Archer Tutor 12/19

The nurse is caring for a patient with a myocardial infarction who is experiencing tachycardia and coughs up frothy, pink-tinged sputum. Which finding would the nurse expect upon auscultation of lung sounds? A. Wheezing B. Crackles C. Rhonchi D. Diminished sounds

B. Crackles common in cases of pulmonary edema related to myocardial infarction. Wheezing is common in cases of inflammation and narrowed airways. Rhonchi occurs in bronchitis and pneumonia. Diminished breath sounds are usually heard with COPD or pneumonia.

The nurse is educating the client with urinary tract calculi regarding diet. Which of the following foods may the client have? Select all that apply. A. Broccoli B. Lettuce C. Cheese D. Apples

A, B, D

Which of the following nursing actions reflects effective time management? A. The nurse asks the patient what is their priority to accomplish each day B. The nurse includes a "nice to do" for every "need to do" task on the list C. The nurse "front loads" the schedule with "must-do" priorities D. The nurse avoids helping other nurses if scheduling does not permit it

A. The nurse asks the patient what is their priority to accomplish each day To manage time; the nurse should establish goals and priorities for each day and include the patient in prioritizing tasks.

The nurse is developing a plan of care for a client who has epilepsy and is undergoing an electroencephalogram. Which of the following should the nurse include in the client's plan of care? Select all that apply. A. Provide padding to the side rails B. Verify suction is at bedside and working properly. C. Keep bite block at bedside in case of seizure. D. Ensure nasal cannula is available and working at the bedside. E. Establish peripheral vascular access

A, B, E Ensuring the side rails are raised and padded will provide a safe environment for the client in case of a seizure. It is imperative to have suction ready at the bedside should the client vomit during a seizure. Timely clearing of the airway will prevent aspiration, maintain a patent airway, and keep your client safe. Suctioning the client should only occur once the seizure has terminated, as it is contraindicated to putting objects in the client's mouth. Ensuring that peripheral vascular access is essential because if the client has a seizure, parenteral benzodiazepines (diazepam/lorazepam) are necessary.

While providing education to your pediatric patient diagnosed with atopic dermatitis, which of the following points are important to make? SATA A. Avoid harsh soaps and detergents B. Wash the affected areas 4-5 times/day C. Apply lotion immediately after bathing D. Keep nails short

A, C, D

The nurse is assessing assigned clients. Which client has a risk for urinary retention? Select all that apply. A. A 78-year-old man diagnosed with an enlarged prostate. B. An 83-year-old woman on bed rest. C. A 75-year-old woman with vaginal prolapse. D. An 89-year-old man with dementia. E. A 73-year-old woman on antihistamines to treat allergies. F. A 90-year-old man with difficulty walking to the restroom.

A, C, E Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman). Antihistaminic medications (such as diphenhydramine) tend to have anticholinergic side effects. Urinary retention can occur from the use of drugs with anticholinergic side effects. The bladder muscle's (detrusor smooth muscle) primary function is to "contract" and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic)receptors that facilitate this contraction. Anticholinergic agents impair this function and predispose to urinary retention. Excessive urinary retention eventually results in "overflow" incontinence.

The nurse is planning a staff development conference about medications utilized in an emergency. Which of the following information should the nurse include? Select all that apply. A. Sodium bicarbonate is prescribed for severe cases of metabolic acidosis. B. Diphenhydramine should be administered before epinephrine for anaphylaxis. C. Glucagon may be prescribed to treat calcium channel blocker toxicity. D. Calcium gluconate is prescribed to treat dysrhythmias associated with hypokalemia. E. Magnesium sulfate is the prescribed treatment for torsades de pointes.

A, C, E Sodium bicarbonate may be used to treat severe metabolic and respiratory acidosis. Glucagon is an approved treatment for calcium channel and beta-blocker toxicity. Magnesium sulfate is the treatment for torsades de pointes, a fatal ventricular dysrhythmia. This should be combined with defibrillation if the client is hemodynamically unstable with torsades de pointes.

The nurse is teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? SATA A. Providing a meal tray B. Changing bed linens C. Replacing a suction cannister D. Obtaining vital signs E. Providing range of motion exercises

A, D, E Anytime the nurse or unlicensed assistive personnel (UAP) engages directly with the client, two identifiers (name and date of birth) should be asked. This prevents misidentification and mitigates errors related to care delivery. Providing a meal tray will require the identifiers because diets vary by client and are prescribed by the primary healthcare provider (PHCP). Obtaining vital signs requires the two identifiers so the nurse (or UAP) may accurately record these vital signs. Finally, providing range of motion requires two identifiers as it is a task directly involving the client.

The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication? Select all that apply. A. Multivitamin B. Aspirin C. Warfarin D. Simvastatin E. Salmeterol

A, E Cystic Fibrosis is a multisystem disorder that causes gastrointestinal disturbances such as malabsorption of essential fat-soluble vitamins (A, D, E, and K). A multivitamin is prescribed to help mitigate these vitamin deficiencies. Salmeterol is a long-acting bronchodilator and has utility in cystic fibrosis as the airways may become narrowed or obstructed.

The nurse is educating a client scheduled for pulmonary function tests. It would indicate effective teaching if the client makes which statement? A. "I should not use my bronchodilator four to six hours before these tests." B. "I should not eat or drink six to eight hours prior to these tests." C. "I will need someone to drive me home after I wake up from the anesthesia." D. "My gag reflex will have to return before I resume eating and drinking."

A. "I should not use my bronchodilator four to six hours before these tests." Before the testing, the client is instructed to withhold any bronchodilators four to six hours prior, abstain from smoking, and refrain from wearing tight or restrictive clothing.

Which of the following would cause an increase in cardiac output? Select all that apply. A. 2 L normal saline fluid bolus B. Furosemide C. Propranolol D. Dopamine

A. 2 L normal saline fluid bolus D. Dopamine When you increase the amount of mass in circulation, you increase the patient's stroke volume. Dopamine is an inotrope that improves the contractility of the heart. This means that the center will contract harder and pump out more blood with each contraction. Furosemide is a potent loop diuretic, which induces diuresis and therefore reduces the amount of fluid in the vasculature. With reduced volume, preload in the heart is decreased. With decreased contraction, there is reduced stroke volume, and therefore decreased cardiac output. The administration of propranolol will decrease cardiac output. Propranolol is a beta-blocker used to control the pulse of the heart and therefore reduces the heart rate.

A 70-year old man in the ICU experiences sudden cardiac arrest. The code team arrives and performs CPR. After about five minutes, the patient obtains a return of spontaneous circulation (ROSC). A carotid pulse is found, but femoral and radial pulses are not. What is this patient's approximate minimum systolic blood pressure? A. 60 mmHg B. 70 mmHg C. 80 mmHg D. 90 mmHg

A. 60 mmHg When pulses are palpable, it can be clinically inferred that a patient with a Carotid > 60 mm Hg Femoral > 70 mm Hg Radial > 80 mm Hg

The nurse in the burn unit is about to perform a dressing change on a patient that has deep-partial thickness and full-thickness burns. The nurse understands that during the dressing change, minimizing pain on the patient is of top priority. All of the following are correct nursing interventions, except: A. Administering COX2 inhibitors orally 10 minutes before the dressing change. B. Giving a clear explanation to the patient about what the procedure is and how it is going to be done. C. Changing the patient's dressing carefully and handling burned areas gently. D. Letting the patient watch his favorite TV show while changing the dressing.

A. Administering COX2 inhibitors orally 10 minutes before the dressing change. The drug of choice for controlling pain in patients with burns is morphine sulfate. Any other pain medication aside from opioids would not provide enough pain relief. Pain medications should be given to the client 30 minutes before any activity (i.e. Dressing change)

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time? A. After exercise tolerance is assessed B. One week after surgery C. When the patient can comfortably jog two miles D. Three months after surgery

A. After exercise tolerance is assessed Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

The nurse is caring for a client who presents with a blood glucose level of 45 mg/dL. Which of the following findings are expected? Select all that apply. A. Blurred vision B. Increased urinary output C. Cool and clammy skin D. Palpitations E. Orthostatic hypotension F. Paresthesias

A. Blurred vision C. Cool and clammy skin D. Palpitations F. Paresthesias

You are caring for a 1-month-old patient who has a sudden cardiac arrest. Which pulse should you palpate to determine circulatory status? A. Brachial B. Femoral C. Carotid D. Popliteal

A. Brachial In infants, the brachial artery is the right site to check for a pulse. This will help determine how to proceed with the code event and if there is a return of spontaneous circulation (ROSC).

Which of the following is considered the gold standard for determining fluid balance? A. Daily weights B. Strict intake and output measurements C. Urine osmolarity testing D. Basal metabolic panel results

A. Daily weights Daily weights are considered the gold standard for monitoring fluid balance. Monitoring for changes in normal pressure is the most direct and useful way to compare changes in fluid status and evaluate needed interventions.

The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by: Select all that apply. A. Fever B. Alzheimer's disease C. Hypoglycemia D. Vascular disease E. Infection

A. Fever C. Hypoglycemia E. Infection Delirium is an alteration in mental status that occurs abruptly. Delirium, unlike dementia, is reversible with treatment.

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern? A. Headache and nausea B. Scant blood on the AV fistula C. Potassium 3.7 mEq/L D. Hemoglobin 8.8 mg/dL

A. Headache and nausea Headache and nausea may be a manifestation associated with dialysis disequilibrium syndrome (DDS). This is a complication experienced by clients undergoing their first dialysis and may range from mild to severe.

A client presents to the clinic asking the nurse about emergency contraception. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? A. Levonorgestrel B. Tamoxifen C. Finasteride D. Methotrexate

A. Levonorgestrel This medication is indicated to be used up to 72 hours following unprotected intercourse, where pregnancy could be possible. It may be used off-label up to 120 hours following the event. This medication works by postponing (or inhibiting) ovulation. B: prevent cancer C: for benign prostatic hyperplasia, cause teratogenic, use gloves with pregnant women. D: for ectopic pregnancy

When assessing hydration in an adult patient, the nurse will: A. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal. B. Pinch a fold of skin on the abdomen and observe for recoil to normal. C. Pinch a fold of skin on the calf and observe for recoil normal. D. Pinch a fold of skin on the forehead and allow for the skin to recoil in children.

A. Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal.

You are teaching a group of new graduate nurses about the long term effects of congestive heart failure. You know that they understand your teaching when they state the following expected findings. Select all that apply. A. Polycythemia B. Clubbing C. Pulsus alternans D. Macewen's sign

A. Polycythemia B. Clubbing Polycythemia is an abnormally increased hemoglobin concentration in the blood; it is a severe long-term effect of congestive heart failure. It is due to the impact of chronic hypoxia on the body. The problem is that there is no more oxygen available, so the body continues to be hypoxic and continues to produce red blood cells in an attempt to correct this. After overproducing red blood cells, the blood becomes very thick. Clubbing is defined as a bulbous enlargement of the ends of the fingers or toes due to the lack of oxygen reaching their distal extremities over time.

The nurse is caring for a client involuntarily admitted to the behavioral health unit. The client has been mailed a package. The nurse should perform which action? A. Provide the client with the package B. Open the package to review its content C. Provide the package upon discharge D. Determine if the sender is the client's next of kin

A. Provide the client with the package Under the patient bill of rights, the client has a right to confidentiality and privacy. The nurse should not open postal packages prior to giving them to the client. If the nurse is concerned that the client could be mailed something harmful, the nurse should request that they open the package up in front of them.

Which stage of cognitive development does the nurse expect her 6-month-old patient to be in? A. Sensorimotor B. Preoperational C. Concrete operational D. Formal operational

A. Sensorimotor This stage occurs between 0 and 2 years old. During this stage, the child learns to coordinate their senses with motor responses. They are curious about the world and use their minds to explore. They start to form language and use it for demands. They also develop object permanence. B. Preoperational: 2 and 7 years old C. Concrete operational: 7 to 11 years old D. Formal operational: begins at 11 years old

A nurse is caring for a post-cardiovascular accident (CVA) client who continues to have slight cognitive difficulties, specifically exhibited via intermittent difficulty understanding verbal communication. Which action by the nurse is most appropriate when talking to this client? A. Speak slowly with simple directions and gestures B. Speaking to the client in a raised tone of voice C. Encouraging the client to respond to every statement by the nurse D. Consistently shifting topics of conversation

A. Speak slowly with simple directions and gestures When providing care for a client experiencing post-CVA cognitive difficulties, nurses should adapt communication to maximize understanding. Ideally, communication should be spoken slightly slower than normal and include simple directions and gestures to facilitate comprehension by the client. By utilizing effective communication techniques, the nurse not only builds rapport with the client but assists in building the client's confidence.

You are working in the emergency department and are preparing to discharge a patient who came in with a magnesium level of 1.4 mEq/L. You are writing a list of foods you recommend that the patient consumes. Which foods would be appropriate for this list? Select all that apply. A. Spinach B. Onions C. Mushrooms D. Salmon

A. Spinach D. Salmon This patient's magnesium level is borderline low, so the nurse must encourage them to eat foods rich in magnesium. Spinach is an excellent source of magnesium, offering about 140 mg per cup (Choice A). Salmon is a good source of magnesium, offering about 88 mg per fillet (Choice D).

Your client is at the end of life and experiences guilt for past transgressions. After a number of independent and dependent nursing functions, what is an expected outcome for this client? A. The client will articulate the nature of humans in terms of fallibility. B. The client will go to confession to ask for forgiveness. C. The client will perform relaxation techniques to dissolve guilt. D. The client will not express any more feelings at the end of life.

A. The client will articulate the nature of humans in terms of fallibility. An expected outcome for this client could be that the client will articulate the nature of humans in terms of fallibility. The purpose of guilt is to allow the person to know that they have done something wrong, and it also permits the person, at the end of life, to make final amends to those that they have hurt.

The nurse is caring for a client with type 1 diabetes mellitus who develops hyperglycemia between 5:00 and 6:00 AM as a result of the nighttime release of growth hormone. The nurse should recognize that this condition is consistent with A. dawn phenomenon. B. Somogyi effect. C. hyperosmolar hyperglycemic syndrome (HHS). D. diabetic ketoacidosis (DKA).

A. dawn phenomenon. For a client with the dawn phenomenon, it would be expected that the client has morning hyperglycemia caused by the release of various hormones (cortisol, growth hormone, and adrenaline). The Somogyi effect is morning hyperglycemia from the counterregulatory response to nighttime hypoglycemia.

The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who A. has atrial fibrillation and a heart rate of 112/minute. B. has glomerulonephritis with a blood pressure of 137/86 mm Hg. C. is receiving amphotericin b, and the most recent temperature is 100.4°F (38°C). D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.

A. has atrial fibrillation and a heart rate of 112/minute. The client with atrial fibrillation and has two treatment goals. 1. The prevention of a stroke 2. Rate control between 60-100. The client with atrial fibrillation with an elevated heart rate requires priority follow-up because the increased rate likely means the client has atrial fibrillation with a rapid ventricular response. The client with this type of arrhythmia requires medications such as diltiazem or amiodarone to achieve rate control.

The nurse is caring for the following assigned clients. The nurse should follow up on which client first? A client who has A. mechanical ventilation and the low-pressure alarm sounds. B. a new colostomy and refuses to participate in care. C. acute glomerulonephritis and has periorbital edema. D. atrial fibrillation and an irregular pulse.

A. mechanical ventilation and the low-pressure alarm sounds. A client receiving mechanical ventilation requires multiple assessments. The low-pressure alarm is concerning for ventilator disconnection or low cuff pressure. The high-pressure alarm is concerning for obstruction such as secretions. This client should be assessed first under the priority model of "ABCs" = airway, breathing, circulation.

The nurse is changing a diaper for her 7-month-old patient suspected of having Celiac disease. She notes a large, pale, oily stool that is malodorous. This assessment finding is known as what? A. Diarrhea B. Steatorrhea C. Hematochezia D. Melena

B. Steatorrhea Steatorrhea refers to the excretion of abnormal quantities of fecal fat due to reduced fat absorption by the intestines. This produces pale, oily, malodorous stools and is a symptom of Celiac disease.

The nurse is inserting a peripheral intravenous catheter. Place each action in the correct order.

Apply a tourniquet and palpate a vein for insertion. Clean the skin with approved solution. Stabilize the vein below the insertion site (digital traction). Puncture the skin and vein with the stylet. Observe for blood return and advance the catheter. Apply pressure above the insertion site and connect the IV tubing. Tape and secure the IV site.

Which of the following are concepts or constructs associated with cultural competence? Select all that apply. A. Cultural obedience B. Cultural skills C. Cultural encounters D. Cultural desire E. Cultural awareness F. Cultural knowledge

B,C,D,E,F

You are reinforcing counseling for two parents that are preparing for the birth of their first child. The father has sickle cell anemia and the mother is a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% B. 50% C. 75% D. 100%

B. 50% father is ss because he has the disease and the mother is Ss since she is a carrier. both copies of the gene in each cell should have the mutations to have that disease (ss). The parents of an individual with an autosomal recessive condition such as sickle cell disease must each carry one copy of the mutated gene.

Due to the influx of patients at a local hospital due to a cholera outbreak, the charge nurse was asked by the nurse manager which patients can be transferred to their rehabilitation ward to free up some space in the medical ward. Which client does this apply to? A. A client with diabetic foot. B. A client with right hemiparesis due to a TIA four days ago. C. A post-myocardial infarction patient with PVCs. D. A client with pneumonia and a respiratory rate of 25.

B. A client with right hemiparesis due to a TIA four days ago. The client with hemiparesis is the most stable of all these patients. The client will also benefit the most from the rehabilitation ward. A: patient still unstable C: High risk of cardiac arrest D: Patient needs to get monitored in case gets into respiratory arrest

A nurse manager of a home health nursing agency is completing client assignments for the nursing staff. Which client should be assigned to the most experienced registered nurse? A. A recovering Guillain-Barre syndrome client complaining of constant fatigue B. A client with stage 3 and 4 pressure injuries present on the sacral area C. A 2-week postoperative laryngectomy client due to laryngeal cancer D. A client due for discharge from home health services in the coming week

B. A client with stage 3 and 4 pressure injuries present on the sacral area A client with stage 3 and 4 pressure injuries present on the sacral region requires extensive wound care from an experienced nurse capable of properly assessing and caring for the client's pressure injuries.

Which of the following are features characteristic of fetal alcohol spectrum disorder? Select all that apply. A. Macrocephaly B. Attention deficit disorder C. Encephalopathy D. Enlarged philtrum

B. Attention deficit disorder C. Encephalopathy Many central nervous system disturbances are observed in these patients, including encephalopathy, hypersensitivity, seizures, learning disabilities, difficulty remembering things, impulsivity, and ADD or ADHD (Choice B). Encephalopathy is a common finding when dealing with a fetal alcohol spectrum disorder. There are many central nervous system disturbances that are observed in these patients, including encephalopathy, hypersensitivity, seizures, learning disabilities, difficulty remembering things, impulsivity, and ADD or ADHD (Choice C).

The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply. A. Carotid pulse check should not take more than 20 seconds. B. The rate of chest compressions should be 100-120 per minute. C. Chest compression depth should be 2 inches on the center breastbone. D. Chest tube insertion should be prepared after five minutes of CPR. E. Early defibrillation is essential in the survival of ventricular fibrillation.

B. C. E High-quality CPR involves a compression depth of two inches on the center breastbone. The rate of the compressions should be 100-120 per minute. The nurse should utilize early defibrillation as it is the most effective treatment for ventricular fibrillation. Carotid should not exceed 10 seconds

The clinic nurse notices bruises at multiple stages of healing on a 2-year-old. The nurse also sees a couple of burns on the toddler's trunk. What would be the nurse's most appropriate action? A. Confront the child's parents B. Call Child Protective services C. Check the child again after two weeks D. Call the physician

B. Call Child Protective services Bruises and burns in a child indicate abuse. Once the nurse suspects child abuse, he/she is responsible for notifying Child Protective Services.

Which procedures necessitate the use of surgical asepsis techniques? Select all that apply. A. Intramuscular medication administration B. Central line intravenous medication administration C. Wearing gloves in the operating room D. Neonatal bathing E. Foley catheter insertion F. Emptying a urinary drainage bag

B. Central line intravenous medication administration C. Wearing gloves in the operating room E. Foley catheter insertion Surgical asepsis is used for all procedures involving the sterile areas of the body. Sepsis is the condition in which acute organ dysfunction occurs secondary to infection. In medical asepsis, objects are referred to as clean, which means the absence of almost all organisms; or dirty (soiled, contaminated), some of which may be capable of causing infection.

The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: A. Half Eclipsed Lipase Levels and Preeclampsia B. Hemolysis, elevated liver enzymes, and lowered platelets C. Hematocrit elevation, low lipase, and pancreatitis D. Hemoglobin, elevated lipids, and low plasma

B. Hemolysis, elevated liver enzymes, and lowered platelets HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as symptoms develop.

You are a nurse in the L&D department of the local hospital. You are caring for a newborn born at term with APGAR scores of 8 and 10. Before discharge from the hospital, you should ensure that the newborn has received: A. Hep A (hepatitis A) vaccine B. Hep B (hepatitis B) vaccine C. RV (Rotavirus) vaccine D. DTaP (diphtheria, tetanus, and pertussis) vaccine

B. Hep B (hepatitis B) vaccine The Hepatitis B vaccine is given in three doses; the first dose is administered at the time of birth, the second dose at two months, and the third dose at six months of age. Hep A vaccine is not given until the child is one year old. Rotavirus vaccine is given in 2 or 3 doses. The first dose is given at 2 months. DTaP vaccine is given in 5 treatments with the first dose administered at two months.

The right brake on your client's wheelchair is not holding as strong as the left brake. What is your priority action? A. Ask the client if this just happened today. B. Immediately remove the wheelchair from use. C. Try to tighten the brake up with a simple tool. D. Call the physical therapist for another device.

B. Immediately remove the wheelchair from use.

A pregnancy-related spinal change that can alter mobility is known as: A. Ankylosing spondylosis B. Lordosis C. Scoliosis D. Kyphosis

B. Lordosis This is the result of the increasing weight of the enlarging uterus and the effect of gravity. As a fetus grows, a variety of changes appear in a pregnant woman's body. The thoracic and lumbar spine curvature change, pain in the low back, and pelvic region can increase, and the balance and gait pattern also changes. Some studies report that the center of gravity of pregnant women moves towards the abdomen, resulting in an increase in lumbar lordosis, posterior tilt of the sacrum, and movement of the head to the back to compensate for the increased weight as the fetus grows.

The nurse is caring for a patient with a history of hyperparathyroidism who is complaining of nausea. Upon assessment, the nurse notes the patient is tachycardic, with a QT interval of 0.3 seconds and slight abdominal distention. What action should the nurse take first? A. Encourage intake of vitamin D-rich foods B. Notify primary healthcare provider ( PHCP) C. Hold patient's scheduled furosemide D. Assess for Chvostek's sign

B. Notify primary healthcare provider (PHCP) Hyperparathyroidism can result in elevated calcium levels due to overproduction of the parathyroid hormone, increased intestinal absorption of calcium, and bone resorption. The client's QT interval is shortened at 0.3 seconds ( normal QTc is 0.4 to 0.44 seconds). This client is showing symptoms and signs of hypercalcemia: nausea, abdominal distention, tachycardia (likely ventricular tachycardia), and shortened QT interval.

The patient that has just undergone cardiac surgery is recovering in the post-anesthetic care unit. The nurse notices that the patient's blood pressure is 88/52 mmHg and that his jugular veins are very prominent. The nurse auscultates his heart rate and cannot hear any heart sounds. The nurse immediately informs the physician on duty and prepares for which procedure: A. Thoracentesis B. Pericardiocentesis C. Arthrocentesis D. Paracentesis

B. Pericardiocentesis The patient in the situation is experiencing a cardiac tamponade, manifested by hypotension, distended neck veins, and inaudible heart sounds (Beck's Triad). If cardiac tamponade is suspected, treatment involves pericardiocentesis to relieve the compression of the ventricles.

You have been caring for a severely depressed client in the community. When you see this client today, the client is far less depressed than they were in the past. What priority should the nurse consider in terms of this client's current psychological state? A. The client has resolved the depression. B. The client may have planned their suicide plan. C. The antidepressant medications are effective. D. Their cognitive behavioral therapy is effective.

B. The client may have planned their suicide plan.

The nurse is caring for assigned clients. The nurse should immediately follow up with the client who A. has influenza and their most recent temperature was 102°F (39°C). B. is recovering from a thoracentesis and reports a nagging cough. C. reports reddish-brown sputum immediately following a bronchoscopy. D. has pulmonary tuberculosis and is wearing a surgical mask while ambulating to radiology.

B. is recovering from a thoracentesis and reports a nagging cough. Manifestations of a pneumothorax that are concerning include a nagging persistent cough, increased heart and respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the pneumothorax, a chest tube may be needed. A fever is common with influenza and would not necessitate the need for immediate follow-up. Following a bronchoscopy, reddish-brown sputum is expected because as the scope passes by the mucosa, it may irritate. Finally, no follow-up is necessary for a client with pulmonary tuberculosis wearing a surgical mask. This is an appropriate infection control measure. It is the healthcare worker that should wear the respirator (N95 mask).

The nurse is counseling a client about a metered-dose inhaler. Which of the following statements by the client indicates effective teaching? Select all that apply. A. "I will be careful not to shake the canister before using it." B. "I will inhale the medication through my nose." C. "After I deliver a dose, I will hold my breath for 10 seconds." D. "I will only inhale one spray with one breath." E. "I will exhale completely and then press down on the inhaler to release the medication."

C, D. E. For clients with a metered dose inhaler (MDI), after a dose is administered, they should hold their breath for ten seconds to allow for the medication to be dispersed in their lungs. The client should only administer one dose (or press the button once) per breath. Before the client presses the button to administer the dose, the client is instructed to exhale completely and then administer the dose during the next inhalation.

A client with Alzheimer's disease is eating in the dining hall along with the other clients. Thirty minutes later, he says to the nurse, "When can I have my breakfast? They haven't given me anything to eat yet." The most appropriate response for the nurse would be: A. "I saw you eating breakfast 30 minutes ago." B. "Are you still not full? I'll ask the kitchen what they served you." C. "I can get you some bread if you like. What else would you like?" D. "You have to wait until it's lunchtime."

C. "I can get you some bread if you like. What else would you like?" The client is displaying acute confusion. The best response for the nurse would be to provide the client with additional food as he requests it.

The nurse is caring for an adolescent taking prescribed paroxetine. Which of the following statements, if made by the client, would require immediate follow-up? A. "This medication makes me feel so tired." B. "I have gained weight since starting this medicine." C. "Since starting this medicine, I feel like giving up." D. "This medicine always makes my stomach upset."

C. "Since starting this medicine, I feel like giving up." An adolescent taking prescribed paroxetine, a selective serotonin reuptake inhibitor (SSRI), should be monitored for suicidal ideations. Statements suggesting a sense of hopelessness are highly concerning and should be the immediate priority.

The nurse is educating a client about their newly prescribed soft diet. It would be appropriate for the nurse to suggest which food item? A. Chunky peanut butter B. Raw carrot sticks C. Applesauce D. Beef jerky

C. Applesauce A soft diet is commonly used for individuals with problems with swallowing, chewing, or trauma to the jaw. Applesauce has a smooth texture acceptable for a client prescribed a soft diet.

Which hazardous gas can be identified in the home with a simple and relatively inexpensive monitor and alarm similar to a smoke alarm? A. Ozone B. Nitrous oxide C. Carbon monoxide D. Carbon dioxide

C. Carbon monoxide This odorless and colorless gas can be deadly, so it is recommended that all homes have a carbon monoxide alarm.

The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected? A. Stools that contain blood and mucus B. Pain with urination C. Episodic upper abdominal pain D. Hypoactive bowel sounds

C. Episodic upper abdominal pain Episodic abdominal pain originating in the right upper quadrant or epigastric area is commonly associated with cholecystitis. The pain may be induced by a meal high in fat.

The nurse is preparing to infuse prescribed cisplatin to a client with cancer. Which priority assessment should the nurse make before administration? A. Cancer staging B. Sodium level C. Intravenous (IV) patency D. Hemoglobin and hematocrit

C. Intravenous (IV) patency IV patency is critical to assess before the infusion of a chemotherapeutic. Serious injuries (extravasation) have been caused by medications like cisplatin being infused into a nonpatent vascular access device. Central lines are highly recommended when infusing chemotherapeutic drugs like cisplatin. Extravasation may lead to tissue necrosis, and medications that cause extravasation are classified as vesicants. If extravasation occurs, the nurse should immediately stop the infusion and aspirate any remaining drug from the vascular device. The nurse should not flush the device because that would further deliver more medication.

You are caring for a 25-year-old male patient in the Intensive Care Unit. He was involved in a motor vehicle accident and required endotracheal intubation. He has been on mechanical ventilation for 24 hours. You draw ABGs. You receive results of the arterial blood gas that show: pH = 7.50 PaCO2 = 28 Bicarbonate = 25 You determine that this ABG shows: A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic acidosis

C. Respiratory alkalosis

You are caring for a patient with a new order for nitroglycerin ointment one inch applied to the skin twice a day to prevent angina. To use nitroglycerin correctly, you know to: A. Apply it only to the upper chest B. Rub the ointment into the skin until it disappears C. Rotate the application sites D. Cover the application site with a gauze dressing

C. Rotate the application sites Topical nitroglycerin is used to help prevent/ treat anginal symptoms in coronary artery disease. To apply nitroglycerin correctly, be sure to rotate the application sites with each application to avoid irritation from the medication. The medication comes with a supply of paper applicators with a small ruler on the paper for proper measurement of the drug. Apply the appropriate amount of ointment on the paper and apply the cream to an area of the skin.

Which of the following expected outcomes is appropriate for a client with heart disease who is complaining of chest pain? A. The client will be free of neuropathic pain related to angina. B. The client will be free of hyperalgesia pain related to angina. C. The client will be free of visceral pain related to angina. D. The client will be free of somatic pain related to angina.

C. The client will be free of visceral pain related to angina. "The client will be free of visceral pain related to angina" is an appropriate expected outcome for a client with heart disease who is complaining of chest pain. Chest pain is an example of visceral pain. Other cases of physical pain are cramping secondary to irritable bowel syndrome and labor pain.

The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN? A. The patient states she feels the need to urinate. B. Patient reports a pinching sensation as the catheter is advanced. C. The student nurse notes resistance when inflating the balloon. D. The student separates the labia majora and labia minora with non-dominant hand.

C. The student nurse notes resistance when inflating the balloon. This may indicate the balloon is within the urethra, not the bladder. If inflated within the urethra, the balloon may cause significant damage. Any complaints or nonverbal signs of discomfort or resistance is noted by the nurse during balloon inflation, are indications to stop this procedure immediately.

A client at 32 weeks gestation arrives at the maternity unit stating she has not felt her baby move for nearly six hours. An external fetal monitor is attached for a nonstress test (NST). The nurse attempts to reassure the client by telling her she has a reactive nonstress test. Which of the following would be indicative of a reactive nonstress test? A. Numerous decelerations lasting between 10 and 20 seconds in duration, all ranging between 15 and 20 beats/minute under the baseline heart rate. B. Fetal heart rate (FHR) of 120 - 160 beats/minute throughout the entire 20-minute monitoring session. C. Three accelerations in a 15-minute period, all ranging between 17 and 21 beats/minute over the baseline heart rate. D. One acceleration in a 20-minute period, lasting 15 seconds at 15 beats/minute over the baseline heart rate.

C. Three accelerations in a 15-minute period, all ranging between 17 and 21 beats/minute over the baseline heart rate. When undergoing a nonstress test (NST), results are considered reactive (reassuring) if there are a minimum of two accelerations of 15 beats/minute above the baseline, each lasting a minimum of 15 seconds over the 20-minute testing period. D: A nonstress test cannot be deemed positive if there are less than two accelerations. Here, there was only one acceleration, making this test nonreassuring (not good).

A 38-week pregnant client is scheduled to undergo a nonstress test (NST). While speaking with the nurse, the client inquires regarding the purpose of this type of testing. The most appropriate response by the nurse would be which of the following? A. "This test determines whether you are ready for labor induction." B. "A nonstress test assesses your blood sugar control." C. "This testing provides an accurate determination of fetal age." D. "A nonstress test assesses the fetal condition in the third trimester."

D. "A nonstress test assesses the fetal condition in the third trimester." A nonstress test (NST) is a non-invasive test performed in pregnancies over 28 weeks gestation. During the procedure, fetal heart rate and uterine contractions are recorded using external electronic monitors and correlated with fetal movements as reported by the mother. This test determines the fetus's condition during the third trimester of pregnancy.

You are reinforcing counseling for two parents that are preparing for the birth of their first child. The mother has sickle cell anemia. So the father has decided to undergo genetic testing to determine if he is a carrier or not. He finds out that he is not a carrier. You tell them that their baby has what chance of having sickle cell anemia? A. 25% B. 50% C. 75% D. 0%

D. 0% The baby has no chance, a 0% chance of having sickle cell anemia. Instead, the baby will be a carrier. Since the baby's mother has the disease, she is ss, and because the father has tested that he is not a carrier nor does he have the disease, he is SS. This means that the only combination possible for the baby is Ss (carrier). mother ss, father SS

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence the way people see and behave within the world is defined as: A. Society B. Community C. Spirituality D. Culture

D. Culture Culture is defined as the customs, arts, social institutions, and achievements of a particular nation, people, or another social group. Society is defined as the people who live in a country or region, their organizations, and their way of life. A community is defined as all the people living in an area or a group or groups of people who share common interests. Spirituality is defined as the quality of being concerned with the human spirit or soul as opposed to material or physical things.

The nurse is conducting a talk about school-age cognitive development to a group of parents. Which statement by the parents would indicate a need for further teaching? A. Collecting marbles and sports cards B. Arranging dolls according to size C. Answering simple trivia D. Deciding which university to go to for college

D. Deciding which university to go to for college Deciding where to go to for college is not developed until adolescence.

A nurse is caring for a client receiving nitroglycerin. It is essential to monitor the client's A. Temperature B. Respirations C. Urinary output D. Blood pressure

D. Blood pressure Nitroglycerin is used in the treatment of angina, pulmonary edema, and hypertensive emergencies. Nitroglycerin decreases both preload and afterload, which may result in hypotension. Thus the client's blood pressure needs to be monitored closely.

You are caring for a family who is experiencing the loss of a child that was given up for adoption. This family is not sharing this loss and their accompanying grief with people outside of their family who, have in the past, served as the family's support system. What type of pain is this family experiencing? A. Complicated grief B. Anticipatory grief C. Inhibited grief D. Disenfranchised grief

D. Disenfranchised grief This family is not sharing this loss and their accompanying grief with people outside of their family (who in the past served as the family's support system) because the damage associated with giving a child up for adoption is experiencing disenfranchised grief. Disenfranchised grief occurs after an injury that is not socially, culturally, religiously, or otherwise not acceptable, such as an abortion, a suicide, and an adoption.

The nurse is caring for a client demonstrating avolition. The nurse would expect to observe the client have which of the following? A. Loss of balance B. Full range of affect C. Diminished expression D. Lack of motivation

D. Lack of motivation Avolition is a lack of motivation and is a key feature in schizophrenia as well as some depressive disorders. Avolition is categorized as a negative symptom associated with schizophrenia.

As you are bathing your client and providing foot care, you notice that the client's toenails appear as shown in the exhibit. Which condition should you suspect? A. Onychomycosis B. Onychomadesis C. Onychorrhexis D. Onychia

D. Onychia Onychia is characterized by inflammation of the nail fold resulting from either injury or infection.

The emergency department nurse is caring for a patient who presents with sudden onset of edema of the lips and acute shortness of breath following a bee sting. The provider's diagnosis is anaphylaxis. The nurse knows that the first-line medication for this diagnosis is: A. Oral diphenhydramine B. Nebulized albuterol C. Oral prednisone D. Parenteral epinephrine

D. Parenteral epinephrine Parenteral epinephrine. Although all of these medications might be appropriate in anaphylaxis, the first-line drug is parenteral epinephrine. Anaphylaxis is an acute antibody-antigen reaction that can be life-threatening. In this case, the patient is at risk for airway compromise. This requires an immediate injection of epinephrine to prevent airway closure. Once the team stabilizes the patient, the nurse might administer the other medications to control the other symptoms.

Which technique is effective for determining and evaluating the effectiveness of the nurse's therapeutic communication and therapeutic communication techniques? A. Performance improvement studies B. ISBAR C. Critical thinking D. Process recording

D. Process recording

The parents of a 2-year old with Hirschsprung's disease are talking to the nurse in the family clinic. They ask the nurse about treatment options for Hirschsprung's disease; the nurse understands that the treatment of choice would be which of the following? A. A colostomy B. Senna concentrate C. Polyethylene glycol D. Pull-through procedure

D. Pull-through procedure In Hirschsprung's disease, the aganglionic section of the colon is removed, and the unaffected, functioning ends are attached to each other. In some cases, a Pull-through procedure is done, where a surgeon removes the segment of the large intestine lacking nerve cells and connects the first part to the anus.

The nurse is discharging the client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral should the nurse make? A. Refer the client to hospice care. B. Refer the client to speech therapy. C. Refer the client to physical therapy. D. Refer the client to a home health agency.

D. Refer the client to a home health agency. The client is going home, thus the client needs to be referred to a home health agency so that there is continuity of care even at home. Hospice care is for clients that are terminally ill. This client is not terminally ill. Speech therapy aids clients in regaining speech and swallowing abilities. Physical therapy aids clients in regaining muscle strength and balance. Physical therapy should have been initiated and ongoing while the client was in the hospital.

The nurse is assessing clients with potential hypothyroidism. Which client most likely has this condition? A. Thin, anxious-appearing female with exophthalmos with rapid pulse and complaints of diarrhea. B. Slightly obese, perspiring female who complains of feeling cold all the time with frequent diarrhea. C. Thin, perspiring male with a hoarse voice, facial edema, and a thick tongue with complaints of diarrhea. D. Slightly obese female with periorbital edema who complains of cold intolerance, brittle hair, and dry skin.

D. Slightly obese female with periorbital edema who complains of cold intolerance, brittle hair, and dry skin. Thyroid hormones maintain the body's temperature, and a slowed metabolism may result in less heat production and slightly lower body temperature. Some patients present with decreased blood flow and oxygen to the brain, and some research has suggested that thyroid disease may also affect neural pathways. Symptoms may include impaired attention and concentration, memory loss, slowed perceptual and visuospatial function, and impaired language and executive function (multi-tasking abilities). Rough, cool, and pale skin are features of an underactive thyroid. This is partially due to decreased blood flow and slower turnover of skin cells.

The nurse is caring for a client who is receiving prescribed risperidone. Which of the following findings would indicate a therapeutic response? The client demonstrates A. a reduction in weight. B. increased mood lability. C. an appropriate gait pattern. D. decreased thoughts of persecution.

D. decreased thoughts of persecution. For schizophrenia, induce metabolic syndrome (increase weight), provide mood stability. A/E extrapyramidal side effects causing gait disturbances.

You are a pediatric emergency room nurse triaging patients on a busy night. A 1-month-old presents with the following symptoms: projectile vomiting after feeding, visible peristaltic waves across the epigastrium, and an olive-shaped mass in the epigastrium just right of the umbilicus. Based on your assessment, choose the image showing the anatomy the nurse expects this patient to demonstrate.

This image demonstrates hypertrophic pyloric stenosis; hypertrophy of the circular muscles of the pylorus. This causes the narrowing of the pyloric canal and does not allow food to pass from the stomach to the duodenum. The symptoms that this infant presents with are a classic presentation of pyloric stenosis. This is what the nurse expects the surgeons to find when they operate.