NCLEX-prep Saunders

The development of a vesicovaginal fistula

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which?

Peripheral neuritis

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect?

Desmopressin (DDAVP)

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the health care provider, and the nurse anticipates a prescription for which medication?

The Blood Bank

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area?

Dry Mouth

A client with Parkinson's disease has been prescribed benztropine (Cogentin). The nurse monitors for which gastrointestinal (GI) side effect of this medication?

In the morning before breakfast

A urinary analgesic is prescribed for a client with a urinary tract infection. When should the nurse tell the client that it is best to take the medication?

...................

Administration of bethanechol chloride could result in cholinergic overdose. The antidote is atropine sulfate (an anticholinergic), which should be readily available for use if overdose occurs

Take the medication with a full glass of water after rising in the morning.

Alendronate (Fosamax) is prescribed for a client with osteoporosis. The nurse should reinforce instructing the client taking this medication to do which?

...................

Allopurinol is an antigout medication that may increase the effect of oral anticoagulants. Warfarin sodium is an anticoagulant, and if this medication was prescribed for the client, the nurse should verify the prescription. The dose of warfarin sodium may need to be decreased.

Return to the clinic weekly for serum drug levels.

Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. Which instruction should the nurse suggest to include in the client teaching plan regarding this medication?

.............

Clients taking allopurinol are encouraged to drink 2000 to 3000 mL of fluid a day to prevent the formation of crystals in the urine. Allopurinol is to be given with or immediately following meals or milk.

.................

Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative-hypnotic (benzodiazepine). The medication can lead to physical or psychological dependence when there is prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted

1.4 mg

Metformin is contraindicated with a creatinine level greater than what?

......................

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

Dyspnea and lung sounds

The nurse has just been given a prescription to administer albuterol (Proventil HFA) to a client. The nurse evaluates the effectiveness of the medication by checking which parameters before and during therapy?

-Pulse -BP -Cardiac Output -Red Blood Cell Mass

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy?

Presence of accelerations

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?

Axilla

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area?

Head elevation of no more than 30 degrees

The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position?

Blood Glucose Level

Which test would the nurse anticipate for a teenage client who has been treated for vaginal Candida infections repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?

10 mm or more

With the tuberculin skin test an induration that measures __________ is considered to be a positive result for children who are younger than 4 years old.

NO

Would you still take repaglinide (Prandin) is a meal was missed?

Pastia's sign

_______________ is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints.

Red-Green Color Blindness

ethambutol (Myambutol) may cause what?

Uric Acid Level

he client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?

Provide visualization of injury to the cornea.

The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. The nurse understands that which is the rationale for the use of this medication?

Positive Romberg Sign

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

Crackles in the lung bases

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted?

Amniocentesis for fetal surfactant level

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?

-Seizures -Irregular Heartbeat

A client is monitoring a client receiving theophylline (Theo-24) to treat symptoms of chronic obstructive pulmonary disease (COPD). Which adverse effects require immediate consultation with the health care provider?

Warfarin sodium (Coumadin)

A client newly diagnosed with gout has been prescribed allopurinol (Zyloprim). The nurse should question the health care provider if the dose for which medication already prescribed has not changed?

Baker's yeast

A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to which product?

...................

A blood glucose level is an indicator of diabetes mellitus. In females, monilial infections of the genitourinary tract are a common symptom of diabetes mellitus. Pap smears are specific for detecting cancer of the cervix.

Positive Kernig's sign

A client complains of pain in the lower back and pain and spasms in the hamstrings when the nurse attempts to extend the client's leg. How should the nurse record this finding on the client's medical record?

Prolonged blood clotting times

A client diagnosed with acute lymphocytic leukemia has been prescribed asparaginase (Elspar). Which finding represents possible medication toxicity?

Low-Fiber (this diet placed less strain on the intestines)

A client has been diagnosed with acute gastroenteritis. Which diet should the nurse anticipate to be prescribed for the client?

Peripheral neuritis

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

Leads to physical and psychological dependence with prolonged, high-dose therapy

A client with a history of simple partial seizures is taking clorazepate (Tranxene). The client asks the nurse whether there is a risk of addiction. The nurse's response is based on which understanding of clorazepate?

Tarry Stools

A client with a partial right adrenalectomy is placed on corticosteroid replacement therapy. Which data would indicate that the client is experiencing an adverse effect related to the pharmacological treatment?

Expect the urine to become reddish orange.

A client with a urinary tract infection with dysuria is given a prescription for phenazopyridine hydrochloride (Pyridium) for symptom relief. Which should the nurse reinforce instructing the client about this medication?

A pregnant caregiver should not be exposed to the crushed tablets of finasteride. (may be harmful to the developing fetus)

A client with benign prostatic hyperplasia is being administered finasteride (Proscar). Which information should be included in the plan of care?

Preserve normal cells

A client with lung cancer is receiving a high dose of methotrexate (Rheumatrex). Leucovorin (citrovorum factor, folic acid) is also prescribed. The nurse who is assisting in planning care for the client understands that administering the leucovorin is for which purpose?

....................

A common adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized by pyridoxine (vitamin B6) intake.

My hair may be lost temporarily but may grow back with a different color and texture.

A female client undergoing chemotherapy with intravenous vincristine sulfate (Oncovin) has been given information about the treatment. The nurse determines that the client has adequate understanding of the side effects of treatment if the client makes which statement about her hair?

Brudzinski's

A positive ____________ sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

-Runny Nose -Burning sensation in the eye -Tearing in the affected eye

Which symptoms would validate the diagnosis of a cluster headache?

...................

Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.

Chlorpropamide

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission?

...................

An adverse effect of isoniazid is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This adverse effect can be minimized with pyridoxine (vitamin B6) intake.

Bilberry

An herbal supplement that has been used to treat varicose veins

Confusion

An older client recently has been taking cimetidine (Tagamet). The nurse should monitor the client for which most frequent central nervous system side effect of this medication?

Stable Angina

Angina that is induced by exercise and relieved by rest or nitroglycerin tablets

Variant angina (Prinzmetal's angina)

Angina that is prolonged and severe and occurs at the same time each day, most often in the morning.

Unstable Angina

Angina that occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction

ABD Distention

When reviewing the health care record of a client with ovarian cancer, the nurse recognizes which sign/symptom as being a typical manifestation of the disease?

Bc it may increase intraocular pressure

Atropine is contraindicated in pts with glaucoma, why?

Somewhere safe from moisture (moisture degrades the med)

Where should indinavir (Crixivan) be stored?

.................

Baclofen is a centrally acting skeletal muscle relaxant. Side effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion.

.................

Baclofen is dispensed in 10- and 20-mg tablets for oral use. Dosages are low initially and then gradually increased. Maintenance doses range from 15 to 20 mg administered 3 or 4 times a day.

..................

Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

...............

Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea

Decerebrate (extension) posturing

Characterized by the rigid extension and pronation of the arms and legs.

Brown pigmentation of the iris

Which finding indicates a side effect associated with the use of latanoprost (Xalatan) eye drops?

Grapefruit Juice

Which food item should the nurse instruct the client to avoid when taking cyclosporine (Sandimmune)?

Glomerulonephritis

Gross hematuria resulting in dark, smoky, cola-colored or red-brown urine is a classic symptom of glomerulonephritis, and hypertension is also common. A mid- to high urinary specific gravity is associated with glomerulonephritis. BUN levels may be elevated.

.........................

Hemorrhagic cystitis is a toxic effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal (GI) upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client should not be told to increase potassium intake. The client should not be instructed to alter sodium intake.

With a full glass of water

How is sulfisoxazole administered?

On an empty stomach

How should oral erythromycin be taken?

......................

Hyperpyrexia up to 107° F may be present in neuroleptic malignant syndrome. Symptoms develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, there is evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium. The presence and severity of symptoms are compounded when two or more antipsychotics are taken concomitantly.

.....................

In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms and soles at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray, and the palms, soles, conjunctivae, and nail beds have a bluish tinge.

Calcium Channel Blocking Agents

Prinzmetal's angina is generally treated with what?

...................

Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage.

Nephrotic syndrome

Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The urine volume is decreased, and the urine is dark and frothy in appearance. The child with this condition gains weight.

180-340 mg/dL

Normal fibrinogen level for men

190-420 mg/dL

Normal fibrinogen level for women

150,000-400,000 cells/mm

Normal platelet count range

Nägele's rule

Nägele's rule is a noninvasive method of calculating the EDD as follows: subtract 3 months, add 7 days to the first day of the LMP, and add 1 year as appropriate. This is based on the assumption that the cycle is 28 days.

..................

Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medications. The client exhibits severe tremors, rigidity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea. The client should be placed in a quiet, dim room, and respiratory and cardiac support should be available.

Scarlet Fever

Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color.

2L/min

Patients with emphysema receiving oxygen therapy should NOT exceed more than _____L/min.

40mL

Which is a normal amount of blood loss during a menstrual period?

.............................

Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.)

Administer the eyedrop first, followed by the eye ointment.

The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take?

..............

Ribavirin is an antiviral respiratory medication that may be used in hospitalized children with severe RSV and in high-risk children. Administration is via hood, face mask, or oxygen tent. The medication is most effective if administered within the first 3 days of the infection.

No

Should Digoxin (Lanoxin) be mixed with food?

No, it should be taken 30min before meals

Should repaglinide (Prandin) be taken with meals?

..................

Signs of placental abruption include a tender, rigid abdomen; pain; severe, dark red vaginal bleeding; maternal shock (hypotension); and fetal distress.

..............

The caloric test is useful in testing the function of cranial nerve VIII. Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds. No nystagmus indicates dysfunction of cranial nerve VIII.

Administering epinephrine (Adrenalin)

The client is brought to the emergency department and is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action?

..........................

The client should not receive cyclobenzaprine if the client has taken a monoamine oxidase (MAO) inhibitor such as tranylcypromine (Parnate) or phenelzine (Nardil) within the past 14 days. Otherwise, the client could experience hypertensive crisis, seizures, or death. Options 1, 2, and 3 are not contraindicated with the use of this medication.

-Radiation -Chemo -Serum Sodium Blood Levels -Medication that is antagonistic to antidiuretic hormone (ADH)

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which may be prescribed to treat this complication?

Extremity numbness

The client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which adverse effect is specific to this medication?

Orthostatic hypotension

The client with small cell lung cancer is being treated with etoposide (Toposar). The nurse assisting in caring for the client during its administration should understand that which side/adverse effect is specifically associated with this medication?

Bedtime

The health care provider has written a prescription for ranitidine (Zantac), once daily. The nurse should schedule the medication for which time?

p24 antigen assay

The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?

-Dry Cough -Distended Neck Veins

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload?

.....................

The most common adverse effects related to fluoxetine include central nervous system (CNS) and gastrointestinal (GI) system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea.

-Inner aspect of the forearm -Dorsal aspect of the upper arm -Away from heavy pigmentation

The nurse determines that which body areas are appropriate for intradermal injections?

Sulfa Drugs

The nurse has a prescription to give a first dose of hydrochlorothiazide (HCTZ) to an assigned client. The nurse should question the prescription if the client had a history of allergy to which item?

Blood urea nitrogen (BUN)

The nurse is assigned to care for a client with herpes simplex virus (HSV) who is receiving acyclovir (Zovirax). The nurse is monitoring for adverse effects of the medication. Which laboratory result should the nurse specifically monitor to identify an adverse effect associated with the use of this medication?

Monitor UOP (bc it may impair renal function)

The nurse is assisting in caring for a client who is receiving amphotericin B intravenously (IV) to treat disseminated candidiasis. The nurse reviews the plan of care and implements which action during the administration of the medication?

Massage the medication into the skin from the chin downward, and apply a second application in 24 hours, followed up with a cleansing bath 48 hours after the second application.

The nurse is caring for a client diagnosed with scabies who has just been prescribed crotamiton (Eurax). The nurse provides which instruction for application of this medication?

Heart and Lungs

The nurse is caring for a client in preterm labor who is receiving terbutaline sulfate to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication?

Aluminum hydroxide gel

The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication should the nurse plan to administer as prescribed to the client?

Protruding and swollen

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

Atropine Sulfate

The nurse is preparing a subcutaneous dose of bethanechol chloride (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?

BP (bc this med can cause life-threatening and fatal hypotension)

The nurse is preparing to administer pentamidine isethionate (Pentam 300) to an assigned client by the intramuscular route. The nurse plans to monitor which parameter closely after administering this medication?

Pulse (to look for possible shock)

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?

Increase fluid intake to 2000 to 3000 mL daily

The nurse is reinforcing medication instructions to a client with breast cancer who is receiving cyclophosphamide. Which instruction should the nurse provide to the client?

-kiwi -bananas -avocados

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy?

Temporal

The nursing student is developing information for use in a clinical conference about hearing disorders. In the presentation, the student plans to include the statement that the ear is housed in which bones of the skull?

............

Triamterene is a potassium-retaining diuretic, and the client should avoid foods high in potassium.

Crackles

What type of breath sounds would you expect to hear with pulmonary edema?

The presence of Reed-Sternberg cells

When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?