NCLEX: Practice test 1 2024/2025 question with acceptable answers latest updated, Exams of Nursing

Download NCLEX: Practice test 1 2024/2025 question with acceptable answers latest updated and more Exams Nursing in PDF only on Docsity! NCLEX: Practice test 1 2024/2025 question with acceptable answers latest updated An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority? 1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid. 2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. 3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin. 4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry - ✅✅✅2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds. -This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem. Which task should the nurse perform first? 1. Suctioning the tracheostomy. 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Notify the primary healthcare provider. - ✅✅✅-Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful? -Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion. -The witness does not have to be an RN. -A witness is required to be over the age of 18. - ✅✅✅ A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? 1. Inform the primary healthcare provider that the client wishes to leave. Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. - ✅✅✅ Make arrangements for a commitment hearing, as soon as possible only if the client is not a threat or potential threat to self or others, the client may leave - ✅✅✅ unlicensed assistive personnel (UAP) cant do invasive tasks like removing catheters or obtaining sterile specimens from indwelling catheter - ✅✅✅ Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Sitting at the bedside and listening to an elderly client - ✅✅✅Sitting at the bedside and listening to an elderly client -Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy. hemiplegia= paralysis of one side of the body. - ✅✅✅ The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? You answered this question Incorrectly * 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Inform the client that personnel are available to assist with completing an advance directive.* 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision. - ✅✅✅1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? 1. Life-threatening complications for the client. 2. Legal action against the nurse and/or healthcare facility. 3. Suspension or loss of license to practice nursing. 4. Suspension or loss of license to practice medicine. 5. Loss of client autonomy and right to make decisions. - ✅✅✅1., 2., 3. & 5. Correct: The role of client advocate is a nurse's responsibility. Failure to act as a client advocate could result in a range of complications for the client, including: -life-threatening or life-ending complications. -Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility -potential suspension or loss of license to practice nursing. -The client advocate protects client autonomy and right to make decisions. Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? 1. Tell the family members that information about clients cannot be provided. 1. Six year old with new onset diabetes. 2. Ten year old with pneumonia admitted two days ago. 3. Three month old admitted with severe dehydration. 4. Four year old admitted for developmental studies. 5. Twelve year old with post op wound infection taking oral antibiotics. - ✅✅✅2.,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. Which nursing intervention should receive priority after a client has returned from having had eye surgery? 1. Administer pain medication around the clock. 2. Maintain head of bed at 35°. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing. - ✅✅✅2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure. The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care? 1. Sit the client up at a 90° angle during meals. 2. Assist the client to hyperextend the head when preparing to swallow. 3. Encourage the client to sit up for 30 minutes after eating. 4. Educate a family member on the Heimlich maneuver. 5. Start the client on a thin liquid diet. - ✅✅✅1., 3. & 4. Correct: This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after 1. Administer the KCL through the lowest IV line port. 2. Clarify the prescription with the primary healthcare provider. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour. - ✅✅✅2. Correct: *Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias. A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can. - ✅✅✅Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. -The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? - ✅✅✅Perform as a clean procedure. -Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. *Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI).* In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. - ✅✅✅First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4's. 4. Washing fruit and vegetables prior to eating. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating. - ✅✅✅*1. Importance of hand washing before eating.* 2. Wearing protective clothing while working in the field and at home. *3. Removing clothing and shoes worn in the field before entering the home. 4. Washing fruit and vegetables prior to eating.* 5. Boiling all vegetables for a minimum of 5 minutes prior to eating. 1., 3. & 4. Correct: The standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure. 2. Incorrect: Yes, wear protective clothing while working in the field, but it is not necessary to wear protective clothing at home. 5. Incorrect: No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce. Washing thoroughly with water is adequate. The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse? 1. Leave the client alone and remove clients from the dayroom. 2. Call for personnel to escort the client out of the day room. 3. Restrain the client, and notify the primary healthcare provider. 4. Tell the client that there is no way that a person can fly. - ✅✅✅2. Correct: The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. 3. Incorrect: The primary healthcare provider does not need to be notified at this time. Restraints should be used as a last resort. A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 3. Vitamin K 4. Lanolin 5. PKU Screening - ✅✅✅1., 2., 3. & 5. Correct: This vaccine is recommended at birth to decrease the incidence of hepatits B virus. Mandatory prophylactic agent is applied in newborn's eyes as precaution against ophthalmia neonatorium. Vitamin K (Aquamephyton) routine injection to prevent hemorrhagic disease of newborn. *PKU- Screening for phenylketonuria is not reliable until the newborn has ingested an ample amount of the amino acid, phenylalanine, a constituent of both human and cow's milk. Nurse must document initial ingestion of milk and perform test at least 24 hours after that time. This test is thus done just prior to discharge.* A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure? 1. Fetal attitude 2. Fetal engagement 3. Fetal lie 4. Fetal position - ✅✅✅2. Correct: Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). If the fetus is not well engaged when the membranes are ruptured, then prolapsed cord could result. 4. Incorrect: Fetal position tells us the presenting part of the fetus to mom's pelvis. Amniotomy - ✅✅✅Artificial rupture of membranes for labor What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly guaiac-based fecal occult blood test. 5. Flexible esophagogastroduodenoscopy every 5 years. - ✅✅✅1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains has been linked with a decreased risk of colorectal cancer; whereas, a diet high in red meats, processed meats, and cooking meats at very high temperature (frying, broiling or grilling) creates chemicals that may increase the risk for colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The guaiac- based fecal occult blood test detects blood likely to develop type 2 diabetes than Caucasians are. A nurse is educating the parents of a child with celiac disease. The nurse knows the teaching is successful if the parents choose which food for their child's dinner? 1. Turkey and lettuce sandwich on rye bread *2. Sirloin steak and diced baked potatoes* 3. Chicken, vegetables and a whole wheat roll 4. Hotdog and baked beans Celiac disease= An immune reaction to eating *gluten, a protein found in wheat, barley and rye.* - ✅✅✅ Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? 1. Notify the primary health care provider of client's refusal to ambulate. 2. Offer the client pain medication. 3. Explain complications associated with bed rest. 4. Perform passive range of motion exercises. - ✅✅✅3. Correct: The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 2. Incorrect: The first action should be for the nurse to educate the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority. A clinic nurse is educating a client diagnosed with Bell's Palsy. What is the most important educational point the nurse must emphasize to the client? 1. Physical therapy will be needed to maintain muscle tone of the face. 2. Massaging the face several times daily using a gentle upward motion. 3. Proper methods of closing eyelids and eye patching. 4. Non-steroidal anti-inflammatory medications are used to alleviate painful muscles. - ✅✅✅3. Proper methods of closing eyelids and eye patching. 3. Correct: Even though all are educational points that need to be provided to the client, this is the most important educational point to make. Keratitis, or the inflammation of the cornea, is one of the most dangerous complications for a client with Bell's palsy. As a precautionary measure, the nurse must ensure that the cornea is protected even if the eyelids will not close. 2. Incorrect: The routine should be maintained each night if at all possible. Only through routine does the child feel secure in preparation for bedtime. 4. Incorrect: A special toy helps the child to feel secure and adds to the nighttime routine. What discharge instructions should the nurse provide to the client post abdominal hysterectomy? 1. Ambulate at least 3-4 times per day. 2. Notify the primary healthcare provider if there is a yellow discharge from the surgical wound. 3. Swimming is allowed if staples were used to close the skin. 4. Press a pillow over incision when coughing to ease discomfort. 5. Apply moist heat to surgical site the first couple of days for pain relief. - ✅✅✅1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember NCLEX wants you to think safety first when it comes to the use of heat. A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Frequent blood glucose monitoring to ensure stable values. - ✅✅✅4. Correct: Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits. 1. Incorrect: Assessing for cephalhematoma is important in macrosomia infants, but not as vital as ensuring stable glucose levels. -antispasmodic INDICATIONS: ~Overactive bladder. ~Movement problems in Parkinson's disease. ~Diarrhea. ~Motion sickness. ~Nausea and/or vomiting. ~Muscle spasms. ~Chronic obstructive pulmonary disease (COPD) ~Asthma. Atropine - ✅✅✅-anticholinergic agent; not used to trt pseudoparkinism -commonly used to treat arrhythmias and preoperatively to decrease secretions Lorazepam - ✅✅✅sedative/hypnotic or antianxiety agent. MED ENDINGS ace inhibitors - ✅✅✅-pril -block angiotensin converting enzyme (angiotensin-renin system) and in turn block aldosterone (lowers BP) Antidiuretic hormones - ✅✅✅end in pressin Antilipidemics - ✅✅✅statin Antivirals - ✅✅✅Have vir in name (Ritonavir) Benzodiazepines - ✅✅✅end in pam (diazepam) -Benzodiazepines possess sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant, and amnesic actions, which are useful in a variety of indications such as alcohol dependence, seizures, anxiety disorders, panic, agitation, and insomnia. Beta blockers - ✅✅✅lol Calcium Channel Blockers - ✅✅✅-usually end in pine or have ca in the name (amplodipine, diltiazem, Nimopidine) -Some calcium channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat. Histamine receptor antagonist - ✅✅✅end in dine (Cimetidine) -H2-antagonists are used by clinicians in the treatment of acid-related gastrointestinal conditions, including: Peptic ulcer disease (PUD) Gastroesophageal reflux disease (GERD/GORD) Dyspepsia. Prevention of stress ulcer (a specific indication of ranitidine) 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Encourage client to express fears and anxiety. - ✅✅✅4. Correct: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. 1. Incorrect: The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional. 2. Incorrect: The client will not be permitted to clean self until all evidence has been collected per protocol. However, initial contact between nurse and client should focus on more than just the physical aspects of the situation. 3. Incorrect: Collection of all evidence for the police is a crucial part of treating rape clients and will be completed according to protocols. But it is more important to remember that this client has already been violated during the attack. Removing clothing before addressing emotional needs may further exacerbate that sense of violation. The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Verbal recognition of the existence of multiple personalities. - ✅✅✅4. Correct: In order for therapy to be successful, the client must first acknowledge that there are multiple personalities within the client's personality. 1. Incorrect: This is related to a client with dissociative amnesia. 2. Incorrect: This is related to a client with disturbed sensory perception. 3. Incorrect: This outcome would not be related to this client. The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? -packaged sugar free jello - ✅✅✅ This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping. Reaction formation is behaving in a way that is exactly opposite of one's true feelings. - ✅✅✅ The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume? 1. Cup of oatmeal, blueberries, soymilk 2. Whole grain pasta, marinara sauce, baked fish, coffee 3. Spaghetti with meat sauce, peas, garlic French bread, tea 4. Lentil soup, vegetable medley, fruit salad, water - ✅✅✅3. Correct: This is not a good choose for this client. Meat is high fat. French bread with butter is low fiber and high fat. 1. Incorrect: This is a good meal choose when on a low fat, high fiber diet. Blueberries are high in fiber and all are low fat. 2. Incorrect: This is a good low fat, high fiber meal choose. Whole grain pasta is high in fiber and low in fat. Fish and marinara sauce are low in fat. 4. Incorrect: These are low fat, high fiber items to consume. Which foods should the nurse teach a client to avoid when prescribed a diet limiting purine rich foods? 1. Peanut butter 2. Potatoes 3. Apples 4. Venison 5. Scallops - ✅✅✅4., & 5. Correct: Meats such as liver, bacon, veal, and venison are high in purine and should be avoided. Seafood such as sardines, mussels, codfish, scallops, trout, and haddock are high in purine and should be avoided. The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? 1. "The pain is getting worse. I can't stand it." failure is worsening and needs to be documented. 1. Incorrect: This is an offensive odor of the client's breath often associated with liver failure. 2. Incorrect: This is uncoordinated movement that is associated with many different neuromuscular disorders. 3. Incorrect: This is a term to describe not using items for their intended purpose and is associated with neurological disorders and damage to the brain. A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. - ✅✅✅In order to keep a client safe, the nurse should first assess the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room. *apply gait belt afterrrr helping to sitting position The nurse is assessing pain after surgery in a 3 year old client with a known developmental delay. Which pain scale should the nurse use to assess this client's pain level? 1. CRIES scale 2. Numeric scale 3. FLACC scale 4. FACES scale - ✅✅✅3. Correct: The FLACC scale can be used for pediatric clients from age 2 months to 7 years and is appropriate when clients cannot communicate their pain. 1. Incorrect: The CRIES scale is used with neonates and infants. 2. Incorrect: Not age-appropriate; used for children ages 5 and up. 4. Incorrect: Not age-appropriate. The FACES scale is indicated for children ages 3 years and up. When using the FACES scale, the child must be able to understand the difference between pain and being sad. Because this child is only 3 years old (the bottom age for use of the FACES scale), and because the client has a developmental delay, the FLACC scale is a better choice as it is based on nursing observations. A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. 2. Notify primary healthcare provider of lithium level. 3. Connect client to heart monitor. 4. Administer sodium polystyrene for hyperkalemia. 5. Pad the siderails of the client's bed. - ✅✅✅1., 2., 3., & 5. Correct: Symptoms of *lithium toxicity begin to appear at blood levels greater than 1.5 mEq/L*. Additionally, *concurrent administration of lithium and diuretics such as furosemide increase the chance of toxicity*. At serum levels of 1.5- 2.0 mEq/L: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea. At serum levels of 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. At serum levels above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse. Arrhythmias and seizures can occur with toxicity. So the lithium dose should be held, and the healthcare provider notified. The client is at risk for arrhythmias, so connect to a heart monitor. The client is also at risk for seizures, so pad the side rails. 4. Incorrect: The potassium level is normal, so there is no need to treat hyperkalemia. normal lithium (mood stabillizer)= .5-1 higher than 1.5 start showing signs of toxicity - ✅✅✅ The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit? 1. Expectorating pink frothy sputum 2. Sudden onset of mid-sternal chest pain 3. Jaundiced conjunctiva 4. Diaphoresis and fever - ✅✅✅3. Correct: This is a sign of liver damage, which is caused by an overdose of acetaminophen. 1. Incorrect: This is a symptom of pulmonary edema, not liver damage. 2. Incorrect: This is a symptom of myocardial ischemia, not liver damage. 4. Incorrect: Acetaminophen would decrease fever, and fever could cause diaphoresis so neither of these are expected with acetaminophen overdose. A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. Normal digoxin level - ✅✅✅.8-2 -A DRUG THAT STRENGTHENS THE CONTRACTION OF THE HEART MUSCLE, SLOWS THE HEART RATE AND HELPS ELIMINATE FLUID FROM BODY TISSUES. IT'S OFTEN USED TO TREAT CONGESTIVE HEART FAILURE AND IS ALSO USED TO TREAT CERTAIN ARRHYTHMIAS -Here are some of the signs and symptoms of digitalis toxicity: includes: ~~~CONFUSION ~~~NAUSEA, VOMITING, ~~~DIARRHEA ~~~BLURRED VISION ~~~HALOS OR RINGS OF LIGHT AROUND OBJECTS A client with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidos and a serum glucose level of 789 mg/dl. The physician prescribes 10 units of regular insulin by intravenous (IV) bolus, followed by a continues insulin infusion at a rate of 5 units/hr. The pharmacy sends 500 ml of normal saline solution containing 50 units of regular insulin. After administering the IV bolus of 10 units of regular insulin, the nurse sets the flow rate of the normal saline solution to infuse at how many milliliters per hour to deliver 5 units/hr? - ✅✅✅50u/500ml * 5/x = 50 ml INR= 1.3-2 - ✅✅✅ BUN - ✅✅✅10-20 Cr - ✅✅✅.5-1 Ca - ✅✅✅9-10.5 Mg 1.3-2.1 - ✅✅✅ RBC - ✅✅✅4.2-6 million aPTT - ✅✅✅-(patients receiving anticoagulant therapy: 1.5-2.5 times the control value in seconds) 30-40 seconds The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority? 1. Take insulin 30 minutes before bedtime 2. Take insulin twice daily in AM and PM 3. Take insulin one hour before meals 4. Take insulin with meals - ✅✅✅4. Correct: Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal. 1. Incorrect: Lispro is a rapid-acting insulin and should not be taken without food. are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. "Glycopyrrolate will decrease stomach secretions." - ✅✅✅-glycopyrrolate is an ANTICHOLINERGIC 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. -hyperkalemia is adverse effect of ace inhibitors - ✅✅✅ The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? 1. Ventrogluteal site 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site - ✅✅✅1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect. - ✅✅✅ What should the nurse include when providing teaching to a female client A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? 1. "Do you take metronidazole on an empty stomach?" 2. "Are you using any products that contain alcohol?" 3. "How long have you had these symptoms?" 4. "What other medications are you currently taking?" - ✅✅✅2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products. A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? 1. Stop taking the medication and call the primary healthcare provider. 2. Drink plenty of water with the medication. 3. Take the medication before bedtime. 4. Take antacids when taking the medication. - ✅✅✅2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: Imipramine HCI is an antidepressant which is not routinely given with methylprednisolone (Although mood changes can occur with steroid administration, anti-depressants are not routinely given). 4. Incorrect: Aminocaproic acid is given when clients are bleeding. Bleeding is not a side effect of methylprednisolone. Guillane Barre - ✅✅✅-condition in which the immune system attacks the nerves. -Symptoms start as weakness and tingling in the feet and legs that spread to the upper body. Paralysis can occur. Special blood treatments (plasma exchange and immunoglobulin therapy) can relieve symptoms. Physical therapy is needed. -difficulty swallowing, facial muscle weakness, shortness of breath, slow reflexes, uncomfortable tingling and burning, urinary retention, difficulty raising the foot, or impaired voice -may need mechanical ventilation or intubation Pagets Disease - ✅✅✅-disease that disrupts the replacement of old bone tissue with new bone tissue. -most commonly occurs in the pelvis, skull, spine, and legs -Treatment involves medications that reduce the breakdown of bone. The primary healthcare provider prescribed tolbutamide 250 mg orally twice a day. The pharmacy dispensed tolbutamide 0.5 g scored tablets. How many tablets will the nurse administer? Round your answer using one decimal point. - ✅✅✅Step 1: 1000 mg : 1 g = x mg: 0.5 g x = 500 mg Step 2: 500 mg: 1 tab = 250 mg : x tab 500 x = 250 X = 0.5 *RULE: if doesnt say in 24 hours then means for that administration only!* Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided. - ✅✅✅ The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? 1. The blood infusion time was within 6 hours. 2. A filter was used when administering the blood. 3. A second nurse checked the blood compatibility. 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider. - ✅✅✅1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine. The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? 1. A primipara 6 hours postpartum saturating one peripad every two hours 2. A multigravida 1 hour postpartum and reporting intense perineal pain 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge. - ✅✅✅2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge. POST PARTUM PERIOD NORMALS: -saturate around 1 peripad every 2 hours -uterine fundus - ✅✅✅ Goodells sign - ✅✅✅-softening of cervix -2nd month Chadwicks sign - ✅✅✅-bluish color of vaginal mucosa/cervix -4 weeks Hegars sign - ✅✅✅softening of lower uterine segment -2nd/3rd month ULTRASOUNDS preg considerations - ✅✅✅-drink water to distend bladder (NO VOID) -you want bladder to push uterus to abdominal surface -UNLESSSS its an ultrasound prior to procedure like amniocentesis, THEN VOID Amniocentesis - ✅✅✅-amniotic fluid test -medical procedure used in prenatal diagnosis of chromosomal abnormalities and fetal infections, and also for sex determination -small amount of amniotic fluid, which contains fetal tissues, is sampled from the amniotic sac surrounding a developing fetus, and then the fetal DNA is examined for genetic abnormalities. -Amniocentesis is performed when a woman is between 14 and 16 weeks gestation Second trimester - ✅✅✅14-26 weeks -1 pound a week -no more N/V or urinary frequency because fundus rises up relieving pressure on bladder -quickening= fetal movement -fetal HR (120-160) FETAL HR ALWAYS - ✅✅✅120-160 normal 110-120: little concerned and watching less than 110= panic term pregnancy= 37-40 weeks - ✅✅✅ Third trimester (27-40 weeks) - ✅✅✅-1 pound a week -fetal position/presentation determined by LEOPOLE MANEUVERS (have pt void 1st and do btw contractions) -done to determine position (fetal dopplar best taken where fetal back is) SIGNS OF LABOR - ✅✅✅-lightening: 2 weeks before term (presenting part of fetus {usually head} descend into pelvis) -pt feels less congested, breathe easier, but urinary frequency problem again b/c pressure back on bladder -*ENGAGEMENT*: fetal largest part in pelvic inlet -*FETAL STATION*: measure in cm and measures relationship of presenting part of fetus to moms ischial spine -bloody show (if lots think hemorrhage) -sudden energy burst (nesting) -diarrhea -rupture of membranes Go to hospital when contractions are 5 mins apart of membranes rupture - ✅✅✅ *RULE: when membranes rupture always concerned about prolapsed cord, so ALWAYS obtain fetal heart tone after rupture*