Missed Prep U Questions

Which two of the following are the most needed actions a nurse should take when a pt presents to the ED with cholecystitis. Obtain supplies for a nasogastric tube. Prepare for an abdominal scan. Place in supine position. Test any vomitus for stomach pH. Administer an antiemetic.

Correct - Prep for an abdominal scan - Administer an antiemetic The nurse is correct to evaluate the client's current symptoms as being classic signs of cholecystitis. The client states that pain and vomiting began after a high-fat diet. Typical signs of cholecystitis include nausea and vomiting with right upper quadrant pain. Due to continued vomiting, even small amounts, an antiemetic is administered. To confirm the diagnosis, the client is typically sent for an ultrasound, computed tomography (CT) of the abdomen or a CCK-HIDA scan. This will assist in determining the medical treatment. Until further diagnosis, a nasogastric tube would not be placed. Having no past history of stomach ulcers, the stomach pH would not be obtained. It is best to place the client in semi fowlers position to decrease the potential for aspiration with vomiting. Pyloric stenosis is typically associated with infants who experience projectile vomiting related to a narrowed pyloric sphincter. GERD involves the reflux of stomach contents into the upper epigastric tract due to a relaxed sphincter. Repeated vomiting is not a typical symptom. Peptic ulcer disease commonly manifests as pain between the umbilicus and sternum. Symptoms of belching bloating are most common. As the nurse is awaiting the results of diagnostic testing, it is important to monitor intake and output. If further vomiting occurs or increases, a nasogastric tube may be indicated. The nurse must also monitor the client's pain level. The client would maintain nothing by mouth status until diagnosis is completed. There is no indication that the client has internal bleeding or needs stools checked for occult blood. Assessing bowel sounds is completed with a routine or focused assessment.

The nurse is caring for a client who is 32 weeks pregnant. The client is started on nifedipine for preterm labor. Which of the following statements made by the client demonstrate an understanding of the plan of care? Select all that apply. "I will check my blood pressure prior to taking my scheduled nifedipine." "I will move about frequently to keep my contractions regular." "I will avoid sexual intercourse until my health care provider says otherwise." "I will drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day." "I will not take my scheduled nifedipine if I have a headache."

Correct "I will check my blood pressure prior to taking my scheduled nifedipine." "I will avoid sexual intercourse until my health care provider says otherwise." "I will drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day." Nifedipine is a calcium channel blocker and can lower the client's blood pressure. Headache is a common side effect of nifedipine but is not an indicator to stop taking the drug. Sexual intercourse and ambulation may increase the risk of preterm birth. Clients should be encouraged to rest. Clients with preterm labor should be encouraged to drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day.

A patient with the following description comes into the ER. A male over age 65 with a history of hypertension; this client has manifestations of an abdominal aortic aneurysm, including gnawing epigastric and low back pain and a pulsating mass and bruit in the epigastric area. Pick 2 of the following actions the nurse should take: Withhold analgesics until a diagnosis is made. Prepare the client for surgical intervention. Teach the client about the need for an immediate blood transfusion. Palpate and measure the pulsatile abdominal mass every 15 minutes. Anticipate an order for IV nitroprusside.

Correct - Prep for surgical intervention - Anticipate and order for IV nitroprusside Because this client is hypertensive (188/94 mm Hg) and high blood pressure increases the risk of aneurysm rupture, the nurse anticipates an order for a medication such as nitroprusside to rapidly reduce the blood pressure. Prompt surgical repair of the aneurysm is recommended if the client initially presents with symptoms such as an abdominal mass, pain, and bruit. The nurse monitors the client's blood pressure because high blood pressure increases the risk for progression of the aneurysm and rupture. A drop in blood pressure may signal hemorrhage, requiring prompt attention. The nurse monitors the client's level of pain because an increase in abdominal pain or a ripping or tearing pain may signal that the aneurysm has progressed to dissection (a tear in the aortic wall), a life-threatening emergency due to hemorrhage. Peptic ulcer disease produces heartburn-like pain, a feeling of fullness after eating, belching, bloating, difficulty swallowing, and epigastric pain that awakens the client at night. Analgesics should not be withheld to prevent an exacerbation of hypertension that can occur with pain, thereby increasing the risk for rupture of the aneurysm. If the client had diverticular disease, the nurse would assess for abdominal distention due to difficulty passing stool past the affected part of the intestine. The nurse would monitor for hematuria if the client had a renal calculi. This is not an expected sign in the client with an abdominal aortic aneurysm. The nurse would monitor for obvious or covert blood in the stool if the client had a peptic ulcer to determine if the ulcer was hemorrhaging.

The nurse is administering a cephalosporin to a client. The nurse should monitor the client for which finding? drug-induced hemolytic anemia purpura infectious emboli ecchymosis

Correct A. drug-induced hemolytic anemia Drug-induced hemolytic anemia is acquired, antibody-mediated, red blood cell destruction precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides. Purpura is a condition with various manifestations characterized by hemorrhages into the skin, mucous membranes, internal organs, and other tissues. Infectious emboli are clumps of bacteria present in blood or lymph. Ecchymoses are skin discolorations due to extravasations of blood into the skin or mucous membranes.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an antibiotic. anticoagulant. antihypertensive. anticonvulsant.

Correct A. Anticoagulant During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine, oxygen, and aspirin. The health care provider diagnoses acute coronary syndrome. The client arrives on the unit with stable vital signs does not report pain. The nurse reviews the health care provider's orders. In addition to the medications already given, which medication does the nurse expect the health care provider to order? carvedilol digoxin furosemide dobutamine

Correct A. Carvedilol A client with suspected myocardial infarction should receive aspirin, nitroglycerin, morphine, and a beta-adrenergic blocker such as carvedilol. Digoxin treats arrhythmias; there is no indication that the client is having arrhythmias. Furosemide is used to treat signs of heart failure, which isn't indicated at this point. Dobutamine is a vasopressor and is used to increase blood pressure. This client has stable vital signs and isn't hypotensive.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see? hypercalcemia hyperkalemia hypernatremia hypermagnesemia

Correct A. Hypercalcemia Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.

A client taking tranylcypromine sulfate for depression was treated in the emergency department for a headache, vomiting, and blood pressure of 190/100 mm/Hg following dinner at a restaurant. At discharge, the nurse evaluated the client's understanding of diet instructions. For what menu choice will the nurse provide further education? Mexican sausage soup with guacamole and chips grilled chicken salad with ranch dressing fresh fruit salad with cottage cheese carrot cake and black coffee

Correct A. Mexican sausage soup with guacamole and chips When taking an MAO inhibitor, the client should avoid consuming high-tyramine foods, such as aged cheese, avocados, delicatessen meats (especially sausage), Chianti, anchovies, and fermented foods such as bean curd, pickled herring, and sauerkraut. These foods interact with the medication to cause a life-threatening hypertensive crisis. Therefore, a client who reports eating these foods requires additional teaching. The client may safely consume low-tyramine foods, such as poultry, whole grain bread, and fresh fish. Coffee, cottage cheese, cream cheese, spinach, tomatoes, and white wine are allowed in moderation.

Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next? No action is needed at this time because the drug level is normal. Contact the health care provider because these levels are elevated and may require a change in dosage. Assess client compliance with the prescribed medication regimen because these values are below therapeutic levels. Ask the laboratory to run the test again because these are critical values.

Correct A. No action is needed at this time because the drug level is normal. Normal therapeutic serum phenytoin level ranges from 10 to 20 mcg/ml. No nursing action is needed at this time.

A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse's best action? Notify the health care provider. Administer the digoxin as prescribed. Encourage the client to increase fluids. Administer calcium gluconate.

Correct A. Notify the health care provider. The decreased magnesium level can potentiate digoxin toxicity, and the health care provider should be notified. The digoxin should not be administered until the nurse receives clarification from the health care provider. Increasing fluids is not appropriate. Calcium gluconate is administered for hypermagnesemia.

A client is taking 50 mg of lamotrigine daily for bipolar disorder. The client shows the nurse a rash on their arm. What should the nurse do? Report the rash to the health care provider (HCP). Explain that the rash is a temporary adverse effect. Give the client an ice pack for their arm. Question the client about recent sun exposure.

Correct A. Report the rash to the health care provider (HCP). The nurse should immediately report the rash to the HCP because lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun exposure are irresponsible nursing actions because of the possible seriousness of the rash.

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess? shoulder dystocia immature lung function hypoglycemia small birth weight

Correct A. Shoulder dystocia This neonate exhibits findings of a post-term infant. Typically they are larger in size and more at risk for having shoulder dystocia. Immature lung function, hypoglycemia, and small birth weight are more common in pre-term infants.

When positioned properly, the tip of a central venous catheter should lie in the: superior vena cava. basilic vein. jugular vein. subclavian vein.

Correct A. Superior vena cava When positioned correctly, the tip of a central venous catheter lies in the superior vena cava, inferior vena cava, or right atrium — that is, in the central venous circulation. Blood flows unimpeded around the tip, allowing the rapid infusion of large amounts of fluid directly into circulation. The basilic, jugular, and subclavian veins are common insertion sites for central venous catheters.

When teaching a client older than age 50 who is receiving long-term prednisone therapy, the nurse should make which suggestion? Take the prednisone with food. Take over-the-counter antiemetics. Exercise three to four times a week. Eat foods that are low in potassium.

Correct A. Take the prednisone with food. Nausea, vomiting, and peptic ulcers are gastrointestinal adverse effects of prednisone, so it is recommended that clients take the prednisone with food. In some instances, the client may be advised to take a prescribed antacid prophylactically. The client should never take over-the-counter drugs without notifying the health care provider (HCP) who prescribed the prednisone. The client should ask the HCP about the amount and kind of exercise because of the need to establish baseline physical values before starting an exercise program and because of the increased potential for comorbidity with increasing age. The client should eat foods that are high in potassium to prevent hypokalemia.

Diphenoxylate/atropine has been prescribed to treat a client's diarrhea. The nurse should teach the client to report: urine retention. diaphoresis. low blood pressure. lethargy.

Correct A. Urinary retention Diphenoxylate/atropine has anticholinergic properties. Common side effects include urine retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating. Diaphoresis, hypotension, and lethargy are not common side effects of diphenoxylate/atropine.

The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indication of infection should the nurse detect during this stage? whitish-yellow patches in the mouth dyspnea bloody diarrhea raised, hyperpigmented lesions on the legs

Correct A. Whitish-yellow patches in the mouth Oropharyngeal candidiasis, or thrush, is the most common infection associated with the early symptomatic stages of HIV infection. Thrush is characterized by whitish-yellow patches in the mouth. Various other opportunistic diseases can occur in clients with HIV infection, but they tend to occur later, after the diagnosis of acquired immunodeficiency syndrome has been made. Dyspnea can be indicative of pneumonia, which is caused by a variety of infective organisms. Bloody diarrhea is indicative of cytomegalovirus infection. Hyperpigmented lesions are indicators of Kaposi sarcoma.

A client with appendicitis is experiencing excruciating abdominal pain. An abdominal X-ray film reveals intraperitoneal air. What should the nurse prepare the client for? surgery colonoscopy nasogastric (NG) tube insertion barium enema

Correct A. surgery The client should be prepared for surgery because the signs and symptoms indicate bowel perforation. Appendicitis is a common cause of bowel perforation. Because perforation can lead to peritonitis and sepsis, surgery would not be delayed to perform other interventions, such as colonoscopy, NG tube insertion, or a barium enema. These procedures are not necessary at this point.

A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The health care provider diagnoses type 1 diabetes and admits the child to the facility for insulin regulation. The health care provider orders an insulin regimen of insulin and isophane insulin administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act? ½ to 1 hour 1 to 2 hours 4 to 8 hours 8 to 10 hours

Correct A. ½ to 1 hour Regular insulin, a rapid-acting insulin, begins to act in ½ to 1 hour, reaches peak concentration levels in 2 to 10 hours, and has a duration of action of 5 to 15 hours.

A nurse is planning to implement nonpharmacological pain management strategies as part of a multimodal approach for managing the client's pain. For which strategy does the nurse seek a prescription from the health care provider? massage application of an ice bag distraction deep breathing

Correct B. Application of an ice bag Application of cold or heat requires a health care provider's prescription. The nurse can initiate massage, distraction, and deep breathing as pain management strategies.

The parent of a young adult client diagnosed with schizophrenia is asking questions about their child's antipsychotic medication, ziprasidone. Which statement by the parent reflects a need for further teaching? "If they experience restlessness or muscle stiffness, they should tell their health care provider (HCP)." "I should give them benztropine to help prevent constipation from the ziprasidone." "If they become dizzy, I'll make sure they don't drive." "The ziprasidone should help them be more motivated and less withdrawn."

Correct B. "I should give them benztropine to help prevent constipation from the ziprasidone." Constipation caused by medication is best managed by diet, fluids, and exercise. Benztropine can increase constipation. However, it may be prescribed for restlessness and stiffness. Restlessness and stiffness should be reported to the HCP. Drowsiness and dizziness are adverse effects of ziprasidone. Clients should not drive if they are experiencing dizziness. Ziprasidone does help improve the negative symptoms of schizophrenia such as avolition.

When assessing a client with left-sided heart failure, the nurse expects to note ascites. jugular vein distention. air hunger. pitting edema of the legs.

Correct B. Air Hunger With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.

The nurse observes an 18-month-old who has been admitted with a respiratory tract infection and is leaning forward with an open mouth and protruding tongue and is drooling. What should the nurse do first? Position the child supine. Call the rapid response team. Suction the airway. Administer oxygen.

Correct B. Call the rapid response team The nurse should suspect epiglottitis in any young child with a respiratory infection who sits leaning forward with an open mouth and protruding tongue and is drooling. Epiglottitis is a medical emergency. The rapid response team should be notified to secure the airway. While waiting for the team, the child should remain sitting upright to facilitate breathing; complete obstruction may occur if the child is placed prone or becomes agitated. Therefore, it is important to avoid any procedures that upset the child such as suctioning or applying oxygen.

A nurse is preparing immunizations for a child being treated for leukemia. Which immunization will the nurse hold at this time? tetanus chickenpox hepatitis A Haemophilus influenzae B (Hib)

Correct B. Chickenpox A child being treated for leukemia is at risk for having a weakened immune system and should not receive attenuated (weakened) live virus vaccines such as chickenpox, rotavirus, influenza nasal mist, or measles, mumps, and rubella. Administering these vaccines in a person with a weakened immune system may result in illness. Tetanus vaccine is a detoxified toxoid and cannot cause disease. Hepatitis A vaccine is an inactivated (killed) virus and cannot cause disease. Haemophilus influenzae B is a conjugate vaccine consisting of proteins, not virus, and cannot cause disease.

The health care provider's order reads "digoxin 0.075 mg." The pharmacy packaging contains three digoxin tablets labeled as 0.25 mg each. The packaging states to administer all 3 tablets to the client. What should the nurse do next? Administer the dose according to the package instructions. Contact the pharmacist because the delivered dose is too high. Contact the pharmacist because the delivered dose is too low. Contact the health care provider to correct the original order.

Correct B. Contact the pharmacist because the delivered dose is too high. Three pills of 0.25 mg equal 0.75 mg, more than the 0.075 mg that was ordered. Because the quantity of medication differs from that ordered, the nurse should not administer it. The next step is to contact the pharmacist, who can check the order, verify its appropriateness, and deliver the dose that matches the order.

The nurse is assessing a client, who is incontinent, for their risk for developing a pressure injury. The client is an 80-year old female who also has hypertension. Which factor contributes most to the client's risk for a pressure injury? gender incontinence hypertension age

Correct B. Incontinence Exposure to moisture can lead to maceration and the development of pressure injuries. It is important for the client's skin to be kept clean and dry with prompt attention to cleanliness after incidents of incontinence. The client's gender and age and the presence of hypertension are not the most significant factors leading to pressure injuries for this client.

The nurse assesses a 4-month-old infant diagnosed with possible intussusception. The nurse should expect the parent to relate which information about the infant's crying and episodes of pain? constant accompanied by leg extension intermittent with knees drawn to the chest shrill during ingestion of solids intermittent while being held in the parent's arms

Correct B. Intermittent with knees drawn to the chest The infant with intussusception experiences acute episodes of colic-like abdominal pain. Typically, the infant screams and draws the knees to the chest. Between these episodes of acute abdominal pain, the infant appears comfortable and normal. Feeding does not precipitate episodes of pain. Additionally, a 4-month-old infant typically would not be ingesting solid foods. Pain exhibited by crying that occurs when the infant is placed in a reclining position, as in the parent's arms, is not associated with intussusception. This type of cry may indicate that the infant wants attention, wants to be held, or needs to have a diaper change.

A client is to take rosuvastatin. What information should the nurse determine before administering the drug? Can the client swallow a pill, or does the client need a liquid form? Is the client of Asian descent? Will the client be able to afford the medication? Does the client have a history of cardiovascular disease?

Correct B. Is the client of Asian descent? Rosuvastatin has been shown to reach higher serum levels in persons of Asian descent and should not be used in this group of clients. There is no liquid form for this medication. The cost is always important, but this is not the most significant concern at this point. It is not uncommon to have this drug prescribed to clients with a history of cardiovascular disease as a means of preventing the progression of the disease.

A dehydrated infant is receiving IV therapy. The parent tells the nurse about wanting to hold the infant but being afraid this might cause the IV line to become dislodged. How should the nurse respond? Encourage the parent to interact with the infant while lying in the bed. Provide a comfortable chair for the parent to hold the infant while connected to the IV. Temporarily disconnect the IV line so the parent can hold the child comfortably. Place a restraint on the arm with the IV site so it cannot move or become dislodged.

Correct B. Provide a comfortable chair for the parent to hold the infant while connected to the IV. Infant bonding is very important, and the need increases when the child is ill. The parent should be provided with a comfortable chair with support to help hold the infant. The IV pump needs to be close to the chair with enough tubing to allow for movement. Placing a restraint over the IV site requires a prescription from the health care provider and is not necessary. The IV site can be protected with blankets or clothing. The nurse should encourage the parent to participate in the child's care whenever possible, not just during IV therapy. The IV should not be disconnected for bonding time. IV fluids should remain continuously at a rate prescribed by the health care provider.

The surgeon prescribes cefazolin 1 g to be given intravenously (IV) at 0730 when the client's surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730? Legally, the medication has to be given at the prescribed time. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. The postoperative dose of cefazolin needs to be started exactly 8 hours after the preoperative dose of cefazolin. The peak and titer levels are needed for antibiotic therapy.

Correct B. The antibiotic is most effective in preventing infection if it is given 30 to 60 minutes before the operative incision is made. The antibiotic is most effective in preventing infection, according to research, if it is given 30 to 60 minutes before the operative incision is made. When the surgeon prescribes the antibiotic to be given at a specific time related to the scheduled time of the surgical procedure, it is imperative that the antibiotic is given on time. Legally, the nurse considers 30 minutes on either side of the scheduled time to be acceptable for administering medications; however, in this situation, giving the antibiotic 30 minutes too soon can make the prophylactic antibiotic ineffective. The postoperative dose of the antibiotic is not timed according to the preoperative dose. Peak and titer levels are measured for some antibiotics, but in this case, the primary reason is to have the antibiotic infused before the time of the incision.

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb? lengthening of the affected extremity with internal rotation shortening of the affected extremity with external rotation abduction with external rotation of the right leg abduction with internal rotation of the left leg

Correct B. shortening of the femur with external rotation of the extremity As a result of the muscles contracting and pulling on the two portions of bone, there is a characteristic shortening of the femur with external rotation of the extremity. The other answers are incorrect based on pathology of a hip fracture.

The nurse is performing discharge teaching with a client with a new colostomy. Which client statement best reflects successful teaching regarding the purpose of ostomy irrigation? "It helps to keep the stoma clean and a nice red color." "It helps improve blood flow to the area." "It helps regulate the passage of stool." "It gives me more fluid to prevent dehydration."

Correct C. "It helps regulate the passage of stool." The purpose of irrigation is to help with regulating evacuation of stool from the bowel. It would not be routinely done but instead used every few days if needed. The fluid may help with keeping stool less dry and able to pass through the colostomy but does not prevent dehydration. It may improve vascularity by clearing stool from the bowel wall but this is not the purpose of the irrigation. The stoma itself would not be affected because the irrigation is placed inside the stoma, and the stoma is best maintained at a pink color versus red, which may indicate the stoma is irritated.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor? trauma during labor and birth moderate fundal massage after birth lengthy and prolonged second stage of labor overdistention of the uterus from hydramnios

Correct D. Overdistention of the uterus from hydramnios The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause, and no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps contract the uterus; it does not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that they had a long labor.

The telehealth nurse obtains a history from a parent of a toddler. Which finding should alert the nurse to suspect that the child has had a febrile seizure? The child has had a low-grade fever for several weeks. The family history is negative for convulsions. The seizure resulted in respiratory arrest. The seizure occurred when the child had a respiratory infection.

Correct D. The seizure occurred when the child had a respiratory infection. Most febrile seizures occur in the presence of an upper respiratory infection, otitis media, or tonsillitis. Febrile seizures typically occur during a temperature rise rather than after prolonged fever. There appears to be increased susceptibility to febrile seizures within families. Infrequently, febrile seizures may lead to respiratory arrest.

A client is prescribed oral metronidazole for the treatment of bacterial vaginosis. What should the nurse instruct the client to avoid during treatment and for 24 hours thereafter? douching sexual intercourse hot tub baths alcohol consumption

Correct D. alcohol consumption Metronidazole interacts with alcohol and can cause a serious disulfiram-type reaction, with severe, prolonged vomiting. The client should not douche unless following a medical prescription, but douching does not interact with metronidazole. Sexual intercourse and hot tub baths are not known to affect the incidence or treatment of bacterial vaginosis.

A health care provider orders digoxin for a client with heart failure. During digoxin therapy, which laboratory value may predispose the client to digoxin toxicity? magnesium level of 2.5 mg/dl (0.1 mmol/L) calcium level of 7.5 mg/dl (0.4 mmol/L) sodium level of 152 mEq/L (152 mmol/L) potassium level of 3.1 mEq/L (3.1 mmol/L)

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

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client? Client will state that they may attempt another pregnancy after 3 months of follow-up care. Client will schedule a first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. Client will state that they won't attempt another pregnancy until their human chorionic gonadotropin (hCG) level rises. Client will use a reliable contraceptive method until the follow-up care is complete in 1 year and their hCG level is negative.

Correct D: Client will use a reliable contraceptive method until the follow-up care is complete in 1 year and their hCG level is negative. After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform mole. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.

A child is diagnosed with Wilms' tumor. During assessment, the nurse expects to detect gross hematuria. dysuria. nausea and vomiting. an abdominal mass.

Correct D: an abdominal mass. The most common sign of Wilms' tumor is a painless, palpable abdominal mass, sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon, although microscopic hematuria may be present. Dysuria isn't associated with Wilms' tumor. Nausea and vomiting are rare in children with Wilms' tumor.

The nurse is caring for a client who has sickle cell disease (SCD). The client is reporting pain in the back, chest, and extremities. The nurse anticipates that the client may present with what other clinical manifestation(s)? Select all that apply. sneezing nausea hypertension tachypnea swelling

Correct Nausea, HTN, tachypnea, swelling Pain episodes in sickle cell disease are often accompanied by clinical manifestations such as fever, swelling, tenderness, tachypnea, hypertension, nausea, and vomiting. Sneezing is the body's way of removing irritants from your nose or throat and is not a clinical manifestation in this scenario.

The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/min, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action? Call the rapid response team. Administer a sedative. Try to elicit a positive Homans sign. Increase the flow rate of intravenous (IV) fluids.

Correct A. Call the rapid response team. Pulmonary embolism is a potentially life-threatening complication of deep vein thrombosis. The client's change in mental status, tachypnea, and tachycardia indicate a possible pulmonary embolism. The nurse should promptly call the rapid response team. Administering a sedative without further evaluation of the client's condition is not appropriate. There is no need to elicit a positive Homans sign; the client is already diagnosed with deep vein thrombosis. Increasing the IV flow rate may be an appropriate action but not without first notifying the health care provider.

While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is: "All family members need to be treated." "If someone develops symptoms, tell them to see a health care provider right away." "Just be careful not to share linens and towels with family members." "After you're treated, family members won't be at risk for contracting scabies."

Correct A. "All family members need to be treated." When someone sharing a home with others contracts scabies, all individuals in the home need prompt treatment whether or not they're symptomatic. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

The client is diagnosed with absence seizures and is prescribed pentobarbital sodium. What should the nurse include in the client's teaching concerning the administration of pentobarbital sodium? "Pentobarbital sodium can cause confusion." "Pentobarbital sodium can cause anxiety." "Pentobarbital sodium can cause hand tremors." "Pentobarbital sodium can cause hypotension."

Correct A. "Pentobarbital sodium can cause confusion." The nurse should explain that adverse effects of pentobarbital sodium include confusion, slurred speech, slow physical movement, blood dyscrasias, nausea, vomiting, constipation, gingival hyperplasia, and hirsutism. Hypotension, hand tremors, and anxiety are not adverse effects of pentobarbital sodium.

The nurse is caring for a client with a double lumen tunneled central catheter with ordered bloodwork and intermittent I.V. medications. What is the correct action by the nurse? Dedicate the largest lumen for blood draws. Use both lumens for blood draws. Insert a peripheral line for I.V. medications. Obtain blood via peripheral blood draws.

Correct A. Dedicate the largest lumen for blood draws. The nurse should dedicate the largest lumen for blood draws and the other for medication administration. There is no need to insert a peripheral line for I.V. medication administration or to obtain bloodwork via peripheral blood draws.

The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should the nurse expect to administer that will help to prevent transmission of the virus to the fetus? zidovudine fluvastatin dimenhydrinate disulfiram

Correct A. Zidovudine Zidovudine is an antiretroviral used to help to prevent the transmission of HIV infection to the neonate. The other medications are not appropriate for this client. Fluvastatin is an antilipemic used for hypercholesterolemia, dimenhydrinate is an antiemetic used for motion sickness, and disulfiram is an alcohol deterrent.

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks? acetaminophen aspirin ibuprofen naproxen

Correct A. acetaminophen The nurse should instruct the client that symptoms from an occasional headache due to eye strain or continuous work at a computer can be relieved by acetaminophen. Although this drug causes prostaglandin inhibition, this effect is rapidly reversed and cleared with no apparent harmful effects in pregnancy. If the headaches become more frequent or severe, the client should be instructed to contact the health care provider (HCP) immediately. Aspirin should be avoided during pregnancy because it inhibits prostaglandin synthesis. It also decreases uterine contractility and may delay the onset of labor or prolong pregnancy and labor. Aspirin decreases platelet aggregation, possibly increasing the risk for bleeding. Ibuprofen and naproxen can lead to premature closure of the fetal ductus arteriosus and decreased amniotic fluid with prolonged use. They may also prolong pregnancy or labor because of their anti-prostaglandin effects.

During an emergency, a health care provider has asked for I.V. calcium to treat a client with hypocalcemia. The nurse should: Hand the health care provider calcium chloride for I.V. use. Check with the health care provider for their complete order. Hand the health care provider calcium gluconate for I.V. use. Hand the health care provider the kind of calcium available on the unit.

Correct B. Check with the health care provider for their complete order. The nurse should first check with the health care provider for the complete order of calcium because calcium chloride has a concentration of 13.6 mEq (3.4 mmol/l) of calcium per gram and calcium gluconate has 4.65 mEq (1.2 mmol/l) of calcium per gram. The nurse can always offer the health care provider the type of calcium available after the conversion in calcium has been made; otherwise, the error could be fatal.

A client with hyperthyroidism is to take saturated solution of potassium iodide (SSKI). What should the nurse do when administering this drug? Pour the solution over ice chips. Dilute the solution with water or juice. Mix the solution with an antacid. Mix the solution in pureed fruit.

Correct B. Dilute the solution with water or juice. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to the mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth.

The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder? levothyroxine phenytoin furosemide morphine sulfate

Correct B. phenytoin Antiseizure medications are often the cause of toxic epidermal necrolysis. Other common medications that may cause toxic epidermal necrolysis include antibiotics, NSAIDs (nonsteroidal anti-inflammatory drugs), and sulfa medications.

Considering a client's atrial fibrillation, a nurse must administer digoxin with caution because it affects the sympathetic division of the autonomic nervous system, decreasing vagal tone. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. can induce a hypertensive crisis by constricting arteries. can trigger proarrhythmia by increasing stroke volume.

Correct B. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. A nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, increasing the potential for new arrhythmias to develop. Digoxin doesn't constrict arteries. Although digoxin can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).

A nurse is teaching a client with bipolar disorder about the drug carbamazepine. The nurse determines teaching was effective when the client states "My hair will fall out after I take this drug for a few months." "I will drink plenty of water so I don't develop kidney problems." I need to have my blood counts checked periodically." "I can't take any other drugs while I am taking this one."

Correct C. "I need to have my blood counts checked periodically." The most dangerous adverse effect of carbamazepine is bone marrow depression. Other medications may be taken with carbamazepine. Hair loss doesn't occur in clients taking carbamazepine. Clients who take lithium, not carbamazepine, must be closely monitored for nephrogenic diabetes insipidus. The interactions of all drugs must be monitored because some can either increase or decrease the blood level of carbamazepine.

A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? 24 hours 2 to 4 days 7 to 14 days 21 to 28 days

Correct C. 7 to 14 days Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.

The nurse is about to administer lithium carbonate to a client with bipolar disorder in a mania state. What is the nurse's action after assessing the client's lithium level to be 1.0 mEq/L (mmol/L)? Notify the health care provider. Hold the lithium carbonate. Administer the lithium carbonate. Repeat the lithium level.

Correct C. Administer the lithium carbonate. To treat acute mania, the client's serum lithium level should be between 0.6 and 1.2 mEq/L (mmol/L). The serum lithium level shouldn't exceed 2 mEq/L (mmol/L). The nurse must monitor the client continuously for signs and symptoms of lithium toxicity, such as diarrhea, vomiting, drowsiness, muscular weakness, ataxia, stupor, and lethargy. The nurse must also keep in mind that even a normal lithium level can become toxic. Notifying the health care provider of the normal level with a client in mania is not appropriate. There are no signs and symptoms of toxicity, so the medication should not be held. There is no reason to repeat the level.

A client had surgery 6 hours ago. The client has a prescription for an opioid medication for pain every 3 to 4 hours. The last dose was administered at 1500. When the nurse enters the room at 1800, the client is restless and grimacing. What action should the nurse take first? Ask the unlicensed assistive personnel (UAP) to help reposition the client. Administer the opioid medication to relieve the pain. Assess the client to determine the cause of the grimacing. Turn the lights down to minimize the client's restlessness.

Correct C. Assess the client to determine the cause of the grimacing. The nurse should carefully assess the client to determine the reason for the grimacing and restlessness. The nurse should not assume by the client's nonverbal communication that the client is in pain and requires pain medication; the nurse must validate the message rather than make assumptions. The nurse should assess the client first before changing the client's position or turning down the lights.

A client with benign prostatic hypertrophy (BPH) is being treated with terazosin 2 mg at bedtime. What should the nurse tell the client to monitor regularly? glucosuria glucose restlessness blood pressure pulse

Correct C. blood pressure Terazosin is an antihypertensive drug that is also used in the treatment of BPH. The client should monitor their blood pressure to ensure they do not develop hypotension, syncope, or orthostatic hypotension. The client should be instructed to change positions slowly. Terazosin does not cause glycosuria, restlessness, or changes in the heart rate.

A nurse is caring for a client receiving thioridazine 300 mg TID. It would be most important for the nurse to follow up with which client statement? "I drink at least ten glasses of water a day." "I am always hungry, and I have been gaining weight." "I take the first dose right when I wake up in the morning." "My ophthalmologist said I have a new pigmented layer on my retina."

Correct D. "My ophthalmologist said I have a new pigmented layer on my retina." Retinal pigmentation may occur if thioridazine dosage exceeds 600 mg per day; this can lead to vision loss, so the nurse should follow up on this statement. Drinking ten glasses of water a day is encouraged. Weight gain is an adverse reaction to thioridazine and should be followed up; however, the immediate priority is preventing vision loss. Administration of thioridazine can be given without regard to food. Therefore, taking the first dose immediately in the morning is appropriate.

A client is to receive epoetin injections. What laboratory value should the nurse review before giving the injection? hematocrit partial thromboplastin time hemoglobin concentration prothrombin time

Correct. A. Hematocrit Epoetin is a recombinant DNA form of erythropoietin, which stimulates the production of red blood cells and therefore causes the hematocrit to rise. The partial thromboplastin time, hemoglobin level, and prothrombin time are not monitored for this drug.

When performing an initial assessment of a postterm neonate weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery after a vaginal birth with low forceps, the nurse detects Ortolani's sign. Which action should the nurse take next? Determine the length of the birth parent's labor. Notify the health care provider (HCP) immediately. Keep the neonate under the radiant warmer for 2 hours. Obtain a blood sample to check for hypoglycemia.

Correct. B. Notify the health care provider (HCP) immediately. Ortolani maneuver involves flexing the neonate's knees and hips at right angles and bringing the sides of the knees down to the surface of the examining table. A characteristic click or "clunk," felt or heard, represents a positive Ortolani sign, suggesting a possible hip dislocation. The nurse should notify the HCP promptly because treatment is needed, while maintaining the dislocated hip in a position of flexion and abduction. It should be noted that many institutions now limit performing the Ortolani's maneuver to APNs or HCPs. Determining the length of the birth parent's labor provides no useful information related to the nurse's finding. Keeping the infant under the radiant warmer is necessary only if the neonate's temperature is low or unstable. Checking for hypoglycemia is not indicated at this time, unless the neonate is exhibiting jitteriness.

A health care provider prescribes several drugs for a client admitted to the emergency department with Laennec's cirrhosis. Which drug order should the nurse question? folic acid ketorolac warfarin vitamin K

Correct. C. Warfarin Laennec's cirrhosis is caused by excessive alcohol use. Folacin or folic acid and vitamin K are all appropriate for this client due to vitamin deficiencies caused by cirrhosis. The client is at risk for bleeding related to the inability of the liver to alteration in clotting factors; therefore, warfarin is contraindicated. Ketorolac is a non-opioid analgesic and is appropriate for pain control in this client.

The nurse is evaluating a hemodynamically unstable client with an arterial line and notes that the client has tachycardia, cool and clammy skin, a pericardial friction rub, and the arterial waveform shows an inspiratory systolic pressure that is 15 mm Hg less than the expiratory systolic pressure. What is the priority intervention by the nurse? Contact the health care provider. Auscultate heart sounds. Assess manual blood pressure. Perform square wave test.

Correct: A. Contact the healthcare provider The priority action is to contact the health care provider because these symptoms are indicative of cardiac tamponade. Assessing the heart sounds is not indicated at this time. The square wave test would be performed to check for accuracy of the arterial readings and optimal wave formation. There is no indication for performing a manual blood pressure at this time.

The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client's functional status before the stroke. How will the nurse incorporate this information into the care plan? The client's functional status before the stroke will: guide the rehabilitation plan. help predict outcomes. help the client recognize physical limitations. determine if the client can be expected to regain most functional status.

Correct: B. Guide the Rehabilitation plan The primary reason for the nursing assessment of a client's functional status before the stroke is to guide the rehabilitation plan. The assessment does not help predict how far the rehabilitation team can help the client recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client's functional status does not help the client recognize limitations.

A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia? glycosuria and blood pressure of 150/92 mmHg reduced urine output, 1+ edema 1+ protein, blood pressure 142/92 mmHg blood pressure 138/78 mmHg, 1+ edema in feet

Correct: D. Blood pressure 138/78mmHg, 1+ edema in feet The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Mild preeclampsia is defined by a blood pressure greater than 140/90 mmHg, 1+ protein, weight gain, and mild hand edema. Abdominal pain, blurry vision, a blood pressure greater than 160/110 mmHg, and reduced urine output are signs of severe preeclampsia. Seizures are a sign of eclampsia. Hyperglycemia is not associated with preeclampsia.

A client with active tuberculosis (TB) has been taking combination therapy with daily doses of isoniazid, rifampin, pyrazinamide, and streptomycin for the past month. What information should the nurse reinforce with the client? "You should continue to attend the clinic and be observed taking the medication as part of direct observation therapy." "Though you feel well now, if you miss any doses, your TB symptoms will become much worse very quickly." "Remember that missing even one dose of these medications can make your TB less responsive to treatment." "Since you have been treated for a full month, we can now run tests to see if the medication can be stopped."

Correct C. "Remember that missing even one dose of these medications can make your TB less responsive to treatment." It is essential that the client comply with the combination drug therapy, or resistance will develop, making the TB more difficult to treat. At no time should the client stop taking the medications without the health care provider's authorization. If the client was required to attend direct observation therapy, the frequency of dosing would be twice weekly, not daily. Treatment must continue for a minimum of 6 months in most cases, though pyrazinamide may be discontinued after 2 months while the other medications are continued. The client will not feel worse when missing doses, which is one of the reasons adherence of this long-term treatment can be difficult.

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth? 12 hours 24 hours 72 hours 48 hours

Correct C. 72 hours For maximum effectiveness, Rho(D) immune globulin should be administered within 72 hours postpartum. Most Rh-negative clients also receive Rho(D) immune globulin during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative clients who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after the pregnancy is terminated, the client should receive the medication.

When discussing the use of a fluticasone and salmeterol inhaler with the parent of a child diagnosed with asthma, the nurse should teach the parent that the medication will be most effective if it is administered at which time? intermittently for short-term use during an asthma attack twice daily before riding a bicycle for a block

Correct C. BID Fluticasone and salmeterol is a combination drug used as a prophylactic agent to help prevent bronchial asthma attacks. Fluticasone is an inhaled corticosteroid that reduces inflammation. Salmeterol is a long-acting beta-agonist (LABA) that reduces bronchospasms. The drug must be taken on a consistent basis, twice a day, over a long period of time to be effective. Short-term dosing right before exercise provides no benefits. LABAs are of no use during an acute asthma attack.

A nurse is caring for a 7-year-old client receiving cyclophosphamide. In addition to administering mesna, which action should the nurse take? Transfuse platelets before administering the drug. Give the child cranberry juice to drink. Encourage the child to void frequently. Limit the child's fluid intake.

Correct C. Encourage the child to void frequently. Hemorrhagic cystitis can result when the by-products of cyclophosphamide metabolism remain in the bladder; therefore, emptying the bladder at least every 2 hours when the child is awake can help prevent this painful condition. The child should be encouraged to void as soon as the urge is felt. Bacteria or low platelets do not cause the condition, so transfusing platelets and giving cranberry juice aren't correct. Fluids should not be limited. The child should be given liberal amounts of fluid, usually by I.V. infusion.

A nurse is monitoring a client for adverse reactions to dantrolene. Which adverse reaction is most common? excessive tearing urine retention muscle weakness slurred speech

Correct C. Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. Muscle weakness is rarely severe enough to cause slurring of speech, drooling, or enuresis. Although excessive tearing and urine retention are adverse reactions associated with dantrolene use, they aren't as common as muscle weakness.

A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium? sexual dysfunction constipation polyuria seizures

Correct C. Polyuria Polyuria commonly occurs early in lithium treatment and could result in deficient volume deficit. Sexual dysfunction isn't a common adverse effect of lithium; it's more common with sedatives and tricyclic antidepressants. Diarrhea, not constipation, occurs with lithium. Constipation can occur with other psychiatric drugs, such as antipsychotic drugs. Seizures may be a later sign of lithium toxicity.

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. What is the nurse's primary goal at this time? Maintain circulation. Manage pain. Prepare the client for emergency surgery. Teach postoperative breathing exercises.

Correct C. Prepare the client for emergency surgery. The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if prescribed.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding? macule papule vesicle pustule

Correct C. Vesicle A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment? vitamin K dextrose 50% activated charcoal powder sodium thiosulfate

Correct C. activated charcoal powder Activated charcoal powder is administered to absorb remaining particles of salicylate. Vitamin K is an antidote for warfarin sodium. Dextrose 50% is used to treat hypoglycemia. Sodium thiosulfate is an antidote for cyanide.

A nurse is admitting a client with barbiturate use disorder. Which drug is most likely to increase the client's depression? methylphenidate cocaine amitriptyline hydrochloride amphetamine

Correct C. amitriptyline hydrochloride Additive effects occur with concomitant use of CNS depressants, antihistamines, antidepressants, and antipsychotics. Amitriptyline is an antidepressant. Methylphenidate, cocaine, and amphetamine are classified as stimulants.

A client, who has just started taking phenytoin, asks the nurse if there are any adverse effects of this medication. What is the nurse's best response? dry mouth furry tongue somnolence tachycardia

Correct C. somnolence Adverse effects of phenytoin (a seizure med) include sedation, somnolence, gingival hyperplasia, blood dyscrasia, and toxicity. The other symptoms aren't adverse effects of phenytoin.

A client with a positive skin test for tuberculosis (TB) is not showing signs of active disease and is being treated with isoniazid, 300 mg daily. The nurse explains to the client that the medication should be taken for 10 to 14 days. 2 to 4 weeks. 3 to 6 months. 9 to 12 months.

Correct D. 9 to 12 months Because of the increasing incidence of resistant strains of TB, the disease must be treated from 9 to 12 months, or up to 24 months in some cases. Isoniazid is the most common medication used for the treatment of TB, but other antibiotics are often added to the regimen to obtain the best results.

A client who underwent esophageal hernia repair 4 hours ago has a temperature of 100.4°F (38°C); pulse of 90 bpm; respiration rate of 16 breaths/min; blood pressure of 130/80 mm Hg; and pulse oximeter reading of 91% on room air. What should the nurse do first? Obtain a culture of the incision. Notify the surgeon to obtain an antibiotic prescription. Offer pain medication. Assist the client to a sitting position to take deep breaths.

Correct D. Assist the client to a sitting position to take deep breaths. When a client has a temperature of 100°F (37.8°C) or higher in the first 24 hours after surgery, the temperature elevation is usually related to atelectasis. Because this client had upper abdominal surgery with manipulation around the diaphragm, the client is more prone to guarding the operative site and shallow breathing. Encouraging the client to take deep breaths is an appropriate measure to prevent atelectasis and pulmonary infection. Changing the client's position from lying to sitting for deep breathing will expand the alveoli in the lower posterior lobes. There is no indication that a surgical wound infection is occurring. An antibiotic is not indicated at this time. Pain medication will decrease respirations, and the client is not indicating pain at the moment.

A client is diagnosed with thrombophlebitis. What nursing action would demonstrate the appropriate level of activity for this client? bed rest with the affected extremity in the dependent position bed rest with all normal activities as long as there no increased pain on the affected site bed rest with the affected extremity flat Bed rest with the affected extremity elevated

Correct D. Bed rest with the affected extremity elevated Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Other answers are incorrect based on appropriate level of activity needed to assist the diagnosis. Bed rest with normal activity is incorrect because pain is not always experienced with a thrombophlebitis.

Which statement by a client with rheumatoid arthritis would indicate the need for additional teaching to safely receive the maximum benefit of aspirin therapy? "I always take aspirin with food to protect my stomach." "Once I learned to take my aspirin with meals, I was able to start using the inexpensive generic brand." "I always watch for bleeding gums or blood in my stool." "I try to take aspirin only on days when the pain seems particularly bad."

Correct D. I try to take aspirin only on days when the pain seems particularly bad." Aspirin therapy in rheumatoid arthritis involves continuous ongoing administration to establish and maintain therapeutic blood levels. Aspirin should not be used on an as-needed basis. Aspirin should always be buffered with food. Generic aspirin is acceptable. Clients should be instructed to observe for symptoms of bleeding.