NCLEX

What does the client with Bells Palsy suffer from?

Temporary facial paralysis that affects chewing, eating, and closing their eyes

What confirms the screening test for HIV

Western blot

the most important medication to know with HIV is

Zidovudine AZT Retrovir

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Ammenorhea 2. Fluid and electrolyte imbalances 3. Heat Intolerance 4. Presence of Lanugo 5. Refusal to Exercise 6. Weight loss of 25% below normal weight

1, 2, 4, 6 the clinical manifestations of anorexia nervosa include extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo. Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.

The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? 1. Amitriptyline 2. chohrephyline 3.docusate 4. donepezil 5.Lorazepam

1, 2, 5, Amitriptyline (Elavil) is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision, and dysrhythmias (Option 1). Chlorpheniramine (ChlorTrimeton) is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects (eg, drowsiness, dizziness) may occur due to its reduced clearance in the elderly (Option 2). Lorazepam (Ativan) is a benzodiazepine with a long half-life (10-17 hours). Side effects include drowsiness, dizziness, ataxia, and confusion (Option 5).

A 2-year-old is diagnosed with atopic dermatitis (eczema). Which instructions should the nurse teach the parents? Select all that apply. 1. Apply emoilment immediately after a bath 2. Dress child in wool PJ's 3. Give tepid baths with warm water 4. Keep child's nails trimmed 5. Thoroughly rub the Childs skin dry after the bath

1, 3 ,4,

A nurse is preparing to teach the parents of a newborn about newborn safety. Which instruction is appropriate for the nurse to include in the teaching plan? 1. dress the newborn in a wearable jacket, such as a sleep sack 2. Layer the newborn with jackets and blankets before securing the carseat 3. place the newborn in the prone position while sleeping 4. place the newborns carseat facing forward

1.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2.7 days postpartum 3.On the day of birth 4.Within 2 weeks postpartum

1. 3 days postpartum

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? Select all that apply. 1. Abdominal distention 2. Absolute constipation 3. Colicky abdominal pain 4. Frequent vomiting 5. Pain during defection

1. Abdominal distention 3. Colicky abdominal pain 4. Frequent vomiting

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. 1. Acting as a witness that the client signed the consent voluntarily 2. Documenting in the medical record the date and time the signature was obtained 3. educating the client if there is a misunderstanding about the procedure 4. Explaining to the client right to refuse surgery 5. Verifying that the client is competent to provide to informed consent

1. Acting as a witness that the client signed the consent voluntarily 2. Documenting in the medical record the date and time the signature was obtained 5. Verifying that the client is competent to provide to informed consent

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply 1. Ask the client if they know what day it is 2. Ask the client to extend their arms 3. Assess for spider nevi 4. Determine if the conjuctiva is jaundiced 5. note amalyse and lipase serum levels

1. Ask the client if they know what day it is 2. Ask the client to extend their arms Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency? 1. Brownish hardened skin on lower extremities 2. Diminished peripheral pulses 3. Non healing ulcers on great toe 4. Shiny, hairless lower extremities

1. Brownish hardened skin on lower extremities Educational objective: Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).

The nurse is reviewing a client's record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2.Decreased hemoglobin level 3.Decreased red blood cell count 4.Increased number of white blood cells in the urine

1. Elevated creatinine level

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? 1. Hypotension and fever 2.Mental status changes and hypertension 3.Subnormal temperature and hypotension 4.Complaints of weakness and hypertension The nurse should be alert to signs And syptoms including _____, hypotension fever and ____ status changes

1. Hypotension and fever Rationale:The nurse should be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes.

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply. 1. Irritability and restless 2. Meconium 3. Microcephaly 4. Nasal congestion 5. Poor feeding and loose stools

1. Irritability and restless 4. Nasal congestion 5. Poor feeding and loose stools Neonatal abstinence syndrome (NAS) or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Opioid abuse (eg, hydrocodone, methadone, heroin) is the most common cause, although other medications (eg, benzodiazepines) can contribute to the condition. Some affected newborns require pharmacologic management of symptoms. Clinical manifestations of NAS may be: Central nervous system findings (eg, irritability, restlessness, high-pitched crying, abnormal sleep pattern, increased muscle tone, hyperactive primitive reflexes), which may require interventions such as swaddling and minimizing stimulation (Option 1) Related to the autonomic nervous system (eg, nasal congestion, sweating, frequent yawning, sneezing, tachypnea) (Option 4) Gastrointestinal (eg, poor feeding, vomiting, diarrhea), which may require smaller, more frequent feedings and skin protection (Option 5)

Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies? 1. Serum potassium, serum calcium 2.Urinalysis, hematocrit, hemoglobin 3.Culture and sensitivity testing, serum sodium 4.Urine specific gravity, intravenous pyelogram

1. Serum potassium, serum calcium

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? 1. Albuterol 2. Doxycycline 3. Insuline Aspart 4. Isoteteronin 5. Levothyroxine 6. Linsinopril

2, 4, 6, Doxycycline, Isotretonin, Lisinopril Doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus (Option 2). Isotretinoin (Accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception (Option 4). ACE inhibitors such as lisinopril (Prinivil) have a black box warning for use in pregnancy because they can affect fetal renal function and lung development or cause fetal death

The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? Select all that apply. 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate of 150 mins 4.Sacral dimple with a 0.4 skin tag 5. single artery in the umbilical cord

2. Decreased muscle tone 4. Sacral dimpling 5. single artery Decreased muscle tone (ie, hypotonia), which may indicate a congenital neurological abnormality (eg, Down syndrome) or spinal injury (Option 2). Newborns normally have increased muscle tone and should resist movement of the extremities. Sacral dimples, with or without tufts of hair or skin tags, are associated with spina bifida occulta, which is an incomplete closure of vertebrae that cannot be seen externally (Option 4). Presence of a single umbilical artery, which is sometimes associated with congenital defects, particularly of the kidneys and heart (Option 5). Normal umbilical cords contain 2 arteries and 1 vein.

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route? 1. Intramuscular 2. IV 3. Oral 4. SubQ

2. IV In clients with severe burns, medications are best administered through the intravenous route given the possibility of reduced absorption from other routes (subcutaneous, intramuscular, oral).

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud-machine like murmur 3. soft distolic murmur 4. Systolic ejection murmur

2. Loud machine like murmur

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1. Difficult to arrouse 2. Muscle stiffness 3. pinpoint pupils 4. temperature 94 degrees

2. Muscle stiffness Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue without CPR until the paramedic arrives 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and other on the lower left side 4. Place one AED pad on the upper right chest and dispose the other

2. Place one AED pad on the chest and the other on the back

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? 1. Left flank area 2. left upper quad radiating to the back 3. periumbilical shifiting to the right 4.right upper quad radiating to the right shoulder

2. left upper quad radiating to the back

The nurse in the oral surgery clinic reviews a client's medical record prior to surgery. Which will the nurse immediately report to the oral surgeon? Select all that apply. 1. Client is on a Consistent restricted calorie diet for obesity 2. Creatinine is 1.3 3. Hx of congenital Heart disease 4. INR 2.5 5. presence of prosthetic valve

3, 4, 5, Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures

A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply. 1. hib 2.hep B 3. Measles, Mumps, Rubella 4. Pneumoccoal 5. Varicella

3, 5 Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity (Options 3 and 5).

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. black stools 2. greasy foul smelling stools 3. stools mixed with blood and mucous 4. thin ribbon like stool

3. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? 1. to lower the blood alcohol level 2. to prevent gross motor temors 3. To prevent Wernicke encephelopothy 4 To treat seizures related to acute alcohol withdrawal

3. A major complication of chronic alcohol abuse is encephalopathy related to poor thiamine absorption. It is critical that these clients receive thiamine replacement. Wernicke encephalopathy can lead to more significant and progressive complications, including death.

The nurse should monitor the client prescribed thioridazine hydrochloride carefully for which adverse effect? 1.Weight gain 2.Photosensitivity 3.Cardiac dysrhythmias 4.Extrapyramidal movements

3. Cardiac Dysrythmias Rationale:Thioridazine hydrochloride is an antipsychotic medication that may be prescribed for the schizophrenic client when other medications have failed to manage the symptoms. Cardiac dysrhythmias are an adverse effect of thioridazine.

The nurse is administering medications to a client who is being evaluated for a brain malignancy. The client is scheduled for a CT scan with IV iodinated contrast the next morning. Which medication should the nurse clarify with the health care provider? 1. Amlodipine 2. Gabapentine 3. Metformin 4. Phenotoynin

3. Metformin Lactic acidosis is a severe complication of metformin, an antidiabetic medication. Administration of IV iodinated contrast to a client who takes metformin can cause an accumulation of metformin in the bloodstream, which increases the risk for lactic acidosis. As a result, many health care providers will discontinue metformin 24-48 hours before administration of IV contrast and restart the medication after 48 hours, when stable renal function is confirmed

When administering an intramuscular injection in the ventrogluteal muscle, how should the nurse position the client to best relax the muscle? 1. Semi-Fowler's position 2.Prone with a toe-in position 3.On the side with the hip and knee of the uppermost leg flexed 4.On the side with the hip and knee of the lowermost leg flexed

3. On the side with the hip and knee of the uppermost leg flexed

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1. Jugular vein distention 2. Mean Arterial BP 65 3. Urine Output less than 0.5 ml/kg/hr 4. warm flushed skin

3. urine output less than 0.5 ml/kg/ hr

The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment? 1."Has your child had difficulty urinating?" 2."Has your child been exposed to anyone with chickenpox?" 3."Has any family member had a sore throat within the past few weeks?" 4Has any family member had a gastrointestinal disorder in the past few weeks?"

3."Has any family member had a sore throat within the past few weeks?" Rationale:Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks.

The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1. Tape the ET tube in place, and note the centimeter marking at the lip line. 2.Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3.Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4.Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

3.Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.

how long after blood is removed from blood banks fridge do you have to start it

30 mins

What is a normal newborn respiratory rate

30-60

The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. head tilt chin lift 2. head tilt chin lift in Trendlurg position 3. Jaw thrust maneuver in semi fowlers 4. Jaw thrust position in supine postion on a backboard

4.

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis? 1. bounding peripheral pulses 2. Diastolic murmur 3. Loud 2nd heart sound 4. Syncope on Exertion

4. Aortic stenosis obstructs blood flow during systole from the left ventricle to the aorta. Clients will develop exertional dyspnea, chest pain, and syncope as the heart is unable to overcome the obstruction to pump enough blood to meet metabolic demands. A systolic ejection murmur over the aortic area, soft or absent second heart sounds, and weak peripheral pulses are characteristic.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. client reports a headache 2. current BP is 160/88 3. heart rate was dropped from 70 to 60 4. Slight wheezes auscultated during inspiration

4. Slight wheezes auscultated during inspiration Educational objective: The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

A primary health care provider (PHCP) is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the PHCP should ask the client to perform which procedure? 1.Take a deep breath. 2.Exhale immediately. 3.Breathe in and out quickly. 4.Take a deep breath and hold it.

4. Take a deep breath and hold it Rationale:When the chest tube is removed, the client is asked to take a deep breath and hold it. The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seal themselves off, and the wound heals in less than 1 week.

A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client? 1. Report for important lab findings 2. store the medication in a cool dry place 3. take the medication after a meal to prevent gastric distress 4. Take the medication with a full glass of water and increase fluids during the day

4. Take the medication with a full glass of water and increase fluids during the day Allopurinol is prescribed to prevent gout attacks (pain and inflammation in joints caused by uric acid deposits). It inhibits uric acid production and improves solubility. Allopurinol should be taken with a full glass of water, and it is very important for the nurse to educate the client about fluid intake with this medication. The client should also increase daily fluid intake as this will help prevent the formation of renal stones and promote diuresis

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. Alaprolzam 2. Dextropomethozon 3. Lisinopril 4. Valsartan

4. Valsartan Major side effects of angiotensin-converting enzyme (ACE) inhibitors include: Symptomatic hypotension Intractable cough Hyperkalemia Angioedema (allergic reaction involving edema of the face and airways) Temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan or losartan are recommended. ARBs prevent the vasoconstrictor and aldosterone-secreting effects of angiotensin II by binding to the angiotensin II receptor sites.

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client? 1. Ask client to place backs of the hands against each other to provide hyper flexion of the wrist while the elbows remain flexed 2. Instruct client to lay down and run the heel of one foot down the shin of the other leg 3. Perform Romberg test by asking the client to stand with eyes closed and feet together 4. place BP cuff on arm to inflate to pressure > than systolic BP and hold in place for 3 mins

4. place BP cuff on arm to inflate to pressure > than systolic BP and hold in place for 3 mins Educational objective: Normal serum calcium is 8.6-10.2 mg/dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy. The nurse should check for Trousseau's and Chevostek's signs as early indications of hypocalcemia.

The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1. "It's a loss of vision associated with aging." 2."A loss of balance occurs with presbycusis." 3."Presbycusis is a conductive hearing loss that occurs with aging." 4."It's a sensorineural hearing loss that occurs with the aging process."

4."It's a sensorineural hearing loss that occurs with the aging process." Rationale:Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

what is the classic sign of appendicitis

Acute right lower abdominal pain

Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: change in ___ status _____ with a thready pulse ____ clammy skin O...... Ta.....

Change in mental status Tachycardia with thready pulse Cool, clammy skin Oliguria Tachypnea

What is another name for Benzotropine and what does it treat

Cogentin it treats ExtraPyradmedial Side effects such as shuffling gait, tremors, ridigity,

What is the virus that causes AIDS?

HIV

How is the presence of HIV confirmed?

Screening is done FIRST to see if HIV antibodies are present. The test is performed to specifically identify the HIV antibodies.

medications that end in 'pril' are ____ inhibitors

ace

Which test should be performed before collecting an ABG on a pt.?

allens test

what is the normal cd4 count in a client with HIV ?

anything at or above 500 client is considrered in good health. if below 500 HIV has progressed to AIDs

what is a major cardiac complication of anorexia

arrhythmias

Clients allergic to latex may also be allergic to which foods?

bananas, kiwis and chestnuts

Signs and symptoms of pulmonary embolism

chest pain dyspena Hypoxemia Tachypnea

Bell's Palsy affects which cranial nerve?

cranial nerve #7

In Acute renal failure what are the 3 phases

olugaric, diuratic and recovery

what is the best diet for a client with acute renal failure

high carb and low protein

What allergy is contraindicated for IV contrast dye?

iodine/shellfish

What malfunction allows reflux in GERD?

lower esophageal sphincter

Normal creatinine levels

0.6-1.3

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply 1. Administer artificial tears to moisten the conjunctiva 2. If the eyelids dont close during the sleep, lightly tape them shut 3. recommend the use of dark glasses to prevent irritation 4. teach importance of smoking cessation 5. teach avoidance of eye movement to prevent further damage

1, 2, 3, 4 Exophthalmos is a complication of hyperthyroidism from Graves' disease leading to increased orbital tissue (connective, adipose, muscular) expansion that can be irreversible. Nursing care to keep eyes moist and protected is needed to prevent corneal ulcers and infection.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply. 1. Chewing sugar free candy 2. scheduling regular dental exams 3. showering with regular lukewarm water 4. using over the counter decongestants 5. using over the counter lubricants to ease vaginal dryness

1, 2, 3, 5, Clients with Sjögren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awake 2. Dry skin 3. frequent loose stools 4. Hoarse cry 5. Tachycardia

1, 2, 4, Congenital hypothyroidism is a partial or complete loss of thyroid function that affects growth, development, and regulation of bodily functions. Clinical manifestations in affected infants may include dry skin, hoarse cry, or difficulty awakening beginning a few months after birth. If untreated, intellectual disability may occur.

The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate? 1. contact the health care provider and clarify 2. Ensure correct placement 3. Select an appropriate size by measuring from nose to tip of earlobe 4. Verify that client has no hx of bleeding

1. contact the health care provider and clarify A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs should not be inserted in clients with suspected head trauma until skull fracture can be excluded as there is a risk for unintentional malpositioning into underlying tissue/structures (eg, brain).

normal heart rate of newborn

110-160

normal hemoglobin level for woman is

12.0 to 15.5 grams

a normal hemoglobin level for men is

13.5 to 17.5

What size IV must the client have when doing a blood transfusion

18 g

A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions? 1. Enteric 2.Airborne 3.Protective 4.Neutropenic

2. Airborne Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? Select all that apply 1. Administer oxytocin through the primary IV line 2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on electronic infusion pump 5. Titrate oxytocin to achieve cervical dilation

2, 3, 4, Oxytocin is a high-alert medication commonly used for labor induction or augmentation. It should be administered via an electronic infusion pump (Option 4), which decreases medication errors, provides for accurate dosing, and prevents maternal hypotension associated with rapid oxytocin bolus. The nurse should evaluate and document the fetal heart rate and uterine contraction pattern every 15 minutes during the first stage of labor and every 5 minutes during the second stage (Option 2). Continuous electronic fetal heart rate monitoring, not intermittent auscultation, is necessary (Option 3). The nurse should also monitor maternal intake and output to identify fluid retention, which precedes water intoxication, a potential adverse reaction of oxytocin administration causing dilutional hyponatremia, convulsions, and death.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1. Ensuring the client wear an N95 respirator at all times 2. Keeping the door shut at all times 3. Maintaining a log of everyone in and out of the patients room 4. Removing both of the pairs of the gloves before removing gown and mask 5. Restricting visitors from entering the clients room

2, 3, 5, Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? 1. Difficulty arousing from sleep 2. excessive daytime sleepiness 3. morning headaches 4. collapse and falling 5. snoring during sleep 6. witnessed episodes of apnea

2, 3, 5, 6,

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2.Leukocytosis with a shift to the left 3.Leukopenia with a shift to the right 4.Leukocytosis with a shift to the right

2.

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? 1. check vital signs 2. Maintain IV access with normal saline 3. Notify Healthcare provider 4. Recheck labels and numbers

2. Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms? 1.Watery diarrhea 2.Projectile vomiting 3.Increased urine output 4.Vomiting large amounts of bile

2. Projectile vomiting Rationale:In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? 1. faceshield/goggles 2. gloves 3. gown 4. mask

2. gloves

A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect? 1. Constipation 2. Sedation 3. Sexual Dysfunction 4. Weight loss

3 SSRIs (eg, fluoxetine, paroxetine, citalopram, escitalopram, sertraline) can cause sexual dysfunction. The client should be encouraged to report this to the health care provider if they are still present 2-4 weeks after treatment initiation.

The nurse is assessing a 3-year-old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the nurse anticipate? 1. 20 gauge needle insertion at the mid axillary line for pleural aspiration 2. 4 L of oxygen per nasal canula 3. Intubation in the OR with a prepared tracheosteomy kit 4. Nebulized epi with pediatric anethiosoligist standing by

3.

The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis? 1. constant, increased by pressure over the suprapubic area 2.dull and continous occasional spasms overs the suprapubic area 3. Dull flank pain; extending toward the umbilicus 4. Excruciating; sharp flank pain radiating to the groin

3. Dull flank pain; extending toward the umbilicus Pain in pyelonephritis is dull, constant, and maximal at the costovertebral angle area. Pain from renal stones is excruciating, sharp, and often radiates toward the groin from the flank. Suprapubic pain indicates bladder distension or cystitis. Spasms can be seen with infection (cystitis) or manipulation of the bladder.

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? 1. Encourages the client to drink extra fluids 2. offers the client orange juice for administeration with ferrous sulfate 3. Plans to administer it an hour before breakfast 4.Prepares to administer a prescribed calcium supplement with ferrous sulfate

4 Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements (eg, pregnancy), or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption (Option 4).

The hospital code team is responding to a respiratory emergency of a client admitted during the night with a fractured hip and pelvis after a motor vehicle collision (MVC). The client first became confused and then developed dyspnea; chest pain; and a petechial rash on his neck, upper arms, and chest. What condition is this client at risk for? 1. Pulmonary fibrosis 2.Hypovolemic shock 3.Blood clot embolism 4.Fat embolism syndrome (FES)

4 Fat embolism Rationale:FES generally happens within 12 to 48 hours after a long bone, hip, or pelvis fracture and occurs most often in young men between ages 20 and 40 years and in older adults between ages 70 and 80. FES is a serious complication in which fat globules are released from the yellow bone marrow into the bloodstream and clog small blood vessels that supply vital organs, most commonly the lungs.

A child is scheduled for allogeneic bone marrow transplantation (BMT). The parent of the child asks the nurse about the procedure. The nurse should provide which description about the BMT? 1. Aspiration of bone marrow from the child 2.Obtaining bone marrow from the child's twin 3Obtaining bovine (cow) bone marrow and administering it to the child 4.Obtaining bone marrow from a donor who matches the child's tissue type

4.Obtaining bone marrow from a donor who matches the child's tissue type

what is the normal cd4 count

700-1000

What blood type is the universal recipient?

AB positive

what test confirms GERD

Barium swallow fluoroscopy

The nurse performs medication reconciliation for a 94-year-old client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous myocardial infarction. Due to risks outweighing benefits, the nurse plans to talk with the health care provider about discontinuing which medication? 1. Aspirin 81 mg 2. Fureosomide 40 3. Glyburide 10 mg 4. Levothyroxine 50

Beers Criteria lists medications that may be inappropriate for the geriatric population due to risks outweighing benefits. The nurse collaborates with the health care provider to minimize polypharmacy and reduce adverse effects (eg, falls, confusion). Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) (Option 3).

What is the screening test for HIV?

ELISA

A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs? 1. Appearance of upper lip 2. Increase in height 3. Presence of axillary hair 4. Testicular enlargement

Educational objective: Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? Select all that apply. 1. BMI 22kg 2. Endometrosis 3. Maternal age 4. Polysystic Ovarian Syndrome 5. Recurrent Chlamydial infections

Educational objective: Infertility is the inability to conceive after unprotected intercourse for >12 months. Factors contributing to female infertility include hormonal dysfunction (eg, polycystic ovarian syndrome) with anovulation, high or low BMI, and conditions that can lead to reproductive tract scarring and damage (eg, infection, endometriosis).

A client is admitted to the ambulatory care unit for an endoscopic procedure. The gastroenterologist administers midazolam 1 mg intravenously for sedation and titrates the dosage upward to 3.5 mg. The client becomes hypotensive (86/60 mm Hg), develops severe respiratory depression (SpO2 86%), and has periods of apnea. The nurse anticipates the administration of which antidote drug? 1. Benzotropine 2. Flumazenil 3. Naloxone 4. Phenotolamine

Flumazenil 2. Midazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines.

During the Oliguric phase what will you see?

Last 1-2 weeks low urine output <400, hyperkalemia, HTN, elevated BUN/ Creatinine, fluid overload

what kind of solution is the only fluid that can be given with a blood transfusion

Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line.

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? 1. Cyanosis 2.Hyperinflated chest 3.Rapid, shallow respirations 4.Coarse crackles auscultated bilaterally

Rapid, shallow respirations

what other two electrolytes will be elevated with acute renal failure

sodium and potassium

what blood type is considered universal and can be used for all other donors

type O negative

what is the treatment for bells palsy

wear eye patch at night use artificial tears wear glasses to protect eye Steroids to reduce edema