NCLEX Saunders study questions 8th edition

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow up if which medication was prescribed?

Glipizide: an oral hypoglycemic drug. Major side effect: hypoglycemia

The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?

Guilt that they did not seek treatment more quickly. Guilt is a common reaction of the parents of a child diagnosed with glomerulonephritis. Parents blame themselves for not responding more quickly to the child's initial symptoms.

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply.

Hemodialysis. Kidney transplant. Bilateral nephrectomy.

The nurse arrives at work and is told to report (float) to the ICU for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply.

Close the client's eyes. Elevate the HOB. Place wet saline gauze pads and a cool pack on the eyes.

Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfu¬sion and records 100.6° F (38.1° C) orally. Which action should the nurse take?

Delay hanging the blood and notify the primary health care provider (PHCP).

The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone?

Devascularization

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?

Maintain inflation of the alveoli. Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk.

Which special population should be targeted for breast cancer screening by way of mammography? SATA

Male to female (MTF) Female to Male (FTM) Women who have sex with men (WSM) Women who have sex with women (WSW)

The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent transmission of the virus?

Mask and gloves

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?

Monitoring the apical pulse. Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action?

Moves downward and out. As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle.

A client has received a dose of dimenhydrinate. The nurse should observe relief of what sign or symptom to evaluate that the medication has been effective?

Nausea and vomiting. Dimenhydrinate is used to prevent and treat the symptoms of dizziness, vertigo, nausea, and vomiting that accompany motion sickness.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?

Nonstop physical activity and poor nutritional intake. Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations

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

Obtain new IV tubing. The nurse should obtain new IV tubing because contamination has occurred and could cause systemic infection in the client.

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?

Vomiting following cancer chemotherapy

The nurse caring for a client receiving vincristine is monitoring the client for toxicity. The nurse interprets that the client is experiencing a toxic effect of this medication on the basis of which assessment finding?

Weakness and sensory loss in the legs. Peripheral neuropathy is the major dose-limiting toxicity associated with vincristine. Nearly all clients exhibit signs and symptoms of sensory or motor nerve injury such as decreased reflexes, weakness, paresthesia, and sensory loss.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response?

"Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus.

A 9-year-old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. Which is an appropriate response by the clinic nurse to the mother?

"Bring the child into the clinic for a vaccine."

A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem?

"I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

"I need to increase my fluid intake." Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations should be taken with a substance that is high in vitamin C to increase its absorption.

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?

"I should not use insect repellents because it will attract the ticks." In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn.

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The primary health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriateresponse to the mother?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response?

"Prolactin stimulates the secretion of milk, which is called lactogenesis."

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?

"This is mostly used in a walk-in clinic or emergency department." A problem-based assessment involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department.

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

"We need to remind him to turn his head to scan the lost visual field." Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank

14. The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.

A primary health care provider prescribes atenolol 0.05 g orally daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.

2 tab.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving theophylline. The nurse monitors the serum theophylline level and concludes that the medication dosage may need to be increased if which value is noted?

5 mg/mL (20 mcmol/L). The therapeutic serum level range is 10 to 20 mg/mL (40 to 79 mcmol/L).

The nurse working in the emergency department has four charts of clients who need to be assessed. Which client should be assessed first?

A client with a history of schizophrenia threatening to harm himself.

The nurse is assigned care for hour clients. in planning client rounds, which client should the nurse assess first?

A client with asthma who requested a breathing treatment during the previous shift

As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior?

A normal behavior that can occur during the termination period

The nurse is caring for a female client in the ER who presents with a complaint of fatigue and SOB. Which physical assessment findings, if noted by the nurse warrant a need for follow up?

A reddish-purple mark on the neck

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likelyfindings related to the fontanels? Select all that apply.

A soft and flat anterior fontanel. A triangular-shaped posterior fontanel. The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. The posterior fontanel is triangular shaped, may be closed at birth or close at about 2 months of age, and is 1 cm by 2 cm in size. A bulging fontanel may indicate increased intracranial pressure. A depressed fontanel may indicate dehydration.

The nurse is discussing the past week's activities with a client receiving amitriptyline hydrochloride. The nurse determines that the medication is most effective for this client if the client reports which information?

Ability to get to work on time each day.

The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness?

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

The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriatesuggestion to the mother?

Allow the bottle if it contains water.

The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication?

Apply saline-soaked dressings over the medication.

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priorityaction in the care of this client?

Assign the client to a private room. The client who has a radiation implant is placed in a private room and has limited visitors. This reduces the exposure of others to the radiation.

The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response?

Autoimmune. The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis.

The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder?

Blood glucose level of 500 mg/dL (28.5 mmol/L)

The nurse is reviewing the laboratory test results for an infant suspected of having hypertrophic pyloric stenosis. The nurse should expect to note which value as the most likely laboratory finding in this infant?

Blood pH of 7.50. Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level.

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item?

Blood pressure and oxygen saturation. Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation.

The nurse is reviewing a client's medication reconciliation form in the medical record and notes that the client is taking tamsulosin at home. Which medication, if started in the hospital, should the nurse question?

Cimetidine. Tamsulosin is used most commonly for the treatment of benign prostatic hyperplasia. This medication should not be used concurrently with cimetidine because of the risk of tamsulosin toxicity.

Which health concern(s) should the nurse be aware of as risk factors when caring for clients of the African American descent? SATA

Cancer, Obesity, Hypertension, Heart Disease, Diabetes Mellitus

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?

Cardiovascular disease. Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs. Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma.

The nurse is providing dietary instructions to a client with an oxalate kidney stone. The nurse should instruct the client to avoid which food?

Chocolate. Clients with oxalate stones should avoid foods high in oxalate, such as tea, instant coffee, cola drinks, beer, rhubarb, beans, asparagus, spinach, cabbage, chocolate, citrus fruits, apples, grapes, cranberries, and peanuts and peanut butter. Large doses of vitamin C may help increase oxalate excretion in the urine.

The nurse calls the PHCP regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due o be administered. Which action should the nurse take?

Contact the nursing supervisor

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?

Continue to monitor the client. The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina?

Generally it is treated with calcium channel-blocking agents.

A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?

Crackles on auscultation of the lungs

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply.

Cyanosis. Tachypnea. Retractions. Audible grunts.

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?

Disconnection of the ventilator tubing

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the primary health care provider about these levels, the nurse should anticipate receiving from the PHCP which prescription for this client?

Discontinue nasogastric suctioning. The arterial blood gas (ABG) results indicate metabolic alkalosis, as the pH and bicarbonate are elevated. Nasogastric suctioning may cause metabolic alkalosis by decreasing the acid components in the stomach. Excess alcohol ingestion and salicylate toxicity may cause metabolic acidosis. Fentanyl (an opioid) may cause respiratory acidosis.

The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply.

Elevate the extremity above heart level. Assess the employee for airway or breathing problems. Examine the amputation site and apply direct pressure to the site using layers of gauze.The gauze that is applied is a pressure dressing and is not removed because of the risk of dislodgment of a clot that may be forming; the pressure dressing will be removed at the hospital. The extremity is elevated above the victim's heart level to decrease the bleeding. The severed finger should be wrapped in dry, sterile gauze (if available) or a clean cloth.

The nurse is caring for a hospitalized client with pancreatitis. Which findings should the nurse look for and expect to note when reviewing the laboratory results? Select all that apply.

Elevated lipase level. Elevated trypsin level. Elevated amylase level. Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

The nurse is preparing to administer a prescribed dose of cyclosporine by intravenous (IV) administration. Which priority item would the nurse have available during administration of this medication?

Epinephrine

A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply.

Fever Vasodilation Inflammation Excessively high environmental temperature

The nurse is teaching a client with hyperthyroidism about the prescribed medication, propylthiouracil. The nurse determines that teaching has been successful if the client states to report which symptom to the primary health care provider (PHCP)?

Fever. An adverse effect of propylthiouracil is agranulocytosis. The client should be alert for this adverse effect by noting the presence of fever or sore throat, which should be reported to the PHCP immediately.

Which therapeutic communication is most helpful when working with transgender persons?

Using open-ended questions

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome?

Increase the client's awareness of the affected side.

A client who has been diagnosed with breast cancer is to receive chemotherapy with both cisplatin and vincristine. The client asks the nurse why both medications must be given together. The nurse should explain to the client that the combination of 2 chemotherapeutic medications is used for which reason?

Increase the destruction of tumor cells. Cisplatin is an alkylatinglike medication, and vincristine is a vinca alkaloid. Alkylating medications are cell-cycle nonspecific. Vinca alkaloids are cell-cycle specific and act on the M phase. Single-agent medication therapy seldom is used. Combinations of medications are used to increase the destruction of tumor cells.

The nurse is administering a dose of pirbuterol to a client. The nurse should monitor for which side or adverse effect of this medication?

Increased pulse. Pirbuterol is an adrenergic bronchodilator. Side and adverse effects include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition?

Infection. Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly.

A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred?

Infiltration. An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop.

The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? Select all that apply.

Instruct the client to tilt the head back. Swab the tonsillar pillars and the posterior pharynx wall. Tell the client that the test will help to identify microorganisms. Place a tongue depressor on the client's tongue before swabbing the throat.

The nurse is caring for a client who is taking oral benztropine mesylate daily. What is the prioritynursing assessment for the client?

Intake and output. Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence.

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply.

It is the way the baby gets food and oxygen. It provides an exchange of nutrients and waste products between the mother and developing fetus. The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? Select all that apply.

Keep suction equipment at the bedside. Elevate the head of the bed 30 degrees. Keep the head and neck in good alignment. Administer prescribed respiratory treatments as needed.

A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take?

Leave the cream on for 8 to 12 hours, and then remove it by washing. Lindane is applied in a thin layer to the body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. In most cases, only 1 application is required.

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

The nurse is assessing the status of pain in an alert older client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply.

Pain is something that must be lived with. Nurses are too busy to listen to reports of pain. Pain signifies a serious illness or impending death. Reporting pain will result in being labeled as a "bad" client.

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

Palpation of a thrill over the fistula. The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill or bruit indicates patency of the fistula. Enlarged visible blood vessels at the fistula site are a normal observation but are not indicative of fistula patency.

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch?

Position hands 2 to 4 in (5 to 10 cm) from the body. During therapeutic touch, nurses use their hands to assess the client's energy field. Hands are positioned 2 to 4 in (5 to 10 cm) from the body. The energy field is assessed for bilateral similarities or differences in the flow of energy. The next step is clearing and balancing the energy field.

The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication?

Potassium level. Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation?

Rapid, shallow respirations. An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation.

The nurse has just assisted a client back to bed after a fall. The nurse and HCP have assessed the client and have determined that the client is not injured. after completing the occurrence report, the nurse should implement which action next ?

Reassess the client

The nurse is caring for a client whose urine output was 25 mL per hour for 2 consecutive hours. The nurse reviews the primary health care provider's prescriptions and plans care, knowing that which client-related factor would increase the amount of blood flow to the kidneys?

Release of low levels of dopamine. The release of low levels of dopamine exerts a vasodilating effect on the renal arteries, increasing urinary output.

Nitrofurantoin is prescribed for the client. The nurse checks the client's record, knowing that this medication is contraindicated in which disorder?

Renal disease. Nitrofurantoin is contraindicated in clients with renal impairment.

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediateaction should the nurse take?

Rewrap the residual limb with an elastic compression bandage.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the clients record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered, which was 1 mg. The nurse should take which action?

Right click on the entry and modify it to reflect the correct information. Document the correct information and end with the nurses signature. Obtain a cosignatory from the RN who witnessed the waste of the remaining 1 mg. Document in a nurse's note in the clients record detailing the corrected information.

The nurse is preparing to care for a client with immunodeficiency. The nurse should plan to address which problem as the priority?

Risk for infection

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out. Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor.

The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group?

Safe sleeping

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?

Showing the client the cast cutter and explaining how it works. Individuals may be fearful of having a cast removed because of misconceptions about the cast-cutting blade. The nurse should show the cast cutter to the client before it is used and explain that he or she may feel heat, vibration, and pressure.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client?

Signs of skin breakdown.

The nurse is working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? SATA

Sleep problems Bipolar disorder Aggressive behavior Attention-deficit hyperactivity disorder (ADHD)

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?

Tachycardia

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze.

The charge nurse on a labor and delivery unit has numerous admissions and must transfer 1 of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer?

The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding.

The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture?

The IV solution for particles or contamination

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

Which identifies accurate nursing documentation(s)? SATA

The client slept through the night. Abdominal wound dressing is dry and intact without drainage. The clients left lower medial leg wound is 3cm in length without redness, drainage, or edema.

The nurse is caring for a client just admitted to the critical care unit with a diagnosis of myocardial infarction (MI). In the early period after an MI, why are nutrition interventions and education so important? Select all that apply.

To reduce angina. To cut down on cardiac workload. To decrease the risk of dysrhythmias

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

At 10 days postpartum, a breast-feeding mother develops mastitis in her right breast. The nurse plans to instruct the client on which interventions? Select all that apply.

Using ice packs. Using analgesics. Wearing proper breast support. Completing the full course of prescribed antibiotics