NCLEX review 8/6/16 Hesi wrong answers

Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications?

BAL may be used in conjunction with EDTA to treat lead poisoning. BAL is administered by way of deep intramuscular injection. EDTA is administered by way of the intravenous or intramuscular route. BAL must not be used in the presence of a glucose-6-phosphate dehydrogenase deficiency (G6PD) or peanut allergy, nor should it be given in conjunction with iron. Therefore the nurse must ask about allergy to peanuts. The assessment questions noted in the remaining options are unrelated to the administration of this medication

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as:

The normal therapeutic range for theophylline is 10 to 20 mcg/mL. The client's value, 20 mcg/mL, is at the top of the therapeutic range.

A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client:

A plasma HIV RNA level of less than 10,000 copies/mL is considered indicative of low risk for the development of AIDS. Levels between 10,000 and 100,000 copies/mL represent a doubled risk for AIDS, and a result of more than 100,000 copies/mL indicates a high risk for AIDS.

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client?

: Acute compartment syndrome is a serious condition in which increased pressure within one or more compartments causes massive compromise of circulation to the area. Resultant edema causes pressure on the nerve endings and subsequent pain. Sensory deficits such as paresthesia generally appear before changes in vascular or motor signs. The client will also complain of severe diffuse pain that is not relieved by analgesics.

An emergency department nurse is monitoring a client who sustained a severe inhalation burn injury during a fire in which the client was trapped in an enclosed space. The nurse auscultates the client's trachea and notes that the previously heard wheezing sounds have disappeared. The nurse most appropriately:

A client with an inhalation burn injury is at risk for respiratory complications. Upper-airway edema and inhalation injury are most notable in the trachea and main stem bronchi. Auscultation of these areas reveals wheezes, which are a sign of obstruction. A client with a severe inhalation injury may sustain such progressive obstruction that within a short time he or she cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation. The nurse would notify the physician immediately. Continuing to monitor the client, documenting the client's improvement in the medical record, and removing the oxygen mask and fitting the client with a nasal cannula are all incorrect and would delay necessary interventions

A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:

A lower abdominal incision is used in suprapubic or retropubic prostatectomy. An upper abdominal incision is not used to remove the prostate. An incision between the scrotum and anus is made when a perineal prostatectomy is performed. Transurethral resection is performed through the urethra; an instrument called a resectoscope is used to cut the tissue by means of a high-frequency current.

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

A temperature of 100.4° F (38° C) is common during the 24 hours after childbirth and may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for more than 24 hours or exceeds 100.4° F (38° C), infection is a possibility, and the fever is reported. The nurse would recheck the temperature in 4 hours. There is no reason to restrict place the client to strict bedrest or to notify the physician. Although the client would be encouraged to breastfeed her newborn, this action is unrelated to the client's temperature

A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the following findings, indicative of this complication, does the nurse notify the physician?

Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children ages 3 months to 6 years. The nurse monitors the child closely for signs of sepsis, peritonitis, and shock.

A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child?

Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally with juice or cola or through a nasogastric tube. Acetylcysteine (Mucomyst)

A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:

Acute pulmonary edema is characterized by profound dyspnea, pallor, audible wheezing, and cyanosis. The nurse would first raise the head of the client's bed and position the client to maximize chest expansion to ease the air hunger that the client is experiencing

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse?

After transsphenoidal hypophysectomy, the client is monitored for transient diabetes insipidus. In a client with diabetes insipidus, the urinary specific gravity is low and urine output is excessive. A blood pressure of 138/80 mm Hg is not cause for concern. The client will have nasal packing and a mustache dressing and may complain of dry mouth because of the necessity for mouth breathing. The nurse would provide frequent oral rinses and apply petroleum jelly to dry lips. The client should perform frequent deep-breathing exercises (coughing is contraindicated) to help prevent pulmonary complications.

Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate?

Alendronate is a medication used to treat postmenopausal osteoporesis, glucocorticoid-induced osteoporosis, and Paget's disease of bone. Proper administration is necessary to maximize bioavailability and minimize the risk of esophagitis. The medication should be taken in the morning before breakfast on an empty stomach to maximize its bioavailability. No food, including orange juice or coffee, should be consumed for at least 30 minutes after alendronate is taken. To minimize the risk of esophagitis, the client should take the medication with a full glass of water and remain upright (seated or standing) for at least 30 minutes. Therefore taking the medication at bedtime, with orange juice to help with absorption, and every morning after breakfast, followed by a 30-minute period of lying down, are all incorrect.

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis.

A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication?

Amphotericin B, an antifungal medication, is highly toxic, and infusion reactions and renal damage occur, to varying degrees, in all clients. As a means of detecting renal injury, tests of kidney function should be performed weekly and intake and output should be monitored closely. Other adverse effects include delirium, hypotension, hypertension, wheezing, and hypoxia. The remaining options are not associated with an adverse effect of the medication.

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?

An objective description is the result of direct observation and measurement. Documenting inferences without supporting factual data is not acceptable, because a client's statements may be misunderstood. Documenting the client's words verbatim and placing them in quotations ensures accurate data. The remaining options do not provide objective descriptions

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction

An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction.

A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?

Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health

Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?

Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication.

A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms. The client calls the physician's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:

Baclofen (Lioresal) is a centrally acting skeletal muscle relaxant. Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Drowsiness usually diminishes with continued therapy. However, the client is told to avoid activities that require alertness until the response to the medication has been established. Therefore it is not necessary to call the physician or discontinue or stop the medication.

Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose?

Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Excessive hypotension (first-dose syncope) may occur in the client with heart failure or in the client who is severely salt or volume depleted. The client is closely monitored for hypotension at the start of therapy and is maintained on bed rest for 3 hours after the initial dose. Checking the apical heart rate will provide information about the client's cardiac status but is not an intervention specifically related to this medication. Increased urine output and decreased wheezing are expected if the client has received a diuretic. Use the process of elimination and focus on the name of the medication. Remember that medication names that end with -pril are ACE inhibitors and that these medications have an effect on blood pressure. This will direct you to the correct option

A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:

Care after abdominal hysterectomy includes maintenance of a patent airway, promotion of circulation and oxygenation, promotion of comfort, monitoring of output and drainage, promotion of elimination, and discharge teaching with regard to medications and therapeutic regimens. The priority is the maintenance of a patent airway and promotion of oxygenation and circulation. Monitoring the client for signs of returning peristalis, instructing her in dietary habits to prevent constipation, and encouraging her to talk about the effects of her surgery are also components of care after this surgery but are of lower priority than encouraging the client to deep-breathe, cough, and use an incentive spirometer

Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?

Colchicine is classified as an antigout agent. It interferes with the capacity of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should maintain a high fluid intake (eight to ten 8-oz glasses of fluid per day) while taking the medication. The client is instructed to report a rash, sore throat, fever, unusual bruising or bleeding, weakness, tiredness, or numbness. A burning sensation in the throat or skin, severe diarrhea, and abdominal pain are signs of overdose.

A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:

Contact the physician if the skin appears yellow. Fluorescein angiography provides a detailed image and permanent record of eye circulation.

Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?

Cyclobenzaprine (Flexeril) is a centrally acting skeletal muscle relaxant used in the management of muscle spasm accompanying a variety of conditions. Drowsiness, dizziness, and dry mouth are the most frequent side effects of cyclobenzaprine. Rare side effects include fatigue, tiredness, blurred vision, headache, nervousness, confusion, nausea, constipation, dyspepsia, and an unpleasant taste in the mouth

A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?

DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC.

A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician?

Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone (ADH). Desmopressin, a synthetic form of antidiuretic hormone, causes increased resorption of water and a resultant decrease in urine output (an expected outcome). One adverse effect of the medication is water intoxication. Early signs of water intoxication include headache, nausea, shortness of breath, drowsiness, and listlessness. The physician is notified if these signs occur. Abdominal cramping is a side effect, not an adverse effect, of the parenteral form of the medication. A runny or stuffy nose is a side effect, not an adverse effect, of the medication.

A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:

If contact with poison ivy is suspected, symptoms may be averted by immediately rinsing the skin for 15 minutes with running water to remove the resin before skin penetration occurs

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant?

EA and TEF, the most life-threatening anomalies of the esophagus, often occur together, although they may occur singly. EA is a congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thereby failing to form a continuous passageway to the stomach. TEF is an abnormal connection between the esophagus and trachea. EA with or without TEF results in excessive oral secretions, drooling, and feeding intolerance. When fed, the infant may swallow but will then cough and gag and return the fluid through the nose and mouth. Bowel sounds over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccuping and spitting up after a meal are clinical manifestations of gastroesophageal reflux. Coughing, wheezing, and short periods of apnea are clinical manifestations of hiatal hernia.

A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note?

Early manifestations of RA include fatigue, low-grade fever, weakness, anorexia, and paresthesias. Anemia, weight loss, and joint deformities are some of the late manifestations.

A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells the client that it is best to take the medication with:

Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product to increase absorption of the iron. Milk and eggs inhibit the absorption of iron. Orange juice is higher in vitamin C than apple juice.

Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:

Ferrous sulfate is an iron product. Absorption of iron is promoted when the supplement is taken with orange juice or another food source of vitamin C or ascorbic acid. Recalling that ferrous sulfate is an iron product and that ascorbic acid increases the absorption of iron will direct you to the correct option.

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?

Focus on the name of the medication and recall that it belongs to the aminoglycoside class of medications. Recalling that the adverse effects of aminoglycosides are ototoxicity and nephrotoxicity will direct you to the correct option.

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed.

Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia?

Glyburide is a hypoglycemic medication. If the client takes a corticosteroid, thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral hypoglycemic

Propylthiouracil (PTU) has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which of the following occurrences does the nurse tells the client to contact the physician?

Graves disease (hyperthyroidism) occurs as a result of excessive thyroid hormone secretion. Propylthiouracil is an antithyroid medication that blocks thyroid hormone production. One adverse effect is agranulocytosis, and the client is instructed to report signs of infection such as a sore throat. Fatigue may or may not occur in this disorder; however, it is not an adverse effect of the medication. One manifestation of Graves disease is heat intolerance, and the client may experience diaphoresis even when the environmental temperature is comfortable for others.

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented?

Histoplasmosis is a fungal infection of the lungs. The client typically experiences a flulike pulmonary illness with cough, chest pain, dyspnea, headache, fever, arthralgia, anorexia, erythema nodosum, hepatomegaly, and splenomegaly. Neurological disturbances, gastrointestinal disturbances, and cardiac dysrhythmias are not associated with this infection

The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition:

In a congenital diaphragmatic hernia, abdominal contents herniate through an opening in the diaphragm. In gastroesophageal reflux disease, gastric contents are regurgitated back into the esophagus. Esophageal atresia is a condition in which the esophagus terminates before it reaches the stomach. A hiatal hernia is a condition in which a portion of the stomach protrudes through the esophageal hiatus of the diaphragm

The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first?

In a disaster situation, the nurse must triage victims on the basis of severity of injury and potential for recovery. Victims with life-threatening injuries that are readily corrected are classified as emergent and are the first priority (in this case, the victim with an open fracture of the arm that is bleeding profusely). Victims with injuries that do not require immediate treatment but that will need to be treated within 1 to 2 hours are classified as urgent and are the second priority (here, the victim with a twisted ankle and leg bruises). Victims with no injuries, those whose condition is noncritical, and victims who are ambulatory are classified as delayed (nonurgent) and are the third priority (in this case, the victim who is anxiously walking about among the victims, searching for her husband). The victim who is unresponsive and not breathing, with severely swollen and bruised eyes, is most likely dead after having sustained a severe head injury and, in this situation, is not the priority. The nurse does not have the resources necessary to save this client, whereas it may be possible for the nurse to save the client who is bleeding profusely by applying pressure to the bleeding site

A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:

Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hours after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Asking the physician to see the client immediately, having another nurse check for the uterine fundus, and placing the client in the supine position for 5 minutes and rechecking the abdomen are all incorrect and unnecessary actions in light of the assessment finding

A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication:

Indomethacin is a nonsteroidal antiinflammatory medication that produces analgesic and antiinflammatory effects by inhibiting prostaglandin synthesis. Adverse effects include ulceration of the esophagus, stomach, duodenum, and small intestine. Therefore the client is instructed to take the medication with food.

A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. Recalling that the need for insulin generally decreases in the first half of pregnancy and increases in the second half will direct you to the correct option

A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?

Intraocular pressure, measured with the use of tonometry, is increased in glaucoma. The normal tonometry reading is 10 to 21 mm Hg. In open-angle glaucoma, the tonometry reading is slightly higher than normal, usually between 22 and 32 mm Hg.

A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?

Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication.

Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because:

Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin sodium are enhanced. If warfarin sodium administration is instituted in a client who takes levothyroxine, the dose of warfarin sodium should be reduced. Warfarin sodium is not contraindicated in the client who is using levothyroxine. Concurrent administration does not cause an allergic reaction.

A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication

Levothyroxine, a synthetic preparation of thyroxine, a naturally occurring thyroid hormone, is used to treat clients who require hormone-replacement therapy. The client is instructed to take the medication on an empty stomach, preferably in the morning, before breakfast.

A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:

Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea, and therefore the nurse would simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the physician, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs of toxicity and if these occur the physician needs to be notified

Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of

Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods.

Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?

Methylergonovine is an oxytocic that stimulates contraction of the uterus and causes arterial vasoconstriction. Because the medication causes arterial vasoconstriction and hypertension, the nurse checks the client's blood pressure before administering the medication.

A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?

Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur. A major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation.

A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes:

Mixtures of insulin in prefilled syringes may be stored in a refrigerator, where they will be stable for at least 1 to 2 weeks. The syringes should be stored vertically, with the needles pointing up to prevent clogging of the needle with the insulin. Before administration of the medication, the syringe should be agitated gently to resuspend the insulin

A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of:

Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication.

Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication?

Oral calcium salts are used to treat mild hypocalcemia and to supplement dietary calcium. The client is instructed to take oral calcium with a large glass of water with or after a meal to promote absorption. The client is also instructed to avoid taking calcium with foods that can suppress calcium absorption. Such foods include spinach, Swiss chard, beets, bran, and whole-wheat cereals. The client does not need to avoid fish, milk, or watermelon.

A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?

Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image.

Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to:

Prednisone is a glucocorticoid that prevents or diminishes tissue response to an inflammatory process. The client taking this medication should notify the physician if fever, sore throat, muscle aches, or sudden weight gain or swelling occurs. The medication is taken with food or milk because it can cause gastrointestinal irritation. The client is instructed not to change the dose and to not stop taking the medication without contacting the physician. The medication must be tapered gradually under medical supervision

A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because:

Prednisone is a glucocorticoid. Glucocorticoids can increase the blood glucose level. Prednisone is not contraindicated in the client taking an oral hypoglycemic agent; however, diabetic clients may require increased dosages of insulin or oral hypoglycemic medications during glucocorticoid therapy.

A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician?

Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Adverse effects include hepatotoxicity, thrombocytopenia, and anemia. The nurse instructs the client to contact the physician if he experiences jaundice (yellow skin or eyes), unusual tiredness, fever, loss of appetite, or hot, painful, or swollen joints. Headache, nasal congestion, and difficulty sleeping are not associated with the use of this medication.

A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration?

Rationale: Ketoacidosis, the most severe manifestation of insulin deficiency, is a life-threatening emergency. IV insulin is a primary component of treatment. Regular insulin, which has a rapid onset and short duration of action, is the only insulin that may be given IV. Because regular insulin forms a true solution, it is safe for IV use. NPH, Lente, NPH/regular 50%/50% are intermediate-acting insulins.

Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?

Risk factors for cervical cancer include multiple sexual partners, a history of human papillomavirus infection, first sexual intercourse before the age of 16, cigarette smoking, environmental tobacco smoke exposure, and use of oral contraceptives for more than 5 years. Nulliparity, early menarche, and the use of hormone-replacement therapy are risk factors for ovarian rather than cervical cancer

A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?

Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis.

A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record?

Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon, pleural effusions, joint inflammation, and myositis

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority?

The FHR is assessed for at least 1 minute when the membranes rupture. The nurse also checks the quantity, color, and odor of the amniotic fluid. The fluid should be clear (often with bits of vernix) and have a mild odor. Fluid with a foul or strong odor, cloudy appearance, or yellow coloration suggests chorioamnionitis and warrants notifying the physician. A large amount of vernix in the fluid suggests that the fetus is preterm. Greenish, meconium-stained fluid may be seen in cases of postterm gestation or placental insufficiency. Checking the fluid for protein is not associated with the data in the question. Although the nurse would continue to monitor the client and the FHR and would document the findings, contacting the physician is the priority

Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease?

The WBC count is usually higher than normal in clients with sickle cell disease. It is believed that this increase is related to chronic inflammation resulting from tissue hypoxia and ischemia

The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother

The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity

The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately:

The client and his wife spouse should be educated about the signs of hypoglycemia (blood glucose level of 60 mg/dL or lower). If a client experiences hypoglycemia and is awake but groggy, corn syrup, honey, or cake icing may be placed in the client's mouth, between the gums and cheek. Once the sugar has been absorbed through the oral mucosa, the client can usually be aroused sufficiently to take a glass of juice, milk, or sugar-sweetened coffee or tea. There is no reason at this time to call the physician or to call an ambulance to bring the client to the emergency department. Glucagon hydrochloride is used to treat hypoglycemic coma.

A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?

The client should be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client should be offered choices of foods and fluids he or she likes, because the client is more likely to consume foods he or she has selected. The client should be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless

A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?

The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness

A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic?

The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your physician has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

The diet should provide ample protein and calories, and fluid and sodium should not be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours). Therefore, urine output of less than 500 mL/24 hr should prompt the client to notify the physician.

A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information?

The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. Symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations

A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis?

The normal Pao2 is 80 to 100 mm Hg and the normal Paco2 is 35 to 45 mm Hg. Respiratory failure may be classified, according to the underlying pathophysiology, as hypoxemic respiratory failure or hypoxemic-hypercapnic respiratory failure. Hypoxemic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and a normal or low Paco2. Hypoxemic-hypercapnic respiratory failure is characterized by a low Pao2 (less than 55 mm Hg) and an increased Paco2 (greater than 50 mm Hg). A Pao2 of 49 mm Hg and Paco2 of 32 mm Hg is the only option that characterizes hypoxemic respiratory failure

A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment?

The normal total serum calcium level ranges from 8.6 to 10 mg/dL. Hypercalcemia occurs when the total serum calcium level exceeds 10 mg/dL. Some of the key features of hypercalcemia are increased heart rate and blood pressure; bounding, full peripheral pulses; ineffective respiratory movement related to profound skeletal muscle weakness; disorientation; diminution or absence of deep tendon reflexes; increased urine output; and hypoactive bowel sounds.

A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?

The observation that the has nurse noted in this tracing is late decelerations. Late decelerations constitute an ominous pattern in labor because they suggest uteroplacental insufficiency, possibly associated with a contraction. Early decelerations result from pressure on the fetal head during a contraction. Variable decelerations suggest umbilical cord compression. The term short-term variability refers to the difference between successive heartbeats, indicating that the natural pacemaker function of the fetal heart is working properly.

A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would:

The therapeutic serum level for digoxin is 0.5 to 2.0 ng/mL. A digoxin concentration greater than 2.0 ng/mL indicates toxicity, and requires the nurse to contact the physician. The remaining options are inappropriate because they could delay necessary and immediate intervention, resulting in harm to the client

A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume:

Theophylline is a methylxanthine bronchodilator. Caffeine is a methylxanthine with pharmacologic properties like those of theophylline. For this reason, caffeine can intensify the adverse effects of theophylline on the central nervous system and heart. In addition, caffeine competes with theophylline for drug-metabolizing enzymes, thereby causing the theophylline level to increase. Because of these interactions, individuals taking theophylline should avoid caffeine-containing beverages such as cola, coffee, tea, and cocoa, as well as other caffeine-containing products.

A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting:

Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs of an adverse reaction to the medication.

A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:

: Gastroschisis is a defect of the abdominal wall in which the viscera are outside the abdominal cavity and not covered with a sac. An umbilical hernia is usually located inside the abdominal cavity and under the dermis or under the skin. An omphalocele is located outside the abdominal cavity and inside a translucent sac covered with peritoneum and amniotic membrane.

The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:

: Imipramine is a tricyclic antidepressant that is often used to treat depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so the nurse would simply document the laboratory result in the client's record. Asking the laboratory to recheck the level and withholding the next dose of the imipramine and contacting the physician are unnecessary

A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client?

: In superior vena cava syndrome, the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms, which generally occur in the early morning, include edema of the face, especially around the eyes (periorbital edema), and complaints of tightness of a shirt or blouse collar (Stokes sign). As the compression worsens, the client experiences edema of the hands and arms, dyspnea, erythema of the upper body, and epistaxis (nosebleeds). Late (and life-threatening) signs and symptoms include hemorrhage, cyanosis, mental status changes resulting from lack of blood to the brain, decreased cardiac output, and hypotension (low blood pressure). Death may result if the compression is not relieved

A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client

: Insulin preparations are stable at room temperature for as long as 1 month without significant loss of chemical activity. Direct sunlight and extreme heat must be avoided. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Insulin stored at room temperature causes less discomfort on injection than does cold insulin

A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside?

: Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency

A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for:

Baclofen is a skeletal muscle relaxant, acting at the level of the spinal cord to reduce the frequency and amplitude of muscle spasms and spasticity in clients with spinal cord injuries and diseases, as well as multiple sclerosis. Abrupt withdrawal of the medication may produce hallucinations or seizures. Drowsiness may occur as a result of taking the medication but diminishes with continued therapy.

A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:

If salicylism develops, aspirin is withheld until the symptoms have subsided; therapy should then be resumed with a small reduction in dosage. A nonsteroidal antiinflammatory medication will not be prescribed, because these medications' chemical properties are similar to those of aspirin.

A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note?

Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine, with associated symptoms that include the "five P's": pressure (paroxysmal increases in blood pressure), palpitations, pallor, perspiration (profuse and generalized), and pain (paroxysmal pulsatile headaches, chest, and abdominal pain). Other clinical signs include weight loss, constipation, tremors, hypertensive retinopathy, hyperglycemia, and hypercalcemia. Recalling that pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and recalling the effects of catecholamines will direct you to the correct option