Practice Questions Banks 106-120 (Not Required)

The nurse has provided instructions to a client on the use of warfarin. Which statement by the client requires further teaching? "If I catch a cold, I will use guaifenesin to make my cough better" "If I develop an itchy rash, I will use a cream with diphenhydramine." "If I develop a headache, I should take ibuprofen to help my pain." "If I become constipated, I can take laxatives containing magnesium salts."

"If I develop a headache, I should take ibuprofen to help my pain." Warfarin is an anticoagulant that prolongs bleeding time and is used to treat and prevent blood clots. One of the most serious side effects of warfarin is excessive bleeding and hemorrhage. Warfarin interacts with a number of other drugs. Clients taking warfarin should not take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen at the same time due to an increased risk for bleeding. There are no known drug interactions between warfarin and laxatives containing magnesium salts, guaifenesin, or diphenhydramine cream. As a result, they may be taken together. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Coumadinwarfarinover-the-counterNSAIDs

The nurse is preparing to discharge a client who has suffered full thickness burns to the chest and upper extremities. Which home care instructions should the nurse include as part of the discharge education to the client and family? Select all that apply. "Arrange for physical therapy if you develop any problems with range of motion." "Wear protective sleeves over your arms to prevent additional injury." "Avoid the use of emollients on affected skin and over scarred areas." "Eat five to six small meals that are high-protein, low carbohydrate." "Notify the health care provider if you experience changes in sleep or mood."

"Wear protective sleeves over your arms to prevent additional injury.""Notify the health care provider if you experience changes in sleep or mood." Full thickness burns destroy multiple layers of skin, including their underlying structures (i.e blood vessels, nerves, sweat glands, etc). The overall goals of the rehabilitation phase with clients who have suffered these types of burns include injury prevention, prevention of loss of range of motion, and mental health wellness. The client should be instructed to use emollients on scarred skin to prevent it from becoming too dry, which can restrict movement. Hypermetabolism can last up to a year and requires the client to have a balanced diet that is high in both carbohydrates and protein. Wounds and scarred areas should be covered to prevent injury to the area while it heals. Physical therapy is a process that starts in the acute care setting and continues for months, and sometimes even years, after the start of therapy. Depression and anxiety are common and should be brought to the attention of the health care provider. Incorrect LESSON Management of Care or Coordinated Care Case and Resource Management COURSE RN Review BODY SYSTEM integumentary KEYWORDS burnproteincarbohydratescartherapy

The nurse is assessing a client with myasthenia gravis who has a dose of pyridostigmine ordered for 7 am. Prior to giving the medication, the nurse observes and notes diplopia, dysphagia and a weak cough. The client has ordered breakfast for 8 am. Which action is the priority? Give the client edrophonium chloride Hold the medication and notify the health care provider Assess for lower extremity weakness Administer the pryidostigmine as soon as possible

Administer the pryidostigmine as soon as possible Myasthenia gravis is a chronic, progressive autoimmune disorder, that is characterized by periods of remission and exacerbation. Auto-antibodies attack the neuromuscular junction of skeletal muscles, thus leading to weakness of skeletal muscle groups. The condition worsens with activity and improves with rest, and progresses to more severe weakness over weeks to months. Edrophonium chloride is typically administered for diagnostic purposes, not for treatment. The findings indicate that the priority is for pyridostigmine to be administered promptly to decrease symptoms of muscle weakness and facilitate the client's ability to eat breakfast. Lower extremity weakness is expected in this diagnosis and is not relevant to the situation. Holding the medication would only be an option if a cholinergic crisis is suspected. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS myasthenia gravispyridostigminediplopiadysphagiaedrophonium chloridepharmacology

The nurse is caring for a client who exhibits delusional behaviors and refuses to eat because of a belief that the food is poisoned. Which of the following responses should be the initial response by the nurse? A. "These feelings are a symptom of your illness." B. "Why do you think the food is poisoned?" C."You think that someone wants to poison you?" D."You're safe here. I won't let anyone poison you."

c;his response acknowledges perception of the client's comment through a reflective question. This reflective question presents an opportunity for discussion, clarification of meaning and expressing doubt. It also provides for verification of the nurse's perceptions and the client's communication. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review KEYWORDS responsedelusionbehaviorpoison

The nurse on a medical unit is about to start a continuous heparin infusion for a client diagnosed with a deep vein thrombosis. The prescription is to start the infusion at 900 units per hour. The supplied heparin solution contain 25,000 units of heparin sodium in 250 mL 5% dextrose in water. At how many mL per hour should the nurse set the infusion pump? Record your answer to one decimal point. mL/hour

Correct answer: 9.0 mLSet-up equation to solve for the unknown.Step 1: Known: 250 mL contain 25,000 unitsStep 2: Unknown: ? mL contain 900 unitsStep 3: Equation: 900 units x 250 mL, divided by 25,000 units = 9.0 mL Incorrect LESSON Pharmacological (and Parenteral Therapies) Dosage Calculation COURSE RN Review KEYWORDS dosage calculation

The nurse is assessing a client in the postoperative area following a thyroidectomy. Which assessment finding should the nurse report immediately to the health care provider? Irritability and insomnia Mild sore throat and hoarseness Tetany and paresthesia Headache and nausea

c;thyroidectomy is the removal of the thyroid gland. Complications of a thyroidectomy include bleeding, infection, airway obstruction, hypoparathyroidism and hypocalcemia. Manifestations of hypocalcemia include tetany and paresthesia. Tetany (involuntary muscle contractions) and paresthesia (numbness and tingling) are indicative of a dangerously low serum calcium level; therefore, the nurse should notify the health care provider immediately of those findings. Correct! LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN Review BODY SYSTEM endocrine KEYWORDS thyroidectomypostoperativetetanyparesthesia

The nurse is caring for a client diagnosed with testicular cancer. Which risk factor supports this diagnosis? Benign prostatic hyperplasia Genital herpes Older than 60 years of age Undescended testis

dTesticular cancer is a rare cancer of the male testes that is common in males between the ages of 15 to 45. Factors that increase a male's risk of testicular cancer include an undescended testicle or testi (cryptorchidism), abnormal testicle development, family history, age (typically occurs in younger males, median age 33), and race (occurs more often in whites). The other conditions are not generally associated with an increased risk for testicular cancer. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM reproductive KEYWORDS cancertesticularhistoryundescended testiscryptorchidism

The provider orders 500 mg erythromycin suspension per gastrostomy tube every six hours for a client with pneumonia. The supplied suspension contains 250 mg/5 mL. How many mL should the nurse administer for each dose? Record your answer as a whole number. mL

Correct answer: 10 mLSteps to solve for unknownStep 1 Known: 5 mL contain 250 mgStep 2 Unknown: ? mL contain 500 mgStep 3 Set-up equation: 500 mg x 5 mL, divided by 250 mg = 10 mL

A nurse is working on a hospital medical-surgical unit. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. Monitoring and documentation of client intake and output Application of barrier cream to the perineal area Assisting a client with ambulation two days post-operatively Educating a client about dietary modifications Insertion of an indwelling urinary catheter

Monitoring and documentation of client intake and output Correct Response Application of barrier cream to the perineal area Correct! Assisting a client with ambulation two days post-operatively; The nurse can delegate tasks to unlicensed assistive personnel (UAP) when it follows within the UAP's scope of practice. Application of barrier cream to the perineal area, assisting a client with ambulation, and monitoring and documentation of client intake and output are all within the UAP's scope of practice and can appropriately be delegated by the nurse. UAPs are unable to insert an indwelling urinary catheter, as this is considered an invasive procedure that should be done by the nurse. Additionally, UAP are not able to provide patient education or teaching. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS delegationunlicensed assistive personnel

The nurse is caring for a client on a behavioral health unit. The client has received several doses of haloperidol for agitation and aggression related to acute psychosis. Before administering the next dose of haloperidol, the nurse assesses the client. Which findings indicate that the client is experiencing an adverse reaction to the drug? Select all that apply. Hyperthermia Diaphoresis Redness at the site of injection Muscular rigidity Sedation

a,b,d Haloperidol is a typical or first-generation antipsychotic. Neuroleptic malignant syndrome (NMS) is one dangerous, life-threatening adverse drug effect associated with typical antipsychotics. Signs of NMS include muscular rigidity, hyperthermia, altered mental status and diaphoresis. Thus, these findings indicate that the client is experiencing an adverse reaction to the drug and the nurse should not give the medication and notify the health care provider. Redness at the site of injection is a common side effect but does not indicate a possible medical emergency. Sedation is a common side effect of typical antipsychotics and also does not indicate a possible medical emergency. LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS antipsychotichaloperidol

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is most appropriate? Allow the child to drink through a straw Observe swallowing patterns Offer ice cream every two hours Place the child in a supine position

Observe swallowing patterns Tonsillectomies and adenoidectomies are the removal of a client's tonsils and adenoids. These procedures are routinely performed when a client suffers from frequent bouts of tonsillitis or resistant forms of tonsillitis. Complications of these procedures include bleeding, infection and dehydration. In the post-operative area, clients should be positioned at a 45° angle. This position allows the client to maintain a patent airway. It also can prevent aspiration in the event that the client begins to hemorrhage. One manifestation of bleeding includes frequent swallowing. It is imperative that the nurse monitors the client's swallowing patterns. In the post-operative area, clients should drink from a glass, not a straw. Straws could disrupt the suture lines from the procedure. After a tonsillectomy, clients should gradually introduce fluids back into their diet. The literature suggests starting with clear fluids, not full liquids. Starting full liquids may cause nausea, vomiting and frequent coughing. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM lymphatic KEYWORDS tonsillectomyadenoidectomysurgerychild

A client requests not to be interrupted before 10 am because it interferes with their time to meditate. Which action should the nurse take first? Meet with the client to formulate a mutually agreeable schedule. Document the client's request in the medical record. Adjust administration times for prescribed medications. Notify the dietary department about the client's request.

The nurse should communicate with the client to help determine how their meditation practice can be incorporated into the morning schedule. This is the first step in the nursing process and will help the nurse develop an individualized plan of care that incorporates respect for the client's personal choices and preferences. Incorrect LESSON Management of Care or Coordinated Care Client Rights COURSE RN & PN Review KEYWORDS plan of careautonomyclient preference

A client has a new order for an open magnetic resonance imaging (MRI) scan to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? The client has a pacemaker. The client is claustrophobic. The client is allergic to shellfish. The client wears prescription glasses.

a Clients with permanent pacemakers cannot have an MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The client will need to be instructed to remove the glasses before the MRI, but this does not require consultation with the health care provider. Should contrast medium be used, a shellfish allergy is no longer considered a contraindication. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review BODY SYSTEM musculoskeletal KEYWORDS MRI scanmetal

The nurse on a medical surgical unit is caring for a client who has just been diagnosed with breast cancer. When entering the client's room, the client loudly says to the nurse: "Get out of my room, I don't want to see anyone right now!" What action should the nurse take? Validate the client's feelings and return later Accept the client's statement and leave without comment Tell the client that they are being inappropriate Notify the client's health care provider

a The client just received a distressing diagnosis and is most likely experiencing feelings of anger and fear. Those are appropriate and expected reactions and responses to a stressful event. The nurse should validate and acknowledge the client's feelings. This can be accomplished by a statement like, "I can see that you are upset right now." The nurse's role and responsibilities include supporting the client during this time of stress and the nurse should make sure to return after giving the client some time to process the news. This can be accomplished by telling the client, "How about I come back in 30 minutes." The other actions are either nontherapeutic or not indicated at this time. Incorrect LESSON Psychosocial Integrity Therapeutic Communication COURSE RN Review BODY SYSTEM reproductive KEYWORDS breastcancertherapeutic

The nurse is teaching a client with asthma about albuterol. How should the nurse best describe the action of this medication? "The medication will help to relax smooth muscles in the airways." "The medication is given to reduce secretions that block airways." "The medication will help to prevent pneumonia." "The medication will stimulate the respiratory center in the brain."

a;Albuterol is a bronchodilator and rescue drug of choice to treat asthma. It is a short-acting beta-adrenergic agonist that is used to prevent and treat wheezing, difficulty breathing, and chest tightness. Albuterol works by relaxing and opening the airways to make breathing easier. The medication comes as a tablet, syrup, inhaler and nebulizer. Albuterol does not reduce secretions, stimulate the respiratory center in the brain or prevent pneumonia. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM respiratory KEYWORDS asthmaalbuterol

The nurse is caring for a client with a new prescription for a selective serotonin reuptake inhibitor (SRRI) to treat depression. In reviewing the admission history and physical, which finding should the nurse clarify with the health care provider? Prescribed monoamine oxidase (MAO) inhibitor Diagnosis of peripheral vascular disease History of morbid obesity Reported frequent use of antacids

a.;elective serotonin reuptake inhibitors (SSRIs) are indicated for treatment of depression, panic attacks, bulimia, social phobias and social anxiety disorders. The medication blocks the uptake of serotonin and increases its level in the synaptic cleft. Examples of SSRIs include fluoxetine, sertraline and escitalopram. Clients should not take monamine oxidase inhibitors (MAOIs) concurrently with SSRIs because serious, life-threatening reactions (i.e., serotonin syndrome) may occur with this combination of drugs. The nurse should notify the provider about this finding. The other findings do not represent a contraindication for taking SSRIs. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS depressionSSRIMAOI

The nurse walks into a client's room and finds the client lying on the floor. What should the nurse do next? Establish if the client is unresponsive Assess if the client's airway is patent Call for help and activate the code team Determine if anyone witnessed the client fall

a; The first step in cardiopulmonary resuscitation (CPR), is to establish the client's responsiveness. The nurse would then call for help, activate the code team, and check the client's pulse. A pulse check should occur for at least five seconds, but no longer than ten seconds. If the client has no pulse, the nurse should immediately start chest compressions. Once the first thirty chest compressions have been completed, the nurse should then open the client's airway, and perform two rescue breaths. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS CPRpulseassess

The nurse is caring for a 6-year-old child with edema and hypertension associated with acute glomerulonephritis (AGN). Which of the following interventions should be the highest priority for the nurse? Establish seizure precautions Relieve boredom through physical activity Administer prescribed antibiotics Encourage protein-rich foods (1 attempt remaining)

a; Acute glomerulonephritis (AGN) is the inflammation of the nephrons and glomeruli caused by a previous streptococcal infection. In AGN, there is a leakage of red blood cells and protein from the inflamed glomeruli. Dietary restrictions should include fluids, sodium, protein and potassium due to the edema and low urine output. A child with edema and severe hypertension may be at risk for complications such as hypertensive encephalopathy. This complication occurs due to decreased kidney function and low urine output. Findings with this complication include headache, confusion and vomiting. Seizure precautions should be instituted in this client. Although antibiotics may be indicated if a bacterial infection is still present, this is not the priority action. The child should be on bed rest during the acute phase, until they start to recover. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS childhypertensionedemaglomerulonephritisseizure

The psychiatric nurse is caring for a client experiencing mania related to bipolar disorder. The client has lost 12 pounds (5.5 kg) over the last three weeks. The client frequently paces the unit and is difficult to redirect. Which intervention should the nurse implement to promote nutritional intake? Offer the client high calorie finger-foods Insert a nasogastric tube for enteral tube feedings Ask the client's family to bring food for the client Allow the client to eat meals in their room

a; Clients with bipolar disorder who are experiencing mania exhibit increases in energy, restlessness, and distractibility. These clients may demonstrate a reduction in caloric intake and subsequent weight loss due to their inability to sit and eat meals. Therefore, promoting adequate nutrition is paramount and the client should be offered high calorie, finger foods so that they can eat while on the move. The other interventions would not be appropriate for this client or helpful in promoting nutritional intake. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS bipolar disordermanianutrition

The nurse assesses several postpartum women. Which of these women is at the highest risk for a puerperal infection? Three days postpartum, temperature is 100.8° (38.2° C) for two days after undergoing cesarean section Five days postpartum, temperature is 99.6° F (37.6° C) since undergoing cesarean section Twelve hours postpartum following vaginal delivery, temperature is 100° F (37.7° C) Seven days postpartum, temperature is 99° F (37.2° C) since vaginal delivery

a;A temperature of 100.4° F (38° C) or higher on two successive days (not counting the first 24 hours after birth) indicates a postpartum infection. Puerperal infections can be due to endometritis, wound and other infections; the risk of endometritis increases after cesarean delivery. The other women are not at risk for infection because their temperatures are within the expected normal findings for the time period. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM reproductive KEYWORDS postpartumpuerperalinfection

The nurse is caring for a 7-year-old child hospitalized for acute glomerulonephritis. Which is the priority intervention to include in the client's plan of care? Monitor for increased blood pressure Encourage rest periods Monitor for increased urinary output Assess for generalized edema (1 attempt remaining)

a;Acute glomerulonephritis (AGN) is the inflammation of the glomeruli and nephrons caused by an immune response secondary to a previous infection. Clients with AGN lose protein and red blood cells in their urine. Clients with AGN will have a decrease in urine output, not an increase in urine output, due to the decrease in glomerular filtration rate (GFR). This decreased in GFR is related to the inflammation of the glomeruli. The priority is the evaluation of hypertension because clients with AGN are at risk for hypertension due to the decrease in urine output and sodium retention. Although rest periods are important for a client with AGN, focusing on the client's blood pressure is the highest priority. Clients with AGN will have edema that is mild. However, assessing for edema is not as high of a priority as hypertension. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM urinary KEYWORDS glomerulonephritisblood pressure

The nurse is caring for an 82-year-old client who complains of chronic constipation. Which of the following actions should the nurse suggest first, to improve bowel function? Increase fiber intake to 20-30 g daily Use laxatives when necessary to treat constipation Encourage the client to increase activity Avoid binding foods such as cheese and chocolate

a;Constipation is a decrease in the frequency of bowel movements accompanied by the difficult passage of hard, dry stools. Older adults are at high risk for developing constipation. The incorporation of fiber into the diet is an effective way to promote bowel elimination in the older adult client. However, clients should be instructed not to add fiber too quickly, because this can promote gas, bloating and cramping. They should gradually increase fiber in their diets and be sure to take in adequate hydration concurrently. Clients should increase their daily level of activity, as it increases peristalsis. However, increasing activity would not be the first action to suggest, as it would take longer to work than increasing daily fiber intake. The client should avoid foods such as cheese as this can lead to constipation. Using laxatives for constipation can actually increase a clients risk for developing constipation. The overuse of laxatives makes the intestines less responsive to stimuli. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS constipationdietbowelfiber

The nurse is caring for a client who is the victim of intimate partner violence. The nurse understands that during the "tension building" phase, the client is most likely to experience which feeling? Helplessness Compassion Anger Optimism

a;Intimate partner violence is all about gaining and maintaining control over the victim. In the 'tension building phase', the victim senses the rising tension in the abuser. The victim tries to appease the abuser and then feels guilty when the appeasement does not work. They also believe that no one can help them. Instead of feeling angry, victims of abuse feel helpless, depressed and anxious. Victims may become more compliant or withdrawn; they cannot allow themselves to become angry or fight back. Victims of intimate partner violence do not feel optimistic or compassionate. They often have poor self-esteem, which makes them more vulnerable to abuse. Incorrect LESSON Psychosocial Integrity Abuse, Neglect COURSE RN & PN Review KEYWORDS intimate partner violence

The nurse is caring for a client diagnosed with multiple sclerosis who plans to begin an exercise program. Which of the following information should the nurse be sure to emphasize when discussing this topic with the client? Avoid dehydration Avoid aerobic exercise Dress warmly Focus on strength training

a;Multiple sclerosis (MS) is an autoimmune disease in which the body's immune system attacks and damages the myelin sheath; the insulating material that surrounds the nerve fibers of the brain and spinal cord. When the myelin sheath becomes damaged, nerve impulses to and from the brain are interrupted. As a result, clients with MS experience muscle weakness; poor balance and coordination; muscle spasticity; and paralysis that may be temporary or permanent. Clients with MS who participate in regular aerobic exercise have better cardiovascular fitness, greater strength, better bowel and bladder function and less fatigue. The client must take in adequate fluids before and during exercise periods to prevent dehydration. It is recommended that clients with MS exercise when it is colder and perform exercise earlier in the day to avoid fatigue. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS multiple sclerosisexercisedehydrationteaching

A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about the client's obstetric history which includes 3-year-old twins and a miscarriage 10 years ago. How should the nurse accurately document this information? Gravida 3 para 1 Gravida 4 para 2 Gravida 3 para 2 Gravida 2 para 1

a;Para is the number of deliveries (of an infant more than 20 weeks gestation). Regardless of how many babies are delivered at one time (twins, triplets, etc.), the delivery is still counted as 1. Gravida is the number of pregnancies. This woman had a miscarriage (at 12 weeks), so that would be gravida 1, para 0. With the twins, the count would be gravida 2, para 1. With the current pregnancy, she is gravida 3, para 1 - 3rd pregnancy to date, but only one previous delivery (of the twins). Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS paragravidapregnanttwins

The nurse has administered fentanyl, atropine, cefazolin and benzocaine to a client for an endoscopic procedure. The nurse is monitoring the client and notes that the heart rate has increased from the pre-procedure baseline. The nurse knows that which of the following medications is most likely responsible for the client's increased heart rate? Atropine Fentanyl Benzocaine Cefazolin

a;Procedural sedation is used in endoscopic procedures as an effective way to provide an appropriate degree of pain and anxiety control; memory loss; and decreased awareness. The most commonly used medication regimen for gastrointestinal endoscopic procedure is still the combination of benzodiazepines, opioids, anticholinergics and topical anesthetics. Atropine is an anticholinergic drug that is used to dry secretions during the procedure. However, it can also increase the heart rate and dilate the pupils and is the most likely cause for the increased heart rate. Fentanyl is an opioid analgesic and short-term central nervous system (CNS) depressant and tends to slow breathing and lower heart rate and blood pressure. Benzocaine is a topical anesthetic and cefazolin is an antibiotic; neither should affect the heart rate. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review KEYWORDS atropine

The nurse is teaching the parents of a 2-week-old infant with tetralogy of Fallot. Which finding should the nurse instruct the parents to immediately report to the health care provider ? Changes in level of consciousness Fatigue with crying Poor weight gain Feeding problems

a;Tetralogy of Fallot (TOF) is a congenital heart defect that is characterized by four structural abnormalities: right ventricular hypertrophy, aortic displacement, pulmonary stenosis and a ventricular septal defect. While parents should report any of these findings, they should immediately notify the health care provider or call 911 if the level of consciousness (LOC) decreases or the infant becomes unresponsive. A decreased LOC indicates brain anoxia, which may lead to death, and is a medical emergency. The other findings (e.g., feeding problems, poor weight gain and fatigue with crying) can indicate the development of heart failure in an infant. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS Level of consciousnessmedical emergency

The nurse is admitting a school-age child to the pediatric unit. Which of the following concerns, provided by the child's parents, would the nurse recognize as a finding of type 1 diabetes? Bed-wetting Decreased appetite Dry skin Weight gain

a;Type 1 diabetes is a condition in which glucose in the blood becomes high due to a lack of insulin. In school-age children, clinical signs of type 1 diabetes include fatigue, poluria (frequent urination), polydipsia (increased thirst), polyphagia (extreme hunger), and weight loss. Diabetics usually have dryer skin. However, dry skin is not a specific finding in this child. Clients with type 1 diabetes, whose glucose is extremely elevated, will present with polyphagia and not a decreased appetite. Due to the insulin deficiency, cells are unable to use glucose for energy production. Clients with type 1 diabetes typically present with weight loss, not weight gain. Due to the insulin deficiency, cells are unable to receive glucose for energy production. As a result, cells are starving, and fats get converted to energy. Bed-wetting in a school-age child who previously did not wet the bed at night, would prompt the parents to seek medical attention. Bed-wetting could be an indication of polyuria due to excess sugar building up in the child's bloodstream, as this pulls fluid from the tissues into the blood stream. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS diabeteschildevaluationbed-wetting

The nurse is preparing to administer eye drops to a 6-year-old child. Which of the following is the correct method the nurse should use when instilling eye drops to the client? A.In the conjunctival sac as the lower lid is pulled down B. In the corner where the lids meet C. Under the upper lid as it is pulled upward D. On the anterior surface of the eyeball

a;When administering eye drops, the nurse should position the client either sitting or lying down with the head supported . They should wash their hands before instilling eye drops to prevent cross infection. Before administration, they should establish that they have the correct eye drops and that they have not expired. The nurse should agitate the bottle before use to make sure the drug is properly mixed. The nurse should instill the eye drops into the space created by gently pulling down the lower lid. The client should look up to make sure the eye drops do not land directly onto the sensitive cornea. Once the eye drops are instilled, the nurse should release the eyelid, and use a tissue or swab to dab any excess from the cheek. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS childeye dropsmethod

The nurse is caring for an 8-month-old infant who has perinatally acquired Human Immunodeficiency Virus (HIV) infection. Which clinical manifestations should the nurse monitor the infant for? Select all that apply. Kaposi sarcoma Hepatomegaly Autism Developmental delays Recurrent diarrhea Failure to thrive

abef The majority of infants with perinatally acquired HIV infection are clinically normal at birth. Common clinical manifestations of HIV infection in children vary and include such signs as lymphadenopathy, hepatosplenomegaly and unexplained diarrhea. Diarrhea may be the result of pathogens or of HIV itself, due to malabsorption of carbohydrate, protein and fat. HIV-infected children often do not grow normally. They may be proportionally smaller in both length and weight for their age.Kaposi sarcoma, one of the hallmarks of adult acquired immunodeficiency syndrome (AIDS), is found in less than 1% of affected children.Autism or developmental delays are not conditions associated with HIV or AIDS. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN & PN Review BODY SYSTEM immune KEYWORDS newbornHIVinfectplancare

The nurse instructs a client on how to collect a stool specimen at home using the guaiac test. The nurse also instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? Select all that apply. Oranges Marinated cauliflower Acetaminophen Broiled salmon Pork chops Sirloin steak

abf A guiac specimen checks to see if there is microscopic blood in the stool. There are various factors and substances that can create a false positive or negative result. Clients should limit their intake of vitamin C because too much can lead to a false negative result. Fruits and vegetables with high peroxidase activity, such as broccoli and cauliflower should be avoided several days prior to obtaining the specimen. Food like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test is performed. Chicken, pork and seafood can be consumed. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test. Acetaminophen does not affect the results of the fecal occult blood test. Incorrect LESSON Reduction of Risk Potential Laboratory Values COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS guaiacstoolspecimenhemoglobin

The nurse is caring for a client who lives in a long-term care (LTC) facility. The client is placed on contact precautions when drainage from a wound culture is positive for methicillin-resistant Staphylococcus aureus (MRSA). Which of the interventions should the nurse include in the client's plan of care? Select all that apply. Move the client to an available private room Plan to transfer the client to the hospital Monitor staff compliance with using required personal protective equipment (PPE) Educate the client on good personal and hand hygiene Collaborate with the facility infection preventionist on treatment for the wound Notify the client's family that no visitors are allowed until the infection is cured

acde Recommendations are very straightforward for the placement of clients with MRSA colonization and infection in a hospital—a private room is preferred. Recommendations for placement in an LTC facility are not as clear cut. Some guidance on the use of contact precautions in an LTC facility is given in the CDC/HICPAC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007.Make decisions regarding client placement on a case-by-case basis, balancing infection risks to other clients in the facility, the presence of risk factors that increase the likelihood of transmission and the potential adverse psychological impact on the infected or colonized client.When single-client rooms are available, assign priority for these rooms to clients with known or suspected multi-drug resistant organism (MDRO) colonization or infection. Give highest priority to those clients who have conditions that may facilitate transmission, such as uncontained secretions or excretions and lack of compliance with personal and hand hygiene due to cognitive deficits.An LTC infection preventionist should collaborate on the care plan of all clients with wounds in the facility and monitor any infections they might have.It is not necessary to transfer the client to a hospital or limiting the client's visitors at this time. On the contrary, limiting visitors would constitute interference with the client's rights and dignity. Incorrect LESSON Safety and Infection Control Standard Precautions, Transmission-Based Precautions, Surgical Asepsis COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS MRSAMDROcontact precautionsinfection control

The nurse is admitting a client to the emergency department (ED) who complains of chest pain. Which of the intervention(s) does the nurse expect to be implemented within the first 10 minutes of the client's arrival in the ED? Select all that apply. Problem-focused cardiovascular assessment Supplemental oxygen Intravenous thrombolysis 12-lead ECG Intravenous access Blood draw for cardiac troponin

adef Chest pain can be associated with a blockage in a coronary artery. All clients reporting with chest pain should be treated as if the pain is cardiac and ischemic in nature. Treatment will depend on whether the chest pain is due to a myocardial infarction (MI) and the type of MI. IV (intravenous) thrombolysis should be used if an ST-elevated myocardial infarction (STEMI) is confirmed, and the client is unable to be transported to the cardiac catheterization lab within 90 minutes. Supplemental oxygen should only be used to maintain an oxygen saturation greater than 90%. Supplemental oxygen may harm nonhypoxic clients with STEMI. Treatment in the emergency department (ED) begins with a problem-focused cardiovascular assessment due to assess history and risk factors. IV access should be established, and labs drawn for cardiac markers (i.e. troponin). A 12-lead ECG should be performed to help confirm if the chest pain is an MI. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS oxygenpainchest pain

The nurse is called to the front desk of a health clinic where an angry client is loudly demanding a refill for a previous prescription of alprazolam. "I feel nauseated, I'm stressed with work and caring for my mother who has dementia is so stressful that I can't sleep. I want a prescription, now!" What action should the nurse take? Inform the client that the physician will be with her soon and she should have a seat in the waiting room. Take the client to a quiet room and assess for acute withdrawal from benzodiazepines. Anticipate the need for flumazenil to counteract the effects of alprazolam. Provide the client with pamphlets and a referral to a self-help group for caregivers of the elderly.

b Alprazolam (Xanax) is a benzodiazepine. Benzodiazepines have abuse potential. The client is demonstrating several signs of acute withdrawal from benzodiazepines, including irritability, sleeplessness and nausea. The priority action would be to assess the client for acute withdrawal and anticipate a tapering dose. While the physician will need to evaluate the client, the nurse can take a history, perform a nursing assessment and establish a therapeutic relationship. The client will eventually need a variety of referrals to help with identified stressors, but this can wait until after treatment for withdrawal. Flumazenil is a benzodiazepine receptor antagonist and precipitates acute withdrawal. Incorrect LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN Review KEYWORDS substance abuseangerbenzodiazepinewithdrawl

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Where should the nurse give the injection? Dorso gluteal muscle Vastus lateralis muscle Deltoid muscle Gastrocnemius muscle

b An intramuscular (IM) injection is an injection that is administered directly into the muscle. The vastus lateralis muscle is the preferred site for infants due to the large muscle mass at this location. The muscle lies along the lateral aspect of the thigh and is large enough to tolerate larger volumes of medication. The muscle is also not located near any nerves or blood vessels. Although the deltoid muscle is an option for IM injections, it is not the preferred site for infants. The other muscles are no longer recommended or appropriate for an IM injection. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS intramuscularinjectionchildsite

The new nurse manager is preparing for a meeting with the staff to come up with ideas for how to reduce the number of falls on the unit. Which approach would be best for the nurse manager to use? Present a research article Have the staff engage in brainstorming Conduct an anonymous staff survey Show a presentation on fall data (1 attempt remaining)

b Brainstorming combines a relaxed, informal approach to problem solving with lateral thinking. It encourages people to come up with thoughts and ideas. The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Therefore, having the staff engage in brainstorming during the meeting would be the best approach. Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS managermeetingstaff

The nurse assesses a client who has been taking haloperidol for several months. Which of the following statements made by the client should be reported to the health care provider immediately? "My bowel movements have become harder and less frequent." "I'm having jerky movements with my arms, that I can't control." "I'm having difficulties with falling asleep at night." "I occasionally have a dry, harsh cough."

b Haloperidol is an anti-psychotic medication that blocks the effects of dopamine. It is used to treat schizophrenia, schizoaffective disorders and aggressive and agitated behaviors. Some of the most common side effects caused by this medication include nausea, vomiting, diarrhea, dry mouth, insomnia and blurred vision. Extrapyramidal side effects may also occur with the long-term administration of haloperidol. Of these effects, tardive dyskinesia is the most concerning because it is difficult to treat and may be irreversible. Tardive dyskinesia may result in tongue protrusions, muscle rigidity, and involuntary movements of the face and limbs. It typically resolves after the medication is discontinued. Severe tardive dyskinesia may affect the larynx and diaphragm, and may be life-threatening. Suspicions of tardive dyskinesia must be immediately reported to the health care provider. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS haloperidoladverse effectdystonia

The home health nurse is developing a teaching plan for a client with Class III left-sided heart failure. Which intervention is the priority? Rest in an armchair instead of lying in bed Record and monitor weights daily Limit the intake of foods high in sodium Engage in moderate exercise 2 to 3 times a week

b Heart failure (HF) is a condition that is characterized by fluid volume excess or overload. The best way for the client to monitor their fluid balance is by weighing themselves daily. An increase in their weight above a couple of pounds over 1 to 2 days can indicate worsening of their HF and the client should be instructed to notify their health care provider right away. Correct! LESSON Basic Care and Comfort Mobility, Immobility COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS heart failurefluid balancedaily weight

The nurse is assessing a client who began taking omeprazole a month ago. Which finding by the nurse, indicates that the drug has had the desired effect? Blood pressure readings are lower Heartburn discomfort is lessened Feelings of depression are not as severe Chronic pain level is markedly decreased

b Omeprazole is a proton pump inhibitor used to decrease stomach acid and relieve symptoms of gastroesophageal reflux disorder (GERD), such as heartburn. Omeprazole is also used to treat gastric ulcers and esophagitis. Omeprazole does not affect blood pressure. A lower blood pressure reading in this client would not be related to administration of medication. Omeprazole is not indicated for depression. Although omeprazole can alleviate abdominal pain in an individual who has a gastric ulcer or suffers from gastric bleeding, the option does not specify what type of pain is being discussed. Secondly, omeprazole is not typically indicated for chronic pain. The desired outcome for this client is to have a decrease in symptoms of GERD within 4 weeks. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS omeprazolegeriatricheartburnGERD

The nurse is admitting a client with pneumonia to the medical-surgical unit. When would it be most appropriate for the nurse to initiate discharge planning for this client? When the client is informed of their date of discharge Upon admission to the hospital When the client or family demonstrates readiness to learn Immediately after the client's condition is stabilized

b With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to an emergency department or hospital unit. Thus, is the thought "discharge planning begins on admission." Incorrect LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS dischargeplan

The nurse is assessing a 2-year-old toddler with a possible diagnosis of congenital heart disease. Which of the following findings will the nurse most likely see with this diagnosis? a. Weight and height in the tenth percentile since birth b. Takes frequent breaks while playing c. Changing food preferences and dislikes d. Several otitis media episodes in the last year (1 attempt remaining)

b Children with heart disease tend to have exercise intolerance. The child self-limits activity, which is consistent with manifestations of congenital heart disease in children. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS congenitalheartactivity

The psychiatric nurse is caring for a client admitted with psychogenic polydipsia. Which finding indicates that the client might be experiencing a complication of the condition? Polyuria Lethargy Muscle spasms Urinary retention (1 attempt remaining)

b. Polydipsia is excessive or abnormal thirst, accompanied by intake of excessive quantities of water or fluid. Psychogenic polydipsia (PPD), or primary polydipsia, is characterized by excessive volitional water intake and is often seen in patients with severe mental illness and/or developmental disability. There may be no physical effects, but hyponatremia can occur. Neuropsychiatric manifestations of hyponatremia include headache, nausea, cramping, hyporeflexia, dysarthric speech, lethargy, confusion, seizures, and delirium. Coma and even sudden death can ensue as sodium status worsens. It is critical that the nurse monitors the client closely for symptoms of hyponatremia. The other findings are either expected with polydipsia (polyuria) or unrelated to hyponatremia. Incorrect LESSON Physiological Adaptation Fluid and Electrolyte Imbalances COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS polydipsiahyponatremia

The nurse is caring for a female, long-distance runner who is diagnosed with anorexia nervosa. Which of the following concerns should the nurse determine to be the priority when planning the client's care? Digestive problems Amenorrhea Electrolyte imbalance Blood disorders

b; Anorexia nervosa is considered an eating disorder that is characterized by low body weight, a fear of gaining weight, and a distorted reality of weight. Clients with anorexia nervosa control their weight through caloric restriction and starvation. Anorexia nervosa affects the whole body. However, women athletes with this condition, can experience a decrease in hormones, which causes irregular periods or even amenorrhea. Low estrogen levels and poor nutrition, especially low calcium intake, can lead to premenopausal osteoporosis. Young women athletes are at high risk of stress fractures and other bone pathology. The three conditions (eating disorder, amenorrhea, and osteoporosis) are sometimes referred to as the female athlete triad. Clients who suffer from anorexia are at risk for malnutrition, digestive problems, and blood disorders. However, the question pertains to a female, long-distance runner. The nurse's priority would be to focus on the client's periods. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review KEYWORDS anorexia nervosaamenorrhea

The nurse is caring for a client who refuses to take their prescribed medications because the client prefers to take alternative, herbal preparations. Which action should the nurse take first? Explain the importance of medication to client Discuss the herbal preparations with the client Report the behavior to the client's family Contact the client's primary care provider

b; Following the nursing process, the first action the nurse should take is to further assess the situation. The nurse must look at all the factors that influence the client's refusal. Although it is important to contact the HCP, it would not be the first action to take. It is important for clients to be informed about the management of their medical conditions. However, providing more information to the client is not as important as figuring out why they're not taking their prescribed medications. Notifying the client's family would violate client confidentiality and should only be done under certain circumstances. Incorrect LESSON Psychosocial Integrity Behavioral Interventions or Behavioral Management COURSE RN Review KEYWORDS medication administrationherbal preparationCAM CONFIDENCE

The nurse is caring for an 80-year-old client in an assisted living facility, who has a temperature of 100.6°F (38.1°C). This is a sudden change from the client's usual temperature. Which of the following assessments should the nurse perform first? Lung sounds Level of alertness Urine output Appetite

b; Older adults have atypical signs and symptoms of infection. This may make it challenging to identify changes in an older client's condition. Anorexia is considered a symptom of infection. However, it is a vague finding that could be applicable to anything. It is not the most important finding. Confusion and decreased level of consciousness are commonly seen in older adults with an infection. They are often the first sign of infection, even in the absence of fever. If the client is alert and responds to questions appropriately, then the temperature should be rechecked. Assessing the client's level of consciousness will help the nurse determine the severity of the temperature elevation and the possibility that this represents an infection. The urine and lungs should be assessed for findings of infection, because urinary tract infections and pneumonia are common causes of fever in the older adult. However, the clients level of consciousness should be assessed first. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS geriatricfeveralertassess

A client has been prescribed cholestyramine (Questran) in addition to other medications for coronary artery disease and hyperlipidemia. When should the nurse instruct the client to take the cholestyramine? Anytime is acceptable At least 1 to 2 hours after other medications Early in the morning, on an empty stomach At least 1 hour before meals

b;Cholestyramine is a bile-acid sequestrant used to reduce LDL cholesterol levels. They are used primarily as adjuncts to statin therapy. Benefits derive from blocking cholesterol synthesis in the liver. The bile-acid sequestrants can form insoluble complexes with other drugs. Medications that undergo binding cannot be absorbed, and hence are not available for systemic effects. Drugs known to form complexes with the sequestrants include thiazide diuretics, digoxin, warfarin, and some antibiotics. To reduce formation of sequestrant-drug complexes, oral medications that are known to interact should be administered either 1 to 2 hour before the sequestrant or 4 hours after. Cholestyramine works best when taken with meals. Incorrect LESSON Management of Care or Coordinated Care Establishing Priorities COURSE RN Review KEYWORDS hyperlipidemiacholestyramine

The nurse is caring for a client who asks the nurse to use a treatment method that the client read about on the internet. Which of the following responses by the nurse would be most appropriate? "You shouldn't really use the internet for health care information. Most of it is incorrect." "Can you tell me more about the website where you read the information?" "Why are you questioning your doctor's order? She is an expert in the field." "I am willing to give it a try. Does it say what the success rate is for using this treatment?" (1 attempt remaining)

b;Clients are internet savvy and often search the internet for medical information about their conditions and request information from others using social media. Since there is a lot of information on the internet, clients need the expertise of nurses and other health care providers to direct clients to information that are reliable, current and evidence-based. Many health care organizations have a list of vetted mobile apps and internet sites clients can use.Asking the client an open-ended question about the origin of the information is a therapeutic communication approach and allows the nurse to determine the quality of the information and demonstrate respect for the client's autonomy.The other responses are non-therapeutic and will most likely make the client feel guilty for taking the initiative to learn more about their health. Incorrect LESSON Management of Care or Coordinated Care Information Technology COURSE RN & PN Review KEYWORDS therapeutic communicationinternethealth information

The nurse is caring for an unconscious client. In order to prevent exposure keratitis, which of the following interventions would be most appropriate for the nurse to implement? Initiate the administration of topical antibiotics to both eyes Apply lanolin alcohol (Lacri-lube) to the inside of the eyelids Apply warm compresses to both eyes daily Tape upper eyelids in both eyes closed

b;Exposure keratitis is the inflammation and dryness of the cornea; which is secondary to air exposure due to incomplete eyelid closure. Clients who are at greatest risk for this condition, are those admitted to a critical care unit. Additional risk factors for exposure keratitis include mechanical ventilation, fluid overload and the administration of sedatives and neuromuscular blockade agents. Although the literature does mention tapping eyelids closed as a method for preventing exposure keratitis, additional evidence suggests that this practice also places the client at risk for developing corneal abrasions. There is no evidence that suggests applying warm compresses to a client's eye, prevents exposure keratitis. In cases where exposure keratitis is identified, topical antibiotics may be initiated if bacterial keratitis is suspected and/or diagnosed. The most appropriate intervention that prevents the development of exposure keratitis, is the use of moisturizing eye drops or ointments to the exposed cornea. Incorrect LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS keratitiscorneaeyelids

The labor and delivery nurse is caring for a 34-weeks gestation client with gestational hypertension who is receiving a continuous intravenous infusion of magnesium sulfate. What is the purpose of the infusion? A. Increase the frequency of contractions B. Prevent preeclamptic seizures C. Maintain adequate respiratory function D. Help speed up fetal lung maturity

b;Gestational hypertension can progress to preeclampsia and eclampsia. Eclampsia is defined as the development of convulsions in a woman with pre-eclampsia. Eclampsia can be prevented by giving magnesium sulfate. Magnesium sulfate is a central nervous system depressant that is used to prevent seizures. The literature has found that magnesium sulfate reduces the occurrence of eclampsia by 50%. The other actions are not related to magnesium sulfate Correct! LESSON Pharmacological (and Parenteral Therapies) Parenteral, Intravenous Therapies - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS Gestational hypertensionEclampsiaMagnesium sulfate

The nurse on a cardiac unit is caring for a client who is receiving nitroglycerin intravenously for unstable angina. During administration of the medication, which assessment is the priority? Respiratory rate Blood pressure Cardiac enzymes Cardiac rhythm (1 attempt remaining)

b;Nitroglycerin is a drug that is used to provide relief from myocardial chest pain and treat hypertensive emergencies. Nitroglycerin causes vasodilation. Common adverse effects of nitroglycerin include hypotension, headache and dizziness; therefore, monitoring the client's blood pressure is the priority. Nitroglycerin does not affect respirations, cardiac enzyme levels or heart rhythm. Incorrect LESSON Pharmacological (and Parenteral Therapies) Expected Action, Outcomes COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS nitroglycerinanginavasodilationhypotension

After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can't do anything that pleases him. I'm not going in there again." Which response by the nurse is most appropriate? "He has a lot of problems. You need to have patience with him." "He may be scared and taking it out on you. Let's talk to figure out what to do next." "I will talk with him and try to figure out what to do or what the problem is." "Ignore him and get the rest of your work done. Someone else can care for him."

b;The first response doesn't address the client's problems and belittles the UAP's feelings. The second response omits the UAP from the issue and excludes her from the plan of care. The third response encourages the UAP to ignore the problem, and it also doesn't fix the problem and excludes the UAP from the plan of care. The UAP should be encouraged to contribute to the plan of care, to help solve the problem. The client should also be encouraged to express their feelings. The nurse and UAP need to collaborate and make sure the client's needs are being met. Incorrect LESSON Management of Care or Coordinated Care Client Care Assignments or Assignment, Delegation and Supervision COURSE RN Review KEYWORDS UAPunlicensed assistive personnelbehavior

The hospital has a mentor program for novice nurse managers. Which of these approaches is most likely to result in a positive experience for both mentor and mentee? The mentee accepts feedback objectively A teacher-coach role is used by the mentor The mentee seeks clarification as needed The mentor is randomly assigned by administration

b;The mentor should adopt the role of teacher-coach. Teaching and coaching are essential elements of the professional role and will facilitate the transition from one role to another, e.g., from staff nurse to nurse manager. The mentor will also assist the novice manager to manage unfamiliar clinical situations and achieve a level of comfort in solving clinical/management problems. Correct! LESSON Management of Care or Coordinated Care Concepts of Management or Supervision COURSE RN Review KEYWORDS mentoradministrativecoach

The emergency room nurse is triaging several clients. Which client should be seen by the health care provider first? A 2-month-old infant who has bulging fontanels and is crying loudly A young adult client who sustained a singed beard, eyebrows and hair from a camp fire An older adult client with complaints of frequent liquid stools A middle-aged client with intermittent epigastric pain after eating

b;The nurse should use the airway-breathing-circulation (ABC) prioritization approach to determine which client should be seen first. The client who suffered singed facial hair from a camp fire is at highest risk for airway problems due to the high likelihood of inhalation injury to the upper and lower airway. This injury is caused by the inhalation of hot air, steam, or smoke. The singed facial hair is a telltale sign of a potential inhalation injury. Pulmonary edema tends to appear around 12 to 48 hours after the injury and manifests as acute respiratory distress syndrome (ARDS). None of the other clients are exhibiting symptoms that pertain to the airway or breathing; therefore, the young adult client should be seen first. Correct! LESSON Management of Care or Coordinated Care Establishing Priorities COURSE RN Review KEYWORDS triageemergency

A client has returned to the unit after having a renal biopsy. Which of these nursing interventions is appropriate? A. Maintain client on NPO status for 24 hours B. Monitor vital signs more frequently C. Change the dressing every eight hours D. Ambulate the client four hours after procedure

b;The potential complication after this procedure is active bleeding from the site of the biopsy. Monitoring vital signs is critical to detect early indications of active bleeding. The other options are incorrect. There is no reason to ambulate every four hours or withhold food and fluids for a day. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS renalbiopsyvital sign

The nurse is assisting with the delivery of a newborn infant. Which intervention immediately after delivery is the priority? Assign one minute APGAR score Dry off infant with a warm blanket Obtain vital signs Apply identification bracelets

b;The priority intervention during the newborn period includes maintaining the infant's temperature by drying and warming the infant; and removing any wet blankets or towels from the infant to avoid dropping their body temperature. Maintaining the temperature of the newborn is essential to decreasing the risk of respiratory distress. Normal temperature promotes normal oxygen requirements. The cold-stressed infant may present with signs of respiratory distress and cardiac depression. Identification bands should be placed on the infant after birth, but this intervention wouldn't take higher priority than warming the newborn. The APGAR score is an important part of the initial assessment and is performed at 1 and 5 minutes after birth. This assesses the infant's overall condition at birth. The score occurs after the baby is being warmed. Vital signs are performed along with the APGAR score. LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN & PN Review BODY SYSTEM respiratory KEYWORDS newborntemperature

A 30-month-old child is admitted to the hospital unit. Which of these toys would be most appropriate for this child? Beach ball Large wooden puzzle Cartoon stickers Blunt scissors and paper

b;This child is 2 ½ years old, or 30 months. Appropriate toys for this child's age include items such as dolls and stuffed animals, toy telephone, wooden puzzles, and/or construction toys that snap together. Child's play between the age of 2 and 3 is more purposeful and they have the fine motor skills needed to complete a large wooden puzzle. Children between the ages of 4 to 5 will start to use blunt scissors with art projects; this age is appropriate for safety purposes as well. Cartoon stickers and a beach ball are toys for a younger child between the ages of 1 to 2. Incorrect LESSON Health Promotion and Maintenance Developmental Stages, Transitions COURSE RN Review KEYWORDS hospitalchildtoy

After eating lunch, an adolescent client diagnosed with anorexia nervosa states, "I shouldn't have eaten all of that sandwich. I don't know why I ate it. I wasn't even hungry." Which term best describes the psychological response the client is experiencing? Fear Guilt Anxiety Bloating

b;When people with anorexia lose control and eat more than they believe to be appropriate, they tend to experience guilt. The client's statements are best described as expressions of feeling guilt about eating the sandwich. Self-hate and guilt are often elevated in adolescents with anorexia nervosa and treatment strategies should take this into consideration when developing treatment options. The other terms do not pertain to the client's feelings of guilt about eating the sandwich. Incorrect LESSON Psychosocial Integrity Mental Health Concepts COURSE RN & PN Review KEYWORDS anorexiaguilt

The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? Select all that apply. Begin the order with the abbreviation "P.O." to indicate that it was a "phone order" Verify understanding by reading the order back to the provider before hanging up Ask a second nurse to listen on another extension while the order is being given Record the order word-for-word and sign the order Request that the order is signed by the provider before implementation (1 attempt remaining) Help|Terms & Trademarks © 2021 NCSBN. All rights reserved.

bd Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility. Incorrect LESSON Safety and Infection Control Accident, Error, Injury Prevention COURSE RN & PN Review KEYWORDS ordertelephone orderread bac

The nurse is caring for a client with portal hypertension and esophageal varices caused by liver failure. Which nursing problem is the priority? Risk for falls Risk for malnutrition Risk for bleeding Risk for impaired skin integrity

c Clients with liver failure are at risk for developing portal hypertension secondary to the fibrous changes that occur with liver failure. Esophageal varices are dilated and tortuous vessels of the esophagus that are at risk for rupture if the portal circulation pressure rises. Bleeding from the varices could lead to shock and death; therefore, risk for bleeding is the priority nursing problem. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS liver failureportal hypertensionesophageal variceshemorrhageprioritization

A health care provider asks the nurse to assist with obtaining consent for central line placement, in a client who is deaf. While the health care provider explains the procedure and risks to the client and family member, the client and family member text each other using their cell phones. What is the most appropriate nursing action? Stand next to the client and verify that the information in the texts is accurate Request the health care provider allow extra time to explain information Obtain interpreter services for the client. Remind the health care provider to ask one question at a time (1 attempt remaining)

c Communication is critical in health care settings. Under the Americans with Disabilities Act (ADA), hospitals must provide effective means of communication for patients who are deaf or hard of hearing. When obtaining informed consent from a client, it is important for the provider to speak slowly and ask one question at a time. However, interpreter services are needed for clients who are deaf. The client must understand the procedure and risks associated with the procedure in order to give informed consent. Interpreter services for clients who are deaf can be provided through video remote interpreting, closed captioning and texting. The client's family should not be relied on to interpret medical information. Family members may be unable to accurately interpret in the emotional situation that often exists during a client's hospitalization. Correct! LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review BODY SYSTEM not assigned KEYWORDS deafinterpretercommunicateconsent

The nurse is caring for a 10-month-old infant diagnosed with iron-deficiency anemia. Based on this diagnosis, which of these findings should the nurse anticipate? Heart rate of 120 bpm Increased appetite Pale mucosa of the eyelids and lips Hemoglobin level of 12 g/dL (1 attempt remaining)

c Iron-deficiency anemia commonly occurs in infants 9-24 months-old. Although infants are born with iron stores available, because they grow very rapidly, they need to absorb iron every day. Breast milk or formula provides enough daily iron for infants. However, in the event that an infant does not absorb enough iron, they may become iron-deficient anemic. Common manifestations of anemia include irritability, fatigue, brittle nails, and cyanosis. An infant with iron-deficiency anemia would suffer from a poor appetite and not an increased appetite. A hemoglobin of 12 g/dL is considered normal in an infant. The normal hemoglobin range for an infant is 11 to 13 g/dL. A heart rate of 120 bpm is considered normal in an infant. The normal heart rate range for an infant is 120 to 180 bpm. Pale mucosa of the eyelids and lips would be the anticipated finding in this client. Correct! LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS anemiainfantironpale

The perioperative nurse must place the anesthetized client into the lithotomy position for a cystoscopic procedure. What is the safest technique for moving the client into this position? Abduct legs, then flex knee of one leg before placing in stirrup; repeat with other leg Rotate hips and flex knees one at a time before placing in stirrup Ask for assistance to raise both legs simultaneously, then to flex both knees and place legs in padded stirrups Raise one leg, flex the knee, and place leg in stirrup; repeat with other leg (1 attempt remaining)

c Proper positioning of the client during a surgical procedure, is a way to help prevent intraoperative nerve injury. The client can become injured while being placed in the lithotomy position. Positioning the client for surgical procedures is the responsibility of the nurse. In some cases, a client under anesthesia may lose some of their protective reflexes and cannot feel or express sensation that might reveal a potential nerve injury. When placing the client in this position, both legs should be moved at the same time to avoid overstretching the nerves of the lumbosacral plexus. Stirrups should be padded so that the client's legs don't touch the poles of the stirrups directly. Compression along the medial and lateral aspects of the calf can damage the saphenous nerve and peroneal nerve. This may lead to weakness in the lower extremities during the postoperative period. Correct! LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review KEYWORDS lithotomypositionsafe

The nurse is admitting a client to the hospital with findings of liver failure and ascites. A health care provider (HCP) orders spironolactone. The nurse understands that the pharmacological effects of the medication, are which of the following? Increases aldosterone levels Combines safely with antihypertensives Promotes sodium and chloride excretion Depletes potassium reserves

c pironolactone is considered a diuretic, that is indicated for individuals with hypertension, edema, congestive heart failure and potassium loss. Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. Spironolactone is often combined with other diuretics and anti-hypertensive agents. Kidney function and electrolytes should be monitored more closely when spironolactone is used in combination with other medications. The medication is considered a potassium-sparing diuretic, because as aldosterone levels decrease and sodium and water is excreted, potassium is spared. A major side effect of spironolactone is hyperkalemia. Correct! LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review KEYWORDS ascitesspironolactone

The nurse is caring for a client who underwent an open cholecystectomy 72 hours ago. Which assessment finding requires the nurse's immediate action? Spots of blood found on gauze dressings Client complains of nausea Temperature of 101.8°F (38.8°C) Client complains of right shoulder pain

c A cholecystectomy is the removal of a client's gallbladder. 'Open' means that the gallbladder was removed through an abdominal incision vs. using laparoscopy. A temperature of 101.8°F three days after surgery may indicate a post-op or surgical-site infection. The temperature should be reported to the health care provider immediately. Nausea after surgery may be common secondary to anesthesia and pain medications. Spots of blood can be expected and shoulder pain from the use of CO2 gas is generally only seen with a laparoscopic cholecystectomy. Incorrect LESSON Reduction of Risk Potential Potential for Complications from Surgical Procedures, Health Alterations COURSE RN & PN Review BODY SYSTEM gastroinstestinal KEYWORDS cholecystectomylaparoscopyteach

vThe nurse is planning care for a client with pneumonia. Which of the following interventions would be the most effective by the nurse, in promoting the clearance of respiratory secretions? Maintain bed rest with bathroom privileges Administer pain medications as needed Increase fluid intake throughout the day Administration of cough suppressants (1 attempt remaining)

c Pneumonia is an infection of the lower respiratory system that affects the lungs and alevoli. The lung fields and sacs can become inflamed and filled with fluid. Pneumonia can be caused by a bacteria, virus or fungus. Manifestations of pneumonia include cough, pleuritic chest pain, fever and shortness of breath. In clients who have pleuritic chest pain, coughing will often exacerbate the client's chest discomfort. Pain medication may be indicated to help the client cough more effectively and remove sputum. Clients need to be out of bed as frequently as tolerated. Lying in bed causes pulmonary secretions to be stagnant in the lung fields. The client should be encouraged to drink adequate fluids (i.e. 2-3 L) throughout the day. Secretion removal is enhanced with adequate hydration, which thins and liquefies secretions, making them easier to cough out. The client should not be instructed to use cough suppressants. Suppressants don't allow clients to cough, and remove secretions and sputum. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS pneumoniapneumococcalsecretion

The office nurse is speaking with a client who is in recovery from alcohol use disorder. The client asks, "Will it be okay for me to just drink at special family gatherings?" Which response by the nurse is most appropriate? "At your next Alcoholic Anonymous meeting, discuss the possibility of limited drinking with your sponsor." "Since you are in recovery, you need to get in touch with your feelings. Do you want a drink?" "You must abstain from drinking alcohol for the rest of your life since you are at high risk for becoming addicted again." "At this phase you have to be very careful not to lose control. Therefore, confine your drinking only to family gatherings."

c Recovery from alcohol requires total abstinence from the desired substance. To take one drink has a high potential for the client to return to addictive behaviors. The nurse should answer questions honestly and provide factual information. Therefore, the most appropriate response is for the client not to return to drinking alcohol; even at family or social gatherings. The client should abstain from drinking any alcohol. Correct! LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN Review KEYWORDS alcohol

The nurse is caring for a client admitted to the acute care setting with a diagnosis of Guillain-Barré. While reviewing the client's chart, which of the following orders would the nurse question? Obtain vital signs prior to plasmapheresis Physical therapy and occupational therapy consults Administer pyridostigmine Schedule surgery for a tracheostomy (1 attempt remaining)

c Guillain-Barré syndrome is an autoimmune condition where the immune system attacks the peripheral nervous system and cranial nerves. More specifically, the immune system attacks the myelin sheath of the nerves. As the myelin sheath starts to break down, nerve transmission slows down. Manifestations of this syndrome include paraesthesias, paralysis, loss of reflexes, and loss of muscle tone. The syndrome is temporary and most clients typically make a full recovery. During the acute phase of the condition, the client may be totally paralyzed and may need to be placed on a mechanical ventilator. Pyridostigmine is a cholinesterase inhibitor medication that is used to treat myasthenia gravis, not Guillain-Barre. Once recovery begins, physical and occupational therapy is ordered. Plasmapheresis is a blood purification procedure used to treat autoimmune conditions; it reduces the severity and duration of the Guillain-Barre episode. The procedure can cause hypotension and arrhythmias. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM nervous KEYWORDS Guillain-Barrepyridostigmineanticholinesterase inhibitorpharmacology

The nurse is caring for a client in the emergency room with a fractured lower right leg, who receives morphine IV for the pain. One hour later, the client reports "the pain is getting worse." The nurse should recognize that the client may be developing which of the following complications? Thromboembolic complications Osteomyelitis Acute compartment syndrome Fatty embolism

c Pain is one of the most common complaints of a client who suffers a fracture. It is not uncommon for clients to receive intravenous (IV) pain medications in the initial setting after a fracture. Thromboembolic complications, such as deep vein thrombosis and pulmonary embolism, are not characterized by increased pain at the site of injury. Increasing pain that is not relieved by narcotic analgesics is a possible sign of compartment syndrome. This condition occurs when the perfusion in the leg decreases due to ongoing swelling at the site. It requires immediate action by the nurse to prevent permanent muscle damage. A fat embolism is associated with sudden changes in respiratory status, petechial hemorrhages and chest pain. This condition does not increase pain at the site of injury. Osteomyelitis is a bone infection that could occur sometime after the initial injury, typically around 48 to 72 hours later. Correct! LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM musculoskeletal KEYWORDS compartment syndromefracturepaincomplication

The home health nurse is teaching a client with reduced mobility after a stroke about how to prevent pressure injuries or ulcers. Which statement from the client indicates that additional teaching is needed? "I should monitor my skin for redness or warmth." "I should walk with my walker when I can." "I should massage areas of my skin that are red." "I should shift my body weight frequently throughout the day."

c; Pressure ulcers occur to areas of soft tissue when pressure applied over time exceeds normal capillary closure pressure, resulting in tissue necrosis. For this reason, a critical intervention is the relief of pressure. Thus, clients should understand that it is important to shift their body weight and re-position throughout the day, and to maximize mobility by ambulating, when they are physically able and with assistive devices. Additionally, clients should monitor for early signs of pressure-related tissue damage, such as skin redness or warmth. The client's statement about massaging any reddened areas is incorrect and requires additional teaching. Clients should avoid massaging areas of tissue damage, as this can lead to capillary damage and deep tissue injury. Correct! LESSON Physiological Adaptation Alternations in Body Systems COURSE RN & PN Review BODY SYSTEM integumentary KEYWORDS skin integritypressure injurypressure ulcer

The nurse is planning care for a client with a myocardial infarction. The client has a nursing problem of pain related to cardiac ischemia. Which of the following interventions would be essential for the nurse to include in the client's plan of care? Obtain a chest X-ray as soon as possible Administer a stool softener to prevent constipation Administer anti-platelet therapy as soon as possible Monitor the client's temperature every four hours

c; The pain that occurs with a myocardial infarction (MI) is related to ischemia of the heart muscle. The majority of clients who suffer a MI develop a thrombus inside a coronary artery. It is these blockages that cause ischemia, which in turn lead to the chest pain. Although the use of stool softeners is recommended in this scenario, it is not the highest priority intervention to be added to the client's plan of care. After a MI, clients may develop a low-grade fever due to an inflammatory response. Although assessing a client's temperature is appropriate in this scenario, it is not the highest priority intervention to be added to the client's plan of care. Administering an anti-platelet agent as soon as possible, would be essential in this scenario. Evidence suggests that aspirin reduces the platelet aggregation of a thrombus. Obtaining a chest radiography after a MI is not the highest priority intervention to be added to this client's plan of care. A chest radiography is not a specific test performed to evaluate the occurrence of a MI. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS myocardial infarctionpainischemia

The nurse is caring for a client with Parkinson's disease. Which finding indicates that the client might be experiencing an adverse side effect from the dopamine-enhancing drugs? Kidney failure Hypertensive urgency Hallucinations Urinary retention (1 attempt remaining)

c;Carbidopa-levodopa-entacapone is the treatment of choice for clients with Parkinson's disease. Common side effects include dyskinesia, confusion and dizziness. Serious side effects include hallucinations, paranoia and agitation. Hallucinations may be relieved by decreasing the dose of levodopa, but this may decrease the effect of the drug on the motor symptoms of Parkinson's disease. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS Parkinson'shallucinationlevodopa

The nurse is caring for a client with cardiogenic shock due to an acute myocardial infarction. The client's urine output has decreased from 60 to 70 mL per hour to 20 mL per hour. Which laboratory test is the priority to monitor? Hematocrit Troponin Serum creatinine Serum sodium

c;Cardiogenic shock occurs when either systolic or diastolic dysfunction of the heart's pumping action results in reduced cardiac output, stroke volume and blood pressure, leading to insufficient perfusion of vital organs such as the kidneys. The drop in urine output is indicative of impaired renal tissue perfusion secondary to the low cardiac output. The serum creatinine level is an important clinical indicator of kidney function and, therefore, is the priority to monitor. Correct! LESSON Reduction of Risk Potential Potential for Alterations in Body Systems COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS cardiac outputshockkidneyscreatinine level

The nurse is caring for a client who is experiencing urinary incontinence. Which of the following teaching points should the nurse reinforce when discussing this health issue with the client? Restrict fluids Hold voiding or urination Avoid taking antihistamines Avoid eating foods high in sodium

c;Urinary incontinence is described as the leakage of urine or involuntary urine loss. Incontinence can be separated into multiple categories, including stress, urge, overflow or functional. Avoiding sodium has not been shown to reduce or minimize urinary incontinence. Due to their anticholinergic action on the urinary sphincter and bladder, antihistamines can cause urinary retention, followed by sudden overflow incontinence. Still other antihistamines relax the bladder, which also contributes to incontinence. Clients with incontinence should control fluid intake and not drink large amounts of fluids at one time, but they should not restrict fluids. If the bladder becomes over-stretched, the muscle may be permanently damaged and lose its ability to contract. Correct! LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM urinary KEYWORDS urinaryincontinenceantihistamine

A client is prescribed eye drops for treatment of glaucoma. What assessment is required before the nurse can begin teaching proper administration of the medication? Assess the client's use of visual assistive devices Identify the client's proximity to health care services Evaluate the client's manual dexterity Determine the client's third-party payment plan (1 attempt remaining)

c;Eye drops are prescribed to treat acute and chronic eye conditions, such as glaucoma. Eye drops are the mainstay of treatment, as they are administered directly at the site of action. Clients must become self-sufficient with eye drop administration. Often, ophthalmic administration of medications is more effective than oral administration of the same medication. Client education on proper instillation of eye medications is important. After a review of the procedure, a return demonstration by the client should be performed. The client's insurance has no relation to their ability to self-administer eye drops. Making sure that the client has ample support services is important, but it is not the most important aspect prior to learning how to self-administer eye drops. Clients must have adequate manual dexterity when self-administering eye drops. The drops need to be administered in an exact location and with aseptic technique. Although clients who suffer from visual disturbances need to use visual assistive devices, assessing their use of a device is not a higher priority than evaluating their manual dexterity. LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS glaucomamedicationdropseye

The nurse is measuring blood pressures at a community health fair. When the nurse tells a client that his blood pressure is 160/96 mm Hg, he states, "My blood pressure is usually much lower." Which of the following options would be the best response by the nurse? "See your health care provider immediately." "Check your blood pressure again in a few months." "Get your blood pressure checked again within the next 1-2 weeks." "Make an appointment to see your health care provider next year."

c;High blood pressure is defined as blood pressure 130/80 mm Hg or higher. Hypertension is determined by systemic vascular resistance and cardiac output. The client's blood pressure reading is moderately high and should be rechecked. Since the client states his blood pressure is "usually much lower" the elevated blood pressure could be a concern, but it is not clear what the client considers to be a "much lower" blood pressure. Hypertension is typically diagnosed after screening. After an elevated blood pressure reading is noted on screening, the average of two or more measurements on at least two separate visits in the next couple weeks is needed to diagnose hypertension. Although the client's blood pressure is higher than normal, it is not considered a medical emergency. It is not necessary to seek medical attention immediately. The client needs to have their blood pressure reevaluated in the next couple weeks. Waiting a year, is too long. Correct! LESSON Health Promotion and Maintenance Health Promotion, Disease Prevention COURSE RN & PN Review BODY SYSTEM cardiovascular KEYWORDS blood pressurescreening

The nurse in an urgent care clinic is preparing discharge instructions for the parents of a 15-month-old child with a first episode of otitis media. Which information is the priority to include? Describe the tympanocentesis most likely needed to clear the infection Offer information on recommended immunizations around the child's second birthday Explain that the child should complete the full 10 days of antibiotics Provide a written handout describing the care of myringotomy tubes

c;Otitis media, an inner ear infection, commonly occurs in young children. Although not always caused by bacteria, many ear infections are treated with oral antibiotics. If a client is prescribed antibiotics, the priority is to make sure that they take the full prescription for the prescribed number of days to prevent recurrence or antibiotic resistance. Correct! LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review BODY SYSTEM nervous KEYWORDS otitisantibioticteach

The nurse is assessing a 5-day-old infant brought to the pediatrician's office by the infant's parents. During the assessment, the nurse identifies clear breath sounds with equal chest expansion, a respiratory rate of 38 to 42 breaths per minute with occasional periods of apnea lasting 10 seconds in length. What is the correct analysis of these findings? A.The infant will need a referral to a respiratory specialist B. The infant will require emergency lifesaving services C.The infant's breathing pattern is normal D. The infant should be seen immediately by the pediatrician

c;Respiratory rates in newborns (first four weeks of life) are 30 to 60 breaths per minute. Newborn infants breathe faster than children and adults. Periods of apnea often occur, lasting up to 15 seconds. The nurse should reassure the infant's parents that this is an expected finding and is known as "periodic breathing" and occurs as the newborn's lungs and brains become more coordinated. Although the pediatrician should examine the infant, it is not imperative that the infant be seen immediately. The infant is not in any respiratory distress. The nurse's assessment findings for the infant are normal. At this point, there is nothing in the nurse's assessment that would indicate that the infant will need a referral to a respiratory specialist or require emergency lifesaving intervention. Incorrect LESSON Health Promotion and Maintenance Health Screening - RN COURSE RN Review BODY SYSTEM respiratory KEYWORDS infantbreathingassessapnea

The nurse on an inpatient hospital unit is preparing to administer insulin aspart per sliding scale to a client whose most recent blood glucose level is 180 mg/dL. Which is the best time in relation to eating to give the insulin? Administer the insulin at any time before or after the meal Administer the insulin 2 hours after the client has finished eating the meal Administer the insulin right before the client is about to start eating Administer the insulin immediately after checking the blood glucose level

c;Sliding scale insulin coverage typically consists of a short or rapid acting insulin and is generally prescribed to be given "AC" (ante cibum) or before meals. The client should begin eating within minutes of receiving the insulin due to the rapid onset of insulin aspart (ranging from 10 to 20 minutes) to prevent hypoglycemia. Therefore, the nurse should first determine that the client's meal has arrived and the client is about to start eating. If the client receives the insulin but the meal is delayed for some reason, the client may become hypoglycemic. Insulin aspart peaks at around 1 to 3 hours after administration. The other times are not appropriate to administer the insulin. Correct! LESSON Reduction of Risk Potential System Specific Assessments - RN COURSE RN Review BODY SYSTEM endocrine KEYWORDS rapid-actinginsulinbreakfastonset

The nurse is assessing a 7-year-old child with acute glomerulonephritis (AGN). The nurse identifies moderate edema and oliguria and laboratory testing reveal an elevated serum blood urea nitrogen (BUN) and serum creatinine. Based on the nurse's findings, which of the following dietary modifications should the nurse make? Increase potassium and protein Decrease sodium and potassium Increase sodium and fluids Decrease carbohydrates and fat (1 attempt remaining)

d Acute glomerulonephritis (AGN) is the inflammation of the glomeruli and nephrons caused by an immune reaction secondary to a previous infection. Clients with AGN lose protein and red blood cells through their urine. Individuals with AGN will have a decrease in urine output due to a decrease in glomerular filtration rate (GFR). As a result, clients with this condition are at risk for hyperkalemia because potassium is unable to be cleared by the kidneys. Clients with AGN are at risk for hypertension due to the decrease in urine output and sodium retention. These clients will also have moderate edema that is secondary to the sodium retention and decrease in urine output. As a result, this client should be on a diet that limits sodium, potassium, fluids and protein. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM urinary KEYWORDS AGNglomerulonephritisedemaoliguria

The nurse knows that a client's information should be kept confidential. In which of these situations shall the nurse make an exception to this practice? When a visitor insists that they have been given permission by the client When the client's family member offers information about the client When the healthcare provider (HCP) decides the family has a right to know When the client threatens to harm themself or another individual

d Client information is kept private unless the client states verbally or in writing that their information can be shared with another individual. In addition, if the client becomes incapacitated and they have a next of kin or health care proxy, their information can be shared with one of these individuals. The only exception to this rule is if the client threatens to harm themself or another individual. The Tarasoff ruling or duty to warn, instructs health care workers that if a client threatens to harm themself or another individual, they must warn the intended victim and contact the police. Incorrect LESSON Management of Care or Coordinated Care Client Rights COURSE RN Review KEYWORDS privacyconfidentialityself-harm

The nurse is reviewing medication instructions with a client who is taking digoxin. The nurse should reinforce to the client to report which of the following side effects? A. Hunger, dizziness, diaphoresis B. Polyuria, thirst, dry skin C.Rash, dyspnea, edema D. Nausea, vomiting, fatigue

d Nausea, vomiting, fatigue Correct Response Digoxin is considered an antidysrhythmic and inotrope, that is used to treat atrial dysrhythmias and congestive heart failure. The medication produces a positive inotropic effect, prolongs the refractory period and slows conduction through the sinoatrial (SA) and atrioventricular (AV) nodes. Overall, digoxin increases cardiac output and slows the heart rate. The effects of digoxin produce many side effects and clients who take digoxin are at risk for digoxin toxicity. Because digoxin improves cardiac output, side effects of the medication would not include dyspnea or edema. Rashes are also not considered a side effect of digoxin. Common manifestations of digoxin toxicity include nausea, vomiting and fatigue. Hunger, dizziness and diaphoresis, together, are not considered side effects of digoxin. Although dizziness could occur with another side effect of digoxin, such as bradycardia. Polyuria, thirst and dry skin are not considered side effects of digoxin. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS digitaliseffectnauseafatigue

The inpatient hospital nurse is caring for a client with hypokalemia. The health care provider prescribed a potassium intravenous (IV) infusion of 40 mEq potassium chloride in 250 mL normal saline to be infused over 4 hours. The nurse receives the infusion from the pharmacy. Which action should the nurse take next? A. Ask another nurse to witness the addition of the prescribed potassium to the IV solution B. Confirm patency of the peripheral venous access device and start the infusion C. Notify the health care provider of the inappropriate dose of the prescribed IV potassium D. Ask another nurse to verify the prescription, IV solution and serum potassium level

d Since potassium chloride is considered a high alert medication, especially when given IV, having two nurses verify the order and IV bag is recommended. The nurses should compare the supplied IV bag to the prescriber's order. If potassium IV is infused too rapidly or in too high a dose, it can cause dysrhythmias and cardiac arrest. In addition, the second nurse should also verify the client's most recent serum potassium level to ensure that the prescription is appropriate. The prescribed dose and amount of IV solution is within normal range for IV potassium replacement therapy. Potassium should never be added by a nurse to an IV bag. Incorrect LESSON Pharmacological (and Parenteral Therapies) Parenteral, Intravenous Therapies - RN COURSE RN Review KEYWORDS potassium infusion

The L&D nurse is caring for a pregnant client at 40-weeks gestation who was admitted with new onset contractions at 8 am. At 10 am, the client is ready to give birth. Based on this abnormal labor pattern, which potential complication should the nurse monitor the client for? Cesarean delivery Placenta previa Eclampsia Fetal hypoxia

d This labor pattern is considered "precipitous," which is defined as active labor lasting less than three hours. Because the contractions are coming rapidly, with little time in between contractions, there is a risk of fetal hypoxia. The other complications are not associated with precipitous labor. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM reproductive KEYWORDS labor and deliveryprecipitous labor

The nurse is caring for a client who voluntarily admitted herself to the substance abuse unit. The next day the client says to the nurse, "My partner told me to get treatment or we would have to get divorced. I don't believe I really need treatment, but I don't want my partner to leave me." Which of the following responses by the nurse would be most appropriate? "In early recovery it's quite common to have mixed feelings. I didn't know you had been pressured to come." "In early recovery it's quite common to have mixed feelings. Perhaps it would be best to seek treatment on an outpatient basis." "In early recovery it's quite common to have mixed feelings. Unmotivated people can't get well." "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."

d "In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." Correct Response Only the correct option focuses on the client and the client's problem. This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. The other options are not therapeutic and do not have the client's best interests at heart. The option about being pressured to come might encourage clients to project blame for their behavior on someone else. The option of outpatient care might be a goal for this client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment. Incorrect LESSON Psychosocial Integrity Chemical and Other Dependencies, Substance Use Disorder COURSE RN & PN Review BODY SYSTEM nervous KEYWORDS substanceabusetreatment

The nurse is preparing a client for a scheduled myelogram. For which statement by the client should the nurse notify the radiologist immediately? "I think I may be allergic to shellfish." "I had a severe headache after a spinal tap last year." "I suffer from claustrophobia and hate loud noises." "I took my regular dose of warfarin last night." (1 attempt remaining)

d A myelogram is a spinal X-ray used to determine the cause of pain, numbness, or weakness in the back, arms or legs. During the exam, contrast material is injected into the spinal canal to provide an outline of the spinal cord. Relative contraindications to myelography include a history of an adverse reaction to the iodine-based contrast media. A history of an allergy to shellfish is no longer considered a contraindication. Clients who are on anticoagulant therapy such as warfarin, are supposed to discontinue these medications prior to undergoing myelography for about 48 hours before and 24 hours after the myelogram. Therefore, since the client took warfarin last night, there is a high risk for bleeding into the spinal column and the radiologist should be notified immediately. Claustrophobia and an aversion to loud noises would be an issue for someone undergoing an magnetic resonance imaging (MRI), not a myelogram. Incorrect LESSON Reduction of Risk Potential Potential for Complications of Diagnostic Tests, Treatments, Procedures COURSE RN Review BODY SYSTEM nervous KEYWORDS myelogramcontraindicationallergywarfarin

The nurse is auditing documentation in clients' medical records. Which entry in a client's progress notes is the most complete? Client's urinary output adequate for the past shift Client expresses anxiety about a low-salt diet Demerol 75 mg administered for severe abdominal pain Dark green drainage 100 mL from nasogastric tube at 0600 (1 attempt remaining)

d Documentation reflects the client's condition and the care they've received during their hospitalization. Documentation needs to be complete, accurate and objective. Reimbursement from third-party payers is facilitated when documentation is accurate, reliable and valid. Nurses need to adhere to good documentation standards, as it minimizes a nurse's chance of being named in a malpractice lawsuit. The word "anxiety" in the answer choice could be defined more specifically, along with the inclusion of information about the nurse's response. The medication order lacks the route, frequency and the client's response to the medication. The description of the nasogastric drainage is the most specific and factual. The criteria for "adequate" urinary output needs to be defined. Incorrect LESSON Management of Care or Coordinated Care Legal Rights and Responsibilites COURSE RN Review KEYWORDS progress notesrecord

The nurse in an obstetrics clinic is reviewing the medical record of a currently pregnant client with a GTPAL history of 3-2-0-1-2. How should the nurse interpret the GTPAL score? The client has been pregnant a total of four times. The client has not had any miscarriages. The client has three living children. The client has had two term birth

d; The GTPAL system calculates the obstetric history of a woman in terms of the number of times she has been pregnant (Gravidity), the number of Term births she has had, the number of Premature births she has had, the number of Abortions or miscarriages she has had, and the number of Living children she currently has. A GTPAL score of 3-2-0-1-2 indicates 3 pregnancies (including the current one), 2 term births, 0 preterm births, 1 miscarriage/abortion and 2 living children. Incorrect LESSON Health Promotion and Maintenance Ante, Intra, Postpartum and Newborn Care COURSE RN Review BODY SYSTEM reproductive KEYWORDS obstetricsprenatal assessmentgravidityGTPAL score

The nursery nurse is caring for a newborn male infant with hypospadias. The infant's parents request for the infant to be circumcised before leaving the hospital. How should the nurse respond? "Circumcision is contraindicated because of the permanent defect." "Circumcision should be performed as soon as the newborn is stable." "Circumcision is not medically indicated for any child." "Circumcision is delayed so the foreskin can be used to correct the defect."

d; Hypospadias is an abnormality of the penis in which the urethral opening is located on the ventral aspect of the penis , roximal to the tip of the glans penis. Hypospadias is a congenital defect that is thought to occur between 8 and 20 weeks' gestation. Hypospadias is generally repaired for functional and cosmetic reasons, typically between 6 and 18 months of age. Boys who are born with hypospadias should not be circumcised immediately after birth. The extra tissue of the foreskin may be needed to repair the hypospadias during surgery. The client can have a circumcision performed at a later age. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM urinary KEYWORDS hypospadiascircumcision

The nurse is counseling a 6-year-old child who was recently diagnosed with nocturnal enuresis. Which of the following must the nurse understand about the pathophysiology of this disorder, prior to counseling the child? Enuresis is a sign of willful misbehavior Enuresis may be associated with sleep phobia Enuresis has a definite genetic link Enuresis often has no clear etiology

d; Nocturnal enuresis (NE) occurs in a child over the age of five who does not have any other physical or mental conditions contributing to the problem. A urinalysis (UA) is indicated to rule out other reasons (i.e. medical and mental disorders) for the nighttime bed-wetting. An individualized treatment plan is indicated for the client. Although there are many predisposing factors associated with NE, no clear etiology has been determined for the condition. NE is not the fault of the child, nor is it caused by willful misbehavior. Often children are asleep when the bed-wetting occurs. It is not done on purpose. There is no evidence that supports that NE is associated with a sleep phobia. Although NE is commonly associated with a family history of the condition, no genetic link has been definitely confirmed. Incorrect LESSON Physiological Adaptation (Basic) Pathophysiology COURSE RN Review BODY SYSTEM urinary KEYWORDS enuresiscounselchildbedwetting

The psychiatric nurse is caring for a client who was voluntarily admitted to the hospital 2 days ago for suicidal ideation. Today, the client states, "I demand to be released now!" Which response by the nurse is most appropriate? "You have a right to sign out as soon as we get the health care provider's discharge order." "You can be released only if you sign a no suicide contract before you leave." "You cannot be released because you are still at risk of being suicidal." "Let's discuss your decision to leave and then we can prepare you for discharge."

d;"Let's discuss your decision to leave and then we can prepare you for discharge." Correct Response Clients who are voluntarily admitted to the hospital have the right to demand and obtain release. Ideally clients should be given discharge instructions before they leave the hospital. However, clients have the right to sign themselves out of the hospital at any time, including against medical advice (AMA). The most appropriate response would be to engage the client in therapeutic communication and find out their current state of mind and risk for suicide. If the nurse felt that the client still represented a risk for suicide, a petition for an involuntary admission/hospitalization should be initiated. The other responses are not therapeutic or appropriate. Incorrect LESSON Management of Care or Coordinated Care Client Rights COURSE RN Review KEYWORDS admitsuicidalmental healthdischarge

The nurse is admitting a client with a diagnosis of acute bacterial endocarditis. Which of the following findings would alert the nurse to a complication of this condition? Hemorrhage Heart murmur Macular rash Pain and pallor in one foot

d;Endocarditis is an inflammation of the endocardium layer of the heart secondary to an infection. Acute endocarditis occurs very quickly and the symptoms are severe. Vegetations grow on the heart valves in bacterial endocarditis. These vegetations may break off and travel through the blood stream, lodge in small vessels and result in necrosis of the tissue distal to the embolus. Although clients with endocarditis can manifest with lesions and petechiae, the presence of a rash is not commonly found with this condition. Pain and pallor are findings in an embolic arterial occlusion of an extremity. Other findings would include pulselessness, parasthesia, paralysis and poikilothermia (coldness), known as the 6 Ps of ischemia. Hemorrhage or bleeding is not a typical manifestation of a complication of endocarditis. Heart murmurs are a common finding in endocarditis, and clients with murmurs caused by valve damage are at highest risk of developing endocarditis. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS endocarditiscomplicationembolus

The nurse is providing discharge instructions to a client with a prescription for chlorpromazine. Which finding should the nurse teach the client to report immediately? Insomnia Breast enlargement Alopecia Fever

d;Fever Correct Response Chlorpromazine is used to treat schizophrenia and psychosis. The medication exhibits anticholinergic activity and alters the effects of dopamine in the central nervous system (CNS). A fever may indicate an infection due to agranulocytosis, a serious side effect of chlorpromazine. If white blood cell counts are low, the treatment should be stopped and antibiotic therapy started. Other common side effects of chlorpromazine include dry mouth and nasal congestion, extrapyramidal reactions, motor restlessness and hypotension. The other findings are not typically associated with this medication. Incorrect LESSON Pharmacological (and Parenteral Therapies) Adverse Effects, Contraindications, Side Effects, Interactions COURSE RN Review BODY SYSTEM nervous KEYWORDS chlorpromazinesore throatfever

The nurse is developing a plan of care for a postoperative client following the surgical creation of an ileostomy. Which intervention should the nurse implement first? Providing emotional support Addressing concerns with body image Teaching the management of the pouch Assessing the appearance of the stoma

d;Following the nursing process, assessing the appearance of the stoma is the intervention that should be implemented first. The nurse needs to monitor for stoma health and possible complications. Examples of complications include bleeding, infection or lack of blood flow to the stoma. As the stoma starts to function, the nurse would explain the care of the stoma to the client. Providing emotional support, teaching how to care for the ostomy and addressing body image concerns are important, but should be implemented after assessing the ostomy. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM gastroinstestinal KEYWORDS ileostomynursing processassessment

The nurse is caring for a client with suspected infective endocarditis. Which laboratory test is the priority? Sedimentation rate C-reactive protein Complete blood count Blood culture

d;Infective endocarditis (IE) is an infection of the endocardium caused by bacteria, fungi or viruses. The most common cause of IE is Staphylococcus aureus in the blood. The key to making a diagnosis of IE is two blood cultures collected at two different sites with two separate venipunctures. A variety of other baseline blood tests are also ordered, however, these blood tests are not specific or they might not be specific enough to diagnose IE specifically and identify the causative organism. Therefore, blood cultures are the priority lab tests to obtain. Incorrect LESSON Reduction of Risk Potential Diagnostic Tests COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS endocarditisblood culture

The nurse is caring for a client who is diagnosed with emphysema. Which of the following information should the nurse emphasize to the client, when teaching the client about their nutritional needs? Eat foods high in sodium to thin secretions Exercise after respiratory therapy to enhance appetite Increase intake of dairy products to soothe the throat Use oxygen during meals to improve gas exchange

d;Malnutrition and muscle wasting is a frequent complication in clients with emphysema, and affects the disease prognosis. Weight loss in clients with emphysema is a result of increased energy requirements unbalanced with dietary intake. Breathing requires more effort in a client with emphysema. Clients should exercise after eating to conserve energy for food consumption. Resting before meals is recommended. Clients diagnosed with emphysema breathe easier when using oxygen while eating. Improved gas exchange facilitates the digestion of food, as more oxygen is available to all areas of the body, including the gastrointestinal tract. Dairy and other mucous-producing foods should be avoided as they thicken secretions and makes them more difficult to control and expectorate. Reducing salt intake is recommended, as it leads to water retention, which makes it more difficult for clients to breathe. However, increased water intake thins secretions, making them easier to expectorate. Incorrect LESSON Basic Care and Comfort Nutrition, Oral Hydration COURSE RN Review BODY SYSTEM respiratory KEYWORDS emphysemanutritionoxygen

The nurse is admitting a 3-year-old child with manifestations of sudden onset of irritability, croaking on inspiration and skin temperature that's hot to the touch. The child is currently leaning forward with suprasternal retractions, a protruded tongue, and excessive drooling. What should the nurse do first? Examine the child's throat for redness Collect a sputum specimen for culture Prepare the child for X-ray of upper airways Notify the health care provider of the child's status

d;Notify the health care provider of the child's status Correct Response The child's manifestations suggest epiglottitis, which is the inflammation of the epiglottis. Although rare, the condition is more commonly found in children and is usually caused by Haemophilus influenza B. Epiglottitis can lead to an airway obstruction, thus is considered a medical emergency. Manifestations of epiglottitis include dysphagia, difficulty talking, apprehension, retractions, stridor on inspiration and an elevated temperature. The nurse would first want to notify the health care provider. The child's condition is worsening as indicated by them leaning forward and having suprasternal retractions. Although a sputum specimen may be warranted in this situation, it is not the first action that should be implemented. In a client with epiglottitis, one should never insert anything into the client's mouth or throat, as this could lead to a spasm of the airway. Radiographic films would not be indicated in the diagnosis of epiglottitis. Incorrect LESSON Physiological Adaptation Medical Emergencies COURSE RN Review BODY SYSTEM respiratory KEYWORDS childepiglottitisrespiratory distress

The nurse is caring for a client at the community clinic who requires treatment for recurrent pelvic inflammatory disease (PID). The nurse knows that this condition most frequently follows which type of infection? Trichomoniasis Herpes simplex 2 Syphillis Chlamydia

d;Pelvic Inflammatory Disease (PID) is an infection of the female upper reproductive tract. Treatment is broad-spectrum antibiotics. Chlamydia and gonorrhea infections are the most frequent cause of PID. These sexually transmitted infections often have subtle findings; therefore they are often not diagnosed early in their course, before more widespread infection and complications occur. This also prevents appropriate detection and treatment before transmission to others during sexual activity. A complication of recurrent infection is the obstruction and scarring of the fallopian tubes, resulting in infertility. Incorrect LESSON Physiological Adaptation Illness Management - RN COURSE RN Review BODY SYSTEM reproductive KEYWORDS clinicPIDpelvic inflammatory diseaseinfectionteaching

The nurse is caring for a client after an acute myocardial infarction, who is receiving supplemental oxygen. What is the purpose of the oxygen therapy? Decrease client's anxiety Prevent pneumonia Reduce cardiac afterload Increase myocardial tissue perfusion

d;The tissue around the myocardium is injured due to a lack of blood flow to the myocardium; thus, the overall purpose of oxygen is to increase the oxygen concentration to the damaged myocardium. Current evidence and recommendations for oxygen administration in clients with an acute MI are to keep oxygen saturation greater than 90%. The other actions are not the purpose for or are helped by oxygen therapy. Incorrect LESSON Reduction of Risk Potential Therapeutic Procedures COURSE RN Review BODY SYSTEM cardiovascular KEYWORDS myocardial infarctionoxygen therapymyocardium

The emergency room nurse is caring for a client admitted with a cervical spinal cord injury. Which assessment is the priority? Muscle weakness Ability to urinate Blood pressure Respiratory function

dA spinal injury at the cervical level can result in quadriplegia with impairment of the phrenic nerve. As a result, the client is at high risk for respiratory insufficiency and failure; therefore, assessing and close monitoring of respiratory function is the priority. Incorrect LESSON Physiological Adaptation Alternations in Body Systems COURSE RN Review BODY SYSTEM nervous KEYWORDS spinal cord respiratoryassessmentteen

The nurse is preparing to administer a liquid medication orally to a 9-month-old infant. Which of the following administration methods would be appropriate for the nurse to use? A. Allow the infant to drink the liquid from a medicine cup B. Hold the child upright and administer with a spoon C. Mix the medication with the infant's formula in the bottle D. Administer the medication with a syringe next to the tongue

dGiving oral medications to an infant requires skill. The use of appropriate administration techniques is essential to prevent aspiration of liquid. Infants usually receive elixir or suspension forms that are administered using an oral syringe. First, the nurse should place the infant in an upright position. The nurse opens the infant's mouth by applying gentle pressure to the cheeks. The nurse should place the syringe in the infant's mouth along the side of the cheek, and then push the medication in slowly as the infant sucks. Using a needless syringe to slowly give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be decreased. Incorrect LESSON Pharmacological (and Parenteral Therapies) Medication Administration COURSE RN Review KEYWORDS administerliquidmedicinechild