NURS 1240 Safety EAQ

A client is to receive 0.22 g of zinc sulfate by mouth. Each tablet contains 110 mg. How many tablets will the nurse administer?

2 tablets rationale: The prescribed dose is 0.22 g. The medication is available in 110 mg tablets. First, convert the prescribed dose in grams to the available medication in milligrams. Then use the dimensional analysis and ratio and proportion methods to determine the appropriate number of tablets to be administered. 0.22 g × 1000 mg/g x 1 tablet/110 mg = 2 tablets.

A client has an intravenous (IV) solution of 5% dextrose in water (D 5W) 250 mL to which 100 mg of morphine is added. The health care provider prescribes 14 mg of morphine per hour for end-of-life palliative treatment of a client. At how many milliliters per hour will the nurse set the IV pump?

35 mL/h rationale: The prescribed rate is 14 mg/h. The available concentration is 100 mg/250 mL. Use dimensional analysis to determine the appropriate rate: 14 mg/h X 250 mL/100m-35 mL/h.

Metformin 2 g by mouth is prescribed for a client with type 2 diabetes. Each tablet contains 500 mg. How many tablets will the nurse administer?

4 tablets rationale: First, convert the prescribed dose (2 g) to the available dose (mg). 2 g x (1000 mg/1 g) = 2000 mg Then, use the dimensional analysis and or ratio and proportion methods to determine the appropriate number of tablets to be administered. 2000 mg x 1 tablet/500 mg = 4 tablets.

Which antipyretic medication may cause Reye syndrome in children? - Aspirin - Naproxen - Ibuprofen - Dantrolene

Aspirin rationale: Aspirin increases the risk of swelling in the brain and liver, which are the main symptoms of Reye syndrome in children. Aspirin is not recommended in children. Medications such as naproxen and ibuprofen do not induce swelling in the brain and liver; therefore, these medications may not cause Reye syndrome. Dantrolene does not induce swelling in the brain and liver; instead, it decreases calcium levels during malignant hyperthermia conditions.

A client is diagnosed with Alzheimer disease and is exhibiting hyperorality. Which parameter would the nurse closely monitor to keep this client safe? - For choking at meal times - For the presence of mouth ulcers - For injuries from touching hot foods - For attempts at eating inedible objects

For attempts at eating inedible objects rationale: The nurse would closely monitor for attempts at eating inedible objects. Hyperorality is the compulsive need to taste, chew, and put everything in the mouth. Hyperorality is not related to choking at meal times; dysphagia is related to choking. Hyperorality is not related to mouth ulcers; stomatitis refers to mouth ulcers. Injuries from touching refers to hypermetamorphosis, the urge to touch everything.

Which medication is used to treat acne vulgaris in adolescents but is contraindicated in pregnancy? - Tretinoin - Adapalene - Isotretinoin - Benzoyl peroxide

Isotretinoin rationale: Isotretinoin passes through the placental barrier and exhibits teratogenic effects, so it is contraindicated in pregnancy. Tretinoin is not harmful when used topically. Adapalene and benzoyl peroxide are safe medications for topical use during pregnancy.

Which amount of time is appropriate for the nurse to spend triaging each client during a mass casualty incident (MCI)? - Less than 10 seconds - Less than 15 seconds - Less than 30 seconds - Less than 60 seconds

Less than 15 seconds rationale: Triage of victims of an emergency or an MC must be conducted in less than 15 seconds. The other time frames, 10 seconds, 30 seconds, and 60 seconds, are not accurate.

Which medication is the first choice of medication for the treatment of attention-deficit/hyperactivity disorder (ADHD)? - Clonidine - Guanfacine - Atomoxetine - Methylphenidate

Methylphenidate rationale: Methylphenidate is the first choice of medication for the treatment of attention-deficit/hyperactivity disorder (ADHD). Clonidine, guanfacine, and atomoxetine are nonstimulants used to treat ADHD; these medications are less effective than methylphenidate.

Which drug category applies to cocaine? - Opioids - Stimulants - Barbiturates - Hallucinogens

Stimulants rationale: Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.

Which response would the nurse provide the parent of a 15-month-old child who expresses feelings of guilt when their child was hospitalized after ingesting toilet bowl cleaner? - "Anyone could make a mistake. Don't dwell on it." - "Let's not worry about the past. Your child is going to get better." - "It was an accident, but you should consider special locks on vour closets." - "That was careless of you. Please make sure that you poison-proof your house."

"It was an accident, but you should consider special locks on vour closets." rationale: Describing the incident as an accident and recommending locks on closets accepts the parent's statement and helps the parent express their guilt while providing directions to safeguard the child. Poisoning is not an everyday occurrence; teaching should be incorporated to protect the child. Telling the parent that the child will get better is false reassurance; the child's condition is still in question. Calling the parent careless only increases the parent's guilt and provides nothing more than a vague suggestion of how to remedy the problem.

Which parental statement would the nurse recognize as indicating the need for further education about bicycle safety for a school-aged client? - "My child should be able to place both feet on the ground while seated." - "My child should be able to easily grasp the brake handles and squeeze them." - "My child will be required to wear a bicycle helmet if he or she wants to ride a bike." - "My child should be able to safely ride after being supervised for a couple of days.'

"My child should be able to safely ride after being supervised for a couple of days." rationale: Children may not safely be able to ride their bike after a couple of days of learning. The child should be able to place the balls of both feet on the ground while sitting on the bike. The child should easily be able to grasp the brake handles and squeeze them. The child should always wear the appropriate safety equipment while riding his or her bike.

Atenolol 150 mg by mouth is prescribed for a client with hypertension. Each tablet contains 50 mg. How many tablets will the nurse administer?

3 tablets rationale: Use the dimensional analysis and or ratio and proportion method to determine how many tablets the nurse would administer. 150 mg × 1 tablet/50 mg = 3 tablets.

At 10:00 AM the nurse hangs a 1000-mL bag of 5% dextrose in water (D 5W) with 20 mEg of potassium chloride to be administered at 80 mL/h. At noon the health care provider prescribes a stat infusion of an intravenous (IV) antibiotic of 100 mL to be administered via piggyback over 1 hour. How much longer than expected will it take the primary bag to empty if the nurse interrupts the primary infusion for infusion of the antibiotic? - 15 minutes - 30 minutes - 45 minutes - 60 minutes

60 minutes rationale: An infusion of 1000 mL at 80 mL should take 12.5 hours. Because the primary infusion is interrupted for an hour while the antibiotic is infused, the primary bag will run an hour longer than if it were running uninterrupted. Minutes that are less than an hour are incorrect calculations.

Which medication may cause photophobia as an adverse effect? - Nifedipine - Alendronate - Clomiphene - Indomethacin

Clomiphene rationale: Clomiphene is a fertility medication that may cause photophobia. Nifedipine may cause maternal fetal problems. Alendronate may cause dysphagia. Indomethacin may cause birth defects.

Which medication is a teratogen that may cause masculinization of a female fetus? - Lithium - Danazol - Nitrofurantoin - Carbamazepine

Danazol rationale: Danazol is a teratogen that may cause masculinization of a female fetus. Lithium may cause cardiac defects. Nitrofurantoin may cause cleft lips with cleft palates. Carbamazepine may cause neural tube defects.

The nurse is teaching a client about tricyclic antidepressants. Which potential side effects would the nurse include? Select all that apply. - Dry mouth - Drowsiness - Constipation - Severe hypertension - Orthostatic hypotension

Dry mouth, Drowsiness, Constipation, Orthostatic hypotension rationale: Dry mouth is a common anticholinergic side effect of tricyclic antidepressants. Drowsiness can be a common side effect but usually decreases with continued treatment. Constipation is a common side effect that usually can be managed with stool softeners and a high-fiber diet. Orthostatic hypotension is a common side effect of tricyclic antidepressants; the client should be instructed to rise slowly from a sitting to a standing position. Hypertension of any type is not a side effect of tricyclic antidepressants.

Which emergency severity index (ESI) level would be considered a high priority for the nurse caring for clients in the emergency department (ED)? - ESI-1 - ESI-2 - ESI-3 - ESI-4

ESI-1 rationale: ESI-1 should be considered a high priority for care in the ED because the ESI-1 clients are in unstable condition. ESI-2 indicates that clients can wait 10 minutes for care in the ED. ESI-3 level clients can wait up to 1 hour because their conditions are stable. ESI-4 clients' treatment can be delayed for longer, depending on the cases in the ED.

Which action would the nurse take when a client who had a total hip replacement states that the plan is to go swimming at the community pool the day after discharge? - Tell the client to take a friend along for safety. - Encourage participation in this activity because it provides excellent range-of-motion exercise. - Explain that the incision should not be immersed in water until it has healed. - Let the client know that swimming can substitute for the prescribed physical therapy.

Explain that the incision should not be immersed in water until it has healed rationale: Because of the risk for infection, the client should avoid tub baths, hot tubs, pools, and immersion in other bodies of water until after the wound has healed and these activities are approved by the primary health care provider. Immersion in water for a prolonged period interferes with wound healing, because water may macerate tissue. Having a friend along does not change the fact that immersion in water for a prolonged period will interfere with wound healing. The client needs to continue physical therapy after discharge whether or not the client goes swimming.

Which high-potency medication is used to treat schizophrenia? - Loxapine - Perphenazine - Fluphenazine - Thioridazine

Fluphenazine rationale: Fluphenazine is a high-potency medication used for schizophrenia. Loxapine and perphenazine are medium-potency medications used to treat schizophrenia. Thioridazine is a low-potency medication used to treat schizophrenia.

A client is receiving haloperidol for agitation, and the nurse is monitoring the client for side effects. Which response identified by the nurse is unrelated to an extrapyramidal tract effect? - Akathisia - Opisthotonos - Oculogyric crisis - Hypertensive crisis

Hypertensive crisis rationale: A hypertensive crisis is not associated with extrapyramidal tract symtoms. Akathisia, characterized by restlessness and twitching or crawling sensations in the muscles, is an extrapyramidal side effect. Opisthotonos, characterized by hyperextension and arching of the back, is an extrapyramidal side effect. Oculogyric crisis, characterized by the uncontrolled upward movement of the eyes, is an extrapyramidal side effect.

Which strategy would the nurses use to minimize aggressive behaviors from the client with a neurocognitive disorder? - Limit the time staff and the client spend together. - Follow an outline of consequences for uncooperative behavior. - Use the client's preferences as a reward or a punishment. - Identify nursing staff members whom the client prefers.

Identify nursing staff members whom the client prefers rationale: The strategy is to identify nursing staff members whom the client prefers. The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with neurocognitive disorder cannot be held responsible for uncooperative behavior. Clients with neurocognitive disorder will not remember and learn from a reward system.

The nurse would utilize the Glasgow Coma Scale on a trauma client to complete which assessment? - Patency of airway - Level of consciousness - Breathing abnormalities - Circulatory abnormalities

Level of consciousness rationale: The nurse uses the Glasgow Coma Scale while performing a primary survey of a traumatized client to assess the level of consciousness. Patency of airway is assessed by manually checking the client's oral cavity. Breathing abnormalities are assessed by checking the chest wall of the client. Circulator abnormalities are assessed by checking the blood volume.

Which medication is unsafe to administer as an intravenous (IV) bolus? - Saline flush - Potassium chloride - Naloxone - Adenosine

Potassium chloride rationale: Potassium chloride given as an I bolus can cause cardiac arrest. It must be diluted and infused slowly through an IV infusion pump. Saline flush, naloxone, and adenosine are appropriate to be given as an IV bolus undiluted.

Which colors are often included in an organizational disaster plan for use during triage? Select all that apply. - Red - Black - Green - White - Yellow

Red Black Green Yellow rationale: Colors that are often used for triage purposes in an organizational disaster plan include red, black, green, yellow, and blue. White is not a color that is used during the triage process.

In which order would clients receive care based on triage tag color? - Black - Yellow - Green - Red

Red —> Yellow —> Green —> Black rationale: Clients with a red tag generally have life-threatening conditions involving airway obstruction and shock. Red-tagged clients should be seen immediately. Clients who are dead or expected to die are labeled with black tags, are classified as expectant, and are given the lowest priority. Green-tagged clients have minor injuries that can receive treatment within 2 hours and are classified as nonurgent. Clients with yellow tags have injuries or conditions that need treatment within 30 minutes to 2 hours and who can be treated after red-tagged clients.

Which initial action would the nurse take when a toddler with autism spectrum disorder suddenly runs to the wall and starts banging his head on it? - Allow the toddler to act out feelings. - Ask the toddler to stop this behavior. - Restrain the toddler to prevent head injury. - Tell the toddler that the behavior is unacceptable.

Restrain the toddler to prevent head injury rationale: The nurse would restrain the toddler to prevent head injury. The child with autism spectrum disorder needs protection from self-injury. Permitting the child to act out feelings is possible only if the acting out does not place the child in jeopardy. The child with autism spectrum disorder has difficulty following directions, especially when out of control; therefore, asking the toddler to stop this behavior will be ineffective. The child with autism spectrum disorder cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.

Which action is accurate in explaining how neuroleptic medications act in the body to promote mental health for clients diagnosed with schizophrenia? - They inhibit enzymes at the postsynaptic receptor site. - They decrease serotonin at the postsynaptic receptor site. - They increase dopamine uptake at the postsynaptic receptor site. - They block access to dopamine receptors at the postsynaptic receptor site.

They block access to dopamine receptors at the postsynaptic receptor site rationale: Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

Which basic strategy would the nurse teach a health class to reduce the incidence of human immunodeficiency virus (HIV) transmission? Select all that apply. - Using condoms - Using separate toilets - Practicing sexual abstinence - Preventing direct casual contacts - Sterilizing the household utensils

Using condoms, Practicing sexual abstinence rationale: HIV is found in body fluids such as blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, and cerebrospinal fluid. A client should use condoms to prevent contact between the vaginal mucous membranes and semen. Practicing sexual abstinence is the best method to prevent transmission of the virus. The HIV virus is not transmitted by sharing the same toilet facilities, casual contacts such as shaking hands and kissing, or by sharing the same household utensils.

Which response would the nurse provide to a client receiving digoxin who calls the clinic and complains of "yellow vision."? - 'This is related to your illness rather than to your medication.* - "This is an expected side effect; you will become accustomed to it over time." - "This side effect is only temporary. You should continue the medication." - "The medication may need to be discontinued. Come to the clinic this afternoon."

"The medication may need to be discontinued. Come to the clinic this afternoon." rationale: Yellow vision indicates digoxin toxicity; the medication should be withheld until the health care provider can assess the client and check the digoxin blood level. Yellow vision is related to digoxin therapy, not the client's underlying medical condition. Yellow vision is a sign of digoxin toxicity, not a temporary side effect. Taking more digoxin will escalate the digoxin toxicity.

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How many milliliters of medication will the nurse administer?

0.5 mL rationale: The prescribed dose is 250 mg. The available concentration is 500 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine the number of milliliters the nurse would administer. 250 mg x 1 mL/500 mg = 0.5 mL.

Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How many milliliters will the nurse administer?

8 mL rationale: The prescribed dose is 200 mg. The available concentration is 125 mg in 5 mL. Use the dimensional analysis and ratio and proportion methods to determine how many milliliters the nurse would administer. 200 mg x 5 mL/125 mg = 8 mL.

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster? - American Red Cross - Disaster Medical Assistance Team (DMAT) - International Medical-Surgical Response Teams (IMSRTs) - Disaster Mortuary Operational Response Teams (DMORTs)

American Red Cross rationale: The American Red Cross sets up shelters for people who have lost their homes or have been evacuated from their homes after an external disaster. A DMAT provides medical equipment that is sufficient for at least 72 hours. IMSRTs establish fully functional field surgical facilities wherever they are needed in the world. DMORTs manage mass fatalities at the disaster site.

The nurse understands which antihypertensive medication is contraindicated in lactating women? - Atenolol - Labetalol - Metoprolol - Propranolol

Atenolol rationale: Atenolol is contraindicated in lactating woman because it enters the breast milk and may cause adverse effects to the neonate. Labetalol and propranolol are safe to administer during lactation. Metoprolol is considered a safe medication to be taken during lactation.

Which medication of choice would be prescribed for a breast-feeding teenage mother diagnosed with syphilis? - Doxycycline - Tetracycline - Azithromycin - Benzathine penicillin

Benzathine penicillin rationale: Benzathine penicillin is safe to use for syphilis in lactating women. Doxycycline and tetracycline are used in the treatment of syphilis in nonpregnant women. Azithromycin is not the medication of choice for the treatment of syphilis.

Which advice would the nurse include in a teaching plan to reduce the side effects of diltiazem? - Lie down after meals. - Avoid dairy products in diet. - Take the medication with an antacid. - Change slowly from sitting to standing.

Change slowly from sitting to standing. rationale: Changing positions slowly will help prevent the side effect of orthostatic hypotension. Diltiazem decreases esophageal tone, so lying down after meals can lead to acid reflux. Avoiding dairy products and taking the medication with an antacid are not necessary.

For which client illness would airborne precautions be implemented? - Influenza - Chickenpox - Pneumonia - Respiratory syncytial virus

Chickenpox rationale: Chickenpox is known or suspected to be transmitted by air. Diseases that are known or suspected to be transmitted by droplet include influenza and pneumonia. A disease that is known or suspected to be transmitted by direct contact is respiratory syncytial virus.

Which hospital department plays a primary role in disaster preparedness? - Medical department - Surgical department - Emergency department - Mental health department

Emergency department rationale: The emergency department plays a primary role in emergency disaster preparedness. Although all departments in the hospital contribute to disaster planning, the only department that plays a primary role is the emergency department.

Which disaster can be categorized as an internal disaster? - Hurricane in a state - Explosion in a hospital - Earthquake in a country - Flooding in a town

Explosion in a hospital rationale: An internal disaster is any event inside a health care facility or campus that could endanger the safety of clients or staff. An explosion inside a hospital is an example of internal disaster. A hurricane, earthquake, or flooding in a town, all occurring out of the hospital setting but requiring an emergency management plan from the hospital, can be categorized as external disasters.

Which assessment after administration of diltiazem to a client with supraventricular tachycardia (ST) and a heart rate of 170 beats/minute indicates that the medication was effective? - Increased urine output - Blood pressure of 90/60 mm Hg - Heart rate of 98 beats/ minute - No longer complaining of heart palpations

Heart rate of 98 beats/ minute rationale: Diltiazem hydrochloride's purpose is to slow down the heart rate. ST has a heart rate of 150 to 250 beats/minute. A heart rate of 98 beats/minute indicates that the diltiazem hydrochloride is having the desired effect. Increased urine output may occur over a period of time because of the increased ventricular filling time but would not occur until after the heart rate had stabilized. Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palpations is a positive finding but is not present in all clients.

Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? - Shut the client's door during the night. - Apply a vest restraint when the client is in bed. - Leave a dim light on in the client's room at night. - Administer the client's prescribed as-needed sedative medication.

Leave a dim light on in the client's room at night. rationale: The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the dient's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

How will the nurse evaluate the effectiveness of the training after teaching a family member how to administer subcutaneous enoxaparin sodium? - Return demonstration on a manikin. - Verbalization of the side effects of the medication. - Observing the family member administering enoxaparin sodium to the client. - Correctly verbalizing all necessary steps in enoxaparin sodium administration.

Observing the family member administering enoxaparin sodium to the client rationale: The best way to evaluate the effectiveness of the teaching is to observe the family member administering the medication to the client. The family member may be able to perform a subcutaneous injection on a manikin but fear hurting the family member. Knowing the side effects of enoxaparin sodium is important, but it does not provide any information as to the family member's ability to administer the medication. The family member may be able to verbalize all the steps but fear puncturing the skin with the needle.

Which hypothalamic hormone would the nurse identify as helping treat postpartum uterine atony and hemorrhage? - Oxytocin - Indomethacin - Dinoprostone - Methylergonovine

Oxytocin rationale: Oxytocin is a hypothalamic secretory hormone that helps treat postpartum uterine atony and hemorrhage. Indomethacin helps maintain pregnancy in preterm labor. Dinoprostone causes ripening of the cervix during labor. Methylergonovine is an ergot alkaloid that helps treat postpartum uterine atony and hemorrhage.

Which emergency medical service (EMS) health care professional provides advanced life support to the clients who survived a large-scale disaster? - Paramedics - Triage officer - Prehospital care providers - Emergency medical technicians

Paramedics rationale: Paramedics provide advanced life support such as cardiac monitoring and establishing intravenous access to the clients who survived a large-scale disaster. A triage officer rapidly evaluates each client to determine priorities for treatment. Prehospital care providers are the first caregivers that clients see before transport to the emergency department (ED) by an ambulance or helicopter. Emergency medical technicians provide basic life support interventions such as oxygen and basic wound care to the clients who survived large-scale disaster.

Which type of room is best to place a client diagnosed with bipolar I disorder, manic phase? - Private - Isolation - Semi-private - Negative-airflow

Private rationale: The nurse would assign the manic client to a private room. The client who is manic needs a nonstimulating environment. A person who is bipolar is not contagious and does not require an isolation room. The presence of another person in the room is considered stimulating and may interfere with the rest and sleep of both clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a client with a communicable disease, such as tuberculosis, that requires airborne precautions.

Which relationship reflects the relationship of naloxone to morphine sulfate? - Aspirin to warfarin - Amoxicillin to infection - Enoxaparin to dalteparin - Protamine sulfate to heparin

Protamine sulfate to heparin rationale: Protamine sulfate is the antidote for heparin overdose, and naloxone will reverse the effects of opioids such as morphine. Aspirin and warfarin both interfere with coagulation. Although amoxicillin is used to treat some infections, an infection is not a medication, so amoxicillin cannot be considered an antidote. Both enoxaparin and dalteparin are low-molecular-weight heparins.

Which condition would the nurse monitor for in the client on aminoglycoside therapy and skeletal muscle relaxants? - Stroke - Respiratory arrest - Myocardial infarction - Abdominal discomfort

Respiratory arrest rationale: Aminoglycosides can intensify the effect of skeletal muscle relaxants, placing the client at risk for respiratory arrest. Aminoglycoside therapy with muscle relaxants does not increase the risk of stroke, myocardial infarction, or abdominal discomfort.

Which adverse effect will the nurse assess for when caring for a client taking morphine sulfate for severe metastatic bone pain? - Diarrhea - Addiction - Respiratory depression - Diuresis

Respiratory depression rationale: Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Urinary retention, not diuresis, is a common side effect of morphine.

Which agent of terrorism can cause death within a few minutes? - Sarin gas - Uranium - lodine-131 - Mustard gas

Sarin gas rationale: Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by paralyzing respiratory muscles. Uranium and iodine-131 can be dangerous in close proximities but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause death within a few minutes.

Which adverse effect can be seen in a female client with gonadotropin deficiency and who is undergoing hormone replacement therapy? - Thrombosis - Hypotension - Dehydration - Increased thirst

Thrombosis rationale: A female client with gonadotropin deficiency is treated by replacement therapy of combined hormones, namely estrogen and progesterone. The side effect of this therapy is the increased risk of thrombosis or formation of blood clots in deep veins. Hypertension is a side effect of estrogen-progesterone therapy, not hypotension. Dehydration and increased thirst could indicate vasopressin deficiency.

Which situation would indicate the need for naltrexone to be administered? - To treat opioid overdose - To block the systemic effects of cocaine - To decrease the recovering alcoholic's desire to drink - To prevent severe withdrawal symptoms from antianxiety agents

To decrease the recovering alcoholic's desire to drink rationale: Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. It is an opioid antagonist. It is not used for antianxiety agent withdrawal.

Which age group has the highest incidence of lead poisoning? - Adult - Toddler - Adolescent - School-age child

Toddler rationale: The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and because of their increased level of oral activity, put objects into their mouths. Adults have a greater risk of cardiovascular or pulmonary disease. Drowning and motor vehicle accidents are more common among adolescents. Bicycle accidents are more common among school-aged children.

Which side effect will the nurse monitor for when assessing a client who has been receiving fluphenazine for several months? Select all that apply. - Tremors - Excess salivation - Rambling speech - Reluctance to converse - Uncoordinated movement of extremities

Tremors, Uncoordinated movement of extremities rationale: Acute dystonic reactions such as tremors, dyskinesia, and akathisia are observable side effects of fluphenazine therapy. There is a decrease, not an increase, in salivation with fluphenazine therapy. Rambling speech is not a side effect of this medication nor is reluctance to converse.

Which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective?. - Heart rate - Triglycerides - Blood pressure - International normalized ratio (INR)

Triglycerides rationale: Therapeutic effects of simvastatin include decreased levels of serum triglycerides, low-density lipoprotein (LDL), and cholesterol. Heart rate and blood pressure are not related to simvastatin. IN is not related to simvastatin; it is a measure used to evaluate blood coagulation.

A client with a history of schizophrenia, who responds poorly to medication, is now being treated for acute depression. Which informaton would the nurse provide in light of the information elicited from the medication list and laboratory results? Laboratory Results Hemoglobin: 13.5 g/dL Hematocrit: 45%. Red blood cells (RBCs): 48 × 10/ml. Platelet count: 150,000 mm White blood cells (WBCs): 3,500 mm Neutrophils: 100 mm Medications Clozapine Fluoxetine - "Come in for weekly blood tests to monitor for medication-induced agranulocytosis." - "Report incidents of unusual bleeding or easy bruising while taking fluoxetine." - "Expect to be prescribed only 1 week's supply of fluoxetine at a time.* - "Consume a high-protein diet to offset the risk of anemia while taking clozapine.

"Come in for weekly blood tests to monitor for medication-induced agranulocytosis." rationale: The antipsychotic medication clozapine poses a risk for the development of agranulocytosis, especially when combined with a selective serotonin reuptake inhibitor such as fluoxetine. The client's neutrophil and white blood cell counts (WBCs) are borderline and therefore suggestive of the disorder. Weekly blood testing to monitor these blood values is required. The client's platelet count is in the low-normal range, but fluoxetine is not generally considered a factor in bleeding disorders. Clozapine, not fluoxetine, would likely be prescribed on a week-by-week basis to both help manage side effects and encourage weekly visits for lab work. Clozapine is not generally considered a factor in the development of anemia.

Which statement by the client receiving corticosteroids after a bilateral adrenalectomy indicates to the nurse that additional education is needed? - "I need to have periodic tests of my blood for glucose." - "I am glad that I only have to take the medication once a day." - "I must take the medicine with meals." - "I should tell my health care provider if I am overly restless or have trouble sleeping."

"I am glad that I only have to take the medication once a day." rationale: Usually, a larger dose is given at 8:00 AM and the second dose is given before 4:00 PM to mimic expected hormonal secretion and prevent insomnia. Having periodic blood tests for glucose is necessary because long-term administration of steroids leads to elevated blood glucose levels and possible steroid-induced diabetes. Oral corticosteroids should be taken with food or antacids to prevent gastric irritation and gastric hemorrhage. Neurological and emotional side effects, such as euphoria, mood swings, and sleeplessness, are expected.

A client who has been taking the prescribed dose of zolpidem for 5 days returns to the clinic for a follow-up visit. Which statement by the client indicates the medication has been effective? - "I have less pain." - "I have been sleeping better." - "My blood glucose is under control!" - "My blood pressure is coming down."

"I have been sleeping better." rationale: Zolpidem is a sedative-hypnotic that produces central nervous system depression in the limbic, thalamic, and hypothalamic areas of the brain. Zolpidem is not an analgesic, antidiabetic, or antihypertensive medication.

After the nurse provides education about all-terrain vehicle (ATV) safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information? - 'I will have my child ride with an adult! - 'I will make sure my child wears a helmet. - 'I will make sure my child does not get on an ATV! - 'I will make sure my child has had safety training before he or she rides.

'I will make sure my child does not get on an ATV!' rationale: The American Academy of Pediatrics recommends that children under 16 years of age not ride in or operate an ATV. The child should not ride with another adult. When the child is 16 years of age and begins riding an ATV, safety gear such as a helmet should be worn and proper safety training should be implemented.

A client is prescribed 4 mg of hydromorphone intravenously (IV) every 4 hours, as needed. Hydromorphone is supplied at 10 mg/mL. How many milliliters of hydromorphone will the nurse administer per dose?

0.4 mL rationale: The prescribed dose is 4 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse would administer. 4 mg x 1 mL/ 10 mg = 0.4 mg.

At which interval are humidified oxygen systems replaced to prevent infection? - 1 day - 3 days - 5 days - 7 days

1 day rationale: Humidified oxygen delivery needs to be changed out daily to prevent infection. Every 3 to 5 days is too long to wait and may promote infection. Oxygen delivery without humidification will need to be changed out every 7 days.

A client is to receive metoclopramide 15 mg orally before meals. The concentrated solution contains 10 mg/mL. How many milliliters of solution will the nurse administer?

1.5 mL rationale: The prescribed dose is 15 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and or ratio and proportion methods to determine the appropriate amount of medication to be administered. 15 mg x 1mL/10 mg = 1.5 mL.

The nurse needs to administer lidocaine HCl at 1.5 mg per minute. The medication is available as 500 mg in 100 mL of D 5W. The nurse will set the intravenous (IV) infusion pump to deliver how many milliliters per hour?

18 mL/h rationale: The prescribed rate is 1.5 mg/min. The available concentration is 500 mg in 100 mL. Use dimensional analysis and/or ratio and proportion to determine the appropriate rate for the infusion pump. 1.5 mg/1 min x 60 min/1 h x 100 mL/500 mg = 18 mL/h.

Colchicine 1200 mcg orally is prescribed for client with gout. Each tablet contains 0.6 mg. How many tablets will the nurse administer?

2 tablets rationale: The prescribed dose is 1200 mcg. The available medication is a 0.6-mg (600 mcg) tablet. First, convert the prescribed medication to units of the available medication. Then use the dimensional analysis and/or ratio and proportion methods to determine the appropriate number of tablets to be administered. 0.6 mg/ tab x 1000 mcg/ 1 mg = 600 mcg/ tab. 1200 mcg x Itab/ 600 mcg = 2 tabs.

How far would the nurse depress the lower sternum when performing cardiac compression on an adult client? - 0.75 to 1 inch (2-2.5 cm) - 0.5 to 0.75 inch (1.3-2 cm) - 1 to 1.4 inches (2.5-3.6 cm) - 2 to 2.4 inches (5-6 cm)

2 to 2.4 inches (5-6 cm) rationale: Current adult cardiopulmonary resuscitation (CPR) guidelines indicate that the sternum should be depressed at least 2 inches (5 cm) and not more than 2.4 inches (6 cm) to compress the heart adequately between the sternum and vertebrae. In infants, the recommendation is that the sternum is compressed by approximately one-third of the anteroposterior diameter of the chest, which is about 1.5 inches (3.8 cm). In children up to the age of puberty, compressions should be about one-third of the anteroposterior diameter of the chest, which is about 2 inches (5 cm). In postpubertal adolescents, recommended compression depth is at the adult range of 2 to 2.4 inches (5-6 cm).

Nortriptyline is prescribed for a depressed client. Which time period identifies when the nurse would expect a therapeutic response? - 1 to 3 days - 12 to 24 hours - 30 minutes to 2 hours - 2 to 3 weeks

2 to 3 weeks rationale: As with other tricyclics, optimal therapeutic effects take 2 to 3 weeks to occur. One to 3 days, 12 to 24 hours, and 30 minutes to 2 hours are all too soon to expect a response to nortriptyline.

A client has a prescription for 125 mg of phenytoin by mouth three times a day. Phenytoin is supplied as an oral suspension of 25 mg/5 mL. How many milliliters of solution will the nurse administer for each dose?

25 mL rationale: The correct amount of solution to administer at each dose is 25 mL. Solve the problem with the use of ratio and proportion

Acyclovir 0.8 g by mouth is prescribed for a client with herpes zoster. The oral suspension contains 200 mg/5 mL. How many milliliters will the nurse administer?

20 mL rationale: The prescribed dose is 0.8 g (800mg). The available concentration of medication is 200 mg in 5 mL. First, convert the prescribed dose to the available concentration. Then use the dimensional analysis and or ratio and proportion methods to determine the appropriate amount of medication to be administered. 800 mg × 5 mL/200 mg = 20 mL.

Which action would the nurse take for a client who is a psychologist and has questioned the authority of the treatment team and advised other clients that their treatment plans are wrong? - Tell the other clients to disregard what the client is saying. - Ignore the client's disruptive behavior while waiting for it to subside. - Restrict the client's contact with other clients until the disruptive behavior ceases. - Accept that the client is unable to control this behavior while setting appropriate limits.

Accept that the client is unable to control this behavior while setting appropriate limits rationale: The nurse would accept that the client is unable to control this behavior while setting appropriate limits. Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach would not be used until other alternatives have been explored.

Which potential health problem would the nurse include in the young adult's discharge teaching? - Kidney dysfunction - Cardiovascular diseases - Eye problems, such as glaucoma - Accidents, including their prevention

Accidents, including their prevention rationale: Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

Which action would be taken by the nurse caring for a client with type 1 diabetes mellitus who has a finger-stick glucose level of 258 mg/dL (14.3 mol/L) at bedtime and a prescription for sliding-scale regular insulin? - Call the health care provider. - Encourage intake of fluids. - Administer the insulin as prescribed. - Give the client 4 ounces of orange juice.

Administer the insulin as prescribed rationale: A value of 258 mg/dL (14.3 mol/L) is above the expected range of 70 to 100 mg/dL (3.6-5.6 mmol/L); the nurse would administer the regular insulin as prescribed. Calling the health care provider is unnecessary; a prescription for insulin exists and should be implemented. Encouraging the intake of fluids is insufficient to lower a glucose level this high. Giving the client orange juice is contraindicated because this will increase the glucose level further. Orange juice, a complex carbohydrate, and a protein should be given if the glucose level is too low.

Which term does the A of the mnemonic ABCDE of primary nursing survey stand for? - Airway - Allergies - Assessment - Aspiration

Airway rationale: À of the mnemonic ABCDE stands for airway/cervical spine. B stands for breathing. C stands for circulation. D stands for disability. E stands for exposure.

Which action would the nurse confirm before approving a client's transfer to radiology for magnetic resonance imaging (MRI)? - The client received the scheduled preprocedure medications. - All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed. - Infusion of intravenous (IV) fluids completed per the preprocedure hydration protocol. - The client emptied the bladder, donned a gown that which opens in the front, and removed underwear.

All metal objects, such as jewelry, hair ornaments, and clothing containing metal were removed rationale: The client must remove all metal before entering the MRI area because the MRI emits a strong magnetic field. All scheduled medications may not be necessary before the test. Pre-hydration is not necessary for an MRI and may cause interruptions for the client to void. Testing with contrast requires pre-hydration, such as computed tomography scans. The client should have the opportunity to void before going for the test. The direction in which the client's gown opens is not a concern. Underwear is removed only if there are metal objects, such as an underwire bra.

Which intervention would the nurse encourage the parent of a child with plumbism (lead poisoning) to do? - Discourage the child's pica by providing nutritious snacks. - Move the family away from areas that are next to gas stations. - Assess the family's home environment for lead sources and have them-removed. - Have the child take repeat x-rays of the wrist and forearm for signs of a lead line.

Assess the family's home environment for lead sources and have them-removed rationale: All sources of lead must be removed from the home if the problem is to be controlled. Sources include lead-painted surfaces and old plumbing that has lead solder. Although pica must be controlled if it is present, this alone will not eliminate the environmental risks. The data do not indicate that the child is engaging in pica. Leaded gasoline is no longer used in the United States. Chelation therapy is based on the blood lead level; changes in bone take longer to evaluate.

Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. - Asthma - Hay fever - Sarcoidosis - Myasthenia gravis - Rheumatoid arthritis

Asthma, Hay fever rationale: Clinical conditions such as asthma and hay fever are considered type I hypersensitive reactions that are mediated by a reaction between IgE antibodies with antigens. It results in the release of mediators such as histamines. Type IV hypersensitivity reactions such as sarcoidosis result from reactions between sensitized T cells with antigens. Myasthenia gravis results from a type II hypersensitivity reaction that occurs due to an interaction between immunoglobulin IgG and the host cell membrane. Rheumatoid arthritis is a type III hypersensitivity reaction that results from the formation of immune complexes between antigens and antibodies that results in inflammation.

Which complication would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries? - Hemorrhage - Hypovolemic shock - Gastrointestinal atony - Autonomic hyperreflexia

Autonomic hyperreflexia rationale: Autonomic hyperreflexia, an uninhibited and exaggerated response of the autonomic nervous system to stimulation, results in a blood pressure greater than 200 mm Hg systolic; it is a medical emergency. Although hemorrhage and hypovolemic shock could occur from the trauma, the scenario stated that no other injuries occurred. Although gastrointestinal atony can result from immobility, it is not a medical emergency.

Which instructions would the nurse share with the client being discharged after rhinoplasty? - Avoid items that may trigger sneezing. - Consume fluids at a tepid temperature. - Brush the teeth thoroughly after each food intake. - Sleep on the back using one pillow under the head

Avoid items that may trigger sneezing. rationale: Sneezing involves high pressures in the respiratory passageways during the expulsive phase of a sneeze; this can disrupt sutures or alignment of bone, promoting bleeding, and therefore should be avoided. Fluids that are soothing for the client are given at any temperature; cool or warm temperatures usually are preferred. Brushing teeth after any intake is not a necessity; the client's regular routine may be followed. Sleeping on the back with one pillow promotes the accumulation of facial edema and possible aspiration of drainage; the semi-Fowler position is preferred

Which required noninvasive assessment and management skills certification would the nurse need to perform airway maintenance and cardiopulmonary resuscitation (CPR)? - Basic Life Support (BLS) - Certified Emergency Nurse (CEN) - Advanced Cardiac Life Support (ACLS) - Pediatric Advanced Life Support (PALS)

Basic Life Support (BLS) rationale: BLS is the certification for emergency nursing that includes assessment and management skills for airway maintenance and CPR. CEN is emergency nursing certification that validates the core emergency nursing knowledge base. ACLS involves invasive airway management skills, pharmacology, electrical therapies, and special resuscitation. PALS involves neonatal and pediatric resuscitation.

Which medication used to treat acne has a bleaching effect? - Isotretinoin - Minocycline - Tetracycline - Benzoyl peroxide

Benzoyl peroxide rationale: Benzoyl peroxide has a bleaching effect on sheets, bedclothes, and towels. Isotretinoin is associated with photosensitivity, nasal irritation, dry skin and mucous membrane. Minocycline and tetracycline are systemic antibiotics that may cause photosensitivity reactions, vaginal candidiasis, and gastrointestinal upset.

A client receiving fluphenazine decanoate develops dystonia early in therapy. Which medication would the nurse anticipate administering to reverse this side effect? - Nafarelin - Fluoxetine - Trandolapril - Benztropine

Benztropine rationale: Dystonia is an extrapyramidal side effect (EPS) of fluphenazine decanoate. The anticholinergic benztropine is used to reverse the signs and symptoms (e.g., oculogyric crisis, torticollis, retrocollis) of dystonia. Nafarelin is a gonadotropin that stimulates the release of luteinizing hormone and follicle-stimulating hormone. Fluoxetine is a selective serotonin reuptake inhibitor antidepressant. Trandolapril is an angiotensin-converting enzyme inhibitor antihypertensive.

Which color tag is assigned the lowest priority for care in a mass casualty event? - Red - Black - Green - Yellow

Black rationale: Clients with black tags are expected to die or are already dead; therefore, these clients are the lowest priority. The first priority should be given for clients with a red tag because the client's life may be saved with immediate treatment. A client with a yellow tag should be given second priority because she or he can wait for the treatment for some time. A client with a green tag can be given care after some time, because her or his condition would be stable.

Which patient condition would contraindicate the use of the medication clozapine? - Seizures - Glaucoma - Dysrhythmias - Bone marrow depression

Bone marrow depression rationale: Clozapine is an atypical antipsychotic medication that is contraindicated in clients with bone marrow depression. Clozapine should be used with caution in clients with seizures. First-generation antipsychotics should be used with caution in clients with glaucoma. Ziprasidone is contraindicated in clients with a history of dysrhythmias.

Which condition would be a contraindication to electroconvulsive therapy (ECT)? - Brain tumor - Type 1 diabetes - Hypothyroid disorder - Urinary tract infection

Brain tumor rationale: ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroidism, or urinary tract infection.

When planning for a client's care during the detoxification phase of early alcohol withdrawal, which action would the nurse take? - Check on the client frequently. - Keep the client's room lights dim. - Address the client in a loud, clear voice. - Restrain the client during periods of agitation.

Check on the client frequently rationale: The nurse would check on the client frequently. During detoxification, frequent checks help ensure safety. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of early alcohol withdrawal usually does not lose the sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to self or others.

To which disaster triage class would the nurse infer a client with a green triage tag belongs? - Class I - Class II - Class III - Class IV

Class III rationale: The green disaster triage tag is issued to nonurgent or walking-wounded' clients who belong to class III. A red disaster triage tag is issued to clients who require immediate treatment and belong to class I. Clients with yellow and black tags belong to class II and IV respectively.

Which benefit would be provided by administering patient-controlled analgesia (PCA) to a client after surgery? Select all that apply. - Client is able to self-administer pain-relieving medications as necessary - Amount of medication received is determined entirely by the client - Decreases client dependency - Relieves the nurse of monitoring the client - Increases client sense of autonomy

Client is able to self-administer pain-relieving medications as necessary, Decreases client dependency, Increases client sense of autonomy rationale: The purpose of patient-controlled analgesia is to give the client the ability to self-administer pain-relieving medications as necessary; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Medication levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. The client isn't dependent on the nurse availability to administer medication. This increases the client's sense of autonomy. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with the prescribed narcotic, and charting the amount administered and the client's response are required.

Which medication used to promote fertility would the nurse identify as a potential cause of esophageal burns? - Estrogen - Clomiphene - Nifedipine - Indomethacin

Clomiphene rationale: Clomiphene is a serum selective receptor modulator that may cause esophageal burns. Estrogen may cause a thromboembolism. Nifedipine may cause maternal-fetal problems. Indomethacin may cause birth defects.

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary health care provider prescribes the anticholinergic medication benztropine, 2 mg daily. Which symptom should the nurse should inquire about when assessing the client? - Constipation - Hypertension - Increased salivation - Excessive perspiration

Constipation rationale: The anticholinergic activity of each medication is magnified, and adverse effects such as paralytic ileus may occur. Hypotension, not hypertension, occurs with anticholinergic medications. Dryness of the mouth, not increased salivation, occurs with anticholinergic medications. Decreased, not increased, perspiration occurs with anticholinergic medications.

A child becomes cyanotic during a generalized tonic-clonic seizure. Which action would the nurse take? - Insert an oral airway - Administer oxygen (O 2) by mask - Continue to observe the seizure - Notify the health care provider immediately

Continue to observe the seizure rationale: The child's status and the progression of the seizure should be monitored: the child will not breathe until the seizure is over, and cyanosis should subside at that time. Attempting to open a clenched jaw may result in injury to the child. O 2 is useless until the child breathes when the seizure is over. The health care provider may be notified later; provisions for the child's safety and observation are the priorities.

A 2-year-old toddler is to have intravenous (IV) antibiotic therapy. Which action will the nurse take to prevent the child from pulling out the IV line? - Keep the arms restrained. - Tell the child not to touch the IV site. - Cover the IV site with a protective device. - Have the parent hold the child continuously.

Cover the IV site with a protective device. rationale: Restraints are a last resort; they cause more anxiety and agitation as the child attempts to get free. Verbal instructions are not sufficient for a 2-year-old child. Securing the IV site and putting protection around it decreases the likelihood that the IV line will be pulled out. Although the family should be involved in care, the staff, not the family, is responsible for preventing the child from pulling out the IV line.

Which assessment finding indicates an improvement when the nurse is evaluating the results of treatment with erythropoietin? - 2+ pedal pulses - Decreased pallor - Decreased jaundice - 2+ deep tendon reflexes

Decreased pallor rationale: Erythropoietin stimulates red blood cell production, thereby decreasing the pallor that accompanies anemia. It would not have an appreciable effect on pulses or deep tendon reflexes. It would not have a role in alleviating jaundice.

Which medication would a nurse suspect is the cause of severe nausea and a heartbeat that is irregular and slow in a client who takes multiple medications? - Digoxin - Captopril - Furosemide - Morphine sulfate

Digoxin rationale: Signs of digoxin toxicity include nausea, vomiting, cardiac dysrhythmias, anorexia, and visual disturbances. Although nausea and heart block may occur with captopril, these symptoms rarely are seen; drowsiness and central nervous system disturbances are more common. Toxic effects of morphine are slow, deep respirations, stupor, and constricted pupils; nausea is a side effect, not a toxic effect. Toxic effects of furosemide are renal failure, blood dyscrasias, and loss of hearing.

Which report by the client post transrectal prostate biopsy needs to be communicated to the health care provider as a possible sign of infection? - Soreness - Rust-colored semen - Light rectal bleeding - Discharge from the penis

Discharge from the penis rationale: Discharge from the penis should be communicated to the health care provider for possible infection because discharge is an indication of infection. Soreness, rust-colored semen, and light rectal bleeding are expected after transrectal prostate biopsy.

Which symptom would the nurse include when teaching a client with arthritis who takes large doses of aspirin about the clinical manifestations of aspirin toxicity? - Feelings of drowsiness - Disturbances in hearing - Intermittent constipation - Metallic taste in the mouth

Disturbances in hearing rationale: Ringing in the ears occurs because of aspirin's effect on the eighth cranial nerve and is a classic symptom of aspirin toxicity. Feelings of drowsiness are not side effects of aspirin; aspirin promotes comfort, which may permit rest. Aspirin may cause diarrhea, nausea, and vomiting, not intermittent constipation. A metallic taste in the mouth is not a side effect of salicylates such as aspirin.

Which medication is associated with sedation as a side effect? Select all that apply. - Doxepin - Zaleplon - Suvorexant - Nefazodone - Mirtazapine - Clonazepam

Doxepin, Zaleplon, Suvorexant, Nefazodone, Mirtazapine, Clonazepam rationale: Doxepin is a low-dose formulation of an old tricyclic antidepressant that is indicated for the treatment of insomnia. Zaleplon is a Z-hypnotic often prescribed for insomnia. Suvorexant is an orexin receptor agonist that can cause daytime sleep and sleep paralysis. Nefazodone is a serotonin blocker indicated for depression that causes sedation. Mirtazapine blocks adrenergic receptors to improve sleep. The most common side effects are sedation and weight gain. Clonazepam is a benzodiazepine. All benzodiazepines can cause sedation at higher therapeutic doses

What step should a nurse take when preparing to administer Rho(D) immune globulin to a postpartum client? - Start a primary intravenous (IV) line so that the medication may be administered via IV piggyback. - Ensure that the client is Rh negative and the neonate is Rh positive. - Obtain a syringe and needle appropriate for the subcutaneous injection. - Determine that the client has not eaten since midnight of the previous night.

Ensure that the client is Rh negative and the neonate is Rh positive. rationale: Rho(D) immune globulin is given to Rh-negative mothers not previously sensitized who have Rh-positive neonates; it prevents Rh incompatibility in the next pregnancy. RhoD) immune globulin is administered intramuscularly, not intravenously or subcutaneously. There is no need for the client to fast; the client may eat and drink before receiving this medication

Which entity is responsible for activating the disaster plan during a mass casualty incident (MCI)? - Local emergency management system - State emergency management system - Federal emergency management agency - Hospital-level emergency management system

Federal emergency management agency rationale: Response to MCIs often requires the aid of a federal agency. The National Incident Management System (NIMS) is a section within the U.S. Department of Homeland Security. NIMS is responsible for coordinating federal, state, and local government efforts to respond to and manage domestic MCs. Local emergency management systems may communicate with the hospital from the field to determine how many clients the hospital can accept.

Which color tag would the nurse use to triage a victim of a train derailment who is able to walk independently to the first aid station? - Red - Black - Green - Yellow

Green rationale: An emergency triage system uses colored tags to designate both the seriousness of the injury and the likelihood of survival. Green would be used for minor injuries such as the victim who is able to ambulate independently. Red indicates life-threatening injuries requiring immediate attention. Black indicates that the victim is expected to die. Yellow indicates urgent but not life-threatening injuries.

Which color tag would be given to walking wounded' clients according to the disaster triage tag system? - Red - Black - Green - Yellow

Green rationale: Green tagged clients are referred to as walking wounded because they may evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Clients with life-threatening conditions that need immediate treatment are given red tags. Black-tagged clients are expected to die or may be dead. Clients with major injuries are tagged with yellow. They may require urgent treatment but can wait a short time for care because their injuries are not life threatening.

Which action would the nurse perform first when a health care provider prescribes milrinone for a client with congestive heart failure? - Administer the loading dose over 10 minutes. - Monitor the electrocardiogram (ECG) continuously for dysrhythmias during infusion. - Assess the heart rate and blood pressure continuously during infusion. - Have the prescription, dosage calculations, and pump settings checked by a second nurse.

Have the prescription, dosage calculations, and pump settings checked by a second nurse. rationale: Accidental overdose can cause death. Another nurse would verify accuracy of the prescription, dose, and pump settings to prevent harm to the client. Although administering the loading dose over 10 minutes is an appropriate intervention, it is not the first thing the nurse would do. Although monitoring for dysrhythmias is important because they are common with this medication and may be life threatening, it is not the first thing the nurse would do. Although taking the vital signs continuously during the infusion is important because the dose needs are slowed or discontinued if the blood pressure decreases excessively, it is not the first thing the nurse would do.

Which emotions should the nurse be especially alert to in order to further assess a client's suicidal potential? - Anger and resentment - Loneliness and anxiety - Frustration and fear of death - Helplessness and hopelessness

Helplessness and hopelessness rationale: The nurse would assess for helplessness and hopelessness. The expression of helplessness and hopelessness may indicate that this client is unable to continue the struggle of life. Anger and resentment are not indications of potential suicide; the client is still responding to the world, not attempting to leave it. Loneliness and anxiety are usually not sufficient to precipitate a suicide attempt. The client attempting suicide usually sees death as a release and does not fear death. Frustration indicates the client is responding to experiences and emotions.

A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor? - Sepsis - Phlebitis - Hemorrhage - Leakage around urinary catheter

Hemorrhage rationale: After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Sepsis is unusual, and if it occurs, it will manifest later in the postoperative course. The nurse assesses for phlebitis, but phlebitis is not the most important complication. Hemorrhage is more important than phlebitis. Leaking around the urinary catheter is not as major as hemorrhage.

Which disease is caused by the virus that causes chickenpox? - Athlete's foot - Herpes zoster - German measles - Infectious hepatitis

Herpes zoster rationale: Invasion of the posterior (dorsal) root ganglia by the same virus that causes chickenpox can result in herpes zoster, or shingles. This may be caused by reactivation of a previous chickenpox virus that has lain dormant in the body or by recent contact with an individual who has chickenpox. Athlete's foot is caused by a fungus. German measles is caused by a virus, but not the herpes virus. Hepatitis type A is caused by a virus, but not the herpes virus.

Which primary advantage applies to the use of fluphenazine for treatment of schizophrenia? - There are no side effects. - It has a long-lasting effect. - There is less need for laboratory monitoring. - It is safe to use during pregnancy.

It has a long-lasting effect. rationale: Fluphenazine may be taken every 2 weeks instead of every day. The side effects and routine monitoring of the client's laboratory results are the same as for most other antipsychotic medications. The action of fluphenazine during pregnancy is uncertain; animal studies have demonstrated an adverse effect on the fetus.

Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior? - Keeping the child from inflicting any self-injury - Assisting the child to improve communication skills - Helping the child formulate realistic ego boundaries - Providing the child with opportunities to discharge energy

Keeping the child from inflicting any self-injury rationale: The nursing objective is to keep the child from inflicting any self-injury. All nursing care would be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills are important, this is usually not an issue with ADHD. Although formulation of realistic ego boundaries is important, it is not the priority. Opportunities to discharge energy are important, but prevention of injury is the priority.

Which functional level of trauma center is involved in providing a full continuum of trauma services? - Level I - Level lI - Level IlI - Level IV

Level I rationale: Level I trauma centers provide a full continuum of trauma services for all clients. Level II trauma centers provide care for most injured clients. Level Ill centers are able to stabilize clients with major injuries, but must transport clients if needs exceed resource capabilities. Level IV trauma centers are usually involved in providing basic trauma client stabilization and advanced life support within the resource capabilities. They are also responsible for the transfer of clients if need exceeds the resource competencies.

Which disaster management team provides voluntary medical service to people? - Medical Reserve Corps (MRC) - Disaster Medical Assistance Team (DMAT) - National Veterinary Response Teams (NVRT) - Disaster Mortuary Operational Response Teams (DMORT)

Medical Reserve Corps (MRC) rationale: MRCs are groups of volunteers, consisting of medical and public health professionals, who offer voluntary support and aid during disaster management. DMAT, NVRT and DMORT are part of the National Disaster Medical System (NDMS), which deploys personnel from other regions.

Which emergency medical service agency offers service such as first aid stations and special-need shelters during a disaster or pandemic disease outbreak? - Medical Reserve Corps (MRC) - National Disaster Medical System (NDMS) - Disaster Medical Assistance Team (DMAT) - Federal Emergency Management Agency (FEMA)

Medical Reserve Corps (MRC) rationale: The MRC may help staff hospitals or community health settings that face shortages and provide first aid stations or special-need shelters. The NDMS manages mass fatalities, emergency animal care, and establishes fully functional field surgical facilities. A DMAT is a medical relief team deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. FEMA provides Community Emergency Response Team (CERT) training so that people are better prepared for disasters and hazard situations in their own communities.

Where is the blood pressure cuff placed on a client with a dialysis access fistula in the right arm? - On the left arm - Over the fistula - Below the fistula - Above the fistula

On the left arm rationale: If the fistula is located in the right arm, then the left arm should be used for blood pressure cuff placement. Blood pressure cuffs or any other restrictive devices should not be placed on the arm with a dialysis access fistula including above, below, or over the fistula site.

A client in active labor who is 90% effaced, 7 cm dilated with the vertex presenting at 2+ station, complains of pain and asks for medication. Which medication would the nurse anticipate causing respiratory depression in the newborn? - Naloxone - Lorazepam - Meperidine - Promethazine

Meperidine rationale: Meperidine is an opioid that can cause respiratory depression in the neonate if administered less than 4 hours before birth. Naloxone is an opioid antagonist that reverses the effects of respiratory depression in the newborn. Lorazepam is a sedative; it does not cause respiratory depression in the newborn, but it does not relieve pain by itself. Promethazine is a tranquilizer; it does not cause respiratory depression in the newborn. Promethazine does not relieve pain by itself.

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site? - Sterile saline - Steroid cream - Oil-based lubricant - Mild soap and water

Mild soap and water rationale: Mild soap and water are used to cleanse the stoma site. Sterile saline, a humidifier, or pans of water can be used to humidify the air entering the stoma. There is no need to use steroid cream at the site unless instructed by the health care provider. Non-oil-based, rather than oil-based, lubricants can be used as needed for lubrication of the site

Which medication for treatment of gastrosophageal reflux disease would be contraindicated in the pregnant client? - Ranitidine - Misoprostol - Esomeprazole - Calcium carbonate

Misoprostol rationale: Misoprostol is contraindicated in pregnancy because it can cause uterine contractions, expelling the developing fetus. Ranitidine, esomeprazole, and calcium carbonate are not contraindicated during pregnancy.

Which medication is indicated to treat shift-work sleep disorder (SWSD)? - Caffeine - Modafinil - Atomoxetine - Methylphenidate

Modafinil rationale: Modafinil is a unique nonamphetamine stimulant used to treat SWSD. This medication promotes wakefulness in clients suffering from excessive sleepiness associated with SWSD. Caffeine is a central nervous stimulant used to promote wakefulness, but this medication is not as effective in the treatment of SWSD. Atomoxetine is a nonstimulant used to treat attention-deficit/hyperactivity disorder (ADHD). Methylphenidate is considered a first-choice medication for the treatment of ADHD.

A health care provider prescribes methylphenidate for a child with attention-deficit/hyperactivity disorder (ADHD). Which instruction would the nurse provide when teaching the parents about this medication? - Monitor the effect of the medication on their child's behavior. - Increase or decrease the dosage, depending on the child's behavior. - Avoid imposing too many rules, because this will frustrate the child. - Reinforce to the child that behavior can be controlled.

Monitor the effect of the medication on their child's behavior. rationale: By monitoring and reporting changes in the child's behavior, the health care provider can determine the effectiveness of the medication. Dosage changes are the responsibility of the health care provider. Children need structure and rules; they provide a sense of security. Behavior is not deliberate or controllable; this statement may diminish the child's self-esteem if he or she cannot exert control.

Which action would be taken when the nurse observes a client who is experiencing a seizure while making rounds? - Hyperextend the client's neck - Move obstacles away from the client - Restrain the client's body movements - Attempt to place an airway in the client's mouth

Move obstacles away from the client rationale: Moving obstacles away from the client helps the client avoid hitting objects and thus prevents trauma during the tonic-clonic phase of the seizure. Hyperextending the neck is contraindicated; it may injure the client. Restraining the client's body movements is contraindicated; it may injure the client. Attempting to place an airway in the client's mouth during the tonic-clonic phase of the seizure can cause injury.

Which medication is indicated for management of clinical manifestations associated with an opioid overdose? - Naloxone - Methadone - Epinephrine - Amphetamine

Naloxone rationale: Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.

Which type of needs would the nurse identify as a high priority in the prioritization of client care? - Developmental needs - Long-term care needs - Potential needs in care - Needs that affect safety

Needs that affect safety rationale: Needs related to survival and safety are the highest priority because these are an immediate threat to client health. Developmental needs and long-term care needs are low priority when prioritizing care because they are not an immediate threat to health. Potential needs in care are intermediate priority because they are best addressed before complications follow.

Which type of behavior exhibited by a patient would haloperidol most effectively treat? - Depressed - Overactive - Withdrawn - Manipulative

Overactive rationale: Haloperidol reduces emotional tension, excessive psychomotor activity, panic, and fear. It is used for clients with thought disorders and hyperactivity. Clients exhibiting excited-depressed behavior do not respond well to haloperidol, because it tends to worsen the depression. Haloperidol appears to have few stimulating effects for a withdrawn client and, in fact, increases feelings of lassitude and fatigue. Haloperidol does not decrease manipulative behavior. Clients who are capable of manipulation usually do not exhibit behavior that involves overactivity, fear, and panic.

Which preferred medication of choice would be prescribed for the treatment of syphilis in a pregnant adolescent? - Penicillin G - Doxycycline - Tetracycline - Erythromycin

Penicillin G rationale: According to the Centers for Disease Control and Prevention, penicillin G is the preferred medication of choice for any stage of syphilis in pregnant women. Both doxycycline and tetracycline are contraindicated during pregnancy. Erythromycin may not be able to cure a fetal infection.

Which effect has resulted in the avoidance of tetracycline use in children under 8 years old? - Birth defects - Allergic responses - Severe nausea and vomiting - Permanent tooth discoloration

Permanent tooth discoloration rationale: Tetracycline use in children under the age of 8 years has been discontinued because it causes permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting are not prevalent reasons for the discontinuation of tetracycline medications in children under 8 years old.

Which statement correctly characterizes pregnancy in the adolescent population? Select all that apply. - Pregnant adolescents often seek out less prenatal care. - Infants of teen mothers are at risk of delivering babies late. - Adolescent mothers need competent daycare for their infants. - Infants of adolescent mothers are at increased risk for prematurity. - Fetuses of adolescent mothers are at higher risk for chromosomal defects.

Pregnant adolescents often seek out less prenatal care, Adolescent mothers need competent daycare for their infants, Infants of adolescent mothers are at increased risk for prematurity rationale: Pregnant adolescents are less likely to seek out prenatal care. Adolescent mothers need competent daycare for their infants. Infants born to teen mothers are at risk of being born prematurely. Pregnancies in older mothers are at greater risk for chromosomal defects.

A client with a diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine medication. Which action is important for the nurse to take to assist this client when the psychiatric daycare center plans a fishing trip? - Provide the client with sunscreen. - Caution the client to limit exertion during the trip. - Give the client an extra dose of medication to take after lunch. - Take the client's blood pressure before allowing participation in the outing.

Provide the client with sunscreen rationale: Phenothiazines commonly cause a photosensitivity that can be controlled with sunscreen. Limiting activity is not a necessary precaution when phenothiazines are prescribed. The medication must be administered as prescribed. Participating in the outing should not negatively affect the client's blood pressure.

Which team member acts as a liaison between the health care facility and the media? - Triage officer - Public information officer - Medical command physician - Hospital incident commander

Public information officer rationale: The public information officer acts as a liaison between the health care facility and the media. The triage officer applies disaster triage tags after evaluating the client's condition. The medical command physician decides the number, acuity, and resource needs of clients. The hospital incident commander assumes overall leadership for implementing the emergency plan.

Which medication action would the nurse identify as the purpose of azathioprine, cyclosporine, and prednisone given before receiving a kidney transplant? - Stimulate leukocytosis - Provide passive immunity - Prevent iatrogenic infection - Reduce antibody production

Reduce antibody production rationale: These drugs suppress the immune system, decreasing the body's production of antibodies in response to the new organ, which acts as an antigen. These medications decrease the risk of rejection. These medications inhibit leukocytosis. These medications do not provide immunity; they interfere with natural immune responses. Because these medications suppress the immune system, they increase the risk of infection.

A client has been prescribed lithium. Which intervention must be implemented while the client is on lithium therapy? - Restricting the client's daily sodium intake - Testing the client's urine specific gravity weekly - Regularly testing the serum medication level - Withholding the client's other medications for several days

Regularly testing the serum medication level rationale: Lithium alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines. Because the range between therapeutic and toxic levels is very slim, the client's serum lithium level should be monitored closely. Sodium restriction may cause electrolyte imbalance and lithium toxicity. Weekly testing of the client's urine specific gravity is not necessary or useful. Withholding the client's other medications for several days may or may not be necessary; it depends on what the client is receiving; also, it requires a primary health care provider's prescription.

Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? - Safety within the environment - Enhancement of psychological faculties - Participation in educational activities - Face-to-face contact with other clients

Safety within the environment rationale: Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.

Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? - Sets limits - Has variety - Is group oriented - Allows freedom of expression

Sets limits rationale: The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.

Which action transmits the human immunodeficiency virus (HIV)? Select all that apply. - Multiple mosquito bites - Sharing syringe needles - Breast-feeding a newborn - Dry kissing an infected individual - Anal intercourse - Sharing drinking glasses

Sharing syringe needles Breast-feeding a newborn Anal intercourse rationale: Fluids such as blood and semen are highly concentrated with HIV. HIV may be transmitted parenterally by sharing needles and postnatally through breast milk. HIV may also be transmitted through anal intercourse. HIV is not transmitted by mosquito bites, dry kissing, or sharing of drinking glasses. Deep kissing involving a large amount of salvia does transmit HIV.

Which action would the nurse take first if an allergic reaction to a blood transfusion occurs? - Shut off the infusion. - Slow the rate of flow. - Administer an antihistamine. - Call the health care provider (HCP).

Shut off the infusion rationale: The client is experiencing an allergic reaction, and the infusion must be stopped immediately to prevent serious complications. Slowing the rate of infusion will not halt the allergic reaction to the transfused blood. Administering an antihistamine is dangerous as an initial action because the degree of allergic reaction cannot be determined at this time. Also, it requires an HCP's prescription. The HCP should be notified after the infusion has been stopped.

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? - Good cry - Grimace - Absent respiration - Slow, weak cry

Slow, weak cry rationale: A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system.

Which characteristic can be observed in abusive parents? Select all that apply. - Social isolation - Poor coping skills - Family authoritarianism - Feeling of no control over life - Inability to seek help from others - Expects child to satisfy needs for love

Social isolation Poor coping skills Family authoritarianism Feeling of no control over life Inability to seek help from others Expects child to satisfy needs for love rationale: Social isolation, poor coping skills, family authoritarianism, feeling of no control over life, inability to seek help from others, and expecting the child to satisfy needs for love, support, and reassurance are all characteristics of abusive parents.

Which intervention is the best approach to condom use for prevention of sexually transmitted infection? - Use of spermicide - Use of oil-based lubricants - Use of a condom with oral sex - Use of natural membrane condoms

Use of a condom with oral sex rationale: Condoms should be used with all sexual encounters, including oral sex, to reduce sexually transmitted infection. There is no evidence that spermicides prevent sexually transmitted infection. Oil-based lubricants can break down latex condoms permitting the transfer of disease. Natural membranes condoms allow the transfer of some infections.

Which clinical manifestations indicate a client who sustained head and chest injuries from a motor vehicle accident, responded to medical treatments, and is ready for transfer to a critical care unit? - Stabilized vital signs and complaints of pain - Pale and alert; remains restless - Increasing temperature and apprehension - Fluctuating vital signs and drowsy, but easily roused

Stabilized vital signs and complaints of pain rationale: Stable vital signs is the major indicator predicting transfer will not jeopardize the client's condition. Although complaints of pain are a concern, they do not place the client in physiologic jeopardy. Restlessness and pallor may be early signs of shock; the client needs further assessment. An increasing temperature is a sign of increasing intracranial pressure; delay transfer of the client at this time. Fluctuating vital signs and drowsiness indicate an unstable client with potentially increasing intracranial pressures.

Which action would be appropriate to implement when collecting a 24-hour urine test? - Start the time of the test after discarding the first voiding. - Discard the last voiding in the 24-hour period for the test. - Insert a urinary retention catheter to promote the collection of urine. - Strain the urine after each voiding before adding the urine to the container.

Start the time of the test after discarding the first voiding. rationale: The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour period for the test is not necessary; voided specimens are acceptable. Inserting a urinary retention catheter is not a standard step. Straining the urine after each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi.

Which action will the nurse take during administration of blood products to ensure the client's safety? - Stay with client during first 15 minutes of infusion. - Flush packed red blood cells with 5% dextrose and 0.45% normal saline. - Remove the intravenous catheter if a blood transfusion reaction occurs. -Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

Stay with client during first 15 minutes of infusion rationale: The nurse would remain with the client for the first 15 to 30 minutes. Any severe reaction usually occurs with the infusion of the first 50 mL of blood. Normal saline is the solution to administer with blood productions. Lactated Ringer and dextrose in water are not used for infusion because of hemolvsis. Removal of the catheter is not necessary if a blood transfusion reaction occurs, that intravenous access may be needed for fluids and medication. Blood components are viscous, requiring a large needle to be used for venous access. A 20-gauge needle is not used to access a central catheter line.

Which condition poses an increased risk for injury for an adolescent? Select all that apply. - Poisoning - Abduction - Home accidents - Substance abuse - Motor vehicle accidents

Substance abuse Motor vehicle accidents rationale: Substance abuse and motor vehicle accidents pose an increased risk of injury among adolescents. Poisoning and child abduction are more common among toddlers and preschoolers. Home accidents are common among toddlers as well.

Which site would the nurse assess first for the amount of drainage from a client discharged from the postanesthesia care unit (PACU)? - Foley catheter - Nasogastric tube - Intravenous (IV) catheter - Surgical incision

Surgical incision rationale: Reviewing the amount of drainage on the dressing of a client is an observation the nurse would make when reviewing the surgical incision site. Focused assessment of the Foley catheter and the nasogastric tube should be made when observing tubes attached to a client after an operation. When a client is receiving IV fluids, the nurse would check the catheter insertion site.

client with schizophrenia is given an antipsychotic medication. Which adverse effect would lead to this medication being discontinued? - Akathisia - Tardive dyskinesia - Parkinsonian syndrome - Acute dystonic reaction

Tardive dyskinesia rationale: Tardive dyskinesia is characterized by protrusion and vermicular movements of the tongue, chewing and puckering movements of the mouth, and a puffing of the cheeks. These adverse effects may or may not be reversible when the antipsychotic medication is withdrawn. Motor restlessness (akathisia), parkinsonian symptoms, or an acute dystonic reaction can be treated with an antiparkinsonian or anticholinergic medication while the antipsychotic medication is continued.

Which precaution will the nurse consider when initiating treatment with fluoxetine? - It must be given with milk and crackers to prevent hyperacidity and discomfort. - Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. - The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. - The blood level should be checked weekly for 3 months to make sure it is appropriate.

The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks rationale: Fluoxetine does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese; pickled herring, and wine is a precaution taken with monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.

For which circumstance would the nurse use the Z-track technique to administer a medication? - A large volume of medication needs to be administered. - The medication is irritating to subcutaneous tissue and skin. - A depot medication is prescribed. - The medication is lipophilic.

The medication is irritating to subcutaneous tissue and skin. rationale: The Z-track method seals the puncture at the intramuscular level, preventing seepage of irritating medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. The Z-track technique is not required for administration of depot medications. Whether or not a medication is lipophilic has no bearing on the need for using the Z-track technique.

Which reason explains why so many psychiatric clients are given benztropine or trihexyphenidyl in conjunction with phenothiazine-derivative neuroleptic medications? - They reduce postural hypotension. - They potentiate the effects of the neuroleptic medication. - They combat the extrapyramidal side effects of the neuroleptic medication. - They ameliorate the depression that may accompany schizophrenia.

They combat the extrapyramidal side effects of the neuroleptic medication rationale: Benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian medications. These medications do not reduce postural hypotension, nor do they potentiate phenothiazine derivatives or have an effect on depression.

A client who has been taking a conventional antipsychotic for several days comes to the clinic complaining of neck spasms. The figure illustrates the client's physical status observed by the nurse. What extrapyramidal side effect has the client developed? - Torticollis - Tardive dyskinesia - Pseudoparkinsonism - Neuroleptic malignant syndrome

Torticollis rationale: Torticollis is an acute dystonia that involves muscle spasms of the head and neck. It develops within 1 to 5 days after beginning therapy with a conventional antipsychotic. Tardive dyskinesia causes involuntary, repetitious tonic muscular spasms that involve the face, tongue, lips, limbs, and trunk. Tardive dyskinesia takes several months to years to develop after the start of therapy with a conventional antipsychotio. Pseudoparkinsonism is an extrapyramidal tract response that includes masklike facies, shuffling gait, pill-rolling tremors, stooped posture, and drooling. Pseudoparkinsonism develops within several days to 1 month after the start of therapy with a conventional antipsychotic. Neuroleptic malignant syndrome is a severe, potentially fatal (10%) response to conventional antipsychotics. It is believed to be caused by an acute reduction in brain dopamine activity, precipitating hyperthermia, tachycardia, tachypnea, unstable blood pressure, hypertonicity, dyskinesia, incontinence, decreased level of consciousness, and pulmonary congestion. Neuroleptic malignant syndrome can occur during the first week of therapy but often occurs later during therapy.

Which issue related to antibiotic use is an increased risk for the older adult? - Allergy - Toxicity - Resistance - Superinfection

Toxicity rationale: The older adult is at increased risk for toxicity related to antibiotic use because of reduced metabolism and excretion of medications. Allergy, resistance, and superinfection are a risk for all antibiotic recipients but not an increased risk in the older adult population.

Which is the minimum number of disaster drills the hospital disaster plan committee must plan and implement each year? - Two - Three - Four - Five

Two rationale: Although it is appropriate to have more than the minimum number of disaster drills each year, the minimum that must be implemented per The Joint Commission (TJC) requirements is twice per calendar year. Three, four, and five are too many.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? - Notifying the receiving unit of the transfer - Having the client's records ready for the transfer - Verifying that the family has been notified of the transfer - Validating availability of a bag-valve-mask during the transfer

Validating availability of a bag-valve-mask during the transfer rationale: Validating availability of a bag-valve-mask during the transfer is vital in case of respiratory distress; increased intracranial pressure compresses the brainstem, which contains the medulla, the respiratory center. Notifying the receiving unit of the transfer is important, but not of primary urgency; the respiratory status is the priority. Having the client's records ready for the transfer is important, but not of primary urgency; the respiratory status is the priority. Verifying notification of the family regarding the transfer is important, but not of primary urgency; the respiratory status is the priority.

Which behavior is an early sign of an abusive personality? Select all that apply. - Verbal abusive - Jealous, controlling - Enforces rigid sex roles - Hypersensitive, easily insulted - Isolates partner from family and friends - Makes others responsible for their feelings

Verbal abusive; Jealous, controlling; Enforces rigid sex roles; Hypersensitive, easily insulted; Isolates partner from family and friends; Makes others responsible for their feelings rationale: Abuser behavior has several characteristics. A typical abuser has poor emotional control, a superior attitude toward women, a history of substance abuse, high levels of jealousy and insecurity, and hypersensitivity. Other characteristics include making others responsible for their feelings and using threats, such as verbal abuse, punishment, and physical violence, to control another's behavior. Control may extend to enforcing rigid sex roles and isolating a partner from family and friends. Early recognition of the characteristics of potential violence allows for effective intervention.

Which action will the nurse take when a client receiving buspirone is admitted to the hospital with a diagnosis of possible hepatitis? - Withhold the medication. - Give the buspirone with milk. - Reduce the dosage of the medication. - Ensure that the medication can be given parenterally.

Withhold the medication rationale: The medication should be held because hepatitis prolongs elimination of the medication and may result in toxic accumulation. Milk does not change the effect of the medication. The medication must be stopped, not reduced. The medication is available only in an oral form; in addition, the route of administration will not influence the occurrence of toxic accumulation.

An older adult living in a long-term care facility has been receiving 600 mg of lithium twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. What is the most appropriate nursing intervention? - Withholding the next dose of lithium and drawing blood to test it for toxicity - Obtaining a prescription for the antidote to lithium and administering it immediately - Suggesting that the primary healthcare provider replace the lithium for an antiepileptic that will control the mania - Assessing the client for coarse hand tremor and, if it is present, giving the daily dose of lithium with a bit of water

Withholding the next dose of lithium and drawing blood to test it for toxicity rationale: The client is displaying signs and symptoms of early lithium toxicity; older dients should be monitored carefully and given smaller doses of lithium because its excretion from the kidneys is slower than that in younger adults. There is no antidote to lithium. Although antiepileptics are effective in 25% to 50% of clients with treatment-resistant bipolar disorder, this is not the appropriate treatment for lithium toxicity. Coarse hand tremor is an indication of advanced lithium toxicity; the lithium should be withheld.

Which symptom will the nurse include as a reason to withhold the medication when teaching a client about digoxin therapy? - Fatigue - Yellow vision - Persistent hiccups. - Increased urinary output

Yellow vision rationale: Digoxin toxicity is a common and dangerous effect. Visual disturbances, most notably yellow vision, may be evidence of digoxin toxicity. Fatigue is not a toxic effect of digoxin. Persistent hiccups are not related to digoxin toxicity. An increased urinary output is not a sign of digoxin toxicity; it may be a sign of a therapeutic response to the medication and an improved cardiac output.