HESI 2
What potentially adverse effect of an intravenous titrated drip of lidocaine (Xylocaine) should the nurse immediately report to the healthcare provider?
Correct1 Tremors 2 Anorexia Incorrect3 Tachycardia 4 Hypertension Tremors are a precursor to the major adverse effect of seizures. Although anorexia may occur, it is not a serious side effect. Bradycardia, which may lead to heart block, may occur, not tachycardia. Hypotension, not hypertension, may occur.
Phenylketonuria
Protein limitation
Ibuprofen (Motrin) and hydroxychloroquine (Plaquenil) are prescribed for an older client with arthritis. The nurse teaches the client about these medications. What responses to the medication should the client be taught to report? Select all that apply.
Correct 1 Blurred vision 2 Urinary retention Correct 3 Bleeding tendencies 4 Difficulty swallowing 5 Feelings of irritability Visual disturbances are serious effects because retinopathy can occur with hydroxychloroquine. Bleeding tendencies, a potential effect of both drugs, may indicate thrombocytopenia, which can be life threatening. Urinary retention is not related to these drugs. Difficulty swallowing does not occur; however, nausea and vomiting may occur with both drugs. Although irritability and restlessness may occur with both drugs, they are not life threatening and do not have to be reported to the health care provider immediately.
Oxytocin (Pitocin) augmentation by way of intravenous piggyback is prescribed for a client in labor after a period of ineffective uterine contractions. What nursing interventions are most important if strong contractions that last 90 seconds or longer occur? Select all that apply.
Correct 1 Stopping the infusion Correct 2 Turning the client on her side Correct 3 Notifying the health care provider Correct 4 Verifying the duration of contractions 5 Administering oxygen by way of nasal cannula Discontinuing the oxytocin (Pitocin) infusion lessens uterine stimulation and eases intrauterine pressure; continuing the oxytocin may lead to fetal hypoxia, placental separation, or uterine rupture. Turning the client on her side increases oxygen perfusion to the fetus. The health care provider should be notified to obtain additional prescriptions. Contractions lasting longer than 90 seconds warrant stopping the oxytocin infusion to prevent uterine rupture. Oxygen administration by way of facemask, not nasal cannula, will increase oxygen supply to the placenta and fetus.
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:
Correct1 Fetal well-being 2 Fetal head compression 3 Uteroplacental insufficiency 4 Umbilical cord compression Nonperiodic accelerations with fetal movement indicate fetal well-being. Early decelerations are associated with fetal head compression. Late decelerations are associated with uteroplacental insufficiency. Variable decelerations are associated with cord compression.
A client who has been taking a conventional antipsychotic for several days comes to the clinic complaining of neck spasms. The figure illustrates the client's physical status observed by the nurse. What extrapyramidal side effect has the client developed?
ct1 Torticollis Incorrect2 Tardive dyskinesia 3 Pseudoparkinsonism 4 Neuroleptic malignant syndrome Torticollis is an acute dystonia that involves muscle spasms of the head and neck. Torticollis develops within 1 to 5 days after beginning therapy with a conventional antipsychotic. Tardive dyskinesia is involuntary repetitious tonic muscular spasms that involve the face, tongue, lips, limbs, and trunk. Tardive dyskinesia takes several months to years to develop after the start of therapy with a conventional antipsychotic. Pseudoparkinsonism is an extrapyramidal tract response that includes masklike facies, shuffling gait, pill-rolling tremors, stooped posture, and drooling. Pseudoparkinsonism develops within several days to 1 month after the start of therapy with a conventional antipsychotic. Neuroleptic malignant syndrome is a severe, potentially fatal (10%) response to conventional antipsychotics. It is believed to be caused by an acute reduction in brain dopamine activity, precipitating hyperthermia, tachycardia, tachypnea, unstable blood pressure, hypertonicity, dyskinesia, incontinence, decreased level of consciousness, and pulmonary congestion. Neuroleptic malignant syndrome can occur during the first week of therapy but often occurs later during therapy.
The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? Select all that apply.
Incorrect 1 Lethargy Correct 2 Headache Correct 3 Diaphoresis 4 Excessive thirst Incorrect 5 Deep respirations Hypoglycemia affects the central nervous system, causing headache. Hypoglycemia affects the sympathetic nervous system, causing diaphoresis. Lethargy is associated with hyperglycemia because glucose is not being used for cellular metabolism. Excessive thirst is associated with hyperglycemia because fluid shifts along with the excess glucose being excreted by the kidneys, resulting in polyuria. Deep respirations (Kussmaul respirations) are associated with hyperglycemia because the body is attempting to blow off carbon dioxide to compensate for the metabolic acidosis.
In addition to hepatitis B, pneumococcal, H. influenza type B, and varicella vaccines, what should the nurse expect a 20-month-old child who has been receiving immunizations on schedule to have had?
Incorrect1 Two DTaPs, two IPVs, and one MMR Correct2 Four DTaPs, three IPVs, and one MMR 3 Three DTaPs, two IPVs, and two MMRs 4 Three DTaPs, three IPVs, and three MMRs By 18 months of age a child should have received four diphtheria, tetanus, and pertussis (DTaP) vaccinations, three inactivated polio vaccinations (IPVs), and one measles, mumps, rubella (MMR) vaccination, as well as hepatitis B, pneumococcal, Haemophilus influenzae type B, and varicella vaccines.
A nurse working in the health services center of a college is reviewing the vaccination records of a young adult who plans to enroll. Which immunizations are required to meet admission criteria according to the American Academy of Pediatrics?
1 One dose of diphtheria toxoid, oral poliomyelitis, live measles, live rubella, and mumps vaccines. 2 Two doses of diphtheria toxoid, oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine. Correct3Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine. Incorrect4Three doses of diphtheria toxoid vaccine, two doses of oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine. Three doses of diphtheria toxoid and oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine is the schedule for active immunization as recommended by the American Academy of Pediatrics. One dose of diphtheria toxoid, oral poliomyelitis, live measles, live rubella, and mumps vaccines does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics. Two doses of diphtheria toxoid, oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics. Three doses of diphtheria toxoid vaccine, two doses of oral poliomyelitis vaccine, and one dose of live measles, live rubella, and mumps vaccine does not follow the schedule for active immunization as recommended by the American Academy of Pediatrics.
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing?
1Atrial fibrillation Correct 2Sinus tachycardia 3Ventricular fibrillation 4 First-degree atrioventricular block The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
