people by themselves and by others. People need self-worth, self-esteem, and the esteem of others. Self Actualization: Self-actualization needs to motivate the person to reach their highest level of ability and potential. In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to manage their time effectively; they should avoid unnecessary interruptions, time-wasters, and helping others when this could potentially jeopardize their priorities of care. Choice A is incorrect. Incision site pain is not uncommon, especially one-day post-op. Choice B is incorrect. Stomach discomfort is not an immediate cause of concern and is not a priority among the available answer choices. Choice C is incorrect. This client's complaint is not the most urgent. An expected symptom of uncontrolled hypertension is a headache.

A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color of the amniotic fluid B. Perform a vaginal examination to assess the cervix for dilation C. Inform the client she is now on strict bed rest until further notice D. Assess the fetal heart tones

Choice D is correct. The initial action the nurse should take is to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, assessing fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid. Choice A is incorrect. Following a spontaneous rupture of the client's membranes, the priority is for the nurse to assess the fetal status via fetal heart tones. Assessment of the color of the amniotic fluid does not indicate the fetus's current status. Choice B is incorrect. While certain circumstances may justify performing a vaginal examination to assess for cervical dilatation, nothing in this scenario suggests such intervention. As such, in this scenario, the nurse's priority following a spontaneous rupture of the client's membranes remains to assess the fetal status via fetal heart tones. Choice C is incorrect. Fetal head engagement and descent are not dependent on the client's movement during labor. Keeping the client on bed rest is not necessary. Often, the client will be encouraged to ambulate. add'l info To confirm the rupture of a client's membranes, the pH of the fluid may be tested. Vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH >6.5 (pH of amniotic fluid is 7.0 to 7.6). Amniotic fluid should be assessed for meconium-stained fluid, other discoloration, etc.

The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take? A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg) B. Turn the client using a foam wedge every two hours C. Ensure that a client's heels are supported with a pillow D. Elevate the foot of the bed to provide countertraction

Choice D is correct. The nurse should slightly elevate the foot of the bed to provide counter traction and prevent the client from being pulled downward. Choice A is incorrect. Buck traction is skin traction, and to prevent injury to the skin, the applied weight should not be more than 5 to 10 lb (2.3 and 4.5 kg). Skeletal traction can handle more weight, usually about 15 to 30 lb (6.8 to 13.6 kg), than skin traction. Choice B is incorrect. The client should not be turned from side to side while in traction, as this could move and further injure the affected extremity. The client's extremity should remain in a neutral position. The client should be placed on a mattress with air loss to prevent pressure ulcers. Choice C is incorrect. The nurse should not support the client's heel with a pillow because the pillow can contribute to pressure ulcers. The nurse should ensure that the heel hangs freely off the pillow's edge.

The nurse transfers a client who received fentanyl 50 mcg IV push 10 minutes ago from the bed to a chair when the client becomes dizzy and falls into the chair. Which of the following actions would be appropriate for the nurse to take? A. Administer prescribed naloxone B. Assist the client back to bed C. Call a code blue D. Assess the client's vital signs

Choice D is correct. This client has likely experienced orthostatic hypotension caused by the prior administration of fentanyl. Fentanyl is an opioid and causes vasodilation. This vasodilation, combined with the client's movement, triggered this response. The nurse should assess vital signs to determine the client's stability. Choices A, B, and C are incorrect. Orthostatic hypotension does not warrant the administration of naloxone. This would be useful if the client experiences severe bradypnea with the opioid. The nurse should determine the client's stability before calling a code blue or repositioning the client. The nurse transferring the client so soon would likely worsen matters because it would cause more hypotension.

The nurse is caring for a client with a peripherally inserted central catheter (PICC) in the left upper extremity. It would indicate correct nursing care if the nurse A. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 5 mL syringe. B. slowly flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe. C. pulsatile flushes each lumen with sterile water in a 10 mL syringe. D. pulsatile flushes each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe.

Choice D is correct. When flushing a central vascular access device, such as a PICC line, the nurse should flush each lumen with 0.9% sodium chloride (normal saline) in a 10 mL syringe. This 10 mL volume of the syringe is necessary because of its pressure to remove adequate debris and any fibrin clots that could form on the tip of the catheter. A pulsatile flushing technique removes any fibrin debris on the end of the catheter, which protects the lumen from becoming occluded. Because of its isotonicity, only 0.9% saline should be used to flush vascular access devices. Choice A is incorrect. A 10 mL syringe should be used to administer medications and flush or aspirate blood from a central vascular access device. A 5 mL syringe would be an inadequate volume size. Choice B is incorrect. The flushing technique for all central vascular access devices is the pulsatile method. The pulsatile method is a guideline because it removes debris that may cause catheter occlusion. Flushing slowly would be less effective in eliminating fibrin debris, and this method is not recommended. Choice C is incorrect. Sterile water should not be used when flushing central vascular access devices. Sterile water is hypotonic, and the clinical guide for flushing all vascular access devices is normal saline (sodium chloride). Additional Info ✓ The Infusion Nurses Society has established clinical guidelines for nursing care-related vascular access devices ✓ Additional guidelines may be obtained from the Centers for Disease Control and Prevention ✓ A PICC line is a central vascular access device that may be used to administer fluids, vasoactive medications, antibiotics, and parenteral nutrition ✓ Strategies to prevent infections include meticulous hand hygiene, disinfection caps, dressing changes every seven days (or sooner if necessary), and appropriate spiking and priming techniques of medications and fluids that avoid contamination ✓ 0.9% sodium chloride (normal saline) is the only fluid that should be flushed through a central vascular access device using a pulsatile method

The nurse is providing discharge instructions to a client with hepatitis A. Which of the following instructions should the nurse include? A. You will need to take daily showers or baths with chlorhexidine. B. It is important to clean common surfaces with warm soapy water. C. You will need to have repeat stool testing to determine if you are still infectious. D. Check with your primary healthcare provider prior to taking any medications.

Choice D is correct. While a client is being treated for hepatitis, they should consult with their primary healthcare provider, so they are not taking any medications or substances that are hepatotoxic. Exposing a client with hepatitis to a hepatotoxic medication would significantly complicate their recovery. Choices A, B, and C are incorrect. Having the client shower with chlorhexidine is not an appropriate teaching point for hepatitis A. The pathogen spreads through contaminated food, water, and surfaces. The primary mode of transmission is fecal-oral. Surfaces contaminated with hepatitis should be sanitized with a bleach solution, not warm soapy water. Repeat stool testing is not indicated for hepatitis as diagnosis of hepatitis is made through serum hepatitis-A antibodies. Additional Info Hepatitis A is an infection contracted through the consumption of raw or undercooked food, fecal-oral route, or contaminated water. Most cases are self-limiting with complete clinical recovery within three to six months. Vaccination for hepatitis A is a two-dose series beginning as early as six months for international travel; 12 months for routine vaccination.

The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications? Select all that apply. Diltiazem Nitroglycerin Clonidine Atorvastatin Warfarin

Choices A and E are correct. Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke. Choices B, C, and D are incorrect. Nitroglycerin is not indicated in the management of atrial fibrillation. This medication is approved for angina. Clonidine is an effective treatment for hypertension and ADHD. The medication is not indicated for atrial fibrillation. Atorvastatin is indicated for hyperlipidemia but is not utilized in the management of atrial fibrillation. Additional Info ✓ The primary goal for a client with atrial fibrillation is to maintain rate control (60-100) and to prevent stroke ✓ Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be used to control heart rate ✓ Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation ✓ Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing ovarian cancer? Select all that apply. Nulliparity Advancing age Family history Herpes simplex virus (HSV) Early menarche

Choices A, B, C, and E are correct. Risk factors for ovarian cancer include nulliparity, advancing age, family history, and early menarche. Choice D is incorrect. Herpes Simplex Virus (HSV) is a virus that may be transmitted sexually but does not raise the risk for ovarian cancer. Additional Info Risk factors for ovarian cancer include - ➢ Early menarche and late menopause; this is because of the increased number of ovulations which may cause endothelial trauma ➢ BRCA variants ➢ Family history ➢ Nulliparity, this is because of the increased number of ovulations which may cause endothelial trauma ➢ Older age, with the highest risk being between ages 55-64

A client with chronic kidney disease (CKD) is receiving hemodialysis treatment. Which of the following nursing interventions should be implemented for this client? Select all that apply. Monitor the client's blood pressure before, during, and after hemodialysis. Administer erythropoietin (EPO) as prescribed to stimulate red blood cell production. Restrict protein intake to minimize uremic symptoms. Assess the client's access site for signs of infection or thrombosis. Administer phosphate binders as prescribed to control serum phosphate levels. Encourage the client to consume a high-potassium diet to prevent electrolyte imbalances.

Choices A, B, D, and E are correct. Hypertension is a common complication of CKD. Regular monitoring of blood pressure is essential to detect and manage any fluctuations effectively. CKD can lead to anemia due to decreased erythropoietin production. EPO may be administered to stimulate red blood cell production and manage anemia in clients with CKD. Clients undergoing hemodialysis require an access site, such as an arteriovenous fistula or graft. Regular assessment of the access site is necessary to detect any signs of infection, thrombosis, or compromised blood flow. Impaired kidney function leads to increased serum phosphate levels. Phosphate binders are prescribed to prevent the absorption of dietary phosphate, thus controlling serum phosphate levels. Choice C is incorrect While protein restriction is often necessary in advanced CKD, during hemodialysis, protein intake is typically increased to compensate for losses during hemodialysis. Dialysis removes protein waste from the blood, so a low-protein diet is no longer needed. Choice F is incorrect. Clients with CKD often experience hyperkalemia due to impaired kidney function. Consuming a high-potassium diet can exacerbate this imbalance and is contraindicated.

The nurse is caring for a client with systolic heart failure. Which of the following heart sounds would the nurse expect to auscultate? Select all that apply. S1 S2 S3 S4 pleural friction rub

Choices A, B, and C are correct. S1 and S2 are normal heart sounds. These normal heart sounds would still be auscultated in a client with heart failure. S1 is a benign heart sound caused by the closure of the mitral and tricuspid valves. S2 is a benign heart sound produced by the closure of the aortic and pulmonic valves. S3 ("ventricular gallop") and S4 ("atrial gallop") are abnormal heart sounds that can be auscultated in heart failure. Both heart sounds are low-pitched and best heard at the apex, with the patient in the left lateral decubitus position. While S3 may sometimes be heard in healthy hearts (normal in children, pregnant women, and trained athletes), S4 is almost always abnormal. While S3 is a sign of systolic heart failure, S4 is heard in diastolic heart failure. Understanding these two types of congestive heart failure (CHF) is essential before discussing how S3 and S4 are produced. The nurse would expect to hear an S3 heart sound (Choice C) in systolic heart failure. S3 occurs after S2 with the opening of the mitral valve, and a passive flow makes the sound of a large amount of blood hitting a compliant left ventricle. This large amount of blood hitting the left ventricle is because of the underlying fluid volume overload seen with systolic heart failure. Choices D and E are incorrect. The nurse would not expect to hear an S4 heart sound in her client with systolic heart failure. This is seen in diastolic heart failure. S4 occurs before S1 when the atria contract to actively force blood into the left ventricle. A stiff, non-compliant left ventricle causes it. When the atrial contraction forces blood through the mitral valve, the force is increased due to resistance offered by a stiff ventricle - in this scenario, S4 is caused by the blood striking the left ventricle. S4 heart sounds can also be heard in active ischemia. If a client has atrial fibrillation and the atria are not contracting, having an S4 heart sound is impossible. A pleural friction rub would not be expected with heart failure; this is an adventitious lung sound caused by inflamed parietal and visceral pleura rubbing together on inspiration. This type of sound may be present with a pulmonary embolism pathology.

The nurse is educating a group of students on the effects of corticosteroids. It would be appropriate for the nurse to identify the following adverse effects associated with corticosteroids. Select all that apply. Mood lability Immunosuppression Hypoglycemia Hyperkalemia Weight gain

Choices A, B, and E are correct. Glucocorticoids may cause potential mood changes such as overall mood lability. This may encompass a client feeling euphoric, agitated, depressed, and anxious. Exposure to long-term corticosteroids may cause an individual to develop leukopenia which may cause immunosuppression. Weight gain is a common finding with corticosteroid use because of the retention of sodium which causes the body to hold onto water. Choices C and D are incorrect. Hyperglycemia, not hypoglycemia, is a potential effect of corticosteroids. Corticosteroids cause an excessive discharge of glucose from the liver which raises glucose levels. Corticosteroids deplete potassium because of the effect of aldosterone (sodium retention; potassium elimination).

The nurse is assessing an infant with suspected cystic fibrosis. Which of the following signs and symptoms would the nurse recognize as supporting this diagnosis? Select all that apply. steatorrhea hypernatremia meconium ileus salty sweat adventitious breath sounds

Choices A, C, D, and E are correct. A is correct. Steatorrhea is a symptom of cystic fibrosis (CF). Steatorrhea is fatty, frothy stools that occur due to fat malabsorption. In CF, the body produces thick, sticky mucus that clogs up the body and interferes with the absorption of many things, including fat. Due to this, fat passes through the digestive tract without being absorbed and is excreted in the form of steatorrhea. C is correct. Meconium ileus is a symptom of CF and is often the first sign of CF in an infant. Meconium ileus is when infants cannot pass their first stool (meconium). In CF, the thick, sticky mucous has clogged up the body, making it difficult for the infant to pass their first stool. D is correct. Salty-tasting sweat is a symptom of CF. A lot of sodium is lost through the sweat, making it taste salty. This increases the risk for hyponatremia and is one of the first things parents might notice about their infant born with CF. E is correct. Adventitious breath sounds are a symptom of CF. Rhonchi may be auscultated because of the thick amount of mucous in the airway. Other lung sounds associated with CF include wheezing. Choice B is incorrect. Clients with CF are at risk for hyponatremia, not hyper. This is due to sweating excessive amounts of sodium out of their body. They lose so much sodium in their sweat that they develop low serum sodium levels (hyponatremia). ✓ Cystic fibrosis is a multisystem disorder that is caused by a genetic defect. This disorder is inherited as an autosomal recessive trait. ✓ Meconium ileus is one of the earliest manifestations in an infant with cystic fibrosis. This may occur within the first two weeks of life. Manifestations of a meconium ileus include abdominal distension and failure to pass meconium, with or without vomiting. ✓ Treatment includes nasogastric tube (NGT) insertion, which may decompress the abdomen.

A newly admitted client is in septic shock. This client has a high risk of injury related to a known clotting disorder. Which of the following are appropriate interventions that should be added to the nursing care plan for this client? Select all that apply. Administer packed RBCs, if ordered. Place a piece of gauze over a venipuncture site and dress with paper tape Obtain an order for a stool softener. Encourage the client to use an oral sponge to brush the teeth. Implement measures to prevent falls and injury

Choices A, C, D, and E are correct. Sepsis claims more than 200,000 lives annually in the United States. Clients often present with a fever, shaking chills, and a rapid heartbeat. Severely ill clients may also have drowsiness, rapid breathing, sweating, decreased urine output, and low blood pressure. Packed red blood cell (pRBC) transfusion has been incorporated into the recommended treatment bundle for sepsis since 2004. Packed red blood cells are used to treat illness and anemia as well as improve oxygen delivery to tissues. Packed red blood cell transfusion may be indicated in clients with evidence of hemorrhagic shock, proof of acute illness, hemodynamic instability, or inadequate oxygen delivery (choice A). Since the client in this question also has a clotting disorder, interventions to prevent bleeding are observed. These measures include avoiding constipation by offering stool softeners (choice C) and preventing the use of sharp or hard objects to provide care. For example, a mouth sponge may be used for oral care rather than a regular toothbrush (choice D). The bristles of the toothbrush may cause too much damage to the client's gingival tissue and cause further bleeding issues. Clients with septic shock are at high risk for falls and injury due to weakness and confusion (choice E). The nursing care plan should include measures to prevent falls, such as bed rails, non-slip footwear, and close monitoring by the nursing staff. Choice B is incorrect. Firm, direct pressure should be applied to venipuncture sites for 30 minutes before the final dressing because of the clotting abnormality. Simply placing a piece of gauze over the venipuncture site will not ensure hemostasis. This client is at high risk for bleeding due to their history of a clotting disorder, in addition to the concern of developing disseminated intravascular coagulation (DIC) while septic. Learning Objective Recognize the complications in a septic client and institute measures to mitigate them. Additional Info ✓ With shock, there is cellular death and tissue damage from too little oxygen reaching the tissues. Vital organs have been damaged and cannot respond effectively to interventions, so the shock cascade will continue. ✓ The rele

The nurse explains the quad screen test to her prenatal client in the second trimester. Which of the following conditions can be detected by the quad screen test? Select all that apply. Down syndrome Tay-Sachs disease Spina bifida Cystic fibrosis Abdominal wall defects

Choices A, C, and E are correct. The quad screen, or quadruple marker test, is done in the second trimester of pregnancy and includes measuring levels of AFP, HCG, estriol, and inhibin A. The clinician uses this test to evaluate the chance of carrying a baby with genetic abnormalities such as Down syndrome (choice A), trisomy 18, and spina bifida (choice C). Gastroschisis or omphalocele are birth defects that affect the abdominal wall (choice E). A quad screen test can also diagnose these abdominal conditions if an ultrasound during the first trimester was not performed or is inconclusive. As DNA screening improves, that diagnostic method might be used instead of the quad screen. Choices B and D are incorrect. The screen does not test for Tay-Sachs disease or cystic fibrosis. Learning Objective Recognize that a quad screen test is used to identify fetuses at risk of certain genetic defects. Additional Info ✓ The quad screen test, also known as the quadruple marker test, is a prenatal blood test that is usually performed between 15 and 22 weeks of pregnancy. ✓ It measures the levels of four substances in the mother's blood to assess the risk of certain genetic conditions in the developing baby. Alpha-fetoprotein (AFP) Human chorionic gonadotropin (hCG) Estriol Inhibin A ✓ An abnormal quad screen test result may indicate an increased risk of certain genetic conditions, including Down syndrome, Trisomy 18, and neural tube defects such as spina bifida. ✓ The quad screen test is not a diagnostic test but rather a screening test. If the results of the test are abnormal, further testing may be recommended to confirm or rule out the presence of a genetic condition.

The nurse is teaching a group of students about renal disorders. Which statement, if made by the student, requires follow-up? Select all that apply. "Pyelonephritis causes a client to have massive amounts of proteinuria." "Acute kidney injury may be caused by nephrotoxic medications." "Bacterial cystitis is diagnosed using a 24-hour urine collection." "Polycystic kidney disease may cause hematuria after a cyst rupture." "Diabetic nephropathy is prevented by increasing the hemoglobin A1C."

Choices A, C, and E are correct. These statements are not accurate and do require further teaching from the nurse. Acute pyelonephritis is a consequence of untreated cystitis. This produces symptoms similar to cystitis in addition to manifestations of flank pain, fever, and dehydration. Massive amounts of proteinuria are a classic manifestation associated with nephrotic syndrome. A 24-hour urine collection is not necessary to diagnose bacterial cystitis. A simple single specimen, urine analysis (UA), would be evaluated to determine if the client has cystitis. Diabetic nephropathy can be prevented by tight glycemic control reflected in the hemoglobin A1C. The higher the A1C equates to more complications such as diabetic nephropathy. Choices B and D are incorrect. These statements are correct and do not require further teaching from the nurse. The cause of AKI may be multifactorial, including the exposure to nephrotoxic medications (NSAIDs, aminoglycosides). PKD is a genetic disorder causing cysts to develop on the affected kidney and may rupture, producing pain and hematuria. This would be an expected finding with PKD.

The nurse is called to the delivery of an infant that is 41 weeks gestation with suspected meconium-stained amniotic fluid. What are some symptoms that may be present following the birth of a baby with meconium-stained amniotic fluid? Select all that apply. Brown-tinged amniotic fluid Thick, white substance coating the newborn Vigorous cry Brown discoloration of the infant's nails Respiratory distress

Choices A, D, and E are correct. If the amniotic fluid is tinged brown, it is a good indication that the meconium was passed before delivery (Choice A). Brown discoloration of the infant's nails, umbilical cord, or tongue can all indicate a meconium aspiration (Choice D). Meconium can be inhaled by the baby during delivery, which can cause respiratory distress (Choice E). The baby may have rapid or labored breathing, cyanosis (bluish discoloration of the skin), or other signs of breathing difficulties. Choices B and C are incorrect. A thick, white substance coating the newborn is known as vernix caseosa. This is a potent substance and serves to moisturize the newborn's skin. A vigorous cry is a good sign in a newborn. This alone is not an indicator of meconium aspiration. If there is meconium in the fluid and then the infant starts to cry vigorously, it can then lead to meconium aspiration.

During a newborn assessment, the nurse performs a variety of reflex assessments to evaluate the newborn's nervous system and overall health. Which of the following statements about reflexes in the newborn is true? Select all that apply. The Babinski reflex is also known as the startle reflex. A positive Babinski sign is normal in the newborn. The Moro reflex is demonstrated when the infant is startled and stretches out their arms in response. The Moro reflex is pathologic in the newborn. The tonic neck reflex is present at birth and is essential for sucking

Choices B and C are correct. A positive Babinski sign is when the toes splay outward after stroking the plantar surface of the foot. It is normal in the newborn but pathologic in the adult population (choice B). When a baby is startled and responds by suddenly stretching out his arms, this is the Moro reflex (choice C). Choices A, D, and E are incorrect. The Moro reflex is also known as the startle reflex, not the Babinski reflex (choice A). The Moro reflex is normal in newborns and is not pathologic (choice D). The tonic neck reflex is when the baby's head is turned to one side; the arm on that side will extend while the opposite arm will flex. Tonic neck reflex disappears around 4-6 months of age. Add'l info The following are some common newborn reflexes that healthcare providers may assess: ✓Moro reflex: The Moro reflex is a startle reflex that occurs when the baby is startled by a sudden noise or movement. The baby will arch their back, extend their arms and legs, and then bring their arms together in front of their body. ✓Rooting reflex: The rooting reflex is a reflexive turning of the head and opening of the mouth when the baby's cheek or mouth is stroked. This reflex helps the baby find the breast or bottle for feeding. ✓Sucking reflex: The sucking reflex is triggered when the roof of the baby's mouth is stimulated. This reflex helps the baby feed and can also have a soothing effect. ✓Grasp reflex: The grasp reflex is a strong grip of the baby's hand when an object is placed in their palm. ✓Babinski reflex: The Babinski reflex is a response to the bottom of the baby's foot being stroked. The big toe will extend upward while the other toes fan out. ✓Stepping reflex: The stepping reflex is a walking-like motion that occurs when the baby's feet touch a flat surface.

The nurse is preparing to administer prescribed medications to a client via a nasogastric tube connected to low-intermittent suction. The nurse should take which appropriate action? Select all that apply. Position the patient in Trendelenburg position. Verify correct placement of the tube before medication administration. Turn off the suction during medication administration. Resume low-intermittent wall suction immediately after medication administration. Irrigate the nasogastric tube (NGT) with sterile water.

Choices B and C are correct. It is very important to always verify the correct placement of the tube before medication administration. The initial verification method for an NGT after placement is an x-ray. Subsequent verification should be completed by aspirating gastric content and assessing its pH (normal is less than 4). It is appropriate to turn off the suction during medication administration. If the client remained on low-intermittent wall suction, it could be evacuated from the stomach via suction before it had the chance to be absorbed. The nurse should stop the suction and clamp the nasogastric tube (NG tube) for 30 minutes after administering the medications to allow them to absorb fully. Choices A, D, and E are incorrect. It would be highly inappropriate to place a client in the Trendelenburg position before administering medications through a nasogastric tube. To prevent aspiration, the nurse should sit the client up as much as tolerated, raising the head of the bed at least 30 degrees. This will allow gravity to help the medication flow into the stomach for absorption. Resuming suctioning immediately after administering the medication would be inappropriate because it would cause the removal of the medications just given. This would prevent the medications from entirely absorbing. Clamping the nasogastric tube for 30 minutes after medication administration will be enough to allow for medication absorption. Then the nurse may return the NG tube to low-intermittent wall suction. Irrigating or flushing the NGT with sterile water is not necessary and inappropriate because this could waste resources. The gut is not sterile, and room-temperature water is sufficient to flush the tube. Additional Info ✓ After the placement of an NGT, the nurse should verify the placement via an x-ray ✓ Subsequent verification should come through gastric pH analysis. A pH < 4 indicates the tube is likely in the stomach. ✓ When administering medications via NGT, the nurse should never crush extended-release or sustained-release medications. ✓ To administer medications via NGT, the nurse should disconnect the NGT suctioning. ✓ The nurse should initially flush the NGT with 20-30 mL of tepid tap water. ✓ The nurse should f

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? Select all that apply. "This procedure will require you to receive general anesthesia." "You will need to report any shortness of breath following the procedure." "You will need to empty your bladder before this procedure." "After the procedure, a follow-up chest x-ray will be done." "You will need to be on a clear liquid diet one day before the procedure."

Choices B and D are correct. These two statements should be included in patient education about thoracentesis. A thoracentesis is a procedure indicated for pleural effusions. The client will need to report any dyspnea after the procedure (Choice B). Shortness of breath following the thoracentesis procedure may indicate either iatrogenic pneumothorax or re-expansion pulmonary edema. Pneumothorax is a common complication following thoracentesis (studies report post-thoracentesis pneumothorax rates ranging from 0 to 19%). The nurse should assess the client carefully for any signs of pneumothorax. Symptoms and signs of a pneumothorax include shortness of breath and reduced or absent breath sounds on the affected side. A more severe pneumothorax, such as tension pneumothorax, may present with obstructive shock. A nurse must notify the physician immediately if any of such signs/symptoms were to occur. A chest x-ray (Choice D) must be completed post-procedure to make sure there is no iatrogenic pneumothorax even if the patient did not show any of the above signs or symptoms. Re-expansion pulmonary edema (REPE) is a complication that occurs after rapid re-expansion of a collapsed lung within 1 to 24 hours. It has been reported <1% in most studies are associated with high mortality. The pathophysiologic mechanism of REPE is unknown. Clinical features vary from cough and chest tightness to acute respiratory failure. Treatment is usually supportive and includes continuous non-invasive positive pressure ventilation or mechanical ventilation in severe cases; some patients also require vasopressors, steroids, and diuretics. Choice A is incorrect. Thoracentesis is a bedside procedure and can be completed under local anesthesia. Choice C is incorrect. It would be inappropriate to advise that the client empty their bladder before the procedure. Choice E is incorrect. Finally, a clear liquid diet one day before the procedure would be appropriate for a colonoscopy - not for a Thoracentesis.

The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply. Urinary incontinence Pupil dilation Diarrhea Altered level of consciousness (LOC) Constipation

Choices D and E are correct. Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, altered level of consciousness, pupil constriction, and urinary retention. Choices A, B, and C are incorrect. Urinary incontinence, pupil dilation, and diarrhea are not expected while a client is receiving hydromorphone.

The nurse is caring for a client receiving albuterol via metered dose inhaler (MDI). Which of the following adverse/side effects of this medication would be expected? Select all that apply. Tachycardia Hypotension Tremors Dry mouth Hyperglycemia Bradycardia

Explanation Choices A, C, D, and E are correct. Albuterol is a short-acting bronchodilator indicated in treating asthma and other chronic respiratory illnesses. Side effects associated with this medication include hyperglycemia, tremors, hypokalemia, and nervousness. Albuterol can stimulate the beta-2 receptors in the salivary glands, which can cause a decrease in the production of saliva. Choices B and F are incorrect. Albuterol is a beta-2 agonist and is a central nervous stimulant. Hypotension would not be expected because the medication causes the adrenal medulla to discharge excessive catecholamines; these catecholamines cause an elevation in the blood pressure, pulse, and blood glucose. An expected side effect of albuterol is tachycardia.

The nurse understands that the prescribed etanercept is intended to treat which condition

Rheumatoid arthritis Etanercept is a biologic intended to treat specific autoimmune conditions such as plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis (RA). This medication decreases the inflammatory process by blocking tumor necrosis factor. This medication is administered subcutaneously on a specified dosing schedule depending on the condition it is intended to treat.

Pleural friction rub

is characterized by loud, rough, grating, scratching sounds caused by the inflamed surfaces of the pleura rubbing together, often associated with pain on deep inspirations.

Erikson's stages of psychosocial development: Autonomy vs. Shame and Doubt

Autonomy vs. Shame and Doubt is the typical stage of development for early childhood, which lasts from ages 2 to 3 years, so this is not the correct developmental stage/care plan for a 4-year-old patient. In Autonomy vs. Shame and Doubt, children seek to develop a sense of personal control over physical skills and knowledge of independence. When they are successful, for example, with a task like toilet training, they feel independent, leading to a sense of autonomy. When unsuccessful, they think they are failures, resulting in shame and self-doubt.

Pericardial tamponade; Beck's triad

Beck's triad is a symptom triad that indicates pericardial tamponade. Hypotension occurs because the patient is actively losing blood into the pericardial space. This sac can hold as little as 150 mL to 1,000 mL and impedes cardiac output. Jugular vein distention (JVD) occurs because the heart is compressed, which leads to delayed venous return. Blood pools in the veins and this can be assessed as jugular vein distention.

Bronchovesicular sounds

Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae.

The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation? A. 4 mL x kg x TBSA burned B. 30 mL/kg C. 0.5 mL/kg/hr D. 0.10 mL/kg/hr

Choice A is correct. The Parkland formula is widely used to calculate the fluid requirements following a major thermal burn. The formula of 4 mL x the client's weight in kilograms x the body surface area burned will determine the 24-hour fluid requirement. Once the total amount of fluid is calculated, divide it by two because of the two phases of fluid resuscitation (8 hours, then the remaining 16 hours). Choices B, C, and D are incorrect. 30 mL/kg is the formula used to determine repletion for a client with sepsis. 0.5 mL/kg/hr determines how much urine a client should produce every hour. UOP is monitored very closely during the acute phase of a burn to determine if the client is responding to treatment. 0.10 mL/kg/hr is not a formula used for any relevant medical calculation.

Hospitalization may affect or delay the progression of which physical development of a 1-yr-old patient? A. Walking B. Running C. Sitting D. CrawlingChoice

Choice A is correct. At 1-year-old, children should be beginning to walk. Hospitalization during this age could delay this stage of development. Choice B is incorrect. The patient should just be learning to walk at this age, not running. Choice C is incorrect. The child should be sitting up by six months of age. Choice D is incorrect. The child should already be crawling before age 1.

The nurse is caring for a patient with suspected kidney disease. Which of the following glomerular filtration rates is considered within normal limits? Correct A. 100 mL per minute B. 60 mL per minute C. 150 mL per minute D. 15 mL per minute

Choice A is correct. Glomerular filtration rate (GFR) measures kidney function. Healthcare practitioners use GFR to evaluate the stage of kidney disease and, in some cases, to determine drug dosing. A GFR of 100 mL/minute falls within the normal expected GFR range of 90 to 125 mL per minute. Chronic kidney disease (CKD) in the presence of a normal GFR is classified as stage I CKD. Choice B is incorrect. A GFR of 60 mL/minute is low and, if chronic, indicates chronic kidney disease stage II. Choice C is incorrect. A GFR of 150 mL/minute is too high and may indicate a testing error that requires a re-test. Choice D is incorrect. A GFR of less than or equal to 15 mL/minute represents end-stage kidney disease (CKD, stage V) and is not a normal finding. Usually, these patients end up needing dialysis.

Which form of therapy would most likely be used to treat a group of clients affected by phobias?

Cognitive-behavioral therapy (CBT) is a treatment that combines cognitive psychotherapy and behavioral psychotherapy. CBT is recommended as a first-line treatment approach for specific phobias. The behavioral component of CBT involves repeated exposure to the feared situations and thereby promotes fear reduction. For example, a virtual reality exposure strategy using computer technology can be used to simulate real-life situations (e.g. treating fear of flying with repeated exposure in a flight simulator). The cognitive component of CBT facilitates the client to identify the maladaptive thoughts relating to stressors and replace them with realistic thoughts. For example, a client with a specific phobia of elevators may incorrectly believe there is an extremely high chance of getting stuck while in an elevator. This distorted belief can be addressed with cognitive therapy and thereby reduce fear. CBT is also used for generalized anxiety disorder, panic disorder, eating disorders (anorexia nervosa, bulimia), and obsessive-compulsive disorder (OCD).

Cushing triad - what is it a sign of?

Cushing's triad is associated with increased ICP and is characterized by irregular respirations widened pulse pressure, and bradycardia.

You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of the tasks listed below should be done for this patient. What is the correct sequence for these tasks? Obtain a non-contrast CT scan Neurologic assessment by the stroke team Administer rtPA General assessment and stabilization

General assessment and stabilization Neurologic assessment by the stroke team Obtain a non-contrast CT scan Administer rtPA

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication? A. Diabetes insipidus B. Cushing's syndrome C. Hemophilia D. Inflammatory bowel disease

Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence. Choices A, C, and D are incorrect. Diabetes insipidus would not increase the risk of wound disruption, whereas diabetes mellitus would increase the risk of poor wound healing, especially if the diabetes is uncontrolled. Hemophilia is a genetic blood clotting disorder and does not directly cause poor wound healing. Inflammatory bowel disorder is a broad term for Crohn's or Ulcerative Colitis. These conditions do not directly lead to poor wound healing like Cushing's syndrome.

Hirschsprung's disease

Hirschsprung's disease is when a large portion of the rectum is not correctly innervated, causing problems with passing stool. It is not characterized by the abdominal contents coming through the umbilicus.

A 14-year-old male presents to the clinic with his parents after experiencing a fever, fatigue, and a sore throat for the past week. The parents note that the client has been too tired to participate in after-school activities and has experienced a decreased appetite. On exam, the client has cervical lymphadenopathy, exudate in the pharynx and on the tonsils, and petechiae. All other physical exam findings were normal except for increased spleen size noted during palpation. The client has no medical history and is current on all scheduled vaccinations.

Mono

A 71-year-old male arrives with his daughter with concerns about memory loss. The client's daughter reports that he has forgotten key dates, such as birthdays and his wedding anniversary, over the past six months. She emphasized that he would never forget these dates. Further, the client's daughter also reports that driving has become more difficult and that the client has been involved in two minor accidents over the past six months. He has also misplaced three sets of keys. The daughter describes her father's judgment as 'declining' along with his memory. The client's daughter is concerned that her father may have dementia. The client is alert and fully oriented. The client had difficulty with remote memory questioning. Immediate and recent memory was intact. The client denied any pain or physical symptoms, stating, "I'm here because my daughter insisted." click to specify if the clinical feature is consistent with delirium or dementia. Each finding may support more than one disease process. The onset of symptoms is months to years May be caused by uncontrolled hypertension and diabetes Progressively worsens Memory impairments May be caused by fluid and electrolyte imbalances or in

This client is likely experiencing the early stages of dementia. Although more testing needs to be completed, the onset of symptoms being months ago, the client having a disturbance in his executive functioning, and lack of insight point to dementia. It is common for clients with memory loss to have limited insight and rely on denial as a defense mechanism. Thus, having a family member identify the issue is common. Additional Info Delirium: Abrupt onset Favorable prognosis if the underlying cause is treated May be caused by infection, medications, F&E imbalance, or sensory impairment Impairments with attention that fluctuate in intensity Difficulty with judgment and executive functioning Memory impairments Altered level of consciousness Emotional lability Dementia: Insidious onset Poor prognosis as the disease is progressive Idiopathic; however, uncontrolled hypertension and diabetes contribute to vascular dementia Attention is unimpaired in the early part of the disease process Memory impairments start with recent memory then impact remote memory Difficulty with judgment and executive functioning No alteration in consciousness Flat affect that may progress to behavioral disturbances such as agitation

Erikson's stages of psychosocial development: Trust vs. Mistrust

Trust vs. Mistrust is the typical stage of development for infancy, which lasts from birth to 18 months. In this stage, children develop confidence when caregivers provide reliability, care, and affection. When infants do not have that, they will build mistrust.

Reactive Nonstress Test (NST)

When undergoing a nonstress test (NST), results are considered reactive (reassuring) if there are a minimum of two accelerations of 15 beats/minute above the baseline, each lasting a minimum of 15 seconds over the 20-minute testing period.

Coarse crackles

are lower-pitched, coarse, rattling sounds caused by fluid or secretions in large airways, likely to change with coughing or suctioning.

Wheezes

creates squeaky, musical, continuous sounds associated with air rushing through narrowed airways; it may be heard without a stethoscope. Wheezes originate from the small airways and usually do not clear with coughing. Treatment for wheezing is bronchodilators and inhaled anticholinergics.

omphalocele

herniation at the umbilicus

stroke impacting the occipital lobe assessment findings would support diagnosis

homonymous hemianopia: Visual disturbances are expected for a client with a stroke impacting the occipital lobe of the brain. The occipital lobe is the primary optical center of the brain. Homonymous hemianopia is a complete left or right visual field defect. The client may need to be taught to scan the room, and the nurse should place objects in the unaffected visual field.

stridor

is a medical emergency and indicates that the upper airways (larynx or pharynx) are closing.

You are caring for a 17-year-old patient who has been taking isotretinoin (Accutane) for the past three months. The most critical assessment for this patient is:

mood changes: Accutane is a synthetic retinoid that is frequently prescribed for severe acne that does not respond to other topical and oral treatments. This medication is usually given for 4 to 6 months or until significant improvement is noticed. Effects can include dry skin and development in the appearance of the skin. However, there are also severe side effects that can develop. The FDA required that the labeling of Accutane be changed to add that there is a possible connection between Accutane and critical mood changes. Depression, irritability, altered sleep patterns, and suicidal ideation should be reviewed with the patient during every visit. Family members should be aware of the possibility of these problems. They should be instructed to watch for these symptoms and should call the physician immediately if issues are noted.

intussusception

occurs when the bowel telescopes into another portion of the intestine. It is not characterized by the abdominal contents coming through the umbilicus while remaining in the peritoneal sac.

Gastroschisis

similar to omphalocele but differs in the fact that with gastroschisis, the intestines protrude outside the abdomen with no covering. This infant has an omphalocele because the abdominal contents come through the umbilicus while remaining in the peritoneal sac.

Fine crackles

sound like popping, discontinuous sounds caused by air moving into previously deflated airways; sounds like hair being rolled between fingers near the ear.

Erikson's stages of psychosocial development: Initiative vs. Guilt

the typical stage of development for preschool children, who are 3 to 5-year-olds, so this is correct for your four-year-old client. In Initiative vs. Guilt, children assert control and power over their environment. Success leads to initiative when they feel a sense of purpose, but children who try to exert too much power and experience disapproval and may feel a sense of guilt

Clinical features of acute cholecystitis include -

✓ Epigastic to right upper quadrant pain that may radiate to the right shoulder ✓ Nausea, vomiting, malaise ✓ Jaundice may be present ✓ Elevated white blood cell count (WBC) ✓ Elevated serum liver enzymes and bilirubin

Rhonchus (rhonchi)

is lower in pitch and sounds like continuous snoring. These sounds arise from the large airways and usually can be cleared with coughing

Erikson's stages of psychosocial development: industry vs. Inferiority

is the typical stage of development for school-age children, who are 6 to 11-year-olds. Children need to cope with new social and academic demands at this stage. When they are successful with this, they feel competent and achieve the industry. When they are not successful, they handle failure, resulting in inferiority.

The nurse is preparing to insert a peripheral vascular access device. The nurse should perform which action? Place the steps in the appropriate order. Palpate vein at intended insertion site by pressing downward Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site Insert the intravenous catheter at a 15 to 30 degree angle Reapply the tourniquet 10 to 15 cm (4-6 inches) above the anticipated insertion site Advance the catheter until a flash of blood is seen, advance the catheter into the vein while removing the needle Release tourniquet temporarily Apply sterile dressing over the intravenous site Release the tourniquet and connect the Luer-Lok end of short extension tubing to the needleless connector to the catheter hub

Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site Palpate vein at intended insertion site by pressing downward Release tourniquet temporarily Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds Reapply the tourniquet 10 to 15 cm (4-6 inches) above the anticipated insertion site Insert the intravenous catheter at a 15 to 30 degree angle Advance the catheter until a flash of blood is seen, advance the catheter into the vein while removing the needle Release the tourniquet and connect the Luer-Lok end of short extension tubing to the needleless connector to the catheter hub Apply sterile dressing over the intravenous site When establishing a vascular access device, the nurse should consider the intention of the therapy and the duration ✓ It is highly preferred that a site be selected on the client's non-dominant arm ✓ To prevent skin injury, the nurse should consider using a blood pressure cuff instead of a tourniquet ✓ Good skin cleansing of at least thirty seconds is necessary to maintain an aseptic technique

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. Nose breathing Occasional sneezing Nasal flaring Head bobbing Grunting

Choices C, D, and E are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort to pull air in through their nose, and their nares flare out with inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Head bobbing is a severe sign of respiratory distress in newborns. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Finally, grunting is a sign of respiratory distress and may be coupled with the infant developing pallor that may transition to cyanosis. Choices A and B are incorrect. Most newborns' primary way to breathe is through their noses. While some evidence may refute this claim, newborns require a patent nasal airway to have an effective gas exchange. Sneezing is a normal finding and does not signify respiratory distress.

You are reinforcing counseling for two parents preparing for their first child's birth. The mother has sickle cell anemia. The father undergoes genetic testing and discovers he is not a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% B. 50% C. 75% D. 0%

punnett square method Choice D is correct. Sickle cell anemia is an autosomal recessive disease. In the above diagram, the normal gene is represented as S, and the sickle cell gene is expressed as s. In an autosomal recessive disease, both the genes need to be abnormal for the individual to have the disease. Therefore, sickle cell anemia is characterized by ss, Ss as the carrier, and SS as the normal phenotype. The baby has no chance—a 0% chance—of having sickle cell anemia. Instead, the baby will be a carrier. Since the baby's mother has the disease, she is ss, and because the father has tested and found that he is neither a carrier nor does he have the disease, he is SS. This means that the only combination possible for the baby is Ss (carrier).

The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isoniazid B. Colchicine C. Allopurinol D. Warfarin Submit Answer

Choice B is correct. The initial treatment for acute pericarditis includes NSAIDs or colchicine. Pericarditis is an inflammatory condition of the pericardium that causes a client to experience chest pain, pericardial friction rub heard on auscultation and leukocytosis. Colchicine reduces the inflammation in the pericardium and may be prescribed for several weeks to achieve efficacy. Corticosteroids may be used as an adjunctive treatment. Choices A, C, and D are incorrect. Isoniazid is indicated for pulmonary tuberculosis, allopurinol is indicated for gout, and warfarin is an anticoagulant used to prevent thrombosis.