Pass point Pt 2
A client presents with diaphoresis, palpitations, jitters, and tachycardia approximately 4 hours after taking the prescribed usual morning insulin. What is the nurse's priority action? Restrict salt, administer diuretics, and perform paracentesis. Check pulse oximetry, and administer oxygen therapy. Check blood glucose level, and administer carbohydrates. Give nitroglycerin, and perform an electrocardiogram (ECG).
Check blood glucose level, and administer carbohydrates. The client is experiencing symptoms of hypoglycemia. Checking the blood glucose level and administering carbohydrates will elevate blood glucose. ECG and nitroglycerin are treatments for myocardial infarction. Administering oxygen won't help correct the low blood glucose level. Restricting salt, administering diuretics, and performing paracentesis are treatments for ascites.
A client has been NPO for 8 hours before a surgical procedure. When the nurse enters the room to take vital signs, the client is cool, diaphoretic, and unresponsive. After calling a rapid response, which intervention should the nurse perform? Administer naloxone. Check the glucose level. Perform an electrocardiogram. Perform an electroencephalogram.
Check the glucose level. Blood glucose level should be immediately measured when a client is unresponsive for no apparent reason or if hypoglycemia is suspected. This client is NPO and at risk for hypoglycemia. When blood glucose levels fall below 40 to 50 mg/dL, cerebral function declines rapidly. An ECG or EEG may be performed but would not be the priority in this situation. There is no indication that the client has received a narcotic, so the administration of a narcotic antagonist would be unnecessary.
For a client with cardiomyopathy, the highest priority nursing diagnosis is: Ineffective coping related to fear of debilitating illness. Decreased cardiac output related to reduced myocardial contractility. Anxiety related to actual threat to health status. Excess fluid volume related to fluid retention and altered compensatory mechanisms.
Decreased cardiac output related to reduced myocardial contractility. Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although the other options are important nursing diagnoses, they can be addressed when cardiac output and myocardial contractility have been restored.
A client who's admitted with new-onset diabetes mellitus is prescribed an 1,800-calorie diabetic diet. His insulin orders include regular insulin coverage using a sliding scale, and long-acting insulin every morning just before breakfast. Why was the sliding scale insulin coverage prescribed? Allows the client to administer his insulin doses according to his blood glucose levels Permits the nurse to administer insulin doses according to blood glucose levels before notifying the physician of results Directs the nurse to administer regular insulin doses according to finger-stick glucose levels without notifying the physician Allows the nurse to calculate long-acting insulin requirements each morning without contacting the physician
Directs the nurse to administer regular insulin doses according to finger-stick glucose levels without notifying the physician The sliding scale directs the nurse to administer doses of regular insulin to the client according to finger-stick glucose levels without notifying the physician. For instances in which the client is able and the physician allows, the client may administer his own regular insulin according to a sliding scale. A sliding scale directs regular — not long-acting — insulin administration after finger-stick glucose levels are obtained.
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important? Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician. Slow the transfusion and monitor the client closely. Stop the transfusion, notify the blood bank, and administer antihistamines. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician.
Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician. When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the blood bank and physician should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines may be administered for a mild allergic reaction.
A client takes 30 ml of magnesium hydroxide and aluminum hydroxide with simethicone by mouth 1 hour and 3 hours after each meal and at bedtime for treatment of a duodenal ulcer. Why does the client take this antacid so frequently? It has a slow onset of action. It has a short duration of action. It's highly metabolized. It has a prolonged half-life.
It has a short duration of action. Because of the short duration of action, frequent doses of antacids are needed. Antacids usually provide a rapid to immediate onset of action, don't have prolonged half-lives, and aren't highly metabolized.
Which statement best explains why furosemide is administered to treat hypertension? It decreases sympathetic cardioacceleration. It inhibits the angiotensin-converting enzyme. It inhibits reabsorption of sodium and water in the loop of Henle. It dilates peripheral blood vessels.
It inhibits reabsorption of sodium and water in the loop of Henle. Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop of Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.
An older adult client with pneumonia is having difficulty managing respiratory secretions and clearing the airways. Which nursing intervention would be most appropriate? Monitor the need for suctioning every hour. Suction every hour. Suction once per shift. Ask the client to notify the nurse when suctioning is needed.
Monitor the need for suctioning every hour. Suctioning should be performed only when necessary, based on the client's condition at the time of evaluation. Therefore, the nurse should monitor the need for suctioning every hour in an older adult client with pneumonia who is having difficulty clearing the respiratory secretions. Suctioning every hour or once per shift would be inappropriate. The nurse should not rely on the client to know when suctioning is needed.
A client who underwent abdominal surgery 2 hours ago reports abdominal pain and feeling "full and uncomfortable." Which action should the nurse perform first? Measure abdominal girth. Auscultate bowel sounds. Check the patency of the nasogastric (NG) tube. Monitor vital signs.
Monitor vital signs. The nurse should begin by checking the patency of the NG tube. When an NG tube is no longer patent, contents collect in the stomach, giving the client a sensation of fullness. If the NG tube is patent, the nurse should then measure abdominal girth, auscultate bowels, and monitor vital signs.
A nurse is caring for a postoperative thyroidectomy client at risk for hypocalcemia. What intervention should the nurse implement in this client's care? Monitor laboratory values daily for an elevated thyroid-stimulating hormone. Observe for swelling of the neck, tracheal deviation, and severe pain. Evaluate the quality of the client's voice postoperatively, noting any drastic changes. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system caused by hypocalcemia. The other options describe complications for which the nurse should also be observing; however, tetany and neurologic alterations are primary indications of hypocalcemia.
A nurse administers glucagon to her diabetic client and then monitors the client for adverse drug reactions and interactions. Which type of drug interacts adversely with glucagon? Thiazide diuretics Oral anticoagulants Anabolic steroids Beta-adrenergic blockers
Oral anticoagulants As a normal body protein, glucagon only interacts adversely with oral anticoagulants, increasing the anticoagulant effects. It doesn't interact adversely with anabolic steroids, beta-adrenergic blockers, or thiazide diuretics.
The nurse is caring for a child with heart failure. What should the nurse recognize when monitoring administration of oxygen to avoid complications? Oxygen is contraindicated in this situation. Oxygen is given at high levels only. Oxygen is a pulmonary bed constrictor. Oxygen decreases the work of breathing.
Oxygen decreases the work of breathing. Oxygen decreases the work of breathing and increases arterial oxygen levels, so it's indicated in this situation. Oxygen usually is administered at low levels with humidification. Oxygen is a pulmonary bed dilator, not constrictor, and can exacerbate any condition in which the lungs are overloaded.
A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client? Administer antihypertensive medication. Administer beta-blocker. Prepare the client for surgery. Transport the client for an aortogram.
Prepare the client for surgery. When the vessel ruptures, surgery is the only intervention that can repair it. Administration of antihypertensive medications and beta-blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.
The nurse, obtaining blood pressure readings during a work place health screening, obtains a blood pressure of 148/89 mm Hg on a client. Which action should the nurse take? Document this finding because it is most likely related to the stress of work. Request that the client wait for 24 hours and return to recheck the blood pressure. Recommend the client have a blood pressure recheck within 2 months. Tell the client to see a health care provider immediately for further evaluation.
Recommend the client have a blood pressure recheck within 2 months. The client should have blood pressure rechecked within 2 months. The blood pressure may be elevated related to stress, but without further information, simply documenting the finding is not a correct option. The client should wait for 20 minutes, and the blood pressure should be rechecked. The client need not see a health care provider immediately unless other symptoms of hypertension develop.
A client is admitted to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, the nurse formulates interventions with which goal in mind? Increasing blood pressure and reducing mobility Stabilizing the heart rate and blood pressure and easing anxiety Decreasing blood pressure and increasing mobility Increasing blood pressure and monitoring fluid intake and output
Stabilizing the heart rate and blood pressure and easing anxiety For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure, to avoid aneurysm rupture. Easing anxiety also is important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an abdominal aortic aneurysm is hypertensive, so the nurse should take measures to lower the blood pressure, such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially when attempting to gain stability.
A client comes to the clinic reporting a sore throat and fever. To obtain a throat culture, the nurse asks the client to tilt his head back, open his mouth, and close his eyes. To best obtain the specimen, which action does the nurse take next? Swab the tonsillar areas from top to bottom. Swab the back of the tongue, then the tonsillar areas from side to side. Swab the tonsillar areas from side to side, avoiding inflamed areas. Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth.
Swab the tonsillar areas from side to side, avoiding contact with the tongue, cheeks, and teeth. The nurse should obtain the specimen by swabbing the tonsillar areas, including the inflamed and purulent sites, from side to side. The nurse should avoid touching the tongue, cheeks, and teeth with the swab to prevent contaminating the specimen.
An 18-year-old client has suffered a C5 spinal cord contusion that resulted in quadriplegia. The parent is crying in the waiting room two days after the injury. When the nurse sits down to talk, the parent asks if the child will ever play sports again. Which response from the nurse would be best? Reassure the parent that, given time and motivation, the child will return to normal function. Advise the parent that it is not in the child's best interest to be so upset. Encourage the parent to express any feelings and fears about the child's injury. Tell the parent that the primary health care provider will be available to talk right away.
Tell the parent that the primary health care provider will be available to talk right away.
The nurse is caring for a child who is receiving steroid therapy as a part of the cancer treatment plan. The child tearfully asks the nurse," Why does my face looks so "fat?" What information should be included in the nurse's response? This change is temporary and will subside once the steroid medication has been discontinued. Drinking more fluids will help ensure toxins are flushed from the system and will reduce this appearance. The facial tissues are retaining fluid as a result of the cancer. An activity plan to promote calorie use will be helpful in reducing this facial appearance.
This change is temporary and will subside once the steroid medication has been discontinued. Steroid therapy is associated with an increased roundness of the face. This may be a source of distress to the child and parents. It is important to explain that this is the result of the medication therapy and will subside.
The nurse is administering sublingual nitroglycerin to the client. Immediately after administration, the nurse observes the client for which possible sign or symptom? Tinnitus or diplopia Throbbing headache or dizziness Drowsiness or blurred vision Nervousness or paresthesia
Throbbing headache or dizziness Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. However, the client usually develops a tolerance. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia don't occur as a result of nitroglycerin therapy.
Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease? To keep gastric pH at 3.0 to 3.5 To promote client compliance To maintain a regular bowel pattern To increase pepsin activity
To keep gastric pH at 3.0 to 3.5 To maintain a gastric pH of 3.0 to 3.5 throughout each 24-hour period, regular (not as needed) doses of an antacid are needed to treat peptic ulcer disease. Frequent administration of an antacid tends to decrease client compliance. Antacids don't regulate bowel patterns, and they decrease pepsin activity.
A client received chemotherapy 24 hours ago. Which intervention is the priority to include in the plan of care? Place incontinence pads in a biohazard bag. Wear personal protective equipment when handling blood, body fluids, or feces. Offer a urinal or bedpan to decrease the likelihood of soiling linens. Use sterile gloves when administering medication.
Wear personal protective equipment when handling blood, body fluids, or feces. Chemotherapy drugs are present in the client's waste and body fluids for 48 hours after administration. The priority in this scenario is to prevent the nurse from exposure to the chemotherapeutic agent. The nurse should wear personal protective equipment, including a face shield, gown, and gloves when exposure to blood, body fluid, or feces is likely. Gloves alone offer minimal protection against exposure. Placing incontinence pads in a biohazard bag and using a urinal or bedpan would be implemented, but are not the priority as they do not protect the nurse from exposure.
A client with primary diabetes insipidus is prescribed desmopressin. Which instruction should the nurse provide before the client is discharged? "Administer desmopressin while the suspension is cold." "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." "You won't need to monitor your fluid intake and output after you start taking desmopressin."
You may not be able to use desmopressin nasally if you have nasal discharge or blockage. Desmopressin may not be absorbed if the intranasal route is compromised. Although diabetes insipidus is treatable, the client should wear medical identification and carry medication at all times to alert medical personnel in an emergency and ensure proper treatment. The client must continue to monitor fluid intake and output and receive adequate fluid replacement.
The nurse observes a child with autism banging his or her head against the floor repetitively. Which nursing action is the priority? apply a helmet on the child administer sedation restrain the child allow the child to continue the repetitive behavior
apply a helmet on the child The priority for all clients is their safety. A helmet should be applied to this child with autistic disorder so that the child will not sustain a head injury. It is not necessary to administer a sedative to the child. Restraining the child will increase the behavior and cause more anxiety and stress reactions. The child may continue the behavior but should be protected.
A family that recently went camping brings their child to the clinic with a report of a rash after a tick bite. Which finding should the nurse expect to see in a child with Lyme disease? onset of a diffuse rash over the entire body 2 months after exposure bright rash with red outer border circling the bite site a linear rash of papules and vesicles that occurs 1 to 3 days after exposure erythematous rash surrounding a necrotic lesion
bright rash with red outer border circling the bite site A bull's-eye rash is a classic symptom of Lyme disease. In Lyme disease, the rash is located primarily at the site of the bite and occurs almost immediately, not 2 months after exposure. Necrotic, painful rashes are associated with the bite of a brown recluse spider. A linear, papular, vesicular rash indicates exposure to the leaves of poison ivy.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? loperamide pseudoephedrine hydrochloride guaifenesin diphenhydramine hydrochloride
diphenhydramine hydrochloride A client who is allergic to bee stings should keep diphenhydramine on hand because its antihistamine action can prevent a severe allergic reaction. Pseudoephedrine is a decongestant, which is used to treat cold symptoms. Guaifenesin is an expectorant, which is used for coughs. Loperamide is an antidiarrheal agent.
When plotting height and weight on a growth chart, which observation by the nurse would indicate that a 4-year-old child has a growth hormone deficiency? upward shift of 5 percentiles or more downward shift of 2 percentiles or more downward shift of 1 percentile or more upward shift of 1 percentile or more
downward shift of 2 percentiles or more When the health care provider evaluates the results of plotting height and weight, upward or downward shifts of 2 percentiles or more in children older than age 3 may indicate a growth abnormality.
The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis? Koplik spots tonsillar exudate vesicular lesions dry, cracked lips, strawberry tongue
dry, cracked lips, strawberry tongue Oral changes associated with Kawasaki disease include a reddened pharynx; red, dry fissured lips; and strawberry tongue. Koplik spots are consistent with measles. Tonsillar exudate is consistent with pharyngitis caused by group A beta-hemolytic streptococci. Vesicular lesions are associated with coxsackievirus.
Which aspect is most important for successful management of the child with Reye syndrome? initiation of antibiotics early diagnosis staging of the illness isolation of the child
early diagnosis Explanation:Early diagnosis and therapy are essential because of the rapid, clinical course of the disease and its high mortality. Reye syndrome is associated with a viral illness, and antibiotic therapy isn't effective to prevent the initial progression of the illness. Isolation isn't necessary because the disease isn't communicable. Staging, although important to therapy, occurs after a differential diagnosis is made.
At 36 weeks' gestation, a client gives birth a neonate who dies shortly after birth. When working as part of the team providing care to the client, which nursing intervention would be most appropriate for this client? avoiding the giving of any information about the neonate encouraging her to see, touch, and hold the neonate limiting the information she receives about the neonate letting the client's partner decide what information she should receive
encouraging her to see, touch, and hold the neonate
The nurse is caring for a client with hypothyroidism. Which client data would the nurse expect to collect? fatigue, cold intolerance, weight gain, and constipation polyuria, polydipsia, and weight loss coarsening of facial features and extremity enlargement heat intolerance, nervousness, weight loss, and hair loss
fatigue, cold intolerance, weight gain, and constipation Explanation: Tiredness, cold intolerance, weight gain, and constipation are symptoms of hypothyroidism, secondary to a decrease in cellular metabolism. Polyuria, polydipsia, and weight loss are symptoms of type 1 diabetes. Hyperthyroidism has symptoms of heat intolerance, nervousness, weight loss, and hair loss. Coarsening of facial features and extremity enlargement are symptoms of acromegaly.
A client with type 1 diabetes asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client: has type 1 diabetes. has type 2 diabetes. prefers to take insulin orally. is pregnant and has type 2 diabetes.
has type 2 diabetes. Type 2 diabetes is controlled primarily through diet, exercise, and oral antidiabetic agents. Desmopressin acetate, a long-acting vasopressin given intranasally, is the treatment of choice for diabetes insipidus. Treatment for diabetic ketoacidosis includes restoration of fluid volume, electrolyte management, reversal of acidosis, and control of blood glucose. Diet and exercise are important in type 1 diabetes, but blood glucose levels are controlled by insulin injections in that disorder.
A client reports weight gain and fatigue. The nurse obtains data that reveal the following: blood pressure 120/74 mm Hg, pulse rate 52 beats/minute, respiratory rate 20 breaths/minute, and temperature 98° F. Laboratory results show low thyroxine (T4) and triiodothyronine (T3) levels. The nurse determines these symptoms are associated with which condition? tetany hypothyroidism hyperthyroidism hypokalemia
hypothyroidism Weight gain, lethargy, and slow pulse rate along with decreased T3 and T4 levels indicate hypothyroidism. T3 and T4 are thyroid hormones that affect growth and development as well as metabolic rate. Tetany is related to low calcium levels. Hypokalemia is a low potassium level.
The nurse is working in the emergency department when a child is admitted in sickle cell crisis. Which intervention should the nurse expect to perform? give antibiotics prepare the child for a splenectomy increase fluid intake and give analgesics give blood transfusions
increase fluid intake and give analgesics The primary therapy for sickle cell crisis is to increase fluid intake (according to age) and to give analgesics. Blood transfusions are only given conservatively to avoid iron overload. Antibiotics are given to children with fever. Routine splenectomy isn't recommended. Splenectomy in a child with sickle cell anemia is controversial.
A client is receiving the drug epoetin alfa. Which findings would indicate the effectiveness of the drug? decrease in blood coagulation increase in white blood cells increase in red blood cells decrease in blood glucose
increase in red blood cells Epoetin alfa is a synthetic form of protein human erythropoietin. It stimulates the bone marrow to produce more red blood cells (RBC). The drug is used to treat anemia caused by chronic kidney disease, chemotherapy, and zidovudine (AZT), which is a drug used to treat HIV infection.
The nurse is caring for a client with hypothyroidism. For which medication will the nurse reinforce instructions? lactulose lidocaine dexamethasone levothyroxine
levothyroxine Levothyroxine, a synthetic form of the thyroid hormone thyroxine, is the medication of choice for treating hypothyroidism. Dexamethasone is a steroid and an antithyroid medication. Lactulose is a laxative used to treat constipation. Lidocaine is used to treat ventricular dysrhythmias.
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by: cerebral bleeding. skeletal muscle damage due to a recent fall. I.M. injection. myocardial necrosis.
myocardial necrosis. An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can be caused by I.M. injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.
The nurse is administering enteric coated erythromycin to a client. What adverse reaction should the nurse monitor for? nausea and vomiting increased appetite constipation weight gain
nausea and vomiting Erythromycin is an antibacterial antibiotic. Common adverse effects include nausea, vomiting, anorexia, diarrhea, and abdominal pain. It should be given with a full glass (8 oz [240 mL]) of water after meals or with food to lessen gastrointestinal symptoms.
A health care provider prescribes diet, exercise, and oral antidiabetic agents for a client with diabetes. Which type of diabetes will the nurse reinforce educating the client about? diabetes insipidus diabetic ketoacidosis type 1 diabetes type 2 diabetes
type 2 diabetes Type 2 diabetes is controlled primarily through diet, exercise, and oral antidiabetic agents. Desmopressin acetate, a long-acting vasopressin given intranasally, is the treatment of choice for diabetes insipidus. Treatment for diabetic ketoacidosis includes restoration of fluid volume, electrolyte management, reversal of acidosis, and control of blood glucose. Diet and exercise are important in type 1 diabetes, but blood glucose levels are controlled by insulin injections in that disorder.
The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and: vitamin D. potassium. folic acid. iron.
vitamin D. Typically, clients with hypoparathyroidism are prescribed daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn't cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn't require daily supplements of these substances to maintain a normal serum calcium level.
A client is 2 weeks post op from knee replacement surgery and has been on warfarin therapy. The client's most recent INR blood level was 5.6. What should the nurse prepare to administer to the client? sodium polystyrene sulfonate acetylcysteine protamine sulfate vitamin K
vitamin K The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for heparin toxicity. Acetylcysteine is the antidote for acetaminophen toxicity. Sodium polystyrene sulfonate is the antidote for potassium toxicity.
A health care provider prescribes phototherapy for a neonate with hyperbilirubinemia and jaundice. When providing care to the neonate, the nurse would be alert for which finding as a common adverse effect of this treatment? kernicterus watery stools positive Coombs test polyuria
watery stools
A nurse is evaluating a client with hyperthyroidism. Which findings should the nurse anticipate that correlate with the diagnosis? appetite loss, constipation, and lethargy weight loss, nervousness, and tachycardia exophthalmos, diarrhea, and cold intolerance cold intolerance, fever, and decreased sweating
weight loss, nervousness, and tachycardia Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.
A nurse is monitoring a client receiving intravenous (IV) fluid via pump. The alarm of the pump starts to beep for occlusion. What should the nurse do first? Flush the IV line with heparin solution. Shut off the pump. Check the roller clamp. Increase the rate of infusion to flush the line.
Check the roller clamp. A closed roller clamp will cause the alarm to beep. Shutting off the pump without checking the source of the problem will stop the client from receiving treatment; this is not a good option. Increasing the rate of infusion can cause fluid overload. There is no indication of a blood clot in the question.
A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk? Pain radiating down the posterior thigh Atrophy of the lower leg muscles Back pain when the knees are flexed Homans' sign
Pain radiating down the posterior thigh
Which symptom should the nurse expect to find in a client with increased blood plasma levels of thyroxine? anorexia weight gain heat intolerance diastolic hypertension
heat intolerance
A nurse is giving discharge instructions to the parents of a child with Kawasaki disease. Which statement by the parents shows an understanding of the treatment plan? "Black, tarry stools are considered normal." "My child should use a soft-bristled toothbrush." "A regular diet can be resumed at home." "My child can return to playing football next week."
"My child should use a soft-bristled toothbrush." Because of the anticoagulant effects of aspirin therapy, a soft-bristled toothbrush will prevent bleeding of the gums. A low-cholesterol diet should be followed until coronary artery involvement resolves, usually within 6 to 8 weeks. Black, tarry stools are abnormal and are signs of bleeding that should be reported to the health care provider immediately. Contact sports should be avoided because of the cardiac involvement and excessive bruising that may occur due to aspirin therapy.
The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? "Place the crutches and injured leg on the first step, followed by the unaffected leg." "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow." "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." "Place both crutches on the first step and swing both legs upward to this step."
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.
A client with rheumatoid arthritis reports flatulence and heartburn after taking piroxicam. Which instruction should the nurse reinforce to address the client's concern? "Take an antacid at the same time that you take the medication." "These side effects will subside as you continue to take the medication." "Try taking a lower dose of the medication to relieve your symptoms." "This medication is used for short-term treatment of your arthritis."
"Take an antacid at the same time that you take the medication." Piroxicam is a nonsteroidal anti-inflammatory drug (NSAID). It should be taken with food or an antacid to decrease the risk of gastrointestinal (GI) upset. Informing the client that the symptoms will subside is not appropriate because the client may continue to experience these side effects from the medication. Because piroxicam may not produce therapeutic effects for 2 to 4 weeks, the client should take it for more than a short time. The client should not adjust the dosage of piroxicam or any other medication unless directed to do so by a healthcare provider.
The nurse reinforces disease management instructions for a client newly diagnosed with type 1 diabetes. Which statement indicates to the nurse that the client has understood the information? "My health care provider will prescribe an oral antidiabetic medication to control my diabetes." "Checking my blood sugar before meals and at bedtime will help me manage my blood sugar." "Losing 10 pounds will reduce my blood glucose levels and improve my insulin production." "I would not be diabetic if I had a healthy diet and avoided eating foods high in sugar content."
"Checking my blood sugar before meals and at bedtime will help me manage my blood sugar." Blood glucose monitoring assists the client and provider with obtaining blood glucose control. Clients with diabetes should also be taught to keep a log of their blood glucose levels to take to the healthcare provider during their follow-up visits. Oral antidiabetic agents are not effective in type 1 diabetes. Pregnant and lactating women are not prescribed oral antidiabetic agents because the effects on the fetus and child are uncertain.
Which statement made by an adolescent with scoliosis indicates that the instruction received is understood? "I will have to wear a brace for several years." "I can put on the brace after I get home from school." "I should avoid any exercise that will stretch my spine." "I can remove the brace at night."
"I will have to wear a brace for several years." A brace worn to correct scoliosis must be worn for several years to correct the spinal deformity. The child must wear the brace all day, even during school and sleep. Exercises are commonly prescribed to be performed several times per day to stretch and strengthen back muscles. The brace should only be removed for 1 hour each day while bathing.
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dL (44.40 mmol/L). Which solution is most appropriate when initiating therapy? 100 units of isophane insulin suspension in normal saline solution 100 units of regular insulin in normal saline solution 100 units of regular insulin in dextrose 5% in water 100 units of isophane insulin suspension in dextrose 5% in water
100 units of regular insulin in normal saline solution Only short-acting regular insulin is used in continuous insulin infusions for a child with diabetic ketoacidosis. Insulin is added to normal saline solution and administered until blood glucose levels fall. Further along in therapy, a dextrose solution is administered to prevent hypoglycemia.
If a central venous catheter becomes disconnected accidentally, what should the nurse do immediately? Apply a dry sterile dressing to the site. Tell the client to take a deep breath and hold it. Clamp the catheter. Call the physician.
Clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp, if available. If a clamp isn't available, the nurse can place a sterile syringe or catheter plug in the catheter hub. After performing these measures, the nurse should notify the registered nurse immediately. The other options aren't appropriate at this time.
client with a history of gout is admitted to the medical-surgical unit. The nurse should expect to administer which medication to a client with gout? Colchicine Aspirin Furosemide Calcium gluconate
Colchicine
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? Coma, anxiety, confusion, headache, and cool, moist skin Kussmaul respirations, dry skin, hypotension, and bradycardia Polyuria, polydipsia, hypotension, and hypernatremia Polyuria, polydipsia, polyphagia, and weight loss
Coma, anxiety, confusion, headache, and cool, moist skin Signs and symptoms of hypoglycemia include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.
The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse? Ask the adolescent's parents to encourage the adolescent to take the medication. Document the adolescent's choice and offer to discuss feelings about the medication. Ensure that the adolescent understands the rationale for taking the medication. Persuade the adolescent to take the medication as ordered.
Document the adolescent's choice and offer to discuss feelings about the medication.
A client has a nasogastric (NG) tube. The physician prescribes an oral medication that is not available in liquid form. Which action should the nurse utilize to administer the tablet form to this client? Cut the tablets in half and wash them down the NG tube, using a syringe filled with water. Crush the tablets and wash the powder down the NG tube, using a syringe filled with saline solution. Dissolve the tablets, and then pour the liquid down the NG tube. Crush the tablets and prepare a liquid form, and then insert it into the NG tube using a syringe.
Crush the tablets and prepare a liquid form, and then insert it into the NG tube using a syringe.
A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and lactated Ringer's solution at 125 ml/hour. Which data collection finding indicates the need for additional I.V. fluids? Serum sodium level of 136 mEq/L Temperature of 99.6° F (37.6° C) Neck vein distention Dark amber urine
Dark amber urine Normally, urine appears light yellow; dark amber urine is concentrated and suggests decreased fluid intake. The serum sodium level normally ranges from 136 to 145 mEq/L. A temperature of 99.6° F (37.6° C) is only slightly elevated and doesn't indicate a fluid volume deficit. Neck vein distention is a sign of fluid volume overload.
A client is evaluated for hypertension. The physician prescribes atenolol, 50 mg by mouth daily. Atenolol should have which therapeutic effect on the client? Decreased blood pressure with reflex tachycardia Decreased cardiac output and systolic and diastolic blood pressure Decreased peripheral vascular resistance Increased cardiac output and systolic and diastolic blood pressure
Decreased cardiac output and systolic and diastolic blood pressure As a long-acting, selective beta1 blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blocking agents, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.
A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? Fear Urinary retention Excess fluid volume Toileting self-care deficit
Excess fluid volume A client with renal failure can't eliminate sufficient fluid, increasing the risk of fluid overload and consequent respiratory and electrolyte problems. This client has signs of excessive fluid volume and is acutely ill. Fear and a toileting self-care deficit may be problems, but they take lower priority because they aren't life-threatening. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance.
After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate? Holding the infant semi-upright during feedings Burping the infant less frequently Placing the infant on the abdomen after feedings Removing the Logan bar during feedings
Holding the infant semi-upright during feedings Holding the infant semi-upright during feedings helps prevent aspiration. The Logan bar must be kept in place at all times to protect the suture line. The infant should be burped more frequently to prevent regurgitation and aspiration. Placing the infant on his abdomen could lead to disruption of the suture line if the infant rubs his face.
A male client who has been married for 10 years arrives at the psychiatric clinic stating, "I can't live this lie anymore. I wish I were a woman. I don't know how to tell my wife." Which nursing intervention would be most appropriate? Provide this information to the primary health care provider. Offer to be with the client while he speaks with his wife. Consider admission for the client due to the statement "I can't live like this anymore." Sit down with the client and talk about his feelings.
Sit down with the client and talk about his feelings.
A client with a diagnosis of diabetes insipidus is being treated with desmopressin acetate. The client asks, "What is this medication?" What is the best response by the nurse? an antidiabetic agent a synthetic vasopressin a hormone secreted by the adrenal gland a type of insulin
a synthetic vasopressin Diabetes insipidus results from a deficiency of circulating antidiuretic hormone (vasopressin). Desmopressin acetate, a synthetic vasopressin, is the medication of choice for treating diabetes insipidus. Glucocorticoids are hormones secreted by the adrenal gland, which isn't involved with diabetes insipidus. Insulin and oral antidiabetic agents are used to treat diabetes, a disorder of glucose metabolism.
A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? administering large doses of I.V. antibiotics as ordered withholding all oral intake administering large doses of oral antibiotics as ordered instructing the client to ambulate twice daily
administering large doses of I.V. antibiotics as ordered Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.
A nurse is about to administer digoxin to a client with heart failure. Which parameter should the nurse check before administering the medication? respiratory rate radial pulse blood pressure apical pulse
apical pulse An apical pulse is essential for accurately assessing the client's heart rate before administering digoxin. The apical pulse is the most accurate pulse point in the body. Blood pressure is usually affected only if the heart rate is too low, in which case the nurse would withhold digoxin. The radial pulse can be affected by cardiac and vascular disease and, therefore, won't always accurately depict the heart rate. Digoxin has no effect on respiratory function.
A client is receiving furosemide, 40 mg by mouth twice per day. In the plan of care, the nurse should emphasize teaching the client about the importance of consuming: bananas and oranges. creamed corn. low-fat milk. fresh green vegetables.
bananas and oranges. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the client to increase intake of potassium-rich foods, such as bananas and oranges. Fresh green vegetables, milk, and creamed corn aren't good sources of potassium.
A client is receiving furosemide, 40 mg by mouth twice per day. In the plan of care, the nurse should emphasize teaching the client about the importance of consuming: fresh green vegetables. low-fat milk. creamed corn. bananas and oranges.
bananas and oranges. Because furosemide is a potassium-wasting diuretic, the nurse should plan to teach the client to increase intake of potassium-rich foods, such as bananas and oranges. Fresh green vegetables, milk, and creamed corn aren't good sources of potassium.
A client is placed on several medications after having a myocardial infarction (MI). Which drug class is part of the medication regimen for this client that will protect the ischemic myocardium by decreasing catecholamines and sympathetic nerve stimulation? nitrates opioids calcium channel blockers beta blockers
beta blockers Beta blockers work by decreasing catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing the heart's workload. Calcium channel blockers reduce workload by decreasing the heart rate and dilating arteries. Opioids reduce myocardial oxygen demand. Nitrates reduce myocardial oxygen consumption and decrease blood pressure.
The nurse is collecting data on a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: thick, coarse skin. hypotension. weight gain in arms and legs. deposits of adipose tissue in the trunk and dorsocervical area.
deposits of adipose tissue in the trunk and dorsocervical area. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face ("moon face"), and dorsocervical areas (buffalo hump) of clients with Cushing's syndrome. Hypertension develops because of fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities.
A nurse is monitoring a client with asthma who is taking atenolol. Which finding would indicate a potential complication associated with atenolol? baseline blood pressure of 166/88 mm Hg followed by a blood pressure of 138/74 mm Hg after two doses of medication baseline resting heart rate of 106 beats/minute followed by a resting heart rate of 88 beats/minute after two doses of medication development of audible expiratory wheezes Serum potassium level of 4.2 mEq/L (4.2 mmol/L)
development of audible expiratory wheezes Audible wheezing may indicate serious bronchospasm, especially in clients with asthma or obstructive pulmonary disease. Decreases in blood pressure and heart rate are expected outcomes when beta blockers are administered. A serum potassium level of 4.2 mEq/L (4.2 mmol/L) is within normal limits.
The nurse is caring for a client with suspected parathyroid dysfunction. Which laboratory results support a diagnosis of primary hyperparathyroidism? low thyroid-stimulating hormone (TSH) and high phosphorus levels high magnesium and high thyroid hormone levels high parathyroid hormone and high calcium levels low parathyroid hormone and low potassium levels
high parathyroid hormone and high calcium levels A diagnosis of primary hyperparathyroidism is established based on increased serum calcium levels and elevated parathyroid hormone levels. Potassium, magnesium, TSH, and thyroid hormone levels aren't used to diagnose hyperparathyroidism.
The nurse is performing an assessment on a client who has developed a paralytic ileus. The nurse expects the client's bowel sounds will be: hyperactive. high-pitched. hypoactive. blowing.
hypoactive If a paralytic ileus occurs, bowel sounds will be hypoactive or absent. Hyperactive bowel sounds may signify hunger, intestinal obstruction, or diarrhea. High-pitched sounds may signify a dilated bowel. A blowing sound may be a bruit from a partially obstructed abdominal aorta.
A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client? headache, fever, and diaphoresis vertigo, weakness, and pulse changes hypotension, rapid pulse, and shortness of breath insomnia, cough with hemoptysis, and fatigue
hypotension, rapid pulse, and shortness of breath Because an MI decreases cardiac output, it causes such symptoms as hypotension, rapid pulse, and shortness of breath. The other evaluation findings are not indicative of an MI.
Which nursing action is most important to decrease the risk of postoperative complications in a child with sickle cell anemia? increasing fluids preparing the child psychologically discouraging coughing limiting the use of analgesics
increasing fluids The main surgical risk from anesthesia is hypoxia; however, emotional stress, demands of wound healing, and the potential for infection can each increase the sickling phenomenon. Increased fluids are encouraged because keeping the child well-hydrated is most important for hemodilution to prevent sickling. Preparing the child psychologically to decrease fear minimizes undue emotional stress. Deep coughing is encouraged to promote pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent abdominal splinting and decreased ventilation.
After reinforcing education with a client about types of insulin, the nurse determines the teaching was successful when the client identifies which product as a long-acting insulin? Select all that apply. isophane insulin suspension insulin aspart insulin detemir insulin lispro insulin glargine
insulin detemir insulin glargine Insulin glargine and insulin detemir are long-acting insulins. Insulins aspart and lispro are rapid-acting insulins. Isophane insulin suspension is an intermediate-acting insulin.
The nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? high serum sodium level low serum potassium level increase in blood volume increase in blood pressure
low serum potassium level Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.
When caring for a child with sickle cell anemia in vaso-occlusive crisis, what does the nurse identify as the priority nursing intervention? manage pain provide a cool environment restrict fluids immobilize the affected part
manage pain
During the first few days of recovery from ostomy surgery for ulcerative colitis, what should be the priority of client care? skin care sexual concerns body image ostomy care
ostomy care
A primipara client at 32 weeks' gestation comes to the hospital reporting vaginal bleeding. She has soaked one peri-pad and has no pain or cramps. Based on this data, the nurse would most likely suspect which condition? vasa previa abruptio placentae placenta previa incompetent cervix
placenta previa
A child with Reye syndrome is exhibiting signs of increased intracranial pressure (ICP). Which nursing intervention would be most appropriate for this child? position the child with the head elevated and the neck in a neutral position maintain the child in the prone position cluster together interventions that may be perceived as noxious position the child in the supine position, with head turned to the side
position the child with the head elevated and the neck in a neutral position Positioning the child with Reye syndrome with the head elevated and the neck in neutral position helps decrease ICP. The prone and supine positions cause increased ICP. Interventions that may be perceived as noxious should be spaced over time because if clustered together they may have a cumulative effect in increasing ICP. Turning the head to the side may impede venous return from the head and increase ICP.
Which communicable disease requires isolating infected children from pregnantwomen? rubella pertussis varicella roseola
rubella Rubella (German measles) has a teratogenic effect on the fetus. An infected child must be isolated from pregnant women. Pertussis, roseola, and varicella don't have any teratogenic effects on a fetus.
The nurse is caring for a child with clubfoot (talipes equinovarus). What intervention does the nurse prepare to assist with? traction serial casting short leg braces inversion range-of-motion exercises
serial casting Serial casting is the treatment of choice when attempting to change the length of soft tissue. Traction isn't a treatment option. Corrective shoes are used instead of short leg braces. Inversion exercises won't help; eversion exercises will.
Which findings should the nurse expect when collecting data on a client admitted in sickle cell crisis? circumoral cyanosis and swelling of the face abdominal swelling and periorbital edema pruritus and pain in the hands and feet tachycardia with paleness of the skin
tachycardia with paleness of the skin With sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, causing occlusion, tissue ischemia, and extreme pain. Signs and symptoms include acute pain, pale skin, tachycardia and tachypnea, swelling in the extremities, fever, infection, neurological changes, fatigue, and jaundice. Paresthesia, hypotension, circumoral cyanosis, pruritus, facial swelling, and periorbital edema are not signs of sickle cell anemia. Abdominal pain and swelling are noted with splenic crisis.
A client is diagnosed with a fat emboli. Which signs and symptoms would the nurse expect to find when gathering data from this client? paresthesia, bradypnea, bradycardia, petechial rash on chest and neck tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck tachypnea, tachycardia, shortness of breath, paresthesia bradypnea, bradycardia, shortness of breath, petechial rash on chest and neck
tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck
A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse? "I will call the physician with this information." "If you do not take your medication, I will report your refusal to the charge nurse." "I will check your chart for documentation of the allergy." "A rash is a side effect not an allergic reaction."
"I will call the physician with this information." Information should be relayed to the physician so that he may change the order to a different medication. The nurse should have checked the chart for documentation of allergies before administering any medications to the client. Telling the client that a rash is an adverse effect is incorrect. Threatening to report the incident to the charge nurse isn't therapeutic.
A nurse is performing discharge teaching for a mobile older adult client diagnosed with osteoporosis. Which statement about home safety should the nurse include? "You should use a wheeled walker at home to increase your stability." "If there are steps outside your home, installing a ramp is recommended." "Avoid performing activities that require any impact or a lot of weight-bearing." "Lower yourself onto chairs slowly and use padded seating as much as possible."
"Lower yourself onto chairs slowly and use padded seating as much as possible." The client is described as mobile, so neither a ramp or walker is indicated in this case. However, having osteoporosis will increase the risk for pathological fractures. Weight-bearing exercise is recommended to help reduce bone loss so should not be discouraged. Compression fractures of the spine are relatively common in clients with osteoporosis of the spine. Recommending elevated, padded seating and encouraging clients to use the arms of a chair to lower themselves onto the seat can help reduce the risk for this type of fracture.
After checking the client's chart for possible contraindications, the nurse is administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse would question which medication if noted on the physician's orders for this client? A monoamine oxidase (MAO) inhibitor An antiemetic A loop diuretic An antibiotic
A monoamine oxidase (MAO) inhibitor
The nurse educator is explaining to a group of newly hired nurses how to auscultate a client's chest. What information would the nurse educator include to explain how to differentiate a pleural friction rub from other abnormal breath sounds? A rub occurs during inspiration only and may be heard anywhere. A rub occurs during both inspiration and expiration and produces a squeaking or grating sound. A rub occurs during inspiration only and clears with coughing. A rub occurs during expiration only and produces a light, popping, musical noise.
A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.
A female client who weighs 210 lb (95 kg) and has been diagnosed with hyperglycemia tells the nurse that her husband sleeps in another room because her snoring keeps him awake. The nurse notices that she has large hands and a hoarse voice. Which of the following would the nurse suspect as a possible cause of the client's hyperglycemia? Acromegaly Type 1 diabetes Hypothyroidism Deficient growth hormone
Acromegaly
A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema? Administer tepid baths, and use moisturizers immediately after the bath. Administer antifungals as ordered. Administer antibiotics as prescribed. Administer hot baths, and pat dry or air-dry the affected areas.
Administer tepid baths, and use moisturizers immediately after the bath. Tepid baths and moisturizers are indicated for eczema to keep the infected areas clean and to minimize itching. Antibiotics are given only when superimposed infection occurs. Antifungals are not usually administered in the treatment of eczema. Hot baths can exacerbate the condition and increase itching.
A nurse is assigned to a client experiencing Stage 3 hypovolemic shock. Which findings should the nurse expect to notice? BP 132/85 mm Hg, HR 116, urine output of 45 ml/hour, warm skin BP 149/92 mm Hg, HR 59, urine output of 57 ml/hour, cold skin BP 87/58 mm Hg, HR 123, urine output of 20 ml/hour, clammy skin BP 91/62 mm Hg, HR 99, urine output of 35 ml/hour, pale skin
BP 87/58 mm Hg, HR 123, urine output of 20 ml/hour, clammy skin Signs and symptoms of hypovolemic shock would include change in the level of consciousness; cool, clammy, and pale skin; hypotension; tachycardia; and tachypnea. The client will also have oliguria or decreased urine output because of decreased circulation of fluid volume. The normal urine output is between 30 to 50 ml/hour.
The nurse is reinforcing education about diet choices for an adolescent with iron deficiency anemia. Which menu selection by the adolescent indicates that more instruction is necessary? Caesar salad and pretzels Cheeseburger and milkshake Red beans and rice with sausage Egg sandwich and snack peanuts
Caesar salad and pretzels Caesar salad and pretzels aren't foods high in iron and protein. Meats (especially organ meats), eggs, and nuts have high protein and iron.
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should be instructed to avoid which of the following? Foods rich in protein Aerobic exercise programs High volumes of fluid intake Caffeine-containing products
Caffeine-containing products Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren't restricted but high-calorie foods are.
A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis? Race History of aortic valve replacement Age History of diabetes mellitus
History of aortic valve replacement A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren't major risk factors for infective endocarditis.
A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter? Choose a No. 12 French catheter. Instruct the client to deep breathe during catheterization. Add tape to the catheter tray for taping the indwelling catheter to the client's abdomen. Instruct the client to turn on her right side with both legs flexed. Instruct the client to deep breathe during catheterization.
Instruct the client to deep breathe during catheterization.
The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy? The client states that sublingual nitroglycerin usually relieves chest pain. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. The client exhibits a heart rate above 100 beats/minute. The client demonstrates the ability to tolerate increasing activity without chest pain.
The client demonstrates the ability to tolerate increasing activity without chest pain. The ability to tolerate increasing activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn't have chest pain.
Each member of the family of a child diagnosed with pinworms is prescribed a single dose of mebendazole. Which statement would the nurse incorporate into the reinforcing teaching plan? The drug may stain the feces red. The dose may be repeated in 2 weeks. Fever and rash are common adverse effects. The medicine will kill the eggs in about 48 hours.
The dose may be repeated in 2 weeks. Mebendazole is effective against the adult worms only (not eggs), so treatment should be repeated to eradicate any emerging parasites in 2 weeks. Staining the feces is not associated with mebendazole. Common adverse effects of mebendazole are reports of headaches and abdominal pain.
Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease? To maintain a regular bowel pattern To keep gastric pH at 3.0 to 3.5 To promote client compliance To increase pepsin activity
To maintain a regular bowel pattern
The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. electroencephalogram serum bilirubin serum troponin serum myoglobin urinalysis 24-hour creatinine clearance
serum troponin serum myoglobin Troponin and myoglobin are enzymes released when cardiac muscle is damaged. Serum troponin levels increase within 2 to 4 hours after MI. Serum myoglobin levels increase within 0.5 to 2 hours after MI. Serum bilirubin evaluates liver function and is not altered with cardiac damage. Urinalysis and 24-hour creatinine clearance reflect kidney, not cardiac, function. An electroencephalogram evaluates the electrical activity of the brain.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. When collecting data, the nurse expects to note: weakness and atrophy of the arm muscles. hypoactive bowel sounds. sensory deficits in one arm. severe low back pain.
severe low back pain. The most common finding in a client with a herniated lumbar disk is severe low back pain, which radiates to the buttocks, legs, and feet — usually unilaterally. A herniated disk also may cause sensory and motor loss (such as footdrop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
