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PACKAGE DEAL BUNDLE FOR NCLEX STUDY GUIDES, EXAMS, PRACTICES, CASES WITH COMPLETE QUESTIONS AND ANSWERS , EASY TO REMEMBER VERIFIED FACTS TO HELP YOU PERFORM BETTER (NUR 101)
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NCLEX EXIT EXAM STUDY GUIDE
The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu items indicate that the client understands what has been... [Show More] taught? a. Spaghetti with fresh tomatoes b. Boiled lobster, baked potato c. Grilled chicken with turnip greens d. Instant hot cereal with bacon e. Tomato soup with a ham sandwich - correct answer Spaghetti/fresh tomatoes Grilled chicken, turnip greens Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and pastas are also low in sodium. Highly processed and refined foods such as lunch meats are high in sodium unless specifically labeled "low sodium". Saltwater fish and shellfish are higher in sodium. A clear liquid diet has been prescribed for a client who has just undergone surgery. Which foods should the nurse offer? SATA a. Custard b. Apple juice c. Orange juice d. Chicken broth e. Orange gelatin f. Vanilla ice cream - correct answer Apple Juice, Chicken Broth, and Orange gelatin A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin. Which are relatively transparent. Custard, orange juice, and vanilla ice cream are components of a full liquid diet. A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate the need for further instruction? SATA a. Carrots b. Tapioca c. Scallops d. Broccoli e. Chicken liver - correct answer Scallops, Chicken liver Rationale: Organ meats such as liver, as well as certain seafoods, including scallops, sardines, and herring, should be omitted from the diet of a client with gout due to high purine content. The foods identified in other options can be consumed freely by this client. Triamterene has been prescribed for a client with history of HTN. Which fruits should the nurse tell the client are acceptable to eat while on this medication? a. Prunes b. Apples c. Peaches d. Avocados e. Nectarines f. Cranberries - correct answer Apples, Peaches, Cranberries Triamterene is a potassium-retaining diuretic, so the client must omit foods high in potassium. Fruits that are naturally high in potassium include prunes, avocados, bananas, fresh oranges, and mangoes, nectarines, and papayas. Diverticulitis is diagnosed in a client who has been experiencing episodes of GI cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? a. Low in fat b. High in fiber c. Low in residue d. High in carbs - correct answer High-fiber When a client's diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, veggies, and whole grains is recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if prescribed, to increase stool mass and softness. Increasing fluids to 2500-3000 mL daily is also important. A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the client include in the diet? SATA a. Avocados b. Baked tuna c. Green olives d. Baked potato e. Fresh cherries f. Cream cheese - correct answer Baked tuna, baked potato, fresh cherries Fruits and veggies tend to be lower in fat because they do not come from animal sources, although olives, though technically a fruit, are high in fat along with avocados . Fish is naturally lower in fat. Meats and dairy products such as cream cheese are higher in fat, although modifications can be made to these foods to reduce fat content. A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? SATA a. Kale b. Cherries c. Broccoli d. Cabbage e. Potatoes f. Spaghetti - correct answer Cherries, potatoes, spaghetti Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green, leafy veggies such as kale, broccoli, spinach, brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are low in vitamin K. A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods will promote wound healing? a. Spare ribs, rice, gelatin, tea b. Pasta, garlic bread, ginger ale c. Chicken breast, broccoli, strawberries, milk d. Peanutbutter and jelly sandwich, chocolate cake, tea - correct answer Chicken breast, broccoli, strawberries, milk Protein and vitamin C are needed for wound healing. Poultry and milk are good sources of protein; broccoli and strawberries are good sources of vitamin C. Peanutbutter is a source if niacin. Gelatin, jelly, tea, and ginger ale have no nutritional value. Pasta, rice and bread delivery complex carbs. Spare ribs may contain some protein but are high in fat. A client who experienced a stroke is experiencing residual dysphagia. Which food should be removed from his meal tray? a. Peas b. Scrambled eggs c. Cheese casserole d. Mashed potatoes - correct answer Peas In general, flavorful, warm, or well-chilled foods with texture stimulate swallow reflex. Moist pastas, casseroles, egg dishes, and potatoes are usually well tolerated. Raw veggies, chunky veggies such as diced beets, stringy veggies, and those with skin such as corn and peas are foods commonly excluded from a diet of a client with dysphagia. A client recovering from acute kidney injury is being discharged. The nurse determine that the client understands the diet regimen when the client states that he will plan a diet low in which substance? a. Fats b. Vitamins c. Potassium d. Carbs - correct answer Potassium Most excretion of potassium and control of potassium balance is carried out by the kidneys. In a client with AKI, potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis. A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? SATA a. Lying down after eating b. Eating high-protein foods c. Drinking liquids with meals d. Eating 6 small meals per day e. Eating concentrated sweets during the day - correct answer Lying down after meals, eating high-protein foods, eating 6 small meals a day The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a diet that is high in protein, moderate in fat, and low in carbs. The client should lie down after meals and avoid drinking liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets. A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates understanding? a. Chicken, potatoes, cranberries b. Spinach salad, milk, banana c. Peanut butter sandwich, milk, prunes d. Linguini with shrimp, salad, a plum - correct answer Spinach salad, milk, banana In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The other options are of an acid ash diet. A client who has sustained multiple fracture of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? a. Left heel b. Scapulae c. Right heel d. Back of the head - correct answer Right heel Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include the elbows (if they are used for repositioning) and the heel of the unaffected leg, which is used as a brace when the client pushes up from the bed. Other such pressure points include popliteal space, achilles tendon, and the ischial tuberosity. Which food should the nurse offer to a client who has been prescribed a full liquid diet? a. Toast b. Plain bagel c. Cooked custard d. Scrambled eggs - correct answer Cooked custard A full liquid diet consists of liquid foods that are clear or opaque liquid foods, including those that are liquid at room temperature. Cooked custard is allowed. Toast and a bagel are allowed on a regular diet; scrambled eggs are allowed on a soft diet. A client with HF and HTN who has been admitted to the hospital is unable to make own selections from the menu. What meal does the nurse select for the client's supper? a. Smoked ham, fresh carrots, boiled potato b. Hot dog in a bun, sauerkraut, baked beans c. Turkey, baked potato, salad with oil and vinegar d. Shrimp, baked potato, salad with blue cheese dressing - correct answer Turkey, baked potato, salad with oil and vinegar Foods that are high in sodium should be limited in the diet of this client. Foods in the meat group that are higher in sodium include bacon, lunch meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for clients with HTN. The nurse teaches a client who has begun taking phenelzine, a MAOI, about the medication. Which foods when selected indicate the need for further teaching? a. Peas b. Broccoli c. Potatoes d. Red wine e. Avocados f. Cereal with raisins - correct answer Red wine, avocados, raisins Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, raisins, avocados, figs, beer. Veggies with the exception of broad-bean pods are generally acceptable. A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed when the client states to eliminate what from the diet? a. Alcohol b. Diet cola c. Bran flakes d. Chicken livers - correct answer Alcohol A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes palpitations, SOB, severe headache, flushing, and nausea. Calcitriol is prescribed for a client with hypocalcemia. The nurse has instructed the client in foods that may interfere with calcium absorption. The nurse realizes the teaching is effective if the client verbalizes the importance of limiting which items? SATA a. Bran b. Milk c. Clams d. Spinach e. Orange juice - correct answer Bran, Spinach The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach, rhubarb, bran, and whole-grain cereals, which all may limit calcium absorption. Good dietary sources of calcium include milk, dark-green leafy veggies, clams, oysters, sardines, and orange juice. The nurse provides instructions to a client two is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when she states she should limit what in the diet? a. Coffee, chocolate, cola b. Oysters, lobster, shrimp c. Apples, oranges, pineapple d. Cottage cheese, cream cheese, dairy creamers - correct answer Coffee, cola, chocolate Theophylline is a bronchodilator, and the nurse teaches the client to limit intake of xanthine-containing foods while taking this medication. A client with a UTI has been started on nitrofurantoin, a urinary antiseptic. The client is taught about foods that will keep the urine acidic. Which food should the nurse tell the client to eliminate? a. Prunes b. Oranges c. Rhubarb d. Cranberries - correct answer Rhubarb When a client is taking nitrofurantoin, the urinary pH must be acidic. The client will be on an acid ash diet. Rhubarb reduces acidity of urine and should be avoided. For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E - correct answer Vitamin B12 The client on a vegan diet does not consume animal products and is therefore at risk for B12 deficiency. Fruits and veggies, which are acceptable to a vegan, contains vitamins A, C and E. A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? a. One low in protein b. One high in fluids c. One high in carbs d. One with a moderate amount of fat - correct answer Low protein A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, forming ammonia. A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates understanding? a. Roast turkey, baked potato b. Fruit plate with whipped cream c. Fried chicken, mac and cheese d. BBQ ribs, buttered noodles - correct answer Roast turkey, baked potato The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which option is best? a. Milk b. Cabbage c. Boiled potatoes d. Coffee with cream - correct answer Boiled potatoes During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-forming foods, milk products, and raw fruits and veggies that are very high in fiber. Vitamins and iron supplements may be prescribed. A nurse has taught a client with a new colostomy about measure to control odor in the ostomy drainage bag. Which foods listed indicate that the client has understood? SATA a. eggs b. yogurt c. parsley d. broccoli e. cucumbers f. cranberry juice - correct answer Yogurt, parsley, cranberry juice Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt. Eggs, broccoli, and cucumbers are gas-forming foods. A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food selected to eat indicates need for further instruction? a. Bran b. Pasta c. Boiled rice d. Low-fat cheese - correct answer Bran Ileostomy output is liquid. The addition or elimination of various foods can help thicken this liquid drainage. Bran is high in fiber and will increase output of liquid stool. Foods that help thicken the stool of a client with an ileostomy include pasta, boiled rice, and low-fat cheese. A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on [Show Less]
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DYSRYTHMIA NURSING STUDENT STUDY BLOG NCLEX
1. A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes mea... [Show More] sure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal sinus rhythm B. Sinus bradycardia C. Sick sinus syndrome D. First-degree heart block. - correct answer 1. measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively. 2 A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? 1. Frequent movement of the client 2. Tightly secured cable connections 3. Leads applied over hairy areas 4. Leads applied to the limbs - correct answer 2. Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection. 3. A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: 1. Premature ventricular contractions 2. Ventricular tachycardia 3. Ventricular fibrillation 4. Sinus tachycardia - correct answer 2. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular. 4. A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? 1. Immediately defibrillate 2. Prepare for pacemaker insertion 3. Administer amiodarone (Cordarone) intravenously 4. Administer epinephrine (Adrenaline) intravenously - correct answer 3. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated. 5. A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? 1. Breathe deeply, regularly, and easily. 2. Inhale deeply and cough forcefully every 1 to 3 seconds. 3. Lie down flat in bed 4. Remove any metal jewelry - correct answer 2. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. 6. A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? 1. Blood pressure and peripheral perfusion 2. Sensation of palpitations 3. Causative factors such as caffeine 4. Precipitating factors such as infection - correct answer 1. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine. 7. A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: 1. Hypotension and dizziness 2. Nausea and vomiting 3. Hypertension and headache 4. Flat neck veins - correct answer 1. The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. 8. A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: 1. Sinus tachycardia 2. Atrial fibrillation 3. Ventricular tachycardia 4. Ventricular fibrillation - correct answer 2. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled). 9. A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate; overdriving the rhythm. 3. Diaphragmic nerve to slow the heart rate 4. Diaphragmic nerve to overdrive the rhythm - correct answer 1. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. 10. A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: 1. Ventricular tachycardia 2. Ventricular fibrillation 3. Atrial fibrillation 4. Asystole - correct answer 2. Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. 11. While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: 1. Increase the IV infusion rate 2. Notify the physician promptly 3. Increase the oxygen concentration 4. Administer a prescribed analgesic - correct answer 2. PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. 12. The adaptations of a client with complete heart block would most likely include: 1. Nausea and vertigo 2. Flushing and slurred speech 3. Cephalalgia and blurred vision 4. Syncope and low ventricular rate - correct answer 4. In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope. 13. A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: 1. Sagging ST segments 2. Absence of P wave configurations 3. Inverted T waves following each QRS complex 4. Widening of QRS complexes to 0.12 second or greater. - correct answer 4. Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex. 14. When ventricular fibrillation occurs in a CCU, the first person reaching the client should: 1. Administer oxygen 2. Defibrillate the client 3. Initiate CPR 4. Administer sodium bicarbonate intravenously - correct answer 2. Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU. 15. What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. 1. The RR intervals are relatively consistent 2. One P wave precedes each QRS complex 3. Four to eight complexes occur in a 6 second strip 4. The ST segment is higher than the PR interval 5. The QRS complex ranges from 0.12 to 0.20 second. - correct answer 1, 2. The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second. 16. When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: 1. The presence of occasional coupled beats 2. Long pauses in an otherwise regular rhythm 3. A continuous and totally unpredictable irregularity 4. Slow but strong and regular beats - correct answer 3. In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions. [Show Less]
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LEWIS CAD -- CH. 33 STUDY GUIDE NCLEX
Which patient is most likely to be in the fibrous stage of development of coronary artery disease (CAD)? a. Age 40, thrombus adhered to the coronary arte... [Show More] ry wall b. Age 50, rapid onset of disease with hypercholesterolemia c. Age 32, thickened coronary arterial walls with narrowed vessel lumen d. Age 19, elevated low-density lipoprotein (LDL) cholesterol, lipid-filled smooth muscle cells - correct answer Age 32, thickened coronary arterial walls with narrowed vessel lumen c. The fibrous plaque stage has progressive changes that can be seen by age 30. Collagen covers the fatty streak and forms a fibrous plaque in the artery. Which stage of CAD does the thrombus adheres to the arterial wall? - correct answer The COMPLICATED LESION STAGE 2. What accurately describes the pathophysiology of CAD? a. Partial or total occlusion of the coronary artery occurs during the stage of raised fibrous plaque. b. Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use. c. Collateral circulation in the coronary circulation is more likely to be present in the young patient with CAD. d. The leading theory of atherogenesis proposes that infection and fatty dietary intake are the basic underlying causes of atherosclerosis. - correct answer Endothelial alteration may be caused by chemical irritants such as hyperlipidemia or by tobacco use. b. The etiology of CAD includes atherosclerosis as the major cause. The pathophysiology of atherosclerosis development and resulting atheromas is related to endothelial injury and inflammation, which can be the result of - tobacco use - hyperlipidemia - hypertension - toxins - diabetes mellitus - hyperhomocysteinemia - infection causing a local inflammatory response in the inner lining of the vessel walls. Rapid onset of coronary artery disease (CAD) with hypercholesterolemia may be related to - correct answer familial hypercholesterolemia, not a stage of CAD development. The fatty streak stage is the - correct answer earliest stage of atherosclerosis and can be seen by age 20. Partial or total occlusion occurs in the ______________stage. - correct answer complicated lesion Extra collateral circulation occurs in the presence of - correct answer chronic ischemia. Therefore it is more likely to occur in an older patient. 3. While obtaining patient histories, which patient does the nurse identify as having the highest risk for CAD? a. A white man, age 54, who is a smoker and has a stressful lifestyle b. A white woman, age 75, with a BP of 172/100 mm Hg and who is physically inactive c. An Asian woman, age 45, with a cholesterol level of 240 mg/dL and a BP of 130/74 mm Hg d. An obese Hispanic man, age 65, with a cholesterol level of 195 mg/dL and a BP of 128/76 mm Hg - correct answer A white woman, age 75, with a BP of 172/100 mm Hg and who is physically inactive b. This white woman has one unmodifiable risk factor (age) and two major modifiable risk factors (hypertension and physical inactivity). Her gender risk is as high as a man's because she is 75 years of age. The white man has one unmodifiable risk factor (gender), one major modifiable risk factor (smoking), and one minor modifiable risk factor (stressful lifestyle). The Asian woman has only one major modifiable risk factor (hyperlipidemia), and Asians in the United States have fewer myocardial infarctions (MIs) than do whites. The Hispanic man has an unmodifiable risk factor related to age and one major modifiable risk factor (obesity). Hispanics have slightly lower rates of CAD than non- Hispanic whites or African Americans. 4. Priority Decision: While teaching women about the risks and incidence of CAD, what should the nurse emphasize? a. Smoking is not as significant a risk factor for CAD in women as it is in men. b. Women seek treatment sooner than men when they have symptoms of CAD. c. Estrogen replacement therapy in postmenopausal women decreases the risk for CAD. d. CAD is the leading cause of death in women, with a higher mortality rate after MI than in men. - correct answer CAD is the leading cause of death in women, with a higher mortality rate after MI than in men. d. CAD is the number-one killer of American women, and women have a much higher mortality rate within 1 year following MI than do men. Smoking carries specific problems for women because smoking has been linked to a decrease in natural estrogen levels and to early menopause, and it has been identified as the most powerful contributor to CAD in women under the age of 50. Fewer women than men present with classic manifestations, and women delay seeking care longer than men. Recent research indicates that estrogen replacement does not always reduce the risk for CAD, even though natural estrogen lowers low-density lipoprotein (LDL) and raises high-density lipoprotein (HDL) cholesterol 5. Which characteristics are associated with LDLs (select all that apply)? a. Increases with exercise b. Contains the most cholesterol c. Has an affinity for arterial walls d. Carries lipids away from arteries to liver e. High levels correlate most closely with CAD f. The higher the level, the lower the risk for CAD - correct answer Contains the most cholesterol Has an affinity for arterial walls High levels correlate most closely with CAD b, c, e. LDLs contain more cholesterol than the other lipoproteins, have an attraction for arterial walls, and correlate most closely with increased incidence of atherosclerosis and CAD. HDLs increase with exercise and carry lipids away from arteries to the liver for metabolism. A high HDL level is associated with a lower risk of CAD. 6. Which serum lipid elevation, along with elevated LDL, is strongly associated with CAD? a. Apolipoproteins b. Fasting triglycerides c. Total serum cholesterol d. High-density lipoprotein (HDL) - correct answer Fasting triglycerides b. Elevated fasting triglyceride levels are associated with cardiovascular disease and diabetes. Apolipoproteins are found in varying amounts on the HDLs and activate enzyme or receptor sites that promote removal of fat from plasma, which is protective. The apolipoprotein A and apolipoprotein B ratio must be done to predict CAD. Elevated total serum cholesterol must be calculated with HDL for a ratio over time to determine an increased risk of CAD. Elevated HDLs are associated with a lower risk of CAD 7. The laboratory tests for four patients show the following results. Which patient should the nurse teach first about preventing CAD because the patient is at the greatest risk for CAD even without other risk factors? a. Total cholesterol: 152 mg/dL, triglycerides: 148 mg/dL, LDL: 148 mg/dL, HDL: 52 mg/dL b. Total cholesterol: 160 mg/dL, triglycerides: 102 mg/dL, LDL: 138 mg/dL, HDL: 56 mg/dL c. Total cholesterol: 200 mg/dL, triglycerides: 150 mg/dL, LDL: 160 mg/dL, HDL: 48 mg/dL d. Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL - correct answer Total cholesterol: 250 mg/dL, triglycerides: 164 mg/dL, LDL: 172 mg/dL, HDL: 32 mg/dL d. All of this patient's results are abnormal. The patient in option "c" is close to being at risk; if this patient is a woman, the HDL is too low and the other results are at or near the cut off for being normal. The other patients' results are at acceptable levels. The nurse is encouraging a sedentary patient with major risks for CAD to perform physical exercise on a regular basis. In addition to decreasing the risk factor of physical inactivity, the nurse tells the patient that exercise will also directly contribute to reducing which risk factors? a. Hyperlipidemia and obesity b. Diabetes mellitus and hypertension c. Elevated serum lipids and stressful lifestyle d. Hypertension and elevated serum homocysteine - correct answer Hyperlipidemia and obesity a. Increased exercise without an increase in caloric intake will result in weight loss, reducing the risk associated with obesity. Exercise increases lipid metabolism and increases HDL, thus reducing CAD risk. Exercise may also indirectly reduce the risk of CAD by controlling hypertension, promoting glucose metabolism in diabetes, and reducing stress. Although research is needed to determine whether a decline in homocysteine can reduce the risk of heart disease, it appears that dietary modifications are indicated for risk reduction. 9. During a routine health examination, a 48-yr-old patient is found to have a total cholesterol level of 224 mg/dL (5.8 mmol/L) and an LDL level of 140 mg/dL (3.6 mmol/L). What does the nurse teach the patient based on the Therapeutic Lifestyle Changes diet (select all that apply)? a. Use fat-free milk. b. Abstain from alcohol use. c. Reduce red meat in the diet. d. Eliminate intake of simple sugars. e. Avoid egg yolks and foods prepared with whole eggs. - correct answer a. use fat free milk c. Reduce red meat in the diet. e. Avoid egg yolks and foods prepared with whole eggs. a, c, e. Therapeutic Lifestyle Changes diet recommendations emphasize reduction in saturated fat and cholesterol intake. X - Whole milk products X - red meats X - eggs X- butter X - stick margarine X - lard X - solid shortening should be reduced or eliminated from diets. If triglyceride levels are high, X - alcohol X - simple sugars should be reduced. 10. To which patients should the nurse teach the Therapeutic Lifestyle Changes diet to reduce the risk of coronary artery disease (CAD)? a. All patients to reduce CAD risk b. Patients who have experienced an MI c. Individuals with two or more risk factors for CAD d. Individuals with a cholesterol level >200 mg/dL (5.2 mmol/L) - correct answer All patients to reduce CAD risk 10. a. The Therapeutic Lifestyle Changes diet includes recommendations for all people, not just those with risk factors, to decrease the risk for CAD. 11. Patient-Centered Care: A 62-yr-old woman has prehypertension (BP 138/88 mm Hg) and smokes a pack of cigarettes per day. She has no symptoms of CAD, but a recent LDL level was 154 mg/dL (3.98 mmol/L). Based on these findings, the nurse would expect that which treatment plan would be used first for this patient? a. Diet and drug therapy b. Exercise instruction only c. Diet therapy and smoking cessation d. Drug therapy and smoking cessation - correct answer Diet therapy and smoking cessation c. Without the total serum cholesterol and HDL results, diet therapy and smoking cessation are indicated for this patient without CAD who has prehypertension and an LDL level ≥130 mg/dL. When the patient's LDL level is 75 to 189 mg/dL with a 10-year risk for CVD of 7.5% or above, drug therapy would be added to diet therapy. Because tobacco use is related to increased BP and LDL level, the benefit of smoking cessation is almost immediate. Exercise is indicated to reduce risk factors throughout treatment 12. What are manifestations of acute coronary syndrome (ACS) (select all that apply)? a. Dysrhythmia b. Stable angina c. Unstable angina d. ST-segment-elevation myocardial infarction (STEMI) e. Non-ST-segment-elevation myocardial infarction (NSTEMI) - correct answer Unstable angina ST-segment-elevation myocardial infarction (STEMI) Non-ST-segment-elevation myocardial infarction (NSTEM c, d, e. Unstable angina, ST-segment-elevation myocardial infarction (STEMI), and non-ST-segment-elevation myocardial infarction (NSTEMI) are conditions that are manifestations of acute coronary syndrome (ACS). The other options are not manifestations of ACS 13. Myocardial ischemia occurs as a result of increased oxygen demand and decreased oxygen supply. What factors and disorders result in increased oxygen demand (select all that apply)? a. Hypovolemia or anemia b. Increased cardiac workload with aortic stenosis c. Narrowed coronary arteries from atherosclerosis d. Angina in the patient with atherosclerotic coronary arteries e. Left ventricular hypertrophy caused by chronic hypertension f. Sympathetic nervous system stimulation by drugs, emotions, or exertion - correct answer Increased cardiac workload with aortic stenosis Angina in the patient with atherosclerotic coronary arteries Left ventricular hypertrophy caused by chronic hypertension Sympathetic nervous system stimulation by drugs, emotions, or exertion b, d, e, f. Increased oxygen demand is caused by increasing the workload of the heart, including left ventricular hypertrophy with hypertension, sympathetic nervous stimulation, and anything precipitating angina. Hypovolemia, anemia, and narrowed coronary arteries contribute to decreased oxygen supply. 14. What causes the pain that occurs with myocardial ischemia? a. Death of myocardial tissue b. Dysrhythmias caused by cellular irritability c. Lactic acid accumulation during anaerobic metabolism d. Elevated pressure in the ventricles and pulmonary vessels - correct answer Lactic acid accumulation during anaerobic metabolism c. When the coronary arteries are occluded, contractility ceases after several minutes, depriving the myocardial cells of glucose and oxygen for aerobic metabolism. Anaerobic metabolism begins and lactic acid accumulates, irritating myocardial nerve fibers that then transmit a pain message to the cardiac nerves and upper thoracic posterior roots. The other factors may occur during vessel occlusion but are not the source of pain. 15. What types of angina can occur in the absence of CAD (select all that apply)? a. Silent ischemia b. Nocturnal angina c. Prinzmetal's angina d. Microvascular angina e. Chronic stable angina - correct answer Microvascular angina Prinzmetal's angina c, d. Prinzmetal's angina and microvascular angina may occur in the absence of CAD but with arterial spasm in Prinzmetal's angina or abnormalities of the coronary microcirculation. 16. Which characteristics describe unstable angina (select all that apply)? a. Usually precipitated by exertion b. New-onset angina with minimal exertion c. Occurs only when the person is recumbent d. Characterized by increased duration or severity e. Usually occurs in response to coronary artery spasm - correct answer New-onset angina with minimal exertion Characterized by increased duration or severity b, d. Unstable angina is new-onset angina occurring at rest or with minimal exertion and increases in frequency, duration, or severity. Chronic stable angina is usually precipitated by exertion. Angina decubitus occurs when the person is . - correct answer recumbent Prinzmetal's angina is frequently caused by a - correct answer coronary artery spasm. Silent ischemia is prevalent in persons with diabetes mellitus and contributes - correct answer to asymptomatic myocardial ischemia. Nocturnal angina occurs - correct answer only at night. Chronic stable angina refers to chest pain that occurs with the same pattern of - correct answer onset duration intensity intermittently over a long period of time. 17. Tachycardia that is a response of the sympathetic nervous system to the pain of ischemia is detrimental because it increases oxygen demand and a. increases cardiac output. b. causes reflex hypotension c. may lead to atrial dysrhythmias. d. impairs perfusion of the coronary arteries. - correct answer impairs perfusion of the coronary arteries. d. An increased heart rate (HR) decreases the time the heart spends in diastole, which is the time of greatest coronary blood flow. Unlike other arteries, coronary arteries are perfused when the myocardium relaxes and blood backflows from the aorta into the sinuses of Valsalva, which have openings to the right and left coronary arteries. Thus the heart has a decreased oxygen supply at a time when there is an increased oxygen demand. Tachycardia may also lead to ventricular dysrhythmia. The other options are incorrect. 18. Which effects contribute to making nitrates the first-line therapy for the treatment of angina (select all that apply)? a. Decrease preload b. Decrease afterload c. Dilate coronary arteries d. Decrease heart rate (HR) e. Prevent thrombosis of plaques f. Decrease myocardial contractility - correct answer Decrease preload Decrease afterload Dilate coronary arteries a, b, c. Nitrates decrease preload and afterload to decrease the coronary workload and dilate coronary arteries to increase coronary blood supply. The other options are not attributed to nitrates. 19. The patient has used sublingual nitroglycerin (NTG) and various long-acting nitrates but now has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling? a. Captopril b. Clopidogrel (Plavix) c. Diltiazem (Cardizem) d. Metoprolol (Lopressor) - correct answer Captopril a. Captopril would be added. It is an angiotensin- converting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling. 20. When instructing the patient with angina about taking sublingual NTG tablets, what should the nurse teach the patient? a. To lie or sit and place one tablet under the tongue when chest pain occurs b. To take the tablet with a large amount of water so that it will dissolve right away c. That if one tablet does not relieve the pain in 15 minutes, the patient should go to the hospital d. That if the tablet causes dizziness and a headache, stop the medication and call the doctor or go to the hospital - correct answer To lie or sit and place one tablet under the tongue when chest pain occurs a. A common complication of nitrates is dizziness caused by orthostatic hypotension, so the patient should sit or lie down and place the tablet under the tongue. The tablet should be allowed to dissolve under the tongue. To prevent the tablet from being swallowed, water should not be taken with it. 21. When teaching an older adult with CAD how to manage the treatment program for angina, which guidelines does the nurse use to teach the patient? a. To sit for 2 to 5 minutes before standing when getting out of bed b. To exercise only twice a week to avoid unnecessary strain on the heart c. That lifestyle changes are not as necessary as they would be in a younger person d. That aspirin therapy is contraindicated in older adults because of the risk for bleeding - correct answer To sit for 2 to 5 minutes before standing when getting out of bed a. Orthostatic hypotension may cause dizziness and falls in older adults taking antianginal agents that decrease preload. Patients should be cautioned to change positions slowly. Daily exercise programs are indicated for older adults and may increase performance, endurance, and ability to tolerate stress. A change in lifestyle behaviors may increase the quality of life and reduce the risks of CAD, even in the older adult. Aspirin is commonly used in these patients and is not contraindicated 22. When a patient reports chest pain, why must unstable angina be identified and rapidly treated? a. The pain may be severe and disabling. b. ECG changes and dysrhythmias may occur during an attack. c. Rupture of unstable plaque may cause complete thrombosis of the vessel lumen. d. Spasm of a major coronary artery may cause total occlusion of the vessel with progression to [Show Less]
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LPN NCLEX CASE STUDY QUESTIONS AND ANSWERS
Which of the following assessment findings could the nurse see in a patient with parkinsonism? (Select all that apply.) a. An abrupt onset of symptoms ... [Show More] b. Muscle rigidity c. Involuntary tremors d. Bradykinesia e. Bilateral muscle weakness - correct answer b. Muscle rigidity c. Involuntary tremors d. Bradykinesia A patient is receiving carbidopa-levodopa for parkinsonism. What should the nurse know about this drug? a. Carbidopa-levodopa may lead to hypertension. b. Carbidopa-levodopa may lead to excessive salivation. c. Dopaminergic and anticholinergic therapy may lead to drowsiness and sedation. d. Dopaminergics and anticholinergics are contraindicated in patients with glaucoma. - correct answer d. Dopaminergics and anticholinergics are contraindicated in patients with glaucoma. The nurse has initiated teaching for a family member of a patient with Alzheimer's disease. The nurse realizes more teaching is needed if the family member makes which statement? a. As the disease gets worse, the memory loss will get worse. b. There are several theories about the cause of the disease. c. Personality changes and hostility may occur. d. It may take several medications to cure the disease. - correct answer d. It may take several medications to cure the disease. A patient is taking rivastigmine (Exelon). The nurse should teach the patient and family which information about rivastigmine? a. That hepatotoxicity may occur b. That the initial dose is 6 mg t.i.d. c. That GI distress is a common side effect d. That weight gain may be a side effect - correct answer c. That GI distress is a common side effect 5.Which is a nursing intervention for a patient taking carbidopa-levodopa for parkinsonism? a. Encourage the patient to adhere to a high-protein diet. b. Inform the patient that perspiration may be dark and stain clothing. c. Advise the patient that glucose levels should be checked with urine testing. d. Warn the patient that it may take 4 to 5 days before symptoms are controlled. - correct answer b. Inform the patient that perspiration may be dark and stain clothing. What would the nurse teach a patient who is taking anticholinergic therapy for parkinsonism? (Select all that apply.) a. Avoid alcohol, cigarettes, and caffeine. b. Relieve dry mouth with hard candy or ice chips. c. Use sunglasses to reduce photophobia. d. Urinate 2 hours after taking the drug. e. Receive routine eye examinations. - correct answer a. Avoid alcohol, cigarettes, and caffeine. A patient is taking rivastigmine (Exelon) to improve cognitive function. What should the nurse teach the patient/family member to do? (Select all that apply.) a. Rise slowly to avoid dizziness. b. Remove obstacles from pathways to avoid injury. c. Closely follow the drug dosing schedule. d. Have frequent checks for hypertension. e. Receive regular liver function tests. - correct answer a. Rise slowly to avoid dizziness. b. Remove obstacles from pathways to avoid injury. c. Closely follow the drug dosing schedule. Your client has a fracture of the radius. There is swelling at the injury site and the client complains of pain in the area. Which stage of bone healing do these signs and symptoms represent? a. Cellular proliferation b. Inflammatory c. Ossification d. Callus formation - correct answer b. Inflammatory During the inflammatory phase, bleeding occurs at the area of injury and results in a hematoma. Why plus I was rushed to the area of injury to begin to debride the dead cells. The patient will experience pain during this phase. Cellular proliferation occurs after approximately 5 days, when the interrupted blood supply is recreated and fibrin strands begin to form. The callus formation stage takes about 3 to 4 weeks, while the ossification stage may take as long as 3 to 4 months. Remodeling of the bone may take months to years. Who was the English Quaker who advocated humane care and built an asylum to reflect a household? a. Florence Nightingale b. William Tukes c. Sigmund Freud d. Benjamin Rush - correct answer b. William Tukes Changes in the delivery of mental health care that resulted from the development of electroconvulsive therapy and psychotherapeutic drugs brought about which phenomenon in the 20th century? a. Behavioral therapy b. Personality disorganization c. Deinstitutionalization d. Brain surgery - correct answer c. Deinstitutionalization What is the best description of personality? a. The level of mental health that a person attains in life b. The relatively consistent set of attitudes and behaviors particular to an individual c. The result of a positive self-concept and acceptable behavior d. The ability to manage stress - correct answer b. The relatively consistent set of attitudes and behaviors particular to an individual The nurse is reviewing the assessment finding for a patient hospitalized with a stress disorder. What findings support the diagnoses? a. A vague feeling of depression b. An assumed role to protect the ego c. A main reason for all mental illnesses d. A response to any demand made upon the individual - correct answer d. A response to any demand made upon the individual The nurse is caring for a patient who is currently voicing feelings of anxiety. The nurse correctly recognizes what as the best description of the feelings that the patient is experiencing? a. A vague feeling of apprehension b. Feelings of paranoia c. Concerns about the impressions others have for her d. Emotional stability - correct answer a. A vague feeling of apprehension An assembly line manager in a factory was told that he would be laid off if his line did not meet the hourly quote. He promptly went to his workers and threatened to fire anyone who was found taking even 1 minute extra on a break. What is the manager displaying? a. Denial b. Regression c. Displacement d. Identification - correct answer c. Displacement Punishment and abandonment were how mentally ill people were treated in medieval times. These practices continued until the 17th and 18th centuries. Which care practice that is still being used today did Dr. Phillipe Pinel of France advocate? a. Electroshock therapy for melancholy b. Humane care with record keeping of behaviors c. Psychoanalysis d. Home care in the community - correct answer b. Humane care with record keeping of behaviors The student nurse is working on a presentation regarding OBRA. What was the result of this landmark legislation? a. Deinstitutionalization b. Approved surgical treatment for schizophrenia c. Prohibition of electroshock therapy d. Increased construction of state facilities for residential mental health care - correct answer a. Deinstitutionalization A 52-year old patient experienced cardiac arrest from a myocardial infarction. During his acute care stay in the hospital, the patient flirts with all female nurses. When he is asked to stop, he withdraws and later complains of chest heaviness. What is a possible explanation for the patient's behavior? a. Boredom from restricted activity b. Lack of motivation to recover c. Frustration from illness d. Threatened self-concept - correct answer d. Threatened self-concept A 14-year-old tells the school nurse that she is self-conscious about her recent breast development. She reports that the boys in her class are teasing her. What is the first step for the nurse to take? a. Call her parents b. Have her describe what happened c. Ask who her friends are d. Provide her with a pamphlet outlining the changes associated with puberty - correct answer b. Have her describe what happened Your patient with heart failure has been responding well to treatments that include medications such as ACE inhibitors and a loop diuretic. Today, the client is complaining about leg weakness and is refusing to ambulate. What is most likely occurring with this client? a. Hyperkalemia b. Hyponatremia c. Hypokalemia d. Hypernatremia - correct answer c. Hypokalemia Hypokalemia, or low potassium, often occurs as the result of treatments with loop diuretics like furosemide (Lasix). The signs and symptoms of hypokalemia include muscular weakness, pain and cramping, as well as serious cardiac dysrhythmias. Clients taking loop diuretics should be closely monitored for hypokalemia and also given potassium supplementation when indicated. Which of the following assistive techniques should the be used to transfer a patient who can bear weight from the bed to the chair? a. mechanical lift b. slide transfer c. pivot transfer d. assisted transfer - correct answer c. pivot transfer Your client is to have an NG tube inserted. To mark the tube prior to insertion, you should: a. place the tip of the tube at the corner of the patient's eye and extend the tip to the earlobe, and then to the tip of the xiphoid process. b. place the tip of the tube at the corner of the mouth and extend the tip to the top of the patient's ear, and then to the umbilicus. c. place the tip of the tube at the patient's nostril and extend the tip of the earlobe, and then to the tip of the xiphoid process. d. place the tip of the tube at the patient's nostril , extend it to the tip of the earlobe, and then to the base of the ribcage. - correct answer c. place the tip of the tube at the patient's nostril and extend the tip of the earlobe, and then to the tip of the xiphoid process. A patient with a history of alcohol abuse is arrested for driving under the influence. His wife bails him out of jail for the third time. His wife's response is an example of: a. attachement disorder b. reactivity c. codependency d. addiction - correct answer c. codependency codependency is a type of dysfunction in which one individual supports the addiction, substance abuse, immaturity, or other poor behavior of another in a relationship. Successful communication includes which of the following components? - correct answer Appropriateness, efficiency, flexibility, feedback According to Elizabeth Kubler-Ross, all of the following are considered stages of grief except: - correct answer Resentment Elizabeth Kubler-Ross, a psychiatrist, proposed a model that describes 5 stages commonly seen in those experiencing grief. These stages, which can occur in any order, include: denial, anger, bargaining, depression, and acceptance. The acronym "DABDA: can be used to help recall the 5 stages of grief. The purpose of inserting a chest tube is to: - correct answer Restore negatie pressure int he intrapleural space. Insertion of a chest tube is an invasive procedure designed to restore negative pressure in the intrapleural space. When the normally negative pressure of the intrapleural space is disrupted, it causes the lung to collapse and a patient to develop respiratory symptoms. Therefore, the tube is placed to restore negative pressure until the underlying condition can heal. Conditions that commonly necessitate a chest tube include a pneumothorax, blunt chest trauma, empyema, or hemothorax A 70-year-old obese males admitted to the cardiac unit with new onset of atrial fibrillation. While in the hospital, the night shift nurse notes that the patient is snoring loudly, then waking abruptly. In the early morning , he reports being excessively tired during the day. The nurse is suspicious for which of the following? - correct answer Obstructive sleep apnea Obstructive sleep apnea is a disorder found most often in older obese males. It is the lack of air flow due to an obstruction of the pharynx during sleep. Patients with obstructive sleep apnea often snore loudly and awaken frequently throughout the night following episodes of apnea. They often report daytime tiredness, sore throat, and headaches. For severe cases of sleep apnea, a device called a continuous positive airway pressure (CPAP) machine may be utilized. An elevated bilirubin may be a sign of: - correct answer Liver disease Bilirubin is a yellowish substance found in bile. It is produced by the body when red blood cells are broken down by the liver. Low levels of bilirubin are not typically a concern. High levels of bilirubin, however, may be a sign of disease and require further evaluation. The diagnostic marker used in patients with CHF is called: - correct answer B-type natriuretic peptide B-type natriuretic peptide (BNP) is secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. An 80-year-old male presents to the emergency department with dyspnea and a history of COPD. The licensed practical nurse teaches him about which type of the following positions to relieve dyspnea? - correct answer Tripod Proper positioning can provide relief for patients with COPD. The tripod position, in which the patient sits or stands leaning forward with the arms supported, forces the diaphragm down and forward and stabilizes the chest while reducing the work of breathing. Purse-lipped breathing may also be encouraged to control dyspnea and shortness of breath. The organization responsible for promoting safer, higher quality care among hospital organizations in addition to evaluating and providing accreditation is known as: - correct answer The joint commission (TJC) The Joint Commission is a non-profit organization that works to promote safer, higher quality care in hospital organizations. The Joint Commission is also responsible for evaluating and designating organizations with accreditation. Finally, the Commission publishes annual patient safety goals in order to improve overall patient safety. You are assigned charge nurse responsibilities for the upcoming month. In creating the schedule, you assign a fellow nurse that you do not get along with every holiday shift, despite the requirements being one holiday per season. This action is a violation of which ethical principle? - correct answer Non-maleficence Non-maleficence is the ethical principle that refers to "doing no harm." It can refer to doing no harm to patients, or doing no harm to fellow health care workers as well. Within this principle, one should act with empathy and without malicious intent. [Show Less]
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MARK KLIMEK BLUE BOOK (ALL) NCLEX STUDY GUIDE
Name the five/six essential nutrients - correct answer carbs, fats, proteins, vitamins, minerals, water The major source of energy for the body is - cor... [Show More] rect answer carbs carbs provide ____________ Kcalories per 1 gram - correct answer 4 Sucrose is a sugar found in ____________ and _____________. - correct answer fruits, veggies Lactose is a sugar found in ? - correct answer milk What is glycogen? - correct answer It is a stored formed of glucose/energy manufactured by the liver Is glycogen eaten in foods? - correct answer NO! It is a stored form of glucose MANUFACTURED by the liver. When the body does not receive enough carbs it burns ___________ and _____________. - correct answer protein, fat The most concentrated source of energy for the body is ___________. - correct answer fats Fats provide ___________ Kcalories per 1 gram. - correct answer 9 Fats carry vitamins - correct answer A,D,E,K (Remember FADE K!) The nutrient needed most for growth and repair of tissues is _____________. - correct answer protein (second best is Vit C) Proteins provide __________ Kcalories per 1 gram. - correct answer 4 Vitamins and minerals provide energy for the body. (T/F) - correct answer False- they are necessary for a body's chemical reactions. Water is present in ALL body tissues. (T/F) - correct answer True (even bone) Water accounts for ________ to ___________% of an adult's total weight? - correct answer 50 to 60% Name the four basic food groups - correct answer Milk & Cheese, Meat & Legumes, Veggies & Fruits, Bread & Cereal Water acounts for __________ to _________% of an infant's total weight? - correct answer 70 to 75% An individual is overweight if they are ________% above the ideal weight. - correct answer 10 An individual is obese if they weigh ________% above the ideal weight. - correct answer 20 What solution and material are used to cleanse the eyes of an infant? - correct answer Plain water, cotton balls, washcloths Can you use cotton swabs to clean the eyes, nares or ears of an infant? - correct answer No, this is dangerous Can you use the same cotton ball/washcloth edge for both eyes? - correct answer No, it would cross contaminate Should you cover an unhealed umbilical site with the diaper? - correct answer No, fold the diaper down. What temperature is appropriate for the water used to bathe an infant? - correct answer 100 to 105 What is the #1 purpose of a tepid sponge bath? - correct answer Lower body temperature during fever. How should the temperature of the water be tested if no thermometer is available? - correct answer Dropping water on inside surface of your forearm. With which body part do you begin when bathing an infant? - correct answer Eyes always When cleansing an infant's eye, cleanse from outer to inner canthus? - correct answer No, inner to outer Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area? - correct answer No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced. When sponge-bathing with tepid water the correct temp is _____________. - correct answer 98.6 F How long does it take for the umbilical stump to fall off? - correct answer 7 to 14 days The primary reason why an infant is draped during the bath is to provide privacy. (T/F) - correct answer False, the primary purpose of draping is to prevent chilling. You may use friction to remove vernix caseosa from an infant's skin. (T/F) - correct answer False, it causes damage/bruising What solution is commonly used for care of umbilical cord? - correct answer 70% alcohol to promote drying (trend is toward soap and water) What cranial nerve is affected in Bell's Palsy? - correct answer #7, facial nerve What is the #1 symptom of Bell's Palsy? - correct answer One sided (unilateral) facial paralysis Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months. - correct answer 4 to 6 In addition to the facial paralysis, the sense of ______ is also affected. - correct answer taste Will the patient be able to close their eye on the affected side? - correct answer no Give three eye interventions for the client with Bell's Palsy. - correct answer Dark glasses, artificial tears, cover eye at night As the prostate enlarges it compresses the ___________ and causes urinary ________. - correct answer Urethra, rentention At what age does BPH occur? - correct answer men over 50 years of age What does BPH stand for? - correct answer Benign Prostatic Hypertrophy IN BPH the man has (increased/decreased) frequency of urination - correct answer increased In BPH the force of the urinary stream is (increased/decreased). - correct answer decreased The man with BPH has a _________-stream of urine - correct answer forked The man with BPH has hesitancey. What does this mean? - correct answer Difficulty starting to void Will the man with BPH have enuresis, nocturia or hematuria? - correct answer Enuresis-No, Nocturia-Yes, and Hematuria-Maybe Enuresis - correct answer inability to control the flow of urine and involuntary urination What is the best way to screen men for BPH? - correct answer Digital rectal exam Should fluids be forced or restricted in BPH? - correct answer forced What does TURP stand for? - correct answer Transurethral resection of the prostate The most radical prostate surgery is the ____________ prostatectomy. - correct answer Perineal What type of diet is used in BPH? - correct answer Acid Ash Acid Ash diet - correct answer Decrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes. What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP? - correct answer To keep the catheter clear of clots and to drain urine What solution is used for CBI? - correct answer Normal saline (0.9 NaCl) How fast do you run the CBI? - correct answer At whatever rate it takes to keep the urine flowing and free of clots What drug is use to treat bladder spasm? - correct answer B&O suppositories (Belladonna & Opiates) Should you take a rectal temp after prostatectomy? Give stool softeners? - correct answer No rectal temperatures, yes stool softeners You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing. - correct answer Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.) If you see an increase in blood content of urine coming out of the catheter, you would first ___________. - correct answer Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon. If you see clots in the tubing you would first ____________. - correct answer Increase the flow-rate. What exercises should the post prostectomy patient do upon discharge? Why? - correct answer Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op Will the post prostectomy patient be impotent? - correct answer If TURP, no impotence, if perineal prostatectomy, yes impotence How often should the drainage bag be emptied? - correct answer Every 8 hours What is the most common problem due to catheterization? - correct answer UTI What is the most common organism to cause UTI with catheterization? - correct answer E. coli What is the most common route for organisms to enter the blader when a catheterization is used? - correct answer Up through the inside of the catheter in the days following catheterization Name foods that make acid urine - correct answer Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What is important about the level of the urinary drainage bag? - correct answer Never have the bag at a higher level than the bladder. How is the catheter taped in a male client? - correct answer To the lateral thigh or abdomen How is the catheter taped in a female client? - correct answer To the upper thigh What urinary pH prevents UTI? - correct answer Acidity, low pH Should the drainage bag ever touch the floor? - correct answer No Is it ok to routinely irrigate indwelling catheters? - correct answer No What agents are best for catheter care? - correct answer Soap and water What is the most effective way to decrease UTI with catheters? - correct answer Keep the drainage system closed, do not disconnect junction of tubing Give some signs of infection in a Foley catheter - correct answer Cloudy urine, foul smelling urine, hematuria Is urinary incontinence an indication for catheterization? - correct answer No Give three appropriate indications for bladder catheterization? - correct answer Urinary retention, to check for residual, to monitor hourly output What are the top 2 diagnoses for a client with a catheter? Which is #1? - correct answer #1- Potential for infection; Potential impairment of urethral tissue integrity What is systole? - correct answer The MAXIMAL force of blood on artery walls What is diastole? - correct answer The LOWEST force of blood on artery walls Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm. - correct answer Two-thirds Which artery is most commonly used to measure blood pressure? - correct answer Brachial Can the thigh EVER be used to obtain a blood pressure? - correct answer Yes, but this is rare. When pressure is auscultated the first sound heard is the ____________ measurement. - correct answer Systolic The change in the character of the sounds is known as the ________ - correct answer First diastolic sound The cessation of sounds is known as the _________ - correct answer Second diastolic sound When 2 values are given in a blood pressure the first is the __________measurement. - correct answer Systolic When 2 values are given in a blood pressue, the bottom number stands for the change in sounds or cessation of sounds? - correct answer Cessation of sounds What is the normal adult blood pressure? - correct answer 120/80 Abnromally high blood pressure is called____________. - correct answer Hypertension What is the pulse pressure? - correct answer The difference between the systolic and the diastolic blood pressure If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why? - correct answer High, venous congestion makes the arterial pressure higher (increases resistance) If you use too narrow of a cuff the reading will be too high or low? - correct answer High Vasoconstriction will ___________ blood pressure. - correct answer Increase Vasodilation will ____________ blood pressure. - correct answer Decrease Shock will ___________ blood pressure. - correct answer Decrease Increased intracranial pressure will _________ the pulse pressure. - correct answer Increase or Widen If my blood pressure is 190/110, what is my pulse pressure? - correct answer 80 mmHg What blood test must be done before a transfusion? - correct answer Type and cross match What does a type and cross match indicate? - correct answer Whether the client's blood and donor blood are compatible. What should the nurse measure before starting a transfusion? - correct answer Vital signs With what solution should blood be transfused? - correct answer 0.9 normal saline How many nurses are requried to check the blood? - correct answer 2 nurses What happens when blood is administered with Dextrose IVs? - correct answer The cells clump together & don't flow well If a transfusion reaction occurs what should the nurse do first? - correct answer Stop the blood flow & start running the saline How long can a unit of blood be on the unit before it must be started? - correct answer Less than 1/2 hour What should the nurse do with the IV line if transfusion reaction is suspected? - correct answer Keep it open with saline If a transfusion reaction is suspected, what two samples are collected and sent to the lab? - correct answer Urine & blood If a unit of blood is infused through a central line it must be__________. - correct answer Warmed Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing, Increased Blood Pressure, Low Back Pain - correct answer Low back pain, wheezing, fever, hives What are three types of transfusion reactions that can occur? - correct answer Hemolytic, febrile, allergic What would you do first if you suspected transfusion reaction? - correct answer Stop the blood and start the saline What are the signs and symptoms of a hemolytic transfusion reaction? - correct answer Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria What are the signs and symptoms of a febrile transfusion reaction? - correct answer Low back pain, shaking HA, increasing temperature, confusion, hemoptysis What are the signs of symptoms of an allergic reaction to a transfusion? - correct answer Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia) Give three reasons for a blood transfusion - correct answer Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components What does blood-typing mean? - correct answer Check for surface antigen on the red blood cell When does typing and cross matching need to be done? - correct answer Whenever a client is to get a blood product. It is only good for 24 hours. What does blood cross matching mean? - correct answer Mixing a little of the client's blood with the donor blood and looking for agglutination. When are hemolytic transfusion reactions likely to occur? - correct answer In the first 10 to 15 minutes When is a febrile reaction likely to occur? - correct answer Within 30 minutes of beginning the transfusion What test identifies Rh factor? - correct answer Coombs test detects antibodies to Rh What is the difference between whole blood and packed cells? - correct answer Packed cells don't have nearly as much plasma or volume as whole blood does What would you do if the client had an increasing temperature and was to get blood? - correct answer Call the MD because blood is often held with an elevated temperature How long should it take for one unit of blood to infuse? - correct answer From one hour to three hours How long should you stay with the patient after beginning a transfusion? - correct answer At least 15 to 30 minutes What blood type is the universal recipient? - correct answer AB What blood type is the universal donor? - correct answer O What is the routine for vital sign measurement with a transfusion? - correct answer Once before administration [Show Less]
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NCLEX STUDY EXAM 3 WITH QUESTIONS-INFANTS
1.The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure. The nurse should assess the infant for which early si... [Show More] gn of HF? a.Pallor b.Cough c.Tachycardia d.Slow and shallow breathing - correct answer c. Tachycardia 2.The nurse reviews the laboratory results for a child with suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? a.Immunoglobulin b.Red blood cell count c.White blood cell count d.Anti-streptolysin O titer - correct answer d. Anti-streptolysin O titer 3. On assessment of a child admitted with a diagnosis of acute stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? a.Cracked lips b.Normal appearance c.Conjunctival hyperemia d.Desquamation of the skin - correct answer c. Conjunctival hyperemia 4.The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? a."I will not mix the medication with food." b."I will take my child's pulse before administering the medication." c."If more than 1 dose is missed, I will call the health care provider." d."If my child vomits after medication administration, I will repeat the dose." - correct answer d. "If my child vomits after medication administration, I will repeat the dose." The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? a.Weighing the diapers b.Inserting a urinary catheter c.Comparing intake with output d.Measuring the amount of water added to formula - correct answer a. Weighing the diapers 6. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? a. Pallor b. Hyperactivity c. Exercise intolerance d. Gastrointestinal disturbances - correct answer c. Exercise intolerance 7. A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? a. "Has the child complained of back pain?" b. "Has the child complained of headaches?" c. "Has the child had any nausea or vomiting?" d. "Did the child have a sore throat or fever within the last two months?" - correct answer d. "Did the child have a sore throat or fever within the last two months?" 8. A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? a. During sleep b. When changing the infant's diapers c. When the mother is holding the infant d. When drawing blood for electrolyte level testing - correct answer d. When drawing blood for electrolyte level testing 9.Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? a. Aortic stenosis b. Arterial septal defect c. Patent ductus arteriosus d. Ventricular septal defect - correct answer c. Patent ductus arteriosus 10. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a. Warm, dry skin b. Decreased wheezing c. Pulse rate of 90 beats/minute d. Respirations of 18 breaths/minute - correct answer b. Decreased wheezing 11. The mother of an 8-year-old child being treated for right lower love pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the ride side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother? a. Increase the dose of ibuprofen b. Increase the frequency of ibuprofen c. Encourage the child to lie on the left side d. Encourage the child to lie on the right side - correct answer d. Encourage the child to lie on the right side 12. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep, in which position should the nurse tell the parent to place the infant? a. Side or prone b. Back or prone c. Stomach with the face turned d. Back rather than on the stomach - correct answer d. Back rather than on the stomach 13. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? a. "The immunization schedule will need to be altered." b. "The child should not receive any hepatitis vaccines." c. "The child will receive all of the vaccines except for the polio series." d. "The child will receive the recommended basic series of immunizations alone with a yearly influenza vaccination." - correct answer d. "The child will receive the recommended basic series of immunizations alone with a yearly influenza vaccination." 14. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor which indication that the child may be experiencing an obstruction? a. The child exhibits nasal flaring and bradycardia b. The child is leaning forward with the chin thrust out c. The child has a low-grade fever and complains of a sore throat d. The child is leaning backward supporting themselves with the hands and arms - correct answer b. The child is leaning forward with the chin thrust out 15. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? a. Tell the mother that the child must stay in the tent. b. Place a toy in the tent to make the child feel more comfortable. c. Call the health care provider and obtain a prescription for a mild sedative. d. Let the mother hold the child and direct the cool mist over the child's face. - correct answer d. Let the mother hold the child and direct the cool mist over the child's face. 16. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? a. Positive b. Negative c. Inconclusive d. Definitive and requiring a repeat test - correct answer a. Positive 17. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? a. "The child may be allergic to antibiotics." b. "The child is too young to receive antibiotics." c. "Antibiotics are not indicated unless a bacterial infection is present." d. "The child still has the maternal antibodies from birth and does not need antibiotics." - correct answer c. "Antibiotics are not indicated unless a bacterial infection is present." 18. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? a. Initiate strict enteric precautions b. Move the infant to a room with another child with RSV. c. Leave the infant in the present room because RSV is not contagious. d. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child. - correct answer b. Move the infant to a room with another child with RSV. 19. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which intervention should the nurse include in the plan of care? Select all that apply. a. Place the infant in a private room b. Ensure that the infant's head is in a flexed position c. Wear a mask at all times when in contact with the infant d. Place the infant in a tent that delivers warm humidified air e. Position the infant on the side, with the head lower than the chest f. Ensure that the nurses caring for the infant with RSV do not care for other high-risk children - correct answer a. Place the infant in a private room f. Ensure that the nurses caring for the infant with RSV do not care for other high-risk children 20. The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings and documented in the record, knowing that which sign is most likely led the mother to seek health care for the infant? a. Diarrhea b. Projectile vomiting c. Regurgitation of feedings d. Foul smelling, ribbon like stools - correct answer d. Foul smelling, ribbon like stools 21. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? a. Prone position b. On the stomach c. Left lateral position d. Right lateral position - correct answer c. Left lateral position 22. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? a. Incessant crying b. Coughing at nighttime c. Choking with feedings d. Severe projectile vomiting - correct answer c. Choking with feedings 23. The nurse is providing feeding instructions to a parent of an infant with gastroesophageal reflux disease (GERD). Which instructions should the nurse give to the parent to reduce the episodes of emesis? a. Provide less frequent, larger feedings b. Burp the infant less frequently during feedings c. Thing the feedings by adding water to the formula d. Thicken the feedings by adding rice cereal to the formula - correct answer d. Thicken the feedings by adding rice cereal to the formula 24. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? a. Diarrhea b. Metabolic acidosis c. Metabolic alkalosis d. Hyperactive bowel sounds - correct answer c. Metabolic alkalosis 25. The nurse is caring for a for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing which is the clinical manifestation associated with this disorder? a. Bile-stained fecal emesis b. The passage of currant jelly-like stools c. Failure to pass meconium stool in the first 24 hours after birth d. Sausage-shaped mass palpated in the upper right abdominal quadrant - correct answer c. Failure to pass meconium stool in the first 24 hours after birth 26. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which date would the nurse expect to obtain when asking the parent about the child's symptoms? a. Watery diarrhea b. Projectile vomiting c. Increased urine output d. Vomiting large amounts of bile - correct answer b. Projectile vomiting 27. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food in the child's diet? a. Rice b. Oatmeal c. Rye toast d. Wheat bread - correct answer a. Rice 28. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which signs of this disorder documented? a. Watery diarrhea b. Ribbon-like stools c. Profuse projectile vomiting d. Bright red blood and mucus in the stools - correct answer d. Bright red blood and mucus in the stools 29. Which interventions should the nurse include when creating a plan of care for a child with hepatitis? Select all that apply. a. Providing a low-fat, well balanced diet b. Teaching the child effective hand-washing techniques c. Scheduling playtime in the playroom with other children d. Notifying the health care provider if jaundice is present e. Instructing the parents to avoid administering medication unless prescribed f. Arranging for indefinite home schooling because the child will not be able to return to school - correct answer a. Providing a low-fat, well balanced diet b. Teaching the child effective hand-washing techniques e. Instructing the parents to avoid administering medication unless prescribed 30. The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis? a. "I'm so glad they didn't find any protein in his urine." b. "I noticed his urine was the color of coca-cola lately." c. "His health care provider said his kidneys are working well." d. "The nurse who admitted my child said his blood pressure was low." - correct answer b. "I noticed his urine was the color of coca-cola lately." 31. The nurse is performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common character is associated with this syndrome? a. Hypertension b. Generalized edema c. Increased urinary output d. Frank, bright red blood in the urine - correct answer b. Generalized edema 32. The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure? a. Restrict fluids as prescribed b. Care for the arteriovenous fistula c. Encourage foods high in potassium d. Administer analgesics as prescribed - correct answer a. Restrict fluids as prescribed 33. A 7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents? a. Primary nocturnal enuresis is caused by a psychiatric problem b. Primary nocturnal enuresis does not respond to treatment c. Primary nocturnal enuresis requires surgical intervention to improve the problem d. Primary nocturnal enuresis is usually outgrown without therapeutic intervention - correct answer d. Primary nocturnal enuresis is usually outgrown without therapeutic intervention 34. The nurse provided discharge instructions to the parents of a 2-year-old who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates a need for further instruction? a. "I'll check his temperature." b. "I'll give him medication so he'll be comfortable." c. "I'll check his voiding to be sure there's no problem." d. "I'll let him decide when to return to his play activities." - correct answer d. "I'll let him decide when to return to his play activities." 35. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? a. "Caution should be used when straddling the infant on the hip." b. "Vital signs should be taken daily to check for bladder infection." c. "Catheterization will be necessary when the infant does not void." d. "Circumcision has been delayed to save tissue for surgical repair." - correct answer d. "Circumcision has been delayed to save tissue for surgical repair." 36. The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? a. Cover the bladder with petroleum jelly gauze b. Cover the bladder with nonadherent plastic wrap c. Apply sterile distilled water dressings over the bladder mucosa d. Keep the bladder tissue dry by covering it with a dry sterile gauze - correct answer b. Cover the bladder with nonadherent plastic wrap 37. Which question should the nurse ask the parents of a child suspected of having glomerulonephritis? a. "Did your child fall off a bike onto the handlebars?" b. "Has the child had persistent nausea and vomiting?" c. "Has the child been itching or had a rash anytime in the last week?" d. "Has the child had a sore throat or a throat infection in the last few weeks?" - correct answer d. "Has the child had a sore throat or a throat infection in the last few weeks?" 38. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note? a. Hematuria b. Proteinuria c. Bacteriuria d. Glucosuria - correct answer c. Bacteriuria 39. The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply. a. Pallor b. Edema c. Anorexia d. Proteinuria e. Weight loss f. Decreased serum lipids - correct answer a. Pallor [Show Less]
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CULTURE NCLEX STUDY QUESTIONS AND ANSWERS NSG 3645
Nurses caring for patients in health care facilities need to provide culturally competent care to an increasingly diverse population. Which statements accu... [Show More] rately describe a characteristic of cultural diversity that exists in the United States? Select all that apply. The United States has become less inclusive of same-sex couples. Cultural diversity is limited to people of varying cultures and races. Cultural diversity is separate and distinct from health and illness. Individuals may be members of multiple cultural groups at one time Culture guides what is acceptable behavior for people in a specific group. Cultural practices may evolve over time but mainly remain constant. - correct answer d, e, f Each individual may be a member of multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. The United States has become more inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, including culture, ethnicity, and race, is an integral component of both health and illness. In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system, including cultural imposition. Which examples exemplify cultural imposition? Select all that apply. a) A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. b) A nurse treats all patients the same whether or not they come from a different culture. c) A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. d)A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. e) A nurse directs interview questions to an elderly patient's daughter even though the patient is capable of answering them. f) A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage. - correct answer a, d Cultural imposition occurs when a hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily and when a Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. Cultural blindness occurs when a nurse treats all patients the same whether or not they come from a different culture. Cultural conflict occurs when a nurse ridicules a patient by telling another nurse that Jewish diet restrictions are just a way for Jewish patients to get a special tray of their favorite foods. When a nurse refuses to respect an elderly person's ability to speak for oneself, or if the nurse refuses to treat a patient based on that patient's sexual orientation, the nurse is engaging in stereotyping. A nurse caring for culturally diverse patients in a physician's office is aware that patients of certain cultures are more prone to specific disease states than the general population.which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. a) A Native American patient b) An African American patient c) A Pacific Island patient d) An Asian patient e) A White patient f) A Hispanic patient - correct answer a, e, f Native Americans, Hispanics, and Whites are more prone to developing diabetes mellitus. African Americans are prone to hypertension, stroke, sickle cell anemia, lactose intolerance, and keloids. Asians and Pacific Islanders are prone to hypertension, liver cancer, thalassemia, and lactose intolerance. A nurse is providing nutritional counseling to culturally diverse patients with dietary restrictions. Which statement accurately describes a dietary concern based on a specific culture? a) Many Native Americans follow a diet that is alcohol- and pork-free. b) Many White Americans have a diet that is high in starch. c) Asians often eat a diet that is high in salt. d) Muslims may have special diets based on the hot/cold theory of treating illness. - correct answer c The Asian diet is often high in salt due to cooking with soy sauce. Many Muslims follow a halal diet that is free of alcohol, pork, and pork products. Hispanics often have a diet that is high in starch. Hispanics also may practice the hot/cold theory of treating illness and require a special diet. The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? a) cultural assimilation b) cultural imposition c) culture shock d) ethnocentrism - correct answer a When minority groups live within a dominant group, many members lose the cultural characteristics that once made them different in a process called assimilation. Cultural imposition occurs when one person believes that everyone should conform to his or her own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups. A nurse states, "That woman is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? a) cultural imposition b) clustering c) cultural competency d) stereotyping - correct answer d stereotyping is assuming that all members of a group are alike A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What should the nurse do? a) Use short words and talk more loudly b) Ask an interpreter for help c) Explain why care can't be provided d) Provide instructions in writing - correct answer b Many agencies have a qualified interpreter who understands the health care system and can reliably provide assistance. A nurse is interviewing a newly admitted patient. Which question would be considered culturally sensitive? a) "Do you think you will be able to eat the food we have here?" b) "Do you understand that we can't prepare special meals?" c) "What types of food do you eat for meals?" d) "Why can't you just eat our food while you are here?" - correct answer c asking patients what types of food they eat for meals is culturally sensitive A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. What term best describes what the nurse is doing? a) cultural imposition b) clustering c) cultural competency d) stereotyping - correct answer a The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years. A nurse is teaching a novice nurse how to provide culturally competent care to patients in a culturally diverse community health clinic. Although all of the following are important to providing culturally competent nursing care, which one is most basic? a) Learning the predominant language of the community b) Obtaining significant information about the community c) Treating each patient at the clinic as an individual d) Recognizing the importance of the patient's family - correct answer c In all aspects of nursing, it is important to treat each patient as an individual. This is also true in providing culturally competent care. This basic objective can be accomplished by learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life. White cultural factors - correct answer Family -Nuclear family is highly valued. - Elderly family members may live in a long-term care facility when they can no longer care for themselves. Folk and Traditional Health Care -Self-diagnosis of illnesses -Use of over-the-counter drugs (especially vitamins and analgesics) -Dieting (especially fad diets) -Extensive use of exercise and exercise facilities Values and Beliefs -Youth is valued over age -Cleanliness -Orderliness -Attractiveness -Individualism -Achievement -Punctuality Nursing Considerations -Careful assessment of client's use of over-the-counter medications (observe for signs and symptoms of toxic medication levels, especially fat-soluble vitamins) -Nutritional assessments of dietary habits African American cultural factors - correct answer Family -Close and supportive extended-family relationships -Strong kinship ties with nonblood relatives from church or organizational and social groups -Family unity, loyalty, and cooperation are important. -Usually matriarchal Folk and Traditional Health Care -Varies extensively and may include spiritualists, herb doctors, root doctors, conjurers, skilled elder family members, voodoo, faith healing Values and Beliefs -Present oriented -Members of the African American clergy are highly respected -Frequently highly religious Nursing Considerations -Many African American families may still use various folk healing practices and home remedies for treating particular illnesses. -Special care may be necessary for the hair and skin. -Special consideration should be given to the sometimes extensive and frequently informal support networks of patients (e.g., religious and community group members who offer assistance in a time of need). Asian cultural factors - correct answer Family -welfare of family is valued above the person -extended families common -person's ancestors are respected -sharing among family members is expected Folk and Traditional Health Care - Theoretical basis is in Taoism, which seeks a balance in all things - proper balance of yin (feminine, negative, dark, cold) and yang (masculine, positive, light, warm) -diseases and foods are classified as hot or cold and a proper balance between them will promote wellness Values and Beliefs - strong sense of self-respect and self-control [Show Less]
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NCLEX STUDY QUESTIONS AND ANSWERS-DRUG ABUSE
A patient is brought to the emergency department (ED) by a friend. The patient is unresponsive and respirations are slow and shallow. Which of the followin... [Show More] g is the priority intervention? -Check the patient's blood glucose level -Administer naloxone, per protocol -Administer 100% oxygen per nasal cannula -Ask the friend if they were using illicit drugs - correct answer -Administer 100% oxygen per nasal cannula Which of the following assessment findings in a patient's health history supports a diagnosis of substance dependence? -Numerous legal problems and interpersonal conflicts -Withdrawal symptoms when not using the substance -Impaired judgment and risk-taking behaviors -Continued tardiness and absenteeism from work - correct answer -Withdrawal symptoms when not using the substance A patient presents to the clinic with a report of fatigue and difficulty concentrating. Which additional statement made by the patient would alert the healthcare provider to possible marijuana use? -"I feel nauseous and don't feel like eating." -"I feel anxious and have trouble sleeping." -"I've noticed that my eyes are red lately." -"I keep having really vivid and scary nightmares." - correct answer -"I've noticed that my eyes are red lately." Emergency medical personnel bring an unconscious patient to the emergency department. The patient's pupils are pinpoint and respirations are depressed. Intoxication of which of the following substances could contribute to these clinical signs? -Methamphetamine -Methadone -Cocaine -Ecstasy - correct answer -Methadone A patient who has a history of chronic back pain requires a higher dose of an opioid medication in order to achieve adequate pain relief. The healthcare provider suspects that these findings are a result of which of the following? -Dependence -Pseudoaddiction -Addiction -Tolerance - correct answer -Tolerance A patient is admitted to the medical unit after experiencing chest pain. Which of these additional findings would support a diagnosis of cocaine abuse? -Jaundice -Hypotension -Perforated nasal septum -Profuse diarrhea - correct answer -Perforated nasal septum 'pseudo-addiction?' - correct answer A condition where a patient is experiencing severe pain, as a result of a chronic illness but the signs and symptoms of this are misunderstood. Carers and other healthcare professionals may interpret the patient's request for painkillers as a form of addiction. Perforated nasal septum - correct answer Where the cartilaginous membrane dividing the nostrils, develops a hole or fissure. Which of the following goals would the healthcare provider identify as realistic for a patient with a substance abuse problem? -Explore genetic anomalies associated with substance abuse -Use the substance only in moderation and in certain situations -Identify situations that trigger a desire to use the substance -Focus on how cravings can be eliminated by enhancing willpower - correct answer -Identify situations that trigger a desire to use the substance A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? -Bradycardia and hyporthermia -Irritability and nausea -Hyperthermia and euphoria -Depressed respirations and somnolence - correct answer -Irritability and nausea Hypothermia - correct answer Abnormally low body temp. Bradycardia - correct answer Abnormally slow heart action. A patient is brought to the emergency department by a family member. The patient has been agitated for the past several hours and has alternated between grandiosity and expressing a desire to commit suicide. Upon examination, the patient is diaphoretic, hypertensive, and tachycardic. Intoxication with which of the following substances would contribute to these symptoms? -Methamphetamine -Benzodiazepine -Marijuana -Alcohol - correct answer -Methamphetamine Diaphoretic - correct answer Inducing perspiration, excessive sweating. Tachycardia - correct answer Abnormally fast heart rate Hypertensive (High blood pressure) - correct answer A condition in which the force of the blood against the artery walls is too high. A patient reports smoking 10 cigarettes per day for 40 years. How will the healthcare provider document this patient's smoking habit in terms of pack years? -20 pack years -10 pack years -4 pack years -5 pack years - correct answer -5 pack years How many cigarettes are in a pack year? - correct answer 20 cigarettes a day for a yea [Show Less]
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NCLEX PNEUMONIA STUDY QUESTIONS
The nurse is caring for a pt w/ COPD and pneumonia who has an order for ABGs to be drawn. What is the min lenth of time the nurse should paln to hold press... [Show More] ure on punture site? 2 min 5 min 10 min 15 min - correct answer 5 min An artery is an elastic vessel under much higher pressure than veins, and significant blood loss or hematoma formation could occur if the time is insufficient. The pt is hospitalized with pneumonia. Which diagnostic test should be used to measure the efficiency of gas transfer in the lung and tissue oxygenation? Thoracentesis Bronchoscopy ABGs Pulmonary Function Tests - correct answer ABGs To promote airway clearance in a pt with pneumonia, what should the nurse instruct the pt to do? Select all that apply. a) Maintain adequate fluid intake. b) Splint the chest when coughing. c) Maintain a 30-degree elevation. d) Maintain a semi-fowlers position. e) Instruct pt to cough at end of exhalation. - correct answer A, B, E Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The RN should instruct pt to splint the chest while coughing. This will reduce discomfort and allow for more effective coughing. Coughing at end of exhalation promotes efficient cough. Pt position should be upright sitting with head slightly flexed. The RN caring for a pt admitted to the hospital with pneumonia. Upon assessment, the RN notes a temp of 101.4, a productive cough w/ yellow sputum, and a RR of 20. Which nursing diagnosis is most appropriate based on this assessment? Hyperthermia related to infectious illness. Ineffective thermoregulation related to chilling Ineffective breathing pattern related to pneumonia Ineffective airway clearance related to thick secretions - correct answer Hyperthermia related to infectious illness. B/c the pt has a spiked temp and has diagnosis of pneumonia, the logical nursing diagnosis is this. There is no evidence of a chill and her breathing pattern is w/in normal limits 12-20 breaths/min. there is no evidence of ineffective airway clearance from info given b/c pt is expectorating sputum. Which clinical manifestations should the nurse expect to find during assessment of a pt admitted with pneumonia? Hyper-resonance on percussion. Vesicular breath sounds in all lobes. Increased vocal fremitus on palpation. Fine crackles in all lobes on auscultation. - correct answer Increased vocal fremitus on palpation. This is a typical physical finding. With pleural effusion, there may be dullness to percussion over the affected area. During discharge teaching for a 65 y.o. pt with COPD and pneumonia, which vaccine should the nurse recommend that this pt receive? Pneumococcal S. Aureus Haemophilus influenzae Bacille-Calmette-Guerin (BCG) - correct answer Pneumococcal This vaccine is important for pt's w/ a hx of heart or lung disease, recovering from severe illness, age 65 or over, or living in a long-term care facility. The RN evaluates that discharge teaching for a pt hospitalized with pneumonia has been EFFECTIVE when the pt makes which statement about measures to prevent a relapse? a) I will seek immediate medical treatment for any upper resp infections. b) I should cont. to do deep-breathing and coughing exercises for at least 12 wks. c) I will increase my food intake to 2400 cal/day to keep my immune system well. d) I must have a follow-up chest x-ray in 6-8 wks to evaluate the pneumonia's resolution. - correct answer D After admitting a pt from home to the medical unit w/ a dx of pneumonia, which physician orders will the RN verify have been completed before administering a dose of cefuroxime (Ceftin) to the pt? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum lab studies ordered for AM - correct answer Sputum culture and sensitivity This is community acquired pneumonia. It is important that the organism is correctly identified before the antibiotic takes effect. The test will determine whether the proper antibiotic has been ordered. A 73 y.o. female pt who lives alone is admitted to the hospital w/ dx of pneumococcal pneumonia. Which clinical manifestation, if observed by the RN, indicates that the pt is likely to by hypoxic? Sudden onset of confusion. Oral temp of 102.3 Coarse crackles in lung bases Clutching the chest on inspiration - correct answer Sudden onset of confusion. Confusion or stupor may be the only clinical manifestation of pneumonia in an older pt. The RN cares for a 50 y.o. pt w/ pneumonia that has been unresponsive to two different antibiotics. Which task is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the pt to cough and deep breathe Take the temp, pulse, and RR Obtain a sputum specimen for culture and Gram stain Check the pt's O2 saturation by pulse oximetry - correct answer Obtain a sputum specimen for culture and Gram stain. To identify the organism. [Show Less]
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CASE STUDY NCLEX QUESTIONS AND ANSWERS>CANCER
Treatment modalities for estrogen-receptor positive tumors include (select all that apply): A. Estrogen-receptor downregulators (ERDs) B. Selective est... [Show More] rogen-receptor response modulators (SERMs) C. Hormone therapy D. Aromatase inhibitors - correct answer A, B, D Stage IIIB describes invasive breast cancer in which: A. The tumor measures up to 2 cm and has not spread outside the breast B. No tumor is found in the breast C. Cancer may have spread to up to 9 axillary lymph nodes causing swelling D. The cancer has metastasized to other organs - correct answer C. Cancer may have spread to up to 9 axillary lymph nodes causing swelling In stage IIIB carcinoma of the breast the cancer may have spread to up to 9 axillary lymph nodes. Ms. T has 8 of 12 lymph nodes affected. Answers A or B may occur in stage I, and answer choice D describes stage IV 3.Which of the following are important interventions when caring for a patient with Cushing syndrome? (Select all that apply) A. Increase carbohydrate intake B. Monitoring blood glucose levels C. Observing for signs of hypotension D. Protecting patient from exposure to infection - correct answer B, D Hyperglycemia occurs with Cushing disease because of glucose intolerance (associated with cortisol-induced insulin resistance) and increased gluconeogenesis by the liver. High levels of corticosteroids increase susceptibility to infection and delay wound healing. In a 29-year-old female client who is being successfully treated for Cushing's syndrome, nurse Lyzette would expect a decline in: A. Menstrual flow B. Bone mineralization C. Hair loss D. Serum glucose level - correct answer D. Serum glucose level Serum glucose levels tend to be high in patients with Cushing's Syndrome due to excess corticosteroids in the body. When Cushing's syndrome is being treated successfully, a nurse should expect a decline in the patient's serum glucose level Mr. A has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing his pain. What type of pain is associated with this diagnosis? A. Burning and aching, located in the left lower quadrant and radiating to the leg B. Severe and unrelenting, located in the epigastric area and radiating to the back C. Burning and aching, located in the epigastric area and radiating to the umbilicus D. Severe and unrelenting, located in the left lower quadrant and radiating to the hip - correct answer B. Severe and unrelenting, located in the epigastric area and radiating to the back The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. It is also described as sudden onset, deep piercing, continuous or steady. The other options are incorrect. The nurse is reviewing the prescription for Mr. A., a 55 year-old male admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. A. Administer antacids as prescribed B. Encourage coughing and deep breathing C. When food is allowed follow a high-carbohydrate, low-fat, high-protein diet D. Maintain the client in a supine and flat position. E. Give Demerol or Dilaudid as prescribed for pain. - correct answer A, B, C, E Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as Demerol or Dilaudid should be administered as prescribed. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore measures such as turning, coughing, and deep breathing should be instituted. Antacids may be prescribed to suppress gastrointestinal secretions. The diet is usually high in carbohydrates since it is less stimulating the exocrine portion of the pancreas. A patient comes into the clinic with complaints of joint stiffness and pain. For which symptom might the nurse assess to distinguish rheumatoid arthritis from other connective tissue disorders? A. The patient has unilateral joint involvement B. Morning stiffness that lasts more than one hour C. Inflammation of the great toe D. Dry mouth and dry eyes - correct answer B. Morning stiffness that lasts more than one hour You are providing education to a patient diagnosed with Rheumatoid Arthritis about how to manage her disease at home. Which statement by the patient would indicate understanding? A. "I should place a pillow under my knees before I sleep." B. "I will add weight lifting to my exercise routine." C. "When I'm having painful inflammation, I should resume total bed rest." D. "I may need 8-10 hours of sleep and daytime naps to help with fatigue." - correct answer D. "I may need 8-10 hours of sleep and daytime naps to help with fatigue." Which of the following are symptoms of a ruptured AAA? Select all that apply: A. Severe back pain B. Ripping or tearing sensation C. Polyuria D. Clammy skin E. Red rash on the abdomen - correct answer A, D Usually, with a rupture back pain becomes severe. Ripping or tearing sensation is a sign of aortic dissection. Urine output should be decreased. The patient is going into shock from blood loss which contributes to his clammy skin. A red rash on the abdomen may be caused by many other conditions, but not a ruptured AAA. Grey Turner's sign is bruising in the flank area due to AAA rupture. When teaching a patient about risk factors for AAA, which of the following, if stated by the patient indicates correct understanding? A. Taking ACE inhibitors or ARBS B. Being female C. Smoking D. Weightlifting - correct answer C. Smoking Aortic Aneurysm can be caused by being male, smoking, family history, and hypertension. ACE inhibitors or ARBS might be useful in treating AAA. Weightlifting should be avoided post AAA repair A patient reports during a routine check-up that he is experiencing chest pain and shortness of breath while performing activities. He states the pain goes away when he rests. This is known as: A. Unstable angina B. Variant angina C. Stable angina D. Prinzmetal angina - correct answer C. Stable Angina Chronic Stable angina, is known to be relieved by resting or by administering nitroglycerin tablets. Stable angina can also be brought on by exercise After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? A. "I will replace my nitroglycerin supply every 6 months." B. "I can take up to five tablets every 3 minutes for relief of my chest pain." C. "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." D. "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain." - correct answer B. "I can take up to five tablets every 3 minutes for relief of my chest pain." This is not the new recommended dosing for nitroglycerin. The correct use of nitroglycerin is to take one pill sublingually, and wait for the pain to subside, if the pain does not subside or worsens after five minutes the patient then should contact emergency personal. If pain is steadily subsiding a patient can repeat another dose every five minutes but with a maximum of three doses only, if pain is not completely diminished, contact EMS. The following are clinical manifestations of acute disseminated intravascular coagulation (DIC) EXCEPT: A. Hypertension B. Petechiae C. Altered mental status D. Mucosal/skin bleeding - correct answer A. Hypertension A patient experiencing acute DIC will experience hypotension, not hypertension. Which lab result would a nurse NOT expect to find in a client diagnosed with DIC? A. Prolonged prothrombin time (PT) B. Prolonged activated partial thromboplastin time (aPTT) C. A decreased platelet count D. A high fibrinogen level - correct answer A patient with DIC would have a low fibrinogen level. Fibrinogen predicts bleeding in DIC. As it decreases, the risk of bleeding increases. A prolonged PT, aPTT and decrease in platelet production are expected. LB is a 40-year-old male with colon cancer presenting with lack of appetite, muscle wasting, and 10-lb weight loss since previous check-up two weeks ago. Which of the following is the best nursing diagnosis for LB? A. Disturbed body image related to cachexia B. Hopelessness related to terminal illness C. Imbalanced nutrition: less than body requirements related to loss of appetite D. Impaired oral mucous membrane related to chemotherapy - correct answer C. Imbalanced nutrition: less than body requirements related to loss of appetite The question indicates that LB has lost 10 lbs within just 2 weeks and that he has a lack of appetite and muscle wasting. This tells you that LB has imbalanced nutrition: less than body requirements related to loss of appetite. The question does not indicate the other possible options and C is the best answer. Which of the following assessment findings would likely be found in a patient with cancer cachexia? (Select all that apply) A. Tardive dyskinesia B. 10% weight loss in past 12 months C. Hemoglobin 8 g/dL D. Muscle wasting E. Elevated energy levels F. Serum albumin 2.5 g/dL - correct answer B, C, D, F A person with cachexia is like to have 10% weight loss in past 12 months, a hemoglobin level of 8 g/dL, muscle wasting, and a serum albumin level of 2.5 g/dL. The other options are not indicated in a patient with cachexia. A nurse is caring for a 57-year-old patient who has just been diagnosed with ER positive breast cancer. What additional teachings would you include as a nurse about treatment for this type of cancer? A. The patient is likely to lose all of their hair B. Drug therapy that lowers estrogen will likely be included in the treatment C. Estrogen replacement drug therapy will likely be included in the treatment D. Chemotherapy will not be necessary - correct answer B. Drug therapy that lowers estrogen will likely be included in the treatment Answer choice A, telling the patient that she will lose all of her hair may be true, depending on the type of cancer treatment she is receiving but is not the best answer. Chemotherapy may be necessary for the patient's cancer therapy. Estrogen replacement is contraindicated for the treatment of ER positive breast cancer. The best answer is choice B, drug therapy that lowers estrogen will likely be included in the treatment A nurse is caring for a 57-year-old patient who has just been diagnosed with ER positive breast cancer. Although a total mastectomy was recommended due to the size of the tumor, Ms. T decided to have a lumpectomy. She is currently 3 weeks post-operation and will begin chemotherapy and hormone therapy. Match the drug therapy to the intended effect: A. Cytoxan- Alkylating agents B. Adriamycin [doxorubicin]- Antitumor Antibiotics C. Anastrozole- Aromatase Inhibitors 1. Causes breaks in the DNA double stranded helix 2. Binds directly to DNA, inhibiting synthesis and interfering with RNA transcription 3. Inhibits synthesis of an enzyme needed in estrogen synthesis - correct answer A - 1 B-2 C-3 Cytoxan works by breaking the DNA double stranded helix; Adriamycin works by binding directly to DNA, inhibiting synthesis and interfering with RNA transcription; Anastrozole works by inhibiting synthesis of an enzyme needed in estrogen synthesis Which nursing intervention would you not implement with a patient who is diagnosed with Cushing's Syndrome? A. Minimize stress in the environment B. Monitor vital signs; observe for hypertension, edema C. Tell patient to increase caloric intake to maintain body weight. D. Protect client from exposure to infection - correct answer C. Tell patient to increase caloric intake to maintain body weight. In patients with Cushing Syndrome, weight gain is a side effect, therefore monitoring caloric intake is an important aspect for the patient to monitor. Nurse Ron is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: A. Hypotension. B. Thick, coarse skin. C. Deposits of adipose tissue in the trunk and dorsocervical area. D. Weight gain in arms and legs. - correct answer C. Deposits of adipose tissue in the trunk and dorsocervical area. Because of changes in fat distribution, adipose tissue accumulates in the trunk, face (moonfaced), and dorso-cervical areas (buffalo hump). Hypertension is caused by fluid retention. Skin becomes thin and bruises easily because of a loss of collagen. Muscle wasting causes muscle atrophy and thin extremities. Which assessment finding of a patient with acute pancreatitis is the nurse's priority and will require immediate intervention? A. Acute LUQ pain radiating to the back B. Rigid, board-like abdomen C. Nausea and Vomiting D. Fatigue - correct answer B. Rigid, board-like abdomen Rigid, board-like abdomen is a sign of peritonitis which is a complication of acute pancreatitis that will require immediate intervention. All the other choices are common clinical manifestations of acute pancreatitis. Which statement about acute pancreatitis made by the nursing student shows that further teaching is required? A. The patient cannot remain on a high-fat diet. B. Patient can request Gatorade if they feel weak. C. Bluish discoloration around the umbilical area may occur in severe cases of acute pancreatitis D. Patient cannot take antacids if they have a stomach ache flare up. - correct answer B. Patient can request Gatorade if they feel weak. Patients with acute pancreatitis should be NPO to allow the pancreas to rest by suppressing pancreatic enzymes. Ms. M, a 36-year-old female, who comes into the clinic complaining about increased pain and stiffness. He wants to know the best ways to help protect his joints. What is one way the nurse can teach Mr. M how he can protect his joints? A. Wringing out water from a sponge B. Stand while preparing and cooking meals C. Push on the palms of your hands, not your fingers, when getting up from a chair D. Modify your home so doorknobs and faucets are able to be turned, not pushed - correct answer C. Push on the palms of your hands, not your fingers, when getting up from a chair [Show Less]
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NCLEX STUDY GUIDE -3
Cheyne-Stokes respirations - correct answer This respiratory pattern is characterized by periods of respirations during which the tidal volume starts shall... [Show More] ow and gets progressively deeper, and then gets progressively shallower. This shallow-deep shallow pattern is followed by periods of significant apnea that can last up to 30 seconds or longer, then the cycle starts over. Each cycle can take anywhere between 30 seconds and 2 minutes or longer. What causes Cheyne-stokes respirations? - correct answer This pattern of respiration is often caused by strokes, traumatic brain injuries, brain tumors, carbon monoxide poisoning, and metabolic encephalopathy. This pattern of respiration can be seen in healthy patients experiencing first time high altitude sickness, and can also be a normal side effect of morphine administration. Biot's breathing (aka cluster respiration) - correct answer A respiratory pattern characterized by periods or clusters of rapid respirations of near equal depth or VT followed by regular periods of apnea. What causes Biot's breathing? - correct answer Caused by damage to the medulla oblongata by stroke (CVA) or trauma, pressure on the medulla due to uncal or tentorial herniation. This type of respiratory pattern can also be caused by prolonged opioid abuse. Kussmaul's respirations - correct answer A type of labored or hyperventilation characterized by a consistently deep and rapid respiratory pattern. What causes Kussmaul's respirations - correct answer This type of labored hyperventilation is usually seen in the late stages of a severe metabolic acidosis such as diabetic ketoacidosis. The patient becomes very "air-hungry" and the desperate gasping characteristic of breathing almost appears involuntary. Most of the time a respiratory pattern secondary to a metabolic acidosis is rapid and shallow and a true Kussmaul's respiration is rarely reached before the acidosis is corrected. Apneustic respirations - correct answer have a prolonged inspiratory phase followed by a prolonged expiratory phase commonly believed to be apneic phases. What causes Apneustic respirations? - correct answer is caused by damage to the upper part of the pons, which is the upper portion of the brain stem. The pons contains, among other things, the "respiratory center" of the brain. Ataxia respirations - correct answer Completely irregular breathing pattern with irregular pauses and increasing episodes of apnea. As breathing continues to deteriorate these respirations begins to merge with agonal respirations. What causes Ataxia respirations? - correct answer are most often caused by damage to the medulla oblongata secondary to trauma or stroke. This respiratory pattern usually indicates a very poor prognosis. BUN - correct answer 10-25 or 5-25 Kaplan Creatinine - correct answer 1.2-1.5 or 0.5-1.5 Kap Creatinine Clearance - correct answer 85-135 Albumin, serum - correct answer 3.5-5.0 Potassium - correct answer 3.5-5.0 Specific Gravity - correct answer 1.010-1.030 Sodium, serum - correct answer 135-145 Calcium - correct answer 9-11 Magnesium - correct answer 1.3-2.1 Critical <0.5 or >3 Chloride - correct answer 95-105 Phosphate - correct answer 3.0-4.5 Serum Osmolarity - correct answer 285-295 Glycosylated Hemoglobin - correct answer 4-6% 3 month review of glucose pH - correct answer 7.35-7.45 ↓Acid ↑Alkaline HCO₃ - correct answer 22-26 ↓Acid ↑Alkaline PCO₂ - correct answer 35-45 ↓Acid ↑Alkaline PO₂ - correct answer 80-100 O₂ saturation - correct answer 96-100 Metabolic Alkalosis - correct answer pH ↑, PCO₂ ↑, HCO₃ ↑ Metabolic Acidosis - correct answer pH ↓, PCO₂ ↓, HCO₃↓ Respiratory Alkalosis - correct answer pH ↑, PCO₂ ↓, HCO₃ ↓ Respiratory Acidosis - correct answer pH ↓, PCO₂ ↑, HCO₃ ↑ Phosphate - correct answer 3.0-4.5 CVP - correct answer 3-11 or 2-8 HGB, hemoglobin - correct answer 12-15 HCT, hemocrit - correct answer 36-45 Platelets - correct answer 150,000-450,000 Neutrophils - correct answer 2500-8000 Lymphocytes - correct answer 1000-4000 RBC - correct answer 3.2-5.2 WBC - correct answer 5000-10,000 ESR - correct answer 0-20 PTT - correct answer 20-45 sec. Max 112 sec. Therapeutic 1.5-2.5 times PT/INR - correct answer 10-14 seconds Bilirubin - correct answer 0.1-1.0 AlT/AST - correct answer 8-20 Digoxin - correct answer 0.5-2 Toxic >2.5 Dilantin - correct answer 10-20 Toxic >30 Theophylline - correct answer 10-20 Toxic >20 Lithium - correct answer 0.5-1.2 Tylenol - correct answer Toxic >4000 mg/day Addison's disease - correct answer Hyponatremia, hyptension, decreased blood col, hyperkalemia, hypoglycemia Cushings disease - correct answer Hypernatremia, hyperension, increased blood vol, hypokalemia,hyperglycemia. No Pee, No K - correct answer do not give potassium without adequate urine output Do not delegate what you can eat - correct answer E -evaluate A - assess T - Teach V, V - correct answer EleVate Veins for better perfusion A,A - correct answer dAngle Artieries for better perfusion APGAR - correct answer A = appearance (color all pink, pink and blue, blue [pale] P = pulse (>100, <100, absent) G = grimace (cough, grimace, no response) A = activity (flexed, flaccid, limp) R = respirations (strong cry, weak cry, absent) Transmission based precautions: - correct answer Airborne: My - Measles Chicken - Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB or MTV = Airborne Measles TB Varicella-Chicken Pox/herpes Zoster -Shingles - Private room - negative pressure with 6-12 air exchanges/ hr Mask, N95 for TB Droplet precautions (think spiderman) - correct answer S - sepsis S - scarlet fever S - Streptococcal pharyngitis P - parvovirus B19 P - pneumonia P - pertussis I - influenza D - diphtheria (pharyngeal) E - epiglottitis R - rubella M - mumps M - meningitis M - mycoplasma or meningeal pneumonia An - Adenovirus - Private room or cohort mask contact precaution - correct answer Mrs. WEE M - multidrug resistant organism R - respiratory infection S - skin infections W - wound infxn E - enteric infxn - clostridium difficile E - eye infxn - conjunctivitis Skin infections - correct answer VCHIPS V - varicella zoster C - cutaneous diphtheria H - herpez simplex I - impetigo P - pediculosis S - scabies Air / pulmonary Embolism - correct answer (S & S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) → turn pt to LEFT side and LOWER the head of the bed. Woman in labor w/ Un-reassuring FHR - correct answer (late decels, decreased variability, fetal bradycardia, etc )→ turn on LEFT side (and give O₂, stop Pitocin, increase IV fluids) Tube Feeding w/ Decreased LOC - correct answer position pt on RIGHT side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration) During Epidural Puncture - correct answer side-lying After Lumbar Puncture - correct answer (and also oil-based Myelogram)→pt lies in FLAT SUPINE (to prevent headache and leaking of CSF) Pt w/ Heat Stroke - correct answer lie FLAT W/ LEGS ELEVATED During Continuous Bladder Irrigation (CBI - correct answer catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. After Myringotomy - correct answer position on side of AFFECTED EAR after surgery (allows drainage of secretions) After Cataract Surgery - correct answer pt will sleep on UNAFFECTED SIDE with a night shield for 1-4 weeks. After Thyroidectomy - correct answer low or semi-Fowler's, support head, neck and shoulders Infant w/ Spina Bifida - correct answer position PRONE (on abdomen) so that sac does not rupture Buck's Traction (skin traction) - correct answer elevate foot of bed for counter-traction After Total Hip Replacement - correct answer don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed Cord - correct answer knee-chest position or Trendelenburg Infant w/ Cleft Lip - correct answer position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. To Prevent Dumping Syndrome - correct answer (post-operative ulcer/stomach surgeries) → eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals) Above Knee Amputation - correct answer elevate for first 24 hours on pillow, position prone daily to provide for hip extension. Below Knee Amputation - correct answer foot of bed elevated for first 24 hours, position prone daily to provide for hip extension. Detached Retina - correct answer area of detachment should be in the dependent position Administration of Enema - correct answer position pt in left side lying (Sims) with knee flexed After Supratentorial Surgery - correct answer (incision behind hairline)→elevate HOB 30-45 degrees After Infratentorial Surgery - correct answer (incision at nape of neck) →Position pt FLAT and lateral on either side. During Internal Radiation - correct answer on BEDREST while implant in place Autonomic Dysreflexia/Hyperreflexia - correct answer (S&S: punding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension)→ place client in sitting position (elevate HOB) first before any other implementation. Shock - correct answer bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) Head Injury - correct answer elevate HOB 30 degrees to decrease intracranial pressure Peritoneal Dialysis when Outflow is Inadequate - correct answer turn pt form side to side BEFORE checking for kinks in tubing (according to Kaplan) Lumbar puncture - correct answer After the procedure, the client should be placed in the supine position for 4 to 12 hours as prescribed Pancreatitis give - correct answer demorol, NOT morphine sulfate [Show Less]
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NCLEX STUDY GUIDE WITH SOLITIONS
What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? - correct answer - Swelling - Fluid leakage - Blanchi... [Show More] ng - Poor arterial waveform The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? - correct answer - Measure the calf and thigh daily - Apply sequential compression devices to the legs - Position paralyzed leg with each distal joint higher than the proximal joint - Passive range of motion several times a day The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? - correct answer - Reporting any chest discomfort following percutaneous intervention - Avoid lifting more than 10 pounds until approved by healthcare provider. - remain on bed rest for a minimum of 4 hours - Fluids need to be increased to flush the dye used during the procedure from the kidneys The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? - correct answer - 60 minutes of moderate-intensity physical activity 7 days a week - Girls should take a least 13,000 steps daily and boys should take 11,000 steps daily - TV viewing and video game playing should be 2 or fewer hours each day. Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? - correct answer - Positive Trousseau's sign - Leg cramps The nurse providing palliative care to a client would include which outcomes in the teaching plan? - correct answer - Maintaining the client's quality of life - Minimizing family caregiver stress - Managing the client's pain - Managing the client's and family's emotional needs - Attending to the client's spiritual needs Which nursing intervention represents secondary prevention level? - correct answer Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease. An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department? - correct answer - Sudden emotional outbursts. - Client report of blurred vision. - Headache unrelieved by acetaminophen. The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? - correct answer - Weight gain of 4 pounds in one week - Serum potassium of 3.2 mEq The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication? - correct answer - Asterixis - Lethargy - Amnesia - Behavioral changes A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? - correct answer - Blood pressure screening - Glucose monitoring - Influenza vaccine - BMI calculation - Test urine for protein Hispanics have a higher incidence of death from heart disease and stroke. Blood pressure monitoring is essential to detect and control hypertension. Diabetes is prevalent in the Hispanic community. Early diagnosis is critical to manage and control for the risk of complications. Flu vaccination is recommended for all ethnic groups. Obesity is very high among Hispanic Americans at >70%. Chronic renal failure is a high risk for Hispanic Americans particularly since diabetes is prevalent. Early testing for protein in urine is recommended. Which interventions should the nurse include in the plan of care for a client following chest tube placement for a spontaneous pneumothorax? - correct answer - Tape all connections between the chest tube and drainage system. - Perform pulmonary assessment every two hours. - water seal chamber kept below client's chest - change when full A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms? - correct answer - chest pain - confusion - palpitations How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child? - correct answer MMR is given Sub-Q. Subcutaneous injections are administered in the fat layer, underneath the skin. When administering SQ injections use a 23-25 gauge needle, needle length for infants (1- 12 months) is 5/8", children 12 months and older 5/8" - ¾". A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high? - correct answer If the levothyroxine dose is too high, the client may experience an tachycardia, dysrhythmias, tremors, and a headache. When the levothyroxine level is too high, the symptoms are the same as hyperthyroidism. The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is prescribed. In reviewing the client's history, which information is of concern to the nurse? - correct answer - coronary artery stent - cardiac pacemaker - extreme obesity - history of working with metal fragments A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? - correct answer - administer furosemide (diuresis) - Measure abdominal girth - weight daily - measure urine output every 30-60 minutes A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which new signs and symptoms noted by the nurse would indicate that the client has developed hepatic encephalopathy? - correct answer A musty or sweet breath odor, poor concentration, slow movement, asterixis (an abnormal tremor consisting of involuntary jerking movements, especially in the hands). A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now? - correct answer The physical therapy department is best qualified to assist a client in adjusting to the use of crutches prior to discharge. Because the client wants to use older crutches, it is even more important for a physical therapist to determine whether it is safe for the client to do so. Physical therapy can evaluate the condition of the old crutches, the client's ability to manage that equipment and to walk safely with those crutches. A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin? - correct answer An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBC's is fatigue and dyspnea upon exertion because RBC's are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication. A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider? - correct answer Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots. A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole? - correct answer Metronidazole is an antibiotic used for the treatment of vaginal infections. Metronidazole and alcohol can interact with each other, causing severe nausea and vomiting as well as cramping and flushed appearance. A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take? - correct answer A Groshong catheter is implanted when other venous access sites are no longer useable. The child has begun to react to the chemotherapy and needs medicated now. Because this implanted device has only one lumen, the nurse must stop the chemotherapy infusion temporarily, flush the port, administer the ondansetron, flush again and restart the chemotherapy infusion. The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time? - correct answer Albuterol and levalbuterol are both rapid acting bronchodilators, that will quickly relieve shortness of breath, chest tightness and wheezing. This client is in distress now. Either medication would be indicated. Fluid Volume Excess/Hypervolemia - correct answer too much fluid in the vascular space FVE causes what? - correct answer - heart failure - renal failure Heart Failure - correct answer - heart is weak - cardiac output goes down - kidney perfusion goes down - urinary output goes down - volume stays in the vascular space Renal failure - correct answer kidneys aren't working Three things with a lot of sodium? - correct answer - effervescent soluble medications - canned/processed foods - IVF with sodium Where is aldosterone found? - correct answer adrenal glands (on top of kidneys) What is the action of aldosterone? - correct answer when blood volume gets low (vomiting, hemorrhage, etc.) it increases and retains sodium/water and blood volume goes up Diseases with too much aldosterone - correct answer - cushing's disease - hyperaldosteronsism (Conn's syndrome) Disease with too little aldosterone - correct answer Addison's Disease What does ADH do? - correct answer makes you retain water SIADH (syndrome of inappropriate antidiuretic hormone) - correct answer - too much ADH (too many letters too much water) - Retains water - Fluid volume EXCESS - urine is concentrated (specific gravity goes up) - blood is diluted (H&H goes down) DI (diabetes insipidus) - correct answer - not enough ADH - lose (diurese) water - Fluid volume DEFICIT (can go into shock) - urine is diluted (specific gravity goes down) - blood is concentrated (H&H goes up) Where is ADH found? - correct answer pituitary Potential ADH problems - correct answer craniotomy, head injury, sinus surgery, transsphenoidal hypophysectomy, or any condition that can lead to an increased ICP (all head injuries/surgeries) Vasopressiin or desmopressin - correct answer ADH replacement medication given as nasal spray in DI. S/S of FVE - correct answer - distended neck veins - peripheral edema/third spacing - CVP is increased (2-6 is normal) - Lung sounds wet (SOB) - Polyuria - pulse increases (full and bounding) - BP increases (more volume more pressure) - weight increases Treatment of FVE - correct answer - low sodium diet/restrict fluids - I&O and daily weights (same time, same scale, same clothing, void first) - Diuretics (furosemide, bumetanide, hydrochlorothiazide, spironolactone) - bed rest (induces diuresis) - physical assessment - Give IVFs slowly to the elderly and very young and clients with a history of heart and kidney problems FVD causes - correct answer - loss of fluid from anywhere (thoracentesis, paracentesis, vomiting, diarrhea, and hemorrhage) - can cause shock!! - third spacing (burns, ascites) - polyuria FVD s/s - correct answer - weight loss - decreased skin turgor - dry mucous membranes - decreased urine output - BP decreases (less volume, less pressure) - Pulse increased (weak and thready) - respirations increased - CVP decreased - cool extremities - urine specific gravity is up (concentrated) Treatment of FVD - correct answer - prevent further losses of fluid - replace volume (po fluids, iv fluids) - fall risks - monitor for overload with IV fluid replacement Hypermagnesemia causes - correct answer - renal failure - antacids Hypermagnesemia s/s - correct answer - flushing and warmth - vasodilation - think muscles Treatment for hypermagnesemia - correct answer - ventilator - dialysis - calcium gluconate = antidote for toxicity - safety precautions Hypercalcemia causes - correct answer - Hyperparathyroidism (too much PTH) **When serum calcium gets low, the PTH kicks in and pulls Ca from the bone and puts it into the blood, therefore the serum Ca goes ↑ - thiazides (retain calcium) [Show Less]
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NCLEX STUDY GUIDE WITH SOLUTIONS
The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. Du... [Show More] ring the test, the client should be instructed to? - correct answer Keep a diary of activities to correlate the clients dsyrhymthmia to their activities. The health care provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse why? What is the best way for the nurse to respond? - correct answer Using patient education by saying "rest helps your body direct energy to healing" After flushing a clients arm with a saline lock, the patient complains about a painful and burning sensation at the site, what should the nurse do? - correct answer Remove the angiocatheter and saline lock and restart the IV in another site because the IV has been infiltrated. A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and Verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for? - correct answer Myocardial depression because both digoxin and verapamil decrease cardiac impulse conduction. The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to? - correct answer Keep a diary of activities because the purpose of a Holter monitor is to correlate dysrhythmia with the clients reported activity. A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be a result of surgery-related trauma, the nurse assesses the clients ability to? - correct answer Speak- because the the laryngeal nerve is close to the operative site and can accidentally be damaged. Daily Humulin R insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 AM. When should the nurse monitor the client for a potential insulin reaction? - correct answer Before lunch- because regular insulin is short acting and peaks in 2-4 hours. A nurse is providing teaching to a client with a newly prescribed proton pump inhibitor. The nurse determines that the teaching is effective when the client states that the medication is used for the treatment of? - correct answer Gastroesophageal reflux (GERD) because PPI's are effective in decreasing the secretion of gastric acid. A client who is receiving total parenteral nutrition (TPN) reports experiencing nausea, thirst, and a headache. Which clinical factor should the nurse monitor initially to further assess the client's status? - correct answer Blood glucose because the client is exhibiting classic signs of hyperglycemia. Six hours after major abdominal surgery, a client complains of severe abdominal pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the Physiological Aspects of Care record and determines that the client can receive another injection of pain medication in an hour. What is the most appropriate action by the nurse? - correct answer Call the health care provider, report the clients symptoms, and obtain further prescriptions because the clients signs and symptoms suggest the possibility of shock. When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client? - correct answer Passes flatus because that indicates peristaltic movement. A client is admitted into the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery? - correct answer Whole bran because it provides bulk that promotes intestinal motility and a regular bowel movement. During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first? - correct answer Gather more data from the night nurse about the technique used because that will give the nurse the best indication of what solution to look for. A nurse observes that an unlicensed assistive personnel did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurses best way to handle this situation is to? - correct answer Review transmission based precautions with the UAP A nurse is preparing to obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the last two days. What is the order of priority? - correct answer Explain the procedure to the client, collect the specimen according to protocol, send the specimen to the laboratory, and administer the first dose of antibiotics. A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to best avoid malaria? - correct answer Mosquito bites because malaria is caused by the protozoan Plasmodium falciparum which is carried by mosquitos. What criteria should the nurse consider when determining if an infection should be categorized as a health care- associated infection? - correct answer Occurred in conjunction with treatment for an illness A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of? - correct answer 30 degrees. Shearing force occurs when two surfaces move against each other, when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon. A states Nurses Practice Act does not allow a registered nurse to suture wounds, but a primary health care provider offers to teach the RN, what should she do? - correct answer Refuse to suture the wounds A client with scleroderma complains of difficulty with chewing and swallowing. When providing dietary counseling, the nurse should advise the client to? - correct answer Purée foods before eating because scleroderma causes chronic hardening and shrinking of the connective tissues of the body, including the esophagus and face. Puréed foods limit the need to chew. A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "am I going to die?" The nurses best response is? - correct answer The prognosis is variable; most individuals experience remissions and exacerbations. After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurses greatest concern at this time is? - correct answer Addressing the pain A nurse performs postoperative teaching for a client who is to have cataract surgery. Which is the most important for the nurse to include concerning what the client should do after surgery? - correct answer Avoid bending from the waist because this increases intraocular pressure. When caring for a client who has acute respiratory distress syndrome, the nurse would implement which measure to promote effective airway clearance? - correct answer Suction as needed A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain in the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the clients right side? - correct answer Decreased breath sounds A healthcare provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens? - correct answer On awakening because during sleep, mucous secretions in the respiratory tract move slowly toward the throat. A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? - correct answer Deep-breathing techniques A client who was recently diagnosed with diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention? - correct answer Encourage deep breathing Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurses first intervention? - correct answer Safely remove the victim from the immediate vicinity The nurse is teaching the client with obstructive pulmonary disease to use pursed lip breathing because this is beneficial for the client through which mechanism? - correct answer Prolonged exhalation to decrease air trapping A client is admitted to the hospital with a diagnosis of pneumonia. The clients pulse rate increases from 88 beats per minute on admission to 120-140 beats per minute on the second day of hospitalization. The client is more restless, complains of a headache, and is diaphoretic. What would the nurse want to check? - correct answer The arterial blood gases Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The most appropriate response by the nurse is? - correct answer There will be an indwelling urinary catheter and a continuous bladder irrigation in place. An older adult client is demonstrating mild confusion after surgical repair of a hernia. What should the nurse do to provide for this clients safety? - correct answer Activate the position-sensitive bed alarm. A nurse is reviewing the laboratory reports of a client with a diagnosis of end stage renal disease. What test result should the nurse anticipate? - correct answer Potassium of 6.3 mEq/L because clients with end stage renal disease have impaired potassium excretion. A client is scheduled to receive intravenous fluids to be delivered at 80 ml/hr. To adjust the drip rate when administering the IV via gravity, the nurse must determine the? - correct answer Drops per milliliter delivered by the infusion set A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery? - correct answer An indwelling urinary catheter is required for at least a day. [Show Less]
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SAUNDERS NCLEX-RN 7TH STUDY - RENAL
A client with acute kidney injury has a serum potassium level of 7.0 mEq/L (7.0 mmol/L). The nurse should plan which actions as a priority? Select all that... [Show More] apply. 1. Place the client on a cardiac monitor. 2. Notify the health care provider (HCP). 3. Put the client on NPO (nothing by mouth) status except for ice chips. 4. Review the client's medications to determine if any contain or retain potassium. 5. Allow an extra 500 mL of intravenous fluid intake to dilute the electrolyte concentration. - correct answer 1, 2, 4 R: NPO is unnecessary. Adding extra fluid may worsen the situation and lead to fluid overload. Excess K can cause heart dysrhythmias, so 1&4 are appropriate. Calling the HCP is also necessary for further orders. A client arrives at the emergency department with complaints of low abdominal pain and hematuria. The client is afebrile. The nurse next assesses the client to determine a history of which condition? 1. Pyelonephritis 2. Glomerulonephritis 3. Trauma to the bladder or abdomen 4. Renal cancer in the client's family - correct answer 3 R: 1& 2 are similar/alike, and they would involve a fever. 4 would have flank pain instead of low abd pain. The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment should be included in this discussion? Select all that apply. 1. Hemodialysis 2. Peritoneal dialysis 3. Kidney transplant 4. Bilateral nephrectomy 5. Intense immunosuppression therapy - correct answer 1,3,4 R: Polycystic KD involves cysts that eventually rupture and damage the kidneys, leading to end-stage renal disease. This requires options 1, 3, or 4. 2 is contraindicated r/t infection. 5 won't help the pt's condition. A client is admitted to the emergency department following a fall from a horse and the health care provider (HCP) prescribes insertion of a urinary catheter. While preparing for the procedure, the nurse notes blood at the urinary meatus. The nurse should take which action? 1. Notify the HCP before performing the catheterization. 2. Use a small-sized catheter and an anesthetic gel as a lubricant. 3. Administer parenteral pain medication before inserting the catheter. 4. Clean the meatus with soap and water before opening the catheterization kit. - correct answer 1 R: blood may = urethral trauma, so you need to notify the HCP first so you can identify the true cause of blood before catheterization. Since there's blood from an unknown cause, you need to assess first before doing anything that can worsen it. The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? 1. Palpation of a thrill over the fistula 2. Presence of a radial pulse in the left wrist 3. Visualization of enlarged blood vessels at the fistula site 4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand - correct answer 1. R: listen for a thrill or bruit over AV fistula site. All other options don't REALLY show if the AV fistula is patent, just that there's perfusion to the hand. A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge - correct answer 4. R: Urethritis usually involves dysuria, so 1&3 are incorrect. Proteinuria is r/t kidney dysfunction, so option 2 is also incorrect. Urethritis is also associated with chlamydia, so discharge is expected. Hematuria is not assoc. with urethritis. The nurse is assessing a client with epididymitis. The nurse anticipates which findings on physical examination? 1. Fever, diarrhea, groin pain, and ecchymosis 2. Nausea, painful scrotal edema, and ecchymosis 3. Fever, nausea, vomiting, and painful scrotal edema 4. Diarrhea, groin pain, testicular torsion, and scrotal edema - correct answer 3 R: -itis is associated w/ fever, so you can narrow it down to 1&3. Epididymitis does not involve bleeding so ecchymosis (option 1) is irrelevant. Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. A client complains of fever, perineal pain, and urinary urgency, frequency, and dysuria. To assess whether the client's problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for which characteristic of this disorder? 1. Soft and swollen prostate gland 2. Swollen, and boggy prostate gland 3. Tender and edematous prostate gland 4. Tender, indurated prostate gland that is warm to the touch - correct answer 4 R: The client with bacterial prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder. *Remember, -itis= inflammation/infection, so tenderness and local warmth is expected. so option 4 is most correct. The nurse is collecting data from a client. Which symptom described by the client is characteristic of an early symptom of benign prostatic hyperplasia? 1. Nocturia 2. Scrotal edema 3. Occasional constipation 4. Decreased force in the stream of urine - correct answer 4 R: Option 1 is a later sign. 2&3 are irrelevant to BPH. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply. 1. Check the level of the drainage bag. 2. Reposition the client to his or her side. 3. Contact the health care provider (HCP). 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution. - correct answer 1,2,4,5 R: Try to fix the flow yourself before calling the HCP or messing with the flow rate. Imbalance may be r/t a kink or improper positioning so fix those first. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication? 1. Warmth, redness, and pain in the left hand 2. Ecchymosis and audible bruit over the fistula 3. Edema and reddish discoloration of the left arm 4. Pallor, diminished pulse, and pain in the left hand - correct answer 4 R: Arterial STEAL syndrome involves vascular insufficiency (literally stealing the blood that the hand's tissue needs!). So you'd see pallor and other signs of decr. perfusion. 1&3 sound more like an infection so they're incorrect. Option 2 is a normal finding for a fistula. The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? 1. Elevated creatinine level 2. Decreased hemoglobin level 3. Decreased red blood cell count 4. Increased number of white blood cells in the urine - correct answer 1 R: Creat is increased only by kidney dysfunction of at least 50% loss. 2&3 are irrelevant. 4 is more involved w/ UTIs. A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client's temperature is 38.5°C (101.2°F). Which nursing action is most appropriate? 1. Encourage fluid intake. 2. Notify the health care provider. 3. Continue to monitor vital signs. 4. Monitor the site of the shunt for infection. - correct answer 2 R: Options 3&4 involve assessment, which is normally good but not for a priority situation like this so they're incorrect (you'll just watch the pt deteriorate lol). You know that dialysis patients have fluid restrictions, so option 2 is the best choice since the HCP can order further & treatment. The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action? 1. Monitor the client. 2. Elevate the head of the bed. 3. Assess the fistula site and dressing. 4. Notify the health care provider (HCP). - correct answer 4 R: "Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the HCP." A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction? Select all that apply. 1. Peritoneal dialysis 2. Analysis of the urinary stone 3. Intravenous opioid analgesics 4. Insertion of a nephrostomy tube 5. Placement of a ureteral stent with ureteroscopy - correct answer 4, 5 R: "Urolithiasis is the condition that occurs when a stone forms in the urinary system. Hydronephrosis develops when the stone has blocked the ureter and urine backs up and dilates and damages the kidney. Priority treatment is to allow the urine to drain and relieve the obstruction in the ureter. This is accomplished by placement of a percutaneous nephrostomy tube to drain urine from the kidney and placement of a ureteral stent to keep the ureter open. Peritoneal dialysis is not needed since the kidney is functioning. Stone analysis will be done later when the stone has been retrieved and analyzed. Opioid analgesics are necessary for pain relief but do not treat the obstruction." The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome - correct answer 2 R: Patients with DM may req an increase in insulin w/ peritoneal dialysis bc there's an increased amount of time for glucose to absorb. Option 1 is r/t improper aseptic technique. 3 is just r/t renal imbalance. 4 is only with HEMOdialysis, not peritoneal. A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment? 1. Antibiotic therapy 2. Peritoneal dialysis 3. Removal of the transplanted kidney 4. Increased immunosuppression therapy - correct answer 4 R: Symptoms of rejection = fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Treatment consists of increasing immunosuppressive therapy. Antibiotics are used to treat infection. Peritoneal dialysis cannot be used with a newly transplanted kidney due to the recent surgery. Removal of the transplanted kidney is indicated with hyperacute rejection, which occurs within 48 hours of the transplant surgery. A client is admitted to the hospital with a diagnosis of benign prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takes the client's vital signs and empties the urinary drainage bag. Which assessment finding indicates the need to notify the health care provider (HCP)? 1. Red, bloody urine 2. Pain rated as 2 on a 0-10 pain scale 3. Urinary output of 200 mL higher than intake 4. Blood pressure, 100/50 mm Hg; pulse, 130 beats/minute - correct answer 4 R: Options 1, 2, and 3 are all expected findings for several days after surgery. Option 4 sounds like a response to excessive blood loss. The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse should assess the client during dialysis for which associated manifestations? 1. Hypertension, tachycardia, and fever 2. Hypotension, bradycardia, and hypothermia 3. Restlessness, irritability, and generalized weakness 4. Headache, deteriorating level of consciousness, and twitching - correct answer 4 R: Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. This is common in pt new to dialysis. The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1. Nocturia 2. Incontinence 3. Enlarged prostate 4. Nocturnal emissions 5. Decreased desire for sexual intercourse - correct answer 1, 2, 3 R: Option 4 is seen commonly in prepubescent males. 5 is seen w/ low testosterone levels. Nocturia=urination at night. Nocturnal emissions=ejaculation while sleeping lol. The nurse is monitoring a client who has just returned from surgery after a transurethral resection of the prostate (TURP). The client has a 3-way Foley catheter in place for ongoing bladder irrigation. The nurse is observing the color of the client's urine and should expect which urine color during the immediate postoperative period? 1. Pale pink urine 2. Dark pink urine 3. Tea-colored urine 4. Bright red blood with small clots in the urine - correct answer 1 R: Option 2 means the irrigation solution should be increased (dark=concentrated). 3 is more r/t renal failure. 4 would indicate a complication, so you'd need to call the HCP. A client who has had a prostatectomy has been instructed in perineal exercises to gain control of the urinary sphincter. The nurse determines that the client demonstrates a need for further teaching when he states that he will perform which movement as part of these exercises? 1. Bearing down as if having a bowel movement 2. Tightening the muscles as if trying to prevent urination 3. Contracting the abdominal, gluteal, and perineal muscles 4. Tightening the rectal sphincter while relaxing abdominal muscles - correct answer 1 R: Bearing down (vagal/vasalva) may increase bleeding from surgical site, and should be avoided. Option 4 is different bc relaxing the abd muscles prevents the vasalva maneuver. A client has developed acute kidney injury (AKI) as a complication of glomerulonephritis. Which should the nurse expect to observe in the client? 1. Bradycardia 2. Hypertension 3. Decreased cardiac output 4. Decreased central venous pressure - correct answer 2 R: Signs of AKI=hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. AKI from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for any form of renal failure. The nurse is planning discharge teaching for a client newly diagnosed with chronic kidney disease (CKD). Which factor will enhance the educational process? 1. Anxiety 2. Memory deficits 3. Presence of family 4. Short attention span - correct answer 3 R: literally the only positive option The nurse is analyzing the posthemodialysis laboratory test results for a client with chronic kidney disease. The nurse interprets that the dialysis is having an expected but nontherapeutic effect if which value is decreased? 1. Potassium 2. Creatinine 3. Phosphorus 4. Red blood cell (RBC) count - correct answer 4 R: Anemia occurs bc RBCs are lost during the dialysis process (sampling, residual blood in dialyzer, etc). Dialysis also lowers 1,2, and 3 but those are therapeutic & expected findings. A client diagnosed with chronic kidney disease (CKD) is scheduled to begin hemodialysis. The nurse determines that which neurological and psychosocial manifestations, if exhibited by this client, are related to the CKD? Select all that apply. 1. Agitation 2. Euphoria 3. Depression 4. Withdrawal 5. Labile emotions - correct answer 1,3,4,5 R: "Clients with CKD may have labile emotions or personality changes and may exhibit withdrawal, depression, or agitation. Delusions and psychosis also can occur." Ok honestly who's gonna have Euphoria with dialysis and CKD A client with chronic kidney disease (CKD) has been taking aluminum hydroxide gel. On the basis of this information, the nurse determines that the client is most at risk for which problem? 1. Constipation 2. Dehydration 3. Inability to tolerate activity 4. Impaired physical mobility - correct answer 1 R: Options 3&4 are too similar and can be eliminated. Aluminum hydroxide can cause constipation, so option 1 is most correct. The nurse is working with a client newly diagnosed with chronic kidney disease (CKD) to set up a [Show Less]
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SAUNDERS MENTAL HEALTH B
The nurse should plan which goals of the termination stage of group development? Select all that apply. - correct answer - the group evaluates the experien... [Show More] ce. - The group explores members' feelings about the group and the impending separation. A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? - correct answer "You're feeling angry that your family continues to hope for you to be cured?" When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? - correct answer Monitor closely for harm to self or others. The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. - correct answer -Restating - Listening - Maintaining neutral responses - Providing acknowledgment and feedback A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach? - correct answer Milieu therapy The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? - correct answer Inquiring about and examining the client's feelings for any that may block adaptive coping A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? - correct answer Use an indirect light source and turn off the television. The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? - correct answer Setting limits on the client's behavior A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult? - correct answer Conversion disorder Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. - correct answer - Communicate expected behaviors to the client. - Assist the client in identifying ways of setting limits on personal behaviors. - Follow through about the consequences of behavior in a nonpunitive manner. - Have the client state the consequences for behaving in ways that are viewed as unacceptable. The nurse is preparing a client with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? - correct answer "When I have command hallucinations, I'll call a friend and ask him what I should do." The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriatenursing intervention? - correct answer Sit beside the client in silence with occasional open-ended questions. The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? - correct answer Writing Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. - correct answer - Monitor vital signs. - Provide a safe environment. -Address hallucinations therapeutically. - Provide reality orientation as appropriate. A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? - correct answer Call the nursing supervisor. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. - correct answer - Loss of tooth enamel -Electrolyte imbalances - Dental decay A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? - correct answer A client undergoing diagnostic tests rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? - correct answer Hypertension, changes in level of consciousness, hallucinations alcohol withdrawal delirium symptoms - correct answer delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions. The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? - correct answer "What do you find difficult about this situation?" A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? - correct answer Evidence of the client's disturbed body image The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? - correct answer The death of a loved one situational crisis - correct answer arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. adventitious crisis - correct answer a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse). adventitious crisis - correct answer - Witnessing a murder - A fire that destroyed the client's home - A recent rape episode experienced by the client The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. - correct answer - Acknowledge the client's behavior. - Assist the client to an area that is quiet. - Maintain a safe distance from the client. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? - correct answer Increasing the level of suicide precautions A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? - correct answer "Tell me more about the incident that causes you to feel like the rape just occurred." A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. - correct answer - I keep reliving the robbery." - "I see his face everywhere I go." - "I might have died over a few dollars in my pocket." The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? - correct answer Removing the client from any immediate danger The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? - correct answer Nonstop physical activity and poor nutritional intake The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? - correct answer Use of confabulation confabulation - correct answer the act of filling in memory gaps by making up stories The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? - correct answer Observing rigid rules and regulations A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? - correct answer Identify recent behaviors or accomplishments that demonstrate the client's skills. A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? - correct answer An expected coping mechanism A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? - correct answer "This form of therapy provides a negative reinforcement when the stimulus is produced." The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? - correct answer Provide authority, action, and participation. A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? - correct answer Remain with the client until the anxiety decreases. The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? - correct answer Lack of ability to cope effectively Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? - correct answer "Discussing suicide with a client is not harmful." Which client is at greatest risk for committing suicide? - correct answer A client with metastatic cancer Which statement by the nurse indicates a need for further teaching concerning family violence? - correct answer "Abusers are more often from low-income families." Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client? - correct answer Assure that an electrocardiogram is performed within 24 hours. A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? - correct answer "It uses negative reinforcement." The nurse in the mental health unit is performing an assessment in a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? - correct answer Somatization disorder Somatization disorder - correct answer is characterized by a long history of multiple physical problems with no satisfactory organic explanation. Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. A psychological issue that causes to report physical symptoms such as pain The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic? - correct answer "Tell me what makes you feel that you are ready. A client diagnosed with depression shares with the outclinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? - correct answer "Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? - correct answer "The focus of today's session is on your issues, so let's get started." The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? - correct answer "You're wearing a new blouse." Which activity should the nurse include in the plan of care for a client who is experiencing psychomotor agitation? - correct answer Attending a clay-molding class that is scheduled for today Psychomotor agitation - correct answer is a symptom related to a wide range of mood disorders. People with this condition engage in movements that serve no purpose. Examples include pacing around the room, tapping your toes, or rapid talking. Psychomotor agitation often occurs with mania or anxiety. The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply - correct answer - Assist the client in selecting foods from the food menu. - Offer high-calorie fluids throughout the day and evening. - Offer small high-calorie, high-protein snacks during the day and evening. incongruent - correct answer is not the same, not compatible or out of place. inappropriate affect - correct answer refers to an emotional response to a situation that is incongruent with the tone of the situation. The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? - correct answer The client giggled while describing being physically abused as a child. A flat affect is manifested as an immobile facial expression or blank look - correct answer A flat affect is manifested as an immobile facial expression or blank look The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? - correct answer During the entire family visit, the client presented with an expressionless, blank look. The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. - correct answer - Ask permission before touching the client. - Eliminate all unnecessary physical contact with the client. - Defuse any anger or verbal attacks with a nondefensive stance. - Use simple and clear language when communicating with the client. The nurse is preparing a client for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. - correct answer - Have the client void. - Obtain an informed consent. - Remove dentures and contact lenses. - Withhold food and fluids for 6 hours. A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? - correct answer - White blood cell count Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? - correct answer When the last alcoholic drink was consumed The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? - correct answer Dementia The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis? - correct answer "I'd be sure to have a panic attack if I left my house." Agoraphobia - correct answer a fear of leaving the house and experiencing panic attacks when doing so. A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? - correct answer Encourage frequent fluid intake and a high-fiber diet. A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client? - correct answer Share that the risk to their safety requires that the client's HCP be notified. Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? - correct answer The client's noncompliance with medication therapy During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primarycharacteristics of bulimia? - correct answer Eating a lot of food in a short period of time and misuse of laxatives What is the appropriate nursing intervention for a client diagnosed with posttraumatic stress disorder and paranoid tendencies who begins to pace and fidget? - correct answer Share the observation with the client so the behavior can be recognized. During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with posttraumatic stress disorder? - correct answer Making the client feel safe A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? - correct answer 1 week after the 3rd treatment session The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed? - correct answer Disulfiram Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply. - correct answer - The average series involves 8 to 12 treatments. - Some confusion may be noted after the procedure. - Memory loss will occur but will resolve with time The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar? - correct answer Progressive muscle relaxation techniques are useful for easing tension from many causes. A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make? - correct answer "It seems that you needed Bobby's help to separate from your family During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response? - correct answer "Have you shared your concerns with the police?" The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? - correct answer The group should be limited to no more than 10 members. Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. - correct answer - Panic disorder - Posttraumatic stress disorder - Obsessive-compulsive disorder The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? - correct answer "My rituals are ways for me to control unpleasant thoughts or feelings." The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care? - correct answer Individualized goals and objectives A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? - correct answer Somatization disorder The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply. - correct answer - Including the family in the medication planning process - Working with the psychiatrist to find the right medication at the right dose - Providing the client with the injectable, long-acting form of the medication if available - Working with the psychiatrist to find the medication that provides the least side effects for the client Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholic Anonymous (AA)? - correct answer "I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people." The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate? - correct answer Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago. Which assessment data would support that the therapy resulted in retrograde amnesia in the client? - correct answer During the admission interview, the client can't remember why the ECT treatment was originally prescribed. Retrograde amnesia - correct answer difficulty recalling information learned before ECT. This kind of amnesia may be long-term The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition? - correct answer Restrict the amount of chocolate and caffeine products in the home. The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which medical diagnosis, if noted on the client's record, would indicate a need to contact the health care provider scheduled to perform the ECT? - correct answer Recent myocardial infarction The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for acute depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? - correct answer "I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end." The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency? - correct answer When asked to pick up the cup, the client consistently fails to identify the cup. agnosia - correct answer the inability to identify well-known objects and people. A client admitted to the mental health unit after attacking his father for disturbing him at his computer, interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact? - correct answer "I will be back to talk with you in 15 minutes after I complete nursing rounds." The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the besttherapeutic value? - correct answer "Do you recall what it was like before you started your medication?" Which client's death was achieved by what is considered a soft suicide method? - correct answer Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation soft suicide methods - correct answer those that are painless and include ingesting pills, or inhaling natural gas or carbon monoxide. Hard suicide methods - correct answer include using a gun, jumping off a high place such as a bridge, hanging, and staging a car crash. A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem? - correct answer "I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep. The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? - correct answer Provide a structured daily program of activities, and encourage the client to participate. The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding? - correct answer Fist clenched, pounding table, fearful A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion? - correct answer Gathering subjective and objective assessment from the caregiver and the client Which is a primary behavior of a client diagnosed with antisocial personality disorder? - correct answer Will take personal items from other clients' rooms The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? - correct answer Making decisions about living arrangements after discharge dependent personality - correct answer is the inability to make decisions with excessive dependence on others. The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms? - correct answer Signs may appear at any time. Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? - correct answer Wernicke-Korsakoff syndrome A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement? - correct answer The charge nurse blames staff for wasting supplies. Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initialnursing action? - correct answer Remain with the client until the anxiety decreases. Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? - correct answer Is pacing while describing the situation using a rapid speech pattern A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? - correct answer The client's physical condition A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective? - correct answer My friends and I went out to lunch today." A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? - correct answer The client will employ new coping methods that will resolve the problem. Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? - correct answer "My boss tells me that I'm being considered for a promotion and a raise." A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? - correct answer Providing the clients with shelter, clothing, and food Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply. - correct answer - Verbal communication is almost nonexistent. - The client needs frequent redirection because of short attention span. The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking? - correct answer Present verbal instructions regarding expectations in single, simple commands. Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? - correct answer The client is convinced that the curtains are actually ghosts. During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likelythe result of which client factor? - correct answer Impaired pain perception A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initialintervention? - correct answer Turn off the television. The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primaryintervention? - correct answer Including the client's support system in the teaching The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? - correct answer Diminishing the effectiveness of psychotropic medication Which goal addresses the therapeutic management needs of a client experiencing hallucinations? - correct answer Facilitate the client's awareness that the hallucination is not the reality of the world. The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. - correct answer - A birthday of March 30 - A loss of interest in hobbies - A suicide attempt 6 months ago - Magnetic resonance imaging shows temporal lobe atrophy The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? - correct answer Atrophy of the lateral and/or third ventricles of the brain The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? - correct answer Coffee, tea, and soda consumption should be limited. Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. - correct answer - Is related to abnormal melatonin metabolism - Improves during the spring and summer months - Is a result of alterations in the available amounts of sunlight - A craving for carbohydrates lessens during sunnier and spring months Which are the most likely characteristics of a client who abuses alcohol? Select all that apply. - correct answer - Male gender - Abuses drugs as well as alcohol - History of at least one suicide attempt The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction? - correct answer Impaired wound healing An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? - correct answer Transdermal patch A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? - correct answer Lack of naturally occurring endorphins To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem? - correct answer Disturbed thinking Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. - correct answer -The client will keep scheduled appointments. - The client's physical wounds will begin to heal properly. -The client will verbalize feelings about the abusive event. - The client will participate in the various aspects of the treatment plan. Which is the best therapeutic approach for the nurse to use in crisis counseling? - correct answer Active, with focus on the current situation A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply. - correct answer - The client will develop adaptive coping patterns. - The client will identify a realistic perception of stressors - The client will express and share feelings regarding the present crisis. - The client will identify effective coping patterns that have worked in the past. The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome? - correct answer Denies presence of suicidal ideations What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? - correct answer The client verbalizes stages of grief and plans to attend a community grief group. A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? - correct answer "I hear what you are saying, but I have no reason to believe your roommate steals." A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? - correct answer "You seem very distressed over learning you have asthma." A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? - correct answer "You need to grieve, and expressing anger can be part of grieving." nyctophobia - correct answer fear of the dark When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? - correct answer Assessing all activities for safety risks The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? - correct answer "Our relationship is a therapeutic and helping one." The client asks the nurse, "Could you ask the health care provider (HCP) to let me have a pass for the weekend?" Which response is appropriate that assists the client in achieving the goal of optimal personal functioning? - correct answer "When the HCP arrives on the unit, I will let them know that you have a question." Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? - correct answer Establishing the parameters of the relationship The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client? - correct answer The client has the right to demand and obtain release from the hospital. The client diagnosed with mild depression says to the nurse, "I haven't had an appet [Show Less]
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PHARM NCLEX STUDY SET 2
The client who chronically uses nonsteroidal anti-inflammatory drugs has been taking misoprostol (Cytotec). The nurse determines that the medication is hav... [Show More] ing the intended therapeutic effect if which of the following is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count - correct answer 2. Relief of epigastric pain Etidronate (Didronel), an antihypercalcemic medication, is prescribed for a client. The nurse instructs the client to take the medication: 1. Two hours before meals 2. With meals 3. With milk 4. With an antacid - correct answer 1. Two hours before meals A client is scheduled for an intravenous pyelogram and has been instructed to take liquid magnesium citrate on the day before the scheduled procedure. The client asks the nurse about the administration procedure for this medication. Which of the following instructions will the nurse provide to the client? 1. "Take the medication on ice." 2. "Mix the medication with apple juice only." 3. "Mix the medication with a full glass of water." 4. "Drink the medication at room temperature." - correct answer 1. "Take the medication on ice." Which statement indicates that a client with Addison's disease knows how to safely manage a medication regimen that consists of daily doses of glucocorticoids? 1. "I will need to call my doctor for an increase in medication dose when I'm experiencing a lot of stress." 2. "I should stop my medication if I begin to experience any unpleasant side effects." 3. "The medication I am taking is very safe and does not cause side effects." 4. "If I'm nauseated and can't take my medicine for a few days, I can do without them." - correct answer 1. "I will need to call my doctor for an increase in medication dose when I'm experiencing a lot of stress." A client recently began medication therapy with propranolol (Inderal-LA). The nurse would be most concerned after noting the presence of which of the following in this client? 1. Blood pressure of 136/84 from 162/90 mm Hg 2. Heart rate of 86 beats per minute decreased to 78 3. Complaints of insomnia 4. Audible expiratory wheezes - correct answer 4. Audible expiratory wheezes A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. What behaviors observed in the client would validate noncompliance with this medication? 1. Complaints of hunger 2. Complaints of insomnia 3. A pulse rate less than 60 beats per minute 4. Frequent handwashing with hot, soapy water - correct answer 4. Frequent handwashing with hot, soapy water A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite (Dakin solution) to be used in the care of the wound. The nurse would do which of the following while using this solution? 1. Let the solution run freely over normal skin tissue. 2. Rinse off immediately following irrigation. 3. Pour onto sterile sponges and pack in the wound. 4. Use each bottle of solution for 1 month before replacing. - correct answer 2. Rinse off immediately following irrigation. A client on the nursing unit has a prescription for dextroamphetamine (Dexedrine) orally daily. The nurse collaborates with the dietitian to limit the amount of which of the following items on the client's dietary trays? 1. Fat 2. Protein 3. Starch 4. Caffeine - correct answer 4. Caffeine Nalidixic acid (NegGram) is prescribed for the client with a urinary tract infection. Reviewing the client's record, the nurse notes that the client is taking warfarin (Coumadin) on a daily basis. Which of the following prescriptions would the nurse anticipate because the client is taking this oral anticoagulant? 1. An increase in the anticoagulation dosage 2. A reduction in the anticoagulation dosage 3. The need to discontinue the warfarin during therapy 4. The need to administer an alternative medication to treat the urinary tract infection - correct answer 2. A reduction in the anticoagulation dosage A client with human immunodeficiency virus is taking nevirapine (Viramune). The nurse should monitor for which adverse effects of the medication? Select all that apply. 1. Rash 2. Hepatotoxicity 3. Hyperglycemia 4. Peripheral neuropathy 5. Reduced bone mineral density - correct answer 1. Rash 2. Hepatotoxicity A female client undergoing chemotherapy with intravenous vincristine sulfate (Oncovin) has been given information about the treatment. The nurse determines that the client has adequate understanding of the side effects of treatment if the client states that her hair: 1. May be lost temporarily but will grow back normally 2. May be lost temporarily but may grow back with a different color and texture 3. Will not be lost with this medication 4. Will permanently be lost with this medication - correct answer 2. May be lost temporarily but may grow back with a different color and texture A client uses the alternative therapy of cascara sagrada known as Californian buckthorn for ongoing management of chronic constipation. The nurse monitors the client's laboratory results for which electrolyte imbalance related to long-term use of this medication? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia - correct answer 1. Hypokalemia The client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1. Intestinal obstruction 2. Peptic ulcer with melena 3. Diverticulitis with perforation 4. Vomiting following cancer chemotherapy - correct answer 4. Vomiting following cancer chemotherapy A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication? 1. Nausea 2. Diarrhea 3. Anorexia 4. Cough and chest pain - correct answer 4. Cough and chest pain The nurse should instruct the client taking codeine sulfate to do which of the following? 1. Avoid the use of stool softeners to prevent diarrhea. 2. Avoid exercise to prevent lightheadedness. 3. Maintain a low-fiber diet. 4. Increase fluid intake. - correct answer 4. Increase fluid intake. A client with myasthenia gravis is receiving pyridostigmine (Mestinon). The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? 1. Vitamin K 2. Atropine sulfate 3. Protamine sulfate 4. Acetylcysteine (Mucomyst) - correct answer 2. Atropine sulfate A client who will undergo thyroidectomy at a later date has been started on medication therapy with potassium iodide (Lugol solution). As the licensed practical nurse (LPN) prepares to administer a scheduled dose, the client states that there is a burning sensation and a brassy taste in the mouth. The LPN should: 1. Give half the prescribed dose and notify the registered nurse (RN). 2. Withhold the medication and notify the RN. 3. Continue to administer the medication. 4. Stop the medication for 24 hours. - correct answer 2. Withhold the medication and notify the RN. A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? 1. Electrolyte levels 2. Coagulation times 3. Liver enzyme levels 4. Serum creatinine level - correct answer 3. Liver enzyme levels Entacapone (Comtan) is prescribed for a client with a diagnosis of Parkinson's disease. The nurse provides medication instructions to the client and tells the client that a frequent side effect is: 1. An elevation in blood pressure 2. Joint pains 3. Urine discoloration to dark yellow or orange 4. Pruritus - correct answer 3. Urine discoloration to dark yellow or orange A client is receiving meperidine hydrochloride (Demerol) for pain. Which of the following are side effects of this medication. Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate - correct answer 2. Tremors 3. Drowsiness 4. Hypotension The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level - correct answer 2. Uric acid level Fluoxetine (Prozac) is prescribed for the client. The nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication? 1. "I should take the medication with my evening meal." 2. "I should take the medication at noon with an antacid." 3. "I should take the medication in the morning when I first arise." 4. "I should take the medication right before bedtime with a snack." - correct answer 3. "I should take the medication in the morning when I first arise." The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. The nurse tells the client that insulin needs in the second and third trimesters of pregnancy: 1. Increase 2. Decrease [Show Less]
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NCLEX REVIEW STUDY GUIDE COMPREHENSIVE
A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does th... [Show More] e nurse make a priority of asking the client? - correct answer "Have you tested your blood glucose?" A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? - correct answer 1670mL A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first: - correct answer Raise the head of the client's bed A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? - correct answer Hearing loss Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? - correct answer Every morning before breakfast, with a full glass of water A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume: - correct answer Apple juice A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? - correct answer Recent stroke An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. - correct answer Nausea Eye pain Vomiting Headache The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client? - correct answer Relief of anxiety An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? - correct answer Administering 100% oxygen A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: - correct answer Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to: - correct answer Closely monitor the blood glucose level Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - correct answer Checking the client's blood pressure A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: - correct answer In about 6 weeks, when the vaginal vault is satisfactorily healed A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: - correct answer Ask the answering service to contact the on-call physician A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? - correct answer "Don't say that. If you can't control yourself, we'll help you." A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? - correct answer Intake and output A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. - correct answer Fatigue Low-grade fever Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: - correct answer Neck stiffness or soreness A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: - correct answer Stops the oxytocin infusion A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: - correct answer Pitting edema is present A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? - correct answer Fever A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? - correct answer Clamping the intravenous catheter A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. - correct answer Seek medical advice if you find a skin lesion. A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? - correct answer Dark urine A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? - correct answer Abduction device A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for: - correct answer Seizure activity A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? - correct answer Checking the client's blood pressure A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information? - correct answer "I should drink a cup of coffee if I feel the urge to smoke." A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis? - correct answer Atropine sulfate A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? - correct answer "Let's talk about the information that you need to determine your risk of contracting HIV." A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: - correct answer Sardines A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered? - correct answer Apical pulse A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? - correct answer "I need to participate in aerobic and weightlifting exercise three times a week." A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? - correct answer Maintaining cuff pressure Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? - correct answer Numbness and tingling of the fingers or toes A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply. - correct answer Smoking High alcohol intake White or Asian ethnicity A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: - correct answer Check for the presence of a gag reflex A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that: - correct answer Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: - correct answer Increase fluid intake A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. - correct answer Spinach Legumes Whole grains A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description? - correct answer Stable A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: - correct answer Improved swallowing function A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child? - correct answer Acetylcysteine (Mucomyst) A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? - correct answer Anxiety A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? - correct answer Assessing the client for organic causes of loss of arm movement After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? - correct answer Replacement of the uterus through the vagina into a normal position A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: - correct answer Conversion disorder A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: - correct answer A lower abdominal incision A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? - correct answer Uteroplacental insufficiency during a contraction A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse - correct answer Place small pieces of tape over the rough edges of the cast A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest. - correct answer 1 Possible infection 2 Decreased nutrition 3 Fatigue 4 Despair An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. - correct answer 1 Use an otoscope to ensure that the tympanic membrane is intact. 2 Warm tap water to body temperature. 3 Fill an irrigating syringe with warm water. 4 Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5 Document the completion of the procedure and how the client tolerated it. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? - correct answer Checking for gastric residual volume and assessing tube placement A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? - correct answer "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? - correct answer Regular (Humulin R) A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? - correct answer The pain is relieved by rest and nitroglycerin. While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? - correct answer Reed-Sternberg cells on biopsy of a lymph node A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? - correct answer Powerlessness Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? - correct answer "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. - correct answer -Drink copious amounts of fluid and void frequently -Avoid contact with any individual who has signs or symptoms of a cold A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of: - correct answer Respiratory alkalosis A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? - correct answer Contacting the child's physician to report the findings A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? - correct answer "I need to keep any unopened bottles of insulin in the freezer." A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would: - correct answer Contact the physician A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? - correct answer Decreased fluid volume A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: - correct answer Decrease A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? - correct answer "The placenta maintains the body temperature of my baby." A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? - correct answer 28 mm Hg Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: - correct answer To contact the physician A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: - correct answer Identify the client's treatment goals A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? - correct answer Thyroid-stimulating hormone (TSH) A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? - correct answer Epistaxis A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: - correct answer July 2, 2013 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. - correct answer "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. - correct answer Skin tenting Flat neck veins Weak peripheral pulses Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: - correct answer Levothyroxine amplifies the effect of warfarin sodium A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? - correct answer Calcium gluconate A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: - correct answer Increase intake of high-fiber foods The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: - correct answer Place some honey in her husband's mouth, between his gums and cheek A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. - correct answer Fever Vasculitis Abdominal pain A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: - correct answer That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? - correct answer Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French. Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? - correct answer Multiple sexual partners A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? - correct answer Yellow skin A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? - correct answer Trapeze bar A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? - correct answer "I need to not drink coffee before the test." A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: - correct answer Get into the shower and rinse the skin for at least 15 minutes A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: - correct answer Helping the woman empty her bladder A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? - correct answer Bleeding A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? - correct answer The client complains of a tingling sensation around the mouth. [Show Less]
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NCLEX REVIEW STUDY GUIDE 2
A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritat... [Show More] ed by the edges of the cast. What is the appropriate action on the part of the nurse - correct answer Place small pieces of tape over the rough edges of the cast A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest. - correct answer 1 Possible infection 2 Decreased nutrition 3 Fatigue 4 Despair An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. - correct answer 1 Use an otoscope to ensure that the tympanic membrane is intact. 2 Warm tap water to body temperature. 3 Fill an irrigating syringe with warm water. 4 Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5 Document the completion of the procedure and how the client tolerated it. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? - correct answer Checking for gastric residual volume and assessing tube placement A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? - correct answer "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? - correct answer Regular (Humulin R) A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? - correct answer The pain is relieved by rest and nitroglycerin. While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? - correct answer Reed-Sternberg cells on biopsy of a lymph node A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? - correct answer Powerlessness Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? - correct answer "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. - correct answer -Drink copious amounts of fluid and void frequently -Avoid contact with any individual who has signs or symptoms of a cold A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of: - correct answer Respiratory alkalosis A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? - correct answer Contacting the child's physician to report the findings A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? - correct answer "I need to keep any unopened bottles of insulin in the freezer." A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would: - correct answer Contact the physician A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? - correct answer Decreased fluid volume A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: - correct answer Decrease A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? - correct answer "The placenta maintains the body temperature of my baby." A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? - correct answer 28 mm Hg Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: - correct answer To contact the physician A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: - correct answer Identify the client's treatment goals A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? - correct answer Thyroid-stimulating hormone (TSH) A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? - correct answer Epistaxis A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: - correct answer July 2, 2013 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. - correct answer "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. - correct answer Skin tenting Flat neck veins Weak peripheral pulses Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: - correct answer Levothyroxine amplifies the effect of warfarin sodium A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? - correct answer Calcium gluconate A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: - correct answer Increase intake of high-fiber foods The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: - correct answer Place some honey in her husband's mouth, between his gums and cheek A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. - correct answer Fever Vasculitis Abdominal pain A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: - correct answer That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? - correct answer Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French. Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? - correct answer Multiple sexual partners A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician? - correct answer Yellow skin A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? - correct answer Trapeze bar A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? - correct answer "I need to not drink coffee before the test." A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: - correct answer Get into the shower and rinse the skin for at least 15 minutes A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: - correct answer Helping the woman empty her bladder A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? - correct answer Bleeding A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? - correct answer The client complains of a tingling sensation around the mouth. A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid? - correct answer High-impact exercise A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? - correct answer "Do you have episodes of dizziness?" A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to: - correct answer Lie down to administer the subcutaneous injection A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that: - correct answer The client's hemoglobin level is low A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? - correct answer "Have you ever worked in a mine?" A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? - correct answer Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: - correct answer In a vertical position with the needles pointing up Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication: - correct answer 2 hours after meals A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. - correct answer Hunger Weakness Blurred vision [Show Less]
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NCLEX REVIEW STUDY GUIDE 1
A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does th... [Show More] e nurse make a priority of asking the client? - correct answer "Have you tested your blood glucose?" A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? - correct answer 1670mL A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first: - correct answer Raise the head of the client's bed A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? - correct answer Hearing loss Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? - correct answer Every morning before breakfast, with a full glass of water A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume: - correct answer Apple juice A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? - correct answer Recent stroke An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. - correct answer Nausea Eye pain Vomiting Headache The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client? - correct answer Relief of anxiety An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? - correct answer Administering 100% oxygen A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: - correct answer Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to: - correct answer Closely monitor the blood glucose level Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? - correct answer Checking the client's blood pressure A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: - correct answer In about 6 weeks, when the vaginal vault is satisfactorily healed A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: - correct answer Ask the answering service to contact the on-call physician A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? - correct answer "Don't say that. If you can't control yourself, we'll help you." A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? - correct answer Intake and output A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. - correct answer Fatigue Low-grade fever Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: - correct answer Neck stiffness or soreness A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: - correct answer Stops the oxytocin infusion A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: - correct answer Pitting edema is present A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? - correct answer Fever A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next? - correct answer Clamping the intravenous catheter A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. - correct answer Seek medical advice if you find a skin lesion. A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? - correct answer Dark urine A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? - correct answer Abduction device A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for: - correct answer Seizure activity A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? - correct answer Checking the client's blood pressure A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information? - correct answer "I should drink a cup of coffee if I feel the urge to smoke." A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis? - correct answer Atropine sulfate A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? - correct answer "Let's talk about the information that you need to determine your risk of contracting HIV." A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: - correct answer Sardines A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered? - correct answer Apical pulse A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction? - correct answer "I need to participate in aerobic and weightlifting exercise three times a week." A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? - correct answer Maintaining cuff pressure Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? - correct answer Numbness and tingling of the fingers or toes A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply. - correct answer Smoking High alcohol intake White or Asian ethnicity A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: - correct answer Check for the presence of a gag reflex A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that: - correct answer Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: - correct answer Increase fluid intake A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. - correct answer Spinach Legumes Whole grains A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description? - correct answer Stable A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: - correct answer Improved swallowing function A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child? - correct answer Acetylcysteine (Mucomyst) A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? - correct answer Anxiety A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? - correct answer Assessing the client for organic causes of loss of arm movement After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? - correct answer Replacement of the uterus through the vagina into a normal position A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: - correct answer Conversion disorder A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: - correct answer A lower abdominal incision A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? - correct answer Uteroplacental insufficiency during a contraction [Show Less]
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NCLEX REVIEW STUDY
A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the develop... [Show More] ment of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? - correct answer Placing the client in a lateral position with the bed flat A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: - correct answer Contact the physician if the skin appears yellow A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately: - correct answer Encourage the child to drink water or milk in small amounts A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first: - correct answer Check the uterus and amount of lochia discharge A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? - correct answer Spontaneous bruising A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? - correct answer A blood pressure higher than the normal range A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication: - correct answer With food A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? - correct answer Bilateral lung wheezes A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. - correct answer Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair. The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: - correct answer Document the laboratory result in the client's record A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? - correct answer Soft, relaxed, nontender uterus A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client: - correct answer Is at low risk for AIDS A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? - correct answer Cheeseburger A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which instructions should the nurse include on the list? Select all that apply. - correct answer Take your pulse before taking each dose. Take the digoxin at the same time each day. Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances. An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply. - correct answer -Ensuring that direct pressure is applied to the external hemorrhage site -Ensuring a patent airway and supplying oxygen to the client as prescribed -Inserting an intravenous (IV) catheter and administering fluids as prescribed A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: - correct answer Assist in intubating the client and beginning mechanical ventilation Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the: - correct answer Albuterol several minutes before inhaling the fluticasone propionate A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: - correct answer Depression A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? - correct answer Obsessive-compulsive disorder A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: - correct answer Document the findings A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching? - correct answer "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work." Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? - correct answer Lithium carbonate (Lithobid) Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? - correct answer "I need to stop the medication and call my doctor if I have severe diarrhea." A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client? - correct answer Pleuritic chest pain A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in: - correct answer Vitamin C Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? - correct answer Checking the client's blood pressure A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: - correct answer Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician? - correct answer Headache and nausea A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? - correct answer Establish a trusting nurse-client relationship A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? - correct answer The client takes isosorbide dinitrate (Isordil). The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to: - correct answer Check the drainage for glucose Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications? - correct answer "Does your child have an allergy to peanuts?" A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? - correct answer "I need to contact my surgeon immediately if I feel any numbness in my genital area." A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply. - correct answer Use a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device. A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: - correct answer Document the findings Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? - correct answer The client takes a prescribed antihypertensive. A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? - correct answer Documenting the finding Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: - correct answer Tomato juice A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? - correct answer Notifying the physician A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? - correct answer Fowler's position A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: - correct answer Helps predict the risk for the development of chronic complications of diabetes mellitus Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the physician's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that: - correct answer The full therapeutic effect may take 4 weeks Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? - correct answer Spinach A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: - correct answer Take the medication with food A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? - correct answer Stokes sign A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? - correct answer White blood cell count of 2500 cells/mm3 [Show Less]
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NCLEX STUDY EXAM WITH SOLUTIONS - CARDIAC MEDS
What are the classifications of cardiac medications? - correct answer Cardiac Glycosides Phosphodiesterase Inhibitors Direct Vasodilators Organic Nitrat... [Show More] e/Vasodilator Beta-adrenergic Antagonists (Beta-Blockers) Calcium Channel Blockers Alpha Adrenergic Agonists Angiotensin-converting enzymes (ACE) inhibitiors Angiotensin II Receptor Blockers (ARBS) Direct Acing Vasodilators What are the names of the cardiac Glycosides? - correct answer Digoxin (Lanoxin, Digitek) What is Digoxin used for? - correct answer HF dysrhythmias What are the therapeutic digoxin levels? - correct answer Between 0.5 and 2 ng/ml What electrolyte should be monitored with digoxin? - correct answer K+ HYPOkalemia can increase potential for toxicity What vital sign should be assessed before administering digoxin? - correct answer Apical pulse Hold med if HR <60 Why may a pt receive a loading dose of digoxin? - correct answer Digitalizing dose may be given to get serum levels w/in therapeutic range. Common adverse effects of Digoxin? - correct answer fatigue anorexia bradycardia What are signs of digoxin toxicity? - correct answer HA vertigo photophobia yellow-green halos tachycardia AV heart block What is the Antidote for Digoxin? - correct answer Digibind What are the names of Phosphodiesterase Inhibitors? - correct answer Milrinone (Primacor) Inamirnone (Inocor) What is the indication for phosphodiesterase inhibitors? Milrinone (primacor) inamirnone (Inocor) - correct answer Short term management of HF What are the adverse effects of phosphodiesterase inhibitors milrinone (Primacor) inamirnone (Inocor) - correct answer ventricular arrhythmias hypotension chest pain HA hypokalemia tremors throbocytopenia Who are the phosphodieasterase inhibitors reserved for? - correct answer Those that do not respond to cardiac glycosides (digoxin) or ACE inhibitors What the name of a direct vasodilator? - correct answer Nesiritide (Natrecor) What are direct vasodilators indicated for? nesiritide (Natrecor) - correct answer Acute treatment of HF in pts with dyspnea at rest and/or minimal activity. What are the common adverse effects of nesiritide (Natrecor)? - correct answer cardiac arrhythmias hypotension HA fainting anxiety What should the nurse do if a patient taking nesiritide (Natrecor) has hypotension? - correct answer reduce or stop administration What labs are important with nesiritide (Natrecor)? - correct answer BASELINE creatinine and continued monitoring b/c natrecor can be nephrotoxic with acutely decompensated heart failure What are common organic nitrate/vasodilators? - correct answer Nitroglycerin (Nitro-Bid) Isosorbide (Isordi) What are organic nitrates indicated for? Nitroglycerin (Nitro-Bid) Isosorbide (Isordi) - correct answer stable and unstable angina rapid acting for acute angina long acting prevention of angina attacks What are the adverse effects of organic nitrate/vasodilators? Nitroglycerin (Nitrobid) Isosorbide (Isordi) - correct answer HA hypotension tachycardia contact dermatitis w/topical What are the contraindications for Nitroglycerin and Isosorbide use? - correct answer preexisting hypotension head trauma increased ICP pericardial tamponade What is required for Nitroglycerin and isosorbide administration? - correct answer Adequate hydration What should be assessed for IV organic nitrate/vasodilator administration? nitroglycerin (nitrobid) isosorbide (isordi) - correct answer MUST USE IV PUMP CHECK BP HOLD IF systolic BP <100 What should the nurse know about sublingual administration of nitroglycerin administration? - correct answer For sublingual: may administer up to 3 SL tabs. Store in dark, light resistant container and replace every 6 months. For topical administration: apply with gloves, non hairy routs, rotate sites, avoid lower extremities What are examples of Beta Blockers? - correct answer propranolol (Inderal) atenolol (Tenormin) metoprolol (Lopressor) Carvedilol (Coreg) What is the mechanism of action of Beta Adrenergic Blockers? - correct answer Block adverse effects from sympathetic nervous system. Blocks the receptor sidtes for epi and norepi so they will DECREASE AFTERLOAD AND CONTRACTILITY resulting in DECREASED BP and DECREASED HR. What are beta blockers used for? - correct answer angina particularly exercise induced angina chest pain HTN ventricular dysrhythmias THYROID STORM MI Off label uses: migranes tachycardia associated w/ stage fright How are beta blockers tolerated? - correct answer tolerated well at low doses withdraw GRADUALLY to avoid rebound HTN angina and MI What are the adverse effects of beta blockers? - correct answer bradycardia hypotension 2nd and 3rd degree heart block fatigue lethargy depression wheezing dyspnea impotence and decreased libido altered glucose and lipid metabolism What should be assessed before administration of beta blockers? - correct answer Hold if HR <60 What should be monitored with beta blockers? - correct answer blood sugar cholesterol and triglicerides Who should not receive beta blockers? - correct answer asthmatics (some beta blockers also constrict the smooth muscle of the bronchioles.) diabetics (beta blockers block the sympathetic responses seen in hypoglycemia.) What are some examples of Angiotensin converting enzyme (ACE) inhibitors? - correct answer Enalapril (Vasotec) Fosinopril (Monopril) Catopril (Capoten) Lisinopril (Zestril, Prinvil) Moexpril (Univasc) Ramipril (Altace) What are the actions of ACE inhibitors? enalapril-Vasotec fosinopril-Monopril captopril-Capoten - correct answer Blocks conversion of angiotensin I to angiotensin II. Promote VASODILATION and DIURESES, DECREASES ALDOSTERONE secretion--- kidneys will get rid of Na+ and water and retain K+. What are ACE inhibitors used for? enalapril- Vasotec captopril- Capotin lisinopril- Zestril, Prinivil fosinopril- Monopril moexpril- Univasc ramipril- Altace - correct answer HTN HF MI What are the adverse effects of ACE inhibitors? lisinopril ramipril captopril enalapril - correct answer generally mild dizziness fatigue DRY NONPRODUCTIVE COUGH chest pain tachycardia Hyperkalemia HYPERmagnesemia What is a rare but serious side effect of ACE inhibitors? captopril lisinopril enalaprol captopril - correct answer angioedema- laryngeal swelling can be fatal What electrolytes should be monitored with ACE inhibitors? - correct answer Mg+ and K+ What effect does ACE inhibitors have on diuretics? - correct answer ENHANCES the effect of thiazide diuretics What should the nurse watch for with ACE inhibitors? - correct answer Hyperkalemia hypermagnesemia othostatic syncope hypotension orthostatic syncope What are the names of the Angiotensin II Receptor Blockers (ARBs)? - correct answer losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro What is the action of ARBs? losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro - correct answer Blocks effects of angiotensin II (a potent vasoconstrictor) at the receptor site (used as an alternative to ACE inhibitors), ACE inhibitors block he conversion of AI to AII but AII can also be formed by other enzymes not blocked by ACE inhibitors. What do ARBs do? losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro - correct answer DECREASE BP INCREASE CO POTENT VASODILATOR What are ARBs used for? losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro - correct answer HTN HF adjunctive therapy What are the adverse effects of ARBs? losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro - correct answer ARBs are a POTENT VASODILATOR effects are generally mild: HA upper respiratory infections dizziness GI complaints fatigue What are ARBs most commonly used for? - correct answer Often used in combination therapy for management of HTN What should the nurse watch for with ARBs? losartan - Cozaar olmesartan - Benicar valsartan - Diovan Irbesartan - Avapro - correct answer hyperkalemia hypotension renal dysfunction What are the names of some Calcium Channel Blockers? - correct answer Amlodipine - Norvasc Diltiazem - Cardizem Ranolazine - Ranexa What are Calcium Channel blockers indicated for? amlodipine - Norvasc diltiazem - Cardizem ranolazine - Ranexa - correct answer angina HTN dysrhythmias migraines Raynauds What are the adverse effects of calcium channel blockers? amlodipine -Norvasc diltiazem - Cardizem ranolazine - Ranexa - correct answer bradycardia or tachycardia heart block hypotension dyspnea wheezing GI complaints dermatitis When should the dose of Calcium channel blockers be reduced? amlodipine -Norvasc diltiazem - Cardizem ranolazine - Ranexa - correct answer Reduce with liver disease and use with caution Taper dose [Show Less]
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NCLEX + 35 PAGE STUDY GUIDE, NCLEX UWORLD
Five Rights of Delegation - correct answer 1. Right Person 2. Right Task 3. Right Circumstance 4. Right Direction and Communication 5. Right Supervisio... [Show More] n and Evaluation Maslow's Hierarchy of Needs - correct answer Five Rights of Medication Administration - correct answer 1. Right Client 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time Acetaminophen (Tylenol) - correct answer Antidote/Reversal: acetylcysteine (Muscomyst) Toxic Level: >250mcg/mL Curare - correct answer Antidote/Reversal: edrophonium (Tensilon) Cyanide Poisoning - correct answer Antidote/Reversal: methylene blue Ethylene Poisoning - correct answer Antidote/Reversal: fomepizole (Antizol) Iron - correct answer Antidote/Reversal: deferoxamine (Desferal) Lead - correct answer Antidote/Reversal: succimer (Chemet) Carbamazepine - correct answer anticonvulsant Therapeutic Level: 5-12 mcg/mL Amitriptyline - correct answer antidepressant and nerve pain med Toxic Level: >500 ng/ML Gentamicin - correct answer antibiotic (renal/oto toxic) Therapeutic Level: 0.5-0.8 mcg/mL Toxic Level: >12mcg/mL Magnesium Sulfate - correct answer anticonvulsant Therapeutic Level: 4-8 mg/dL Toxic Level: >9mg/dL Antidote/Reversal: calcium gluconate 10% (Kalcinate) Methotrexate - correct answer Chemotherapy/Immunosuppressant Toxic Level: >10 mcmol over 24 hours Quinidine - correct answer antiarrhythmic/anti-parasite Therapeutic Level: 2-5 mcg/mL Toxic Level: >10 mcg/mL Salicylate - correct answer NSAID Therapeutic Level: 100-250 mcg/mL Toxic Level: >300 mcg/mL Tobramycin - correct answer Therapeutic Level: 5-10 mcg/mL Toxic Level: >12 mcg/mL Sodium (Na) - correct answer 135-145 Potassium (K) - correct answer 3.5-5 Calcium (Ca) - correct answer 8.5-10.5 Magnesium (Mg) - correct answer 1.5-2.5 Phosphorus (PO4) - correct answer 2.5-4.5 pH - correct answer 7.35-7.45 PaCO2 - correct answer 35-45 PaO2 - correct answer 80-100 HCO3 (bicarbonate) - correct answer 22-26 RBC - correct answer 4,000,000-6,000,000 Hgb - correct answer 12-18 Hct - correct answer 36-50 WBC - correct answer 5,000-10,000 Cholesterol - correct answer <200 INR - correct answer <2. Warfarin Therapeutic Range: 2-3 PT - correct answer 11-15. Warfarin Therapeutic Range: 1.5-2 times normal value (16.5-30) PTT - correct answer 25-35. Heparin Therapeutic Range: 1.5-2 times normal value. (37.5-70) Platelets - correct answer 150,000-400,000. <20,000 be very concerned. Urine Specific Gravity - correct answer 1.01-1.025. High gravity means urine is concentrated. Low gravity means urine is dilute. Creatinine - correct answer 0.6-1.2. BUN - correct answer 10-20 TPN Total Parenteral Nutrition - correct answer Hypertonic Solution Given via PICC line, tunneled catheter Prepared daily by pharmacy Use Sterile Asepsis for dressing change Check blood glucose every 4-6 hours Change bag every 24 Standard Precautions - correct answer When handling blood, bodily fluid, bodily tissue, mucous membranes, open skin PPE: depends on type of exposure (minimal is nothing) Contact Precautions - correct answer Used when germs are spread by touching ex) C. Difficile, Norovirus Minimal PPE: Gloves and Gown Droplet Precautions - correct answer Used to prevent contact with mucus and other secretions from nose, sinuses, throat, airway, and lungs. Use when contact will be within 3 ft or less ex) infulenza, mumps, pertussis Minimal PPE: Mask Airborne Precautions - correct answer Needed to prevent transmission from particles so small the can float in the air and travel long distances. ex) chickenpox, measles, Tuberculosis, SARS Minimal PPE: Well fitting mask *Use respirator mask for TB and SARS **Negative Pressure room Trust vs. Mistrust - correct answer 0-1 yr Teach parents to meet infant's physical and social needs Autonomy vs. Shame and Doubt - correct answer 1-3 yrs Provide child with acceptable options. Let them CHOOSE Initiative vs. Guilt - correct answer 3-6 yrs Assist parents to identify age/disease appropriate activities Idustry vs. Inferiority - correct answer 6-12 yrs Encourage child's participation in their care Identity vs. Role Confusion - correct answer 12-20 yrs Provide same age support group Intimacy vs. Isolation - correct answer 20-35 yrs Provide private time with partner/family Generativity vs. Stagnation - correct answer 35-65 yrs assist client with illness adaptation and home/work demands Integrity vs. Despair - correct answer 65+ yrs Encourage use of personal items when not at home HYPOnatremia - correct answer abnormally low sodium level (<135) in the blood, which helps regulate the amount of H2O in and around the cells HYPERnatremia - correct answer abnormally high sodium level (>145) in the blood, which helps regulate the amount of H2O in and around the cells. HYPOcalcemia - correct answer low blood calcium level (<4.0). HYPERcalcemia - correct answer high blood calcium level (>10.5) HYPOglycemia - correct answer HYPERglycemia - correct answer HYPOthyroidism (Hashimotos) - correct answer HYPERthyroidism (Graves Disease) - correct answer HYPOparathyroidism - correct answer HYPERparathyroidism - correct answer HYPOkalemia - correct answer HYPERkalemia - correct answer In delegation, nurses must take patients where there is... - correct answer Evaluation Assessment Teaching Dont delegate what you can EAT Addison disease vs Cushings disease - correct answer Addisions: down down down up down (hyponatremia, hypotension, decreased blood volume, kyperkalemia, hypoglycemia) Cushings: up up up down up (hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia) When do we hold potassium - correct answer Do not give potassium without adequate urine output "No Pee, No K" APGAR - correct answer Appearance (color all pink, pink and blue, blue/pale) Pulse (>100, <100, none) Grimace (cough, grimace, none) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, none) For what diseases do we use airborne precautions - correct answer My (measles) Chicken (chicken pox/varicella) Hez (disseminated herpes zoster, shingles) TB (TB) When implementing airborne precautions, what do we have to do - correct answer Private, negative pressure room Must wear mask Can cohort with patient who has same organism, but not if they have different organisms Place mask on client when they are being transported For what diseases do we use droplet precautions - correct answer Think SPIDERMAN S:sepsis S:scarlet fever S: streptococcal pharyngitis P:Parvovirus B19 P:Pneumonia P:Pertussis I:Influenza Type B D: Diptheria (pharyngeal) E: Epiglottitis R: Rubella M:mumps M:Mengitis M:Mycoplasm or meningeal pneumonia An: Adenovirus When implementing droplet precautions, what do we have to do - correct answer Private room or cohort them with a client with the same infection Wear a mask Door may remain open For what diseases do we use contact precautions - correct answer MRS.WEE M:multi drug resistant organism R: Respiratory infection (RSV) S: Skin infections (varicella zoster, cutaneous diptheria, herpes simplex, impetigo, pediculosis, scabies) W:wound infection E: Enteric infection (C Diff) E: eye infection (pink eye) Signs and symptoms of air/pulmonary embolism - correct answer Chest pain Difficulty breathing Tachycardia Pale/Cyanotic Sense of impending doom What do we do as the nurse for air/pulmonary embolism - correct answer Turn patient to the LEFT side and LOWER the head of the bed Signs and symptoms of a woman in labor with a baby who has an unreassuring FHR - correct answer Late decels Fetal bradycardia Decreased variability What do we do for a woman in labor who has an unreassuring FHR - correct answer Turn to the LEFT side Give O2 Stop the Pitocin Increase IV fluids (LR and NS) What position is someone in for an epidural puncture - correct answer Side-lying What position is the patient in AFTER a lumbar puncture (and also oil-based myelogram) - correct answer Have the pt lie Flat and Supine to prevent CSF from leaking out and prevent a headache What do we do if a patient has decreased LOC during tube feeding - correct answer Position the patient on the RIGHT side (to increase gastric emptying) and RAISE the head of the bed to at least 30 degrees (to prevent aspiration) Position for a patient with a CBI - correct answer The catheter is taped to the patients leg so the leg should be kept straight, but there are no other positioning limitations Position of a patient after a myringotomy - correct answer Position the patient on the side of the AFFECTED EAR after surgery to allow for drainage of secretions. This procedure is surgical incision into the eardrum (tympanic membrane), to relieve pressure or drain fluid. Position of a patient after cataract surgery - correct answer Patient should sleep on the UNAFFECTED side and have a night shield for 1-4 weeks Position of a patient after a thyroidectomy - correct answer Low or semi-fowlers. Support the head, neck, and shoulders. Have a trach at the bedside Position of an infant with spina bifida - correct answer Prone! So their sac does not rupture Position of a patient with bucks traction - correct answer Elevate the food of the bed for counter traction Position of a patient after total hip replacement - correct answer Do not sleep on the operated side. No flexing the hip more than 45-60 degrees. Don't elevate the HOB more than 45 degrees. Keep the hip abducted by separating legs with a pillow or abductor Position for a mom with a prolapsed cord - correct answer Knee-chest position or trendelenburg Position for an infant with a cleft lip - correct answer On their back or in an infant seat to prevent trauma to the suture line. If feeding, hold in an upright position Position for an ABOVE the knee amputation - correct answer Elevate for the first 24 hours on a pillow. Position prone daily to help with hip extension Position for a BELOW the knee amputation - correct answer Foot of bed elevated for the first 24 hours. Position prone daily to help with hip extension Position for a detatched retina - correct answer Area of detachment should be in the dependent position Position for administration of an enema - correct answer Patient should be LEFT side laying with the knee flexed (Sims position) Position during internal radiation - correct answer On bedrest while the implant is in place Position if the patient has autonomic dysreflexia/hyperreflexia - correct answer Place the client in a sitting position (elevate the HOB to 90) FIRST before any other implementation S&S include: extreme HTN, pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia,) Position for a patient in shock - correct answer Modified trendelenberg (extremities elevated 20 degrees) with the knees straight and head slightly elevated Position for a patient with a head injury - correct answer Elevate the HOB 30 degrees to decrease ICP Position for a patient with peritoneal dialysis when the outflow is inadequate - correct answer Turn the patient from side to side BEFORE checking the tube for kinking When someone has a head injury, what medication are we likely to give - correct answer Mannitol. An osmotic diuretic that decreases ICP and increase urine output. This crystallizes at room temperature so ALWAYS use a FILTER NEEDLE What is myasthenia gravis - correct answer Muscular weakness produced by repeated movements. Disappears when the patient rests. No problems with CNS or PNS just random. We see diplopia, ptosis, impaired speech, dysphagia, respiratory distress As the nurse, what do we do for myasthenia gravis - correct answer Administer meds before eating (anti cholinesterase, corticosteroids, immunosuppressants) Optimal eye care (to prevent and help diplopia) Maintain optimal mobility Avoid things that precipitate myasthenia crisis (infections, stress, neomycin/streptomycin, surgery) What S&S will show if it proceeds to a Myasthenia crisis - correct answer Sudden inability to swallow, speak, or maintain a patent airway What test do we use to diagnose people with Myasthenia Gravis - correct answer Tensilon test. Where we inject tensilon and ask you to do activities like stand up and sit down and stand up and sit down. If you get tired we inject another dose. If you can stand up again, you probably have MG. MG is susceptible to the Tensilon test What lab value do we need to be aware of prior to a liver biopsy - correct answer PTT Thyroid storm - correct answer Caused by untreated Hyperthyroidism. Increased temp, pulses and BP Give hypothermia blanket, O2, PTU, potassium iodine Hypoparathyrodism - correct answer CATS: convulsions, arrythmias, tetany, spasms, stridor Too little calcium Hyperparathyroidism - correct answer Fatigue Muscle weakness Renal calculi Back/joint pain and pathological fractures Too much calcium Hypovolemia - correct answer Increased temp Rapid/weak pulse Increased respirations Decrease BP [Show Less]
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NCLEX STUDY FROM MARK KLIMEK
Hyperthyroidism is also called - correct answer Grave's disease or hypermetabolism Tip to remember Grave's disease s/s's - correct answer "Run yourself ... [Show More] into the Grave" - everything is up ... diarrhea, thin, hot, high BP, high HR, cold tolerance, hot intolerance Treatment for Grave's disease - correct answer Radioactive Iodine, PTU (put thyroid under), surgically remove Total thyroidectomy ... totals get - correct answer tetany, need lifelong hormone replacement After thyroidectomy patients are at risk for - correct answer hypocalcemia, remember hypocalcemia is opposite of the prefix and anything to BP so tetany, parasthesia parathesia - correct answer numbness and tingling, first sign of electrolyte imbalance Subtotal thyroidectomy ... subs get - correct answer storm S/S of thyroid storm - correct answer Extremely high vital signs, hyperpyrexia, psychotic delerium How to treat thyroid storm - correct answer give o2, lower temp to spare brain Risks post op for total thyroidectomy - correct answer airway, hemorrhage for 1st 12 hours then for 12-48 hours hypocalcemia leading to tetany Risks post op for sub total thyroidectomy - correct answer airway, hemorrage for 1st 12 hours then for 12-48 hours thyroid storm Hypothyroidism is also called - correct answer Myxedema or hypometabolism S/S of mydexema - correct answer everything is down, constipation, heat tolerance, cold intolerance Treatment for mydexema - correct answer give thyroid medications Where to put the 5 ice packs to cool a thyroid storm patient - correct answer neck pits groin If you cool a patient too fast what might happen? - correct answer Heart arrythmias Never hold the hormone for what patient? - correct answer patient who is NPO with mydexema Addison's disease easy way to remember - correct answer Add a Sone (sone = steroid) Adrenal Cortex diseases easy way to remember - correct answer A in Adrenal stands for Addison's C in Cortex stands for Cushing's Addison's disease is - correct answer undersecretion of adrenal cortex, not enough hormone, BRONZE/tan, go into shock very easily. STRESS can trigger. Addison's disease treatment - correct answer give a steroid, chronic steroid therapy Cushing's syndrome - correct answer Over secretion of adrenal cortex, too much hormone, too much steroid. S/S of Cushing's syndrome - correct answer same as steroid use ... moon face, think cushman "I'm mad I have an infection", high blood sugar, losing Potassium, Treatment for Cushing's syndrome - correct answer Surgery, bi or uni lateral adrenalectomy (bilateral is worse) Donning PPE's order - correct answer Gown, Mask, Goggles, Gloves Removing PPE's order - correct answer alphabetically inside the room For airborne precautions the mask is removed where? - correct answer outside of the room Avoid answers with what words for children 9 mths and younger? - correct answer build, sort, stack, construct, make Toddlers (1-3) work on - correct answer their gross motor skills (jump, hop, throw), NO fine motor, parallel play Preschoolers (3-6) work on - correct answer fine motor, balance (tumbling, dance, tricycle), cooperative play, pretend School age (7-11) work on - correct answer creative, collect, competitive Best default order for click and drag order questions? - correct answer Hold ..... med Assess ..... what med does Prepare ...... the correction Call ..... or notify Rarely if ever answer ... - correct answer call Doctor, NCLEX wants you to think critically Creatinine lab values - correct answer same as lithium 0.6-1.2 Not a huge worry, not a dangerous lab to worry about INR lab values - correct answer 2-3, critical value if off, potential for patient to bleed. Use default order for order ?'s (hold all coumadin, assess for bleeding, prepare Vit K (antidote for Coumadin), Call or notify Potassium lab values - correct answer 3.5-5.3 If low it is a critical lab to worry about assess the heart and then prepare to give K if high, hold all K, assess heart (EKG), give D5W and reg insulin, call if really high, hold, assess, prepare, call STAT Get someone else involved! Dangerous!! pH lab values - correct answer 7.35-7.45 if pH is in the 6;s VERY dangerous remember as the patient's pH goes so goes the patient If bad vitals, call rapid response team BUN lab values - correct answer 8-30 check for dehydration if elevated not a big deal, just be concerned If a deadly or dangerous lab value is discovered AND they have symptoms call the - correct answer rapid response team! HgB lab values - correct answer 12-18 check for bleeding if low or high, if low prepare for tranfussion HCO3 lab values - correct answer 22-26 if it is abnormal so what! CO2 lab values - correct answer 35-45 if in the 50's assess respiratory status and have patient do pursed lip breathing, if in 60's considered deadly and respiratory failure, need intubated Hct lab values - correct answer 36-54 thickness of blood if abnormal not too big of a deal, assess for dehydration PO2 lab values - correct answer 78-100 this is only obtained from an ABG if low give O2 but if really low it is respiratory failure give O2, prepare for intubation, call resp therapy and call Dr O2 sat lab values - correct answer 93-100 pulse ox, if under 93 assess resp status and give O2 BNP lab value - correct answer less than 100 is normal, good indicator of CHF, edema, if elevated assess s/s of CHF NA lab values - correct answer 135-145, if a change in LOC then evaluate for fall/safety risk WBC lab values - correct answer 5000-11000 if low assess for infection CD4 count less than 200 equals - correct answer AIDS Neutropenic precautions (low WBC) - correct answer strict handwashing, avoid crowds, private room, low bacteria diet (no raw or undercooked), no water that has been standing longer than 15 min, vital signs Q4H Platelets lab value - correct answer 150000-400000 if lower than 90000 bad if lower than 40000 REALLY bad, if they sneeze they could die. Called thrombocytopenia Bleeding precautions - correct answer no venipuncture, injection or IV, if necessary use small guage, handle patient gently, use drawsheet, no razor, no toothbrush, blow nose gently, no aspriin, no rectal temp, no hard foods RBC lab values - correct answer 4-6 million abnormal doesn't really matter Reason for laminectomy - correct answer treat nerve root compression S/S of nerve root compression - correct answer Pain Parasthesia (numbness & tingling) Paresis (muscle weakness) Cervical - correct answer Diaphram and Arms affected, breathing, respiratory pattern Thoracic - correct answer Abd muscles and gut affected, ability to cough Lumbar - correct answer Bladder and legs affected, when did they last void, are they distended #1 post op answer for spinal problems is - correct answer log roll patient Activity post op spinal issue - correct answer do not dangle stand, walk, lie down w/o restricitons limit sitting to 30 min at a time Post op complications for cervical spinal surgery - correct answer pneumonia Post op complications for thoracic spinal surgery - correct answer pneumonia (no cough), paralytic illeus (gut shuts down) Post op complications for lumbar spinal surgery - correct answer urinary retention How long does temporary restrictions usually mean? - correct answer 6 weeks (driving, lifting, etc.) Nagele's Rule - correct answer 1st day of last period + 7 days - 3 months Weight gain during pregnancy - correct answer 28 lbs plus or minus 3 lbs 1st trimester weight gain - correct answer 1 lb/month or 3 lbs for 1st trimester 2nd/3rd trimester weight gain - correct answer 1 lb/week Easy way to calculate appropriate weight gain during pregnancy - correct answer The week number minus 9 so if 12 weeks pregnant 12-9=3 lbs. not allowed to be off by more than 2 lbs. Fundal Height - correct answer not palpable until 12 weeks, 2nd and 3rd trimesters week gestation 20-22 in cm so at the navel is 20 weeks Positive signs of pregnancy - correct answer xray, ultrasound, auscultation of fetal HR on doppler 10 weeks, examiner (not the mother) palpates fetal movement Probable signs of pregnancy - correct answer blood and urine tests, Chadwick's sign, Goodell's sign, Hegar's sign Chadwick's sign - correct answer Cervical color changes to Cyanosis See all the CCCCCC's! Goodell's sign - correct answer Cervical softening Hegar's sign - correct answer Uterine softening All changes in cervix and vagina occur in what order? - correct answer alphabetical order Pattern of Office Visits for prenatal care - correct answer once a month until 28 weeks, once every 2 weeks until week 36, once a week until delivery or week 42 when induction is scheduled Pregnancy hemoglobin - correct answer normal is 12-18, first trimester falls to 11 which is okay, second trimester falls to 10.5 which is okay and then third trimester falls to 10 also okay Easy way to remember station - correct answer has it made it through the "tight squeeze" (ischial spine) no then its a negative, yes then its a positive, 0 station is when it's at the ischial spine Presenting part is 99% of the time the - correct answer head What is bad as far as Lie? - correct answer Transverse is bad, vertical is good, parallel is good Stage 1 of L&D - correct answer Labor - thinning and opening, has 3 phases, Latent, Active, Transitional, nothing to do with the baby just the cervix, no baby at the end of labor Stage 2 of L&D - correct answer Delivery - pushing the baby out Stage 3 of L&D - correct answer Placenta delivery Stage 4 of L&D - correct answer Recovery (1st 2 hrs after delivery of placenta), considered unstable patient, stop the bleeding in stage 4 Memorize 1st stage 2nd phase of L&D then you know the rest - correct answer Active phase CM dilated 5-7 cm CXN Freq 3-5 min Duration 30-60 sec Intensity moderate Contractions should not be longer than ____ seconds or closer than every _____ minutes. - correct answer 90, 2 Prolapsed cord - correct answer OB emergency, baby will die if you don't do something What to do with prolapsed cord - correct answer Push then position! Push head off cord then position in knee/chest of trendelenburg (head down) Lithotomy position - correct answer on back with knees drawn up [Show Less]
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ANTEPARTUM NCLEX STUDY QUESTIONS
A client is at 8 weeks gestation. Which of the following findings would the nurse expect to see? 1. Multiple pillow orthopnea 2. Maternal ambivalence ... [Show More] 3. Fundus at the umbilicus 4. Pedal and ankle edema - correct answer 2. Maternal ambivalence Ambivalence is a common finding of women during the first trimester During a vaginal examination, the nurse palpates the back of a fetus' head 2 cm below the mother's ischial spines and facing toward the right side of the mother's back. Which of the following is consistent with this assessment? 1. ROA, -2 station 2. RSP, -2 station 3. RMA, +2 station 4. ROP, +2 station - correct answer 4. ROP, +2 station ROP = Right occipital posterior (the back of the baby's head is facing toward the mother's right posterior), and +2 Station - the presenting part is 2 cm below the ischial spines Incorrect ROA = Right occipital anterior (the back of the babay's head is facing toward the mother's right anterior). -2 Station - the presenting part is 2 cm above the inschial spines Incorrect RSP = Risht sacral posterior (the buttocks of the baby are facing towards the mother's right posterior). -2 Station - the presenting part is 2 cm above the ischial spines Incorrect RMA = Right mentum anterior (the face of the baby is facing toward the mother's right anterior). +2 Station - presenting part is 2 cm below the ischial spines The result of a pregnant woman's glucose challenge test is 145 mg/dL. Which of the following information is appropriate for the nurse to give the client at this time? 1. "You will need to inject insulin at least once a day for the rest of the pregnancy" 2. "Daily oral medicines will be prescribed for you to take" 3. "You need to have a fasting glucose tolerance test as soon as possible" 4. "The results are within normal limits so no intervention is needed" - correct answer 3. "You need to have a fasting glucose tolerance test as soon as possible" While performing Leopold's maneuvers on a laboring woman, the nurse palpates a flat area in the fundal region, a hard round mass on the left side, a soft round mass on the right side, and small parts just above the symphysis. The nurse concludes which of the following? 1. The fetal position is right occiput posterior 2. The fetal attitude is flexed 3. The fetal presentation is scapular 4. The fetal lie is vertical - correct answer 3. The fetal presentation is scapular This is a shoulder presentation A gravid woman and her husband inform the nurse that they have purchased a three-story home that was built in the 1930's. It is critical that the nurse counsel the couple that before moving into the home they do which of the following? 1. Remove all old carpeting 2. Check the water for heavy metals 3. Replace ll copper pipes 4. Monitor the bathrooms for signs of mildew - correct answer 2. Check the water for heavy metals The water should be checked for lead. Lead consumption by the woman during pregnancy and/or by the baby can result in permanent central nervous system damage in the child A nurse is working in the prenatal clinic. Which of the following findings would the nurse consider to be within normal limits for a client in the third trimester of pregnancy? 1. Diplopia 2. Epistaxis 3. Bradycardia 4. Oliguria - correct answer 2. Epistaxis Epistaxis is commonly seen in pregnant clients. The bleeding is related to the increased vascularity of the mucous membranes. Unless the blood loss is significant, it is a normal finding. A gravida G4 P1203, fetal heart rate 142, is 13 weeks pregnant, fundal height 1 cm above the symphysis. She denies experiencing quickening. Which of the following nursing conclusions made by the nurse is correct? 1. The woman is experiencing a normal pregnancy 2. The woman may be having difficulty accepting this pregnancy 3. The woman must see a nutritionist as soon as possible 4. The woman will likely miscarry the conceptus - correct answer 1. The woman is experiencing a normal pregnancy A primigravid client is 39 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? 1. Nausea 2. Dysuria 3. Urinary frequency 4. Intermittent diarrhea - correct answer 3. Urinary frequency Urinary frequency recurs at the end of the third trimester. As the uterus enlarges, it again compresses the bladder, causing urinary frequency A 36-week gestation client is being seen in the prenatal clinic. Where would the nurse expect the fundal height to be felt? 1. At the xiphoid process 2. At a point between the umbilicus and the xiphoid 3. At the umbilicus 4. At a level directly above the symphysis pubis - correct answer 1. At the xiphoid process At 36 weeks' gestation, the fundus should be felt at the xiphoid process At 20 weeks' gestation, the fundus should be felt at the umbilicus At 12 weeks' gestation, the fundus should be felt directly above the symphysis pubis A woman who has had no prenatal care was found to have hydramnios (excessive amniotic fluid) on admission to the labor unit and has since delivered a baby weighing 4500 grams. Which of the following complications of pregnancy likely contributed to these findings? 1. Pyelonephritis 2. Pregnancy-induced hypertention 3. Gestational diabetes 4. Abruptio placentae - correct answer 3. Gestational diabetes Untreated gestational diabetics often have hydramnios and often deliver macrosomic (big body) babies A pregnant woman informs the nurse that her last normal menstrual period was on July 6, 2012. Using Naegele's rule, which of the following would the nurse determine to be the client's estimated date of delivery (EDC)? 1. January 9, 2013 2. April 13, 2013 3. April 20, 2013 4. September 6, 2013 - correct answer 2. April 13, 2013 The EDC is calculated as April 13, 2013. Naegeles rule: First, identify the first day of the last normal menstrual period. Then, subtract 3 months and add 7 days, adjust the year if needed A pregnant woman has Marfan syndrome, n autosomal dominant disease. It has previously been determined that the woman is heterozygous for the condition. Her husband has no known genetic diseases. The nurse advises the couple that their unborn child has which of the following probabilities of having Marfan's? 1. 25% probability 2. 50% probability 3. 75% probability 4. 100% probability - correct answer 2. 50% probability This couple has a 50% probability of having a child who has Marfan's A 32-week gestation client was last seen in the prenatal clinic at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the Certified Nurse's Midwife? 1. Weight change from 128 pounds to 132 pounds 2. Pulse changes from 88 bpm to 92 bpm 3. Blood pressure changes from 110/70 to 140/90 4. Respiratory change from 16 rpm to 20 rpm - correct answer 3. Blood pressure changes from 110/70 to 140/90 A blood pressure elevation to 140/90 is a sign of mild pre-eclampsia An ultrasound of a fetus' heart shows that "normal fetal circulation is occurring." Which of the following statements is consistent with the finding? 1. A right to left shunt is seen between the atria 2. Blood is returning to the placenta via the umbilical vein 3. Blood is returning to the right atrium from the pulmonary system 4. A right to left shunt is seen between the umbilical arteries - correct answer 1. A right to left shunt is seen between the atria The foramen ovale is a duct between the atria. In fetal circulation, there is a right to left shunt through the duct A nurse is caring for a pregnant woman who has been diagnosed with listeriosis. The nurse monitors the woman carefully for which of the following complications of pregnancy? 1. Uterine rupture 2. Pre-eclampsia 3. Fetal death 4. Polyhydramnios - correct answer 3. Fetal death Fetal death is one of the complications associated with listeriosis (disease caused by infection with listeria) A woman, who is being seen in the prenatal clinic, is found to be 12 weeks pregnant. She confides to the nurse that she is afraid her baby may be permanently damaged because she takes penicillin, a pregnancy B category medication, every day to prevent rheumatic fever. Which of the following responses by the nurse would be appropriate? 1. "I would let the doctor know that if I were you" 2. "It is unlikely that the baby was affected" 3. "First-trimester abortions are very safe" 4. "An ultrasound will tell you if the baby was affected" - correct answer 2. "It is unlikely that the baby was affected" Although o controlled human trials have been conducted, there is no evidence that category B medications cause birth defects in animals. They are, therefore, considered safe for women to take during pregnancy A woman with ah history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary healthcare practitioner? 1. Presence of chloasma 2. Presence of severe heartburn 3. 10-pound weight gain in a month 4. Patellar reflexes 1+ - correct answer 3. 10-pound weight gain in a month The weight gain may be due to fluid retention. Fluid retention occur in clients with pregnancy-induced hypertension and in clients with congestive heart failure. The physician should be notified A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid during her pregnancy? 1. Brie cheese 2. Bartlett pears 3. Sweet potatoes 4. Grilled lamb - correct answer 1. Brie cheese Soft cheese may harbor Listeria. The client should avoid consuming uncooked soft cheese A client with a 4+ protein and 4+ reflexes is admitted to the hospital with a diagnosis of severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. High leukocyte count 2. Explosive diarrhea 3. Fractured pelvis 4. Low platelet count - correct answer 4. Low platelet count Low platelet count is one of the signs associated with HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) The nurse is interviewing a gravid client during the first prenatal visit. The client confides to the nurse that she owns a number of pet animals. The nurse should advise the client to be especially careful to refrain from coming in contact with the stools of which of the pets? 1. Cat 2. Dog 3. Hamster 4. Bird - correct answer 1. Cat The client should refrain from coming into contact with cat feces. Cats often harbor toxoplasmosis, a teratogenic illness A nurse, who is discussing serving sizes of foods with a new prenatal client, would state that which of the following is equal to 1 (one) serving from the dairy group? 1. 1 cup chocolate milk 2. 1/2 cup vanilla yogurt 3. 2 cups cottage cheese 4. 1 ounce cream cheese - correct answer 1. 1 cup chocolate milk I cup of any milk (e.g. whole milk, skim milk, buttermilk, chocolate milk) is equal to 1 serving size from the dairy group A nurse is developing a standard of care plan for teen women in an obstetrical clinic. Which f the following client care outcomes would be appropriate to include in the plan of care? 1. The teen gravida will have her fetus assessed for chromosomal anomalies 2. The teen gravida will eat a diet high in calcium and iron 3. The teen gravida will deliver the baby before 37 weeks gestation 4. The teen gravida will gain no more than 25 pounds during the pregnancy - correct answer 2. The teen gravida will eat a diet high in calcium and iron Teens tend to consume less calcium and iron than they should consume during their pregnancies; therefore. this is an appropriate patient care outcome for pregnant teens A nurse who sees the follow tracing on an electronic fetal monitor determines that the frequency and duration of the contractions are which of the following? 1. q 2 min x 60 secs 2. q 2 min x 90 secs 3. q 3 min x 30 secs 4. q 3 min x 60 secs - correct answer 4. q 3 min x 60 secs The nurse notes each of the following findings in a 12-week gestation client. Which of the finding would enable the nurse to tell the client that she is PROBABLY pregnant? 1. Fetal heart rate via Doppler 2. Positive pregnancy test 3. Positive ultrasound assessment 4. Absence of menstrual period - correct answer 2. Positive pregnancy test A positive pregnancy test is a PROBABLE sign of pregnancy. It is not a POSITIVE sign since the hormone tested for - human chorionic gonadotropin (hCG) - may be produced by, for example, a hydatidiform mole FHR is a positive sign Positive ultrasound is a positive sign Amenorrhea is a presumptive sign A nurse is caring for a 30-week gestation client who is high risk for preterm labor. The nurse would expect that the client would exhibit which of the following test results? 1. Marked amniotic fluid density 2. Positive fetal fibronectin test 3, Cervix that is over 1 inch long 4. Biophysical profile of 10 - correct answer 2. Positive fetal fibronectin test A 30-week gestation client with a positive fetal fibronectin test is high risk for preterm labor Marked amniotic fluid density may be seen in pregnancies complicated by blood incompatibilities. It is not associated with preterm labor A 30-week gestation client with a cervix that is SHORTER than 1 inch is high risk for preterm labor A biophysical profile is performed to determine the well-being of the fetus. It is not related to preterm labor The nurse is providing health teaching to a group of gravid women. One woman, who states that is a smoker, asks about its impact on her pregnancy. The nurse responds that which of the following fetal complications may develop? 1. Low neonatal birth weight 2. Excess pregnancy weight 3. Severe neonatal anemia 4. Maternal hyperbilirubinemia - correct answer 1. Low neonatal birth weight Low neonatal birth weight is the most common complication seen in pregnancies complicated by cigarette smoking A client is 9 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit? 1. Urinary frequency 2. Occipital headache 3. Diarrhea 4. Leg cramps - correct answer 1. Urinary frequency Urinary frequency is a common complaint of women during their first trimester H/A may be benign or, especially if noted after 20 weeks' gestation, may be a symptom of pregnancy-induced hypertension (PIH) Diarrhea rarely seen in pregnancy; constipation is a common complaint Leg cramps commonly seen in second and third trimesters A 39-year-old, 16-week gravida woman has had an amniocentesis. Before discharge, the nurse [Show Less]
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STUDY EXAM FOR NCLEX
A nurse is performing an ECG on a client who is scheduled for surgery the following morning. What location should the nurse place the V1 electrode? - corre... [Show More] ct answer The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just right of the sternum. A nurse is collecting data from a 55 year old female client who reports of vaginal dryness and hot flashes. The client is interest in trying hormone replacement therapy (HRT). What should the nurse recognize as a contraindication to HRT? - correct answer History of treatment for blood clots. A nurse is reinforcing discharge teaching with a client who has cirrhosis. What instructions should the nurse include? - correct answer Consume foods low in sodium A nurse is caring fro a client who has bacterial meningitis.. Upon monitoring the client, what findings should the nurse expect? - correct answer Red macular rash A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. What interventions should the nurse include? - correct answer Dangle the extremities off the side of the bed. A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as a priority? - correct answer Dysrhythmia A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate what complication? - correct answer Pulmonary embolism A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What findings should the nurse expect related to hyperkalemia? - correct answer Bradycardia A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. What intervention should the nurse include in the plan? - correct answer Encourage abdominal breathing A nurse is caring for a client who has a prescription for phenazopyridine. What finding should the nurse identify as a therapeutic effect of the medication? - correct answer Decreases pain during urination A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of what? - correct answer Intra-abdominal bleeding A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. What action should the nurse take first? - correct answer Palpate the abdomen A nurse is reviewing the lab results of a client who has a chronic kidney failure and is receiving epotein alfa. The nurse should identify what lab value indicates the treatment is effective? - correct answer Hgb 11g/dL A nurse is caring for a client who has a hx of breast cancer. The client asks the nurse about birth control. What method of birth control is contraindicated for this client? - correct answer Combination oral contraceptives A nurse is caring for a client who had an acute ischemic stroke 1 day ago. What action should the nurse take to reduce the risk for aspiration? - correct answer Allow 30 minutes of rest before meals A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What finding should the nurse instruct the client to report to the provider? - correct answer Onset of nausea A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. What action should the nurse take? - correct answer Perform pin site care daily A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks how to improve the taste of bland food. What should the nurse recommend? - correct answer Lemon juice A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. What should the nurse include in teaching? - correct answer Increase intake of fiber rich foods A nurse in a long term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. What finding should indicate to the nurse that the client might have a fecal impaction? - correct answer Small liquid stools A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate what complication of IV therapy? - correct answer Thrombophlebitis A nurse is participating in a heath fair for older adult clients. What immunization should the nurse recommend for this age group? - correct answer Herpes zoster A nurse is monitoring a client who is taking acarbse. What finding should the nurse identify as an adverse effect of the medication? - correct answer Abdominal cramps Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of? - correct answer Secondary prevention Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to? - correct answer Help improve body defenses The major electrolytes in the extracellular fluid are? - correct answer Sodium and Chloride What nursing diagnoses might be appropriate as Parkinson disease progresses and complications develop? - correct answer Impaired physical mobility A teenage client is admitted to the hospital because of tylenol overdose. Overdose of tylenol can precipitate life-threatening abnormalities in what organ? - correct answer Liver Ill health, malnutrition, and wasting as a result of chronic disease are all associated with? - correct answer Cachexia Prolonged arching of the back with the head and heels bent backward? - correct answer Opisthotonos A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period? - correct answer "The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions." The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. What should the nurse do first? - correct answer Check for kinks in the chest drainage system. The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. What should be included in the plan? - correct answer Pull the earlobe down and back before instilling the ear drops. Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. What instruction should the nurse reinforce in the client-teaching plan regarding this medication? - correct answer To return to the clinic weekly for serum drug-level testing The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, what additional data specific to this calcium level should the nurse collect? - correct answer -Presence of Chvostek's sign -Presence of electrocardiogram abnormality -Presence of tingling in the fingertips and around the mouth -Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history? - correct answer Whether the client has had a recent upper respiratory infection (URI) Administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB? - correct answer Calmette-Guerin Vaccine (BCG) The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by what action? - correct answer Observing rigid rules and regulations Enoxaparin sodium (Lovenox) is prescribed for the client following hip replacement surgery. The nurse prepares to have what available in the event that an overdose of the medication occurs? - correct answer Protamine sulfate A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove what food items that arrived on the client's meal tray from the dietary department? - correct answer Peas The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing what action? - correct answer Monitoring for signs of dyspnea A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. What findings validate this suspicion? - correct answer -Oliguria -Restlessness -Abdominal pain -Unexplained tachycardia After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in what appropriate position? - correct answer Prone The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. What are the primary features of azotemia and oliguria? - correct answer -Increase in serum creatinine -Increase in blood urea nitrogen (BUN) -Urine output less than 0.5 mL/kg/hour A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. What position should the nurse assist the client into for this procedure? - correct answer Upright "The disease is transmitted by contact with nasal or oral fluids, so any items contaminated with these types of fluids, such as a drinking cup, should not be used by your other children." - correct answer Roseola infantum The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). What method should be used to monitor the client for crepitus? - correct answer Palpating for the leakage of air into the subcutaneous tissues The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find what sign/symptoms of lithium toxicity associated with this level? - correct answer -Incoordiantaion -Mental confusion -Muscle hyper irritability The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if what is documented in the client's history? - correct answer Pancreatitis A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid what fruit? - correct answer Bananas The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate what potential complication? - correct answer Infection of a central catheter site can lead to septicemia The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note what finding? - correct answer Rhythmic respirations with periods of apnea The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make what observation while caring for the neonate? - correct answer The neonate cries incessantly. In caring for a preterm newborn's skin, what special characteristics should the nurse expect to note? - correct answer Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture Heparin sodium is prescribed for the client. What laboratory result indicates that the heparin is prescribed at a therapeutic level? - correct answer Activated partial thromboplastin time (aPTT) of 55 seconds A client with lung cancer is receiving a high dose of methotrexate (Rheumatrex). Leucovorin (citrovorum factor, folic acid) is also prescribed. The nurse who is assisting in planning care for the client understands that administering the leucovorin is for what purpose? - correct answer Preserve normal cells. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that what has probably occurred? - correct answer Infiltration Primary belief of psychiatric mental health nursing is? - correct answer Every person is worthy of dignity and respect What fetal heart monitoring pattern can indicate cord compression? - correct answer Variable deceleration What is the HEELP Syndrome? - correct answer This is pre-eclampsia with liver involvement How many arteries and veins are in the umbilical cord? - correct answer 2 arteries, 1 vein The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted (hip dyslpasia) is called? - correct answer Ortilani's sign What is ptosis? - correct answer Drooping What cranial nerve is optic? - correct answer Cranial nerve 2 What sign is the softening of the cervix? - correct answer Goodell's What is the normal Lithium value? - correct answer Normal= less than 1.5 mEq/L Toxic= greater than 2 mEq/L Antidote for acetaminophen? - correct answer Mucomyst (Nacetylcysteine) Dietary considerations for Celiac disease? - correct answer -No gluten -Increase calories -Increase protein What is a continuous seizure that must be interrupted by emergency measures? - correct answer Status epilepticus Meds most often used to treat status epilepticus? - correct answer -Diazepam (Valium) -Phenytoin (Dilantin) -Phenobarbitol (Luminol) Supine with legs straight and elevated at the hips and head is slightly raised (increases blood flow to heart and brain) - correct answer Modified Trendelenburg -Called the "Shock" position Amount of blood ejected by the heart in any one contraction is called? - correct answer Stroke volume Do Mydriatic drops constrict or dilate the pupils? - correct answer Dilate (myDriatic...D for dilate) How to mix insulin? - correct answer Clear before Cloudy (NPH) Normal sodium values? - correct answer 135-145 What is the normal PT value? - correct answer 9.5-12 seconds Normal creatinine values? - correct answer 0.5-1.5 mg/dl What is the normal heart and blood flow in the correct order? - correct answer Blood enters, Right atrium, Tricuspid valve, right ventricle, pulmonic valve, left atrium, mitral valve, left ventricle, aortic valve, and out to the body Normal blood pH? - correct answer 7.35-7.45 [Show Less]
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NCLEX PN STUDIES RENAL EXAM WITH ANSWERS
A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, includ... [Show More] ing aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? - correct answer Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which signs/symptoms after the dialysis treatment? - correct answer Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. It results from rapid removal of solutes from the body during hemodialysis, with a higher residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and the onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates. A client with acute glomerulonephritis is admitted to the nursing unit. The nurse should plan to do which action immediately on admission? - correct answer The client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction and ongoing monitoring of weight, intake, and output. It is unnecessary to monitor the temperature as frequently as every 2 hours. The client is placed on bed rest or at least encouraged to rest because increased activity levels are correlated directly with proteinuria and hematuria. The diet is high in calories but low in protein. A client with end stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply. - correct answer Postoperatively, the nurse should observe the site for bleeding and swelling. The nurse determines that circulation is adequate in the fistula by feeling for a palpable thrill with the fingers and hearing an audible bruit with a stethoscope. The nurse asks the client to rate the pain in the surgical area and administers prescribed analgesics. Blood pressure is not assessed in the limb where the fistula was created because that procedure blocks the blood flow and may lead to thrombosis or clotting off of the fistula. Circulation should be assessed distal to the fistula. A "steal syndrome" is a possible complication of the arteriovenous fistula in which blood flow to the area distal to the fistula is inadequate. The nurse observes for signs of ischemia, such as coldness, cyanosis, and numbness, below the fistula and notifies the surgeon of ischemic changes if observed. A client contacts the health care provider's office to report she is not feeling well, has burning with urination, and suspects she may have a urinary tract infection. The nurse instructs the client to collect a urine specimen for testing. Which urinalysis findings indicate the presence of a urinary tract infection? Select all that apply. - correct answer A urinalysis reveals the appearance of the urine specimen, presence of abnormal substances, and microscopic examination findings. The urinalysis results that indicate a urinary tract infection include the presence of nitrites and leukoesterase and the microscopic finding of 10 white blood cells. If bacteria are present in the urine, nitrates are converted to nitrites. Leukoesterase is an enzyme found in neutrophil white blood cells and its presence in urine indicates infection. The normal number of white blood cells in the urine is 0 to 5 in females. One would expect the turbidity with a urinary tract infection to be cloudy. The moderate amount of ketones indicates that fat was used to supply energy instead of glucose. This would occur if the client had not eaten for an extended period or was experiencing diabetic ketoacidosis. Specific gravity (normal: 1.010 to 1.030) is the density of the urine compared with water. A client with end stage kidney disease (ESKD) begins peritoneal dialysis. The nurse observes for which signs/symptoms indicating peritonitis? Select all that apply. - correct answer Peritoneal dialysis is a treatment used in clients with ESKD as an alternative to hemodialysis. The procedure involves the instillation of dialysate fluid into the peritoneal cavity where excess body wastes, fluid, and electrolytes are removed through diffusion and osmosis across the semipermeable peritoneal membrane and peritoneal capillaries. A peritoneal catheter is surgically placed into the abdominal cavity and is used to instill and drain the dialysate fluid, known as effluent. Peritonitis, or infection of the peritoneal cavity, is a possible complication of peritoneal dialysis. The effluent becomes cloudy instead of the normal clear straw color, and the client has symptoms of abdominal tenderness and pain, nausea, vomiting, and fever. Thirty-eight degrees Celsius is an elevated temperature indicating fever, a sign of infection. Poor dialysate outflow is usually caused by constipation. Leakage of clear fluid at the exit site of the peritoneal catheter is more likely to occur in obese or diabetic clients. It occurs as the client physiologically adjusts to the instillation of 2 L of dialysate fluid into the abdominal cavity. A client who underwent a kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply. - correct answer Acute rejection occurs 1 week to 2 years after a kidney transplant. Antibodies and white blood cells cause inflammation and vasculitis within the transplanted organ. Diagnosis is made by laboratory tests demonstrating impaired function of the organ and by changes in the donated organs found upon biopsy. Acute rejection is treated with increased immunosuppressant medication. Signs/symptoms of acute rejection of a transplanted kidney include abdominal tenderness over the transplanted kidney and decrease in organ function. Signs of decreased kidney function include oliguria (urine output between 100 and 400 mL in 24 hours), elevation in blood pressure, and elevation in the BUN and creatinine levels. Swelling of the lips is a sign of angioedema that occurs with an acute hypersensitivity reaction or anaphylaxis. Tachypnea (rapid breathing) with wheezing, the sound resulting from airway inflammation, occurs with many types of respiratory distress. It is not specific to acute rejection in a transplanted kidney. The nurse is speaking with a client who underwent a minimally invasive procedure treatment for recurrent urolithiasis. Which instructions are appropriate to reinforce in the teaching plan? Select all that apply - correct answer The nurse is speaking with a client who underwent a minimally invasive procedure treatment for recurrent urolithiasis. Which instructions are appropriate to reinforce in the teaching plan? Select all that apply. - correct answer Kidney stones or urolithiasis is often treated with minimally invasive surgical procedures that may include placement of a stent. The stent allows passage of the stone without further irritation of the ureter. Clients should drink at least 3 L of fluid to promote passage of the stone and prevent future stone formation. Filtering the urine and retrieving the stone allows stone analysis. Further preventive treatment is prescribed based on the type of stone. It is important that clients complete the course of prescribed antibiotics to prevent infection after the procedure. Clients should contact the urologic health care provider if hematuria or fever occur and not self-treat. A client, on the waiting list for a renal transplant, receives a hemodialysis treatment. Which findings indicate to the nurse that the treatment has been effective? Select all that apply. - correct answer The purpose of hemodialysis is to replace the client's kidney function. Hemodialysis removes waste products and excess fluid from the body and attains electrolyte balance. An effective hemodialysis treatment removes fluid resulting in a loss of weight. Body waste products are removed as reflected in a lower serum BUN and creatinine levels. Potassium is excreted by healthy kidneys, so a normal serum potassium level signifies that dialysis treatment is effective. Fatigue and a functioning arteriovenous fistula are normal findings but do not demonstrate that the dialysis treatment was effective in achieving kidney functions. In some clients, the hemodialysis procedure leads to fatigue, and clients prefer to rest after the treatment. A palpable thrill in the arteriovenous fistula signifies that the fistula has not clotted. Which observations by the nurse caring for clients on a hospital medical-surgical unit should be immediately reported to the health care provider? Select all that apply. - correct answer The nurse should report the new confusion and slightly tachycardic condition of the older client because these data suggest symptoms of a urinary tract infection requiring antibiotic therapy. The nurse should report the low urinary output in the postoperative client, so interventions can be prescribed to diagnose and/or avoid acute kidney injury (AKI). Slight hematuria is an expected finding in a client with urolithiasis (renal stones). Urine with mucous shreds is an expected finding in a client with an ileal conduit because the portionof ileum that functions as the "bladder" is bowel mucosa. Some clients who receive routine hemodialysis produce small amounts of urine but others do not urinate because the kidney function is now done through hemodialysis. A client tells the nurse she completed an educational program to manage her stress incontinence but is now discouraged. Which information from the client indicates the need for further teaching? Select all that apply. - correct answer With stress incontinence, the client loses a small amount of urine involuntarily during activities that increase abdominal pressure, such as coughing, jogging, or lifting weights. This is due to weakened pelvic muscles and the inability to tighten the urethra enough to counteract bladder contraction. Kegel exercises, in which the woman contracts and relaxes the pelvic muscles to regain muscle tone should be done on a daily basis and may take up to 3 months before yielding positive results. Clients should avoid caffeine and alcoholthat stimulate bladder contraction. Diet cola likely contains caffeine. The exercise program involving weight lifting also increases abdominal pressure, leading to incontinence. The client is correct to lose weight (source for increased abdominal pressure) and maintaining adequate fluid intake. A client, who had experienced significant blood loss in an automobile crash, was admitted to the hospital 2 days earlier. The nurse observes the client for which signs/symptoms that indicate acute kidney injury (AKI)? Select all that apply. - correct answer Any condition that interrupts blood flow to the kidneys may cause AKI due to a prerenal etiology. Correcting fluid and blood deficits improves blood flow to the kidneys and prevents or treats AKI. Signs associated with AKI include low urinary output of concentrated urine (elevated specific gravity). The BUN and creatinine rise to levels above normal because the kidneys are not effective in clearing the waste products from the body. Hematuria and spasmodic pain are associated with urolithiasis. Hematuria occurs with multiple renal conditions including cancerous tumors in the urinary system and renal trauma The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. Which are the primary features of azotemia and oliguria? Select all that apply. - correct answer Azotemia and oliguria refers to an increase in serum creatinine and BUN and oliguria is defined as a urine output less than 0.5 mL/kg/hour. Acute kidney injury with a decrease in GFR is often due to sepsis with related sepsis features. The nurse is caring for a 58-year-old client with renal failure who is on peritoneal dialysis. Which finding is considered most important by the nurse, requiring health care provider notification? Refer to chart. - correct answer Peritonitis is the most common complication of peritoneal dialysis and is often caused by a contamination in the system. This infection can initially be determined by an increased WBC count. It can also include abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting. The nurse is caring for a client who received a recent kidney transplant. Besides actual rejection of the transplant, which are some of the most important complications this client is at risk for? Select all that apply. - correct answer The nurse is caring for a client who received a recent kidney transplant. Besides actual rejection of the transplant, which are some of the most important complications this client is at risk for? Select all that apply. - correct answer Rejection is one of the major problems of kidney transplant recipients. Besides recurrence of renal disease, kidney transplant clients are also at risk for malignancies, cardiovascular disease caused by atherosclerotic vascular disease, infection, and corticosteroid-related complications. Incidences of infection usually occur within the first month of transplant. The nurse is evaluating the assessment of a client's arteriovenous fistula being used for hemodialysis. Which findings would prompt the nurse to notify the health care provider immediately? Select all that apply. - correct answer The health care provider must be notified immediately when there is no thrill or bruit assessed at the fistula site or if there is no pulse noted distal to the site. This indicates a clot. Hemodialysis treatments usually last about 3 to 4 hours. Dressings to the site are changed every 7 days, but it is not necessary to immediately notify the health care provider if it hasn't been changed in 8 days. The nurse is caring for a hemodialysis client who has been receiving treatment for several years and is not a candidate for kidney transplant. The nurse knows that the majority of deaths of hemodialysis clients are related to which causes? Select all that apply. - correct answer The majority of deaths of hemodialysis clients are related to cardiovascular events such as stroke and myocardial infarction and infectious complications. A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take which priority precaution, knowing that bleeding is a potential complication? - correct answer An AV shunt is a cannula with two ends that are tunneled subcutaneously into an artery and a vein. An AV shunt is a less common form of access site but carries a risk for bleeding when it is used. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be observed at least every 4 hours. Once per shift is insufficient. Checking for blood results, bruit, and thrill all apply to the care of this client but do not focus on bleeding. [Show Less]
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NCLEX STUDY EXAM GUIDE
Mineral oil has been prescribed for constipation, and the nurse teaches about administration of the mineral oil. Which statement by the mother indicates th... [Show More] at teaching was effective? 1. "I will administer the mineral oil before each meal." 2. "I will administer the mineral oil followed by a glass of warm water." 3. "I will mix the mineral oil with a chilled drink before administration." 4. "I will mix the mineral oil with 8 ounces of warm juice before administration." - correct answer 3. I will mix the mineral oil with a chilled drink before administration Mineral oil is best tolerated when it is given chilled or mixed with cold drinks. Mixing the oil with chocolate milk, blending it with ice cubes and fruit juice, or chilling it helps to disguise the taste. Administering mineral oil before meals would affect appetite A client has been taking glucocorticoids to control rheumatoid arthritis. Which laboratory abnormality is the client at risk for as a result of taking this medication? 1. Increased serum glucose 2. Decreased serum sodium 3. Elevated serum potassium 4. Increased white blood cells - correct answer 1. Increased serum glucose Glucocorticoids have 3 primary uses: replacement therapy for adrenal insufficiency, immunosuppressive therapy, and antiinflammatory therapy. Exogenous glucocorticoids cause the same effects on cellular activity as those of the naturally produced glucocorticoids; however, exogenous glucocorticoids also may have undesired effects. The glucocorticoids stimulate appetite and increase caloric intake. They also increase the availability of glucose for energy. These combined effects cause the blood glucose levels to rise, making the client prone to hyperglycemia. Glucocorticoids can also lead to hypokalemia. The remaining options are not expected effects of the use of glucocorticoids. What is the priority nursing action when admitting a client who has just attempted suicide? 1. Ensure constant observation of the client at all times. 2. Conduct a thorough mental health assessment of the client. 3. Determine whether the client has ever attempted suicide previously. 4. Remove all potentially dangerous articles from among the client's belongings. - correct answer 1. Ensure constant observation of the client at all times The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission. A patient is brought to the emergency department (ED) by a friend. The patient is unresponsive and respirations are slow and shallow. Which of the following is the priority intervention? Choose 1 answer: A Check the patient's blood glucose level B Ask the friend if they were using illicit drugs C Administer naloxone, per protocol D Administer 100% oxygen per nasal cannula - correct answer D patient is admitted to the emergency department (ED) after ingesting MDMA (ecstasy). Which of the following symptoms would the healthcare provider anticipate? Choose all answers that apply: A Chest pain B Flaccid extremities C Hypertension D Seizures E Hypothermia F Agitation - correct answer A, C, D, F A patient who overdosed on oxycodone is given naloxone. When assessing the patient, the healthcare provider would anticipate which of these clinical manifestations of opioid withdrawal? Choose 1 answer: A Depressed respirations and somnolence B Bradycardia and hyporthermia C Hyperthermia and euphoria D Irritability and nausea - correct answer D A patient is brought to the emergency department by a family member. The patient has been agitated for the past several hours and has alternated between grandiosity and expressing a desire to commit suicide. Upon examination, the patient is diaphoretic, hypertensive, and tachycardic. Intoxication with which of the following substances would contribute to these symptoms? Choose 1 answer: A Benzodiazepine B Alcohol C Methamphetamine D Marijuana - correct answer C A patient reports smoking 10 cigarettes per day for 40 years. How will the healthcare provider document this patient's smoking habit in terms of pack years? Choose 1 answer: A 10 pack years B 5 pack years C 4 pack years D 20 pack years - correct answer D Emergency medical personnel bring an unconscious patient to the emergency department. The patient's pupils are pinpoint and respirations are depressed. Intoxication of which of the following substances could contribute to these clinical signs? Choose 1 answer: A Ecstasy B Cocaine C Methadone D Methamphetamine - correct answer C A clinic nurse is assessing a client who has been on isoniazid for 6 months. Which client complaint should most concern the nurse? 1. Dry mouth 2. Cramping diarrhea 3. Frequent headaches 4. Difficulty tying shoes - correct answer 4 The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1. Increased systolic blood pressure 2. Abnormal posturing of extremities 3. Significant widening pulse pressure 4. Changes in level of consciousness - correct answer 4 The nurse is caring for an infant with spina bifida (myelomeningocele type) who had the sac on the back containing cerebrospinal fluid, the meninges, and the nerves (gibbus) surgically removed. The nursing plan of care for the postoperative period should include which action to maintain the infant's safety? 1. Covering the back dressing with a binder 2. Placing the infant in a head-down position 3. Strapping the infant in a baby seat sitting up 4. Elevating the head with the infant in the prone position - correct answer 4 The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. 1. "It causes the cessation of menstruation." 2. "It is pain that occurs during ovulation." 3. "It is the presence of tissue outside the uterus that resembles the endometrium." 4. "It is also known as primary dysmenorrhea and causes lower abdominal discomfort." 5. "Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia." - correct answer 3, 5 The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction? 1. "I will clean up any spills from the diaper with diluted alcohol." 2. "I will wash baby bottles, nipples, and pacifiers in the dishwasher." 3. "I will be sure to prepare foods that are high in calories and high in protein." 4. "I will be sure to wash my hands carefully before and after caring for my infant." - correct answer 1 HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child's diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control. The pediatric nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia and suspected central nervous system metastasis. The nurse should place the child in which position for this procedure? 1. Lithotomy position 2. Modified Sims' position 3. Lateral recumbent, knees flexed to the abdomen and the head bent, chin down 4. Prone, with the knees flexed to the abdomen and the head bent, the chin resting on the chest - correct answer 3 A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The remaining options are incorrect positions. The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital after a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms. The health care provider has prescribed 350 mg to be administered four times a day. What should the nurse conclude? 1. The prescription is the normal adult dosage. 2. The prescription is lower than normal dosage. 3. The prescription is higher than normal dosage. 4. The dosage prescribed requires further clarification with the health care provider. - correct answer 1 The normal adult dosage for carisoprodol is 350 mg orally three to four times daily The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1. Flashbacks 2. Amotivational syndrome 3. Enhanced physical strength 4. Absence of pain perception - correct answer 1 Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs. Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use, whereas marijuana abuse can result in amotivational syndrome The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes - correct answer 1, 4, 5 Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care - correct answer 1 he nurse is providing education to a client with type 2 diabetes about starting insulin glargine to help with improved glycemic control. Which statement made by the client indicates understanding? 1. "It has a distinct peak." 2. "It can be given intravenously." 3. "It has a decreased risk for hypoglycemia." 4. "I don't have to perform fingerstick glucose monitoring." - correct answer 3 In contrast to other long-acting insulins, insulin glargine achieves blood levels that are relatively steady over 24 hours. As a result, there is less risk of hypoglycemia or hyperglycemia. The only insulins that can be administered intravenously are the short-acting insulins. All medications used to treat diabetes mellitus require fingerstick monitoring. A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? 1. The woman has the herpes simplex virus (HSV). 2. The woman has contracted an airborne viral disease. 3. The neonate will definitely develop this disease after birth. 4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. - correct answer 4 Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA. HIV and herpes simplex virus are different types of infections. HIV infection occurs primarily through the exchange of body fluids, not via airborne disease. A neonate born to an HIV-positive mother is at risk for developing the virus, but it is not an absolute The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. [Show Less]
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NCLEX STUDY EXAM GUIDE
The client needs to see a health care provider for further care. Lactic acidosis can occur when taking Metformin in the presence of dehydration and renal i... [Show More] nsufficiency, typically seen in type 2 diabetics. Manifestations of lactic acidosis include Kussmaul's breathing and severe muscle pain caused by the buildup of lactic acid in the muscles. - correct answer The triage nurse receives a call from a client with a history of type 2 diabetes mellitus controlled by metformin (Glucophage). The client is reporting muscle pain and shortness of breath with exercise. Which of the following is the most appropriate response from the nurse b. Seek the assistance of a nurse on the floor who is fluent in the client's language. Correct The nurse is responsible for ensuring that the client understands the information provided regarding the procedure. - correct answer A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? d. "My Dilantin dose will be increased several days before the procedure." Correct Because the therapeutic action of ECT is to induce seizures, any medications that affect the client's seizure threshold must be decreased or discontinued several days before the procedure - correct answer A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching? "The living will documents your mother's wishes and must be followed." Correct A living will is a document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. The client's wishes should be followed by the health care provider. - correct answer daughter of a client with a terminal illness pulls a nurse to the side and says, "Although my mother's living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest." How should the nurse respond? If the nurse believes the provider's actions are directly against the client's wishes, the nurse should contact the hospital's ethics committee. These committees are typically multidisciplinary and are organized to consciously and reflectively consider significant and often difficult issues related to client care. Any nurse can consult the hospital's ethics committee when deemed necessary. - correct answer A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client's wishes. What is the appropriate action by the nurse? . "I have excellent job skills; I just need to find a new employer." Correct Cognitive reframing is a simple and effective technique for reducing stress by looking at things in a more positive light in order to experience them as less stressful. Cognitive reframing for this client would involve building confidence in job skills and searching for a new job. - correct answer Management of Care: Stress management; teaching stress management techniques A client is seeking treatment for stress related to unexpected loss of employment and is engaging in the stress management technique of cognitive reframing. Which of the following statements would indicate to the nurse that the client understands this stress management technique Contact the client's case manager - correct answer Management of Care: Act as a client advocate A nurse is preparing a client with terminal illness for discharge to a nursing home when he states: "I don't want to go to a nursing home to die. I would rather die at home." What would be the most appropriate action by the nurse? Assist the client to deep breathe, splinting with a pillow. Correct The client is experiencing respiratory acidosis from hypoventilation caused by painful respirations due to fractured ribs. Splinting the chest wall with a pillow will decrease pain associated with deep breathing. Deeper breaths will allow for better gas exchange, which will correct the acidosis. - correct answer Management of Care: Safe and Effective Care Environment: Arterial Blood Gases Priority A client is hospitalized for multiple rib fractures following a motor vehicle accident (MVA). The results of an arterial blood gas (ABG's) are; pH 7.30, pCO2 48, HCO3 26 and pO2 91 on 2 L/min of oxygen per nasal cannula. Which of the following interventions has the highest priority? Notify the client's health care provider Correct The client is febrile, tachycardic and hypotensive with verbalization of increased worsening abdominal pain. These are signs of possible rupture of the diverticulum, pelvic abscess, or bowel obstruction and the provider needs to be notified. - correct answer Management of Care: Assessment of Bowel Disorders The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client's abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client? c. A client with breast cancer and a sodium level of 115 mEq/L Correct A sodium level less than 120 mEq/L is considered a medical emergency and needs immediate assessment and treatment. - correct answer Management of Care: Cancer: Chemotherapy The nurse is caring for four clients receiving chemotherapy. Which of the following clients should the nurse see first? Collaborate with the health care team and the referring agency to assess client needs. Correct The nurses who receive the referrals need to work collaboratively with the health care team and the referring agency or persons. Continuous coordinated care among all health care providers involved in a client's care is essential to avoid duplication of effort by the various personnel caring for the client. Understanding client needs is the first step in the referral process. - correct answer Management of Care: Safe and Effective Care Environment : Coordinating Client Care: Referrals A community based nurse receives a client referral. Which of the following actions should be performed first? a. A client with diabetes mellitus type I waiting for a breakfast tray at 0745. Correct The diabetic client waiting for breakfast should be assessed first. Prior to breakfast the client's blood glucose needs to be drawn and if insulin coverage is required it is administered before breakfast. Once the client begins to eat and digest food they will be at risk for increasing blood glucose levels without their insulin coverage. - correct answer Management of Care: Creating and Maintaining a Therapeutic and Safe Environment: Group of clients At 0715 the nurse is assigned to care for the following four clients. Which of the following clients should the nurse plan to see first? c. The client has the right to refuse treatment, unless he has been judged to be incompetent. Correct Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent. The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if they were still competent. - correct answer Management of Care: Educate Client and staff about client's rights and responsibilities A nurse is caring for a client who has been committed to an acute Mental Health facility with an involuntary emergency commitment order. What should the nurse include when orienting the client to the facility . A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's. Correct While all of these clients require nursing care, the 48 year-old male with c/o chest pain and a cardiac rhythm of sinus tachycardia with occasional PVC's needs immediate attention! Chest pain is an indication of myocardial ischemia and this client has other factors that put him at risk for sudden death: gender, age and PVC's. PVC's are not normal in a 48 year old. PVC's occur when the myocardium is irritated, usually from hypoxia but also from electrolyte imbalance, usually involving K+. This client is young and as a result has not had sufficient time to develop adequate collateral circulation. - correct answer Management of Care: Emergency Department Triage The following clients have been assessed in the emergency department. Which of the following clients requires immediate attention? . Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms. Correct An epidural is indicated in the active phase of labor. Active labor is defined as: cervical dilation of 4-7 cms, contractions occurring every 3-5 minutes and lasting 30-60 seconds. - correct answer Safe and Effective Care Environment: Management of Care: Epidural A nurse is caring for four laboring clients. Each of the clients is requesting an epidural. Which of the following clients should receive her epidural first? Seek the assistance of a nurse on the floor who is fluent in the client's language. Correct The nurse is responsible for ensuring that the client understands the information provided regarding the procedure. - correct answer Management of Care: Informed Consent: Ensure Informed Consent: Ethical and Legal Issues A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? [Show Less]
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PHARMACOLOGY STUDY SET NCLEX
A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the HCP? - cor... [Show More] rect answer 1. Excess blinking of eyes 2. Lip smaking 3. Puffing of cheeks (Metoclopramide/REGLAN, is prescirbed for the treatment of GERD and delayed gastric emptying and as an antiemetic. It can cause extrapyramidal side effects similar to antipsychotics) Tardive Dyskinesia symptoms - correct answer caused from: Metoclopramide (Reglan) and antipsychotic drugs -Protruding and twisting of the tongue -Lip smacking -Puffing of cheeks -Chewing movements -Frowning or blinking of eyes -Twisting fingers -Twisted or rotated neck An elderly client w/depression, diabetes, and HF has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? - correct answer Serum creatinine is 2.3 Creatinine levels - correct answer 0.6-1.3 The home health nurse visits a client w/hand osteoarthritis topical capsaicin for pain relief. Which instruction about capsaicin should the nurse provide the client? - correct answer Apply cream to hands and wait at least 30 minutes before washing them Commonly used MAOI's - correct answer Isocarboxazid, phenelzine, tranylcypromine A 21 yo client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the clients statements needs to be addressed first? - correct answer "This medication is not working; I am so tired of being depressed" (MAOI's and other antidepressants are associated w/an increased risk of suicidal ideation during the first few weeks of treatment) A client w/a brain tumor is admitted for surgery. The HCP prescribes levetiracetam. The client asks why. What is the nurses's response? - correct answer "It prevents seizure development" (Levetiracetam/KEPPRA is used to treat seizures) The nurse develops a teaching care plan for the client w/a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? - correct answer Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine. (when switching from a tricyclic antidpressant to a MAOI, withdraw gradually w/a drug free period before the new antidepressant is initiated to avoid adverse reactions) Commonly used Tricyclic antidepressants - correct answer Amitriptyline, Nortriptyline, desipramine, imipramine...also used to treat neuropathic pain Neuroleptic Malignant Syndrome (NMS) - correct answer -uncommon but life threatening adverse reaction to anti-psychotic medications (haloperidol, fluphenazine). Symptoms are high fever, muscular rigidity, ams, autonomic dysfunction Treatment is rehydration, cooling body temp and immediate d/c of the medication and notify HCP immediately The nurse is working in the ER. Which client should the nurse see first? - correct answer Client taking clozapine who has sudden onset of high fever, diaphoresis and change in mental status (Neuroleptic Malignant syndrome) A client w/active pulmonary TB is prescribed 4-drug therapy ethambutol. The community health nurse instructs the client to notify the HCP immediately if which adverse effect associated with ethambutol occurs? - correct answer Blurred vision (Ethambutol/MYAMBUTOL, is used in combination w/other antitubercular drugs to treat active TB. The client must have baseline eye examinations during therapy as optic neuritis is a potentially reversible adverse effect) The nurse teaches the client taking atorvastatin to call the HCP if experiencing which symptom associated w/a serious adverse effect of atorvastatin? - correct answer Muscle aches (symptom of myopathy) A client w/seizure activity is receiving a continuous tube feeding via a small bore enteral tube. The nurse prepares to administer phenytoin oral suspension via the enteral route. What is the nurse's priority action before administering this medication? - correct answer Stop the feeding for 1 to 2 hours (Phenytoin/Dilantin, is an anticonvulsant drug commonly used to treat seizures d/o's. Steady absorption is necessary to maintain a therapeutic dosage range and drug level to control seizure activity) The clinic nurse evaluates a client's response to levothyroxine after 8 weeks of treatment. What therapeutic responses to the medication should the nurse expect? - correct answer 1. Apical heart rate of 88/min 2. Elevation of mood 3. Improved energy levels (used to treat hypothyroid. Notify HCP is HR is >100 or if the pt reports c/p, nervousness, or tremors...dose may be too high) The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? - correct answer 1. Notify the HCP if you feel a fluttering or rapid heartbeat 2. You will need to take this medication for the rest of your life (is safe to take during pregnancy, take first thing in the morning on an empty stomach) The nurse is caring for a client who started receiving chemotherapy 10 days ago. Today the HCP prescribes Filgrastim. Which of the following is an expected outcome of this medication? - correct answer Increase in neutrophil count A client is receiving chemotherapy for acute myeloid leukemia. The HCP prescribes allopurinol to prevent tumor lysis syndrome (TLS). Which lab value indicates a therapeutic response to the medication? - correct answer Serum uric acid level of 6.0 (the therapeutic effect of allopurinol is to decrease hyperuricemia caused by TLS. Lab values include rising blood uric acid, potassium and phosphate levels with decreasing calcium levels) Uric acid levels - correct answer male 4.4-7.6; female 2.3-6.6 Calcium levels - correct answer 8.6-10.2 Phosphate levels - correct answer 2.4-4.4 Potassium levels - correct answer 3.5-5.0 The nurse administers a prescribed oral dose of radioactive iodine (RAI) to a female client w/hyperthyroidism. The nurse should instruct that the client utilize the following home precautions during the first 3-7 days after ingestion? - correct answer 1. Do not use bare hands to handle food that is to be served to others 2. Isolate personal clothing, towels and linens; wash them separately from rest of laundry in the home 3. Use a separate toilet and flush 2-3 times after each use (Do not breastfeed, avoid being around pregnant mothers, sleep in separate bed) A client w/a hx of HF calls the clinic and reports a 3lb weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipates the immediate need for dosage adjustment of which medication? - correct answer Bumetanide (loop diuretic) Urine specific gravity - correct answer 1.003-1.030 elevated SG=dehydration Lithium therpeutic index - correct answer 0.6-1.2 >1.5=toxicity The community health nurse prepares a teaching plan for a client w/latent tuberculosis who is prescribed oral isoniazid (INH). Which instructions should the nurse include? - correct answer 1. Avoid drinking alcohol 2. Report yellowing of skin or sclera 3. Report numbness and tingling of extremities A nurse is caring for a client w/an exacerbation of COPD and a hx of type 2 diabetes requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? - correct answer Increasing the insulin dose (corticosteroids cause hyperglycemia and worsen hypertension) Ethambutol - correct answer Frequent eye examinations are needed Phenytoin (Dilantin) therpeutic index - correct answer 10-20 A client w/cancer is to receive a third dose of cisplatin. The client's lab results are shown in the exhibit. Which factor would be important for the nurse to assess before confirming the dose w/the HCP? - correct answer Urine output (Cisplatin is an antineoplastic med that can cause renal toxicity.) BUN levels - correct answer 6-20 The hospice nurse is caring for an actively dying client who is unresonsive and has developed a loud rattling sound w/breathing (death rattle) that distresses family members. Which prescription would be the most appropriate to treat this symptoms? - correct answer Atropine sublingual drops (atropine dries up secretions that cause the rattle noise) A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which combination of medications does the nurse question? - correct answer A client w/depression prescribed escitalopram and selegiline (MAOI's interact w/many meds including many antidepressants) The nurse administers 8 units of regular insulin at 11:30 am to a client w/type 1 diabetes and serves the client lunch 30 minutes later. The client eats a few bites, becomes nauseated and is unable to finish the meal. When is the client at highest risk for experiencing an insulin-related hypoglycemic reaction - correct answer 2:00pm (The client is at highest risk for experiencing an insulin-related hypoglycemic reaction when the drug peaks. Regular insulin is short acting and peaks 2-4 hours after administration Insulin peak times - correct answer -Rapid acting (lispro/humalog, aspart/novolog, glulisine/apidra) 30min-3hours; make sure client eats wiin 15 minutes of administration -Intermediate acting (NPH) 4 hours -Detemir-4-9 hours -Long acting (glargine) no peak Teratogenic medications - correct answer Phenytoin (dilantin) Lithium Valproate Isotretinoin Methotrexate Ace Inhibitors Warfarin The nurse provides medication teaching to a client w/primary adrenal insufficiency (Addison's) who is prescribed hydrocortisone 10mg by mouth 3 times/day. Which instructions should be included in the client's teaching plan? - correct answer 1. "Make an appointment w/an optometrist yearly to assess for cataracts" 2. "Report even a low grade fever to the HCP immediately" 3. "Report signs of hyperglycemia including increased urine, hunger and thirst" Platelet range - correct answer 150,000-400,000 aPTT - correct answer Normal level 25-35 seconds Therapeutic level 46-70 seconds INR therapeutic range - correct answer 2-3 The nurse is providing d/c instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? - correct answer "I am looking forward to our summer vacation at the beach" (anticholinergic medications can lead to hyperthermia d/t constipation, urinary retention, flushing, dry mouth, heat intolerance) Anticholinergic medications - correct answer atropine=bradyarrythmias benztropine=parkinsons ipatropium=bronchospasm oxybutynin=urinary tract antispasmodics scopolamine=nausea/vomitting (motion sickness) propantheline/glycopyrrolate=decrease gastric secretory activity c/i in clients susceptible to glaucoma or BPH The home health nurse prepares to give benztropine to a 70yo client w/parkinsons disease. Which client statement is most concerning and would warrant HCP notification? - correct answer "I am going for repeat testing to confirm glaucoma" (anticholinergic medications are c/i in pt's susceptible to glaucoma or BPH) The nurse is providing d/c instructions to several clients w/new prescriptions. Which instructions by the nurse are correct in regard to medication administration? - correct answer 1. Avoid salt substitutes when taking valsartan for hypertension 2. When taking ethambutol, notify the HCP of any changes in vision The HCP has just prescribed tetracycline for an adolescent w/acne vulgaris. The client takes oral contraceptives. The nurse should educate the teen about which topics? - correct answer 1. Not taking tetracycline w/dairy products 2. Using additional contraceptive techniques 3. Using sunblock 4. Take on an empty stomach 5. Take w/a full glass of water 6. Avoid antacids Calcium channel blockers - correct answer nifedipine; amlodipine; felodipine; nicardipine -Treat HTN and chronic stable angina. -Important adverse effects: dizziness; flushing; headache; peripheral edema; constipation The nurse has provided education for a client newly prescribed alprazolam for generalized anxiety d/o. Which client statement indicates that teaching has been effective? - correct answer "I will take my daily dose at bedtime" (Benzo's have a sedative effect and should be given at bedtime. They should never be stopped abruptly in long-term users) A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? - correct answer Improvement in spontaneous activity A nurse teaches a client who is being d/c'd on warfarin for a-fib. Which client statements indicate that teaching has been effective? - correct answer 1. "Antibiotics can affect my INR value" 2. "I will take warfarin at the same time daily." 3. "I will shoot for my INR value to be between 2-3 The nurse is preparing medication for 4 clients on a respiratory medical-surgical unit. Which situation would prompt the nurse to clarify the prescribed treatment w/HCP? - correct answer Client w/bronchospasm who is d/t receive nebulized acetylcysteine (medication is inhaled to help loosen thick respiratory secretions. Nurses caring for pt's w/reactive airway disease, eg. asthma, who are prescribed acetylcysteine should clarify w/HCP as it may cause or worsen bronchospasm) The nurse precepts a nursing student caring for a client w/glaucoma and observes the student administer timolol maleate, an opthalmic medication. Which student action indicates that further instruction is needed? - correct answer Removes dried secretions w/moistened sterile gauze pads by wiping from the outer to inner canthus (client should remove contact lenses; uses aseptic technique; remove dried secretions w/moistened sterile gauze by wiping from inner to outer canthus; place client in supine or sitting w/head tilted back toward side of affected eye; rest hand on clients forehead and hold dropper 1-2cm above conjunctival sac; pull lower lid down gently; instruct client to look upward; then apply pressure to the lacrimal duct for 30-60 seconds) The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? - correct answer 1. Amitriptyline 2. Chlorpheniramine 3. Lorazepam (Beers criteria classifies potentially harmful drugs w/the elderly...antipsychotics, anticholinergics, antihistamines, antihypertensives, benzodiaepines, diuretics, opioids, sliding scale insulins) The nurse is performing d/c teaching for the parents of a 4yo w/HF. Which statement by the parents indicates the need for further teaching r/t the administration of digoxin? - correct answer "We will hold the dose if our child's HR is above 90/min" (parent teaching for digoxin: hold <90-110 for infants and young children and <70 in older children; do not mix the drug w/food or liquids; if dose is missed do not give extra or increase dose, stay on same schedule; if more than 2 doses missed notify HCP; if child vomits do not give 2nd dose...could indicate toxicity; give water or brush teeth after) The clinic nurse reviews the medical record of the client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? - correct answer Tuberculin skin test (TST) (major side effects of TNF's include severe infections and bone marrow suppression. TB reactivation is a major concern) A client has a serum potassium level of 2.8 and the HCP prescribes IV potassium chloride. The nurse administers 10mEq KCL/100 mL5% dextrose in water at 100ml/hr through the client's peripheral IV line sing an infusion pump. Shortly after the initiation of the infusion, the client reports feeling burning and discomfort at the IV site. What is the nurses priority action? - correct answer Slow the rate of the KCL infusion (It is irritating to the vein but can be administered slowly through a peripheral vein) A nurse is assessing a client w/type 2 diabetes mellitus who was recently started on pioglitazone. Which client data obtained by the nurse is most important to bring to the attention of the HCP? - correct answer Bilateral pitting edema in ankles (Thiazolidinediones ((rosiglitazone/avandia, pioglitazone/actos)) increase the risk of cardiovascular events and bladder cancer; similar to metformin) A client has just been prescribed allopurinol for chronic gout. Which instruction is most important for the nurse to emphasize to the client? - correct answer Take the medication w/a full glass of water and increase fluids during the day. (increase fluids to help prevent renal stones and promote diuresis and uric acid excretion) A client w/bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over the counter medications taken by the client could be contributing to increased asthma symptoms? - correct answer Ibuprofen 400mg orally every 6 hours for pain as needed (Ibuprofen and aspirin are common OTC anti-inflammatory drugs that can cause bronchospasm in some clients w/asthma The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the HCP? - correct answer "My periods have been heavy lately" (Tamoxifen is associated w/increased risk of endometrial cancer and venous thromboembolism; excessive menstrual bleeding can be a sign of endometrial cancer) The nurse reviews assigned client's medical and medication administration records. Which prescription should the nurse validate w/the HCP before administering? - correct answer Azathioprine for a client w/Crohn disease who reports fatigue and nausea and has leukopenia (Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow suppression and increase the risk for infection) The nurse performs medication reconciliation for a 94yo client who has type 2 diabetes, hypothyroidism, and heart failure caused by a previous MI. D/t risks outweighing benefits, the nurse plans to talk w/the HCP about d/c'ing which medication? - correct answer Glyburide 10mg PO/once day (Beers criteria; glyburide should be avoided d/t potential delayed elimination causing risk for prolonged hypoglycemia) A client has a follow up checkup in the urology clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the HCP? - correct answer Client excitedly reports being able to go an entire work day w/out having to urinate. (Tolterodine/Detrol, oxybutynin/ditropan and solifenacin/vesicare are anticholinergic medications; they decrease the urgency and frequency of urination; not urinating the entire day while at work may indicate that the dosage is too high and is causing urinary retention) A client w/latent TB has been taking oral isoniazid (INH) 300mg daily for 2 months. The client tells the nurse that for the past week she had numbness, a burning sensation and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this? - correct answer Vitamin B6 (INH interferes w/the action of vitamin B6, resulting in peripheral neuropathy) The home health hospice nurse visits a client who is newly prescribed extended release oxycodone 40mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the clients caregiver? - correct answer Administer the medication around the clock even if the clock even if the client denies having pain. (administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours) The nurse administers the prescribed dose of hydromorphone 2mg to a client who is 2 days postoperative from a colostomy. Which assessment finding is most important for the nurse to follow-up? - correct answer Client falls asleep while talking to the nurse A community health nurse evaluates several clients' vaccination status. Which clients would the nurse recommend receive the influenza vaccine injection? - correct answer 1. 9mo old w/no known medical conditions 2. 5yo w/congenital heart defect 3. 23yo recently dx'd w/HIV 4. 45yo caretaker of elderly patient [Show Less]
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MED-SURG CH 35 HIV-AIDS, STUDY GUIDE AND NCLEX QUESTIONS
When herpes zoster virus (HZV) is reactivated in an immunocompromised patient, it can cause which painful and serious condition? A. Measles B. Shingles... [Show More] C. Genital sores D. Mouth ulcers - correct answer B. Shingles The nurse is participating in a care-planning conference for a patient who prefers to avoid taking more medications to treat Kaposi sarcoma. What option might be offered? A. HAART B. Radiotherapy C. Chemotherapy D. Topical ointments - correct answer B. Radiotherapy A patient with AIDS states that several purple and white "spots" have appeared on the arm and the chest; they are not painful and are nonpruritic. Several days after the appearance of these spots, the patient believes there is also some blood in the stool. What might be the cause of the skin lesions and the blood in the stool? A. Kaposi sarcoma B. Herpes simplex C. Herpes zoster D. Basal cell carcinoma - correct answer A. Kaposi sarcoma The caregiver for a patient with AIDS requires some input on maximizing calorie and nutrient intake. The caregiver states that the patient tolerates liquids better than solid food. The nurse can suggest which nutrient-dense liquid supplement? A. Homemade eggnog B. One or two soft-cooked eggs C. Applesauce with a crushed multivitamin D. Meal replacement beverages, such as Ensure or Carnation Instant Breakfast - correct answer D. Meal replacement beverages, such as Ensure or Carnation Instant Breakfast A public health nurse is participating in a community health forum for World AIDS Day. Which statement by a community member indicates the need for additional teaching? A. "AIDS was recognized as a new pathogen in the early 1980s." B. "Men who have sex with men were the first group to be affected by AIDS." C. "Scientists believe the original source of HIV infection in humans was from gorillas." D. "In 1986, the HIV-1 and HIV-2 viruses were isolated as the viruses that cause AIDS." - correct answer C. "Scientists believe the original source of HIV infection in humans was from gorillas." The nurse is explaining the need to protect an immunocompromised HIV patient from infection to the patient's family. The nurse explains that the patient is immunocompromised because the pathophysiology of HIV centers on which process? A. Destruction of the T4 cells B. Insufficient number of neutrophils C. Inhibition of the inflammatory response D. An abnormal increase of immature white blood cells - correct answer A. Destruction of the T4 cells A college student presents to the campus health clinic 2 days after unprotected sexual intercourse. The student is requesting an HIV test. After the initial test is negative result, the nurse provides which advice to the student? A. Return to the clinic as needed. B. Obtain a repeat test in 3 months. C. Begin an intense regimen of antibiotics. D. Visually inspect the body daily for dark skin spots. - correct answer B. Obtain a repeat test in 3 months. A patient has recently had CD4 level testing, and the result was found to be 98 cells/mm3. The nurse realizes which condition has developed? A. The patient has AIDS. B. The patient is HIV positive. C. The patient has leukopenia. D. The patient has neutropenia. - correct answer A. The patient has AIDS. The nurse has been asked to present information regarding HIV risks to a group of young adults. Which populations are at risk for HIV infection? (Select all that apply.) A. Injection drug users B. Adolescents who engage in athletics (e.g. baseball, soccer, gymnastics) C. Patients who receive a transfusion with HIV-infected blood or blood products D. Neonates and breastfed infants of HIV-infected mothers (perinatal transmission) E. Laboratory technicians who use appropriate protocols for handling blood products F.Partners, including heterosexuals, who have unprotected sex with those infected with HIV - correct answer A. Injection drug users C. Patients who receive a transfusion with HIV-infected blood or blood products D. Neonates and breastfed infants of HIV-infected mothers (perinatal transmission) F.Partners, including heterosexuals, who have unprotected sex with those infected with HIV Medication that interferes with the maturation of viral particles - correct answer Protease inhibitor Retrovirus that causes AIDS - correct answer HIV Disease that is now viewed less as a fatal illness than as a manageable chronic condition - correct answer AIDS Medication regimen or combo of drugs recommended when viral load reaches certain levels - correct answer HAART What 4 cancers occur in 40% of pts with HIV? - correct answer KS non-Hodgkin Lymphoma Anal cancer Cervical cancer Why are pts with HIV infection at increased risk for cancer? - correct answer The immune system is unable to identify and destroy cells that undergo malignant changes How is HIV transmitted? Select all that apply 1. Saliva 2. Breast milk 3. Semen 4. Urine 5. Blood 6. Vaginal fluids 7. Tears 8. Sweat - correct answer 2. Breast milk 3. Semen 5. Blood 6. Vaginal fluids Which 4 types of diagnostic blood work may aid in the diagnosis of HIV infection? Select all that apply? 1. ELISA 2. Western blot 3. PIT 4. T cell count 5. Viral load count 6. Lipid profile - correct answer 1. ELISA 2. Western blot 4. T cell count 5. Viral load count What is the leading cause of death in ppl with AIDS? 1. KS 2. Malnutrition 3. Infection 4. Encephalopathy - correct answer 3. Infection About how long after infection does the body produce enough antibodies to be detected by standard HIV testing? 1. 2-3 days 2. 1 week 3. 12 weeks 4. 6 months - correct answer 3. 12 weeks Which substances remain at high levels throughout the course of HIV infection? 1. HIV antibodies 2. CD8 cells 3. CD4 cells 4. Red blood cells - correct answer 1. HIV antibodies Antiviral medications are given to pts with HIV infection to: 1. prevent viral replication and destroy infected cells 2. destroy viral cells that are infected 3. slow viral replication and progression 4. destroy bacteria and prevent infection - correct answer 3. slow viral replication and progression Which test for HIV infection is the most reliable diagnostic test? 1. ELISA 2. Western blot 3. CD4 count 4. CD8 count - correct answer 2. Western blot How many newly diagnosed HIV infections occur annually in the US? 1. 20,000 2. 50,000 3. 100,000 4. 540,000 - correct answer 2. 50,000 Which drug is used to treat opportunistic fungal infections in ppl with HIV infection? 1. AZT 2. Retrovir 3. Amphotericin B 4. Bactrim - correct answer 3. Amphotericin B Which opportunistic infection is treated with Bactrim and Pentamidine? 1. PJP 2. Candidiasis 3. Histoplasmosis 4. Cytomegalovirus - correct answer 1. PJP What is the usual combination of drugs for HIV pts who started on the medication regimen called HAART? 1. Antimicrobials and protease inhibitors 2. NRTIs and protease inhibitors 3. NRTIs and NNRTIs 4. Antimycotics and NNRTIs - correct answer 2. NRTIs and protease inhibitors What is the most serious problem with HAART therapy? 1. Resistance 2. Hypolipidemia 3. Renal failure 4. Infection - correct answer 1. Resistance What type of cells does HIV gradually destroy that are essential for resisting pathogens? 1. Neutrophils 2. T4 cells 3. B cells 4. Eosinophils - correct answer 2. T4 cells HIV is passed from person to person primarily through? 1. air droplet contact 2. hand to mouth contact 3. exposure to bodily fluids 4. mouth to mouth contact - correct answer 3. exposure to bodily fluids A pt with HIV has developed some GI infections, causing diarrhea, N&V, and poor appetite. What is he priority nrusing intervention for this pt? 1. Provide periods of rest during day 2. Provide a diet high in protein and low in calories 3. Monitor for fluid and electrolyte imbalance 4. Monitor for signs of infection - correct answer 3. Monitor for fluid and electrolyte imbalance What are 2 nursing interventions for an HIV pt who is experiencing N&V, diarrhea, and poor appetite? Select all that apply 1. Discuss ways to conserve energy and promote restful sleep 2. Talk to nurse practitioner about prescribing antinausea meds, an appetite stimulant, and an antidiarrheal 3. Encourage pt to ask questions and talk about feelings 4. Teach importance of regular dentsal care 5. Provide a diet high in protein and calories - correct answer 2. Talk to nurse practitioner about prescribing antinausea meds, an appetite stimulant, and an antidiarrheal 5. Provide a diet high in protein and calories For many women, one of the fisrt symptoms of HIV infection is: 1. Vaginal candidiasis 2. Burning on urination 3. Menstrual irregularities 4. Hemorrhoids - correct answer 1. Vaginal candidiasis A type of skin cancer that has dramatically increased as a result of AIDS is: 1. Basal cell carcinoma 2. Melanoma 3. KS 4. Venereal warts - correct answer 3. KS The medical tx of HIV infection includes the use of zidovudine (AZT; Retrovir), which is given to: 1. cure AIDS 2. prevent transmission to sexual partners 3. treat the secondary infections of AIDS 4. slow progress of AIDS - correct answer 4. slow progress of AIDS Drugs such as clindamycin, Pentamidine, and Bactrim are used to: 1. Prevent or treat opportunistic infections 2. Slow the progress of AIDS 3. Decrease the dermatitis associated with AIDS 4. Increase T4 lymphocytes - correct answer 1. Prevent or treat opportunistic infections [Show Less]
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NCLEX STUDY QUESTIONS-HEALTH ASSESSMENT
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which fi... [Show More] nding? a. Rhythmic respirations with periods of apnea b. Regular rapid and deep, sustained respirations c. Totally irregular respiration in rhythm and depth d. Irregular respirations with pauses at the end of the inspiration and expiration - correct answer a. Rhythmic respirations w/periods of apnea pg. 834 box 58-2 A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? a. A defect in the cochlea b. A defect in the cranial nerve VIII c. A physical obstruction to the transmission of sound waves d. A defect in the sensory fibers that lead to the cerebral cortex - correct answer c. A physical obstruction to the transmission of sound waves pg. 155 #3c-d or pg. 808 How would a client complete the Romberg's test? - correct answer Patient standing, arms to the side, eyes closed, feet together (Failure would mean patient loses balance) pg. 164 #9b While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? a. Lub-dub sounds b. Scratchy, leathery heart noise c. A blowing or swooshing noise d. Abrupt, high-pitched snapping noise - correct answer c. A blowing or swooshing noise pg. 160c The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye? a. Test the corneal reflexes b. Test the 6 cardinal positions of gaze c. Test visual acuity, using a Snellen eye chart d. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin - correct answer b. Test the 6 cardinal positions of gaze pg. 154 The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? a. After a shower or bath b. While standing to void c. After having a bowel movement d. While lying in bed before arising - correct answer a. After a shower or bath The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? a. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. b. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. c. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. d. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. - correct answer c. The client passively flexes the hip and knee in response to the next flexion and reports pain in the vertebral column pg. 165 #14a-b A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? a. Stridor b. Crackles c. Wheezes d. Diminished - correct answer c. Wheezes (Asthma: dyspnea, constriction of bronchi, wheezing) The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. a. Auscultating lung sounds b. Obtaining the client's temperature c. Assessing the strength of peripheral pulses d. Obtaining information about the client's respirations e. Performing a musculoskeletal and neurological examination f. Asking the client about a family history of any illness or disease - correct answer a. Auscultating lung sounds b. Obtaining the clients temperature d. Obtain information about client respirations The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? a. An involuntary rhythmic, rapid, twitching of the eyeballs b. A dorsiflexion of the great toe with fanning of the other toes c. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed d. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference - correct answer c. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? a. To examine the testicles while lying down b. That the best time for the examination after a shower c. To gently feel the testicle with one finger to feel for a growth d. That TSE's should be done at least every 6 months - correct answer b. That the best time for the examination after a shower The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? a. At the onset of menstruation b. Every month during ovulation c. Weekly at the same time of day d. One week after menstruation begins - correct answer d. One week after menstruation begins The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? a. The right eye is tested, followed by the left eye, and then both are tested b. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye c. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart d. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read from 200 feet (60 meters) away by an individual with unimpaired vision - correct answer a. The right eye is tested, followed by the left eye, and then both are tested A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? a. Provide the client with materials on legal blindness b. Instruct the client that he or she may need glasses when driving c. Inform the client of where he or she can purchase a white cane with a red tip d. Inform the client that it is best to sit near the back of the room when attending when attending lectures - correct answer b. Instruct the client that he or she may need glasses when driving The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. a. Set the room temperature at a comfortable level b. Remove distracting objects from the interviewing area c. Place a chair for the client across from the nurse's desk d. Ensure comfortable seating at eye level for the client and a nurse e. Provide seating for the client so that the client faces strong light f. Ensure that the distance between the client and the nurse is at least 7 feet (2.1 meters) - correct answer a. Set the room temperature at a comfortable level b. Remove distracting objects from the interviewing area d. Ensure comfortable seating at eye level for the client and a nurse [Show Less]
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