Safety

Which of the following terms refers to the inability to coordinate muscle movements, resulting difficulty walking?

Ataxia

While caring for a patient who is treated for severe PID, the nurse insists on keeping the patient in a semi-sitting position. Which of the following is correct rationale for this positioning?

Facilitation of pelvic drainage and minimizing the upward extension of infection

A physician orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity?

Potassium level of 3.1 mEq/L (3.1 mmol/L) Explanation: Conditions that may predispose a client to digoxin toxicity include hypokalemia (evidenced by a potassium level less than 3.5 mEq/L), hypomagnesemia (evidenced by a magnesium level less than 1.5 mEq/L), hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia (evidenced by a magnesium level greater than 2.5 mEq/L), hypercalcemia (evidenced by an ionized calcium level greater than 5.3 mg/dl), and hypernatremia (evidenced by a sodium level greater than 145 mEq/L) aren't associated with a risk of

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first?

Turn patient on her side.

Which of the following terms is the tendency for a chemical to become a vapor?

Volatility

A client admitted with a gastric ulcer has been vomiting bright red blood. The hemoglobin level is 5.11 g/dL (51.1 g/L), and blood pressure is 100/50 mm Hg. The client and family state that their religious beliefs do not support the use of blood products and refuse blood transfusions as a treatment for the bleeding. The nurse should collaborate with the health care provider (HCP) and family to next:

attempt to stabilize the client through the use of fluid replacement

A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:

discontinue the transfusion.

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant?

hemoglobin level, hematocrit, and platelet count

A client presents at the testing center for an intravenous pyelogram. What question should the nurse ask to ensure the safety of the client?

"Do you have any allergies?"

The nurse is preparing to administer a rubella vaccine to a postpartum client before discharge. Which of the following should the nurse caution the client to avoid?

Becoming pregnant for at least 1 month. Correct

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?

Blue Explanation: If the client's membranes have ruptured, the nitrazine paper will turn blue, an alkaline reaction. False positives may occur when the nitrazine paper is exposed to blood or semen. The definitive test for rupture of membranes is fern testing, where amniotic fluid is allowed to dry on a slide and then viewed under a microscope. Dried amniotic fluid will form a fern pattern. No other fluid forms this type of pattern

During the first hemodialysis treatment, the client develops a headache, confusion, and nausea. The nurse should assess the client further for:

Disequilibrium syndrome. Explanation: Common symptoms of disequilibrium syndrome include headache, nausea and vomiting, confusion, and even seizures. Disequilibrium syndrome typically occurs near the end or after the completion of hemodialysis treatment. It is the result of rapid changes in solute composition and osmolality of the extracellular fluid. These symptoms are not related to cardiac function, air embolism, or peritonitis.

Colles' fracture occurs in which of the following areas?

Distal radius

When the female patient demonstrates a wartlike growth near the nipple, causing bloody nipple discharge, the patient is exhibiting signs of which disease process?

Intraductal papilloma Explanation: Intraductal papilloma is a wartlike growth that often involves the large milk ducts near the nipple, causing bloody nipple discharge. Surgery usually involves removal of the papilloma and a segment of the duct where the papilloma is found. Paget's disease is a malignancy of mammary ducts with early signs of erythema of nipple and areola. Acute mastitis is demonstrated by nipple cracks or abrasions along with reddened and warm breast skin and tenderness. Fibroadenoma is characterized as the occurrence of a single, nontender mass that is firm, mobile, and not fixed to breast tissue or chest wall.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every one to two hours?

Remove restraints and assess skin and circulation.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor?

The nurse must file an incident or adverse event report.

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

Uterine atony. Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site. Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration. Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.

An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following reasons?

She is taking coumadin.

The nurse is providing teaching to a patient with acne who is using isotretinoin (Accutane) therapy. Which of the following statements should the nurse make?

It is teratogenic in humans

The nurse is providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following?

Swimming. Swimming is not recommended because a person with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the patient wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange.