Physiological adaptation (goal > 65%)

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? You answered this question Incorrectly 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1., 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. 4. Incorrect: Never place an object in a client's mouth who is experiencing a seizure. 5. Incorrect: Magnesium sulfate is administered to control BP and decrease seizures. Magnesium sulfate leads to fewer maternal deaths and fewer future seizures when given for eclamptic seizures. Diazepam is contraindicated for use in pregnancy.

The nurse is planning an educational seminar on ophthalmic health. Which risk factors for cataract formation should be included in the discussion? You answered this question Incorrectly 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.

1., 2. & 4. Correct: All these factors put a client at greater risk for development of cataracts.

A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client? You answered this question Incorrectly 1. Encourage use of cotton gloves during sleep 2. Apply emollients to the skin 3. Increase protein rich foods in the diet. 4. Cut fingernails short 5. Provide mouth care prior to meals

1., 2., 4. & 5. Correct: The build up of uremic frost associated with end stage renal disease causes pruritus. Gloves reduce the risk of dermal injury. Emollients and lotion will aid dry, itchy skin. Apply after bathing. Cutting nails short will decrease risk of skin breakdown when scratching. Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste.

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? You answered this question Correctly 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

4

clients who are most at risk for atelectasis

CF, COPD

Emphysema is characterized by

shortness of breath, destruction of alveolar surfaces, and an increase in compliance

Are there dietary restrictions for individuals in renal failure? What are they and why limit these things?

yes protein should be limited potassium should be limited phosphate binders should be taken

are emollients good for the skin?

yes, help with dry cracked and risky looking skin breakdown

What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? You answered this question Incorrectly 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.

1., 3., 4., & 5. Correct: As rheumatoid arthritis worsens, the joints become progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows.

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? You answered this question Incorrectly 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma

2. Correct: Hemophilia is a heredity disease characterized by a deficiency of specific clotting factors, including Factor VIII, Factor XIII, and fibrinogen. Clients with hemophilia are given cryoprecipitate prophylactically prior to invasive procedures to replace these deficient factors and prevent hemorrhaging. 3. Incorrect: Packed red blood cells (PRBC's) mean the liquid portion of the blood has been removed so only the cells are infused. PRBC 's are generally administered in the face of severe hemorrhaging or very low hemoglobin and hematocrit. Bleeding is the main concern for this client, but packed red blood cells would not be the correct intervention prior to the procedure.

The nurse, assessing the lung sounds of a client diagnosed with pneumonia, notes diminished lung sounds and dull percussion in the lower lungs bilaterally. What intervention is correct by the nurse? You answered this question Incorrectly 1. Place the client in a left lateral recumbent position. 2. Instruct the client to perform incentive spirometry every hour. 3. Encourage the client to increase fluid intake of at least 50 mL/ hour. 4. Have the client use the bedpan to avoid overexertion and exacerbation of symptoms.

2. Correct: Incentive spirometry promotes maximum lung expansion, mobilizes secretions, and encourages coughing. 1. Incorrect: The client should be placed in a semi-Fowlers position and told to change positions frequently. 3. Incorrect: The nurse should encourage hydration up to 2 to 3L/day for adequate hydration.

A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform? You answered this question Incorrectly 1. Initiate cardiac monitoring. 2. Monitor intake and output hourly. 3. Position client in recumbant position. 4. Limit physical activity. 5. Administer dopamine at 5 micrograms/kg/min.

1., 2., 4. & 5. Correct: This client exhibits signs of cardiogenic shock, a complication of myocardial infarction. Hypotension accompanied by clinical signs of increased peripheral resistance (weak, thready pulse and cool, clammy skin) and inadequate organ perfusion (altered mental status and decreased urinary output) are found in this client. Initiate cardiac monitoring, watching for dysrhythmias, monitor I&O hourly to make sure kidneys are perfused. Limit activity to decrease oxygen demand. Dopamine is administered to increase BP and cardiac output.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? You answered this question Incorrectly 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1., 2. & 6. Correct: The CVP reading reflects the client's fluid volume status. If the CVP is elevated, indicating FVE, then the nurse is likely to hear S3 sounds when auscultating the heart sounds. The client's skin turgor and urine output would reflect the client's fluid volume status. 5. Incorrect: The CVP reading reflects the client's fluid volume status. The EKG rhythm would not reflect the client's fluid volume status.

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? You answered this question Incorrectly 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room

1., 2., 3. & 5. Correct: An acute onset of fever, headache, stiff neck, n/v, and mental status changes are consistent with bacterial meningitis. Elevate the head of the bed to promote comfort and decrease intracranial pressure. The client is at an increased risk for seizures, and the nurse should implement seizure precautions which include padding the side rails. A sponge bath is an independent nursing intervention appropriate for a fever greater than 101°F (38.3°C). Darkening the room is also a comfort measure as this client will have photophobia.

Which signs/symptoms does the nurse expect to note when caring for a client with a suspected cystitis? You answered this question Incorrectly 1. Incontinence 2. Urgency 3. Frequency 4. Hematuria 5. Nocturia 6. Flank pain

1., 2., 3., 4. & 5. Correct: Signs and symptoms of cystitis include burning on urination, nocturia, incontinence, suprapubic or pelvic pain, hematuria, and back pain.

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? You answered this question Incorrectly 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Correct: Preeclampsia is a condition in which the client's blood pressure is consistently elevated, with a systolic greater than 140 mm Hg and a diastolic above 90 mm Hg. The greatest main concern is decreased perfusion to the placenta, endangering mother and fetus, potentially accompanied by seizures, kidney or liver failure. This client has had only 80 mL of urine in four hours, indicating an output less than the minimum required of 30 mL per hour. This indication of possible kidney failure should be reported to the primary healthcare provider immediately. 4. Incorrect: The combination of increased blood pressure and swelling in preeclampsia frequently results in severe headaches and blurred vision. If the blood pressure reaches life-threatening levels, clients have been known to develop blindness because of retinal response to the decreased body perfusion. Although headache and blurred vision are serious symptoms, this is not completely unexpected and therefore does not need to be reported to the primary healthcare provider immediately.

Which signs/symptoms noted by the nurse would support a client history of chronic emphysema? You answered this question Incorrectly 1. Atelectasis. 2. Increased anteroposterior (AP) diameter. (barrell chest) 3. Breathlessness. 4. Use of accessory muscles with respiration. 5. Leans backwards to breathe. 6. Clubbing of fingernails

2., 3., 4., & 6. Correct: Emphysema is described as a permanent hyperinflation of lung beyond the bronchioles with destruction of alveolar walls. Airway resistance is increased, especially on expiration. Inspection reveals dyspnea on exertion, barrel chest (anteroposterior diameter is equal to transverse diameter), tachypnea, and use of accessory muscles with respiration. Clubbing of fingernails is due to chronically decreased oxygen levels. emphysema makes you feel like you're suffocating, so leaning back (which narrows your airway) wouldn't make it easier to breath, but leaning forward would...

The nurse is providing care for an elderly client who has a percutaneous endoscopic gastrostomy (PEG) feeding tube and is receiving continuous feeding. Which interventions should the nurse include when providing care? You answered this question Incorrectly 1. Add medications to enteral feeding formula. 2. Change dressing around insertion site weekly. 3. Flush feeding tube with 30 mL warm tap water every 4 hours. 4. Maintain head of bed at 30 degree elevation. 5. Monitor for hypoglycemia.

3., & 4. Correct: All enteral feedings require flushing. Flush feeding tubes in adults with 30 mL of warm tap water every 4 hours during continuous feedings or before and after each intermittent feeding. To prevent aspiration, elevate the head of bed to a minimum of 30 degrees, but preferably 45 degrees. 5. Incorrect: The elderly client is more likely to experience hyperglycemia rather than hypoglycemia. This is due to the high carbohydrate load in some enteral feeding formulas.

What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? You answered this question Incorrectly 1. Monitor Central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities

3., 4. & 5. Correct: These are independent nursing actions that will increase venous return and decrease edema. Also the nurse should assess for crackles, changes in respiratory pattern, shortness of breath (SOB), orthopnea.

Following a hemorrhagic stroke, a client had a craniotomy with insertion of a ventriculostomy. Upon arrival in the ICU, the nurse's initial readings indicate an increase in intracranial pressure (ICP). What is the nurse's priority action? You answered this question Incorrectly 1. Position client on the right side. 2. Call the primary healthcare provider. 3. Lower the head of the bed immediately. 4. Hyperventilate client with a bag valve mask.

4. Correct: A ventriculostomy is a temporary drain placed in the brain to remove excess cerebral spinal fluid in order to decrease intracranial pressure. Because the client's ICP readings are increasing, the nurse's initial action is to try to reduce that pressure by hyperventilating the client with a bag valve mask, also called an Ambu bag or manual resuscitator. This lowers cerebral CO2 levels, causing vasoconstriction which temporarily decreasing blood flow and reducing pressure within the brain. 2. Incorrect: The primary healthcare provider or surgeon will indeed need to be notified. However, the nurse's initial action is always focused on stabilizing the client if possible. In this case, the nurse can intervene prior to calling the primary healthcare provider.

should you ever place an object in the mouth of a client who is seizing?

hell no!

bloody sputum on NCLEX will be referred to as...

hemoptysis

continuous tube feeds, means the client is most at risk for this effect on blood sugar

hyperglycemia

seizures during pregnancy are controlled with this med

mag sulfate

when you block aldosterone, it's like you gave yourself what medication

potassium sparring diuretic

when you think of neck swan deformity...what is your first thought

rheumatoid arthritis

positive sign / symptoms are occurring, the client has an abg taken... what diagnosis should you anticipate

alkalosis positive includes RR, tingling

a client with emphysema will definitely not have this

atelectasis

#3 cream is an example of an

emollient

Cardiomegaly of the lungs. Permanent hyperinflation lungs which results in abnormal pneumo anatomy is called

emphysema

risk factors for glaucoma

fam hx thin cornea