Nurs396

First indication of digoxin toxicity is...

nausea and loss of appetite.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1) Loosening of the sutures 2) Sharp increase in serosanguineous drainage 3) Purplish color of the incision 4) Protrusion of organs through an open incision

Answer: 2 Rationale: Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1) Discharge planning is not covered by insurance. 2) Client cannot consent to his or her own surgery. 3) Postoperative complications occur that require additional treatment. 4) In case of the client's death, there will be directions about which client's belongings are to be given to family members.

Correct 2 Rationale: Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1) Tetany 2) Seizures 3) Diarrhea 4) Weakness 5) Dysrhythmia

Correct, 3.4.5 Rationale: Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

A plan of care for a client newly diagnosed with type 1 diabetes includes teaching how to self-administer insulin, adjust insulin dosage, select appropriate food on the prescribed diet, and test the serum for glucose. The client demonstrates achievement of these skills and is discharged five days following admission. What is the legal implication in this situation? 1) The nurse was functioning as a health teacher when providing the instructions. 2) A home health care nurse should have done the health teaching in the client's home. 3) Before discharge, family members also should have been taught how to administer insulin and perform other aspects of care. 4) Before implementation, the nurse should have the plan approved by all other members of the client's health care team.

Correct: 1 Rationale: The Nurse Practice Act states that the nurse will do health teaching and administer nursing care supportive to life and well-being. The teaching was essential before discharge. The client is responsible for self-care. Health teaching is an independent nursing function. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? 1) Take the medication with breakfast. 2) Have liver function tests every six months. 3) Wear sunscreen to prevent photosensitivity reactions. 4) Inform the health care provider if the client wishes to become pregnant.

Correct: 4 Rationale: Simvastatin is contraindicated in pregnancy because it is capable of causing fetal damage (teratogenic). It is a Pregnancy Category X teratogen. Simvastatin should be taken in the evening because most cholesterol is synthesized between 12 midnight and 3:00 AM. Liver function tests should be done at 6 to 12 weeks initially and only then every 6 months. Although wearing sunscreen should be taught, sensitivity reactions are a rare occurrence; it is not as important as an action in another option.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in: 1) Serum sodium 2) Urinary output 3) Hematocrit level 4) Serum potassium

Correct: 2 Rationale: As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1) Pain history, including location, intensity, and quality of pain 2) Client's purposeful body movement in arranging the papers on the bedside table 3) Pain pattern, including precipitating and alleviating factors 4) Vital signs such as increased blood pressure and heart rate 5) The client's family statement about increases in pain with ambulation

Correct: 1, 3 Rationale: Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention? 1) Titrate the dose until pain is tolerable. 2) Manage pain with oral pain medication. 3) Assess the client for anticholinergic side effects. 4) Instruct the client to take the medication with food.

Correct: 2 Rationale: It takes 24 hours to reach the peak effect of transdermal fentanyl (Duragesic). Oral pain medication may be necessary to support client comfort until the fentanyl reaches its peak effect. The nurse needs to administer the dose of transdermal fentanyl exactly as prescribed by the health care provider. This is associated with tricyclic antidepressants, not transdermal fentanyl. A transdermal medication is administered through the skin via a patch applied to the skin, not via the gastrointestinal tract.

Before a male client signs an operative consent for an abdominoperineal resection, the nurse verifies that the client understands that surgery likely will result in which outcome? 1)Permanent ileostomy in the jejunum 2) Permanent colostomy and impotence 3) Temporary ileostomy and diminished libido 4) Temporary colostomy in the descending colon

Correct: 2 Rationale: Large portions of bowel and rectum are removed; during the perineal portion of the surgery, nerves involved in penile erection often are damaged. An ileostomy will not be performed because the lesion is in the descending colon. A colostomy after an abdominoperineal resection is permanent because the rectum is removed; sexual functioning, not libido, may be affected. The descending colon is removed; the colostomy will be permanent.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1) After reporting severe pain 2) On admission to the hospital 3) Upon entering the operating room 4) Before transfer to a rehabilitation facility 5) At time of scheduling for the surgical procedure

Correct: 2, 4 Rationale: Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking — including drug name, dosage, frequency, and route — and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications ...

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1) Low in fat 2) High in iron 3) High in fluids 4) Low in residue

Correct: 3 Rationale: A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to: 1) Provide nutrients. 2) Increase protein stores. 3) Elevate the circulating blood volume. 4) Divert blood flow away from the liver temporarily.

Correct: 3 Rationale: Increasing oncotic pressure increases the client's circulating blood volume; salt-poor albumin pulls interstitial fluid into the blood vessels, restoring blood volume and limiting ascites. Nutrients are provided by total parenteral nutrition, not salt-poor albumin. Salt-poor albumin is not given to increase protein stores. Salt-poor albumin has no effect on diverting blood flow away from the liver. Study Tip: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1) Sprinkle the powder from the capsule into a cup of water. 2) Insert a rectal suppository containing 100 mg of phenytoin. 3) Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. 4) Obtain a change in the administration route to allow an intramuscular (IM) injection.

Correct: 3 Rationale: When an oral medication is available in a suspension form, the nurse can use it for clients who cannot swallow capsules. Use the "Desire over Have" formula to solve the problem. Desire 100 mg = x mL Have 125 mg 5 mL 125x = 500 X = 500 ÷ 125 X = 4 mL Because a palatable suspension is available, it is a better alternative than opening the capsule. The route of administration cannot be altered without the health care provider's approval. Intramuscular injections should be avoided because of risks for tissue injury and infection.

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1) Isoniazid (INH) 2) Rifampin (Rifadin) 3) Streptomycin 4) Ethambutol (Myambutol)

Correct: 3 Streptomycin Rationale: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may occur. Rifampin does not affect hearing; however, visual disturbances may occur. Ethambutol does not affect hearing; however, visual disturbances may occur.

A nurse teaches a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1)... apple juice." 2) ... grape juice." 3)... orange juice." 4)... cranberry juice."

Correct: 4 Rationale: Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

Later indications of digoxin toxicity is...

yellow vision.