Physiological integrity

Elevated serum ASO titer (antistreptolysin O)

indicates glomerulonepritis

The home care nurse visits a client who is diagnosed w/dementia. The client's daughter tells the nurse that after talking with the HCP, the client is taking ginkgo. Which statement, if made by the client's daughter to the nurse, requires an intervention? 1. "My mother takes ibuprofen every day for arthritis" 2. "There is a large clock and calendar in my mother's room" 3. "I encourage my mother to take a walk with me every day" 4. "My mother takes digoxin every day"

1. "My mother takes ibuprofen every day for arthritis" Ginkgo is an anti-platelet agent and CNS stimulant given for dementia syndromes; increases risk of bleeding when given w/NSAIDs

The nurse cares for patients in the ED. Four patients come to the ED at the same time. Which of the following patients should the nurse see FIRST? 1. A 1-year-old w/vomiting and diarrhea 2. A 2-year-old w/a temperature of 101 F 3. A 20-year-old at 8 weeks gestation who is complaining of vaginal spotting 4. A 32-year-old complaining of N/V for the past several hours

1. A 1-year-old w/vomiting and diarrhea At significant risk for dehydration; which may r/i electrolyte imbalances, as well as shock, depending on the amount of fluid lost

The nurse cares for a client receiving albuterol 2 puffs and beclomethasone 2 puffs through inhalers. The nurse should include which statement when counseling the client? 1. "Use the albuterol inhaler and then use the beclomethasone inhaler" 2. "Use the beclomethasone inhaler and then the albuterol inhaler" 3. "You should take 1 puff of each inhaler, wait a minute, and then repeat the process" 4. "Either the inhaler can be used first as long as you wait 2 minutes between puffs"

1. "Use the albuterol inhaler and then use the beclomethasone inhaler" Albuterol is a bronchodilator that opens the passageways so that the steroid medication (beclomethasone) can get into the bronchioles

The nurse in the surgeon's office obtains a history from a client scheduled for knee replacement. The client expresses a desire to make an autologous blood donation. It is MOST important for the nurse to follow up on which client statement? 1. "Because my surgery is scheduled in 8 weeks, I will make the first donation this week" 2. "I may have to start taking oral iron supplements" 3. "I am glad that I can give 3 units of blood" 4. "I have to make the last donation at least 3 days before surgery"

1. "Because my surgery is scheduled in 8 weeks, I will make the first donation this week" May give blood up to 5 weeks before surgery; advantage of autologous blood donation is that it eliminates transfusion reaction

Diagnostic testing indicates that a bottle fed infant is allergic to cow's milk. The nurse discusses w/the mother the adaptive measures to take. Which statement by the infant's mother to the nurse indicates that the mother has a correct understanding of how to proceed? 1. "I am glad there are so many varieties of soy-based formulas available" 2. "Goat's milk is supposed to be very gentle on the stomach" 3. "Those predigested formulas sound like they would be a good choice" 4. "The store near my house is always having a sale on fresh yogurt"

1. "I am glad there are so many varieties of soy-based formulas available" Soy-based formulas are used for infants w/cow's milk allergy before trying the predigested formulas

A client receives isoniazid, rifmapin, and ethambutol. Which statement, if made by the client to the nurse, MOST concerns the nurse? 1. "I seem to be becoming color blind- I can't see green" 2. "My urine and sweat are reddish-orange" 3. "Sometimes I wonder what I did to deserve all this" 4. "My big toe has started hurting so I can hardly walk"

1. "I seem to be becoming color blind- I can't see green" A major common adverse effect of ethambutol is optic neuritis, with reduced visual activity; lessened ability to see green is a possible initial sign

The nurse cares for a client 2 days after the client sustained an injury in an auto accident. The client is placed in halo vest traction. The nurse is MOST concerned if the client states which of the following? 1. "It hurts when I chew" 2. "My back itches" 3. "I have a headache" 4. "Why did this happen to me?"

1. "It hurts when I chew" If pain occurs w/jaw movement 24-48 hours after traction applied, may indicate that skull pins have slippped onto the thin temporal plate; notify physician immediately

The nurse cares for a 7-month-old infant diagnosed w/HF. Which of the following assessments by the nurse BEST detects fluid retention in the infant? 1. Daily weights 2. Test the urine for presence of blood 3. Measure the abdominal girth 4. Count the number of wet diapers

1. Daily weights Earliest sign of fluid retention is weight gain

The nurse performs an assessment of a client diagnosed w/Parkinson's disease. The nurse expects to observe which of the following ? SATA 1. Tremors 2. Diplopia 3. Bradykinesia 4. Slurred speech 5. Respiratory distress 6. Propulsive gait

1. Tremors 3. Bradykinesia 4. Slurred speech 6. Propulsive gait - Resting tremor that disappears w/purposeful movements - Abnormally slow muscle movement; has trouble initiating movement - Caused by weakness and uncoordination of muscle - Instruct client to walk erect, watch the horizon, and use a wide based gait

The nurse assesses a client in the outpatient clinic for treatment of MS. The nurse should assess for which clinical manifestations? SATA 1. Urinary retention 2. Decreased LOC 3. Hypoactive DTRs 4. Intestinal obstruction 5. Numbness or tingling sensation 6. Decreased short-term memory

1. Urinary retention 5. Numbness or tingling sensation 6. Decreased short-term memory - Causes progressive demyelination of spinal cord, will see gradual weakness l/t paralysis, alteration in innervation of bladder and urinary tract - Client will also experience decreased sensitivity to pain, facial pain, and decreased temperature perception - Cognitive changes are seen late in the disease and include decreased concentration, decreased ability to perform circulations, impaired judgement

The nurse in the outpatient clinic prepares a client for a pap smear. The client takes atenolol 50 mg daily. It is MOST important for the nurse to follow up on which client statement? 1. "I haven't had a pelvic exam in 3 years" 2. "Black cohosh helps my hot flashes" 3. "I exercise three times per week" 4. "I don't like it when my partner uses a condom"

2. "Black cohosh helps my hot flashes" Herbal used in management of menopausal symptoms; may cause hypotension when used in combination w/antihypertensive drugs

The nurse admits a patient to his room following a thyroidectomy. It is MOST important for the nurse to assess for which of the following? 1. Muscle flaccidity 2. Numbness in the fingers 3. Pain in the lower extremities 4. Confusion

2. Numbness in the fingers Injury to the parathyroid glands causes decrease in serum calcium, assess for tingling around mouth, toes, fingers and muscular twitching Other complications of thyroidectomy include hemorrhage, respiratory distress, laryngeal nerve damage, and thyroid storm

The nurse in the ED cares for a client who presents w/a bee sting. The nurse notes that the client is sneezing and coughing, is flushed, has generalized hives, and complains of feeling warm. Which of the following actions should the nurse take FIRST? 1. Continue to monitor the client 2. Immediately administer Prednisone 3. Establish an IV infusion w/normal saline 4. Ask the client about previous reactions to bee stings

3. Establish an IV infusion w/normal saline Priority to monitor circulation status and maintain BP

The nurse performs discharge teaching for a client who had a CABG. The nurse knows that teaching is successful if the client makes which statement? 1. "I may have a moderate amount of bloody drainage from the incision after I go home" 2. "I will have an elevated temperature and excessive fatigue for about one month" 3. "I will have moderate pain and tenderness of the incision sites for 2-4 weeks after surgery" 4. "After I go home, I may see some swelling in the leg used for the donor graft"

4. "After I go home, I may see some swelling in the leg used for the donor graft" Edema increases at home b/c client is usually more active

The nurse in the outpatient clinic counsels an 18-year-old boy who is 6'5" tall and weighs 190 lbs. The teen states he is trying to increase his weight. The nurse determines that teaching is effective if the client states which of the following? 1. "I have increased my intake of fresh fruits and vegetables" 2. "I eat bread at each meal" 3. "I use low-fat salad dressing" 4. "I like to snack on pecans and raisins"

4. "I like to snack on pecans and raisins" Foods add calories and are nutritious

Which client statement BEST indicates to the nurse the client understands teaching to prevent hypokalemia? 1. "I should take the potassium supplements on an empty stomach" 2. "I should crush the potassium tablets if I can't swallow them" 3. "I should eat more lettuce as well as take the potassium supplement" 4. "I should avoid salt substitutes while taking the potassium supplement"

4. "I should avoid salt substitutes while taking the potassium supplement" Many salt substitutes are high in potassium, which combined with the prescribed potassium supplement may r/i hyperkalemia

The nurse performs discharge teaching for a client receiving ethacrynic acid. The nurse determines that further teaching is needed if the client states which? 1. "I will take the medication early in the day" 2. "I will contact the HCP if I feel dizzy" 3. "I will take the medication w/meals" 4. "I will avoid OJ and bananas"

4. "I will avoid OJ and bananas" Loop diuretics are potassium wasting; encourage client to increase intake of potassium rich foods

The nurse on the surgical unit cares for a client after an ileostomy. It is MOST important for the nurse to take which of the following actions? 1. Empty the ileostomy bag from the bottom 2. Apply lotion to the skin around the stoma 3. Cover the ileostomy w/gauze 4. Measure the output from the ileostomy

4. Measure the output from the ileostomy Output from the ileostomy is liquid and usually copious in amount; include in client's intake and output

The nurse cares for a client in balanced suspension traction. The client reports pain in the affected extremity, and the nurse administers the prescribed pain medication. One hour later the client tells the nurse that the pain is unrelieved. Which action should the nurse take FIRST? 1. Contact the physician 2. Turn on client's radio 3. Ask the client to rate his pain using a numeric rating scale 4. Perform a neurovascular assessment

4. Perform a neurovascular assessment Pain unrelieved by medication is a sign of acute compartment symdrome

During the acute phase of a stroke, the nurse should maintain the client in which position? 1. Semi-prone w/the HOB elevated 30-45 degrees 2. Lateral, w/the HOB flat 3. Prone, w/the HOB flat 4. Supine, w/the HOB elevated 15-30 degrees

4. Supine, w/the HOB elevated 15-30 degrees Facilitates venous drainage from brain; reduces ICP; keeps head in midline position

A nurse cares for a child diagnosed w/Wilm's tumor. Pre-op, it is MOST important for the nurse to take which of the following actions? 1. Palpate the child's abdomen 2. Measure the client's abdominal girth 3. Assess for hypotension 4. Monitor the child's intake and output

2. Measure the client's abdominal girth Assess the size of the tumor, treatment is surgery followed by radiotherapy and chemotherapy

A patient has a vagotomy w/antrectomy to treat a duodenal ulcer. Post-op the patient develops dumping syndrome. Which of the following statements, if made by the patient, indicates to the nurse that further teaching is necessary? 1. I should eat bread w/each meal 2. I should eat smaller meals more frequently 3. I should lie down after eating 4. I should avoid drinking fluids w/my meals

1. I should eat bread w/each meal Should decrease intake of carbohydrates since they are first food to be digested; undigested food is dumped into the jejunum, r/i distention, cramping, pain, diarrhea 15-30 minutes after eating; causes diaphoresis, diarrhea and hypotension

A client w/a history of pulmonary disease comes to the ER w/pronounced wheezing and mild dyspnea. The nurse obtains ABGs and the results are: pH 7.32, PaCO2 48, HCO3 24, PaO2 51. The client is given 1 L/min of O2 via NC and placed in Fowler's position. An hour later the ABGs are: pH 7.35, PaCO2 38, HCO3 24, and PaO2 60. Which of the following actions, if taken by the nurse is BEST? 1. Increase the O2 flow rate 2. Prepare the client for ICU admission 3. Continue to monitor the client 4. Place the client in semi-Fowler's position

1. Increase the O2 flow rate Acidosis has imporved; but PaO2 remains decreased, normal PaO2 is 80-100

The nurse performs an initial assessment on a middle-aged male. It is MOST important for the nurse to follow up on which client statement? 1. "My brother was just diagnosed w/prostate cancer" 2. "I take enalapril 5 mg PO daily" 3. "I had a lumbar laminectomy 2 years ago but still have some low back pain" 4. "Lately, I just don't have as much desire to engage in sex"

1. "My brother was just diagnosed w/prostate cancer" Middle-aged male is at risk for prostate cancer; having a father or brother with the cancer increases the client's risk by 50%

The nurse observes a client have a tonic clonic seizure lasting about 90 seconds, followed by a period of decreased consciousness lasting 2 minutes. Then the client begins to have another seizure. It is MOST important for the nurse to take which action? 1. Administer diazepam as ordered 2. Monitor serum glucose levels closely 3. Assess the client's blood pressure and pulse 4. Remove excessive clothing

1. Administer diazepam as ordered Implementation; give IV to stop seizure activity; support ABCs, protect client from injury, provide oxygen, establish and IV access

The medical unit nurse review the blood-test results of four adult clients. Which result indicates that the client has the HIGHEST risk of falling? 1. BUN of 28 mg/dL 2. Serum sodium of 140 mEq/L and potassium of 4.2 mEq/L 3. ESR of 30 mm/hr 4. Serum calcium of 9.0 mg/dL and magnesium of 1.8 mg/dL

1. BUN of 28 mg/dL BUN is elevated in salt and water depletion; high BUN can cause confusion, disorientation, convulsions, which could easily lead to falls; water depletion could also r/i falls d/t orthostatic hypotension

The NAP on an acute urology unit gives the nurse the I&O sheet for a client diagnosed w/chronic kidney disease. The client's output was measured on the day shift but not recorded on the evening shift. Which action should the charge nurse take FIRST? 1. Call the nurse assigned to the evening shift and request the information 2. Complete an agency incident report 3. Ask the client to give the output for last evening 4. Notify immediate supervisor of the incident

1. Call the nurse assigned to the evening shift and request the information The goal is to make every effort to retrieve the data; knowledge of output used to support decision making about most appropriate interventions; nurses often carry notes home with them or store their work sheets in their lockers; this method seeks a possible resource

A client is admitted to the hospital w/a diagnosis of MI and morphine sulfate is ordered for pain relief. The nurse explains to the client that morphine sulfate is given b/c of which reason? 1. Decreases blood return to the right side of the heart and decreases peripheral resistance 2. Increases blood return to the right side of the heart and increases peripheral resistance 3. Decreases blood return to the right side of the heart and maintains peripheral resistance 4. Increases blood return to the right side of the heart and decreases peripheral resistance

1. Decreases blood return to the right side of the heart and decreases peripheral resistance Decreses preload and afterload pressures and cardiac workload; causes vasodilation and pooling of fluid in extremities; provides relief from anxiety

The nurse on the med/surg unit reviews lab results. The nurse notes that a client's serum albumin level is 2.5 g/dL, fasting blood sugar is 110 mg/dL, potassium is 4.2 mEq/L, and sodium is 140 mEq/L. It is MOST important for the nurse to assess for which finding? 1. Edema 2. Nausea 3. Muscle weakness 4. Blurred vision

1. Edema Normal serum albumin is 3.5 to 5.5 g/dL; albumin deficit decreases oncotic pressure and fluids shift from vascular area to tissue

The nurse cares for a client w/moderate flail chest. The nursing care plan includes which interventions? SATA 1. Monitor client's VS for shock 2. Maintain Pler-evac drainage system 3. Administer pain medication at regular intervals 4. Encourage client to turn, cough, and breathe deep 5. Monitor ABGs 6. Prepare client for surgery

1. Monitor client's VS for shock 3. Administer pain medication at regular intervals 4. Encourage client to turn, cough, and breathe deep 5. Monitor ABGs - Treat hypovolemia immediately - Caused by blunt chest trauma and is extremely painful - Promotes lung expansion - Assess for hypoxemia and hypercapnia

The nurse cares for a newborn diagnosed w/a myelomeningocele. The nurse identifies that which of the following actions is MOST important? 1. Monitor for elevated temperature, irritability, and lethargy 2. Perform ROM exercises to feet, ankles, and knee joints 3. Apply lotion to healthy skin and gently massage skin 4. Measure occipitofrontal circumference daily

1. Monitor for elevated temperature, irritability, and lethargy Infant is at risk to develop infection (meningitis) b/c of myelomeningocele sac; change dressing every 2-4 hours using aseptic technique

The nurse assesses a client in the outpatient clinic reporting repeated severe headaches. Which action should the nurse take FIRST? 1. Obtain a description of the HA 2. Determine how the client usually relieves HAs 3. Ask how long the client has been having HAs 4. Obtain a list of medication the client is currently taking

1. Obtain a description of the HA Ask client to describe HA in own words; HA is usually a symptom and not a disease; can be a result of neurological disease, c/b vasodilation, or skeletal muscle lesion

Because of persistent absenteeism and decreased peformance, a 35-year-old African American who works at a national cell telephone company is referred to the occupational nurse's office. The client tells the nurse of feeling tired all of the time and has HAs unrelieved by 2 tablets of acetaminophen. It is MOST important for the nurse to take which action? 1. Obtain the client's BP 2. Schedule an appointment w/the nephrologist 3. Ask the client when the last appointment with the HCP was 4. Instruct the client to schedule an appointment w/the HCP

1. Obtain the client's BP Race, age, gender and s/s are reflective of HTN; fatigue may indicate early development of kidney disease

The nurse cares for a client receiving furosemide. The nurse determines that teaching is effective if the client selects which foods? SATA 1. One medium baked potato 2. One slice of white bread 3. One medium apple 4. One scrambled egg 5. 1 1/4 cup of corn flakes 6. 1 cup of cantaloupe

1. One medium baked potato 6. 1 cup of cantaloupe - Contains 407 mg of potassium - Contains 825 mg of potassium

The nurse cares for the client reporting weakness, confusion, and hypoactive bowel sounds. The client's lab results reveal sodium 140 mEq/L, ionized serum calcium 4.7 mEq/L, potassium 1.8 mEq/L, and blood sugar 110 mg/dL. Which action should the nurse initiate FIRST? 1. Place the client on a cardiac monitor 2. Place the client on 2 L of O2 3. Administer potassium chloride 20 mEq/hour 4. Offer the client 240 mL of OJ

1. Place the client on a cardiac monitor Altered potassium level can r/i cardiac dysrhythmia; place client on a monitor while preparing administration of potassium chloride

A patient comes to the ER w/a possible pneumothorax. The nurse should assess for which of the following? 1. Rapid respirations 2. Deep, rapid respirations 3. Respiratory depression 4. Periods of hyperpnea alternating w/periods of apnea

1. Rapid respirations Describes tachypnea

The nurse cares for a client hospitalized w/a VTE. The client is a single mother of a 5-year-old child. It is MOST important for the nurse to respond to which client statement? 1. "My work doesn't offer any sick leave" 2. "What am I going to do while I am stuck in this bed?" 3. "I am not sure who is taking care of my daughter" 4. "I am missing my mother's 50th birthday party"

3. "I am not sure who is taking care of my daughter" Safety need; nurse should contact social services about arranging care for the client's child

The nurse admits a client to the outpatient surgical unit for a mastoidectomy d/t chronic otitis media. Which of the following quesitons should the nurse ask FIRST? 1. "When did you begin having problems w/your ears?" 2. "Do you have problems w/vertigo?" 3. "Do you have any questions about the procedure?" 4. "What are your concerns about the post-op period?"

2. "Do you have problems w/vertigo?" Nurse anticipates problems w/vertigo and asks about it first to prevent injury to the client

The nurse in the outpatient surgical center instructs a client preparing for surgical removal of a cataract of the left eye w/a lens implant. The nurse determines teaching is effective if the client states which of the following? 1. "My eyelids will be swollen shut for 3 days" 2. "I am happy that I will only need reading glasses" 3. "I can return to normal activities w/out restrictions" 4. "I will have severe pain that will be relieved by narcotics"

2. "I am happy that I will only need reading glasses" Replacement lens implants are selected to allow correction of refraction for distal vision; client may not require glasses to see distances, but my still require glasses for reading or for close work

The nurse cares for a client receiving doxycycline 50 mg PO BID for acne. The nurse is concerned if the client makes which statement? SATA 1. "I wear sunscreen when I am outdoors" 2. "I have a vaginal discharge" 3. "I take the medication at 10:30 am and 10:30 pm" 4. "My husband and I use condoms for birth control" 5. "I take all of the medication in the bottle" 6. "I take an antacid immediately before going to bed"

2. "I have a vaginal discharge" 3. "I take the medication at 10:30 am and 10:30 pm" 6. "I take an antacid immediately before going to bed" - May indicate superinfection - Medication is taken at regular intervals around the clock but should not be taken within 1 hour of bedtime b/c it may cause esophageal irritation; nurse should find out what time client usually goes to bed - Do not take antacids w/in 1 to 3 hours of taking oral tetracycline; statement requires further assessment

The clinic nurse assesses a client who is presenting w/a documented history of gastric ulcer and current symptoms of nausea, vomiting, and diarrhea of 2 days duration. It is MOST important for the nurse to follow up on which statement made by the client? 1. "I take aspirin for HAs and arthritis pain, and antacids for this ulcer of mine" 2. "I have been drinking more fluids to keep from getting dehydrated. It's odd, but I'm urinating less than I though I would" 3. "On my last visit to the doctor, I was told I may be developing cataracts" 4. "When this first began, I didn't know what had hit me. I knew that I had been under a lot of stress at work but I thought I was coping well, considering the circumstances"

2. "I have been drinking more fluids to keep from getting dehydrated. It's odd, but I'm urinating less than I though I would" It is particularly important to assess the UOP b/c of the potential for FVD causing shock; in the first stages of shock there is decreased UOP, even when there is normal fluid intake; it is especially important for the nurse to elicit information about fluid intake and output during the preceding 24 hours; this client has an ulcer, which might be bleeding or for which the client might be taking medications that could lead to hypovolemic shock; loss of fluid from vomiting and diarrhea could cause dehydration and hypovolemia

The home care nurse assesses a client diagnosed w/HF. The nurse is MOST concerned if the client states which of the following? 1. "My ankles and hands become swollen at the end of the day" 2. "I have trouble catching my breath after taking out the garbage" 3. "I don't feel hungry and my stomach feels bloated" 4. "I have pain in my chest each time I cough"

2. "I have trouble catching my breath after taking out the garbage" Pulmonary edema is manifested as dyspnea; fluid remains in the vessels of the lung instead of going in to the left side of the heart; decreased CO r/i tissue congestion; fluid passes from the pulmonary capillaries to the alveoli, causing cough and SOB; dyspnea may occur or become worse w/physical exertion

A client diagnosed w/alcoholism is scheduled to take disulfiram. Which statement, if made by the client to the clinic nurse, MOST concerns the nurse? 1. "I will take it at night so it helps me sleep" 2. "I like to work on crafts, especially unfinished furniture" 3. "I understand that disulfiram loses its effectiveness over time" 4. "I hope this works, I'm tired of being drunk"

2. "I like to work on crafts, especially unfinished furniture" Potential contact w/alcohol both by inhalation of paint or wood stain fumes as well as by skin contact w/these substances; any contact w/any amount or any form of alcohol, even a very small amount, like 7 to 15 mL, will cause an alcohol-disulfiram reaction, which is extremely uncomfortable and may even l/t shock and cardiac dysrhythmias

The nurse instructs a client diagnosed w/PUD receiving cimetidine. Which statement, if made by the client to the nurse, indicates that teaching is successful? 1. "I should eat foods like creamed soups, oatmeal, and pudding" 2. "I should eat 3 meals each day" 3. "I can't eat salad or strawberries" 4. "I can drink coffee as long at it is decaffeinated"

2. "I should eat 3 meals each day" If taking a histamine blocker, small frequent feedings are not necessary; should avoid aspirin, meat extracts, alcohol, and caffeinated beverages

The nurse plans care for an adult woman admitted with TSS. The nurse is MOST concerned if the client states which of the following? 1. "I am very frightened of doctors and hospitals" 2. "I vomited 12 times in the past 24 hours" 3. "I have abdominal pain and pressure" 4. "I use extra-absorbent tampons"

2. "I vomited 12 times in the past 24 hours" Physical need; would l/t fluid volume deficit; fluids lost d/t vomiting and diarrhea; symptoms of TSS include fever of sudden onset, hypotension and rash

A patient newly diagnosed w/Meniere's disease is counseled by the office nurse as to important dietary modifications. Which of the following comments, if made by the patient to the nurse, BEST indicates that teaching is successful? 1. "I have seen a lot of dietetic foods in the store. I will focus on buying them" 2. "I will avoid Chinese restaurants and fast-food places when I go out to eat" 3. "I will buy one of those commercial salt substitutes to use when I have a craving for salt" 4. "I understand that I can have corned beef and smoked fish, but not pickles or creamed sauces"

2. "I will avoid Chinese restaurants and fast-food places when I go out to eat" Patients w/Meniere's disease require a low-sodium diet to decrease fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of which are high in sodium; fast-food places and products also have a tendency to be high in sodium

The nurse cares for a client receiving fluoxetine. The nurse determines that teaching is effective if the client makes which statements? SATA 1. "If I forget to take a dose, I should take it as soon as I remember" 2. "I will chew sugarless gum" 3. "I will sit on the side of the bed before arising" 4. "I will use sunscreen when I go outdoors" 5. "I'm glad that this medication will increase my sex drive" 6. "I should stop the medication if I start having side effects"

2. "I will chew sugarless gum" 3. "I will sit on the side of the bed before arising" 4. "I will use sunscreen when I go outdoors" - May minimize dry mouth; instruct client to rinse mouth frequently and use good oral hygiene - May cause dizziness; fluoxetine is an SSRI used to treat depression and OCD - Appropriate behavior

A client is admitted for regulation if insulin dosage. The client takes 15 units of isophane insulin at 0800 every day. At 1600, which nursing observations indicate a complication from the insulin? 1. Acetone odor to the breath, polyuria, and flushed skin 2. Irritability, tachycardia, and diaphoresis 3. Headache, nervousness, and polydipsia 4. Tenseness, tachycardia, and anorexia

2. Irritability, tachycardia, and diaphoresis Isophane insulin is an intermediate-acting insulin that peaks from 8-12 hours after administration; this is when signs and symptoms of hypoglycemia will occur

The new graduate nurse on the neurology unit reviews plans of caring for a patient w/increased ICP secondary to supratentorial surgery/head injury. Which of the following statements by the new graduate nurse requires correction by the preceptor? 1. "I will give the patient a cool sponge bath if a fever occurs" 2. "I will do as many procedures close together as I can" 3. "I will hyperventilate the patient before and after suctioning" 4. "I will be sure to keep the HOB elevated 30 degrees"

2. "I will do as many procedures close together as I can" Nursing care should be spaced out to minimize elevation of the ICP; patients are sensitive to sudden and/or noxious stimuli such as touching, jarring, loud noises, and bright lights, all of which can further increase ICP

The nurse reviews circumcision site care with the parents of a boy who had a circumcision using a circumcision clamp. Which of the following statements by the mother to the nurse indicates that teaching is successful? 1. "I will wipe of any discharge that appears using warm water and a gentle circular motion" 2. "I will put Vaseline on a gauze pad and put that over the circumcision area before I diaper him" 3. "I will be sure the diaper fits snugly but not too tightly and that it is changed when wet" 4. "I understand that it is normal for the first few days for the penis to look red or swollen and for my son not to be urinating much"

2. "I will put Vaseline on a gauze pad and put that over the circumcision area before I diaper him" Correct action; a 4x4 gauze pad with either petroleum jelly or A&D ointment on it is placed on the circumcision site as a dressing to prevent the wound from adhering to the dressing or diaper; the dressing changes occur for 3 days after procedure

The home care nurse counsels a client diagnosed w/glaucoma. The nurse determines that teaching is successful if the client makes which of the following statements? 1. "Because of glaucoma, the correction in my eyeglasses needs to be changed" 2. "I will schedule appointments w/my physician early in the morning" 3. "I'm glad that surgery can reverse the damage caused by glaucoma" 4. "I will be happy when I don't have to use the eyedrops anymore"

2. "I will schedule appointments w/my physician early in the morning" IOP tends to be higher in the early morning hours; an early morning assessment is likely to be more accurate

The home health nurse visits a client who was hospitalized w/chronic kidney disease and sent home on continuous ambulatory peritoneal dialysis. Which statement by the client MOST concerns the nurse? 1. "I seem to still get constipated, even though I eat the high-fiber diet they told me to eat" 2. "Maybe it's my imagination, but the fluid draining out has looked cloudy the last couple of days" 3. "Sometimes I forget and carry the groceries in my left arm" 4. "I am worried about getting fat. I am gaining weight even though I am not eating more than usual

2. "Maybe it's my imagination, but the fluid draining out has looked cloudy the last couple of days" Cloudy or opaque dialysate output is the earliest sign of peritonitis, which is the major complication; normal outflow drainage is relatively clear and light yellow

The nurse counsels a client diagnosed w/a seizure disorder. The client has just won a national beauty pageant and will be frequently traveling during the next year. It is MOST important for the nurse to include which of the following instructions? 1. "Travel w/a person experienced in handling health problems" 2. "Place your medication in a carry-on bad" 3. "Ask for hotel rooms on the first floor" 4. "Avoid flashing lights"

2. "Place your medication in a carry-on bad" Take medication as prescribed to keep drug levels constant to prevent seizures; should carry medication b/c luggage can get lost

The nurse cares for a patient after a laminectomy and spinal fusion. The patient receives both continuous IV infusion and PCA medicated demand dosing of morphine. As the nurse takes VS, the patient, who appears to be sleeping comfortably, suddenly looks startled and says, " Whoops, I keep forgetting to push this" and pushed the PCA pump button. Which of the following responses by the nurse is BEST? 1. "Good. The more you can keep the morphine at an even level, the better" 2. "Tell me where you are feeling pain and show me on this pain chart the level of pain you are feeling" 3. "You seem very comfortable using the pump" 4. "The combination of the surgery and the medication can temporarily affect the memory"

2. "Tell me where you are feeling pain and show me on this pain chart the level of pain you are feeling" Assessment of pain status and apparent discrepancy between the patient's having appeared comfortable and relaxed and suddenly "remembering" pain; patient's response to nurse's question may l/t needed patient teaching

The office nurse prepares a patient diagnosed w/epilepsy for a PET scan. Which of the following directions to the patient is MOST important for the nurse to include? 1. "Be prepared to feel a warm sensation when the dye is injected" 2. "You'll want to empty your bladder before the test" 3. "Be sure to remove all your jewelry before you go in" 4. "You will be asked to think in different ways during the test"

2. "You'll want to empty your bladder before the test" Ensures that patient will be comfortable and able to lie still throughout the procedure, which may last as long as 2 hours; after radioisotope administration, patient will wait 30-45 minutes on a stretcher or table so the substance can circulate to the brain; then the scan is done

The nurse knows that which of the following clients is at highest risk for developing Dupuytren contracture? 1. A 75-year-old woman from Russia diagnosed w/osteoarthritis 2. A 54-year-old man from Norway diagnosed w/DM 3. A 34-year-old woman from Haiti diagnosed w/a fractured femur 4. An 11-year-old boy from Poland diagnosed w/Duchenne MD

2. A 54-year-old man from Norway diagnosed w/DM Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers; r/f inherited autosomal dominant trait; occurs most often in men over 50 years of age, of Scandinavian or Celtic descent, and is associated w/DM, gout, arthritis, and alcoholism

The charge nurse on the medical unit reviews physician's orders for four newly admitted patients. The nurse should question which of the following orders? 1. A CT scan for a patient w/suspected intracranial bleeding 2. A bone imaging study for a patient w/multiple myeloma 3. A chest x-ray for a patient w/a positive TB skin test 4. An upper GI tract endoscopy for a patient w/cirrhosis

2. A bone imaging study for a patient w/multiple myeloma Every contrast medium has a risk for causing reactions; benefit vs. risk should be considered; multiple myeloma involves overproduciton of plasma cells, w/resultant destruction of bone marrow products; multiple myeloma is unique as a neoplastic condition that is better detected w/a plain radiograph than w/a nuclear scan; if a bone scan is done, false-negative results occur

The nurse cares for a 4-year-old who sustained a fractured wrist from a fall. The nurse prepares the child for the application of a plaster cast. Which of the following actions by the nurse is MOST appropriate? 1. Tell the child the cast will feel cold when it is first applies 2. Allow the child to play w/a doll wearing a cast on the arm 3. Tell the child the application of the cast will not hurt 4. Ask the child if she would like to meet another child w/a cast

2. Allow the child to play w/a doll wearing a cast on the arm Preschoolers need to see and play w/the equipment; this is the age of the greatest number of fears

The nurse on the medical unit administers acetaminophen w/codeine #3 tab ii PO to a client. The HCP ordered acetaminophen 325 mg tab ii PO. Because the client is allergic to codeine, the HCP orders diphenhydramine 50 mg IM. After informing the client of the error and administering the IM medication, it is MOST important for the nurse to take which action? 1. Apologize to the client for administering the wrong medication 2. Ask the client to remain in bed for 3-4 hours 3. Explain to the client the signs/symptoms of a reaction to codeine 4. Clarify why the nurse administered the diphenhydramine

2. Ask the client to remain in bed for 3-4 hours Acetaminophen w/codeine and diphenhydramine causes drowsiness; maintain client safety

The nurse receives report on a patient admitted to the unit w/a new diagnosis of abdominal aortic aneurysm (AAA). When teaching the patient measures to reduce the risk of complications associated w/AAA, the nurse should include which of the following? 1. Elevate the lower extremities about the level of the heart 2. Encourage the patient to increase fluid intake and dietary fiber 3. Teach the patient to utilize proper lifting techniques 4. Advise the patient not to wear a seat belt while driving

2. Encourage the patient to increase fluid intake and dietary fiber Prevents constipation and the need for straining w/bowel movements that may cause increased intra-abdominal pressure and risk of rupture

The nurse in the outpatient clinic cares for the client who experienced sudden loss of central vision. The HCPs examination reveals neurovascular exudate age-related macular degeneration (ARMD). It is MOST important for the nurse to assess which area? 1. Allergies to medication and food 2. Feelings about permanent loss of vision 3. History of HTN 4. History of smoking

2. Feelings about permanent loss of vision Because loss of vision is permanent, it is important for the nurse to allow the client to verbalize fears about the future and to assist the client to maximize remaining vision

The nurse uses a trochanter roll to position an unconscious patient. Which of the following most accurately describes the correct location for a trochanter roll? 1. From the iliac crest to the 2. From the lateral aspect of the hip to the mid-thigh 3. From the mid-thigh to the ankle 4. From the medial aspect of the hip to the mid-calf

2. From the lateral aspect of the hip to the mid-thigh Hip joint lies between these points; hip tends to rotate externally when the patient is positioned on back if hip in correct alignment, patella faces upward

a 55 year old client is seen in the outpaint clinic for complaints of perineal irritation d/t frequent incontinence. Which of the following measures, if suggested to the client by the nurse, is BEST? 1. Apply betadine ointment to the perineum 2. Gently cleanse the perineum w/warm water 2-3 times/day 3. Use extra large incontinence briefs during the day 4. Expose the perineum to the air for 20 minutes each day

2. Gently cleanse the perineum w/warm water 2-3 times/day Warm water and gentle stroking stimulates circulation, promote good hygiene; barrier creams may be used

The nurse notes the HCP has ordered a diet consisting of increased amounts of fresh fruits and veggies, chicken, and whole grain breads for a 45-year-old client. Which finding does the nurse expect to see on the client's chart? 1. BP of 128/80 lying down and 134/84 standing 2. Hematocrit of 40% and a hemoglobin of 11.2 mg/dL 3. AST 30 U/mL and ALT 35 U/mL 4. Creatinine 12.2 mg/dL and BUN 25 mg/dL

2. Hematocrit of 40% and a hemoglobin of 11.2 mg/dL Normal hematocrit for a man is 42-52%, normal hemoglobin for a man is 13-18 mg/dL; both reduced w/anemia; clients diagnosed w/anemia need a diet high in protein, iron and vitamis

The public health nurse visits an older Asian American client who has been taking isoniazid for 4 months. The client complains of nausea and anorexia. What action should the nurse take FIRST? 1. Obtain a sputum specimen 2. Inspect the hard palate 3. Assess skin color on the abdomen 4. Instruct the client to stop the medication

2. Inspect the hard palate Due to biocultural skin variations, signs of early jaundice are best observed on posterior hard palate in Asians. Even sclera may contain carotene pigments that mimic jaundice in Asians

The nurse cares for the client in the ED. The nurse reviews the HCPs orders and notes that digoxin 1.25 mg PO now has been ordered for the client. Which action by the nurse is BEST? 1. Administer the medication as ordered 2. Notify the HCP 3. Ask another nurse if the dosage is appropriate 4. Ask the client if this is the daily dosage

2. Notify the HCP Ensure the five rights of drug administration; nurse needs to clarify order; if digitalizing dose, give in divided doses over 24 hours; if maintenance dose, dose is incorrect

A patient is brought to the ED by a family member, who reports that the patient had a sudden onset of decreased LOC, blurred vision, HA, and slurred speech. Before sending the patient for a stat head CT scan, which of the following actions should the nurse take FIRST? 1. Elevate the HOB 90 degrees 2. Obtain a finger-stick blood glucose level 3. Pad the side of the patient's bed 4. Obtain a urine specimen from the patient

2. Obtain a finger-stick blood glucose level Symptoms are suggestive of a possible TIA or CVA; assessment of other possible underlying causes that can be quickly and easily corrected should be ruled out; patient w/hypoglycemia may present w/similar symptoms

The nurse on the med/surg unit admits the client w/a hemoglobin level of 6.8 g/dL. Which intervention should the nurse perform FIRST? 1. Draw a type and cross for 2 units PRBC 2. Place the client on 2 L of O2 per NC 3. Start and IV w/at least a 20-gauge IV catheter 4. Place the client on a cardiac monitor

2. Place the client on 2 L of O2 per NC Critically low hemoglobin indicates less circulating O2; important that the hemoglobin available is well oxygenated

The nurse is caring for a patient w/a casted left leg. Which exercise should the nurse recommend? 1. Passive exercise of the affected limb 2. Quadriceps setting of the affected limb 3. Active ROM exercises of the unaffected limb 4. Passive exercise of the upper extremities

2. Quadriceps setting of the affected limb Isometric exercise; contraction of muscle w/out movement of joint; maintains strength while in cast

The home care nurse visits a client w/a history of type I diabetes. The client has recently suffered permanent loss of vision and is having difficulty adjusting. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Ask the physician for a psychiatric referral 2. Recommend that the client join a support group 3. Warn client that failure to adapt can increase risk for safety 4. Reassure client that change in visual abilities does not change personal identity

2. Recommend that the client join a support group Clients often respond more positively to peers w/same health alterations than to health professionals

A client receiving phenelzine sulfate is diagnosed w/Cushing symdrome and found to be hypokalemic. Which food is BEST for the nurse to recommend the client add to the diet? 1. Banana and raisin fruit salad 2. Spinach and tuna fish salad 3. Whole-wheat bread and cream cheese 4. Guacamole and brown rice

2. Spinach and tuna fish salad Both are high in potassium and neither is contraindicated w/MAOI; most vegetables are acceptable w/MAOI Bananas are contraindicated b/c of tyramine which is contraindicated w/MAOI

The nurse supervises care of a client who is receiving enteral feeding via an NG tube. The nurse determines that care is appropriate if which of the following is observed? SATA 1. The NAP aspirates and measures the amount of the gastric aspirate 2. The NAP elevates the HOB 30 degrees 3. The NAP warms the formula to room temperature 4. The NAP measures the pH of the gastric aspirate 5. The NAP infuses the intermittent feeding in 20 minutes 6. The NAP clamps the proximal end of the feeding tube at the end of the feeding

2. The NAP elevates the HOB 30 degrees 3. The NAP warms the formula to room temperature 6. The NAP clamps the proximal end of the feeding tube at the end of the feeding - Prevents aspiration - Prevents cramping - Prevents air from entering the stomach

The home care nurse monitors the progress of a client after a laryngectomy. Which observation, if made by the nurse, requires an intervention? 1. The client uses a finger to apply A&D ointment around the stoma 2. The client inserts a few drops of water into the stoma every evening 3. The client leaves the stoma uncovered when taking a bubble bath 4. The client covers the stoma w/a cotton scarf when outside

2. The client inserts a few drops of water into the stoma every evening Humidification should be provided w/humidifier or nebulizer

The nurse cares for clients in the outpatient clinic. During the nursing assessment, the nurse learns that the client takes garlic capsules daily. After completing the history, it is MOST important for the nurse to follow up on which of the following client information? 1. The client was diagnosed w/hypertension 2 years ago 2. The client takes insulin for type 1 diabetes 3. The client is CEO of a large real-estate company 4. The client's father died at age 42 of an MI

2. The client takes insulin for type 1 diabetes Can have direct hypoglycemic effect; may potentiate action of diabetic drugs; information should be reported to physician

The nurse cares for a client w/a head injury on a volume-cycled ventilator. Which of the following actions, if performed by the nurse, BEST indicates an understanding of proper management of a patient on a mechanical ventilator? 1. Water is added to the tubing to provide for humidification of inspired air 2. The sigh setting on the ventilator is adjusted to occur every hour 3. Ventilator settings are adjusted according to the patient's serum electrolytes 4. A high concentration of O2 is delivered to prevent tissue ischemia and necrosis

2. The sigh setting on the ventilator is adjusted to occur every hour Setting should be set for 1.5 times tidal volume and occur every 1-3 hours

The nurse supervises care for a client who just had a short leg cast applied. The nurse determines that care is appropriate if which is observe? SATA 1. The cast is covered w/a light sheet 2. The staff handles the cast using the palms of their hands 3. The affected limb is elevated to the level of the heart 4. The nurse compares the toes of the casted leg w/the opposite leg 5. The staff places a fan in the client's room 6. The staff turns the client every 4 hours

2. The staff handles the cast using the palms of their hands 3. The affected limb is elevated to the level of the heart 4. The nurse compares the toes of the casted leg w/the opposite leg 5. The staff places a fan in the client's room - Prevents development of pressure area - Decreased edema - Assess for neurovascular functioning; also assess circulation, motion, and sensation in the casted extremity - Increases circulation of air in room to facilitate drying of the cast

The office nurse observes a student nurse assess the blood flow in a patient diagnosed w/HTN and PAD using a Doppler ultrasound device. The nurse should intervene if which of the following is observed? 1. The student nurse holds the probe at a 45-degree angle to the artery being assessed 2. The student nurse presses firmly while moving the probe proximal to distal 3. The student nurse applies lukewarm gel over the vessel to be assessed 4. The student nurse marks the pulse locations w/a waterproof pen

2. The student nurse presses firmly while moving the probe proximal to distal Pressing snugly or excessively can compress the artery, abolishing the signal; direction of movement, if done, should be distal to proximal

The nurse manager on the oncology unit makes rounds during the day shift. Which observation by the manager requires an IMMEDIATE intervention? 1. Wearing gloves, the nurse firmly seals w/tape all four edges of the sterile gauze dressing at an IV insertion site 2. Using a marking pen, the nurse labels an IV bag w/the date and time the IV was initiated and the nurse's initials 3. The nurse secures aluminum foil around a hanging IV solution of nitroprusside 4. The nurse wears a cap, mask, gown, and gloves when initiating a peripherally inserted central catheter (PICC)

2. Using a marking pen, the nurse labels an IV bag w/the date and time the IV was initiated and the nurse's initials Marking pen should not be used, especially directly on the plastic IV bag; ink can penetrate the plastic and get into the solution; labeling should be done on the bag label, if there is one, or tape using a regular pen

The home care nurse instructs a client diagnosed w/MS. The client relates to the nurse that she has poor concentration and has difficulty pronouncing words. The nurse notes that the client's speech is slow and slurred. Which statement, if made by the client to the nurse, indicates further teaching is necessary? 1. "I will sit up straight when I talk and will feel confident" 2. "I will turn off the TV when speaking and look at the person with whom I am talking" 3. "During a conversation. I will carefully build up to my most important points" 4. "If words fail me, I will draw a picture"

3. "During a conversation. I will carefully build up to my most important points" Building up can l/t confusion and frustration c/b difficulty concentrating and fatigue; most important points should be communicated at the beginning of the sentence

The nurse assists a client diagnosed w/oral candidiasis (moniliasis, thrush) secondary to antibiotic treatment in preparing for discharge to home. Which statement, if made by the client to the nurse, indicates that teaching is successful? 1. "I will stop on the way home to get some mouthwash at the store" 2. "I will swish the nystatin around in my mouth thoroughly before I spit it out" 3. "I think I will take it easy for a while by reading some books" 4. "I will start cooking w/some strong spices that I know have healing properties"

3. "I think I will take it easy for a while by reading some books" Relaxation can help immune system repair itself, and engaging in an enjoyable activity can be a distraction form the pain of the stomatitis

The nurse instructs a client diagnosed w/COPD about how to perform pursed lip breathing. Which of the following statements by the client to the nurse indicates further teaching is necessary? 1. "I will tighten my stomach muscles as I finish breathing out" 2. "I will take twice as long to breathe out as I did to breathe in" 3. "I will breathe in deeply through my nose, hold it, and then breathe out" 4. "I will pretend I am whistling when I breathe out"

3. "I will breathe in deeply through my nose, hold it, and then breathe out" Incorrect action; breathe should never be held during pursed lip breathing

A patient is discharged from the orthopedic unit after receiving treatment for low-back pain. The nurse counsels the patient about how to prevent further back injury. Which of the following statements, if made by the patient to the nurse, indicates correct understanding of appropriate preventive measures? 1. "It is all right to reach up for things, but if I am picking something up from the floor, I will squat rather than bend and reach down" 2. "I will sleep on my side or abdomen rather than lie flat on my back" 3. "If my back starts to hurt, I will immediately stop what I am doing" 4. "I will sit as far back from the pedals on my car as my legs can comfortable stretch, and I will use a firm backrest"

3. "If my back starts to hurt, I will immediately stop what I am doing" Pain is the body's signal that there is a potential for physical harm and that the patient needs to withdraw from the pain-producing situation

The HCP prescribes phenazopyridine 200 mg PO TID for a client. Which information should the nurse include when teaching the client about this medication? 1. "Take your medication at least 6 hours before bed so it doesn't cause insomnia" 2. "Wear sunglasses when you are outdoors and try to avoid bright lights" 3. "If you skin or sclera develops a yellowish tinge, call the HCP" 4. "Avoid driving or activities that require alertness while taking this medication"

3. "If you skin or sclera develops a yellowish tinge, call the HCP" Yellowish discoloration of the skin or sclera indicates medication accumulation d/t kidney disease

The nurse prepares the client for a lumbar puncture. It is MOST important that the nurse make which statement? 1. "Don't worry b/c a general anesthetic will be used" 2. "You can't drink fluids for eight hours before the test" 3. "You'll remain flat in bed for eight hours after the test" 4. "A compression bandage will be in place for 10 hours after the test"

3. "You'll remain flat in bed for eight hours after the test" To prevent a post-lumbar puncture headache, client should remain flat in bed for eight hours after the test

The nurse in the outpatient clinic identifies that which of the following clients has the LOWEST risk for developing pneumonia? 1. A 43-year-old homeless man consumes a quart of wine daily 2. A 56-year-old woman NPO d/t perforated bowel 3. A 60-year-old woman diagnosed w/mitral valve prolapse 4. A 76-year-old man w/dysphagia following a CVA

3. A 60-year-old woman diagnosed w/mitral valve prolapse Lowest risk for developing pneumonia

The nurse should question an order for propanolol for which client? 1. A client w/type 1 diabetes 2. A client w/PUD 3. A client w/a history of bronchial asthma 4. A client w/atrial tachycardia

3. A client w/a history of bronchial asthma May cause bronchospasms; other side effects include bradycardia and depression; nursing cares include taking pulse before administering medication; dosage should be gradually reduced before discontinued

The client diagnosed w/type II DM receives treatment for HTN w/atenolol. History reveals that the client has glaucoma and is allergic to sulfa. The nurse is MOST concerned if the HCP orders which medication? 1. Glycerin 2. Pilocarpine 3. Acetazolamide 4. Timolol maleate

3. Acetazolamide Contraindicated; cross sensitivity can occur d/t allergy to antibacterial sulfonamides and sulfonamide derivatives

The nurse cares for a client receiving IV antibiotics every 8 hours for the past 4 days. The antibiotic is mixed in D5W. The nurse determines that a post-op infusion phlebitis has occurred if which of the following is observe? 1. Tenderness at the IV site 2. Increased swelling at the insertion site 3. Area around the IV site is reddened w/red streaks 4. Fluid is leaking around the IV catheter

3. Area around the IV site is reddened w/red streaks Reddened, warm area noted around insertion site or on path of vein; discontinue IV, apply warm, moist compresses, restart IV at new site

The nurse admits the client from the post-op recovery area after abdominal exploratory surgery. After the nurse determines the client's VS, which action should the nurse perform NEXT? 1. Position the client on her left side, supported w/pillows 2. Check the chart, and determine the status of the fluid balance from surgery 3. Check the client's abdominal dressing for any evidence of bleeding 4. Monitor the incision and pulmonary status for the presence of infection

3. Check the client's abdominal dressing for any evidence of bleeding Assessment; dressing should be checked on admission to the room and frequently for the next several hours

The nurse plans care for a client diagnosed w/meningitis d/t Haemophilus influenza. It is MOST important for the nurse to include which of the following in the client's plan of care? 1. Place the client in protective isolation for 24 hours 2. Monitor VS and perform neuro checks every 4 to 6 hours 3. Dim the lights and minimize environmental stimuli 4. Encourage oral fluids

3. Dim the lights and minimize environmental stimuli Prevents complications of seizures

A university sponsors a trip abroad for students majoring in international law. At 0300, a student awakens the nurse to report that the student has frequency, urgency, and dysuria. Because of safety concerns, night travel is prohibited. Which of the following actions should the nurse take FIRST? 1. Ask the student if she has experienced this problem previously 2. Obtain the student's temperature 3. Encourage the student to drink large volumes of fluid 4. Insist that the police override the curfew and allow travel

3. Encourage the student to drink large volumes of fluid Will help flush the system; encourage client to take a warm sitz bath; treatment of choice for UTI is antibiotics

The nurse evaluates the nutritional intake of the adolescent girl attending camp. The adolescent eats all of the food provided at the camp cafeteria. Each of the day's three meals contains foods from all areas of the "My food plate", and each meal averages about 900 calories and 3 mg of iron. The girl has been menstruating for about two years. Which description, if made by the nurse, BEST describes the girl's intake if her weight is appropriate for her height? 1. Her diet is low in calories and high in iron 2. Her diet is low in calories and low in iron 3. Her diet is high in calories and low in iron 4. Her diet is high in calories and high in iron

3. Her diet is high in calories and low in iron 900 x 3 = 2,700 calories/day and females 12-18 years old need 2,000 kcal/day (males 12-13 years old need 2200 kcal/day; males at 14 years old need 2400 kcal/day; males 15 years old need 2600 kcal/day; males 16-18 years old need 2800 kcal/day); 3 mg x 3 = 9 mg/day of iron and females 12-13 years old need 8 mg/day and females 14-18 years old need 15 mg/day of iron (males 12-13 years old need 8 mg/day and males 14-18 years old need 11 mg/day of iron); w/pregnancy 30 mg/day is required

The nurse cares for a client receiving aluminum hydroxide gel. The nurse determines that teaching is effective if the client makes which statement? 1. I will only take this medication before bedtime 2. I will decrease side effects by taking this medication before meals 3. I will take the medication 1 hour after meals 4. I will take the medication when I feel epigastric pain

3. I will take the medication 1 hour after meals Antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin; contains sodium, check if patient is on sodium restrictive diet

The nurse on the psychiatric unit is caring for a client who is taking fluvoxamine 100 mg PO at HS. Stat a.m. laboratory results reveal Na+ 124 mEq, K+ 4.6 mEq, Cl- 96 mEq, and serum osmolality 275 mOsm. Which action should the nurse take FIRST? 1. Place the client on one-to-one suicide precautions 2. Prepare to administer NaCl 0.45% IV 3. Initiate seizure precautions w/constant observation 4. Ask the client about side effects experienced during the night

3. Initiate seizure precautions w/constant observation Lab results suggest dilutional hyponatremia from obsessive-compulsive water intake (aka psychogenic polydipsia); at high risk for convulsions and cerebral edema; also needs monitoring to prevent further water intake

A patient receives aminophylline 0.7 mg/kg/hour by continuous IV infusion into the left arm. It is MOST important for the nurse to observe for which effect? 1. Decreased pulse and reduced BP 2. Constipation and decreased bowel sounds 3. Palpitations and nervousness 4. Difficulty voiding and oliguria

3. Palpitations and nervousness Major side effect of aminophylline; toxic effects include confusion, HA, flushing, tachycardia, and seizure; notify the HCP immediately if symptoms of drug toxicity occur

The client is admitted to the ED after a MVA. The client does not remember the accident. The client is awake and oriented to person, but does not know what city he is in. He is confused regarding the day and the month. Pupils are equal in size and equally reactive to direct light. The client reports a severe HA and becomes restless. Which action should the nurse take FIRST? 1. Continue to stimulate the client to keep oriented to surroundings 2. Restrain the client to prevent injuring themselves 3. Perform bedside neuro checks every 15 minutes 4. Administer morphine

3. Perform bedside neuro checks every 15 minutes May be developing increased ICP; confusion, restlessness, pupillary changes, and altered LOC are earliest signs of increased ICP

The nurse cares for the client diagnosed w/spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client reports a pounding headache and nasal stuffiness. Arrange the actions in the proper sequence from FIRST to LAST. ALL OPTIONS MUST BE USED. 1. Label the chart w/a visible note about the risk for autonomic dysreflexia 2. Instruct the client about how to prevent autonomic dysreflexia 3. Place the client in a sitting position 4. Check the Foley catheter tubing for kinks or obstruciton 5. Monitor the BP every 10-15 min

3. Place the client in a sitting position 4. Check the Foley catheter tubing for kinks or obstruction 5. Monitor the BP every 10-15 min 1. Label the chart w/a visible note about the risk for autonomic dysreflexia 2. Instruct the client about how to prevent autonomic dysreflexia - Lowers BP immediately - Most common cause is distended bladder and constipation - If emptying the bladder or removing the fecal mass does not decrease BP, hydralazine hydrochloride is administered IV - Ensures that staff is aware of the risk - Instruct about S/S and causes (full bladder, impaction, pressure on skin, cool draft)

The nurse responds to a call light and finds the client's IV tubing disconnected from the client's central line. The client is restless and complains of difficulty breathing. After the nurse locks the open catheter, which series of interventions should the nurse perform FIRST? 1. Place the client in a flat supine position, initiate O2 therapy, and notify HCP 2. Place the client in a high Fowler's position, initiate O2 therapy, and notify HCP 3. Place the client on the left side in Trendelenburg position, initiate O2 therapy, and notify the HCP 4. Place the client on the left side w/the lower extremities elevated, initiate O2 therapy, and notify the HCP

3. Place the client on the left side in Trendelenburg position, initiate O2 therapy, and notify the HCP This position decreases the likelihood that the air will enter the pulmonary circulation; is a priority

The nurse responds to a call light and finds the patients's IV tubing disconnected from the patient's central line. The patient is restless and complains of difficulty breathing. After the nurse locks the open catheter, which of the following series of interventions is the nurse MOST likely to perform FIRST? 1. Place the patient in a flat supine position, initiate O2 therapy and notify physician 2. Place the patient in high-Fowler's position, initiate O2 therapy and notify physician 3. Place the patient on the left side in Trendelenburg position and notify the physician 4. Place the patient on the left side w/the lower extremities elevated, initiate O2 therapy and notify the physician

3. Place the patient on the left side in Trendelenburg position and notify the physician Placing the patient in this position increases the likelihood that the air will pass into the right atrium and be dispersed by way of the pulmonary artery

The home care nurse makes an initial visit to a client diagnosed w/nephrotic syndrome c/b acute poststreptococcal glomerlonephritis (ASGN). After obtaining a client history, it is MOST important for the nurse to instruct the client about which activity? 1. Take the BP daily 2. Low fat diet 3. S/S of venous thrombosis 4. Low sodium diet

3. S/S of venous thrombosis Common complication of nephrotic syndrome

The nurse assesses a child admitted w/status asthmaticus. The child's pulse is 120 bpm, RR are 26, and temperature is 98.6 F. The child is receiving O2 50% per Venturi mask. The nurse is MOST concerned if which of the following is observed? 1. The child has expiratory wheezes 2. The child's fingertips are dusky 3. The child's O2 saturation is 85% 4. The child has intercostal retractions

3. The child's O2 saturation is 85% Translates to a PO2 < 60 on the O2 dissociation curve; child needs more O2

The client receives treatment for recurrent VTE of the right leg. The nurse is MOST concerned if which observation is noted? 1. The client is crying 2. The right leg is warm to the touch 3. The client ambulates to the bathroom 4. The right ankle is edematous

3. The client ambulates to the bathroom Physical; on bed rest until anticoagulant is started to prevent embolism; monitor peripheral pulses, administer anticoagulants, elevate legs, apply warm moist packs

The nurse provides postoperative care for a patient after an ileal conduit procedure. Which of the following observations of the patient MOST concerns the nurse? 1. There is bleeding from the stoma when the appliance is changed 2. The skin under the ostomy pouch is irritated 3. The patient has abdominal pain and a temperature of 100.4 F 4. Bowel sounds are absent in all four quadrants

3. The patient has abdominal pain and a temperature of 100.4 F Fever and abdominal rigidity and pain are two indications of peritonitis; urine may have entered the peritoneal cavity from anastomosis site leakage or from separation of the ureter from the ileal segment; there may have been spillage from the intestine during the surgery; physician should be notified at once; requires immediate medical intervention

The nurse assesses a patient 48 hours after a total joint replacement of the right hip. Which of the following should the nurse report to the physician? 1. The patient requests analgesics less frequently 2. The right leg is abducted beyond the body's midline 3. The right leg is outwardly rotated 4. The hip joint is flexed at a 70 degree angle when the patient sits in the chair

3. The right leg is outwardly rotated Indicates dislocation of prosthesis; may also see shortening of extremity, inability to move it, altered alignment, abnormal rotation, increased pain

The nurse prepares to administer medication into an established IV line by IVP. Which of the following is the MOST important action for the nurse to take? 1. Select the port farthest from the insertion site 2. Ensure that the tubing above the injection port is patent 3. Time the medication administration w/a watch 4. Explain the procedure to the patient

3. Time the medication administration w/a watch This ensures safe drug infusion; ideally, the watch should have a second hand or digital readout; many medications which are ordered as IVP or bolus need to be given slowly over several minutes

The nurse prepares a client for a barium enema. It is most important for the nurse to include which of the following instructions? 1. "Your stool will be light-colored for 2-3 days after the test" 2. "Once the test is over and you go to the toilet, you will be able to resume normal activities" 3. "The x-ray table will be tilted so you can assume various positions" 4. "During the test, it is crucial that you take slow, deep breaths through your mouth"

4. "During the test, it is crucial that you take slow, deep breaths through your mouth" For test to be successful, client must retain barium; as barium is introduced, client may have the urge to defecate; slow, deep breathing will help ease the discomfort

The nurse cares for a client requiring fluorescein angiography. The nurse determines that further teaching is required if the client states which of the following? 1. "I'll have to wear dark glasses for a while" 2. "I may notice yellowing staining of my skin, but it will disappear" 3. "I will have to drink more fluids immediately after the test" 4. "The test determines the amount of pressure w/in my eyes"

4. "The test determines the amount of pressure w/in my eyes" Tonometry measures pressure in the eye; fluorescein angiography measures circulation in the retina

The office nurse administers iron dextran IM to the client w/severe iron deficiency anemia. Which action indicates that the nurse has an incorrect understanding of the appropriate medication procedures? 1. The nurse injects the medication at the rate of 1 mL per 10 seconds 2. The nurse pulls the skin and subcutaneous tissue 1 inch to one side of the intended injection site and holds it there while injecting the medication 3. The nurse waits 10 seconds after injecting the medication before removing the needle 4. The nurse penetrates the deltoid muscle site, injects the medication slowly and smoothly, and massages the site upon needle withdrawal

4. The nurse penetrates the deltoid muscle site, injects the medication slowly and smoothly, and massages the site upon needle withdrawal The injection site should not be massaged

A middle-aged woman is brought to the ED by family. The patient reports to the nurse that yesterday morning her legs were tingling. She also stated that when she got out of bed, her lower legs felt unusually weak. Now it seems that the weakness is progressing upward. The patient states, "I'm scare. I can't imagine what is wrong with me. I have always been in good health" Which of the following statements by the patient is MOST important for the nurse to pursue during the assessment process? 1. "My grandfather had polio when he was young" 2. "I have been a vegetarian for several months now" 3. "Things have been stressful at work lately" 4. "We have been in the final preparations for a trip overseas"

4. "We have been in the final preparations for a trip overseas" Needs immediate further investigation; immunizations may have been given in preparation for this trip, depending on where the couple was to travel; trauma, surgery, acute illness, or immunizations often precede the onset of the neurologic symptoms of Guillain-Barre syndrome; symptom onset of Guillain-Barre is usually abrupt and can progress rapidly; symptoms usually, but not always, progress in an ascending direction; it is seen as an emergency condition and the patient is placed in intensive care unit; most immediate concern is potential respiratory compromise from respiratory muscle weakness; examples of immunizations that may be given to travelers are DPT, yellow fever, typhoid, plague, meningococcal pneumonia, Hepatitis A, cholera, BCG for TB immunity; what is given depends on whether the travel is to a country where the disease is endemic

The nurse instructs a client diagnosed w/chronic kidney disease about the appropriate diet. The nurse determines that teaching is successful if the client chooses which food? 1. Half cup beets 2. 1 Orange 3. 2 tbsp. peanut butter 4. 3 oz. chicken breast

4. 3 oz. chicken breast Eggs, lean meat, fish and poultry are high biological protein sources that contain sufficient amounts of all the amino acids; protein intake determined on basis of kidney impairment (GFR) Kidney disease diet should contain increased calories, high biological protein, low potassium, low sodium

The nurse cares for clients in the ED. Which client should the nurse see FIRST? 1. A 2-year-old w/a temperature of 101 F 2. A 20-year-old w/a history of asthma and a productive cough 3. A 32-year-old w/nausea and vomiting for the past several hours 4. A 60-year-old w/one episode of fainting

4. A 60-year-old w/one episode of fainting May be the result of an irregular cardiac rhythm or rate change; requires an immediate cardiac evaluation

The nurse reviews records and determines which of the following clients is at highest risk for developing pneumonia? 1. A 15-year-old client diagnosed w/cystic fibrosis 2. A 36-year-old client who has smoked for 16 years 3. A 57-year-old client diagnosed w/hypertension 4. A 78-year-old client diagnosed w/colon cancer

4. A 78-year-old client diagnosed w/colon cancer Risk factors for pneumonia include advanced age, underlying lung disease, bedridden, and post-op as well as immunosuppressed

The school nurse is observing a high-school basketball game. Two cheerleaders are tumbling and hit each other in mid-air. One of the cheerleader's begins to cry and says, "I think my arm is broken." Which of the following actions should the school nurse take FIRST? 1. Call 911 2. Immobilize the arm 3. Observe the arm for deformity 4. Cut away the teen's sweater on the affected arm

4. Cut away the teen's sweater on the affected arm Inspection is the first step of physical assessment; remove the clothing to inspect for bleeding, swelling, or deformity

A client receives pentamidine isethionate. Which observation of the client BEST indicates to the nurse that the medication is effective? 1. Increased T-cell count 2. Increased DTR 3. Decreased bleeding and bruising 4. Decreased crackles and dyspnea

4. Decreased crackles and dyspnea Pentamidine is an antiprotozoal agent used to prevent and/or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in AIDS clients' manifestations usually include coughing, fever, dyspnea, fatigue, and weight loss, and crackles are heard in the lungs

The nurse determines that a client brought in to the urgent care center may be in shock. It is MOST important for the nurse to place the client in which position? 1. Trendelenburg position 2. Elevate the HOB 45 degrees 3. On the left side 4. Elevate the lower extremities

4. Elevate the lower extremities Improves circulation to the brain and vital organs without increasing workload or impairing respiratory effort

The nurse cares for clients on the med/surg unit. A NAP reports to the nurse that a comatose client receiving O2 through a tracheostomy has "lots of water in the tubing." Which of the following actions should the nurse take FIRST? 1. Ask the NAP to clarify "lots of water" 2. Instruct the NAP to empty the fluid from the tubing 3. Contact respiratory therapy 4. Empty the fluid from the tubing

4. Empty the fluid from the tubing Client as risk for aspiration; caring for the tracheostomy is within the scope of nursing practice

A woman returns to her room following a myelogram using Pantopaque, an oil-based dye. It is MOST important for the nurse to take which of the following actions? 1. Apply ice packs to the puncture site 2. Ambulate the patient 3. Monitor for seizures 4. Encourage oral fluids

4. Encourage oral fluids Need to replace fluid lost w/removal of oil-based dye; offer oral analgesics for HA

The home care nurse visits a 52-year-old man w/an above the knee amputation (AKA). The nurse reviews w/him how to care for the residual limb. Which of the following instructions by the nurse is BEST? 1. Apply cream to the residual limb every day 2. Cover the residual limb w/a nylon sock while awake 3. Keep the residual limb elevated on a pillow at night 4. Expose the residual limb to air daily

4. Expose the residual limb to air daily Facilitates healing of residual limb; inspect daily for pressure areas, dermatitis, and blisters Do not elevate after first 24 hours--> may result in flexion contracture

The home care nurse assesses a client receiving doxorubicin hydrochloride (Adriamycin) IV. The nurse is MOST concerned if which of the following is observed? 1. Ulceration in mouth 2. Red urine 3. Alopecia 4. Fever

4. Fever Causes bone marrow depression; promptly report fever, sore throat, and signs of infection

The nurse instructs a client 5 days after a lumbar laminectomy w/spinal fusion about how to move from a supine position to standing at the left side of the bed w/a walker. Which of the following directions by the nurse is BEST? 1. Raise the HOB so you are sitting straight up, bend your knees, and swing your legs to the side and then to the floor 2. Rock your body from side to side, going further each time until you build up enough momentum to be lying on your right side, and then raise your trunk your toes 3. Reach over to the left side rail with your right hand, pull your body onto its left side, bend your upper leg so the foot is on the bed, and push down to evaluate your trunk 4. Focus on using your arms, the left elbow as a pivot w/the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress

4. Focus on using your arms, the left elbow as a pivot w/the left hand grasping the mattress edge and the right hand pushing on the mattress above the elbow, then slide your legs over the side of the mattress Maintains spinal alignment and prevents injury; relatively easy to accomplis

The nurse in the pediatric clinic counsels the mother of a school-aged-child diagnosed w/laryngitis secondary to pharyngitis. Which of the following is BEST for the nurse to suggest to the mother? 1. Instruct the child to come close and whisper when something is needed 2. Encourage the child to take frequent sips of warm or cold milk 3. Encourage the child to sing favorite songs while taking a shower 4. Give the child a paper and pencil to communicate

4. Give the child a paper and pencil to communicate Rest the voice for at least 24 hours or until inflammation subsides; most effective measure for healing laryngitis

A client is scheduled for surgery in 10 days for removal of a piloidal cyst. The nurse notes the client is diagnosed w/adrenal insufficiency and has been taking prednisone 5 mg PO BID. The nurse expects the physician to take which of the following actions? 1. Continue the medication as prescribed before surgery 2. Discontinue the medication before surgery 3. Reduce the dosage of medication before surgery 4. Increase the dosage of medication before surgery

4. Increase the dosage of medication before surgery Surgery increases the demand for corticosteriods; nurse should monitor VS and blood sugar, and check for infection and bleeding

The nurse teaches a group of women about how to perform breast self-examinations? PLACE THE FOLLOWING INSTRUCTIONS IN THE CORRECT ORDER, BEGINNING W/THE FIRST ACTION. ALL OPTIONS MUST BE USED. 1. With hands on hips inspect the breasts 2. While lying, use the pads of the middle three fingers to palpate breasts 3. With hands by side examine the breasts 4. Looking in mirror, look for any changes in the breasts and nipples

4. Looking in mirror, look for any changes in the breasts and nipples 3. With hands by side examine the breasts 1. With hands on hips inspect the breasts 2. While lying, use the pads of the middle three fingers to palpate breasts - Look for any changes in appearance, symmetry, nipple or texture and for any discharge - While standing in front of the mirror with arms at sides, inspect breast and nipples for symmetry, changes, drainage - With hands firmly on hips and bow slightly, examine breast and nipples - With pads of fingers on left hand palpate the right breast using light pressure that feels the tissue just below the skin, medium pressure that feels the deeper tissue, firm that feels the tissue closest to the chest wall and ribs; this method feels all the breast tissue; then use the eighth finger to palpate the left breast; using a vertical pattern, the preferred method, palpate the entire breast from sternum outward including the Tail of Spence under the arm

The nurse is contracted by the client diagnosed w/a chronic idopathic seizure disorder currently controlled w/anticonvulsant medication. The client is getting married in five weeks, and she concerned about having a seizure during the ceremony. Which of the following actions by the nurse is BEST? 1. Ask physician to increase the client's medication dosage for the wedding day 2. Ask a nurse to attend the wedding and assist as needed 3. Teach the bride-to-be how to perform relaxation exercises 4. Tell the bride-to-be to make a medication and seizure chart

4. Tell the bride-to-be to make a medication and seizure chart May help identify seizure triggers such as alcohol, stress, caffeine, constipation; may be increase in seizure activity during menses

An infant is treated in the newborn nursery for hyperbilirubinemia using photo therapy lights. It is MOST important for the nurse to intervene in which of the following situations? 1. The mother turns off the photo therapy lights and removes the infant's eye patches in preparation for feeding 2. The mother is worried b/c the infant experiences frequent loose, greenish stools and increased UOP 3. A laboratory technician turns off the photo therapy lights to draw blood 4. The jaundice observed around the infants eyes has begun to disappear

4. The jaundice observed around the infants eyes has begun to disappear Indicates that the eye patches are not adequately placed or are not of adequate opaqueness and are allowing light to enter; with photo therapy, eyes must be completely shielded w/patches or an opaque mask in order to prevent exposure to the light, which could r/i eye damage, especially of the retina

The nurse supervises care of a client after a laminectomy. Three staff members who have completed training prepare to turn the client. Which of the following observations by the nurse requires an immediate intervention? 1. One staff member stands alone holding the draw sheet 2. Two staff members stand side by side supporting the client's head, neck, shoulders, hips, and knees 3. The arms of the client are crossed on the chest 4. The legs of the client are straight and in contact with each other

4. The legs of the client are straight and in contact with each other Pillow should be placed longitudinally between the legs to prevent hip and lower leg adduction and spinal torque

The ICU nurse cares for a patient diagnosed w/septic shock. which of the following observations MOST concerns the nurse? 1. The peripheral pulses are strong and bounding and the RR is 26 breaths/minute 2. The WBC differential results indicate that there are predominately band neutrophils rather than segmented neutrophils 3. The skin changes from warm, dry and flushed to cool, clammy and pale 4. There is blood at a venipuncture site and around an IV catheter

4. There is blood at a venipuncture site and around an IV catheter This is an indicator of disseminated intravascular coagulation (DIC), a life-threatening problem; sepsis is the most frequent cause of DIC

The nurse reviews the record of a client diagnosed w/acute kidney disease. It is MOST important for the nurse to review which lab value? 1. Fasting blood sugar 2. Serum uric acid 3. Serum protein 4. Urine specific gravity

4. Urine specific gravity Inability of kidneys to concentrate urine occurs in acute kidney injury; normal is 1.010 to 1.030

The nurse cares for a patient diagnosed w/acute MI. The nurse determines that an appropriate nursing diagnosis is alteration in cardiac output secondary to which of the following? 1. Hypertensive crisis 2. Congestive heart failure 3. Recurrent MI 4. Ventricular dysrhythmias

4. Ventricular dysrhythmias Reduces efficiency of heart; common after MI

The nurse prepares a client for surgery. Place the following pre-op activities in the correct sequence from FIRST action to LAST. All options must be used. 1. Instruct the client to remain in bed 2. Obtain and record VS 3. Ask the client to empty the bladder 4. Verify that operative permit is signed 5. Administer pre-op medication

4. Verify that operative permit is signed 2. Obtain and record VS 3. Ask the client to empty the bladder 1. Instruct the client to remain in bed 5. Administer pre-op medication - Perform first before continuing preparation; confirm that lab results are posted - Provides baseline for anesthesiologist - Do not allow client to ambulate after receiving pre-op medication - Safety measure; raise side rails and put bed in low position - Provide all nursing car prior to administering pre-op medication

Aspirin toxicity

HA, hyperventilation, agitation, confusion, diarrhea, sweating and tinnitus

Addisonian crisis

increase fluids--> needs to have glucose in it b/c during this crisis patients blood glucose will drop provide steroids client is hyperkalemic--> do no give potassium