NCLEX/EXIT HESI Critical Thinking

A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings?

platelet count of 80 x 103/mm3 (80 X 109/L)

A client has been treated for major depression and is taking antidepressants. He asks the nurse, "How long do I have to take these pills?" How should the nurse respond to the client's question?

"Antidepressants are prescribed for 6 to 12 months before considering discontinuation." With major depression, antidepressants are prescribed for 6 to 12 months before the client is evaluated for discontinuation. Discontinuation of the medication prematurely may cause a relapse. An adequate duration for maintenance treatment is a minimum of 6 months; it is often longer depending on the stage of the illness and the specific client's characteristics. This regimen must be explained to clients as they often want to stop the medication when they feel better.

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement?

"I'm constantly sick and feel like I always have a fever." A major adverse reaction of risperidone is agranulocytosis. Therefore, it is a priority for the nurse to follow up if the client reports constantly being sick. Risperidone can be given without regard to meals; taking it at the same time every day is encouraged. Clients are encouraged to exercise regularly; the nurse should monitor the client taking risperidone for weight gain. Orthostatic hypotension is a common side effect of risperidone, and the nurse should follow up; however, the priority concern is agranulocytosis. Additionally, the cleint indicates experiencing dizziness "sometimes" but the feeling sick "constantly."

The nurse is assigned to care for a client admitted with depression as well as a dependent personality disorder. Which statement by the client is indicative of this personality disorder?

"Please don't forget to wait for me to go to dinner. I don't want to go by myself." A client with a dependent personality disorder does not like to be alone and attaches themselves to others emotionally as well as physically. This client can be in relationships in which they are the submissive party. The statement regarding not wanting to talk to anyone because the client feels stupid is an example of an avoidant personality disorder. When client states, "They all love me!" they are displaying a narcissistic personality disorder. A paranoid personality disorder is demonstrated by the comment regarding people staring and talking about them.

A client with a urinary tract infection is to take nitrofurantoin four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client?

"Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." Antibiotics have the maximum effect when the level of the medication in the blood is maintained, and the client should take the medication as soon as possible after missing a dose. Because nitrofurantoin is readily absorbed from the gastrointestinal tract and is primarily excreted in urine, toxicity may develop by taking the dose too close to the time the next dose should be taken or doubling the dose. If possible, the client should not skip a dose, if one dose is missed. It is not necessary to contact the HCP as the dosage does not need to be adjusted. The nurse can coach the client to set a timer or use a pill container with timed doses so that the client does not forget to take the medication.

A nurse is administering vitamin K to a neonate following birth. The medication comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places.

0.25 Use the following formula to calculate drug dosages:Dose on hand/Quantity on hand = Dose desired/XPlug in the values and the equation is as follows:2 mg/ml = 0.5 mg/XX = 0.25 ml.

The healthcare provider prescribes meperidine hydrochloride 1.5 mg/kg intramuscularly to a school-age client. The pharmacy supplies meperidine hydrochloride injection as 50 mg/mL. The client weighs 25 kg. How many milliliters will the nurse administer? Record your answer using two decimal places.

0.75 1.5 mg/kg × 25 kg = 37.5 mg per dose 37.5 mg / 50 mg x 1ml = 0.75 ml for injection

The health care provider (HCP) changes a client's current dose of IM meperidine hydrochloride to an oral dosage. The current IM dosage is 75 mg every 4 hours as needed. What dosage of oral meperidine will be required to provide an equivalent analgesic dose?

150 to 300 mg every 4 hours The equianalgesic dose of oral meperidine hydrochloride is up to four times the IM dose. Meperidine hydrochloride can be given orally, but it is much more effective when given IM.

A child is to receive IV fluids at a rate of 95 mL/h. The tubing for the infusion delivers 10 drops/mL. At which rate should the nurse infuse the solution?

16 drops/min To determine the number of drops per minute, multiply 95 ml/hour by 10 drops/mL (drop factor). This equals 950 mL/h. Dividing 950 mL/h by 60 min/h yields 15.8 drops/min. Therefore, 16 drops/min should be infused.

An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intrvenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.

187.5 The nurse would calculate the correct dose using the following equation:25 mg/kg × 7.5 kg = 187.5 mg

The client is ordered oxycodone/acetaminophen 20mg tablets, one or two prn for pain. The client rates the pain as a 7 on the numeric scale of 0/10. The nurse should administer how many oxycodone/acetaminophen?

2 The nurse should administer 1 tablets for pain less than 5 on a numeric scale of 0/10, and administer 2 tablets for pain greater than 5 on a numeric scale of 0/10.

A child with a body surface area (BSA) of 0.82 m2 has been prescribed actinomycin 2.5 mg/m2intravenously. What is the correct amount to be given? Record your answer using two decimal places.

2.05 0.82 m2 × 2.5 mg/m2 = 2.05 mg

A client at 28 weeks' gestation in premature labor was placed on nifedipine. To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? Record your answer using military time.

2200 If 20 mg were administered at 0600 and then 20 mg were administered at 1400, the dose at 2200 reached the maximum oral dose of 60 mg/day.

A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 ml/hour. How long will this transfusion take to infuse?

4 hours One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia.

Two days after a client undergoes repair of a ruptured cerebral aneurysm, a physician orders mannitol, 0.5 g/kg to be infused over 60 minutes. The client weighs 175 lb. The nurse should administer how many grams of mannitol? Record your answer using a whole number.

40 To determine the number of grams to administer, the nurse first must convert the client's weight from pounds to kilograms using the conversion factor: 1 kg = 2.2 lb 175 lb x 1 kg / 2.2 lb = 79.55 kg (pounds cancel out in this equation) 175 lb / 2.2 lb = 79.55 kg Next multiply the client's weight by the ordered amount (0.5 mg / kg). 79.55 kg x 0.5 g/kg = 39.775 g (kilograms cancel out) Round this number to the nearest whole number to determine the dose to be administered equals 40 grams.

A client is to receive total parental nutrition (TPN) solution. The nurse is aware it will be given via a central line and contains which main nutrient?

50% dextrose TPN is a hypertonic solution that consists of dextrose, proteins, and electrolytes. High-glucose solutions are better tolerated in a central line based on viscosity. Other answers can be given peripherally and do not require a central line.

Which client should the nurse expect to manage a percutaneous feeding tube as part of daily care?

90-year-old client with dysphagia following a stroke A percutaneous feeding tube is usually placed when there is difficulty with swallowing because of neurologic or anatomic disorders and can help prevent aspiration. It is a tube into the stomach or intestine and used to give medications and long-term enteral nutrition, such as for the 90-year-old client with dysphagia (difficulty swallowing) from a stroke. The client with bilateral upper extremity amputations may require assistance feeding oneself, but nothing in this scenario indicates the client would need a percutaneous feeding tube. The client wiht paraplegia would not have feeding difficulty or dysphagia, as the lower extremities would be affected in this case. The child with an autism spectrum disorder would not need a feeding tube for behavioral disturbances.

A client has suffered a deep partial-thickness burn to the right arm from a high-voltage source of energy that was not turned off while working on it. What is the priority nursing intervention in the acute phase of care?

A cardiac monitor should be used for at least 24 hours to anticipate the potential for cardiac dysrhythmias. A client with electrical burns based on energy and potential damage to the heart needs cardiac monitoring. Dextrose is not useful for fluid volume expansion and infection would occur much later. Urine output needs hourly monitoring based on myoglobin release.

A nurse should question an order for a heating pad for a client who has

active bleeding. Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

The nurse has assisted the health care provider at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. What should the nurse do next?

Assess breath sounds. he nurse should first assess for bilateral breath sounds since a complication of central line insertion is a pneumothorax, which would cause an increase in respiratory rate and drop in oxygen, causing irritability. The nurse should also assess blood pressure and heart rate for the complication of bleeding. A chest x-ray will be performed to determine correct placement and complications. A central line was most likely placed because peripheral IV access was not available or adequate for the client. Repositioning may be considered after assessments are done.

A client's electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse?

Assess the client's apical-radial pulse rate. Nonsustained ventricular tachycardia is several consecutive PVCs followed by the return to normal sinus rhythm. PVCs may reduce the CO and lead to angina and heart failure depending on frequency. Because PVCs in CAD or acute MI indicate ventricular irritability the nurse should first assess the client's physiologic response to PVCs by obtaining the client's apical-radial pulse rate, since PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse. This can lead to a pulse deficit. Assessment of the client's hemodynamic status is important to determine if treatment with drug therapy is needed. Treatment relates to the cause of the PVCs such as oxygen therapy for hypoxia, electrolyte replacement, and drug therapy includes beta-adrenergic blockers, procainamide, or amiodarone.

What is the priority nursing intervention in the postictal phase of a seizure?

Assess the client's breathing pattern. A priority for the client in the postictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client's level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.

A 67-year-old client will be discharged to home with imipramine. Which information would be mostimportant for the nurse to include when instructing the client and spouse about the medication?

Avoid alcohol Alcohol potentiates the central nervous system depression that can occur with imipramine, leading to increased sedation, confusion, and disorientation and consequently placing the client at risk for injury. Therefore, instructing the client and spouse about avoiding alcohol is most important.It is not necessary to eat a high-fiber diet while taking imipramine.Imipramine does not cause photosensitivity or changes in urinary patterns.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings?

Bronchial edema and constriction have worsened During an acute asthma attack, wheezing may stop and breath sounds become inaudible because the airways have swollen and gas exchange is limited. If the attack is over and bronchial swelling has decreased, there would be audible breath sounds and no more wheezing. If the administered albuterol was effective, the wheezing would diminish and gas exchange would improve. Pulmonary edema results in bilateral crackles on auscultation.

The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next?

Call the health care provider (HCP) immediately to report changes. The nurse should call the HCP to report symptoms of a sore throat, fever, and chills because these symptoms may be signs of serious adverse effects of the medication, including potentially fatal hematologic, cardiovascular, and hepatic complications. Giving the dose of carbamazepine is contraindicated in this situation. Giving the acetaminophen would be inappropriate and potentially detrimental to the client's health. Waiting until morning to report the client's symptoms is a serious error in judgment.

A client reports pain in the right heel and is requesting medication. The nurse assesses the client and administers an analgesic. The client experiences no pain relief and states that the heel pain is worse. What is an appropriate intervention by the nurse?

Call the physician to report the finding. The best response would be to notify the physician. The nurse cannot repeat the dose of analgesic without an order. Massaging the ankle and applying moist heat would be inappropriate for a number of reasons. The client could be developing a deep vein thrombosis, which may dislodge an embolus. Unrelieved pain indicates that an adverse event is developing, and the physician should be made aware of the situation.

The nurse is caring for a primagravida in active labor. The provider performs an amniotomy to augment labor. What is the nurse's priority action after the procedure is completed?

Check the fetal heart rate for bradycardia. After a client has an amniotomy, the nurse should ensure that the cord is not prolapsed and that the fetus tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes does not indicate an imminent birth.

An HIV-positive client who has been treated with antiretroviral therapy for two decades presents at the emergency department with symptoms typically associated with myocardial infarction. The nurse assessing this client should immediately recognize which factor associated with chronic HIV?

Chronic HIV clients are at increased risk for cardiovascular disease. The nurse should recognize that a long-term HIV-positive client is at increased risk for many chronic conditions, including cardiovascular disease and myocardial infarction. HIV causes chronic inflammation that can contribute to cardiovascular disease. Some antiretroviral medications are associated with insulin resistance and hyperlipidemia, thus increasing the risk of cardiovascular disease. It is judgmental to assume that this client is a smoker because of the HIV diagnosis. It is not true that either antiretroviral agents protect against cardiovascular disease or that emergency cardiac drugs are contraindicated in clients taking antiretroviral agents.

A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin as prescribed. What is the expected outcome of this drug?

Contractions will occur every 2 to 3 minutes, lasting 40-60 seconds, moderate intensity, resting tone between contractions. The goal of oxytocin administration in labor augmentation is to establish an adequate contraction pattern to enhance the forces of labor. The expected outcome is a pattern of contractions occurring every 2 to 3 minutes, lasting 40 to 60 seconds, of moderate intensity with a palpable resting tone between contractions. Other contraction patterns will cause the cervix to dilate too quickly or too slowly. Cervical changes in softening, effacement, and moving to an anterior position are associated with use of cervical ripening agents, such as prostaglandin gel. Cervical dilation of 2 cm/h is too rapid for the induction/augmentation process.

During the nurse's assessment, the newborn wakes and is in a quiet-alert state. The nurse counts the apical pulse to be 157 beats per minute. Which is the most appropriate nursing action?

Document this finding as on the high end of the normal range and plan to reassess. Heart rates can be as fast as 180 bpm, but the normal range for a newborn heart rate is 110-160 bpm. Thus, the newborn's heart rate of 157 bpm is on the high end of the normal range, but still within the normal range. It would be appropriate to reassess the client's heart rate because newborn heart rates can fluctuate depending on the state of consciousness/wakefulness, hunger, temperature, and especially if the newborn is moving or startled. It would be inappropriate to call the pediatrician or to notify the charge nurse at this time because the value is currently within the normal range.

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?

Further assess the client for reinflation of the lung. A lack of bubbling in the water chamber and normal lung sounds are an indication that lung reinflation has occurred. The nurse can further assess the client in relation to pulse oximetry, respiratory rate, and other signs that indicate improvement and can be relayed to the physician for possible removal of the chest tube.

A school nurse is called to assess a 12-year-old child with type 1 diabetes mellitus who is experiencing lightheadedness, tachycardia, and pallor during physical education class. What is the priority action by the nurse?

Give the child some fruit juice to drink. Increased exercise has likely caused a drop in serum glucose levels, producing symptoms of hypoglycemia. The first action is to give the child a source of fast-acting carbohydrate (approximately15 grams) such as juice or candy. Cheese and crackers can be given once the acute symptoms of hypoglycemia have resolved to provide a longer-lasting source of complex carbohydrate and protein. Ideally the nurse would use blood glucose monitoring to direct this treatment. The nurse should not give insulin even if it is due now, because of the child's symptoms. The parents need to be notified of the child's symptoms, but the priority action is to care for the client.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed?

Level of consciousness, pain level, and wound dressing Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

A client is ordered prednisone daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?

Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Early-morning prednisone administration mimics the circadian rhythm of natural corticosteroid secretion — higher in the morning and lower in the evening. Although establishing a regular medication routine helps prevent missing a dose, this isn't the reason for taking prednisone in the morning. The half-life of prednisone doesn't depend on the time of administration. The client should take prednisone with food or milk to minimize GI upset.

An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, board-like abdomen. After obtaining the client's vital signs, what should the nurse do next?

Notify the health care provider. The client is likely experiencing a perforation of the ulcer, and the nurse should notify the health care provider immediately. The body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in board-like abdominal rigidity, usually with extreme pain. Perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perforation.Administering pain medication is not the first action, although the nurse later should institute measures to relieve pain.Elevating the head of the bed will not minimize the perforation.A nasogastric tube may be used following surgery.

A client's prenatal record shows a gravida 2, para 0111. From this information, the nurse knows that the client has been pregnant twice. What else does this information reveal about the client's obstetric history?

One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living. A client's previous pregnancies are documented according to her number of Term infants, number of Preterm infants, number of Abortions, and number of Living children (or TPAL). In the TPAL method, the first element (0, in this case) indicates the number of term neonates. The second element (1) indicates the number of preterm neonates delivered. The third element (1) represents the number of spontaneous or therapeutic abortions. The fourth element (1) represents the number of children alive. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who's living would be documented as para 1102. One pregnancy that resulted in an abortion and one that resulted in a term neonate who's living would be documented as para 1011. One pregnancy that resulted in a term neonate who's living and one that resulted in a preterm neonate who died would be documented as para 1101.

The nurse working at a public health clinic needs to perform an intradermal test on a client. Put the actions in order for intradermal testing the nurse needs to perform. All options must be used.

Pick a 0.5 mL sterile syringe. Choose a 26 gauge needle. Insert the needle with the bevel facing upward. Ensure the syringe is parallel to the skin. Allergen solution is injected. A 5 mm bleb is created. The first step is to pick a 0.5 mL sterile syringe. The second step is to choose a 26 gauge needle. The third step is to insert the needle with the bevel facing upward. The fourth step is to make sure the syringe is parallel to the skin. The fifth step is to inject the allergen solution. The sixth step is to create a 5 mm bleb.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take?

Question the physician about the order. Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

The nurse is administering epinephrine using an EpiPen autoinjector. Place the steps for administering the epinephrine using an EpiPen autoinjector in the correct order. All options must be used.

Remove the EpiPen autoinjector from its carrying tube. Grasp the EpiPen autoinjector with the injecting end pointing downward. Remove the safety release cap. Jab the EpiPen autoinjector firmly into the outer thigh. Hold the EpiPen autoinjector against the thigh for 10 seconds. Massage the injection site area for 10 seconds. The EpiPen autoinjector is removed from its carrying tube. A fist is formed around the EpiPen autoinjector unit. The EpiPen autoinjector is grasped with the injecting end pointing downward. The safety release cap is removed. The EpiPen autoinjector is firmly jabbed into the outer thigh to ensure the needle pierces the skin. The EpiPen autoinjector is held against the thigh for 10 seconds to give the medication time to fully be administered. The injection site is massaged for 10 seconds to increase the speed of absorption.

The nurse is assessing a client who is receiving normal saline intravenously at 100 mL/hr through the right forearm. The nurse observes that the forearm is swollen, cold to the touch, and pale. What action would the nurse take?

Restart the infusion at a different site. Swelling, coldness, and pallor are all indications of peripheral intravenous line infiltration. Restarting the infusion at a different site is the correct action because the intravenous fluids are leaking into the tissue surrounding the vein being used. The client is not receiving the intravenous fluids needed. Turning the intravenous fluids off for 1 hour and reassessing the right forearm do not address the problem of the infiltration. Decreasing the rate will not resolve the infiltration either; in fact, continuing to infuse the normal saline will make the infiltration worse. Gently flushing the peripheral intravenous line does not address the infiltration and may make the infiltration worse.

A client in labor is 8 cm dilated. The fetus, which is in vertex presentation, is 75% effaced and is at 0 station. In the illustration, identify the level of the fetus's head.

Station refers to the level of the presenting part in relation to the pelvic inlet and the ischial spines. A 0 station indicates that the presenting part lies at the level of the ischial spines. Other stations are defined by their distance in centimeters above or below the ischial spines.

A client receiving a blood transfusion calls the nurse to the room and reports feeling hot and itchy. The client's temperature is 101.4°F (38.6°C) after 100 mL of the blood is infused. What are the priority actions for the nurse?

Stop the blood transfusion and maintain the intravenous site with normal saline. Initial treatment is to stop cause of reaction. The other choices do not address stopping what is causing the allergic reaction.

A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order from first to last should the nurse provide care for this client? All options must be used.

Stop the transfusion. Keep the vein open with normal saline solution. Administer an antihistamine as directed. Send the blood bag and blood slip to the blood bank. The nurse should first stop the transfusion. The nurse should next keep the IV open at the original blood transfusion site with normal saline at a keep-vein-open rate. Then, the nurse should administer an antihistamine. Last, the nurse should return the blood bag and blood slip to the blood bank for testing.

A nurse is about to admit a client to the medical surgical unit directly from the healthcare provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which action is the nurse's priority?

Strict intake and output assessment and documentation Symptoms are highly suggestive of glomerulonephritis. Clients require strict intake and output are generally placed on a high protein diet. Monitoring of laboratory values is good nursing practice overall, but not the priority with this diagnosis. Ambulation is not the priority, as client requires rest.

The client has just undergone abdominal surgery and returned from the post-anesthesia care unit (PACU) with a patient-controlled analgesia (PCA) pump. Which interventions should the nurse implement? Select all that apply.

Tell the client to push the button when in pain. Check the patient-controlled analgesia (PCA) settings with another nurse. Assess the IV insertion site. The client is the only person who should push the PCA button and only when in pain. The settings should be checked with another nurse, ensuring the correct dosage is being administered. The PCA is intravenous and the site should be patent and free of erythema and infiltration.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain. Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.

The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first?

a 74-year-old who has periodontal disease with periodontitis Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, or elderly, and those who have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy The client who has had 3 prior births and has polyhydraminios has the potential for uterine atony and would be most at risk for a postpartum hemorrhage. The client at 34 weeks with mild pregnancy-induced hypertension would be at minimal risk because the uterus is not extraordinarily distended at this gestation. The gravida 4 para 0 client, who has diet-controlled gestational diabetes, has a risk of hemorrhage from being induced, but her uterus should be able to contract appropriately after the birth as long as there is no history of macrosomia. A history of genital herpes is not a risk factor for a postpartum hemorrhage.

Which client would benefit from the application of warm moist heat?

a client with low back pain Direct application of warm moist heat would benefit a client with low back pain because the heat relaxes muscle spasms. Heat should not be applied to a client who has appendicitis because it can lead to rupture of the appendix and peritonitis. Ice is applied to recently sprained joints to help decrease edema. Applying heat to the area of a suspected malignancy can increase blood flow to the tumor and promote nourishment of the cancer cells.

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. The nurse should expect

a drop in the client's heart rate. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn't lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions.

These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first?

a quiet 2-year-old with nasal flaring who is sitting in a tripod position The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.

A client with a chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:

a tension pneumothorax. Atmospheric pressure is greater than the pressure inside the pleural space. If a chest tube were clamped for a period of time, the intrathoracic pressure would increase, and subsequently so would tension. The other choices are not reflective of a clamped chest tube.

When assessing a client with asthma, which findings would most likely indicate the presence of a respiratory infection?

cough productive of yellow sputum A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows to monitor closely for complications that include which of the following?

acute respiratory distress syndrome (ARDS) A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. ARDS refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

A 30-year-old multiparous client has been prescribed oral contraceptives as a method of birth control. The nurse instructs the client that decreased effectiveness may occur if the client is prescribed which drug?

ampicillin Oral contraceptives may interact with other medications, and the effectiveness may be decreased if the client is prescribed ampicillin, tetracycline, or anticonvulsants, such as phenytoin.Indomethacin, an anti-inflammatory agent; amitriptyline, an antidepressant agent; and omeprazole, a drug used to suppress gastric acid secretion, do not decrease the effectiveness of oral contraceptives.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

assessing the extremity for neurovascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?

auscultation of bowel sounds Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.

Which is a priority nursing action for a child with croup?

continually assessing respiratory status Respiratory status should be assessed continually as the child may have laryngeal spasms without notice. Antipyretics may be given as well as oxygen, but respiratory status takes priority. Parents would be encouraged to stay with their child but this is not an immediate priority.

An older adult with a history of heart failure is admitted to the emergency department with pulmonary edema. During admission, what should the nurse assess first?

blood pressure It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown, but when the client is stable and when the nurse obtains a complete health history, the nurse should inspect the client's skin for any signs of breakdown; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling?

changes in respiration Impaired diaphragm function is common with cervical cord injuries in children and is potentially life threatening. It interferes with the ability to breathe, causing changes in respiration.

A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs and symptoms?

coma, anxiety, confusion, headache, and cool, moist skin Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45 mg/dl (2.5 mmol/L)] include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul's respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.

The client with a depressive disorder has been consistent with taking 12.5 mg of paroxetine extended release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which behaviors? Select all that apply.

completes homework assignments decreases pacing verbalizes feelings Symptoms of depression include depressed mood, anhedonia, appetite disturbance, sleep disturbance, psychomotor disturbance, fatigue, feelings of worthlessness, excessive or inappropriate guilt, decreased concentration, and recurrent thoughts of death or suicide. Paroxetine is a selective serotonin reuptake inhibitor antidepressant that also can be used to treat anxiety. Improved concentration, verbalization of feelings, and decreased agitation or pacing are signs of improvement. Taking 2-hour evening naps daily is still a sign of fatigue or lack of energy, and the increased use of somatization (bodily problems) could be signs of continued symptoms of depression.

The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock?

confusion In the progressive stage of shock, the client can display listlessness or agitation, confusion, and slowed speech. Restlessness occurs in the compensatory stage. Incoherent speech and unconsciousness are clinical manifestations of the irreversible stage.

The nurse has administered meperidine to a client in labor. Which change in the fetal heart rate tracing would the nurse expect to occur as a result of the meperidine administration?

decreased fetal heart rate variability Possible fetal adverse reactions include moderate central nervous system depression and decreased fetal heart rate variability. Bradycardia, late decelerations, and increased fetal movement don't occur as a result of meperidine administration.

A child with diabetes insipidus receives desmopressin acetate. When evaluating for therapeutic effectiveness, the nurse should interpret which finding as a positive response to this drug?

decreased urine output The primary action of desmopressin acetate is to stimulate water reabsorption by the kidneys, thereby decreasing the urine output. Desmopressin acetate has no effect on glucose levels, blood pressure, or nausea.

A full-term client is admitted for induction of labor. When admitted, her cervix is effaced 25% but has not dilated. The initial goal is cervical ripening prior to labor induction. Which drug will prepare her cervix for induction?

dinoprostone Cervical ripening, or creating a cervix that is soft, anterior, and dilated to 2 to 3 cm, must occur before the cervix can efface and dilate with oxytocin. Drugs to accomplish this goal include dinoprostone, misoprostol, and prostaglandin E2. Nalbuphine is a narcotic analgesic used in early labor and has no influence on the cervix. Betamethasone is a corticosteroid given to mature fetal lungs.

A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the

frontal and maxillary sinuses. After detecting tenderness of the paranasal sinuses, the nurse should transilluminate both the frontal and maxillary sinuses; lack of illumination may indicate sinus congestion and pus accumulation. The sphenoidal and ethmoidal sinuses can't be transilluminated because of their location.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy.

A nurse is reviewing the medication list of a client who presents with slow, involuntary muscle spasms of the arms and legs and twisting of the neck. The nurse reviews the client's prescriptions for which medication that could correlate with these symptoms?

haloperidol Haloperidol is a phenothiazine and is capable of causing dystonic reactions. Dystonia involves slow, involuntary contractions of an isolated muscle or groups of muscles in the limbs, trunk, and neck. It may involve spasmodic torticollis (involuntary turning of the neck). Diazepam and clonazepam are benzodiazepines. Benzodiazepines don't cause dystonic reactions; however, they can cause drowsiness, lethargy, and hypotension. Tricyclic antidepressants, like amitriptyline, rarely cause severe dystonic reactions; however, they can cause a decreased level of consciousness, tachycardia, dry mouth, and dilated pupils.

A nurse is caring for a client admitted with arching of the back, extension and rotation of the neck, and slow involuntary contractions of the arms and neck. After review of the client's medication list, the nurse would be correct in associating these symptoms with which medication?

haloperidol Slow, involuntary contractions of the arms and neck, arching of the back, and extension and rotation of the neck are signs of dystonia. Dystonia is a common adverse effect of antipsychotic medications such as haloperidol. Benztropine is an antiparkinsonian drug, pantoprazole is an antiulcer medication, and propranolol is an antihypertensive.

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which indicator of early shock?

heart rate above 100 beats/minute In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation.The skin becomes cool and clammy.Urine output in early shock may be normal or slightly decreased.The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.

Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

hemorrhagic skin rash Disseminated intravascular coagulation is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Heparin therapy is often used to interrupt the clotting process. Edema would suggest a fluid volume excess. Cyanosis would indicate decreased tissue oxygenation. Dyspnea on exertion would suggest respiratory problems, such as pulmonary edema.

A client has been severely depressed since the client's partner died 6 months earlier. The physician orders amitriptyline hydrochloride, 50 mg by mouth daily. Before administering amitriptyline, the nurse reviews the client's medical history. Which preexisting condition requires cautious use of this drug?

hepatic disease Conditions requiring cautious use of amitriptyline include pregnancy, breast-feeding, suicidal tendencies, cardiovascular disease, and impaired hepatic function. Hiatal hernia, hypernatremia, and hypokalemia don't affect amitriptyline therapy.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

increased urine output The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

A client with schizoaffective disorder is brought to the hospital by a family member. The family member states that the client is having an increase in auditory hallucinations and is becoming significantly more withdrawn. The nurse reviewing the admission blood work expects which blood level to be subtherapeutic?

lithium carbonate Lithium carbonate, an antimania drug, is used to treat clients with cyclical schizoaffective disorder, a psychotic disorder once classified under schizophrenia that causes affective symptoms, including manic and depressive activity. Lithium helps control this disorder's affective component. Phenobarbital can cause schizophrenia-like symptoms in some people and would not be prescribed for a person with schizophrenia. Chlordiazepoxide, an antianxiety agent, is generally contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.

A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal?

maintaining effective respirations As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation. Although maintaining an adequate circulatory volume, reducing anxiety, and relieving pain are pertinent for this client, they're secondary to maintaining effective respirations.

A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication?

metabolic alkalosis Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

When developing the collaborative plan of care with the health care provider (HCP) for a multigravid client at 10 weeks' gestation with a history of cardiac disease who was being treated with digitalis therapy before this pregnancy, the nurse should instruct the client about which modifications regarding the client's drug therapy regimen?

need for an increased dosage Clients on cardiac medications may need dosage increases as their blood volume increases. Drug level monitoring may be needed after dose changes or if the client presents with toxicity, but weekly monitoring is unnecessary. The medication would be switched only if digitalis toxicity occurs. A diuretic is added only if congestive heart failure is not controlled by sodium and activity restrictions.

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

partial pressure of arterial oxygen (PaO2) of 69 mm Hg In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A client is experiencing autonomic dysreflexia. The nurse should first:

place the client in Fowler's position. utonomic dysreflexia is a medical emergency. The rising blood pressure can cause cerebrovascular accident, blindness, or even death. Placing the client in Fowler's position lowers blood pressure. Administering nitroprusside IV is appropriate if the conservative measures are ineffective. Although notifying the health care provider is important, it is more essential that the nurse intervene immediately in the situation. A urine sample for culture should be obtained if the client has an elevated temperature and no other cause for the dysreflexia is found. A urinary tract infection may be causing symptoms.

The nurse is aware that a client receiving morphine sulfate intravenously post-surgical repair of a hip fracture may exhibit which outcome when getting out of bed for the first time?

postural or orthostatic hypotension After the administration of certain antihypertensives or narcotics, the client's neurocirculatory reflexes may have some difficulty adjusting to the force of gravity when assuming an upright position. Postural or orthostatic hypotension may then occur, causing a temporarily decreased blood supply to the brain. The client received analgesia, so pain should be controlled and the client's blood pressure should be within normal range or slightly lower. Pain should not be acute.

When caring for the client diagnosed with delirium, the nurse should investigate which condition as the most important?

prescription drug intoxication Polypharmacy is much more common in the older adult. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the older adult, the onset would be more gradual.

A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing which factor?

relief from anxiety. A client who is exhibiting compulsive behavior is attempting to control his anxiety. The compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an attempt to express hostility.

The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia?

restlessness One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia.

An RN preceptor is assisting a new graduate to access a port-a-cath with a Huber needle. Which action by the new graduate would require intervention by the RN preceptor?

rotating the needle immediately after access Accessing a port-a-cath is a sterile procedure which requires a mask and sterile gloves. The needle should be placed at a 90 degree angle and should NOT be rotated as this may damage the port.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

Which food should the nurse tell the client to avoid while taking phenelzine?

salami Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the enzyme monoamine oxidase, which is involved in the decomposition and inactivation of norepinephrine, serotonin, dopamine, and tyramine (a precursor to the previously stated neurotransmitters). Foods high in tyramine—those that are fermented, pickled, aged, or smoked—must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis occurs. Some examples include salami, bologna, dried fish, sour cream, yogurt, aged cheese, bananas, pickled herring, caffeinated beverages, chocolate, licorice, beer, red wine, and alcohol-free beer.

A client comes to the emergency department with severe back pain. The client reports taking several pain pills at home but cannot remember how many and provides the nurse with an empty bottle of acetaminophen with codeine. Which laboratory value should the nurse address?

serum aminotransferase level (AST) of 256 u/L and international normalized ratio (INR) of 3.0 Hepatic necrosis is the most serious toxic effect of an acute overdose of acetaminophen. The nurse should monitor the liver enzymes and INR level. Renal failure is not a consideration since the lab values are within normal limits. Total CPK would not need to be monitored; if the level is high, it usually means there has been injury or stress to muscle tissue, the heart, or the brain. The CPK level is within normal limits. Both the Na+ and K+ levels are also within normal limits.

A client has a history of schizophrenia. Because of a history of noncompliance with antipsychotic therapy, the client will receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in the teaching plan?

sitting up for a few minutes before standing to minimize orthostatic hypotension The nurse should teach the client how to manage common adverse reactions, such as orthostatic hypotension and anticholinergic effects. Antipsychotic effects of the drug may not become evident for several weeks. Droperidol increases the risk of extrapyramidal effects when given in conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a possible adverse reaction and should be reported immediately.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving them anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first?

the client with unilateral leg swelling who reports anxiety and shortness of breath The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.

A 20-year-old client visiting the clinic requests the use of oral contraceptives. When reviewing the client's history, which finding would alert the nurse to a possible contraindication to using these agents?

thrombophlebitis Oral contraceptives are contraindicated for clients with a history of thrombophlebitis because a serious side effect of oral contraceptives is thrombus formation. Other contraindications include stroke and liver disease. Oral contraceptives are used cautiously in clients with hypertension or diabetes. Close follow-up of these clients is essential.Urinary tract infections (UTIs) do not contraindicate the use of oral contraceptives. If the client is suffering from UTIs, the nurse can instruct her to increase her fluid intake and wipe from front to back after urinating or defecating.Ulcerative colitis does not contraindicate using oral contraceptives.Menorrhagia is typically reduced through the use of oral contraceptives.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

urine output of 90 mL over the past 6 hours Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension. Confusion with explanations of procedures does not mean that the client has a cerebral impairment. Further assessment is warranted. In the elderly, lack of fever is a poor indicator of presence or absence of sepsis due to decreased sensation from the hypothalamus. Polydipsia is reflective of diabetes.

When assessing a client who is receiving tricyclic antidepressant therapy, the nurse should be alert for which finding that could suggest the client is experiencing anticholinergic effects?

urine retention and blurred vision Anticholinergic effects, which result from blockage of the parasympathetic nervous system, include urine retention, blurred vision, dry mouth, and constipation. Tremors, cardiac arrhythmias, and sexual dysfunction are possible side effects, but they are caused by increased norepinephrine availability. Sedation and delirium are not anticholinergic effects. Sedation may be a therapeutic effect because many clients with depression experience agitation and insomnia. Delirium, typically not a side effect, would indicate toxicity, especially in older adult clients. Respiratory depression, convulsions, ataxia, agitation, stupor, and coma indicate tricyclic antidepressant toxicity.

A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when the client:

uses the sternocleidomastoid muscles. Use of accessory muscles indicates worsening breathing conditions. Asking for an additional pillow, having a 91% pulse oximetry reading, and requesting the nurse to raise the head of the bed are not indications of a worsening condition.

A healthy client presents to the clinic for a routine examination. When auscultating the client's lower lung lobes, the nurse should expect to hear which type of breath sound?

vesicular Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation. They're best heard over the upper third of the sternum and between the scapulae.