study set test 13

The nurse at a community health clinic assesses multiple clients' risk for oral cancer. Which of the following clients does the nurse recognize as having a risk factor for oral cancer? Select all that apply. 1.A client who consumes alcohol daily 2.A client who recently had a wisdom tooth extraction 3.A client who works outside and does not use sun protection 4.A client with a history of chronic tobacco use 5.A client with a history of human papillomavirus infection

1,3,4,5

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs? 1.Descends with the cane on the step first, followed by the left leg, and then the right leg 2.Descends with the cane on the step first, followed by the right leg, and then the left leg 3.Descends with the left leg on the step first, followed by the cane, and then the right leg 4.Descends with the right leg on the step first, followed by the left leg, and then the cane

1.Descends with the cane on the step first, followed by the left leg, and then the right leg

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? 1.Infant birth weight of 9 lb 2 oz (4139 g) 2.Labor and birth without pain medication 3.Labor that lasted 8 hours 4.Third stage of labor lasting 20 minutes

1.Infant birth weight of 9 lb 2 oz (4139 g) Rationale:Risk factors for PPH include: History of PPH in prior pregnancy Uterine distension due to:Multiple gestationPolyhydramnios (ie, excessive amniotic fluid)Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option 1) Uterine fatigue (labor lasting >24 hours) High parity Use of certain medications:Magnesium sulfateProlonged use of oxytocin during laborInhaled anesthesia (ie, general anesthesia)

A child received the varicella immunization. The day after the injection, the parent calls the nurse to say that the child has discomfort, slight redness, and 2 vesicles at the injection site. Which instruction should the nurse reinforce? 1.Administer aspirin to decrease discomfort 2.Cover the vesicles with a small bandage until they are dry 3.Isolate the child from other children for 21 days to avoid exposure 4.Make an appointment with the health care provider (HCP) as soon as possible

2.Cover the vesicles with a small bandage until they are dry rationale: The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary. (Option 1) Acetaminophen is the appropriate medication to reduce the discomfort of the injection. Aspirin should be avoided in children due to the risk of Reye syndrome. (Option 3) Unless the rash becomes widespread, isolation of the child is unnecessary. It is unlikely that the infection will be transmitted by the 2 vesicles, but covering them with clothing or a small bandage will decrease the risk of transmission. (Option 4) Discomfort, redness, and a few vesicles at the injection site are common side effects of the varicella immunization and do not require the attention of a healthcare provider.

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply. 1.Assist maternal pushing efforts by applying fundal pressure during each contraction 2.Document the time the fetal head was born 3.Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 4.Prepare for a forceps-assisted birth 5.Request additional assistance from other nurses immediately

2.Document the time the fetal head was born 3.Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis 5.Request additional assistance from other nurses immediately

A client with atrial fibrillation has just been placed on warfarin therapy. The nurse preceptor overhears the student nurse reinforcing teaching to the client about potential food-drug interactions. Which statement made by the student nurse requires the nurse preceptor to intervene? 1."Do you take any nutritional supplements?" 2."You will need to monitor your intake of foods containing vitamin K." 3."You will not be able to eat green leafy vegetables while taking warfarin." 4."Your blood will be tested at regular intervals."

2."You will need to monitor your intake of foods containing vitamin K." Rational: Warfarin (Coumadin) works by blocking the availability of vitamin K, which is essential for blood clotting. As a result, the clotting mechanism is disrupted, reducing the risk of stroke, venous thrombosis, and pulmonary embolism.

A practical nurse is collaborating with the registered nurse to form a care plan for a client diagnosed with placenta previa at 33 weeks gestation. What does the nurse anticipate being included in the plan of care? Select all that apply. 1.Activity as tolerated 2.Nonstress test 1 or 2 times a week 3.Prepare for cesarean birth at any time 4.Type and screen blood 5.Vaginal examinations twice weekly

2.Nonstress test 1 or 2 times a week 3.Prepare for cesarean birth at any time 4. Type and screen blood Rationale:In placenta previa, the placenta is implanted over or very near the cervix. As a result, placental blood vessels may be disrupted during dilation and effacement. Because of the increased risk of hemorrhage, the client should have a type and screen on file at the selected hospital. A nonstress test or biophysical profile should be performed once or twice a week to ensure fetal well-being. With asymptomatic clients, a cesarean birth is planned after 36 weeks gestation and prior to the onset of labor to prevent blood loss of mother and fetus. However, if the client is bleeding profusely or constantly or goes into active labor, a cesarean birth is typically performed immediately.

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1."I should not donate blood while taking this medication." 2."I will stop taking my tetracycline prior to taking this medication." 3."I will take vitamin A supplements." 4."I will use condoms and birth control pills."

3."I will take vitamin A supplements." rationale: Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception (Option 4). Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication (Option 3). (Option 1) Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. (Option 2) Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension. Educational objective:Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1.Clubbing of fingertips 2.Cyanosis when crying 3.Diaphoresis during feedings 4.Heart murmur 5.Poor weight gain

3.Diaphoresis during feedings 4.Heart murmur 5.Poor weight gain rationale:Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain (Option 5) (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion.

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching? 1. Faces forward when going up and down the stairs 2.Holds the cane with the right hand 3.Leads with left leg, follows next with cane, and finally right leg when going up the stairs 4.Places full weight on left leg when going down the stairs

3.Leads with left leg, follows next with cane, and finally right leg Rationale: up with good down with bad When ascending stairs: Step up with the stronger leg first (in this client, the right leg) Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg (in this client, the left leg) When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first? 1.Client after a colonoscopic polypectomy today with abdominal cramping and a small amount of rectal bleeding 2.Client after a laparoscopic inguinal hernia repair yesterday who reports urinary hesitancy while voiding 3.Client after a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement 4.Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C)

4.Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C) Rationale:Arteriovenous (AV) graft placement involves surgical connection of an artery to a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection usually manifests approximately 3-5 days after surgery (eg, fever, purulent drainage, swelling) and may cause thrombosis (clotting), graft failure, or systemic infection (Option 4). The health care provider (HCP) should be notified, as this client may require antibiotics and surgical revision or removal of the graft. (Option 1) A small amount of rectal bleeding and abdominal cramping are expected following a colonoscopy. Abdominal cramping occurs as the bowel contracts to expel air that was blown into the colon (insufflated) during the procedure. The HCP should be notified if the client experiences symptoms of bowel perforation (eg, severe abdominal pain, distension, excessive rectal bleeding). (Option 2) Anesthesia and opioid analgesics may cause postoperative urinary hesitancy and retention for up to 3 days following surgery, especially abdominal or pelvic surgery. This client should be instructed on measures to improve voiding (eg, standing) and may ultimately require urinary catheterization. (Option 3) Following surgery, constipation can occur due to narcotic pain medications and decreased ambulation. The client may require a stool softener to reduce straining.

The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler? 1.½ cup orange juice 2.Dry, sweetened cereal 3.Raw carrot sticks 4.Slice of cheese

4.Slice of cheese Rationale:When choosing foods for a toddler (age 1-3 years), parents should consider the following factors: Safety: Small, hard, sticky, or slippery foods (eg, hot dogs, whole grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, fruit snacks) pose a choking risk and should not be offered. Nutrient density: Foods should contain valuable nutrients (eg, protein, vitamins) rather than just "empty calories" (eg, sugars). Potential for foodborne illness: Children are at a higher risk for developing food-related infections, especially if given raw, unpasteurized foods (eg, partially cooked eggs, raw fish, raw bean sprouts). Healthy snacks for a toddler include pieces of cheese, whole-wheat crackers, banana slices, yogurt, cooked vegetables, and cottage cheese with thinly, sliced fruit (Option 4). (Option 1) Although orange juice is a source of vitamin C, it contains a large amount of sugar and lacks fiber. Toddlers should have no more than 4-6 oz of 100% fruit juice per day. (Option 2) Sweetened cereals, especially those marketed toward children, can be high in sugar and low in nutrients. (Option 3) Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked.

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1.Client has been sleeping on the floor in the den rather than the bed 2.Client has refused food and water for 4 days and has poor skin turgor 3.Client repeatedly mumbles, "I must kill them before they get me" 4.Marijuana was found in the client's personal belongings 5.The health care provider makes a diagnosis of schizophrenia

2,3 Rationale: Involuntary admission requirements: individual appears to be a danger to self or others and the individual has a grave disability to care for basic needs

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. All options must be used. 2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair

2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair

The nurse is reinforcing teaching of proper foot care to a client with diabetes mellitus. Which statement by the client indicates that further teaching is needed? 1."I will apply lanolin to my feet to prevent dry skin." 2."I will make sure my flip-flops are made of leather." 3."I will not apply a heating pad directly to my feet." 4."I will test the water with a thermometer before bathing."

2."I will make sure my flip-flops are made of leather."

The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia? 1.Decreased right hip adduction 2.Presence of extra gluteal folds on right side 3.Right leg longer than the left leg 4.Right pelvic tilt with lordosis

2.Presence of extra gluteal folds on right side rationale:Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head. Because it is much easier to treat during infancy, DDH screening is a standard assessment for newborns and infants. Manifestations in infants age <2-3 months include: The presence of extra inguinal or thigh folds Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers. However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is not treated, these signs disappear after age 2-3 months due to the development of muscle contractures. (Option 1) Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months. (Option 3) In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also apparent after age 3 months. (Option 4) If DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs include a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis.

The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? A.)irritability B.)joint pain C.)skin peeling D.)fever

D. Fever kawaski disease is a systemic vasculitis disease with a fever greater than 5 days, nonexudative conjuctivitus, hand a foot swelling and a rash. tx: IV Immunoglobin and aspirin to prevent coronary artery anuersisms.

The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? 1."A capsule holds the powdered medication that I put in a special inhaler." 2."I do not need to rinse my mouth out with water after taking tiotropium." 3."I have been taking tiotropium every time I have difficulty breathing." 4."Tiotropium helps control my COPD by reducing inflammation in my airway."

1."A capsule holds the powdered medication that I put in a special inhaler." rationale:Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic inhaled medication used to control chronic obstructive pulmonary disease (COPD) and is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client how to administer the medication prior to the first dose, emphasizing that the capsules should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option 2) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. (Option 3) Tiotropium is a controller medication for COPD, and the peak effect takes about a week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help to dry up airway secretions.

A nurse is performing an assessment of a 12-month-old child. Which of the following findings would the nurse expect? Select all that apply. 1.Approaches strangers with ease 2.Birth weight is tripled 3.Can skip and hop on one foot 4.Fully developed pincer grasp 5.Sits from a standing position

2.Birth weight is tripled 4.Fully developed pincer grasp 5.Sits from a standing position

A nurse is reinforcing teaching to a breastfeeding client who has been diagnosed with mastitis of the right breast. Which instructions should be included? Select all that apply. 1.Cease breastfeeding from right breast 2.Increase oral fluid intake 3.Reduce frequency of feeds to every 8 hours in right breast 4.Take ibuprofen as needed for pain 5.Use underwire bra 24 hours a day for support

2.Increase oral fluid intake 4.Take ibuprofen as needed for pain

The nurse administers the prescribed dose of hydromorphone 2 mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? 1.Client has 1 emesis of green fluid 2.Client has had no bowel movement for 2 days 3.Client falls asleep while talking to the nurse 4.Client reports experiencing pruritus

3.Client falls asleep while talking to the nurse rationale:Respiratory depression is the most serious side effect of narcotic medication. Sedation precedes respiratory depression. Falling asleep during a conversation scores "3" on the Pasero Opioid-Induced Sedation Scale (POSS); no additional narcotics should be given to the client. Other classes of drugs (eg, non-steroidal anti-inflammatory medications) can be given if the client is still in pain. The client will also be at increased risk for respiratory depression if the pain is completely relieved and/or it is night time. No additional narcotics should be given until the client is at level 2 sedation on POSS (eg, slightly drowsy, easily aroused). (Option 1) Nausea or vomiting is a typical side-effect of narcotic administration, especially when it is given in a larger dose or to the opioid-naïve client. It usually lessens with time and repeat administration. Nausea or vomiting would not be a concern unless it is excessive or severe. The nurse should ensure that the client receives adequate hydration (eg, intravenous fluids, clear liquids, antiemetics). (Option 2) Constipation is a known side effect of opioid administration and does not lessen with long-term administration. Proactive measures are needed as long as the client is on narcotics. However, large intestine peristalsis does not usually start until 2-3 days after surgery. (Option 4) Pruritus (itching) is a known side effect of narcotic administration. It is usually treated with diphenhydramine (Benadryl) or some other antihistamine.

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription? 1.Blood urea nitrogen of 12 mg/dL (4.28 mmol/L) 2.BMI of 34 kg/m2 recorded during today's examination 3.Past medical history of uncontrolled hypertension 4.Takes alprazolam as prescribed for anxiety

3.Past medical history of uncontrolled hypertension Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider (Option 3).

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. 1.High Fowler position in preparation for a paracentesis 2.Left side-lying position after percutaneous liver biopsy 3.Semi-Fowler after cardiac catheterization via femoral entry 4.Sims during soap-suds enema administration 5.Supine position after a lumbar puncture

3.Semi-Fowler after cardiac catheterization via femoral entry 2.Left side-lying position after percutaneous liver biopsy rationale:A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it (Option 1). Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid (Option 5). Sims position (left side-lying with right hip and knee flexed) is best for enema administration (Option 4). (Option 2) After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding. (Option 3) After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma.

A nurse has reinforced teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? 1."I need to drink 1-2 liters of fluid daily." 2."I need to have my blood levels checked periodically." 3."I should not limit my sodium intake." 4."I should use ibuprofen for pain relief."

4."I should use ibuprofen for pain relief." rationale: Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following: Dehydration Decreased renal function (eg, elderly clients) Diet low in sodium Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics) Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4). (Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium /water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. (Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity.

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy? 1.Assess how far the client can walk 2.Check sensation in fingers and toes 3.Inspect extremities for diabetic ulcers 4.Take the blood pressure sitting and standing

4.Take the blood pressure sitting and standing rationale:Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. (Options 1, 2 & 3) Sensory or peripheral neuropathy affects the peripheral nervous system and may cause problems with the extremities.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1.Atropine sublingual drops 2.Lorazepam sublingual tablet 3.Morphine sublingual liquid 4.Ondansetron sublingual tablet

Atropine sublingual drops Rationale:the "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle."

When monitoring a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply. 1.Flank pain radiating to the groin 2.Ingestion of high-protein food before onset of pain 3.Low-grade fever with chills 4.Pain at the umbilicus 5.Right upper-quadrant pain radiating to the right shoulder

Cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the right upper quadrant (RUQ) with referred pain to the right shoulder and scapula (Option 5). Clients often report fatty food ingestion 1-3 hours before initial onset of pain. Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia (Option 3). During an acute attack of cholecystitis, inflammation of the mucous lining and gallbladder wall occurs as a result of gallstone(s) obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct result in Murphy's sign; palpation over the RUQ causes pain and inability to inhale deeply. Laboratory results show leukocytosis. (Option 1) Flank pain radiating to the groin is seen with renal colic (ureteral stones). (Option 2) Ingestion of high-fat foods (eg, cheese, avocado, fried foods, hamburger), not dietary protein, signals the gallbladder to contract and empty bile into the duodenum to help digestion. Gallstones, which normally float harmlessly around the gallbladder, are then squeezed into the bile duct, causing the pain of biliary colic. Gallstones stuck further down the bile duct (choledocholithiasis) may become colonized by bacteria. (Option 4) Initial onset of pain at the umbilicus is seen with acute appendicitis.

Z-Track Administration

Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle 2. Inject medication slowly with dominant hand while maintaining traction 6. Wait 10 seconds after injecting the medication and withdraw the needle 5. Release the hold on the skin, allowing the layers to slide back to their original position 1. Apply gentle pressure at the injection site but do not massage Incorrect Correct answer 4,3,2,6,5,1 52%Answered correctly 02 mins, 07 secsTime Spent 2022Version Explanation The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps: Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option 4). Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle (Option 3). Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication (Option 2). Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking (Option 6). Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track (Option 5). Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation (Option 1).

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1."A high-calorie, high-protein diet is best for our child. "2."It is extremely important that we do not allow our child to become dehydrated. "3."Our child should wear a medical alert bracelet at all times." 4."We should avoid giving our child over-the-counter medicine containing aspirin. "5."We should encourage a noncontact sport such as swimming."

"3."Our child should wear a medical alert bracelet at all times." 4."We should avoid giving our child over-the-counter medicine containing aspirin. "5."We should encourage a noncontact sport such as swimming." rationale:Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). Avoid intramuscular injections; subcutaneous injections are preferred. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times (Option 3). (Option 1) Malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet. (Option 2) Dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia.

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome. Which instructions should the nurse reinforce with the client regarding this test? Select all that apply. 1.A continuous urinary catheter must be inserted for this test and the urine will collect in an attached bag." 2."Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." 3."Only daytime urine should be collected in the container as cortisol levels are higher in the morning. "4."Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder. "5."You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug."

"4."Record the time the urine collection is started and then empty the bladder into the toilet so that the start time coincides with an empty bladder. "5."You will be given a dark plastic jug containing a powder that absorbs into the urine that you will collect in the jug." 2."Keep the urine collection container in the refrigerator or a cooled ice chest when it is not in use." Rationale:A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity (Options 1 and 5). Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded (Options 3 and 4). Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (Option 2). Rationale:

The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1."I can stop taking these HIV drugs once my viral levels are undetectable." 2."I need to get tested regularly for sexually transmitted infections because I'm sexually active." 3."I should use latex condoms and barriers when having anal, vaginal, or oral sex." 4."I won't stop injecting drugs, but I will use a needle exchange program."

1. " I can stop taking these HIV drugs once my viral levels are undetectable Rationale: Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance. (Option 2) Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Regular testing (≥1 time annually) and treatment for STIs are recommended. (Option 3) Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission. (Option 4) IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange programs.

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1.0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2.IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3.IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L) 4.IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure

1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours Rationale:The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury.

A client was medicated 2 hours ago with IV morphine 2 mg to relieve moderate abdominal pain after an appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply 1. nasal canula 2.non rebreather mask 3.simple face mask 4.the venturi mask

1. Nasal cannula rationale:The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and unobtrusive so the client can eat and drink fluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication but is still alert, oriented, and able to follow directions. Therefore, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option 2) In emergency situations, a non-rebreather mask is used to deliver high concentrations of oxygen (up to 90%-95%). It requires a tight face seal and is both restrictive and uncomfortable. (Option 3) The simple face mask delivers a higher concentration of oxygen (40%-60%). However, it is uncomfortable and restrictive as it must be removed to eat or drink. Use of this mask may be appropriate at a later time if hypoxemia does not resolve. (Option 4) The Venturi mask is an expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease who cannot tolerate changes in oxygen concentration.

The nurse is reinforcing home care instructions for the parents of a child diagnosed with rotavirus infection. Which statements by the parents indicate that teaching has been effective? Select all that apply. 1."Hand washing is extremely important in slowing the spread of rotavirus." 2."I will observe my child for decreased urination and dry mucous membranes." 3."I will resume breastfeeding as soon as the diarrhea subsides. "4."I will use commercial baby wipes that contain alcohol. "5."My child can spread the infection with contaminated hands, toys, and food."

1."Hand washing is extremely important in slowing the spread of rotaviru 2."I will observe my child for decreased urination and dry mucous membranes."s. "5."My child can spread the infection with contaminated hands, toys, and food." rationale:Rotavirus is a contagious virus and the leading cause of diarrhea in children less than 5 years old; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus lives easily outside a human host, transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus (Options 1 and 5). Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccination is available and must be given before the child is 8 months old. However, vaccinated children can still acquire Rotavirus as many strains are not covered by the vaccine. Antibiotics are not effective against this viral agent. Because the virus can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration (Option 2). (Option 3) Breastfeeding and normal diet should be maintained. There is no evidence that these are harmful. (Option 4) Parents should change the child's diapers more frequently and wash the perianal area with mild soap and water. Commercial baby wipes containing alcohol should not be used as they are irritating. Protective zinc oxide can be applied instead.

The home health nurse reviews the serum laboratory test results for a client with seizures. The phenytoin level is 27 mcg/mL. The client makes which statement that may indicate the presence of dose-related drug toxicity and prompt the nurse to notify the supervisory registered nurse? 1."I am feeling unsteady when I walk." 2."I am getting up to urinate about 4 times during the night." 3."I have a metallic taste in my mouth when I eat." 4."My gums are getting so puffy and red."

1."I am feeling unsteady when I walk." rationale:Phenytoin (Dilantin) is an anticonvulsant drug used to treat generalized tonic-clonic seizures. The therapeutic serum phenytoin reference range is between 10-20 mcg/mL. Levels are measured when therapy is initiated, periodically throughout treatment to guide dosing until a steady state is attained (3-12 months), and if seizure activity increases. Early signs of toxicity include horizontal nystagmus and gait unsteadiness. These may be followed by slurred speech, lethargy, confusion, and even coma. Bradyarrhythmias and hypotension are usually seen with intravenous phenytoin. (Option 2) Nocturia is an expected side effect of diuretics but not phenytoin. Nocturia is also seen with diabetes mellitus and benign prostatic hyperplasia. (Option 3) Metallic taste in the mouth is often seen with metronidazole but not with phenytoin. (Option 4) Gingival hyperplasia is a common expected side effect of phenytoin and does not indicate drug toxicity. It occurs more often in clients <23 years of age who are prescribed >500 mg/day. Good oral hygiene can limit symptoms. Educational objective:

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1."I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." 2."I will immediately change the tracheostomy tube if my child has difficulty breathing." 3."I will provide deep suctioning frequently to prevent any airway obstruction." 4."I will remove the humidifier if my child starts developing more secretions."

1."I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." Rationale: In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. (Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. (Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. (Option 4) Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect.

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1."I will apply moisturizing lotion on my legs every day." 2."I will elevate my legs at night when I am sleeping." 3."I will keep my legs below heart level when sitting." 4."I will start walking outside with my neighbor." 5."I will use a heating pad to promote circulation."

1."I will apply moisturizing lotion on my legs every day." 3."I will keep my legs below heart level when sitting." 4."I will start walking outside with my neighbor." Rationale:Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development(Option 2) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option 5) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns. Educational objective:Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyle changes and medications. Health Promotion and Maintenance

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1.blurred vision 2.Dark-colored urine 3.Difficulty hearing 4.Yellow skin

1.blurred vision rationale: Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a possible although potentially reversible adverse effect. The client is instructed to report any signs of decreased visual acuity or loss of color (red-green) discrimination.

A parent rushes a 4-year-old to the emergency department after finding the child sitting on the kitchen floor holding an empty bottle of aspirin. The parent has no idea how many tablets were left in the container. The child is sniffling and crying quietly. The practical nurse anticipates initially assisting with the implementation of which treatment? 1.Activated charcoal 2.Gastric lavage 3.Sodium bicarbonate 4.Syrup of ipecac

1.Activated charcoal rationale:Activated charcoal is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for gastrointestinal decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic. Activated charcoal binds to available salicylates, thereby limiting further absorption in the small intestine and enhancing elimination. (Option 2) Similar to syrup of ipecac, gastric lavage is associated with risk of aspiration. In addition, there is no convincing evidence that it decreases morbidity. Gastric lavage is not routinely recommended but may be performed for the ingestion of a massive or life-threatening amount of drug. If necessary, it should be administered within 1 hour of ASA ingestion; administration requires a protected airway and possible sedation. (Option 3) The practical nurse may anticipate the administration of IV sodium bicarbonate as it is an appropriate treatment for aspirin toxicity after the administration of activated charcoal. It is given to make the blood and urine more alkaline, thereby promoting urinary excretion of salicylate. (Option 4) Syrup of ipecac has been shown to have minimal benefit in treating aspirin overdose; in addition, it is not recommended due to the risk of aspiration pneumonia secondary to induced vomiting.

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? Select all that apply. 1.Add high-protein foods to diet 2.Consume high-carbohydrate meals 3.Eat small, frequent meals 4.Increase intake of fluids with meals 5.Lie down after eating

1.Add high-protein foods to diet 3.Eat small, frequent meals 5.Lie down after eating Rationale: Recommendations to delay gastric emptying include: Consume meals high in fat, protein, and fiber, which take more time to digest and remain in the stomach longer than carbohydrates (Option 1). These foods also help meet the body's energy needs. Avoid consuming fluids with meals because this causes stomach contents to pass faster into the jejunum, which worsens symptoms. Fluid intake should occur up to 30 minutes before or after meals. Slowly consume small, frequent meals to reduce the amount of food in the stomach (Option 3). Avoid meals high in simple carbohydrates (eg, sugar, syrup) because these may trigger symptoms when the carbohydrates break down into simple sugars. Avoid sitting up after a meal because gravity increases gastric emptying. Instead, lying down after meals is encouraged (Option 5).

A nursing diagnosis of "ineffective airway clearance related to pain" is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first? 1.Administer prescribed analgesic medication for incisional pain 2.Encourage use of incentive spirometer every 2 hours while awake 3.Offer an additional pillow to splint the incision while coughing 4.Promote increased oral fluid intake

1.Administer prescribed analgesic medication for incisional pain rationale:Postoperative clients are at risk for atelectasis and possibly for pneumonia following surgery as a result of retained secretions. Effective coughing is essential to prevent these complications. The nurse can promote many client actions that will facilitate effective coughing. These include splinting the incision while coughing, changing position every 1-2 hours, ambulating early, using an incentive spirometer, and hydrating adequately to thin the secretions. However, all of these interventions are less effective if the client is in pain. The nurse should instruct the client to request pain medication before the pain becomes intense. Pain relief should be addressed prior to implementing coughing exercises and ambulation. (Options 2, 3, and 4) These are appropriate interventions but will be more effective if pain is managed first.

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply. 1.Advising measles vaccination for susceptible family members 2.Applying calamine lotion to reduce itching 3.Placing a tracheostomy tray at the bedside 4.Placing the client in a negative-pressure isolation room 5.Using an N95 respirator mask during client contact

1.Advising measles vaccination for susceptible family members 4.Placing the client in a negative-pressure isolation room 5.Using an N95 respirator mask during client contact rationale: Measles (rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus into the air, where it remains suspended for up to 2 hours. In the United States, widespread use of the measles, mumps, and rubella (MMR) vaccine has reduced measles incidence by 99%. However, increased frequency of international travel and number of unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, interventions should include the following: Recommendation of postexposure prophylaxis (eg, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms should they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas (Option 2) An erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rash (eg, varicella [chickenpox]). (Option 3) A tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected.

The psychiatric nurse is collaborating with the registered nurse to develop a plan of care for a 16-year-old client with bulimia nervosa. Which of the following interventions are appropriate to include in the plan of care? Select all that apply. 1.Ask if the client has experienced any thoughts of suicide 2.Assist in monitoring the client for signs of electrolyte imbalances 3.Collaborate ways for the client to be involved in the plan of care 4.Encourage the client to use a food diary for diet recall 5.Monitor the client for 1-2 hours after meals in a central area

1.Ask if the client has experienced any thoughts of suicide 2.Assist in monitoring the client for signs of electrolyte imbalances 3.Collaborate ways for the client to be involved in the plan of care 4.Encourage the client to use a food diary for diet recall 5.Monitor the client for 1-2 hours after meals in a central area

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? 1.Auscultate breath sounds to assess for crackles 2.Monitor for >50 mL/hr urine output 3.Monitor Glasgow Coma Scale increasing from 8/15 to 9/15 4.Press over the tibia to assess for pitting edema

1.Auscultate breath sounds to assess for crackles Rationale: Mannitol (Osmitrol) is an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. (Option 2) Urine output would be expected to increase from the diuretic effect of mannitol. This is not a complication. (Option 3) Glasgow Coma Scale scores range from 3-15. Improved mental status (orientation, alertness) is a desired effect of treatment. (Option 4) The presence of crackles is a more sensitive sign of fluid overload than pedal edema. Furthermore, in a bedridden client, the assessment should take place at a dependent part of the body, usually the sacral area

A client with a history of heart failure calls the clinic and reports a 3-lb (1.4-kg) weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? 1.Bumetanide 2.Candesartan 3.Carvedilol 4.Isosorbide

1.Bumetanide rationale: Most clients with heart failure are prescribed a loop diuretic (eg, furosemide, torsemide, bumetanide) to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms (eg, shortness of breath). If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic (eg, bumetanide).Option 2) Losartan, valsartan, and candesartan (sartans) are the commonly used angiotensin II receptor blockers. They are used in clients who cannot take ACE inhibitors (eg, lisinopril, ramipril). They block the renin-angiotensin-aldosterone system but will not affect the fluid status of the client with acute heart failure.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply. 1.Choose foods that are low in fat 2.Do not consume any foods containing dairy 3.Eat three large meals a day and minimize snacking 4.Limit or eliminate the use of alcohol and tobacco 5.Try to avoid caffeine, chocolate, and peppermint

1.Choose foods that are low in fat 4.Limit or eliminate the use of alcohol and tobacco 5.Try to avoid caffeine, chocolate, and peppermint Rationale:Gastroesophageal reflux disease (GERD) occurs when chronic reflux of stomach contents causes inflammation of the esophageal mucosa. The lower esophageal sphincter (LES) normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the LES (eg, caffeine, alcohol), delays gastric emptying (eg, fatty foods), or increases gastric pressure (eg, large meals) can precipitate GERD. Lifestyle and dietary measures that may prevent GERD and associated symptoms include: Weight loss, as excessive abdominal fat may increase gastric pressure Small, frequent meals with sips of water or fluids to help facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals (Option 3) Avoiding GERD triggers such as caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages (Options 1, 4, and 5) Chewing gum to promote salivation, which may help neutralize and clear acid from the esophagus Sleeping with the head of the bed elevated Refraining from eating at bedtime and/or lying down immediately after eating (Option 2) Clients with GERD generally do not need to minimize or eliminate dairy products from the diet; however, they should choose low-fat or nonfat products.

A client with myocardial infarction underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations. What teaching should the nurse reinforce with this client? 1.Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs 2.Client will be ready for sexual activity after completion of cardiac rehabilitation 3.It will be 6 months before the heart is healthy enough for sexual activity 4.Medications such as sildenafil or tadalafil are available as prescriptions from the health care provider

1.Client may be ready for sexual activity if no symptoms occur when climbing 2 flights of stairs rationale: Sexual counseling is important for clients with cardiac alterations, yet the subject of sex can be difficult for clients and health care providers (HCPs) to discuss and is often neglected. A client's concern about resumption of sexual activity can be very stressful, even more stressful than sexual activity. Therefore, the nurse should encourage clients to discuss concerns with the HCP. In general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely after receiving HCP approval. (Option 2) This client will participate in cardiac rehabilitation, but it likely will not impact the client's ability to engage in sexual activity, especially if the client remains asymptomatic.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1.Contact the clinic if any hot areas or foul odors develop in the cast 2.Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3.Elevate the affected extremity above heart level for the first 48 hours 4.Expect some numbness and tingling of the fingers during the first week 5.Use only soft, padded objects to scratch the skin under the cast

1.Contact the clinic if any hot areas or foul odors develop in the cast 2.Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3.Elevate the affected extremity above heart level for the first 48 hours Rationale: Option 4) The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching.

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1.Contraction duration of 95 seconds 2.Contraction frequency of every 3 minutes 3.Contraction intensity of 45 mm Hg 4.Uterine resting tone of 10 mm Hg

1.Contraction duration of 95 seconds rational:Uterine contractions decrease circulation through the spiral arterioles and the intervillous space, which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. (Option 2) Uterine frequency should be 2-5 contractions every 10 minutes. If contractions occur less than 2 minutes apart, fetal distress can occur as a result of uteroplacental insufficiency. (Option 3) In the first stage of labor, the intensity of uterine contractions should be 25-50 mm Hg. Intrauterine pressure of more than 80 mm Hg is a sign of hypertonicity of the uterus. (Option 4) Uterine resting tone of 20 mm Hg or less is considered acceptable. Uterine resting tone allows blood flow to the placenta and therefore the fetus,

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1.Haemophilus influenzae type b (Hib) 2.Hepatitis A (Hep A) 3.Measles, mumps, rubella (MMR) 4.Pneumococcal conjugate vaccine (PCV) 5.Varicella

1.Haemophiles influenza type b )Hib) 2. Hepatitis A (Hep A) 4.Pnemococcal conjugate vaccine (PCV) Rationale: live vaccines are contraindicated for pts with compromised immune system. Live vaccines: Measles, mumps, Rubella, Varicella

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1.Hemoglobin and hematocrit levels 2.Human chorionic gonadotropin level 3.Serum folate level 4.White blood cell count

1.Hemoglobin and hematocrit levels rationale:Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option 2) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option 3) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option 4) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection.

The practical nurse is assisting the registered nurse to create a care plan for a 3-year-old client admitted with a pertussis infection. Which of the following interventions should be included? Select all that apply. 1.Institute droplet precautions 2.Monitor for signs of airway obstruction 3.Offer small sips of fluid frequently 4.Place client in a negative-pressure isolation room 5.Request a prescription for cough suppressants

1.Institute droplet precautions 2.Monitor for signs of airway obstruction 3.Offer small sips of fluid frequently rationale:Pertussis (whooping cough) is caused by the highly contagious bacterium, Bordetella pertussis, which is spread through close human contact, coughing, and sneezing. Once attached to cilia in the client's upper respiratory tract, this bacterium releases a toxin that causes irritation and swelling. To prevent transmission, the nurse should implement standard (universal) and droplet precautions (Option 1). Pertussis is characterized by a violent, spasmodic cough and a distinctive high-pitched "whooping" sound heard during inhalation. Coughing may continue until the client expectorates a thick mucous plug or vomits (posttussive emesis). Therefore, the nurse should closely monitor for airway obstruction (eg, cyanosis) during coughing episodes, place clients on their sides if vomiting, and suction the airway and provide oxygen as needed (Option 2). Treatment consists of antibiotics and other supportive measures (eg, humidified oxygen, oral fluids). Small amounts of oral fluids help loosen mucus so that it can be expectorated (Option 3). (Option 4) Airborne precautions (ie, negative-pressure isolation room) are appropriate for clients with measles, tuberculosis, and varicella-zoster infections (mnemonic - airing MTV). (Option 5) Cough suppressants interfere with the expectoration of mucous plugs that develop in the airway and are not recommended for pertussis because they are usually ineffective.

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply. 1.Not taking tetracycline with dairy products 2.Taking tetracycline at bedtime 3.Taking tetracycline with food 4.Using additional contraceptive techniques 5.Using sunblock

1.Not taking tetracycline with dairy products 4.Using additional contraceptive techniques 5.Using sunblock

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1.The client had 1 birth at 37 wk 0 d gestation or beyond 2.The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation 3.The client has 3 currently living children 4.The client is currently not pregnant

1.The client had 1 birth at 37 wk 0 d gestation or beyond Rationale:This client (G5T1P2A1L2) has been pregnant 5 times (G5); had 1 term birth (T1), 2 preterm births (P2), and 1 abortion (A1); and has 2 currently living children (L2). The client's term birth is indicated by the T1 portion of the GTPAL notation

The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate? 1."Eliminate green, leafy, vitamin K-rich vegetables from your diet." 2."Mild bruising or redness may occur at the injection site." 3."You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort." 4."You will need PT/INR assessments at regular intervals while on enoxaparin therapy."

2."Mild bruising or redness may occur at the injection site." rationale:Enoxaparin (Lovenox) is a low molecular weight heparin (LMWH) that may be prescribed for up to 10-14 days following hip and knee surgery to prevent deep venous thrombosis. Teaching for the client discharged on enoxaparin therapy includes the following: Pinch 1 inch of skin upward and insert the needle at a 90-degree angle into the skinfold. Continue to hold the skin fold throughout the injection process and then remove the needle at a 90-degree angle. Mild pain, bruising, irritation, or redness of the skin at the injection site is common. Do not rub the site with the hand. Using an ice cube on the injection site can provide relief (Option 2). Avoid taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements (eg, Ginkgo biloba, vitamin E) without health care provider approval as these can increase bleeding risk (Option 3). Monitor complete blood count (CBC) to assess for thrombocytopenia. (Option 1) Vitamin K-rich foods do not need to be eliminated from the diet during enoxaparin therapy; prothrombin time (PT) and International Normalized Ratio (INR) are not affected. However, PT and INR are decreased when a vitamin K antagonist (eg, warfarin [Coumadin]) is taken with vitamin K-rich foods. (Option 4) Routine coagulation studies (eg, PT, INR, partial thromboplastin time [PTT]) do not need to be monitored in a client who is taking enoxaparin. However, periodic assessment of CBC is usually required to monitor for hidden bleeding and thrombocytopenia, especially in older clients with renal insufficiency.

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1."I periodically take docusate sodium for constipation." 2."I regularly take ibuprofen for chronic low back pain." 3."I take hydrochlorothiazide to prevent swelling around my ankles." 4."I take omeprazole daily to prevent heartburn."

2."I regularly take ibuprofen for chronic low back pain." Rationale:Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time.

The nurse on the mental health unit is collaborating with the registered nurse to develop the care plan for a newly admitted client with a diagnosis of schizophrenia with persecutory delusions. Which interventions should the nurse expect to include with regard to the delusional thinking? Select all that apply. 1.Explore the meaning behind the client's delusions 2.Focus on reality and verbally reinforce it 3.Focus on the client's feelings secondary to the delusions 4.Gently confront the client about the false beliefs 5.Present logical explanations to discredit the delusions

2.) forcus on the reality and verbally reinforcing it 3.) focus of the clients feelings secondary to the delusions Clients with persecutory (paranoid) delusions believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to think that someone is trying to poison you." When nurses attempt to understand clients' feelings and their meaning, the clients take note of this and the nurse-client relationship grows (Option 3). Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). (Option 1) Attempting to explore the meaning behind a delusion will encourage the client to focus on and think more about the delusion. (Option 4) Confronting the client about the delusion is not therapeutic as arguing will not eradicate it. Confrontation also hinders the development of a trusting nurse-client relationship. (Option 5) Clients believe that their delusions are real despite proof otherwise. Presenting logical explanations to discredit the delusions will not help

Which actions would the nurse expect to be included in the care plan for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. 1.Ask the client to plan an outing for the unit 2.Assign the client to a private room 3.Choose clothing for the client 4.Include the client in group therapy sessions 5.Schedule the client for physical activity with a staff member 6.Seat the client with other clients in the dining room for meals

2.Assign the client to a private room 3.Choose clothing for the client 5.Schedule the client for physical activity with a staff member Rationale:The care plan for a client experiencing an acute manic episode includes the following: Reduction of environmental stimuli,Providing a quiet, calm environment,Limiting the number of people who come in contact with the client.One-on-one interactions rather than group activities,Low lighting A structured schedule of activities to help the client stay focused Physical activities to help relieve excess energy Providing high-protein, high-calorie meals and snacks that are easy to eat Setting limits on behavior (Option 1) The client is easily distractible and would not be able to focus on planning an activity. (Option 4) The client with acute mania is not ready to participate in group activities. (Option 6) The client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity.

A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1.Acetaminophen being given every 4 hours for fever 2.Bismuth subsalicylate being used for nausea 3.Ibuprofen being given every 6 hours for body aches 4.Popsicles and gelatin desserts being used for hydration

2.Bismuth subsalicylate being used for nausea ratioanle:The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1.Angle bottle up and toward cleft 2.Burping the infant often 3.Feeding in an upright position 4.Feeding slowly over 45 minutes or more 5.Using a specialty bottle or nipple

2.Burping the infant often 3.Feeding in an upright position 5.Using a specialty bottle or nipple rationale:A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth.

The nurse completes the following drug administrations. Which would require an incident report? 1.Client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held 2.Client with depression stopped phenelzine yesterday; escitalopram given today 3.Client with diabetes and morning glucose of 90 mg/dL (5.0 mmol/L); the daily NPH insulin 20 units given at 8:00 AM 4.Client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin

2.Client with depression stopped phenelzine yesterday; escitalopram given today Rationale: Phenelzine is a MAOI and Escitalopram is a SSRI. These two medications should not be taken within 14 days of each other because it will increase Serotonin Syndrome. Isorbide monitrate is a vasodialator like nitroglycerin and should be held because of the risk of hypotension when bp is 84/52 insulin is given to control diabetes with a normal fasting glucose level or (70-99) indicates that the dosing is corredt and should be given to control the BG Warfarin is monitored by INR. Normal range is 2-3

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? 1.Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia 2.Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus 3.IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago 4.Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs

2.Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus rationale:Dicyclomine (Bentyl) is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition (Option 2). The nurse should question this prescription and contact the health care provider.Option 1) Tumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are prescribed to promote purine excretion and prevent acute kidney injury. (Option 3) Although opioids (eg, morphine) can cause constipation, symptoms can be managed with pharmacologic (eg, docusate sodium, sennoside) and nonpharmacologic interventions (eg, increased activity, increased fiber and fluid intake). Percutaneous nephrolithotripsy breaks and removes kidney stones, and can lead to severe pain. Therefore, pain medication is appropriate. (Option 4) Levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur.

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? 1.Client reports chest pain that is worse with deep inspiration 2.Distant heart tones and jugular venous distension 3.ECG showing ST-segment elevations in all leads 4.Pericardial friction rub auscultated at the left sternal border

2.Distant heart tones and jugular venous distension Rationale:Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound.

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? 1.Discomfort during fundal palpation 2.Foul-smelling lochia 3.Oral temperature 100.1 F (37.8 C) 4.White blood cell count 24,000/mm3 (24.0 x 109/L)

2.Foul-smelling lochia Rationale:A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option 1) Palpation of the postpartum uterine fundus is commonly uncomfortable. If the client has increasing pain, further evaluation is needed. (Option 3) Major signs and symptoms of endometrial infection include temperature >100.4 F (38.0 C), chills, malaise, excessive uterine tenderness, and purulent, foul-smelling lochia. During the first 24 hours postpartum, temperature is normally elevated, but a reading of >100.4 F (38 C) requires further evaluation. (Option 4) The white blood cell count is normally elevated during the first 24 hours postpartum (up to 30,000/mm3 [30.0 x 109/L]). Leukocyte levels that are not decreasing require further evaluation.

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1.Black cohosh 2.Garlic 3.Ginger 4.Ginkgo biloba 5.Hawthorn

2.Garlic 3.Ginger 4.Ginkgo biloba Rationale: Clients are often aware of the need to discontinue prescription medications such as aspirin and anticoagulants prior to elective surgery, but they may not know that some herbal supplements can increase bleeding risk. The nurse should question the client specifically about the use of herbal supplements. Herbal supplements that can increase risk for bleeding include: Gingko biloba Garlic Ginseng Ginger Feverfew (Option 1) Black cohosh is used for treatment of menopausal symptoms. The main side effect is liver injury. (Option 5) Hawthorn extract is used to control hypertension and mild to moderate heart failure. Hawthorn use does not increase the risk of bleeding.

A client with asthma and sinusitis has increased wheezing and decreased peak flow readings. The nurse recognizes that which of the following over-the-counter home medications taken by the client could be contributing to increased asthma symptoms? 1.Guaifenesin 600 mg orally twice a day as needed 2.Ibuprofen 400 mg orally every 6 hours for pain as needed 3.Loratadine 1 tablet orally every day as needed 4.Vitamin D 2,000 units orally every day

2.Ibuprofen 400 mg orally every 6 hours for pain as needed rationale:Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort, and fever. About 10%-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis. (Option 1) Guaifenesin (Mucinex) is an expectorant used to thin respiratory secretions and should not have the potential to exacerbate asthma or cause an attack. (Option 3) Loratadine (Claritin) is an antihistamine and should not have the potential to exacerbate asthma or cause an attack. (Option 4) Vitamin D is used to help maintain bone density and should not have the potential to exacerbate asthma or cause an attack.

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. 1.Check gastric residual every 12 hours 2.Keep head of the bed at ≥30 degrees 3.Maintain endotracheal cuff pressure 4.Monitor for abdominal distension every 4 hours 5.Use caution when administering sedatives

2.Keep head of the bed at ≥30 degrees 3.Maintain endotracheal cuff pressure 4.Monitor for abdominal distension every 4 hours 5.Use caution when administering sedatives

The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply. 1.Eating a high-protein snack at bedtime 2.Limiting alcohol intake 3.Losing weight 4.Taking a mild sedative at bedtime 5.Taking a nap during the day6.Taking modafinil at bedtime

2.Limiting alcohol intake 3.Losing weight Rationale: Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs from relaxation of the tongue and soft palate. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia (decreased PaO2) and hypercapnia (increased PaCO2). Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions for OSA include: Using a continuous positive airway pressure (CPAP) device at night to keep the tongue from collapsing backward Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax, leading to airway obstruction (Option 2) Weight loss and exercise may reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA (Option 3). Avoiding sedating medications (eg, benzodiazepines, certain antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness (Option 1) Eating before bedtime can interfere with sleep and contribute to excess weight. (Option 4) Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction. (Option 5) Napping during the day can make it more difficult to sleep through the night. (Option 6) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can cause insomnia.

The practical nurse is collaborating with the registered nurse to create a care plan for a child being admitted with Kawasaki disease. Which nursing intervention is the priority? 1.Apply cool compresses to the skin of the hands and feet 2.Monitor for a gallop heart rhythm and decreased urine output 3.Prepare a quiet, non-stimulating, and restful environment 4.Provide soft foods and liberal amounts of clear liquids

2.Monitor for a gallop heart rhythm and decreased urine output rationale:Kawasaki disease (KD) is a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has the following 3 phases: Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV immune globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure; signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). (Option 1) During the acute phase (swollen hands and feet), skin discomfort can be eased with cool compresses and lotions. No treatment is needed in the subacute phase (skin peeling), but the new skin might be very tender. (Option 3) The child will be very irritable during the acute phase of KD. A non-stimulating, quiet environment will help to promote rest. After a KD episode, it is important for parents to understand that their child's irritability may last for up to 2 months and that follow-up appointments for cardiac evaluation are important. (Option 4) During the acute phase (painful swollen lips and tongue), the child should be given soft foods and clear liquids as these are tolerated best.

The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 7-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern? 1."I get embarrassed if my child screams when approached by unfamiliar people." 2."I thought my child would be sitting without needing their hands for support by now." 3."I wonder when my child will put their pacifier to their mouth without my help." 4."It seems odd that my child says 'mama' and 'dada' to strangers."

3. I wonder when my child will put their pacifier to their mouth without my help Rationale: infants should develop fine motor skills such as grasping around 4-5 months. If the infant does not grasp objects by 7 months a further assessment is needed Option 1) Stranger anxiety begins around age 6-8 months and demonstrates age-appropriate social development. Some infants cry loudly whereas others become quiet and stare fearfully at strangers. (Option 2) Sitting alone while using the hands for support (ie, tripod sitting) is expected for a 7-month-old client. This demonstrates age-appropriate gross motor development. Sitting alone without support occurs by age 8-9 months. (Option 4) By age 6-7 months, the infant may imitate sounds (eg, "mama," "dada") without knowing the meaning of words. This demonstrates age-appropriate vocal development. Comprehension of some words occurs around age 10 months.

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1."I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped." ( 2."I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding." 3."I will begin using condoms to prevent pregnancy once menses returns." 4."I will try to feed my baby before my partner and I engage in sexual activity."

3."I will begin using condoms to prevent pregnancy once menses returns." rationale:Initiating an open discussion about sexual activity after childbirth allows the nurse to provide anticipatory guidance and recognize individual client concerns (eg, discomfort, fatigue, fear, body image). The nurse should plan to reinforce the use of contraception because many clients resume sexual activity before their postpartum checkup (4-6 weeks after birth), when contraception methods are usually prescribed. Ovulation may occur as early as 4 weeks after birth and before resumption of menses, especially in clients who formula feed. Clients should be encouraged to use a barrier contraceptive such as condoms to prevent pregnancy until another form of birth control can be prescribed (Option 3). (Option 1) Sexual activity may be resumed once lacerations/episiotomy are healed, and vaginal bleeding has stopped. For clients with no birth complications, risk of infection or bleeding is low at ≥2 weeks postpartum. (Option 2) Sexual arousal takes more time for most postpartum clients due to hormonal changes. Lactating clients may especially experience symptoms of estrogen deficiency (eg, vaginal dryness). Vaginal lubrication is recommended to increase comfort. (Option 4) Sexual activity may be inhibited by the couple's sense of responsibility for newborn needs. In addition, sexual arousal may stimulate leakage of breast milk. Feeding the newborn before sexual activity helps alleviate these

The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern? 1."I've felt the need for an afternoon nap most days this week." 2."I've gained 3 lb (1.36 kg) since I began taking this medication." 3."I've had the stomach flu for the past couple of days." 4."My mouth seems to be drier than usual lately."

3."I've had the stomach flu for the past couple of days." rationale:Lithium is often used in the treatment of bipolar disorder. It has expected, mild side effects as well as potentially serious ones related to drug toxicity. Drowsiness, weight gain, dry mouth, and gastrointestinal upset are expected, mild side effects. Lithium toxicity occurs with dehydration, hyponatremia, decreased renal function, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs, thiazide diuretics). Lithium and sodium are closely related in the body. Acute viral gastroenteritis (stomach flu) presents with abrupt onset of diarrhea, nausea, vomiting, and abdominal pain. Clients with vomiting and diarrhea are at risk of developing dehydration and/or low serum sodium, increasing the risk for lithium toxicity

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider? 1."I don't have much interest in sex lately." 2."I feel like I might be getting a cold." 3."My periods have been heavy lately." 4."These hot flashes are occurring a lot."

3."My periods have been heavy lately." Rationale:Selective estrogen receptor modulators (eg, tamoxifen) have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting the growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer (Option 3). Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis). Clients with breast cancer take tamoxifen for several (5-10) years to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important. (Options 1 and 4) Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido (sexual dysfunction) are common and would be discussed after addressing more concerning symptoms. (Option 2) Tamoxifen is not associated with significant immunosuppression although it may rarely cause leukopenia. Educational objective:Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues. It is used for several years in estrogen-responsive breast cancer. However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect.

Which prescriptions for these clients does the nurse question? Select all that apply. 1.Client with Clostridium difficile colitis, prescribed vancomycin 125 mg PO 2.Client with diabetes and elevated mealtime glucose, prescribed lispro insulin scale 6 units subcutaneously 3.Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4.Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO5.Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO

3.Client with gastrointestinal bleed and nasogastric tube, prescribed pantoprazole 40 mg intravenous 4.Client with hypertension and blood pressure (BP) 94/40 mm Hg, prescribed metoprolol succinate SR 50 mg PO5.Client with otitis media and penicillin allergy, prescribed ampicillin 500 mg PO RationaleClient with hypertension and BP 94/40 mm Hg, prescribed metoprolol succinate SR (Toprol-XL) 50 mg PO: This client's mean arterial pressure (MAP) is only 58 mm Hg ({[2x diastolic] + systolic} ÷ 3). A MAP >60-65 mm Hg is necessary to perfuse the vital organs (eg, brain, coronary arteries, kidneys). Toprol-XL is a long-acting beta blocker and will continue to drop the client's BP over a 24-hour period. Client with otitis media and penicillin allergy prescribed ampicillin 500 mg PO: Ampicillin is classified as a penicillin antibiotic and is contraindicated in clients with a penicillin allergy

The practical nurse (PN) is assisting the registered nurse (RN) to care for a client receiving oxytocin for induction of labor. Which of the following actions by the PN are appropriate during oxytocin infusion? Select all that apply. 1.Assess deep tendon reflexes every hour 2.Assist RN to initiate intermittent fetal monitoring 3.Evaluate fluid intake and output every 4 hours 4.Notify RN if >5 contractions occur in 10 minutes 5.Obtain blood pressure with each oxytocin dose change

3.Evaluate fluid intake and output every 4 hours 4.Notify RN if >5 contractions occur in 10 minutes 5.Obtain blood pressure with each oxytocin dose change rationale:Oxytocin is a high-alert medication commonly used for labor induction or augmentation. Oxytocin is titrated by the registered nurse (RN) on an infusion pump to achieve an adequate contraction pattern (eg, contractions every 2-3 min). If >5 contractions occur in 10 minutes (ie, uterine tachysystole), the practical nurse (PN) should notify the RN immediately to decrease the infusion rate (Option 4). Uterine tachysystole can cause decreased placental perfusion, a nonreassuring fetal heart rate (FHR), or uterine rupture. Water intoxication is a potential complication of oxytocin administration that causes dilutional hyponatremia, convulsions, and death. Therefore, the PN should monitor fluid intake and output every 4 hours to identify fluid retention, which is an early sign of water intoxication (Option 3). Hypotension can occur with rapid oxytocin bolus; therefore, blood pressure, heart rate, and respirations are assessed every 30 minutes or with each oxytocin dose change to identify changes from baseline (Option 5). (Option 1) Regular assessment of deep tendon reflexes is necessary for clients receiving magnesium sulfate, which causes central nervous system depression. (Option 2) The PN should anticipate continuous, not intermittent, electronic FHR and contraction monitoring for clients receiving oxytocin because of the potential for uterine tachysystole and abnormal FHR patterns.

The nurse is preparing to administer IV cefazolin to a client who is newly admitted with cellulitis. The client's allergies include amoxicillin, ciprofloxacin, and sulfa drugs. What should the nurse do first? 1.Administer the medication as ordered 2.Clarify the order with the supervising registered nurse 3.Get more information from the client about the client's allergies 4.Notify the pharmacy that the drug is inappropriate for this client

3.Get more information from the client about the client's allergies rationale:The nurse should find out more about this client's allergies before giving the medication. Specifically, the nurse must learn what type of reaction the client had to amoxicillin, a penicillin antibiotic. With a history of anaphylaxis to penicillin, cephalosporins (eg, cefazolin) are contraindicated. Penicillin-cephalosporin cross-sensitivity occurs due to the structural similarity between the cephalosporin and penicillin molecules. If this client's reaction to amoxicillin was only a rash or other mild reaction that was not life-threatening, the cephalosporin can be safely administered. However, if the client had an anaphylactic reaction to penicillin, the health care provider (HCP) will need to prescribe a different antibiotic. (Option 1) The nurse should hold the medication until more is known about the client's reaction to amoxicillin. (Option 2) The nurse does not have enough information to determine whether the supervising registered nurse or the HCP needs to be notified. (Option 4) The nurse does not have enough information to determine whether the medication is appropriate.

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? Click the exhibit button for additional information. 1.Administer atropine 0.5 mg IV 2.Administer dopamine 5 mcg/kg/min IV 3.Initiate transcutaneous pacing 4.Notify the health care provider

3.Initiate transcutaneous pacing The client is experiencing failure to capture from the permanent pacemaker with subsequent bradycardia and hypotension. Failure to capture appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of lead wire(s) preventing adequate voltage for depolarization. This client is symptomatic (eg, hypotension, dizziness) from insufficient perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced (Option 3). Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very uncomfortable for the client. (Option 1) Atropine is administered to clients with symptomatic bradycardia; however, this client's symptoms are caused by failure to capture. Therefore, obtaining capture via transcutaneous pacing should resolve the client's symptoms. (Option 2) Dopamine is an inotrope used to treat hypotension due to bradycardia. This client is bradycardic and hypotensive due to failure to capture. If hypotension persists after transcutaneous pacing is initiated, an inotrope may be necessary. (Option 4) The health care provider needs to be notified, but the nurse should first use the transcutaneous pacemaker to stabilize the client. Educational objective:

The nurse is reinforcing prior teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss? 1.Heart valve injury 2.Intellectual disability 3.Joint destruction 4.Recurrent pneumonia

3.Joint destruction Ratioanle: Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur. (Option 1) Heart valve injury is common with rheumatic heart disease not hemophilia. (Option 2) Intellectual disability in children is commonly seen with fetal alcohol syndrome, Down syndrome, hypothyroidism, and lead poisoning. In rare cases, hemophilia can cause life-threatening intracranial bleeding. However, isolated intellectual disability is not seen. (Option 4) Recurrent pneumonia is commonly seen with cystic fibrosis not hemophilia.

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply. 1.Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L) 2.High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L) 3.Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) 4.Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) 5.Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

3.Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) 4.Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) 5.Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L) Rationale:Statins (rosuvastatin, atorvastatin, simvastatin) are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride levels. This client's LDL level has decreased to a target range (diabetic client <100 mg/dL [2.6 mmol/L]), total cholesterol has decreased to a normal range (adult <200 mg/dL [5.2 mmol/L]), and triglyceride level has decreased to a normal range (adult <150 mg/dL [1.7 mmol/L)); all these changes indicate a therapeutic response (Options 3, 4, and 5). (Option 1) The adult therapeutic range of alanine aminotransferase (ALT) is 10-40 U/L (0.17-0.68 µkat/L). Increased aspartate aminotransferase (AST) and ALT may indicate hepatic dysfunction, a potential adverse effect of statin medication. (Option 2) The therapeutic range of high-density lipoprotein (HDL) cholesterol for adult men is >40 mg/dL (1.04 mmol/L). HDL is good cholesterol. This client's HDL level is below the therapeutic range, indicating a nontherapeutic response.

The nurse is caring for a client admitted with serotonin syndrome after taking citalopram and tramadol. Which findings does the nurse expect to observe? Select all that apply. 1.Absent deep tendon reflexes 2.Cold, clammy skin 3.Muscle rigidity 4.Restlessness and agitation 5.Sinus tachycardia

3.Muscle rigidity 4.Restlessness and agitation 5.Sinus tachycardia Rationale:Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). (Option 1) The client experiencing serotonin syndrome would exhibit hyperreflexia. (Option 2) The client experiencing serotonin syndrome would exhibit warm moist skin and a fever.

The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective? 1.Episodes of spasmodic coughing have decreased 2.No wheezes are audible on chest auscultation 3.Oxygen saturation has increased from 88% to 93% 4.Peak expiratory flow rate has dropped from 212 L/min to 127 L/min (

3.Oxygen saturation has increased from 88% to 93% Rationale:Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. (Option 1) Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. (Option 2) The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. (Option 4) Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1.Gently flush the eye with cool water 2.Instill optic antibiotic ointment 3.Patch both eyes with eye shields 4.Remove the splinter using tweezers

3.Patch both eyes with eye shields rationale:The camp nurse protects the injured eye using an eye shield (eg, small Styrofoam or paper cup), ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center for assessment and treatment by an ophthalmologist. (Option 1) Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens.

A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse? 1.Dizziness on standing 2.Fasting blood glucose of 160 mg/dL (8.9 mmol/L) 3.Presence of muscle cramps 4.Sunburn on both arms

3.Presence of muscle cramps rationale:Thiazide diuretics (eg, hydrochlorothiazide, chlorthalidone) are prescribed to treat hypertension and edema. The major side effects of thiazide diuretics include: Hypokalemia - manifests as muscle cramps (Option 3) Hyponatremia - manifests as altered mental status and seizures Hyperuricemia - may precipitate or worsen gout attacks Hyperglycemia - may require adjustment of diabetic medications Hypokalemia is the most serious side effect of thiazide diuretics as it can lead to life-threatening cardiac dysrhythmias. (Option 1) Orthostatic hypotension may be a side effect of any diuretic. The nurse should teach the client to sit for a few minutes before standing and rise slowly. The nurse should also check that the client's blood pressure is not too low. (Option 2) Mild to moderate hyperglycemia is common with thiazides and needs to be addressed. However, it is not life-threatening and therefore not a priority. (Option 4) Most thiazide diuretics are sulfa derivatives and can therefore cause photosensitivity. The nurse should encourage the client to use sunscreen and wear protective clothing.

The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity? 1.Encouraging use of puzzles for play 2.Offering the child stacking blocks for diversion 3.Providing crayons to draw noses on facemasks 4.Suggesting that playmates visit the child

3.Providing crayons to draw noses on facemasks rationale:Clients with influenza are maintained on droplet precautions, and anyone entering the room must wear a facemask. Medical play during the preschool period (age 3-5 years) facilitates psychosocial integrity. Crayons are age-appropriate toys. Drawing noses on facemasks will help the child feel more comfortable with procedures and provides a developmentally appropriate diversion. (Option 1) Puzzles would be more appropriate for the school-age child (6-12 years). (Option 2) Stacking blocks would be more appropriate for the toddler (age 1-3 years). (Option 4) Maintaining contact with peers would be more appropriate for the adolescent (age 12-19 years).

The nurse on a pediatric unit is caring for a school-age child with suspected Reye syndrome. Which subjective client data is most consistent with this condition? 1.No history of varicella vaccine administration 2.Recent exposure to bats 3.Recent influenza infection 4.Recent use of acetaminophen for fever

3.Recent influenza infection Rationale:Children who develop Reye syndrome have often had a recent viral infection, especially varicella (chicken pox) or influenza. Clinical manifestations of Reye syndrome include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. In addition, acute encephalopathy manifests with vomiting and a severely altered level of consciousness; it can rapidly progress to seizures and/or coma. The risk of developing Reye syndrome increases if aspirin is used to treat the fever associated with varicella or influenza. As a result, the use of acetaminophen or ibuprofen for fever management in children has increased significantly.(Option 4) The use of aspirin to treat fever in children is associated with Reye syndrome and is contraindicated, except in conditions such as Kawasaki disease. Acetaminophen is an appropriate antipyretic choice to reduce Reye syndrome risk.

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1.Edema of the scalp crossing the suture lines 2.Flat, bluish, discolored area on the buttocks 3.Small tuft of hair at the base of the spine 4.White, waxy substance in the axillae and labial folds

3.Small tuft of hair at the base of the spine Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest form is spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required (Option 3). (Option 1) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. (Option 2) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). (Option 4) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns.

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. 1.Dodgeball 2.Reading a book 3.Stationary bicycling 4.Swimming 5.Yoga

3.Stationary bicycling 4.Swimming 5.Yoga Rationale:Children with JIA are at high risk for becoming deconditioned due to decreased muscle strength and endurance and overall capacity for exercise. They tend to tire quickly even when the disease is in remission. Both aerobic and anaerobic exercise can help minimize this risk, and resistance training can increase muscle strength and endurance. Exercise may also have a positive effect on low bone density, a secondary condition often associated with JIA. In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause overtiring and joint pain should be avoided. Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a ball, low-impact aerobic dancing, walking, and yoga. (Option 1) Playing dodgeball places the child at risk for joint or other injury. (Option 2) Reading a book does not provide physical activity.

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client? 1.Avoid a high-potassium diet 2.Exercise regularly and maintain a high-fiber diet 3.Maintain oral hygiene 4.Report excessive urination and increased thirst

4. Report excessive urination and increased thirst. Risk factors for lithium toxicity include dehydration, decreased renal function (in the elderly), diet low in sodium, and drug-drug interactions (eg, nonsteroidal anti-inflammatory drugs [NSAIDS] and thiazide diuretics). Rationale: lithium range: 0.6-1.2mEq/L Chronic toxicity can result in: Neurologic manifestations - ataxia, confusion or agitation, and neuromuscular excitability (tremor, myoclonic jerks) Nephrogenic diabetes insipidus - polyuria and polydipsia (increased thirst) (Option 4)

The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1.Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain 2.Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale 3.Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale 4.Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

4.Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain

he nurse is caring for a client with alcohol intoxication who is exhibiting nystagmus, ataxia, and confusion. Which prescription from the health care provider would the nurse expect to be implemented first? 1.Blood draw for liver function tests 2.D5 1/2 normal saline 3.Folic acid, IV 4.Thiamine, IV

4. Thiamine IV Rationale: a client with alcholisim is at risk for hypoglycemia and B1( thiamine) deficiency which can result into Wernicke encephalopathy. All intoxicated clients should be given IV thiamine or IV glucose. Option 1) A blood draw for liver function tests to rule out alcoholic hepatitis is important but not a priority. (Option 2) D5 1/2 normal saline can be administered either in conjunction with or after the thiamine. Thiamine is the priority. (Option 3) Clients with alcoholism usually have additional nutritional deficiencies (eg, folic acid, magnesium). Magnesium and multiple vitamins should also be given to these clients. However, thiamine is the essential vitamin to administer before or with IV glucose in a client with suspected alcoholism.

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? 1."I will hold the cane in my right hand." 2."I will move my left leg forward after moving the cane." 3."I will place the cane several inches in front of and to the side of my right foot." 4."My cane should equal the distance from my waist to the floor."

4." My cane should equal the distance from my waist to the floor." Rationale: cane length should equal the distance from the client's greater trochanter to the floor. A cane measured from the waist would be too long to provide optimal support. Teaching points: 1.hold the cane onthe stronger side, keeping elbow slightly flexed (20-30 degrees) 2. Place the cane6-10 in front and to the side of the foot to keep the body weight on both legs to provide balance 3.)Move the stronger leg forward past the cane and the weaker leg so the weight is divided between the cane and the weaker leg 4.) always keep at least 2 points of support on the floor at all times

Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply. 1.After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor 2.After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg 3.Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine 4.Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion; current values are 90/70 mm Hg and 100/min, respectively 5.Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction

4.Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion; current values are 90/70 mm Hg and 100/min, respectively 5.Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction Rationale:Acute hemolytic reaction during a blood transfusion usually develops within the first 15 minutes. Signs/symptoms include chills, fever, lower back pain (from damaged cells in the kidneys), tachycardia, tachypnea, and hypotension. Acute hemolytic reaction is an emergency that requires the nurse to stop the transfusion and treat shock. Normal fetal heart tones range from 110-160/min. A decrease in heart rate that occurs on or after the peak of a contraction is a late deceleration. This may indicate uteroplacental insufficiency and must be assessed. Nifedipine (Procardia) is a potent calcium channel blocker antihypertensive. It should not be administered when the client's blood pressure is on the lower end of the acceptable range as this may result in hypotension. (Option 1) Albuterol (Ventolin) is a bronchodilator beta-adrenergic agonist. Expected side effects include tremor, tachycardia, and palpitations. Normal pulse rate in a 5-year-old ranges from 70-120/min and averages 100/min. This client's pulse is close to the upper limit of the normal range. (Option 2) This is the upper normal dosing limit for initial IV push administration of hydromorphone (Dilaudid), a potent narcotic. Hypotension and bradycardia are expected adverse effects. Orthostatic hypotension occurs most often with ambulation or positioning in the semi-Fowler's position. Clients are not generally allowed to ambulate for 20-30 minutes after IV push administration of narcotics. This onetime reading is not significant enough to require emergency intervention.

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1.Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 2.Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3.Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4.Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

4.Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting rationale:An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical.

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. Aspirin: 81 mg PO, daily Clopidogrel: 75 mg PO, daily Metoprolol XL: 50 mg PO, daily Furosemide: 40 mg PO, twice daily Fish oil: 4 g PO, daily 1.Bruising easily, especially on the arms 2.Fatigue 3.Feeling depressed 4.Muscle cramps in the legs

4.Muscle cramps in the legs rationale: Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis.

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? 1.Bradycardia 2.Hypokalemia 3.Nephrotoxicity 4.Ototoxicity

4.Ototoxicity Rationale:IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses >120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg) / (4 mg/min) = 40 min (Option 1) Bradycardia is an adverse effect of beta blockers (eg, metoprolol, atenolol), calcium channel blockers (eg, verapamil), and digoxin. It is not an adverse effect of furosemide. (Option 2) Hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect. (Option 3) Although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration.

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 28 Fr, 30-mL balloon, 3-way Foley catheter with continuous bladder irrigation. Which finding by the nurse best indicates that the bladder irrigation is running at an adequate rate? 1.Blood pressure 120/80 mm Hg, pulse 80/min 2.Intake 3200 mL, output 3000 mL 3.Lack of bladder spasms 4.Output urine is light pink in color

4.Output urine is light pink in color rationale:Transurethral resection of the prostate (TURP) involves insertion of a rectoscope to excise obstructing prostate tissue. Continuous bladder irrigation is initiated after the procedure. The large catheter and balloon apply direct pressure on the bleeding tissue and allow urine to drain. A specific rate is not prescribed; the irrigation flow is adjusted so that the urine remains light pink without clots. Typically, the irrigation rate will gradually decrease during the first 24 hours. (Option 1) Vital signs within normal limits indicate hemodynamic stability but not patency of the draining catheter from irrigation. (Option 2) Overall, the intake and output should be equal (considering approximately 400-500 mL/day of insensible loss). If the negative balance is ≥500 mL, further assessment/intervention is needed. However, fluid balance is not the best indicator of irrigation infusion rate in these clients. (Option 3) Painful bladder spasms are expected after TURP and catheter placement. The spasms are typically treated with belladonna-opium suppositories or other antispasmodics (eg, anticholinergics such as oxybutynin [Ditropan]). The nurse should remind the client to refrain from trying to void around the catheter as this can trigger the spasms.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1.Administer pain medication 2.Call the health care provider to meet with the family to obtain informed consent 3.Complete the preoperative checklist 4.Perform the morning assessment

4.Perform the morning assessment Rationale:The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained.

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? 1.Encourages the client to drink extra fluids while taking ferrous sulfate 2.Offers the client orange juice for administration of ferrous sulfate 3.Plans to administer ferrous sulfate one hour before breakfast 4.Prepares to administer a prescribed calcium supplement with ferrous sulfate

4.Prepares to administer a prescribed calcium supplement with ferrous sulfate Rationale: Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption (Option 4). (Option 1) Taking an iron supplement increases the client's risk for constipation. Instructing the client to increase fluid intake during therapy may help prevent hard stools. (Options 2 and 3) Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? 1.Isolation gown, surgical mask, goggles, and gloves 2.Isolation gown and surgical mask 3.N95 respirator mask 4.Surgical mask

4.Surgical mask Rationale:Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. (Options 1 and 2) The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. (Option 3) The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air.

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? 1.C-reactive protein (CRP) 2.Prothrombin time (PT) 3.Serum LDL cholesterol 4.Tuberculin skin test (TST)

4.Tuberculin skin test (TST) rationale:TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4). (Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications.

A male client admitted with a traumatic open fracture of the femur, hematocrit of 36% (0.36), and hemoglobin of 12 g/dL (120 g/L) is being prepared for surgery. Which prescription should the practical nurse validate with the registered nurse before administration?? 1.Cefazolin 2.Enoxaparin 3.Morphine 4.Tetanus toxoid

Enoxaparin

Interdisciplinary client care rounds and hand-off communication are examples of strategies used to improve communication in health care settings. What is the most important outcome of effective communication among care givers? A.) Decreased length of hospital stay B.)Less obvious needs of clients met accordingly C.)properly educated clients D.) reduced number of medical errors

D.) REDUCED NUMBER OF MEDICAL ERRORS

The nurse is reviewing the telemetry strips of assigned clients. The rhythm strip displayed in the exhibit is given to the nurse by the telemetry technician. The nurse recognizes it as which rhythm? Click on the exhibit button for additional information. 1. Atrial fibrillation 2.First-degree atrioventricular block 3.Sinus bradycardia 4.Sinus rhythm

sinus rhythym look up rhythm

A client has a follow-up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care provider? 1.Client excitedly reports being able to go an entire work day without having to urinate 2.Client is using an over-the-counter artificial saliva product for dry mouth 3.Client reports occasional dizziness in the morning and when changing positions 4.Client reports symptoms of constipation

tolterdine: rationale:Tolterodine (Detrol LA), oxybutynin (Ditropan), and solifenacin (Vesicare) are antimuscarinic/anticholinergic medications used for overactive bladder and urge urinary incontinence. They decrease urinary urgency and frequency. The most common side effects are anticholinergic (eg, dry mouth, constipation, cognitive dysfunction). The client's report of not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention. Urinary retention can lead to bladder infections and distension. This information should be reported to the health care provider (HCP). (Option 2) Artificial saliva products and sugar-free hard candy and gum are acceptable ways to manage dry mouth caused by anticholinergic medications. (Option 3) Occasional dizziness is a side effect of tolterodine. The client should rise and change positions slowly. However, if this client is receiving too high a dose, reduction of the dose may alleviate the dizziness. Severe dizziness should be reported to the HCP. (Option 4) Constipation can be managed with increased fiber in the diet, fluids, stool softeners, or laxatives.