Marty's Saunders NCLEX-RN Remediation

The health care provider has written a prescription for ranitidine (Zantac), 300 mg once daily. Which time should the nurse schedule the medication? At bedtime After lunch With supper Before breakfast

At bedtime Rationale: Ranitidine is a histamine2 (H2)-receptor antagonist. A single daily dose of ranitidine is scheduled to be given at bedtime. This allows for a prolonged effect and the greatest protection of the gastric mucosa. Therefore, the other options are incorrect.

Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? Lochial flow Urine output Temperature Blood pressure

Blood pressure Rationale: Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman's blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication.

A nurse is caring for a client admitted to the hospital for an infection who is receiving an aminoglycoside twice a day, intravenously. The nurse is planning to obtain blood for a peak aminoglycoside level. When should the blood be drawn? A peak level is not indicated. 1 hour after completing the infusion 1 hour before administration of the infusion 15 minutes before administration of the infusion

1 hour after completing the infusion Rationale: Peak medication levels are obtained 1 hour after completing the infusion. Therefore, options 1, 3, and 4 are incorrect.

Isoniazid is prescribed for a child with human immunodeficiency virus infection who has a positive Mantoux tuberculin skin test result. The mother of the child asks the nurse how long the child will need to take the medication. For how long should the nurse tell the mother the medication will need to be taken? 4 months 6 months 9 months 12 months

12 months Rationale: For children with human immunodeficiency virus infection who demonstrate a positive Mantoux tuberculin skin test result, a minimum of 12 months of treatment with isoniazid is recommended.

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the gender of the fetus is determined by which weeks? 6 to 8 8 to 10 13 to 16 20 to 22

13 to 16 Rationale: By the end of the twelfth week of gestation, the fetal gender can be determined by the appearance of the external genitalia on ultrasound; therefore the other options are incorrect.

A 7-year-old child is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child? A board game A large puzzle A finger-painting set A coloring book with crayons

A board game Rationale: The school-age child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board and computer games, riddles, hobbies, competitive games, and listening to the radio or television. Options 3 and 4 are appropriate for a preschooler. Option 2 is appropriate for a toddler.

A mental health nurse who has been meeting with a client with a diagnosis of post-traumatic stress disorder is in the termination phase of the nurse-client relationship. The nurse notes that the client has been quiet and withdrawn. Which interpretation should the nurse make about the client's behavior? An indication of the need for antidepressants An inability of the client to terminate from the nurse A normal behavior that can occur during termination An indication of the need for additional therapy sessions

A normal behavior that can occur during termination Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include the return of symptoms, anger, withdrawal, and minimizing the relationship. The behavior that the client is experiencing is normal during the termination phase and does not necessarily indicate the need for hospitalization, additional sessions, or antidepressants.

A nurse is caring for a client with Paget's disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse should check to see that which medication is available in the stock medication supply for possible use to reverse this elevation? Calcitonin Vitamin D Calcium chloride Calcium gluconate

Calcitonin The normal serum calcium level is 8.6 to 10 mg/dL. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones, thus keeping it out of the serum. In hypercalcemia, large doses of vitamin D should be avoided. Calcium gluconate and calcium chloride would be used to treat tetany that results from acute hypocalcemia.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? Client pain level Inadequate urinary output Client perception of body changes Potential for imbalanced body fluid volume

Client pain level Rationale: The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? Clear CSF, decreased pressure, and elevated protein level Clear CSF, elevated protein, and decreased glucose levels Cloudy CSF, elevated protein, and decreased glucose levels Cloudy CSF, decreased protein, and decreased glucose levels

Cloudy CSF, elevated protein, and decreased glucose levels Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy cerebrospinal fluid; and elevated leukocyte, elevated protein, and decreased glucose levels.

A client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse should provide a list of foods from which diet type? Liquid Fat-free Low-protein High-carbohydrate

Fat-free Rationale: Normal dietary intake of fat should be maintained during the days preceding the test to empty bile from the gallbladder. A low-fat or fat-free diet is prescribed on the evening before the test. This prevents contraction of the gallbladder and allows for accumulation of the contrast substance needed for x-ray visualization during the testing procedure. Therefore, options 1, 3, and 4 are incorrect.

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? Increase oral fluids. Document the finding. Notify the health care provider. Place the infant supine in a side-lying position.

Notify the health care provider. Rationale: The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider.

The nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet to increase her intake of calcium. The nurse determines the need for further instruction when the woman tells the nurse that she will be sure to increase her intake of which food that is lowest in calcium? Pork Seafood Sardines Plain yogurt

Pork Rationale: Of the items listed, pork contains the least amount of calcium. Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and some cereals.

Butorphanol tartrate is prescribed for a client in labor. The nurse understands that this medication is prescribed to achieve which outcome? Providing pain relief Promoting fetal lung maturity Increasing uterine contractions Decreasing uterine contractions

Providing pain relief Rationale: The client in labor may be given parenteral analgesia during the first stage of labor, up to 2 to 3 hours before the anticipated delivery. Butorphanol tartrate is a medication that may be prescribed for pain relief. Options 2, 3, and 4 are not actions of this medication.

The nurse would expect the health care provider (HCP) to add which medication to the regimen of the client receiving isoniazid? Niacin Neurontin Pyridoxine (vitamin B6) Cyanocobalamin (vitamin B12)

Pyridoxine (vitamin B6) Rationale: isoniazid is an anti-tuberculosis medication. Clients receiving isoniazid can develop neuropathy, and the agent of choice to help prevent this adverse effect is pyridoxine, vitamin B6. Niacin is used to lower the cholesterol level. Neurontin is used to prevent seizures, and cyanocobalamin is used to treat anemia.

The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply. Station Dilation Effacement Bloody show Contraction effort

Station Dilation Effacement Rationale: The vaginal examination for a client in labor specifically determines effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics? Clear and dark amber color Light green color with no odor Thick white color with no odor Straw-colored, with flecks of vernix

Straw-colored, with flecks of vernix Rationale: Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid.

The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which item? Iodine Shellfish Penicillin Sulfa drugs

Sulfa drugs Rationale: Thiazide diuretics, such as hydrochlorothiazide, are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, health care provider, nurse, and other health care providers. The other options are not contraindications for administering the medication.

A client taking metronidazole telephones the home health nurse to report dark discoloration to the urine. The nurse interprets that the client's complaint warrants which nursing action at this time? Instruct the client to increase fluid intake. Tell the client to discontinue the medication. Instruct the client to call the health care provider (HCP). Tell the client that this is a harmless medication side effect.

Tell the client that this is a harmless medication side effect. Rationale: Harmless darkening of the urine may occur, and the client should be told of this effect. Metronidazole can produce a variety of side effects, but they rarely require termination of treatment. Increasing fluid intake is a good health measure but will not prevent this side effect from occurring. It is not necessary to discontinue the medication or call the HCP.

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which is the least appropriate way for the nurse to aid the client in relieving the spasm? Ice Heat Analgesics Prescribed intermittent traction

Ice Rationale: Heat, analgesics, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse should tell the mother to implement which action? Keep the child in a room with dim lights. Give the child warm baths to help prevent itching. Allow the child to play outdoors because sunlight will help the rash. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.

Keep the child in a room with dim lights. Rationale: A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Warm baths and sunlight will aggravate itching. Additionally, the child needs to rest. Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome.

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3 is 22 mEq/L. The nurse interprets these results as indicating which condition? Metabolic acidosis, compensated Respiratory alkalosis, compensated Metabolic alkalosis, uncompensated Respiratory acidosis, uncompensated

Respiratory acidosis, uncompensated Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Pco2 will exhibit opposite effects; in this case, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.

A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? "Do you have any joint pain?" "Are you having any diarrhea?" "Are you experiencing heartburn?" "Do you have frequent headaches?"

"Are you having any diarrhea?" Rationale: Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or effectiveness of the medication.

A client is hospitalized with a diagnosis of viral hepatitis. To detect any difficulty in coping with this disease, the nurse should ask which question? "Do you have a fever?" "Are you losing weight?" "Have you enjoyed having visitors?" "Do you rest sometime during the day?"

"Have you enjoyed having visitors?" Rationale: Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

A nurse has given post-procedure instructions to a client who has undergone a colonoscopy. Which statement by the client indicates the need for further teaching? "It is normal to feel gassy or bloated after the procedure." "The abdominal muscles may be tender from the procedure." "It is all right to drive once I've been home for an hour or so." "Intake should be light at first and then progress to regular intake."

"It is all right to drive once I've been home for an hour or so." Rationale: The client should not drive for several hours after discharge because of the sedative medications used during the procedure. Important decisions also should be delayed for at least 12 to 24 hours for the same reason. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal. The client should resume intake slowly and progress as tolerated.

After completing an assessment and reviewing the laboratory test results of an adult client admitted to the hospital with acute abdominal pain, the nurse should take action for which serum amylase level noted? 54 units/dL 100 units/dL 120 units/dL 200 units/dL

200 units/dL Rationale: The normal serum amylase level ranges from 25 to 151 units/L, depending on the laboratory running the test. Option 4 is out of range for a serum amylase level and would require action by the nurse. Options 1, 2, and 3 are normal serum amylase levels and would not require any action.

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? 20 to 40 breaths/min 40 to 60 breaths/min 70 to 80 breaths/min 80 to 100 breaths/min

40 to 60 breaths/min Rationale: If the newborn is apneic or has gasping respirations after stimulation, or the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? 7 9 8 10

9 Rationale: The newborn has a score of 9 because his heart rate, respiratory effort, muscle tone, and reflex irritability all have a score of 2, with color having a score of 1 because of the acrocyanosis.

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? A psychologist A social worker A neuropsychologist A vocational rehabilitation specialist

A neuropsychologist Rationale: Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist, who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation. Options 1, 2, and 4 are incorrect because these health care workers do not specialize in evaluating and treating cognitive problems.

A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? Pain related to fluid accumulation in scrotum Uneasiness related to inability to reduce scrotal swelling Guilt related to possibility of sterility secondary to scrotal swelling Altered body appearance related to change in appearance of the scrotum

Altered body appearance related to change in appearance of the scrotum Rationale: Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Pain may apply but does not correlate with the information in the question. There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern.

A client with a subarachnoid hemorrhage needs to have surgery delayed until a stable clinical condition is achieved. The nurse prepares to administer which medication as prescribed to prevent clot breakdown and dissolution? Alteplase (Activase) Warfarin (Coumadin) Heparin sodium (Heparin) Aminocaproic acid (Amicar)

Aminocaproic acid (Amicar) Rationale: Aminocaproic acid (Amicar) is an antifibrinolytic agent that prevents clot breakdown or dissolution. It is commonly prescribed after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Alteplase is a fibrinolytic that actively breaks down clots. Warfarin and heparin sodium are anticoagulants that interfere with propagation or growth of a clot.

Cyclosporine (Sandimmune) is prescribed for the client following allogenic kidney transplantation. The nurse should provide which instruction to the client regarding the medication? There are no known adverse effects of the medication. The medication will need to be taken for a period of 6 months. Blood levels of the medication will need to be measured periodically. The medication is administered by the intravenous (IV) route on a monthly basis.

Blood levels of the medication will need to be measured periodically. Rationale: To avoid toxicity from high medication levels and to avoid organ rejection from low medication levels, blood levels of cyclosporine should be measured periodically. In the organ transplant client, an immunosuppressant will need to be taken for life. Oral administration is the route of choice; IV administration is reserved for clients who cannot take the medication orally. The most serious adverse effects are nephrotoxicity and infection.

A nurse is reviewing the medical record of a client and notes documentation of melasma. What should the nurse anticipate that the client will exhibit? Skin that is uniformly dark Very pale skin with little pigmentation Patches of skin with loss of pigmentation Blotchy brown macules across the cheeks and forehead

Blotchy brown macules across the cheeks and forehead Rationale: Melasma is a condition caused by hormonal influences on melanin production and is characterized by blotchy brown macules across the cheeks and forehead. Options 1 and 2 refer to normal variations in skin color. Option 3 describes vitiligo.

Which would be considered a normal finding in a newborn less than 12 hours old? Grunting respirations Heart rate of 190 beats/minute Bluish discoloration of the hands and feet A yellow discoloration of the sclera and body

Bluish discoloration of the hands and feet Rationale: A bluish discoloration of the hands and feet is termed acrocyanosis and is a normal finding in the newborn. Grunting respirations is a sign of possible respiratory distress. The normal newborn heart rate is 100 to 160 beats/minute. A yellow discoloration of the sclera and skin indicates jaundice.

The nurse is caring for a client with preeclampsia. The client is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? Tongue blade Percussion hammer Potassium chloride injection Calcium gluconate injection

Calcium gluconate injection Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes but is not the highest-priority item. Potassium chloride is not related to the administration of magnesium sulfate.

A home health nurse is visiting a client with type 1 diabetes mellitus. The client tells the nurse that he is not feeling well and has had a "respiratory infection" for the past week, which seems to be getting worse. After interviewing the client, what should be the initial nursing action? Notify the health care provider. Document the assessment data. Check the client's blood glucose. Obtain the client's sputum for culture and sensitivity.

Check the client's blood glucose. Rationale: Uncontrolled hyperglycemia may lead to the production of ketones, thus leading to diabetic ketoacidosis (DKA), a life-threatening condition. The most common precipitating factor for development of diabetic ketoacidosis (DKA) is infection. Assessment data should be documented but are not a priority. The health care provider may need to be notified if the client's blood glucose is elevated and the client has other symptoms of DKA or a respiratory infection. After determining the client's blood glucose, the nurse should obtain a sputum sample if the client is expectorating yellow, green, or bloody secretions.

A client has begun therapy with oxtriphylline (Choledyl). The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply. Milk Coffee Oysters Oranges Pineapple Chocolate

Coffee Chocolate Rationale: Oxtriphylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These include coffee and chocolate. The other food items are acceptable to consume.

A client with atrial fibrillation secondary to mitral stenosis is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium (Coumadin) 7.5 mg at 5:00 pm daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT) = 32 seconds; internationalized normalized ratio (INR) = 1.3. The nurse should plan to take which action based on the client's laboratory results? Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate (Pradaxa) in place of warfarin sodium.

Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. Rationale: When a client is receiving warfarin (Coumadin) for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the health care provider to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

A nurse is caring for a client who had a thyroidectomy 1 day ago. Which client laboratory data should the nurse identify as a possible thyroid surgery complication? Increased serum sodium level Increased serum glucose level Decreased serum calcium level Decreased serum albumin level

Decreased serum calcium level Rationale: Hypocalcemia may occur if the parathyroid glands are removed, damaged, or their blood supply is impaired during thyroid surgery, resulting in decreased parathyroid hormone (PTH) levels and lead to decreased serum calcium levels. Serum sodium, albumin, or glucose levels are not affected by thyroid surgery.

A nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it has which effect? Is drying to nasal mucosal passages Decreases diaphragmatic excursion and depth Increases the risk of pneumonia and atelectasis Decreases the client's oxygen-based respiratory drive

Decreases the client's oxygen-based respiratory drive Rationale: Normally respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural process becomes ineffective after exposure to high carbon dioxide levels for prolonged periods of time. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase oxygen levels independently because this could severely decrease the respiratory drive, leading to respiratory failure.

A client admitted to the hospital is taking capecitabine (Xeloda). The nurse should monitor the client for which symptom that is an adverse effect of the medication? Dyspnea Dizziness Headache Constipation

Dyspnea Rationale: Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. Headache, constipation, and dizziness are not adverse effects of this medication.

A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the assessment findings and expects to note documentation of which sign of this disorder? Diarrhea Malaise and anorexia Nausea and vomiting Evidence of soiled clothing

Evidence of soiled clothing Rationale: Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include evidence of soiled clothing, scratching or rubbing the anal area because of irritation, fecal odor without apparent awareness by the child, and social withdrawal.

After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should the nurse take to administer medication via a volume control container? Arrange the actions in the order that they should be performed. All options must be used. Remove the needle cap and insert the needleless syringe tip through port, then inject the medication and label volume control container with name of medication, dosage, total volume including diluents, and time of administration. Close the clamp and check to be sure clamp on air vent volume control container is open. Dispose the syringe in puncture proof and leakproof container. Discard supplies and perform hand hygiene. Clean injection port on top of volume control container with an antiseptic swab Fill volume control container with desired amount of intravenous (IV) fluid by opening clamp between volume control container and main IV bag. Regulate IV infusion rate to allow medication to infuse in time recommended by institutional policies

Fill volume control container with desired amount of intravenous (IV) fluid by opening clamp between volume control container and main IV bag. Close the clamp and check to be sure clamp on air vent volume control container is open. Clean injection port on top of volume control container with an antiseptic swab. Remove the needle cap and insert the needleless syringe tip through port, then inject the medication and label volume control container with name of medication, dosage, total volume including diluents, and time of administration. Regulate IV infusion rate to allow medication to infuse in time recommended by institutional policies. Dispose the syringe in puncture proof and leakproof container. Discard supplies and perform hand hygiene. Rationale: The steps a nurse take to administer medication via a volume control container are as follows: (1) Fill the volume control container with desired amount of IV fluid by opening the clamp between the volume control container and main IV bag. (2) Close the clamp, and check to be sure clamp on the air vent volume control container is open. (3) Clean injection port on top of volume control container with an antiseptic swab. (4) Remove needle cap and insert needleless syringe tip through the port, then inject the medication. Label the volume control container with name of medication, dosage, total volume including diluents, and time of administration. (5) Regulate IV infusion rate to allow medication to infuse in time recommended by institutional policies. (6) Dispose of syringe in puncture proof and leakproof container. Discard supplies and perform hand hygiene.

A client involved in a head-on automobile crash has awakened from a coma and asks for her husband, who was killed in the same accident. The family does not want the client to know at this time that her husband has died. The family wants all nursing staff to tell the client that the husband was taken by helicopter to another hospital, has a head injury, and is in the intensive care unit (ICU). Because the American Nurses Association Code of Ethics requires the nurse to preserve integrity, but the nurse wants to follow the family's instruction, the nurse faces an ethical dilemma. Which steps should the nurse take to systematically process this ethical dilemma? Arrange in order the steps for systematic processing of the ethical dilemma. All options must be used. Verbalize the problem. Examine and determine one's own values on the issues. Evaluate the action. Gather all of the information relevant to the case. Negotiate the outcome. Evaluate the action.

Gather all of the information relevant to the case. Examine and determine one's own values on the issues. Verbalize the problem. Consider possible courses of action. Negotiate the outcome. Evaluate the action. Rationale: Ethical reasoning is the process of thinking through what one ought to do in an orderly and systematic manner to provide justification for actions based on principles. First, the nurse determines whether or not the issue involves an ethical dilemma and gathers information that is relevant to the case. Next, the nurse undertakes personal value clarification and identifies his or her own values regarding the issue. Third, the nurse verbalizes the problem in a simple sentence. Fourth, the nurse considers possible courses of action. In this case the nurse may choose to seek the counsel of the agency's ethicist regarding the issue. Fifth, the nurse negotiates the outcome by developing confidence in her or his own point of view with deep respect for the opinions of others. In this case the nurse may negotiate with the family to determine a course of action that would allow the nurse to preserve integrity and yet allow the family to determine when the client should be informed of the tragic loss. Finally, the nurse evaluates the action.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? Prone position Knee-chest position High Fowler's position Reverse Trendelenburg's position

Knee-chest position Rationale: Tetralogy of Fallot includes four defects-ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to right. If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. All other options will not improve systemic arterial oxygen saturation.

A nurse is reviewing laboratory results for a client taking dantrolene sodium (Dantrium). The nurse should notify the health care provider (HCP) if which finding is noted on the laboratory report sheet? Creatinine level 0.6 mg/dL Platelet count 290,000 cells/mm3 Blood urea nitrogen (BUN) level 9 mg/dL Lactic dehydrogenase (LDH) level 600 units/L

Lactic dehydrogenase (LDH) level 600 units/L Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed prior to treatment and throughout the treatment interval. It is administered in the lowest effective dosage for the shortest time necessary. The LDH level reported in option 4 is high. (The normal level is 140 to 280 units/L). The other options indicate normal laboratory results.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? Accepting the client's feelings Acknowledging the client's apprehension Assisting the client with giving the baths to allow her to become more at ease Leaving the infant with the client so that she will be required to provide the care

Leaving the infant with the client so that she will be required to provide the care Rationale: A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease.

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? Nausea Papilledema Decerebrate posturing Alterations in pupil size

Nausea Rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

The nurse in the labor room is performing an initial assessment on a newborn. The infant is evidencing mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply. Start chest compressions. Notify the health care provider. Orally administer a sucrose solution. Position the infant flat on his right side. Insert an orogastric tube and connect it to low suction. Provide support for respiratory distress via an endotracheal (ET) tube.

Notify the health care provider. Insert an orogastric tube and connect it to low suction. Provide support for respiratory distress via an endotracheal (ET) tube. Rationale: Worsening respiratory distress, audible bowel sounds in the chest, and a flat or scaphoid abdomen are all signs and symptoms of a congenital diaphragmatic hernia. For this condition to be verified, appropriate x-rays must be prescribed by the health care provider. If verified, operative intervention is necessary. As mechanical ventilation is administered, the bowel fills with air, thus worsening the respiratory status of the infant; therefore gastrointestinal decompression is necessary as well as ventilation via an ET tube rather than a bag and mask. There is no evidence stated in the question that the infant is requiring chest compressions. The infant must be kept NPO for operative intervention and to decrease gastric distention. Proper positioning for this condition is supine with the head elevated.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? Obtain a new IV bag. Obtain new IV tubing. Wipe the spike end of the tubing with Betadine. Scrub the spike end of the tubing with an alcohol swab.

Obtain new IV tubing. Rationale: The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection to the client. There is no need to obtain a new IV bag because the bag was not contaminated. Wiping with Betadine or alcohol is insufficient and is contraindicated because the spike will be inserted into the IV bag.

A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse should prepare the client for which test to confirm the presence of this type of sarcoma? Liver biopsy Sputum culture White blood cell count Punch biopsy of the cutaneous lesions

Punch biopsy of the cutaneous lesions Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis to the upper body, then to the face and oral mucosa. The lymphatic system, lungs, and gastrointestinal (GI) tract can become involved as well. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is by punch biopsy of cutaneous lesions and biopsy of pulmonary and GI lesions. Options 1, 2, and 3 are incorrect and would not confirm the presence of Kaposi's sarcoma.

Which would be the highest expected growth and development occurrences at 9 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply. Will smile spontaneously Rolls over in both directions Able to sit steadily unsupported Should be able to say "mama" and "dada" Will pull up and stand for several seconds holding on to furniture Will be able to pick up small pieces of food when placed in a high chair

Should be able to say "mama" and "dada" Will pull up and stand for several seconds holding on to furniture Will be able to pick up small pieces of food when placed in a high chair Rationale: Growth and development are sequential and predictable. One task builds on another. Mastery of a lower-level task must occur before higher level tasks are completed. A child must be able to roll over before sitting alone and before beginning to creep and crawl. After mastering crawling, the infant (9 months of age) will pull up and hold on to furniture. Sitting steadily unsupported begins soon after 6 months. The pincer grasp is mastered by 12 months, but begins refinement at 9 months (option 6). Once this is accomplished the infant will begin grasping a spoon. Language development begins at 6 months with imitating sounds and smiling spontaneously, progressing to saying "mama" and "dada" at 9 months of age.

The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What should the nurse monitor to detect the most common complication of TPN? Temperature Daily weight Intake and output Serum creatinine level

Temperature Rationale: The most common complication associated with total parenteral nutrition is infection. Monitoring the temperature would provide data that would indicate infection in the client. Monitoring the serum creatinine level would not provide information related to infection and is most closely related to assessing renal function. Weighing the client daily and monitoring intake and output would provide information related to fluid volume overload.

Which should the nurse do when setting up an arterial line? Tighten all tubing connections. Use macrodrop intravenous tubing. Level the transducer to the ventricle. Raise the height of the normal saline infusion to prevent backup.

Tighten all tubing connections. Rationale: Because the arterial vasculature is a high-pressure system, all tubing connections must be tight to avoid blood loss from loose connections. High-pressure tubing with a transducer is used (not macrodrip tubing). The transducer should be level to the atrium not the ventricle. Raising the height of the infusion is not sufficient to prevent backflow.

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? Administer an enema daily. Use a fracture pan for bowel elimination. Use a bedside commode for all elimination needs. Use a regular bedpan to prevent spilling of contents in the bed.

Use a fracture pan for bowel elimination. Rationale: A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.

The nurse is performing a voice test to assess the hearing of a client. Which describes the accurate procedure for performing this test? Whisper a statement while the client blocks one ear. Whisper a statement while the client blocks both ears. Whisper a statement with the examiner's back facing the client. Stand 4 feet away from the client to ensure that the client can hear at this distance.

Whisper a statement while the client blocks one ear. Rationale: In the voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately. Therefore options 2, 3, and 4 are incorrect.

The clinic nurse provides information to the mother of a toddler regarding toilet training. Which statement by the mother indicates a need for further information regarding toilet training? "Bladder control usually is achieved before bowel control." "The child should not be forced to sit on the potty for long periods." "The ability of the child to remove clothing is a sign of physical readiness." "The child will not be ready to toilet train until the age of about 18 to 24 months."

"Bladder control usually is achieved before bowel control." Rationale: Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods . The ability to remove clothing is one of the physical signs of readiness for toilet training. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the ages of 18 and 24 months.

A hospitalized client with a diagnosis of schizophrenia who is experiencing delusions says to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? "I don't believe this is true." "The doctor is not talking to the mob." "What makes you think the doctor wants to get rid of you?" "I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?"

"I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?" Rationale: When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? "Why do you believe this?" "Tell me more about the details of your belief." "I hear what you are saying, but I don't share your belief." "If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute."

"I hear what you are saying, but I don't share your belief." Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client.

A nurse reinforces medication instructions to a client who has received a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client would indicate a need for further instruction? "I need to obtain a yearly influenza vaccine." "I need to have dental checkups every 3 months." "I need to self-monitor my blood pressure at home." "I need to call the health care provider if my urine volume decreases or it becomes cloudy."

"I need to obtain a yearly influenza vaccine." Rationale: Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia. The client must be able to self-monitor blood pressure to check for the side effect of hypertension.

The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) has begun taking misoprostol (Cytotec). Which statement by the client indicates that the misoprostol is effective? "I have fewer muscle aches." "My joint mobility has improved." "I no longer have pain above my stomach." "I am no longer experiencing constipation."

"I no longer have pain above my stomach." Rationale: The client who chronically uses NSAIDs is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Constipation is not associated with the use of NSAIDs. Options 1 and 2 are incorrect because they are intended effects of the NSAID.

A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. What statement by the client indicates the need for further education regarding his prescription? "I will take the daily dose at bedtime." "I need to drink at least 2 liters of fluid per day." "I know to avoid changing brands of the medication without my health care provider's approval." "I'll avoid over-the-counter cough and cold medications unless approved by my health care provider (HCP)."

"I will take the daily dose at bedtime." Rationale: The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. Additionally, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the HCP before changing brands of the medication because levels of bioavailability may vary for different preparations. The client also should check with the HCP before taking over-the-counter cough, cold, or other respiratory preparations because they could have interactive effects, increasing the side and adverse effects of theophylline and causing dysrhythmias.

Propylthiouracil (PTU) is prescribed for a client with hyperthyroidism. The nurse provides instructions to the client regarding the medication and informs the client to notify the health care provider if which sign/symptom occurs? Fever Dry mouth Drowsiness Increased urination

Fever Rationale: An adverse effect of PTU is agranulocytosis. The client needs to be informed of the early signs of this adverse effect, which include fever and sore throat. Drowsiness is an occasional side effect of the medication. Dry mouth and increased urination are unrelated to this medication.

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer? "The pain doesn't usually come right after I eat." "The pain gets so bad that it wakes me up at night." "The pain that I get is located on the right side of my chest." "My pain comes shortly after I eat, maybe a half-hour or so later."

"My pain comes shortly after I eat, maybe a half-hour or so later." Rationale: Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by intake of food. The pain occurs 30 to 60 minutes after a meal and rarely occurs at night. Duodenal ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and often awakens the client at night.

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? "The client would be independent." "The client initiates activities on her own." "The client participates in mothering tasks." "The client is self-focused and talks to others about labor."

"The client is self-focused and talks to others about labor." Rationale: *Rubin* has identified three phases of regeneration during the postpartum period. *The taking-in phase occurs in the first 3 days postpartum*, and the *taking-hold phase occurs between days 3 to 10.* During the *taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent.* In the *taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks.* In the *letting-go phase, the mother may grieve over the separation of the baby from part of her body.*

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? "I will probably need my mother to help me with housekeeping." "Because I am so sore, I will nurse the baby while lying on my side." "My husband and I will not have intercourse until the stitches are healed." "The only medications I will take are prenatal vitamins and stool softeners."

"The only medications I will take are prenatal vitamins and stool softeners." Rationale: A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma.

The nurse has given instructions to a client who has just been prescribed cholestyramine (Questran). Which statement by the client indicates a need for further instructions? "I will continue taking vitamin supplements." "This medication will help lower my cholesterol." "This medication should only be taken with water." "A high-fiber diet is important while taking this medication."

"This medication should only be taken with water." Rationale: Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? Select all that apply. "Where is the pain located?" "Does pain medication help?" "What does the pain feel like?" "How does the pain affect you?" "Do you have the pain when you sleep?" "What makes your pain better or worse?"

"Where is the pain located?" "What does the pain feel like?" "How does the pain affect you?" "What makes your pain better or worse?" Rationale: The PQRSTU method is one method of assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects yoU (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method.

A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The health care provider prescribes determination of the serum digoxin level to rule out digoxin toxicity. The nurse checks the results, knowing that which value is the therapeutic serum level (range) for digoxin? 0.5 to 2 ng/mL 1.2 to 2.8 ng/mL 3.0 to 5.0 ng/mL 3.5 to 5.5 ng/mL

0.5 to 2 ng/mL Rationale: Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. The ranges in the remaining options are incorrect.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? 3 5 7 10

5 Rationale: One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation.

A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection? A mother who had ten vaginal exams during labor A mother with a history of previous puerperal infections A mother who gave birth vaginally to a 3200 gram infant A mother who experienced prolonged rupture of the membranes

A mother who gave birth vaginally to a 3200 gram infant Rationale: Risk factors associated for *puerperal (any bacterial infection of the female reproductive tract following childbirth or miscarriage.) infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments.*

A client with myasthenia gravis becomes increasingly weaker. The health care provider (HCP) injects a dose of edrophonium (Enlon) to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if in cholinergic crisis? No change in the condition Complaints of muscle spasms An improvement of the weakness A temporary worsening of the condition

A temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement of the condition indicates myasthenic crisis. The other two options are unrelated to the test.

A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? Soft uterus Abdominal pain Nontender uterus Painless vaginal bleeding

Abdominal pain Rationale: Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

Which are modes of heat loss in the newborn? Select all that apply. Radiation Urination Convection Conduction Evaporation

Radiation Convection Conduction Evaporation Rationale: The newborn can lose heat through radiation, convection, conduction, and evaporation. Heat is not lost through urination.

A nurse is discussing the past week's activities with a client receiving amitriptyline hydrochloride. The nurse determines that the medication is most effective for this client if the client reports which? A decrease in appetite Sleeping 14 to 16 hours each day Ability to get to work on time each day Having difficulty concentrating on an activity

Ability to get to work on time each day Rationale: Depressed individuals will sleep for extended periods, have a change in appetite, be unable to go to work, and have difficulty concentrating. They may also experience fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. After they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply. Administer oxygen. Assess the blood pressure. Start an intravenous (IV) line. Prepare to administer morphine sulfate. Place the client on bed rest in a supine position. Prepare to administer warfarin sodium (Coumadin).

Administer oxygen. Assess the blood pressure. Start an intravenous (IV) line. Prepare to administer morphine sulfate. Rationale: If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

The client has a prescription to receive pirbuterol (Maxair Autoinhaler) two puffs and beclomethasone dipropionate (Beclovent) two puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness? Administering the pirbuterol before the beclomethasone Alternating a single puff of each hourly, beginning with the beclomethasone Alternating a single puff of beclomethasone with pirbuterol; repeat the steps Administering the pirbuterol; wait 30 minutes and administer the beclomethasone

Administering the pirbuterol before the beclomethasone Rationale: Pirbuterol is a bronchodilator. Beclomethasone is a glucocorticoid. Bronchodilators are administered before glucocorticoids when both are to be given on the same time schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? Elevate her legs. Remain on bed rest. Ambulate frequently. Apply warm, moist packs to the legs.

Ambulate frequently. Rationale: Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. The other options may be interventions for the client diagnosed with thrombophlebitis. Additionally, bed rest promotes stasis.

A client with an exacerbation of chronic obstructive pulmonary disease has been on oral glucocorticoids and is currently being weaned to triamcinolone (Azmacort) by inhalation. The nurse determines that the client understands the potential adverse effects to watch for during this medication change when the client states the need to report which signs and symptoms? Chills, fever, and generalized rash Vomiting, diarrhea, and increased thirst Blurred vision, headache, and insomnia Anorexia, nausea, weakness, and fatigue

Anorexia, nausea, weakness, and fatigue Rationale: The client being changed from oral to inhalation glucocorticoids could experience signs of adrenal insufficiency. The nurse teaches the client to report anorexia, nausea, weakness, and fatigue. Other signs that can be detected and are objective include hypotension and hypoglycemia.

A nurse is providing dietary teaching to a client receiving a potassium-retaining diuretic about foods that are low in potassium. Which foods should the nurse include on a list of foods with low potassium content? Apple Carrots Spinach Avocado

Apple Rationale: One medium apple with skin provides approximately 159 mg of potassium per serving, so it has the lowest potassium content of these choices. One large carrot has 341 mg of potassium. Raw spinach (oz) provides 470 mg of potassium. One medium avocado provides the highest potassium content, 1097 mg.

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? Apply heat to the affected area. Take acetaminophen (Tylenol) every 4 hours. Self-administer calcium carbonate tablets three times daily. Purchase a chewable antacid that contains calcium and take a tablet with each meal.

Apply heat to the affected area. Rationale: Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? Tetany Tremors Areflexia Muscular excitability

Areflexia Rationale: Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

The nurse is preparing a subcutaneous dose of bethanechol (Urecholine) prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart for use if needed? Vitamin K Mucomyst Atropine sulfate Protamine sulfate

Atropine sulfate Rationale: Bethanechol (Urecholine) is a cholinergic medication. Administration of bethanechol (Urecholine) could result in cholinergic overdose. The antidote is atropine (an anticholinergic), which should be readily available for use if overdose occurs. Mucomyst is the antidote for acetaminophen (Tylenol) overdose. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin.

The nurse is administering an intravenous dose of methocarbamol (Robaxin) to a client with multiple sclerosis. For which side/adverse effect should the nurse monitor? Tachycardia Rapid pulse Bradycardia Hypertension

Bradycardia Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these side/adverse effects. Options 1, 2, and 4 are not side/adverse effects of this medication.

A nurse is planning the menu for a Chinese-American client. Which foods should the nurse plan to include in the dietary plan? Select all that apply. Milk Yogurt Broccoli Green beans Peanut butter cookies

Broccoli Green beans Rationale: The Chinese-American diet is generally vegetarian, although meat is often served. Native Chinese generally do not drink milk or eat milk products because of a genetic tendency for lactose intolerance. Most Chinese-Americans do not eat desserts high in sugar; their desserts are usually fruits.

A man who has developed atrial fibrillation and has been placed on warfarin (Coumadin). The nurse is doing discharge dietary teaching with the client and determines that the client needs additional education if he stated he would choose which foods while taking this medication? Cherries Potatoes Broccoli Spaghetti

Broccoli Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables, such as broccoli, cabbage, turnip greens, and lettuce. The other options listed are foods that are lower in vitamin K.

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? Glucose level Calcium level Potassium level Prothrombin time

Calcium level Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

A client taking rifampin (Rifadin) reports, "My urine has blood in it." When the nurse assesses the urine, it is brown. Which is the nurse's best action? Notify the health care provider. Chart the finding as a normal response to the rifampin. Get the client into bed, and put the bed in Trendelenburg's position. Immediately start prescribed intravenous (IV) fluids to prevent shock.

Chart the finding as a normal response to the rifampin. Rationale: Brown-tinged urine is a normal finding associated with rifampin; thus, there is no need to notify the health care provider. There is no indication the client is in shock, so eliminate options 3 and 4.

A nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? Client in heart failure Client with an ileostomy Client in acute kidney injury Client with controlled hypertension

Client with an ileostomy Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal (GI) tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

An older client has been receiving cimetidine (Tagamet). The nurse should report to the health care provider (HCP) that the client is experiencing a side effect of the medication if which finding is noted during the assessment? Tremors Confusion Stiff joints Constipation

Confusion Rationale: Older clients are especially susceptible to central nervous system (CNS) side effects of cimetidine; the most frequent of these is confusion. Additionally, renal impairment in this population further increases this risk for confusion. Less common CNS side effects include headache, dizziness, drowsiness, and hallucinations. Options 1, 3, and 4 are not associated with this medication.

A client taking verapamil (Calan) has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? Weight loss Constipation Nasal stuffiness Abdominal cramping

Constipation Rationale: Verapamil (Calan) is a calcium-channel blocker. The most common complaint with the use of verapamil is constipation. Other frequent side effects are dizziness, facial flushing, headache, and edema of the hands and feet. Weight loss, nasal stuffiness, and abdominal cramping are not associated with the use of this medication.

A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action? Refer to Figure. A-fib Continue to watch the monitor. Contact the health care provider. Check to see if cardiac medications are due. Call respiratory therapy to do a respiratory treatment.

Contact the health care provider. Rationale: Atrial fibrillation is characterized by multiple rapid impulses from many atrial foci in a totally disorganized manner at a rate of 350 to 600 times per minute. The atria quiver in fibrillation. As a result, thrombi can form within the right atrium and move through the right ventricle to the lungs. This can be a life-threatening situation requiring pharmacological therapy. Therefore, the health care provider needs to be contacted. Options 1 and 3 delay necessary and required interventions. Option 4 is not useful for this client.

A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? Reinforce the dressing. Document the findings. Contact the health care provider. Swab the drainage and send the sample to the laboratory for culture.

Contact the health care provider. Rationale: Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test.

The nurse is providing discharge instructions to a client who will be taking tacrolimus (Prograf) daily following allogenic liver transplantation. The nurse instructs the client that which is a frequent side effect related to this medication? Diarrhea Confusion Loss of memory A decrease in urine output

Diarrhea Rationale: Tacrolimus is an immunosuppressant medication used in the prophylaxis of organ rejection in clients who receive allogenic liver transplants. Frequent side effects include headache, tremors, insomnia, paresthesia, diarrhea, nausea, constipation, vomiting, abdominal pain, and hypertension. Adverse reactions and toxic effects include nephrotoxicity and pleural effusion, which can occur frequently. Nephrotoxicity is characterized by increasing serum creatinine and a decrease in urine output. Thrombocytopenia, leukocytosis, anemia, and atelectasis occur occasionally. Neurotoxicity, including tremor, headache, and mental status changes, also can occur. It is imperative for the nurse to assess laboratory results, particularly renal function tests, and to monitor intake and output closely.

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? Contact the health care provider. Place the mother in a Trendelenburg position. Administer oxygen to the client by face mask. Document the findings and continue to monitor fetal patterns.

Document the findings and continue to monitor fetal patterns. Rationale: Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse should assess for which manifestations that could indicate digoxin toxicity? Dyspnea, edema, and palpitations Chest pain, hypotension, and paresthesias Constipation, dry mouth, and sleep disorder Double vision, loss of appetite, and nausea

Double vision, loss of appetite, and nausea Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (such as green and yellow vision, or seeing spots or halos), confusion, vomiting, diarrhea, decreased libido, and impotence. The other options are incorrect because they do not identify manifestations of digoxin toxicity.

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? Enteric Contact Droplet Neutropenic

Droplet Rationale: A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

The nurse in the health care clinic is reviewing the record of a client with diabetes mellitus who was just seen by the health care provider (HCP). The nurse notes that the HCP has prescribed metformin (Glucophage). What preexisting disorder, if noted in the client's record, would indicate a need to collaborate with the HCP before instructing the client to take the medication? Foot ulcer Emphysema Hypertension Hypothyroidism

Emphysema Rationale: Metformin is an antidiabetic agent and acts by decreasing hepatic production of glucose. Metformin should be used with caution in clients with kidney or liver disease, heart failure, chronic lung disease, or a history of heavy alcohol consumption. Options 1, 3, and 4 are not cautions or contraindications associated with use of this medication.

A client with a urinary tract infection (UTI) has dysuria and is given a prescription for phenazopyridine (Pyridium) for symptom relief. The nurse provides medication information and should provide the client with which information? Take the medication at bedtime. Take the medication before meals. Expect the urine to become reddish-orange. Notify the health care provider if headache occurs.

Expect the urine to become reddish-orange. Rationale: Phenazopyridine is a urinary tract analgesic with no antimicrobial properties. It can cause a reddish-orange discoloration of urine and tears and can stain undergarments and soft contact lenses. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant notifying the health care provider.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? Quickening Braxton Hicks contractions Fetal heart rate of 180 beats/minute Consistent increase in fundal height

Fetal heart rate of 180 beats/minute Rationale: The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. Options 1, 2, and 4 are normal expected findings. Quickening refers to the first fetal movements and are often described as flutters.

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which condition? Myxedema Graves' disease Addison's disease Cushing's syndrome

Graves' disease Rationale: Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

A client with psoriasis is being treated with calcipotriene (Dovonex) cream. Administration of high doses of this medication can cause which adverse effect? Alopecia Hyperkalemia Hypercalcemia Thinning of the skin

Hypercalcemia Rationale: Calcipotriene (Dovonex), an analogue of vitamin D3, is indicated for mild to moderate psoriasis. Responses are equal to those achieved with medium-potency topical glucocorticoids. The most common adverse effect is local irritation. Unlike glucocorticoids, calcipotriene does not cause thinning of the skin. At high doses, calcipotriene has caused hypercalcemia. Alopecia and hyperkalemia is not associated with this medication.

An ambulatory care nurse is providing instructions to a client with a urinary tract infection (UTI) being started on medication therapy with nitrofurantoin (Macrodantin), a urinary antiseptic agent. The nurse should provide the client with which information? It can cause urinary retention. It will cause the urine to become clear. The sun should be avoided because it is a sulfa-based medication. If taken with meals, it will help decrease the risk for gastrointestinal (GI) upset.

If taken with meals, it will help decrease the risk for gastrointestinal (GI) upset. Rationale: Nitrofurantoin is a urinary antiseptic (not a sulfa-based medication) and should be taken with meals to decrease the incidence of GI side effects. Food or milk decreases the GI upset. The medication could cause the urine to turn rust yellow or brown. It does not cause urinary retention.

A nurse is assessing the cultural beliefs of five clients requiring specimen collection for a diagnostic test. Which cultural assessments are correct? Select all that apply. Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. Amish clients may only have vaginal or urinary specimens collected by an adult Amish male family member. Hispanic clients often become anxious during blood specimen collection because they consider blood as irreplaceable. Hindus collecting a stool specimen for a Hemoccult screening test need to use the left hand to place the stool onto the Hemoccult card. Self-urine collection performed by a right hand-dominant Muslim client may be collected incorrectly because only a Muslim's left hand can be used for dirty activities.

Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. Hindus collecting a stool specimen for a Hemoccult screening test need to use the left hand to place the stool onto the Hemoccult card. Self-urine collection performed by a right hand-dominant Muslim client may be collected incorrectly because only a Muslim's left hand can be used for dirty activities. Rationale: The correct statements regarding cultural considerations for specimen collection are important to know. Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. Muslims and Hindus designate which hand can be used for clean and dirty tasks. Collecting their own stool and urine specimen may be difficult for them because only the left hand can be used for "dirty" activities. Privacy should be maintained for any client providing vaginal or urinary specimens. Gender congruent family member would be best to conduct specimen collection. Asians (not Hispanics) may consider blood irreplaceable.

A nurse is monitoring the client for hypocalcemia. Which are indicative of this imbalance? *Select all that apply.* Irritability Muscle cramps Tingling sensations Hyperactive reflexes Memory impairment Severe muscle weakness

Irritability Muscle cramps Tingling sensations Hyperactive reflexes Memory impairment Rationale: Signs of hypocalcemia include tingling sensations, hyperactive reflexes, and a positive Trousseau or Chvostek sign. Other signs include increased neuromuscular excitability, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Severe muscle weakness is seen in hypercalcemia not hypocalcemia.

The nurse understands that which is correct about tetracycline (Sumycin)? It is classified as a narrow-spectrum antibiotic. It is identified as safe for use during pregnancy. It is used to treat a wide variety of disease processes. It is contraindicated in children younger than 8 years of age.

It is contraindicated in children younger than 8 years of age. Rationale: *All tetracyclines are contraindicated in children younger than 8 years of age because the medication deposits in bone and teeth enamel and can result in permanent discoloration of developing teeth.* Tetracyclines are broad-spectrum antibiotics. Tetracyclines are used to treat specific infections and are contraindicated during pregnancy because of their effects on developing teeth.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? Offer only one breast at each feeding. Massage distended areas as the infant nurses. Cleanse nipples with a mild antibacterial soap before and after infant feedings. Express and discard milk from the affected breast at the first signs of mastitis.

Massage distended areas as the infant nurses. Rationale: Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should plan to take which action first? Massage the uterus until firm. Take the client's blood pressure. Ask the client about the presence of pain. Recheck the amount of drainage on the peripad.

Massage the uterus until firm. Rationale: When uterine atony occurs, the first nursing action would be to massage the uterus until firm. If this does not assist in controlling blood loss, then the health care provider is notified. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? Positive Negative Inconclusive Definitive and requiring a repeat test

Negative Rationale: Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations.

The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium (Solaraze). The nurse teaches the client that this medication is from which class of medications? Anti-infectives Vitamin A lotions Coal tar preparations Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale: Diclofenac sodium (Solaraze) is a nonsteroidal anti-inflammatory drug (NSAID) for topical use. It is indicated for use for actinic keratosis. The mechanism underlying its benefits is unknown. The most common side effects are dry skin, itching, redness, and rash at the site of application. Diclofenac may sensitize the skin to ultraviolet radiation, and clients should therefore avoid sunlamps and minimize exposure to sunlight. Anti-infectives are used for infections. Vitamin A would be contraindicated in the treatment of actinic keratosis. Coal tar is for psoriasis.

The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Which nursing action is most appropriate initially? Document the findings. Arrange for hearing testing. Cover the ears with gauze pads. Notify the health care provider (HCP).

Notify the health care provider (HCP). Rationale: Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action initial immediate actions would be to notify the HCP. Options 2 and 3 are inaccurate and inappropriate nursing actions. Option 1 is not an initial action.

Oxybutynin is prescribed for a client. Based on this prescription, the nurse suspects that the client has which condition? Gastritis Renal calculi Ulcerative colitis Overactive bladder

Overactive bladder Rationale: When medication therapy for overactive bladder is indicated, anticholinergic agents are the medications generally prescribed. These medications block muscarinic receptors on the bladder detrusor, and thereby inhibit bladder contractions and decrease the urge to void. It is not used to treat gastritis. The medication would not be used to treat renal calculi or ulcerative colitis. In fact, it may make those conditions worse.

Cyclosporine (Sandimmune) is prescribed for a client who received a kidney transplant. The nurse would be most concerned if a review of the medical record revealed that the client currently is taking which prescribed medications? Prednisone Digoxin (Lanoxin) Propranolol (Inderal) Phenytoin (Dilantin)

Phenytoin (Dilantin) Rationale: Medications known to lower cyclosporine levels include phenytoin (anticonvulsive medication), phenobarbital, rifampin, and trimethoprim-sulfamethoxazole. Cyclosporine levels should be monitored and the dosage adjusted in clients taking these medications.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position? Prone Supine High Fowler's Trendelenburg

Prone Rationale: The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal.

A nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who has undergone lumbar puncture. The nurse determines that which is an abnormal finding? Red blood cells, 0 Glucose, 52 mg/dL Protein, 100 mg/dL White blood cells, 3 cells/mm3

Protein, 100 mg/dL Rationale: Protein (15 to 45 mg/dL) and glucose (50 to 75 mg/dL) normally are present in CSF; however, the protein level for this client is above the expected range. The adult with normal CSF has no red blood cells in the CSF. The client may have small numbers of white blood cells (0 to 5 cells/mm3).

A client with chronic kidney disease (CKD) is being managed by continuous ambulatory peritoneal dialysis (CAPD). During outflow, the nurse notes that only half of the 2-L dialysate has returned and the flow has stopped. Which interventions should the nurse take to enhance the outflow? Select all that apply. Reposition the client. Encourage a low-fiber diet. Make sure the peritoneal catheter is not kinked. Slide the peritoneal catheter farther into the abdomen. Check that the drainage bag is lower than the client's abdomen. Assess the stool history, and institute elimination measures if the client is constipated.

Reposition the client. Make sure the peritoneal catheter is not kinked. Check that the drainage bag is lower than the client's abdomen. Assess the stool history, and institute elimination measures if the client is constipated. Rationale: CAPD is a method of peritoneal dialysis in which the client infuses dialysate into the abdomen through a special peritoneal catheter and then lets it dwell for a period of hours. After a specified time, the client drains the dialysate out of the abdomen by gravity and then instills another 1.5 to 3 L of dialysate into the peritoneal cavity. During the dwell time, substances are exchanged across the peritoneal membrane through the process of diffusion. It is important for the nurse to make sure that all the dialysate in each treatment is removed to ensure proper waste and fluid removal. The distal end of the peritoneal catheter hangs loosely within the abdomen cavity, so if the nurse encourages the client to change position, placement of the catheter also could be changed, potentially increasing outflow. Because the peritoneal catheter and the tubing to the drainage bag are long and flexible, either could get kinked. Correcting this is an easy solution to the outflow problem. The peritoneal catheter is surgically placed in the abdomen, and the skin grows around the cuff. With peritoneal dialysis, gravity is the process whereby dialysate is removed from the peritoneal cavity. Keeping the bag lower than the abdomen enhances gravity. Constipation is one of the primary causes of poor outflow. Assessing and intervening for constipation and encouraging a high-fiber diet are important actions to include in the care of a client on peritoneal dialysis. The catheter cannot be physically manipulated. Additionally, this is not action that would be within the focus of a nursing responsibility.

A woman with preeclampsia is receiving magnesium sulfate. Which assessment finding indicates to the nurse that the magnesium sulfate therapy is effective? Scotomas are present. Seizures do not occur. Ankle clonus is noted. The blood pressure decreases.

Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). *Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure. Ankle clonus indicates hyperreflexia and may precede the onset of eclampsia. Magnesium sulfate is an anticonvulsant*, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient.

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. Stop the infusion. Notify the health care provider (HCP). Prepare to apply ice or heat to the site. Restart the IV at a distal part of the same vein. Prepare to administer a prescribed antidote into the site. Increase the flow rate of the solution to flush the skin and subcutaneous tissue.

Stop the infusion. Notify the health care provider (HCP). Prepare to apply ice or heat to the site. Prepare to administer a prescribed antidote into the site. Rationale: Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the intravenous administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. *All options must be used.* Reposition the client. Stop the oxytocin infusion. Perform a vaginal examination. Administer oxygen by face mask at 8 to 10 L/min. Administer medication as prescribed to reduce uterine activity. Check the client's blood pressure.

Stop the oxytocin infusion. Administer oxygen by face mask at 8 to 10 L/min. Check the client's blood pressure. Reposition the client. Perform a vaginal examination. Administer medication as prescribed to reduce uterine activity. Rationale: If uterine hypertonicity occurs, the nurse would immediately intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen by face mask at 8 to 10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal examination to check for a prolapsed cord. The nurse would check maternal blood pressure for the presence of hypertension or hypotension. The nurse stays with the client and contacts the health care provider (HCP) as soon as possible (or asks another nurse to contact the HCP) and then implements prescribed HCP prescriptions, including the administration of medications to reduce uterine activity.

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? Try to convince the client of the need for the transfusion. Speak to the family regarding the need for a blood transfusion. Support the client's decision not to receive a blood transfusion. Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels.

Support the client's decision not to receive a blood transfusion. Rationale: A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation to the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item? Over-bed trapeze Dry sterile dressings Surgical tourniquet Incentive spirometer

Surgical tourniquet Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.

A client diagnosed with active tuberculosis has been prescribed a combination of isoniazid and rifampin (Rifadin) for treatment. The nurse teaches the client to perform which action? Report any change in urine color. Take both medications with food. Take both medications together once a day. Expect to take the medication for 2 to 3 weeks.

Take both medications together once a day. Rationale: Rifampin in combination with isoniazid prevents the emergence of drug-resistant organisms. This combination, taken together daily, eliminates the tubercle bacilli from the sputum and improves clinical status. Rifampin produces a harmless red-orange color in all body fluids and should be taken along with the isoniazid 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 months for effectiveness, and the therapeutic effect may be evident in 2 to 3 weeks.

A client is beginning to take trimethoprim-sulfamethoxazole (Bactrim) for a recurrent urinary tract infection (UTI). The nurse would give the client which instruction regarding this medication? Expect rashes or skin changes as a result of therapy. Discontinue the medication when symptoms subside. Take most doses early in the day when fluid intake is greatest. Take each dose with 8 oz of water, and drink extra water each day.

Take each dose with 8 oz of water, and drink extra water each day. Rationale: Bactrim is a combination medication, with both sulfamethoxazole and trimethoprim. The client takes each dose with 8 oz of water and drinks several extra glasses of water each day. The client should space doses evenly around the clock for stable blood levels and should take the medication for the full course of therapy. The client should report rashes or other skin changes, which could indicate an allergy to sulfa.

When teaching the client with adrenal insufficiency about cortisone (Cortone Acetate) the nurse should include which items? Select all that apply. Increase intake of sodium. Take the medication with food. Increase intake of potassium-rich foods. Stay away from people with active infections. Discontinue the medication when symptoms subside. Notify the health care provider if illness occurs or surgery is anticipated.

Take the medication with food. Increase intake of potassium-rich foods. Stay away from people with active infections. Notify the health care provider if illness occurs or surgery is anticipated. Rationale: Glucocorticoids should not be abruptly discontinued because acute adrenal insufficiency could occur. Because glucocorticoids cause sodium and water to be retained while causing loss of potassium, the client should limit sodium intake and increase potassium intake. These medications can increase the risk of infection, therefore the client should avoid contact with clients who are ill. Taking the medication with food helps prevent stomach upset. Individuals may need an increase in dosage during illness or times of stress (surgery).

The nurse is presenting information regarding treatment of influenza and the use of oseltamivir (Tamiflu). The nurse should provide which information regarding the use of Tamiflu? Select all that apply. Tamiflu is effective for all types of influenza. The incidence of flu complications is reduced. Dosing must begin within 2 days after symptom onset. No interactions with other medications have been reported. It is best to begin dosing within the first 12 hours after symptom onset. Tamiflu is highly toxic to the liver, and liver function studies must be performed.

Tamiflu is effective for all types of influenza. The incidence of flu complications is reduced. Dosing must begin within 2 days after symptom onset. No interactions with other medications have been reported. It is best to begin dosing within the first 12 hours after symptom onset. Rationale: Options 1 through 5 are correct. Tamiflu treatment must begin early, no later than 2 days after symptom onset, and preferably much sooner, even during the first 12 hours, because benefits decline greatly when treatment is delayed. Tamiflu reduces complications of the flu and is effective for all flu types. It has no reported interactions with other medications. The only major side effects are nausea and vomiting. It is not toxic to the liver.

The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer one of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client would be the most appropriate one to transfer? The 36-year-old, gravida I, para 0 client who is at 24 weeks' gestation and is being monitored for preterm labor The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding The 40-year-old, gravida III, para 0 client who is at 38 weeks' gestation and is complaining of decreased fetal movement The 29-year-old, gravida I, para 0 client who is at 42 weeks' gestation and had a biophysical profile score of 5 earlier today

The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding Rationale: The fetus of the client at 10 weeks' gestation is in a pre-viability stage, whereas those of the other clients are at a stage of viability. There is limited monitoring that can be done with a 10-week fetus; Doppler monitoring is not feasible during the first trimester. Bed rest would be the primary treatment for this client at this point in her pregnancy. Bed rest could be maintained, and bleeding could be monitored by a postpartum nurse. The clients with preterm and postterm gestations (24 and 42 weeks, respectively) are those most at risk, so these clients would require more fetal monitoring. The woman who is at 38 weeks' gestation is also in need of fetal monitoring because of a possibility of decreased fetal movement. Until the fetal well-being can be confirmed with fetal monitoring, this client should remain on the labor and delivery unit where she can be continuously monitored. Additionally, the two older clients (36 and 40 years) are considered to be of advanced maternal age, indicating a need for closer monitoring.

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? The client is hemorrhaging. The client needs to increase oral fluids. The client is experiencing normal lochia discharge. The client's health care provider needs to be notified of the finding.

The client is experiencing normal lochia discharge. Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

After review of the client's laboratory values, the nurse notes that a phenytoin (Dilantin) level for a client receiving phenytoin (Dilantin) is 7 mcg/mL. The nurse makes which interpretation regarding this laboratory result? The level is within the expected therapeutic range. The level indicates the medication should be stopped. The level is lower than the expected therapeutic range. The level is higher than the expected therapeutic range.

The level is lower than the expected therapeutic range. Rationale: The target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL, signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs? Five sputum cultures are negative. Three sputum cultures are negative. A sputum culture and a chest x-ray are negative. A sputum culture and a tuberculin skin test are negative.

Three sputum cultures are negative. Rationale: The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis drug therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. Therefore the remaining options are incorrect. A negative chest x-ray does not mean that the client is noninfectious. A positive tuberculin skin test never reverts to negative.

A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Painless, bright red vaginal bleeding Increased uterine resting tone on fetal monitoring

Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring Rationale: In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. Wear a supportive bra between feedings. Avoid breast-feeding during the time of breast engorgement. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Apply moist heat to both breasts for about 20 minutes before a feeding. Massage the breasts gently during a feeding, from the outer areas to the nipples.

Wear a supportive bra between feedings. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Apply moist heat to both breasts for about 20 minutes before a feeding. Massage the breasts gently during a feeding, from the outer areas to the nipples. Rationale: During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client should also be instructed to wear a supportive bra between feedings.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? Apply a heating pad to breasts for comfort. Wear a breast shield to correct nipple inversion. Wear a supportive brassiere continuously for 72 hours. Use the manual breast pump provided to express milk.

Wear a supportive brassiere continuously for 72 hours. Rationale: Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs? Urine tests negative for protein. Fetal movements are more than four per hour. Weight increases by more than 1 pound in a week. The blood pressure reading is ranging between 122/80 and 132/88 mm Hg.

Weight increases by more than 1 pound in a week. Rationale: The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported.

A health care provider writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure? Count the radial and carotid pulses every morning. Check the blood pressure every morning and evening. Stop taking the medication if the pulse is faster than 100 beats/min. Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min.

Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min. Rationale: An important component of taking digoxin is monitoring the pulse rate; however, it is not necessary for the client to take both radial and carotid pulses. It is also unnecessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the health care provider. The client should not stop taking the medication.

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action? Withhold the medication. Administer the medication. Double-check the apical heart rate and administer the medication. Check the blood pressure and respirations and administer the medication.

Withhold the medication. Rationale: Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to administer the medication.