NR 565 MIDTERM EXAMS AND STUDY GUIDE, Exams of Nursing

Download NR 565 MIDTERM EXAMS AND STUDY GUIDE and more Exams Nursing in PDF only on Docsity! 1 | P a g e NR 565 MIDTERM EXAMS AND STUDY GUIDE WITH ATUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS LATEST 2024 ALREADY GRADED A+ (NEWEST) NR 565 MIDTERM EXAMS Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure Checking the client's peripheral pulses Checking the most recent potassium level Checking the client's intake-and-output record for the last 24 hours Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? "The test will take about 30 minutes." "I need to fast for 8 hours before the test." "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Rationale: No special preparation is necessary before a GI series, except that NPO (nothing by mouth) status must be maintained for 8 hours before the test. An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves 2 | P a g e swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction. A nurse on the evening shift checks a primary health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the primary health care provider's answering service and is told that the primary health care provider is off for the night and will be available in the morning. What should the nurse do next? Call the nursing supervisor Ask the answering service to contact the on-call primary health care provider Withhold the medication until the primary health care provider can be reached in the morning Administer the medication but consult the primary health care provider when he becomes available Ask the answering service to contact the on-call primary health care provider Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a primary health care provider's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not perfusing. What is the nurse's most appropriate action? Document the findings Ask the ED primary health care provider to check the client Continue to monitor the client's cardiac status Inform the client that PVCs are expected after an MI Ask the ED primary health care provider to check the client Rationale: The most appropriate action by the nurse would be to ask the ED health care provider to check the client. PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore, the nurse would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. 5 | P a g e about her condition. HIV is a concern of rape victims. Such concern should always be addressed, and the victim should be given the information needed to evaluate his or her risk. Pregnancy may occur as a result of rape, and pregnancy prophylaxis can be offered in the emergency department or during follow-up, once the results of a pregnancy test have been obtained. However, stating, "You're more likely to get pregnant than to contract HIV" avoids the client's concern. Similarly, "HIV is rarely an issue in rape victims" and "Every rape victim is concerned about HIV" are generalized responses that avoid the client's concern. A client is taking prescribed ibuprofen 200 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. What should the nurse tell the client? "I will contact your primary health care provider." "Stop taking the medication." "Take the medication with food." "Take the medication twice a day instead of four times a day." "Take the medication with food." Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the primary health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food. The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take? Document the amount in the client's record. Discontinue the Jackson-Pratt drain from suction. Continue to monitor the amount and color of the drainage. Notify the primary health care provider immediately of the amount of drainage. Notify the primary health care provider immediately of the amount of drainage. Rationale: The nurse must immediately notify the primary health care provider of this excessive amount of drainage. The primary health care provider must also be immediately notified of any saturated head dressings. The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the suction from the J-P drain is not an option and is not done. Also, just documenting the amount in the client's record is not correct even though the nurse would document that the primary health care provider was notified of the total drain amount. Just continuing to monitor the amount of drainage is also not an option. 6 | P a g e Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed. Over what period of time should the nurse administer this medication? 3 minutes 10 seconds 15 seconds 30 minutes 3 minutes Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period. A nurse, conducting an assessment of a client being seen in the clinic for signs/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. On the basis of this information, the nurse determines that the client most likely has a history of what problem? Depression Diabetes mellitus Hyperthyroidism Coronary artery disease Depression Rationale: The client is most likely suffering from depression. Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication. Phenelzine sulfate 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 primary health care provider immediately if he/she experiences what sign/symptom? Dry mouth Restlessness Feelings of depression Neck stiffness or soreness Neck stiffness or soreness Rationale: The client is taught to immediately contact the primary health care provider if the client experiences any occipital headache radiating frontally and neck stiffness or soreness, which could be the first sign of a hypertensive crisis. Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and 7 | P a g e soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. Dry mouth and restlessness are common side effects of the medication. Risperidone 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 primary health care provider before administering the medication? The client has a history of cataracts. The client has a history of hypothyroidism. The client takes a prescribed antihypertensive. The client is allergic to acetylsalicylic acid (aspirin). The client takes a prescribed antihypertensive. Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication. A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Fever Diarrhea Hypertension Tongue protrusion Tongue protrusion Rationale: The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the primary health care provider who is scheduled to perform the ECT? Recent stroke Hypothyroidism History of glaucoma Peripheral vascular disease 10 | P a g e A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? "What are your feelings right now?" "Why don't you feel like washing up?" "You aren't talking today. Cat got your tongue?" "You need to get yourself cleaned up. You have company coming today." "What are your feelings right now?" Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and nontherapeutic. Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. The nurse is assisting the primary health care provider with the procedure. What characteristics of the fluid removed during thoracentesis should the nurse expect to note? Clear and yellow Thick and opaque White and odorless Clear, with a foul odor Thick and opaque Rationale: Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder. 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? Administering 100% oxygen Having a crisis counselor available Instituting suicide precautions for the client Obtaining blood for determination of the client's carboxyhemoglobin level Administering 100% oxygen Rationale: With a client with carbon monoxide poisoning, the priority is to treat the client with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric 11 | P a g e oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this is not the priority. Suicide precautions should be instituted once emergency interventions have been completed and the client has been admitted to the hospital. The diagnosis is confirmed with a measurement of the carboxyhemoglobin level in the client's blood. Obtaining a blood specimen to measure the carboxyhemoglobin level is a priority; however, the nurse would immediately administer 100% oxygen to the client. 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? Anxiety Powerlessness Disruption of thought processes Inability to maintain health Anxiety Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health. 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? "Do you chew tobacco?" "Do you smoke cigarettes?" "Have you ever worked in a mine?" "Are you frequently exposed to paint products?" "Have you ever worked in a mine?" Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely ground silica used in soaps, polishes, and filters also presents a risk. The assessment questions noted in the other options are unrelated to the cause of silicosis. A primary health care provider prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of 12 | P a g e morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. _____ mL 0.625 A client undergoing therapy with carbidopa/levodopa calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. What should the nurse tell the client? To call his primary health care provider That he needs to drink more fluids That this is an occasional side effect of the medication That this may be a sign/symptom of developing toxicity of the medication That this is an occasional side effect of the medication Rationale: Carbidopa/levodopa, an antiparkinson agent, may cause darkening of the urine or sweat. The client should be reassured that this is a harmless side effect of the medication and that the medication's use should be continued. Although fluid intake is important, telling the client that he needs to drink more fluid is incorrect and unnecessary. Telling the client that the darkening of his urine may signal developing medication toxicity is incorrect and might alarm the client unnecessarily. There is no need for the client to call the primary health care provider. A client with myasthenia gravis is taking neostigmine bromide. What does the nurse note that indicates the client is gaining a therapeutic effect from the medication? Bradycardia Increased heart rate Decreased blood pressure Improved swallowing function Improved swallowing function Rationale: Neostigmine bromide, a cholinergic medication that prevents the destruction of acetylcholine, is used to treat myanthenia gravis. The nurse would monitor the client for a therapeutic response, which includes increased muscle strength, an easing of fatigue, and improved chewing and swallowing function. Bradycardia, increased heart rate, and decreased blood pressure are signs/symptoms of an adverse reaction to the medication. A nurse is assessing a client who has been taking amantadine hydrochloride 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? Insomnia Rigidity and akinesia Bilateral lung wheezes Orthostatic hypotension 15 | P a g e Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon (discoloration of fingers and/or toes after exposure to changes in temperature), pleural effusions, joint inflammation, and myositis. A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. Beer Apples Yogurt Baked haddock Pickled herring Roasted fresh potatoes Beer Yogurt Pickled herring Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used to treat depression. The client must follow a tyramine-restricted diet while taking the medication to help prevent hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided include meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausages (e.g., salami, pepperoni, bologna). In addition, figs, bananas, aged cheeses, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented, or smoked foods must be avoided. Many over-the-counter medications contain tyramine and must be avoided as well. The blood serum level of imipramine is determined in a client who is being treated for depression. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, what should the nurse do? Contact the primary health care provider Hold the next dose of imipramine Document the laboratory result in the client's record Have another blood sample drawn and ask the laboratory to recheck the imipramine level Document the laboratory result in the client's record Rationale: Imipramine is a tricyclic antidepressant that is often used to treat depression. The therapeutic blood serum level is between 225 and 300 ng/mL, so the nurse would simply document the laboratory result in the client's record. Asking the laboratory to recheck the level and withholding the next dose of the imipramine and contacting the primary health care provider are unnecessary. 16 | P a g e nurse provides instructions to a client who has been prescribed lithium carbonate for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "I need to come back to the clinic to have my lithium blood level checked." "I should drink 2 to 3 quarts (1.9 to 2.8 litres) of liquid every day." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." "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." Rationale: Lithium carbonate is a mood stabilizer used to treat manic-depressive illness. Equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Therefore the client should maintain a normal salt intake and drink 2 to 3 quarts (1.9 to 2.8 litres) of fluid each day. Many over-the-counter medications contain sodium and would therefore affect the lithium concentration, possibly pushing it out of the therapeutic range. For this reason, over-the-counter medications must be avoided. The blood level of lithium should be tested every 3 or 4 days during the initial phase of therapy and every 1 to 2 months during maintenance therapy. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of toxicity; if any of these problems occur, the primary health care provider must be notified. A client who is taking lithium carbonate complains of mild nausea and voiding in large volumes. On assessment, the nurse notes that the client is also complaining of mild thirst. On the basis of these findings, what would the nurse do? Contact the primary health care provider Document the findings Institute seizure precautions Have a blood specimen drawn immediately for serum lithium testing Document the findings Rationale: Lithium carbonate is a mood stabilizer that is used to treat manic-depressive illness. Side effects include polyuria, mild thirst, and mild nausea. Therefore, the nurse should simply document the findings. Because the client's complaints are side effects, not toxic effects, contacting the primary health care provider, instituting seizure precautions, and having a specimen drawn immediately for a serum lithium determination are all unnecessary. Vomiting, diarrhea, muscle weakness, tremors, drowsiness, and ataxia are signs/symptoms of toxicity and if these occur the primary health care provider needs to be notified. A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, what does the nurse tell the client this technique involves? 17 | P a g e Having the client perform a healthy coping behavior Having the client perform a ritualistic or compulsive behavior Providing a high degree of exposure of the client to the stimulus that the client finds undesirable Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Rationale: The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive- compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, it is not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding. The 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, what would the nurse do? Check the client's vital signs Check for the presence of a gag reflex Assess the client for the presence of bowel sounds Ask the client to gargle with a warm saline solution Check for the presence of a gag reflex Rationale: After an EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. In preparation for EGD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. No food or oral fluids are given to the client until the gag reflex is fully intact.Vital signs are checked frequently, but this action is not associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test. 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? Inability to cope Decreased nutrition Decreased fluid volume Inability to tolerate activity 20 | P a g e than 500 mL in a 24-hour period Urinary protein must be measured and the primary health care provider should be notified if the results indicate a trace amount of protein Urine output must be measured and the primary health care provider should be notified if output is less than 500 mL in a 24-hour period Rationale: Urine output of less than 500 mL/24 hr should prompt the client to notify the primary health care provider. Preeclampsia is considered mild when the diastolic blood pressure does not exceed 100 mm Hg, proteinuria is no more than 500 mg/day (trace to 1+), and signs/symptoms such as headache, visual disturbances, and abdominal pain are absent. The diet should provide ample protein and calories, and fluid and sodium should not be limited. The disease is considered severe when the blood pressure is higher than 160/110 mm Hg, proteinuria is greater than 5 g/24 hr (3+ or more), and oliguria is present (500 mL or less in 24 hours). A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which finding elicited during the assessment indicates that the condition has not yet resolved? Type the option number that is the correct answer. _____ Nursing Progress Notes Hyperreflexia is present. Urinary protein is not detectable. Urine output is 45 mL/hr. Blood pressure is 128/78 mm Hg. 1 Rationale: In a client with preeclampsia, deep tendon reflexes may be very brisk (hyperreflexia) and clonus (series of involuntary, rhythmic, muscular contractions and relaxations)may be present, suggesting cerebral irritability resulting from decreased brain circulation and edema. Hypertension, generalized edema, and proteinuria are the three classic signs of preeclampsia. Decreased urinary output (less than 30 mL/hr) indicates poor perfusion of the kidneys and may precede acute renal failure. Negative findings of the urinary protein assay, urine output of 45 mL/hr, and a blood pressure of 128/78 mm Hg are all signs that preeclampsia is resolving. 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? Spontaneous bruising Decrease in uterine size Urine output of 30 mL/hr Brownish vaginal discharge Spontaneous bruising Rationale: A major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and 21 | P a g e spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation. Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early signs/symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur. A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity. What does the nurse immediately do? Stop the oxytocin infusion Check the vagina for crowning Encourage the client to take short, deep breaths Increase the rate of the oxytocin infusion and call the primary health care provider Stop the oxytocin infusion Rationale: The nurse would immediately stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would also notify the primary health care provider. Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions. A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation? Reposition the mother Document the finding Notify the nurse-midwife Take the mother's vital signs Document the finding Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. Ths nurse should document the finding. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions. A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client? Nausea 22 | P a g e Bloody urine Hearing loss Electrocardiographic changes Hearing loss Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity. A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred? A discoid uterus Sudden sharp vaginal pain Shortening of the umbilical cord A sudden gush of dark blood from the introitus A sudden gush of dark blood from the introitus Rationale: Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual 25 | P a g e Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness. Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements (repetitive and rapid, jerky, involuntary movements that appear well-coordinated). Of which common side effect does the nurse warn the client? Headache Drowsiness Photophobia Urinary frequency Drowsiness Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication. A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client? Diarrhea Vomiting Epistaxis Epigastric pain Epistaxis Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hours of an AMI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea are not adverse effects of this therapy. A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? Count the number of times that the infant swallows during a feeding 26 | P a g e Weigh the infant every day and check for a daily weight gain of 2 oz (60 ml) Count wet diapers to be sure that the infant is having at least six to 10 each day Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant Count wet diapers to be sure that the infant is having at least six to 10 each day Rationale: The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle-feeding technique. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "My child will need to do exercises." "My child needs to wear the brace 18 to 23 hours per day." "Wearing the brace is really important in curing the scoliosis." "I need to check my child's skin under the brace to be sure it doesn't break down." "Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown. Ferrous sulfate is prescribed for a client. What does the nurse tell the client is best to take the medication with? Milk Water Any meal Tomato juice Tomato juice Rationale: Ferrous sulfate is an iron product. Absorption of iron is best promoted when the supplement is taken with orange juice or tomato juice another food source of vitamin C or ascorbic acid. Calcium and 27 | P a g e phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid. client diagnosed 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. What comment by the client suggests an understanding of the information?"I know I will have to increase my insulin during this time period." "My insulin needs should decrease during the first trimester." "Needs for insulin will not change during the first 3 months of pregnancy." "I will have to double up on the insulin dose during this time span." "My insulin needs should decrease during the first trimester." Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect. 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, what does the nurse conclude? No edema is present The client is dehydrated Pitting edema is present Blood is not pooling in the extremities Pitting edema is present Rationale: Edema in the lower extremities reflects pooling of blood, which results in a shift of intravascular fluid into the interstitial spaces. Dehydration is not likely to cause pitting edema. When pressure exerted with a finger or thumb leaves a persistent depression, the client is said to have "pitting edema." Therefore, the other options identify incorrect interpretations. The nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, what should the nurse do? Document the findings Contact the primary health care provider Ask the client to walk for 5 minutes, then recheck the reflexes Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes Document the findings Rationale: The scale for rating deep tendon reflexes is as follows: 0 = absent; 1+ = present, hypoactive; 2+ = normal; 3+ = hyperactive; 4+ = hyperactive with clonus. Deep tendon reflexes should be 1+ or 2+. 30 | P a g e Positive result on d-dimer study Rationale: The d-dimer study is used to confirm the presence of fibrin split products; a positive result is indicative of DIC. DIC is a life-threatening defect in coagulation. As plasma factors are consumed, the circulating blood becomes deficient in clotting factors and unable to clot. Even as anticoagulation is occurring, inappropriate coagulation is also taking place in the microcirculation, and tiny clots form in the smallest blood vessels, blocking blood flow to the organs and causing ischemia. Laboratory studies help establish a diagnosis. The fibrinogen value and platelet count are usually decreased, prothrombin and activated partial thromboplastin times may be prolonged, and levels of fibrin degradation products (the most sensitive measurement) are increased. A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs/symptoms of hypovolemic shock does the nurse closely monitor the client? Select all that apply. Tachycardia Cool, clammy skin Decreased respiratory rate Diminished peripheral pulses Urine output of less than 30 mL/hr Tachycardia Diminished peripheral pulses Rationale: When hypovolemic shock develops, the body attempts to compensate for decreased blood volume and to maintain oxygenation of essential organs by increasing the rate and effort of the heart and lungs by shunting blood from less essential organs, such as the skin and extremities, to more essential ones, such as the brain and kidneys. This compensatory mechanism results in the early signs/symptoms of hypovolemic shock, which include tachycardia, diminished peripheral pulses, normal or slightly decreased blood pressure, increased respiratory rate, and cool, pale skin and mucous membranes. The compensatory mechanism fails if hypovolemic shock progresses and there is insufficient blood to perfuse the brain, heart, and kidneys. Later signs/symptoms of hypovolemic shock include decreasing blood pressure, pallor, cold and clammy skin, and urine output of less than 30 mL/hr. 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 development of shock. After contacting the primary health care provider, which does the nurse specify as the first action in the event of shock? Checking the client's urine output Inserting an intravenous (IV) line Obtaining informed consent for a cesarean delivery Placing the client in a lateral position with the bed flat Placing the client in a lateral position with the bed flat Rationale: If the client exhibits signs/symptoms of hypovolemic shock, the client would first be placed in a lateral position, with the head of the bed flat to increase cardiac return. It is necessary for the nurse to 31 | P a g e take this initial action to minimize the effects of hypovolemic shock and promote tissue oxygenation and thus increase circulation and oxygenation of the placenta and other vital organs. The nurse would also contact the primary health care provider and monitor fetal status closely. After positioning the client, the nurse would insert IV lines in accordance with the primary health care provider's prescriptions and hospital protocols so that blood and replacement fluids may be administered. Quick preparation of the client for cesarean delivery may be necessary, but obtaining informed consent for the procedure is not the first action. Urine output is monitored to ensure an output of at least 30 mL/hr but, again, this is not the first action. A postpartum nurse provides information about normal and abnormal characteristics of lochia to a client who has delivered a healthy newborn. Which finding does the nurse tell the client to report to the primary health care provider? Pink lochia on postpartum day 4 White lochia on postpartum day 11 Bloody lochia on postpartum day 2 Reddish lochia on postpartum day 8 Reddish lochia on postpartum day 8 Rationale: Reddish lochia on postpartum day 8 is an abnormal finding and would be reported to the primary health care provider. Lochia is the postdelivery vaginal discharge from the uterus consisting of blood from the vessels of the placental site and debris from the deciduas. Rubra is the bright-red lochial discharge that appears from delivery day to day 3. Serosa is the brownish-pink lochial discharge that appears on days 4 to 10. Alba is the white lochial discharge that appears on days 10 to 14. A nurse in a primary health care provider'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 what action by the nurse? Document the findings Ask the primary health care provider to see the client immediately Ask another nurse to check for the uterine fundus Place the client in the supine position for 5 minutes, then recheck the abdomen Document the findings Rationale: By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally. Involution is the progressive descent of the uterus into the pelvic cavity after delivery. Twenty-four hours after birth, descent of the fundus begins at a rate of approximately 1 fingerbreadth, or approximately 1 cm, per day. Asking the primary health care provider to see the client immediately, having another nurse check for the uterine fundus, and placing the client in the supine position for 5 minutes and rechecking the abdomen are all incorrect and unnecessary actions in light of the assessment finding. 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 32 | P a g e for further discussion of the purpose of the placenta? "Many of my antibodies are passed through the placenta." "The placenta maintains the body temperature of my baby." "Glucose, vitamins, and electrolytes pass through the placenta." "It provides an exchange of oxygen and carbon dioxide between me and my baby." "The placenta maintains the body temperature of my baby." Rationale: There is a need for further discussion if the woman states that the placenta maintains the body temperature of the baby. Many of the immunoglobulin G (IgG) class of antibodies are passed from mother to fetus through the placenta. Glucose, fatty acids, vitamins, and electrolytes pass readily across the placenta; glucose is the major source of energy for fetal growth and metabolic activities. The placenta provides an exchange of nutrients and waste products between the mother and fetus. Oxygen and carbon dioxide pass through the placental membrane by way of simple diffusion. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. 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, 2017. Using Nagele's rule, what item of client information is needed for the nurse to accurately determine estimated date of delivery (EDD)? Client has never had an abortion Client has regular 28-day menstrual cycle Client was 14 years old when menses first started Client's menstrual periods never last longer than 3 days Client has regular 28-day menstrual cycle Rationale: Accurate use of Nagele's rule is used to calculate the EDD. It requires that the woman have a regular 28-day menstrual cycle. A client has been given a prescription for lovastatin. Which food does the nurse instruct the client to limit consumption of while taking this medication? Steak Spinach Chicken Oranges Steak Rationale: Lovastatin is a lipid-lowering agent. The client is instructed to consume foods that are low in fat, cholesterol, and complex sugars. The item highest in fat here is steak; therefore the client should limit the intake of steak. Fruits, vegetables, and chicken are low in fat.Test-Taking Strategy: Focus on the subject 35 | P a g e Fever Rationale: Levofloxacin is an antibiotic of the fluoroquinolone class. Pseudomembranous colitis is an adverse reaction associated with the use of this medication. It is characterized by severe abdominal pain or cramps, severe watery diarrhea, and fever. Dizziness, flatulence, and drowsiness are side effects of the medication. A nurse is providing instructions to a client with glaucoma who will be using acetazolamide daily. Which finding, an adverse effect, does the nurse instruct the client to report to the primary health care provider? Nausea Dark urine Urinary frequency Decreased appetite Dark urine Rationale: Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity may occur, manifesting as dark urine and stools, lower back pain, jaundice, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression may also occur as an adverse effect. Nausea, urinary frequency, and decreased appetite are side effects of the medication. 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? Frequent suctioning Maintaining cuff pressure Maintaining mechanical ventilation settings Alternating the use of a cuffed tube with a cuffless tube on a daily basis Maintaining cuff pressure Rationale: Necrosis of the tracheal wall caused by pressure of the cuff of an endotracheal tube can lead to the development of an opening between the posterior trachea and esophagus, a complication known as tracheoesophageal fistula. The fistula allows air to escape into the stomach, resulting in abdominal distention. It also leads to the aspiration of gastric contents. To prevent this complication, the nurse must maintain cuff pressure, monitor the amount of air needed for cuff inflation, and help the client progress to a deflated cuff or cuffless tube as soon as possible as prescribed by the primary health care provider. Suctioning should be performed only as needed; frequent suctioning can cause mucosal damage. Maintenance of mechanical ventilation settings ensures that the client is adequately oxygenated, but this intervention is not a measure for the prevention of tracheoesophageal fistula. Alternating the use of a cuffed tube and a cuffless tube on a daily basis is incorrect, because the endotracheal tube would not be removed and replaced on a daily basis. 36 | P a g e 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? Rationale: A nasogastric tube is inserted through the nose and into the stomach for the purpose of gastric decompression or feeding the client. The client is placed in the Fowler position before insertion of the tube to promote comfort and easy insertion. A flat position may be used for clients who are hypotensive. In the reverse Trendelenburg position, the entire bed frame is tilted with the foot of the bed down and may be used to promote gastric emptying or prevent esophageal reflux. A trendelenburg position is one in which the entire bed frame is tilted with the head of the bed down and may be used for postural drainage or to facilitate venous return in clients with poor peripheral perfusion. Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. Keeping the room slightly darkened Placing the client in a room with a quiet roommate Encouraging isometric exercises if bed rest is prescribed Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short Rationale: The room is kept slightly darkened, and bright lighting is avoided. The client is placed in a quiet private room without a telephone. The client is monitored for changes in alertness or mental status. Visitors are restricted to close family members and significant others, and visits are kept short. Any contact with visitors who upset or excite the client is avoided. A cerebral aneurysm is a thin-walled outpouching or dilation of an artery of the brain. When an aneurysm ruptures, bleeding into the subarachnoid space usually ensues. Aneurysm precautions are implemented to maintain a stable perfusion pressure and help prevent rupture. Stool softeners are administered to help keep the client from straining during defecation. Isometric exercises and use of the Valsalva maneuver are avoided because both increase intrathoracic and intraabdominal pressure. Bed rest with the head of the bed elevated 30 degrees may be prescribed. Some primary health care providers permit bathroom privileges for selected clients. If the client is allowed out of bed, the nurse stresses the importance of not bending over. A nurse, providing information to a client who has just been diagnosed with diabetes mellitus, gives the client a list of signs/symptoms of hypoglycemia. Which answers by the client, on being asked to list the signs/symptoms, tells the nurse that the client understands the information? Select all that apply. Hunger Weakness Blurred vision Increased thirst Increased urine output 37 | P a g e Hunger Weakness Blurred vision Rationale: Signs/symptoms of hypoglycemia include weakness, double vision, blurred vision, hunger, tachycardia, and palpitations. The manifestations of diabetes mellitus (hyperglycemia) include polydipsia, polyuria, and polyphagia. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse knows that what elements are related to the basic crutch stance? Select all that apply. Improves client's balance Hips and knees are extended Provides narrow base of support Axillae bear half of client's weight Incorrect Tripod position assumed before crutch walking Body alignment includes erect head and neck and straight vertebrae Improves client's balance Hips and knees are extended Tripod position assumed before crutch walking Body alignment includes erect head and neck and straight vertebrae Rationale: The basic crutch stance is the tripod position, which the client assumes before crutch walking. It is formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot. This position improves the client's balance by providing a wider, not narrower, base of support. The body alignment of the client in the tripod position includes an erect head and neck, straight vertebrae, and extended hips and knees. The axillae should not bear any weight. A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he/she is discharged home. When the nurse tells the client that he/she will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate? "Have you told your doctor how you feel?" "Tell me more about your concerns regarding the tube feedings." "Don't worry. We'll keep you in the hospital until you're ready to do them by yourself." "We'll ask the doctor about having a visiting nurse come to your home to give you your feedings." "Tell me more about your concerns regarding the tube feedings." Rationale: An open statement such as "Tell me more about..." often elicits valuable information about the client and the client's concerns. Clients often have fears about leaving the secure environment of the healthcare facility, where he/she is cared for. This client fears that he/she will not be able to care for self at home by administering the tube feedings. The remaining nursing responses are incorrect because they are nontherapeutic statements that do not address the client's expressed concern. 40 | P a g e is also instructed to do this exercise 15 times while lying down, sitting up, and standing (a total of 45 repetitions). The client is told that an improvement in the control of urine will be noticed after several weeks of the exercises; some individuals report that improvement takes as long as 3 months. Ergotamine is prescribed to a client with cluster headaches. Which occurrence does the nurse tell the client to report to the primary health care provider if she experiences them while taking the medication? Cough Fatigue and lethargy Dizziness and fatigue Numbness and tingling of the fingers or toes Numbness and tingling of the fingers or toes Rationale: Ergotamine is an antimigraine medication. Prolonged administration or an excessive dosage may produce ergotamine poisoning (ergotism). Signs/symptoms include nausea, vomiting, weakness in the legs, pain in the limb muscles, and numbness and tingling of the fingers and toes. The client is instructed to report these signs/symptoms to the primary health care provider if they occur. Cough, fatigue, lethargy, and dizziness are side effects and not adverse effects of the medication. A client diagnosed with post-traumatic stress disorder tells the nurse that he/she has stopped taking his/her prescribed medication because he/she didn't like how the medication was making him/her feel. Which initial response by the nurse is appropriate? "That's all right. I'd stop, too, if it made me feel funny." "Tell me more about how the medication was making you feel." "Did you let your doctor know that you stopped taking the medication?" "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that." "Tell me more about how the medication was making you feel." Rationale: The appropriate response by the nurse acknowledges the client's feelings and opens the channel of communication between the nurse and client. "That's all right. I'd stop, too, if it made me feel funny," indicating approval, is a nontherapeutic response and is therefore inappropriate. "Did you let your doctor know that you stopped taking the medication?" may be an appropriate question at some point during the conversation, but it is not the most appropriate initial question. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that" demeans the client. A nurse provides information to a client diagnosed with peripheral vascular disease about ways to limit the disease's progression. Which measures does the nurse tell the client to take? Select all that apply. Crossing the legs at the ankles only Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Inspecting the feet at least once a week for injuries, especially abrasions Using a heating pad on the legs to help keep the blood vessels dilated 41 | P a g e Engaging in exercise such as walking on a daily basis Washing the feet daily with a mild soap and drying them well Rationale: Long-term management of peripheral vascular disease consists of measures that increase peripheral circulation. The client is instructed to exercise regularly and is encouraged to walk for 20 minutes each day. The client also needs to wash the feet daily with a mild soap, to dry the feet well, and to inspect the feet daily for injuries or abrasions. Crossing the legs at any level should be avoided because it promotes vasoconstriction. Keeping the extremities warm is important; however, heating pads and hot water bottles should not be placed on the extremity. Sensitivity may be diminished in the affected extremity, increasing the risk for burns. Also, direct application of heat increases the oxygen and nutritional requirements of the tissue even further. A client diagnosed with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? Providing food and fluid as the client requests Offering high-calorie and high-protein foods and fluids frequently throughout the day Completing the dietary menu for the client to ensure that adequate nutrition is provided Weighing the client daily so that the client may determine whether the nutritional plan is working Offering high-calorie and high-protein foods and fluids frequently throughout the day Rationale: The client should be offered high-calorie and high-protein foods and fluids frequently throughout the day. Small, frequent snacks are more easily tolerated than large plates of food when the client is anorexic. The client should be offered choices of foods and fluids he/she likes, because the client is more likely to consume foods he/she has selected. The client should be weighed weekly, not daily. Weight gain may not be noted daily, which may cause the client to view the interventions to improve nutritional status as useless. Disulfiram is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication. What does the nurse tell the client? That driving is prohibited while the client is taking the medication To take the medication immediately if the desire to drink alcohol occurs That the effect of the medication ends as soon as the client stops taking the medication That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol Rationale: Disulfiram is an alcohol abuse deterrent prescribed to motivated clients who have shown the ability to stay sober. Driving is not prohibited; however, the client is instructed to use caution when driving and performing other tasks that require alertness. The medication is taken daily (not just when the client has a desire to drink alcohol), and the effects of the medication last 5 days to 2 weeks after the last dose is taken. The medication cannot be started until at least 12 hours has elapsed since the 42 | P a g e client's last ingestion of alcohol. Otherwise, an alcohol-disulfiram reaction will occur, with effects consisting of facial flushing, sweating, a throbbing headache, neck pain, tachycardia, respiratory distress, a potentially serious decrease in blood pressure, and nausea and vomiting. This reaction may last 30 to 120 minutes. A client diagnosed with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which response by the nurse is therapeutic? "Why don't you really want to attend?" "This is what your primary health care provider has prescribed for you as part of the treatment plan." "OK, let's have you attend music therapy. You can sing there. How does that sound?" "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." Rationale: The correct response encourages the client to socialize and deflects the client's attention from the issue of drawing and painting. "Why don't you really want to attend?" challenges the client. "This is what your primary health care provider has prescribed for you as part of the treatment plan" ignores the client's rights. "OK, let's have you attend music therapy. You can sing there. How does that sound?" does not address the client's concern. A hospitalized female client demonstrating 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? "Why are you saying that?" "Stop saying that. It's not true!" "You wouldn't like someone saying that to you. Would you?" "Don't say that. If you can't control yourself, we'll help you." "Don't say that. If you can't control yourself, we'll help you." Rationale: The nurse should respond using a firm, calm approach, providing the client with clear expectations. The appropriate response is the only one that involves a firm, calm approach and offers the client help if she needs it. The other three statements challenge the client. A nurse working the evening shift is helping clients get ready for sleep. A female client diagnosed with mania is hyperactive and pacing the hallway. What is the most appropriate action the nurse can take? Stay with the client and observe her behavior Take the client to the bathroom and provide her with a warm bath Tell the client that it is time for sleep and that she needs to go to her room Tell the client that other clients are trying to sleep and that she is being disruptive Take the client to the bathroom and provide her with a warm bath Rationale: At bedtime, the nurse should take the client to the bathroom and provide warm baths, 45 | P a g e Is a response by the client to voices saying that everything is contaminated and that he/she must engage in this behavior Temporarily eases anxiety in the client Rationale: Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. The other options identify interpretations of the client's obsessive behavior. 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? Assessing the client for organic causes of loss of arm movement Calling the crisis intervention team and asking them to assess the client Performing active and passive range-of-motion (ROM) exercises of the client's arms Asking the client to move his arms and documenting the loss of movement he has experienced Assessing the client for organic causes of loss of arm movement Rationale: The priority is assessing the client for organic causes of loss of arm movement and ruling out any neurological disorders. After it has been determined that there is no physiological basis for the problem, further psychiatric evaluation can be done. Encouraging the client to move his arms and performing active and passive ROM exercises have no beneficial effect in this situation. In fact, either option could be harmful if there is a physiological basis for the client's problem. 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? Perform the physical assessment Tell the client about the nursing unit rules Establish a trusting nurse-client relationship Tell the client that he/she will have to participate in self-care Establish a trusting nurse-client relationship Rationale: Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. The nurse should first develop a trusting relationship with the client. It is most important to establish a trusting relationship, which will indicate to the client that the client is important. After a therapeutic relationship has been established, other interventions may be carried out. The nurse would perform a physical assessment, but this would not be the first intervention. The client should be informed of the nursing unit's rules, but, again, this is not the first intervention. Telling the client that he/she will have to participate in self-care is inappropriate. The client with bipolar disorder requiring hospitalization is likely to need assistance with care. 46 | P a g e A client arrives in the emergency department and tells the nurse that he/she is experiencing tingling in both hands and is unable to move his/her fingers. The client states that he/she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier his/her partner said he/she wanted a separation and that he/she would have to support self financially. What problem does the nurse conclude that this client is exhibiting signs/symptoms compatible with? Severe anxiety Conversion disorder Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder Conversion disorder Rationale: Conversion disorder is characterized by the presence of one or more signs/symptoms suggesting a neurological problem that cannot be attributed to a medical disorder. Psychological factors such as stress and conflict are associated with the onset or exacerbation of the sign/symptom. A person with severe anxiety may focus on a particular detail or many scattered details. The person may have difficulty noticing what is going on in the environment, even when it is pointed out by another. Learning and problem-solving are not possible at this level of anxiety, and the client may be dazed and confused. PTSD is characterized by repeated re-experiencing of a highly traumatic event that involved actual or threatened death or serious injury to self or others to which the individual responded with intense fear, helplessness, or horror. Obsessions are thoughts, impulses, or images that persist and recur so that they cannot be dismissed from the mind. Compulsions are ritualistic behaviors that an individual feels driven to perform in an attempt to reduce anxiety. A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? "Tell me your plan for saving the world." "Why do you think that you can accomplish this by yourself?" "I don't think anyone can save the world from the terrorists by himself/herself." "You must be powerful. Do you really believe that you can do this by yourself?" "I don't think anyone can save the world from the terrorists by himself/herself." Rationale: The appropriate response by the nurse is "I don't think anyone can save the world from the terrorists by himself/herself." The nurse should not go along with or reinforce the client's delusion. The nurse should respond to the client by presenting reality. "Tell me your plan for saving the world," "Why do you think that you can accomplish this by yourself?" and "You must be powerful. Do you really believe you can do this by yourself?" all reinforce the delusion and encourage further conversation about it. A client diagnosed 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. 47 | P a g e Eat foods that are low in fat and protein Obtain pneumococcal and influenza vaccines Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Avoid contact with all individuals other than immediate family members Drink copious amounts of fluid and void frequently Avoid contact with any individual who has signs/symptoms of a cold Rationale: Hemorrhagic cystitis is an adverse effect of this medication. The client is encouraged to drink copious amounts of fluid at least 24 hours before, during, and after chemotherapy, and avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. The client is also encouraged to void frequently to prevent cystitis. The client is not to receive immunizations without the primary health care provider's approval, because they could diminish the body's resistance, putting the client at increased risk for infection. It is not necessary for the client to avoid contact with all individuals other than immediate family members. The client should, however, avoid contact with individuals who are ill, have a cold, or have recently received a live-virus vaccine. Encouraging adequate dietary intake is appropriate, but a low-protein or low-fat diet is not necessary. The client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" What does the nurse tell the client? Her hair will definitely fall out She should not be worrying about her hair at this point Her hair may fall out but will regrow after the chemotherapy is discontinued Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss Her hair may fall out but will regrow after the chemotherapy is discontinued Rationale: Some chemotherapeutic agents cause hair loss, and the client should be informed of this possibility. The client should also be reassured that chemotherapy-related hair loss is temporary and that the hair will regrow after the chemotherapy is discontinued, perhaps in a different shade, color, or texture. Telling the client that her hair will definitely fall out is incorrect and telling her that she should not be worrying about her hair at this point ignores the client's concern. Hair dyes, permanents, and vigorous hair-brushing are avoided to minimize thinning. A nurse has given a client with viral hepatitis instructions about home care. Which statement by the client indicates to the nurse that the client needs further teaching? "I can't drink alcohol." "I have to avoid having sex until the test for antibodies comes back negative." "I need to rest a lot during the day and get enough sleep at night." "I need to eat three meals a day with foods high in protein, fat, and carbs." "I need to eat three meals a day with foods high in protein, fat, and carbs." Rationale: The client needs further teaching if the client states, "I need to eat three meals a day with 50 | P a g e not yet able to count to 100 or to understand the value of numbers in relation to other numbers. A child of preschool age is too young to control a PCA pump. A school nurse observing a child diagnosed 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? Contacting the child's primary health care provider to report the findings Administering acetaminophen to the child to relieve the pain Asking that the child not attend the physical education class until the neck pain has subsided Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control Contacting the child's primary health care provider to report the findings Rationale: Children with Down syndrome who participate in sports that may involve stress on the neck should be evaluated radiologically for atlantoaxial instability. Signs/symptoms of the disorder include neck pain, weakness, and torticollis. Affected children are at risk for spinal cord compression. Signs/symptoms of spinal cord compression include persistent neck pain, loss of established motor skills and bladder or bowel control, and changes in sensation. If any of these signs/symptoms are noted, it must be reported immediately to the primary health care provider. Administering acetaminophen to relieve the pain and not allowing the child to attend physical education class until the pain has subsided are inappropriate actions that will delay necessary interventions. Teaching the child to use peripads to prevent embarrassment resulting from loss of bladder control may be appropriate in certain scenarios, but in this situation the child is exhibiting signs/symptoms of spinal cord compression, requiring immediate intervention. A client is taking gentamicin sulfate for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? "When was your last bowel movement?" "When was your last menstrual period?" "Are you having any difficulty hearing?" "Are you having any difficulty breathing?" "Are you having any difficulty hearing?" Rationale: Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity. Gentamicin sulfate is an aminoglycoside. It inhibits bacterial protein synthesis and has a bactericidal effect. The nurse must assess the client for changes in hearing, balance, and urine output. The remaining assessment questions are not associated with the adverse effects of this medication. 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? "It's important to rotate injection sites." 51 | P a g e "I need to store the insulin in a cool, dry place." "I need to keep any unopened bottles of insulin in the freezer." "I need to check the expiration date on the insulin before I use it." "I need to keep any unopened bottles of insulin in the freezer." Rationale: There is a need for further instruction if the client states, "I need to keep any unopened bottles of insulin in the freezer." Insulin is stored in a cool, dry place. It should not be placed in the freezer or exposed to excess heat or agitation. Injection sites should be rotated to ensure adequate insulin absorption and to prevent complications of insulin administration. Once a bottle of insulin has been opened, it is dated and discarded as recommended. The client should check the expiration date on the insulin vial before using it. A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. What does the nurse tell the client about this blood test? Is a measure of the client's hematocrit level Is a measure of the client's hemoglobin level Helps predict the risk for the development of chronic complications of diabetes mellitus Provides a determination of short-term glycemic control in the client with diabetes mellitus Helps predict the risk for the development of chronic complications of diabetes mellitus Rationale: The nurse tells the client that the blood test is used to assess long-term glycemic control, as well as to predict the risk for the development of chronic complications. Glycosylated hemoglobin is the best indicator of the average blood glucose level. Because glucose attaches itself to the hemoglobin molecule, measurement of glycosylated hemoglobin indicates the average blood glucose level during the previous 120 days, the lifespan of the red blood cell. A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the most appropriate way for the nurse to document this occurrence in the client's record? Writing that the client is very agitated Writing that the client yelled at the nurse Writing that the client is able to perform his/her own care Writing down the client's words and placing them in quotation marks Writing down the client's words and placing them in quotation marks Rationale: Documenting the client's words verbatim and placing them in quotations ensures accurate data. An objective description is the result of direct observation and measurement. Documenting inferences without supporting factual data is not acceptable, because a client's statements may be misunderstood. The remaining options do not provide objective descriptions. A nurse in the cardiac care unit (CCU) is told that a client with a diagnosis of myocardial infarction (MI) will be admitted from the emergency department (ED). Which item does the nurse give priority to 52 | P a g e placing at the client's bedside? Bedside commode Suctioning equipment Electrocardiography machine Oxygen cannula and flowmeter Oxygen cannula and flowmeter Rationale: The oxygen cannula and flowmeter are the priority. The client will require oxygen therapy after myocardial infarction to improve oxygen supply to the myocardium and ease the pain resulting from ischemia. Suctioning equipment is not the priority item but may be needed if a complication occurs. An electrocardiogram machine and bedside commode may be necessary but are not the priority items. A laxative 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. What does the nurse tell the client to do? Increase fluid intake Consume low-fiber foods Consume foods that are low in potassium Contact the primary health care provider if the urine turns yellow-brown Increase fluid intake Rationale: The nurse encourages the client to increase fluid intake, to consume a high-fiber diet, and to exercise. Hypokalemia may result from use of a laxative, so the nurse encourages the client to consume foods high in potassium. The client's urine may turn pink-red, red-violet, red-brown, or yellow-brown, but the client is told that this is a temporary, harmless effect. Cyclobenzaprine is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client? Diarrhea Drowsiness Abdominal pain Increased salivation Drowsiness Rationale: Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. Cyclobenzaprine is a centrally acting skeletal muscle relaxant used in the management of muscle spasm accompanying a variety of conditions. Rare side effects include fatigue, tiredness, blurred vision, headache, nervousness, confusion, nausea, constipation, dyspepsia, and an unpleasant taste in the mouth. 55 | P a g e Blood-pressure cuff Suction catheter and suction machine Cardiac monitor Rationale: Obtaining a cardiac monitor is the priority. Wolff-Parkinson-White syndrome is an abnormality of cardiac rhythm that is manifested as supraventricular tachycardia. Adenosine is an antidysrhythmic medication used to treat this dysrhythmia. It is administered intravenously. A pulse oximeter and blood pressure cuff will each provide information about the client's cardiovascular status, but neither is the priority. There is no information in the question to indicate that a suction catheter and suction machine are necessary. A nurse provides information about smoking-cessation measures to a client diagnosed with coronary artery disease (CAD). Which statement by the client indicates a need for further information? "A community support group will help me quit." "I should drink a cup (235 ml) of coffee if I feel the urge to smoke." "Relaxation exercises will help control my urge to smoke." "I can try chewing gum or sucking on hard candy if I feel the urge to smoke." "I should drink a cup (235 ml) of coffee if I feel the urge to smoke." Rationale: The nurse should reinforce education about the hazards of smoking and provide encouragement to clients who are interested in or willing to try smoking cessation. The client should avoid using coffee and other caffeine-containing products, which can cause restlessness and anxiety, increasing the urge to smoke. There are appropriate strategies to assist in smoking cessation. Among these are community support groups, relaxation exercises, and strategies such as chewing gum or sucking on hard candy if the urge to smoke arises. Captopril is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? Checking the client's apical heart rate Maintaining the client on bed rest for 3 hours Monitoring the client for increased urine output Checking the client's breath sounds for decreased wheezing Maintaining the client on bed rest for 3 hours Rationale: The client is closely monitored for hypotension at the start of therapy and is maintained on bed rest for 3 hours after the initial dose. Captopril is an angiotensin-converting enzyme (ACE) inhibitor. Excessive hypotension (first-dose syncope) may occur in the client with heart failure or in the client who is severely salt or volume depleted. Checking the apical heart rate will provide information about the client's cardiac status but is not an intervention specifically related to this medication. Increased urine output and decreased wheezing are expected if the client has received a diuretic. 56 | P a g e A client diagnosed with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. What should the nurse do first? Obtain a pulse oximetry reading Raise the head of the client's bed Administer a dose of morphine sulfate Obtain a specimen for an arterial blood gas determination Raise the head of the client's bed Rationale: The nurse would first raise the head of the client's bed and position the client to maximize chest expansion to ease the air hunger that the client is experiencing. Acute pulmonary edema is characterized by profound dyspnea, pallor, audible wheezing, and cyanosis. An arterial blood gas or pulse oximetry reading will reveal the need for supplemental oxygen. Morphine sulfate may be administered because it blunts the sympathetic response and promotes peripheral vasodilation. However, the nurse also needs to contact the primary health case provider to prescribe that medication. On the basis of the options provided, however, the initial action is placing the client in a head-elevated position. 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? Relief of pain Relief of anxiety Decreased urine output Increased blood pressure Relief of anxiety Rationale: Morphine sulfate reduces anxiety in the client in pulmonary edema. It blunts the sympathetic response and increases venous capacitance, thereby decreasing left atrial pressure. It also promotes peripheral vasodilation and causes blood to pool in the periphery. The client receiving morphine sulfate is monitored for signs/symptoms of respiratory depression and extreme decreases in blood pressure, especially when the medication is administered intravenously. Although morphine sulfate is an opioid analgesic and relieves pain, it is not administered to the client with pulmonary edema for its analgesic effect. Furosemide is administered to the client with pulmonary edema to increase urine output. A nurse is providing home care instructions to a client diagnosed with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. What does the nurse tell the client? To stop the aspirin if nausea occurs To take the aspirin on an empty stomach That ringing in the ears is a sign of toxicity That the aspirin is a short-term treatment and will probably be discontinued in 2 weeks That ringing in the ears is a sign of toxicity 57 | P a g e Rationale: Ringing in the ears (tinnitus) is a sign of toxicity; if it occurs, the client should contact the primary health care provider. Aspirin, an antiplatelet agent, helps prevent blood clotting. A single low daily dose of aspirin may be a long-term component of the standard treatment regimen for the client with CAD. Gastric irritation may occur with the use of aspirin, and the client is advised to take the daily dose with food to prevent this. The client would not stop the medication if nausea occurs but would instead take the medication with food to relieve this discomfort. 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? Auscultating heart sounds Clamping the intravenous catheter Checking the client's blood pressure Obtaining an arterial blood gas specimen Clamping the intravenous catheter Rationale: The nurse next clamps the intravenous catheter and notifies the primary health care provider. The signs/symptoms of air embolism include chest pain, dyspnea, and hypoxia. Tachycardia and hypotension will also be present, and the client will experience anxiety. The nurse will also hear a loud churning sound on auscultation over the pericardium. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. This position prevents air from flowing into the pulmonary veins. Although auscultating heart sounds, checking the client's blood pressure, and obtaining an arterial blood gas specimen may be appropriate interventions, none is the next action to take after positioning the client. A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. What does the nurse ensure? The client places the cane on the left side The top of the cane is level with the client's waist 30-degree flexion of the client's elbow is maintained when the client is holding the cane The client leans on the cane and places as much weight as possible on the cane when moving it forward 30-degree flexion of the client's elbow is maintained when the client is holding the cane Rationale: The cane, which is placed on the unaffected side, should produce no more than 30 degrees of flexion of the elbow. A cane may be used if a client needs minimal support for an affected leg. A straight cane offers the least support. A hemi-cane or quad-cane provides a broader base for the cane and therefore more support. The top of the cane should be level with the greater trochanter of the femur 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 most important? Telephone Television 60 | P a g e Carbohydrates Concentrated sugar Vitamin C Rationale: If a fracture has occurred, the nurse encourages the client to eat foods high in vitamin C, protein, and iron, because these nutrients will promote healing. Dietary therapy for the client with osteoporosis includes foods high in calcium. Although fats and carbohydrates should be included in the daily diet, they are not specifically related to the healing process. Foods containing concentrated sugar do not promote healing. A nurse in a primary health care provider's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem? Inability to cope Distorted body image Inability to care for self Inability to maintain health Distorted body image Rationale: Distorted body image is characterized by negative verbalizations or feelings about a body part. This is a common response after mastectomy. The nurse supports the client and helps her work through these feelings. There is no information in the question to indicate that inability to care for self, inability to cope, or inability to maintain health is a problem. The nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred? Enoxaparin Phytonadione Protamine sulfate Aminocaproic acid Protamine sulfate Rationale: The nurse checks for protamine sulfate in the medication room in case a heparin overdose occurs. If the IV tubing is removed from an infusion pump and the tubing is not clamped, the client will receive a bolus of the solution of the medication contained in the solution. Heparin is an anticoagulant, and the client who receives a bolus dose of heparin is at risk for bleeding. The nurse would notify the primary health care provider. A blood sample for partial thromboplastin time (PTT) would be drawn and the results of testing evaluated. If the PTT is too high, the infusion may be stopped for a time, or a dose of protamine sulfate, the antidote for heparin, may be prescribed. Enoxaparin is an anticoagulant. 61 | P a g e Phytonadione is the antidote for warfarin sodium.Aminocaproic acid is an antifibrinolytic, inhibiting clot breakdown. The nurse is explaining the diagnosis of congenital diaphragmatic hernia (CDH) related to a left posterolateral defect (also called Bochdalek hernia) to a postpartum client. What body system does the nurse emphasize is the system most at risk for problems? Respiratory system Genitourinary system Musculoskeletal system Gastrointestinal system Respiratory system Rationale: With a congenital diaphragmatic hernia, abdominal contents herniate through an opening in the diaphragm. If caused by a left posterolateral defect, the respiratory system is most at risk for problems. This serious defect requires prompt recognition (usually in utero) and aggressive treatment to reduce its high mortality. Intestines and other abdominal structures, such as the liver, can enter the thoracic cavity, compressing the lung. Lung hypoplasia may occur on the affected side and to a lesser degree on the contralateral side. Ventilation is further compromised by hypoplasia and compression of the lung, including the airways and blood vessels. In addition to the anatomic defect, pulmonary hypoplasia and pulmonary hypertension have also been recently recognized as components in the pathology of CDH. A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. Drooling Wheezing Hiccuping Short periods of apnea Excessive oral secretions Bowel sounds over the chest Drooling Excessive oral secretions Rationale: EA with or without TEF results in excessive oral secretions, drooling, and feeding intolerance. EA and TEF, the most life-threatening anomalies of the esophagus, often occur together, although they may occur singly. EA is a congenital anomaly in which the esophagus ends in a blind pouch or narrows into a thin cord, thereby failing to form a continuous passageway to the stomach. TEF is an abnormal connection between the esophagus and trachea. When fed, the infant may swallow but will then cough and gag and return the fluid through the nose and mouth. Bowel sounds over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccuping and spitting up after a meal 62 | P a g e are clinical manifestations of gastroesophageal reflux. Coughing, wheezing, and short periods of apnea are clinical manifestations of hiatal hernia. A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expect to see documented in the infant's medical record? Select all that apply. Weight loss Facial edema Metabolic acidosis Projectile vomiting Distended upper abdomen Weight loss Projectile vomiting Distended upper abdomen Rationale: HPS occurs when the circular muscle of the pylorus becomes thickened, causing constriction of the pylorus and obstruction of the gastric outlet. Clinical manifestations include projectile vomiting, a hungry infant who eagerly accepts a second feeding after the vomiting episode, weight loss, signs/symptoms of dehydration, and a distended upper abdomen. A readily palpable olive-shaped mass in the epigastrium just to the right of the umbilicus is noted, and gastric peristaltic waves, moving from left to right across the epigastrium, are visible. Laboratory findings include metabolic alkalosis, a result of the vomiting that occurs in this disorder. Facial edema and metabolic acidosis do not occur in this disorder. The nurse is assessing a client who has a history of Prinzmetal's angina. The nurse knows that what type of medication is given to treat this condition? Inotropes Beta blockers ACE inhibitors Calcium channel blockers Calcium channel blockers Rationale: Prinzmetal's, or variant, angina is prolonged and severe and occurs at the same time each day, most often at rest. The treatment of choice is usually a calcium channel blocker. Calcium channel blockers relax and dilate the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Inotropes, beta blockers, and angiotensin-converting enzyme (ACE) inhibitors are not given to treat this disorder. Methylergonovine is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? Checking the episiotomy site Palpating the client's bladder 65 | P a g e Singing games Watching videos Simple board games Large building blocks Large building blocks Rationale: The toddler is developing the use of motor skills and enjoys manipulating small objects such as blocks, push-pull toys, and toy people, cars, and animals. Therefore large building blocks are appropriate for a client of this age. Singing games, simple board games, and videos are appropriate for the preschooler. A nurse in a primary health care provider's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to see documented in the child's record? Fatty stools Episodes of foul-smelling ribbon-like stools Episodes of profuse watery diarrhea and vomiting Episodes of cramping abdominal pain and excessive flatus Episodes of cramping abdominal pain and excessive flatus Rationale: Manifestations of lactose intolerance include diarrhea that is frothy (but not fatty), abdominal distention, cramping abdominal pain, and excessive flatus. The presence of fatty stools may indicate a problem with bile flow. Foul-smelling ribbon-like stool is a clinical manifestation of Hirschsprung disease. Profuse watery diarrhea and vomiting is one clinical manifestation of celiac disease. A nurse is providing dietary instructions to the mother of a child with celiac disease. What does the nurse tell the mother is acceptable to give the child? Boiled rice Cooked pasta Warm oatmeal Baked macaroni and cheese Boiled rice Rationale: The nurse tells the mother that corn, rice, and millet may be substituted as grains. Celiac disease is a disorder in which the affected person has an intolerance to wheat, rye, barley, and oats. Dietary management is the mainstay of treatment for the child with celiac disease. Products containing gluten (e.g., wheat, rye, barley, oats, hydrolyzed vegetable protein) should be eliminated from the child's diet. This includes most pasta and baked products, as well as many breakfast cereals. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies. 66 | P a g e The nurse is caring for a newborn recently diagnosed with gastroschisis. What does the nurse know about this condition? Select all that apply. Care similar to that for omphalocele Viscera are inside the abdominal cavity Surgery performed within several hours after birth Exposed bowel directly wrapped in saline-soaked pads Postoperatively most infants develop prolonged ileus Results from a defect in the abdominal wall Care similar to that for omphalocele Surgery performed within several hours after birth Postoperatively most infants develop prolonged ileus Results from a defect in the abdominal wall Rationale: The nurse knows that gastroschisis results from a defect in the abdominal wall in which the viscera is outside, not inside, the abdominal cavity and are also not covered by a sac. Care of the newborn is similar to that for newborns with omphalocele. The exposed bowel is covered loosely in saline-soaked pads, not directly wrapped around the bowel. Surgery needs to be performed within several hours after birth, and postoperatively most newborns develop prolonged ileus. A nurse is monitoring a child with intussusception for signs/symptoms of peritonitis. For which finding, indicative of this complication, does the nurse notify the primary health care provider? Increased alertness Increased heart rate A sausage-shaped abdominal mass Diarrhea and the passage of bloody mucous stool Increased heart rate Rationale: The nurse monitors the child closely for signs/symptoms of sepsis, peritonitis, and shock. Possible indicators of peritonitis include fever, increased heart rate, changes in the level of consciousness or in blood pressure, and respiratory distress. Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children ages 3 months to 6 years. The classic signs of intussusception are a sausage-shaped abdominal mass and the passage of bloody ("currant jelly") stool and diarrhea. The nurse, auscultating the breath sounds of a client, hears these sounds. What are they? Rhonchi Crackles Wheezes Vesicular Wheezes 67 | P a g e Rationale: Wheezes are continuous squeaky, musical sounds, the result of air rushing through narrowed airways. They are associated with inflammation, bronchospasm, edema, secretions, or pulmonary vessel engorgement. Rhonchi are continuous low-pitched, coarse snoring sounds associated with thick, tenacious secretions; sputum production; or obstruction by a foreign body. Crackles are discontinuous popping sounds caused by air moving into previously deflated airways (they sound like air is being rolled between the fingers near the ear). Vesicular sounds are rustling sounds heard over the peripheral lung fields. They are a normal finding. A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and an assistive personnel (AP) on the team. Which client is the most appropriate choice for the AP? A client with hemophilia who needs assistance with shaving A client with pneumonia who requires frequent oropharyngeal suctioning A client with rheumatoid arthritis who needs assistance with feeding and ambulation A client with heart failure who needs daily weights and monitoring of intake and output A client with rheumatoid arthritis who needs assistance with feeding and ambulation Rationale: The most appropriate client for the AP is the client with rheumatoid arthritis who needs assistance with feeding and ambulation. When a nurse delegates aspects of a client's care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. A client with hemophilia is at risk for bleeding and should be cared for by a licensed nurse. Suctioning, an invasive treatment, must be performed by a licensed nurse. Although a AP may weigh a client and monitor intake and output, this client has heart failure and should be monitored by a licensed nurse who will be able to listen to breath sounds and detect changes in the client's status. Feeding a client, turning and repositioning a client, assisting with hygiene measures, and ambulating a client are noninvasive interventions and that may be assigned to a AP. A nurse is monitoring a client with bronchogenic carcinoma for signs/symptoms of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client? Dyspnea Cyanosis Hypotension Stokes sign Stokes sign Rationale: In superior vena cava syndrome, the superior vena cava is compressed or obstructed by tumor growth. Early signs/symptoms, which generally occur in the early morning, include edema of the face, especially around the eyes (periorbital edema), and complaints of tightness of a shirt or blouse collar (Stokes sign). As the compression worsens, the client experiences edema of the hands and arms, dyspnea, erythema of the upper body, and epistaxis (nosebleeds). Late (and life-threatening) signs/symptoms include hemorrhage, cyanosis, mental status changes resulting from lack of blood to 70 | P a g e Propylthiouracil has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which occurrence does the nurse tell the client to contact the primary health care provider? Fatigue Diaphoresis Sore throat Heat intolerance Sore throat Rationale: "Propylthiouracil is an antithyroid medication that blocks thyroid hormone production. One adverse effect of propylthiouracil is agranulocytosis. Agranulocytosiss is a serous condition that occurs when the body does not make enough granulocytes (type of white blood cell). The immune system is affected, so a person with this condition is at risk of developing a severe or even life-threatening infection." The client is instructed to report signs/symptoms of infection such as a sore throat. Graves disease (hyperthyroidism) occurs as a result of excessive thyroid hormone secretion. Fatigue may or may not occur in this disorder; however, it is not an adverse effect of the medication. One manifestation of Graves disease is heat intolerance, and the client may experience diaphoresis even when the environmental temperature is comfortable for others. Agranulocytos is a serious that occurs when the body does not make enough granulocytes (type of white blood cell). The immune system is affected, so a person with this condition is at risk of developing a severe or even life-threatening infection. A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate by way of the nasal route. For which occurrence does the nurse tell the client to contact the primary health care provider? Abdominal cramps Stuffy or runny nose Headache and nausea Decreased urine output Headache and nausea Rationale: One adverse effect of desmopressin acetate is water intoxication. Early signs/symptoms of water intoxication include headache, nausea, shortness of breath, drowsiness, and listlessness. The primary health care provider is notified if these signs/symptoms occur. Desmopressin, a synthetic form of antidiuretic hormone, causes increased resorption of water and a resultant decrease in urine output (an expected outcome). Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone (ADH). Abdominal cramping is a side effect, not an adverse effect, of the parenteral form of the medication. A runny or stuffy nose is a side effect, not an adverse effect, of the medication. A client with diabetes mellitus calls the clinic nurse and reports that he/she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? 71 | P a g e "Do you have a fever?" "Did you eat any breakfast?" "Are you urinating frequently?" "Have you tested your blood glucose?" "Have you tested your blood glucose?" Rationale: The priority is learning whether the client has tested his/her blood glucose level and what the level is. During illness, the client should follow the "sick-day rules" for diabetics. The blood glucose level should be checked every 4 hours. Urine is tested for ketones if the blood glucose level is greater than 240 mg/dL (13.3 mmol/L). The client should take the prescribed insulin or oral antidiabetic medication and should drink 8 to 12 oz (135 to 350 mL) of sugar-free liquids every hour when awake. The client should notify the primary health care provider if he/she becomes ill. The remaining options are questions that may be asked, but they are not the priority. A nurse is providing information about the storage of insulin to a client who will be self-administering regular insulin. What does the nurse tell the client? That placing the vial near heat or in sunlight will not affect the insulin To freeze unopened vials and remove a vial from the freezer 24 hours before opening it That insulin stored at room temperature causes more discomfort on injection than does cold insulin That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity Rationale: Insulin preparations are stable at room temperature for as long as 1 month without significant loss of chemical activity. Direct sunlight and extreme heat must be avoided. Insulin should not be frozen. If the insulin is frozen, the insulin should be discarded and the nurse should obtain another vial. Insulin stored at room temperature causes less discomfort on injection than does cold insulin. A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? Neurological deficits Cardiac dysrhythmias Gastrointestinal disturbances Flulike pulmonary signs/symptoms Flulike pulmonary signs/symptoms Rationale: Histoplasmosis is a fungal infection of the lungs. The client typically experiences a flulike pulmonary illness with cough, chest pain, dyspnea, headache, fever, arthralgia, anorexia, erythema nodosum, hepatomegaly, and splenomegaly. Neurological disturbances, gastrointestinal disturbances, and cardiac dysrhythmias are not associated with this infection. 72 | P a g e 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. What does the nurse tell the client? Eat foods that are high in sodium Decrease the daily dose of insulin Eat foods that are low in potassium Closely monitor the blood glucose level Closely monitor the blood glucose level Rationale: The client with diabetes mellitus who is taking prednisone would be instructed to closely monitor the blood glucose level. When taken over an extensive period of time, prednisone may cause increased blood glucose and decreased potassium. It may also cause increased blood pressure and sodium retention. Sarcoidosis is a multisystem granulomatous disorder of unknown cause that can affect virtually any organ. Corticosteroids are the primary pharmacological therapy for sarcoidosis. The primary health care provider may prescribe an increased dose of insulin while the client is taking this medication. A client diagnosed with tuberculosis will be taking pyrazinamide, and the nurse provides instructions about the adverse effects of the medication. For which occurrence does the nurse tell the client to contact the primary health care provider? Headache Yellow skin Difficulty sleeping Nasal congestion Yellow skin Rationale: The nurse instructs the client to contact the primary health care provider if he/she experiences jaundice (yellow skin or eyes); unusual tiredness; fever; loss of appetite; or hot, painful, or swollen joints. Adverse effects include hepatotoxicity, thrombocytopenia, and anemia. Pyrazinamide is an antitubercular medication that is given in conjunction with other antitubercular medications. Headache, nasal congestion, and difficulty sleeping are not associated with the use of this medication. A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which finding indicates to the nurse that the client has sustained a flail chest? Asymmetrical chest movement Complaints of mild chest discomfort Increased breath sounds on auscultation Deep respirations, 18 breaths/min Asymmetrical chest movement Rationale: The nurse specifically notes paradoxical breathing (asymmetrical chest movement); oscillation 75 | P a g e A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign/symptom of this complication does the nurse monitor the client? Pleuritic chest pain Slowed heart rate Chills and a high fever Decreased respiratory rate Pleuritic chest pain Rationale: The characteristic signs/symptoms of pulmonary embolism are dyspnea, tachypnea, tachycardia, and pleuritic chest pain (sharp, stabbing pain on inspiration). Pulmonary embolism, whch results in blockage of the main artery of the lung or one of its branches, occurs when an object, such as a clot, or substance travels from elsewhere in the body through the bloodstream (embolism). The client may become apprehensive and restless. A low-grade fever may occur. Chills and a high fever are characteristics of an infection. A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, what should the nurse do? Document the findings Contact the primary health care provider Ask the primary health care provider to remove the drains Increase the pressure on the wound suction device Document the findings Rationale: Because the findings detailed in the question are expected, the nurse would document them. Immediately after radical neck dissection, the client will have a wound drain in the neck, attached to portable suction. The nurse places the client in the semi-Fowler position to minimize postoperative edema and monitors the neck drainage for volume and color. Sanguineous and serosanguineous drainage is expected in the 72 hours after surgery. Once drainage has stopped, the wound drains are removed. Although previously well controlled with glyburide, a client's fasting blood glucose has been running 180 to 200 mg/dL (10 to 11.1 mmol/L). 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? Atenolol Phenelzine Allopurinol Lithium carbonate Lithium carbonate Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid, thiazide diuretic, 76 | P a g e or lithium carbonate concurrently, the effect of the glyburide is diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral hypoglycemic. A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? Weight gain Flushed face Client complaint of diarrhea A blood pressure higher than the normal range A blood pressure higher than the normal range Rationale: Pheochromocytoma is a catecholamine-producing tumor arising from cells of the adrenal medulla and sympathetic ganglia. These tumors release excessive amounts of catecholamines, mainly norepinephrine, with associated signs/symptoms that include the "five P's": pressure (paroxysmal increases in blood pressure), palpitations, pallor, perspiration (profuse and generalized), and pain (paroxysmal pulsatile headaches, chest, and abdominal pain). Other clinical signs/symptoms include weight loss, constipation, tremors, hypertensive retinopathy, hyperglycemia, and hypercalcemia. The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first? A victim with a twisted ankle and leg bruises A victim with an open fracture of the arm that is bleeding profusely A victim who is anxiously moving among the victims, searching for her husband A victim who is unresponsive, with severe swelling and bruising around the eyes, and is not breathing A victim with an open fracture of the arm that is bleeding profusely Rationale: In a disaster situation, the nurse must triage victims on the basis of severity of injury and potential for recovery. Victims with life-threatening injuries that are readily corrected are classified as emergent and are the first priority (in this case, the victim with an open fracture of the arm that is bleeding profusely). Victims with injuries that do not require immediate treatment but that will need to be treated within 1 to 2 hours are classified as urgent and are the second priority (here, the victim with a twisted ankle and leg bruises). Victims with no injuries, those whose condition is noncritical, and victims who are ambulatory are classified as delayed (nonurgent) and are the third priority (in this case, the victim who is anxiously walking about among the victims, searching for her husband). The victim who is unresponsive and not breathing, with severely swollen and bruised eyes, is most likely dead after having sustained a severe head injury and, in this situation, is not the priority. The nurse does not have the resources necessary to save this client, whereas it may be possible for the nurse to save the client who is bleeding profusely by applying pressure to the bleeding site. The nurse is caring for a newborn who was born to a mother infected with HIV. The nurse knows what manifestations of treatment are included in the care of this neonate? Select all that apply. 77 | P a g e The newborn must be isolated from the mother. All neonates born to HIV-positive clients will acquire infection. Administer zidovudine to the newborn as prescribed for the first 6 weeks. For all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. Neonates born to HIV-positive clients never test positive at birth because antibodies received from the mother may persist for 18 months after birth. Administer zidovudine to the newborn as prescribed for the first 6 weeks. For all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. All HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. Rationale: The nurse should administer zidovudine to the newborn as prescribed for the first 6 weeks of life. Also, for all neonates born to HIV-positive clients, an HIV culture is recommended at 1 and 4 months after birth. In addition, all HIV-exposed newborns should be treated with medication to prevent infection by Pneumocystis jiroveci. The newborn can room with the mother. All neonates acquire maternal antibody to HIV infection, but not all acquire infection. Neonates born to HIV-positive clients may test positive because antibodies received from the mother may persist for 18 months after birth. A client is found to have iron-deficiency anemia, and ferrous sulfate is prescribed. What does the nurse tell the client is best to take the medication with? Milk Apple juice Orange juice Scrambled eggs Orange juice Rationale: Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product to increase absorption of the iron. Milk and eggs inhibit the absorption of iron. Orange juice is higher in vitamin C than apple juice. A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion? Apical pulse Respirations Temperature Blood pressure 80 | P a g e poisoning. Dimercaprol is administered by way of deep intramuscular injection. Calcium disodium edetate is administered by way of the intravenous or intramuscular route. The assessment questions noted in the remaining options are unrelated to the administration of this medication. A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen. What statement by the nurse indicates a need for further information? "We need to administer the antidote N-acetyl cysteine and dilute it in juice or soda." "A loading dose of N-acetyl cysteine has to be followed by maintenance doses." Incorrect "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." "If the child is unconscious, we must do gastric lavage with activated charcoal to decrease the absorption of acetaminophen." "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." Rationale: There is a need for further information if the nurse states, "We need to give N-acetyl cysteine before we do gastric lavage with activated charcoal." Activated charcoal with lavage is done if the child is unconscious, but N-acetyl cysteine cannot be used because activated charcoal inactivates the antidote. If given orally, it can be diluted in juice or soda, and a loading dose of N-acetyl cysteine must be followed by maintenance doses. A client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid daily in a divided dose. At the primary health care provider's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. What should the nurse tell the client? This is expected and nothing to be concerned about It is important to drink at least 10 glasses of water a day to prevent ringing in the ears This is a sign/symptom of toxicity, so the aspirin will be discontinued and replaced with a nonsteroidal antiinflammatory medication The primary health care provider will probably withhold the aspirin until the signs/symptoms have subsided, then resume the aspirin at a lower dosage The primary health care provider will probably withhold the aspirin until the signs/symptoms have subsided, then resume the aspirin at a lower dosage Rationale: The nurse should tell the client that the primary health care provider will probably withhold the aspirin until the signs/symptoms have subsided, then resume the aspirin at a lower dosage. Salicylism is a syndrome that begins to develop when the aspirin level climbs just slightly above the therapeutic level. Overt signs/symptoms include tinnitus (ringing in the ears), sweating, headache, and dizziness. If salicylism develops, aspirin is withheld until the signs/symptoms have subsided; therapy should then be resumed with a small reduction in dosage. Tinnitus is not an expected finding. Drinking water will not prevent tinnitus. A nonsteroidal antiinflammatory medication will not be prescribed, because these medications' chemical properties are similar to those of aspirin. The emergency room nurse is caring for a client who sustained extensive burn injuries. What are the nurse's primary goals for this client? Select all that apply. 81 | P a g e Administer oxygen Insert a Foley catheter Maintain a patent airway Contact the client's family Preserve vital organ functioning Administer IV fluids to prevent hypovolemic shock Maintain a patent airway Preserve vital organ functioning Administer IV fluids to prevent hypovolemic shock Rationale: The primary goals for the client with a burn injury are to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. What should the nurse plan to do first? Check for a patent IV line Provide emotional support to the client Provide the client with 100% oxygen by mask Administer intravenous (IV) fluids as prescribed Provide the client with 100% oxygen by mask Rationale: The nurse should first provide the client with 100% oxygen by mask. When smoke is inhaled, carbon monoxide binds with hemoglobin, displacing oxygen. A high carboxyhemoglobin level impairs tissue oxygenation, resulting in tissue asphyxia. Providing the client with 100% oxygen by mask reverses this condition. The nurse would next ensure that the client has a patent IV line and then administer fluids as prescribed. The nurse would also maintain body temperature, provide wound care as needed, and provide comfort and emotional support. A client with emphysema is receiving theophylline. While providing dietary instructions, what does the nurse tell the client is acceptable to consume? Cola Coffee Hot cocoa Apple juice Apple juice Rationale: The nurse tells the client that apple juice is acceptable to consume. Theophylline is a methylxanthine bronchodilator. Caffeine is a methylxanthine with pharmacologic properties like those of theophylline. For this reason, caffeine can intensify the adverse effects of theophylline on the central nervous system and heart. In addition, caffeine competes with theophylline for drug-metabolizing enzymes, thereby causing the theophylline level to increase. Because of these interactions, individuals 82 | P a g e taking theophylline should avoid caffeine-containing beverages such as cola, coffee, tea, and cocoa, as well as other caffeine-containing products. Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a toxic level of 24 mcg/mL (111 umol/L). What early signs of toxicity does the nurse assess for? Select all that apply. Tremors Lethargy Bradycardia Palpitations Nervousness Tremors Palpitations Nervousness Rationale: Theophylline toxicity is likely to occur when the serum level is higher than 20 mcg/mL (111 mcmol/L). Early signs of toxicity include restlessness, not lethargy; nervousness; tremors; palpitations; and tachycardia, not bradycardia. The normal therapeutic range for theophylline is 10 to 20 mcg/mL (55.5 to 111 umol/L). Fluticasone propionate and albuterol, administered by inhalation twice daily, are prescribed for a client with asthma. The nurse provides information to the client about administration of the medication. What does the nurse tell the client about how to take the medications? Fluticasone propionate immediately after inhaling the albuterol Albuterol immediately after inhaling the fluticasone propionate Fluticasone propionate several minutes before inhaling the albuterol Albuterol several minutes before inhaling the fluticasone propionate Albuterol several minutes before inhaling the fluticasone propionate Rationale: In a client receiving a bronchodilator by way of inhalation concomitantly with corticosteroid therapy, the client is instructed to use the bronchodilator several minutes before corticosteroid inhalation to enhance penetration of the corticosteroid into the bronchial tree. Albuterol is a bronchodilator, and fluticasone propionate is a corticosteroid. The other options are incorrect. A nurse assessing the wound of a client with a stage 3 pressure ulcer notes that the wound bed is pale. What does the nurse interpret this finding as a possible indication of? The wound is healthy The wound is improving Necrotic tissue is present The client's hemoglobin level is low 85 | P a g e 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? "Do you have headaches?" "Have you had any loss of appetite?" "Do you have episodes of dizziness?" "Have you been having any diarrhea?" "Do you have episodes of dizziness?" Rationale: Ménière disease or syndrome, also called idiopathic endolymphatic hydrops, occurs when the normal fluid and electrolyte balance of the inner ear is disrupted. The classic triad consists of episodic true vertigo (dizziness), sensorineural hearing loss, and tinnitus. Some clients experience vertigo associated with nausea, vomiting, and ataxia. Diarrhea, headaches, and loss of appetite are not associated with this disease. A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. What would the nurse initially do? Identify the client's treatment goals Share current research outcomes with the client Offer options that may be beneficial to the client Tell the client that the primary health care provider does not believe in these therapies Identify the client's treatment goals. Rationale: If a client asks a nurse about complementary and alternative therapies, the nurse should initially identify the client's treatment goals, such as sign/symptom management. The nurse should respect the client's request and inquiry about these therapies. Offering options that may be beneficial to the client are appropriate but would not be the initial nursing action. Telling the client that the primary health care provider does not believe in these therapies is a violation of the client's right to be informed about treatment options. 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? "I shouldn't drink coffee before the test." "I'll need to receive sedation before the test." "I won't be able to eat for 24 hours after the test." "I can eat a light breakfast on the morning of the test." "I shouldn't drink coffee before the test." Rationale: The client understands the instructions for an ENG if the client states, "I shouldn't drink coffee before the test." The client must fast for several hours (but not for 24 hours) before the test and should avoid caffeine-containing products for 24 to 48 hours before the test. An ENG is a test that is sensitive in detecting both central and peripheral disease of the vestibular system in the ear. It detects nystagmus (involuntary eye movements), which can be recorded. 86 | P a g e After electrodes are taped to the skin near the eyes, procedures are performed to stimulate nystagmus. No sedation is used for the ENG. Fluids are given to the client after the test but are introduced carefully to prevent nausea. 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. Always sneeze with the mouth closed. Occlude one nostril when blowing the nose. 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. Be cautious when using cotton-tipped applicators to clean the external ear canal. 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. Rationale: The client is instructed to wash the external ear and canal daily in the shower or while washing his or her hair. The client should also wear sound protection around loud or continuous noises, avoid activities with a high risk for ear trauma, keep the volume of headphones at the lowest setting, and avoid environmental conditions involving rapid changes in air pressure. The client should never use a small object such as a cotton-tipped applicator to clean the external ear canal. The client should always sneeze with the mouth open (not closed), and also be instructed to blow the nose gently and not occlude a nostril when blowing the nose. A nurse assigns an assistive personnel (AP) to care for a client who is hearing impaired and provides instructions to the AP about the effective methods for communicating with the client. Which statement by the AP indicates that further instruction is needed? "I should speak slowly and clearly to the client." "I should stand directly in front of the client when I'm talking." "I should make sure that the room is well lit when I'm talking to the client." "I should raise the volume of my voice and stand on the client's affected side when I'm talking to him." "I should raise the volume of my voice and stand on the client's affected side when I'm talking to him." Rationale: Further instruction is needed if the AP states, "I should raise the volume of my voice and stand on the client's affected side when I'm talking to him." When communicating with a hearing- impaired client, the nurse should position herself or himself directly in front of the client so that the client may read the nurse's lips. The room should be well lit, and the nurse should get the client's attention before speaking. The nurse should move closer to the ear with better hearing and speak slowly and clearly. The nurse should speak in a normal tone of voice and keep his or her hands and other objects away from the mouth while talking to the client. 87 | P a g e The nurse is instructing a client who has been diagnosed with myasthenia gravis. What comment by the client indicates a need for further instruction? "I know that treatment for myasthenia gravis is life-long." "I need to take medications on time to help prevent weakness." "I must take my medications about 45 minutes before eating a meal." "I should take the medications with a very small amount of food to prevent gastrointestinal (GI) symptoms." "I must take my medications about 45 minutes before eating a meal." Rationale: There is a need for further instruction if the client states, "I must take my medications about 45 minutes before eating a meal." The client needs to eat a meal 45 to 60 minutes after, not before, taking medications to decrease the risk for aspiration. The other client statements are correct. Myasthenia gravis is a disease that affects the myoneural junction. It is believed to result from an autoimmune response that destroys a variable number of acetylcholine receptors at the myoneural junction. A client with myasthenia gravis who has been taking pyridostigmine bromide for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. What muscles are involved first in a cholinergic crisis? Respiratory muscles Chewing and swallowing Pelvic girdle and leg muscles Shoulder girdle and upper extremities Chewing and swallowing Rationale: Cholinergic crisis is defined as an over-stimulation at a neuromuscular junction due to an excess of acetylcholine (ACh) caused by an overdose of anticholinesterase drugs. The weakness first appears in the muscles involved in chewing and swallowing and is followed by weakness of the shoulder girdle and upper extremities, respiratory muscles, and pelvic girdle and leg muscles. A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction? "He needs to have a broad base of support when ambulating." "He needs to avoid staying in one position for a prolonged period." "I should encourage him to keep his hands hanging at his side when he walks." "I should help him perform range-of-motion exercises of his joints three times a day." "I should encourage him to keep his hands hanging at his side when he walks." Rationale: There is a need for further instruction if the client's spouse states, "I should encourage him to keep his hands hanging at his side when he walks." Parkinson's disease is a chronic degenerative disorder that primarily affects the neurons of the basal ganglia. The client's muscles become stiff and 90 | P a g e A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin daily has been prescribed. The nurse makes a note in the client's medication record. When should the medication be administered? At noon With supper With the morning meal With the midafternoon snack With the morning meal Rationale: Metformin is an antihyperglycemic medication used as an adjunct to diet in the management of type 2 diabetes mellitus. When it is prescribed for daily use, it is administered with the morning meal. Giving the medication at noon, with supper, or with a midafternoon snack is incorrect because the medication is needed to maintain a controlled and consistent blood glucose level. If the prescribed metformin is an extended-release form, the primary health care provider may prescribe a daily dose of the medication with the evening meal, because this timing may enhance absorption as a result of slower nighttime gastrointestinal transit time. The wife of a client diagnosed with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL (3.3 mmol/L) and that her husband is awake but groggy. What does the nurse tell the client's wife to immediately do? Call the primary health care provider Administer glucagon hydrochloride Call an ambulance to bring her husband to the emergency department Place some honey in her husband's mouth, between his gums and cheek Place some honey in her husband's mouth, between his gums and cheek Rationale: The nurse tells the client's wife to immediately place some honey in her husband's mouth, between his gums and cheek. Once the sugar has been absorbed through the oral mucosa, the client can usually be aroused sufficiently to take a glass of juice, milk, or sugar-sweetened coffee or tea. The client and his spouse should be educated about the signs/symptoms of hypoglycemia (blood glucose level of 60 mg/dL [3.3 mmol/L] or lower). There is no reason at this time to call the primary health care provider or to call an ambulance to bring the client to the emergency department. Glucagon hydrochloride is used to treat hypoglycemic coma. A client with type 1 diabetes mellitus is instructed by the primary health care provider to obtain glucagon hydrochloride for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information? "I need to store this medication in the freezer." "I know that this is used to treat episodes of high blood sugar." 91 | P a g e "I can give this medication instead of insulin if his insulin runs out." "I need to give this if he has signs of low blood sugar and goes into a coma." "I need to give this if he has signs of low blood sugar and goes into a coma." Rationale: The statement by the client's wife that indicates she understands the information is, "I need to give this medication if he has signs of low blood sugar and goes into a coma." Glucagon is used to treat hypoglycemia resulting from insulin overdose. If hypoglycemic coma develops, glucagon is administered promptly. The family of the client is instructed in how to administer the medication. In an unconscious client, arousal usually occurs within 20 minutes of injection. Once consciousness has been produced, oral carbohydrates should be given. Insulin should never be stored in the freezer. Glucagon is not used to treat hyperglycemia or used in place of insulin; also, the client should be instructed to have additional vials of insulin on hand at home so that he will not run out. Glucagon is stored at room temperature. A client diagnosed with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. What should the nurse tell the client to do? Stop the medication Contact the primary health care provider immediately Increase intake of high-fiber foods Add a half-ounce (15 ml) of mineral oil to the daily diet Increase intake of high-fiber foods Rationale: The nurse should tell the client to increase intake of high-fiber foods. Calcium gluconate is a calcium supplement, and constipation is a side effect of calcium gluconate. It is not necessary for the client to contact the primary health care provider immediately if constipation occurs. Rather, the nurse would suggest interventions to alleviate and prevent constipation (e.g., increased fluid intake, high-fiber diet, exercise). Clients taking calcium supplements should be instructed to avoid the use of mineral oil as a laxative because it reduces vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. The client should not stop taking the medication. A client has a primary health care provider's appointment to get a prescription for sildenafil. The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated? The client has type 2 diabetes mellitus. The client has a history of renal calculi. The client is taking glargine insulin. The client takes isosorbide dinitrate The client takes isosorbide dinitrate . Rationale: Sildenafil is used to treat male erectile dysfunction. It is contraindicated in the client who is using isosorbide dinitrate, a form of sodium nitroprusside or organic nitrates in any form, because both 92 | P a g e sildenafil and nitrates promote hypotension. When these medications are combined, life-threatening hypotension may result. Type 2 diabetes mellitus, a history of renal calculi, and the use of glargine insulin are not contraindications to the use of sildenafil. Vasopressin is prescribed to a client with diabetes insipidus. For which sign/symptom, indicative of an adverse effect of the medication, does the nurse monitor the client? Chest pain Constipation Loss of appetite Decreased urine output Chest pain Rationale: Chest pain is a sign of an adverse effect of vasopressin, and if it occurs, the primary health care provider must be notified. Because of its powerful vasoconstrictive action, vasopressin can cause adverse cardiovascular effects. By constricting arteries of the heart, vasopressin can cause angina pectoris and even myocardial infarction, especially if the medication is administered to a client with existing coronary artery disease. Vasopressin may also cause gangrene by decreasing blood flow in the periphery. Decreased urine output is an expected effect. Neither constipation nor loss of appetite is associated with this medication. Desmopressin is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while taking the medication? Appetite Pulse rate Bowel pattern Intake and output Intake and output Rationale: The client is instructed to monitor and record daily intake and output of fluid. Diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone. Desmopressin promotes renal conservation of water. The hormone accomplishes this by acting on the collecting ducts of the kidney to increase their permeability to water, resulting in increased water reabsorption. If the dose prescribed is adequate, urine volume should rapidly drop to normal. Appetite, pulse rate, and changes in bowel pattern are not associated with the use of this medication. The nurse is giving discharge instructions to a client recently diagnosed with hypothyroidism. The client was also given a prescription for levothyroxine by the primary health care provider. What comment by the client indicates a need for further instruction? "I'm glad constipation won't be such a problem anymore." "I'll remember to take the medication without food in the morning." "I'm looking forward to maybe losing some weight with this medication." "I know I have to notify the primary health care provider if I have any problems with a slow heart rate." 95 | P a g e where they will be stable for at least 1 to 2 weeks. Before administration of the medication, the syringe should be agitated gently to resuspend the insulin. Tolbutamide 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? "I need to maintain my exercise program." "I need to stay on my calorie-restricted diet." "I can take the medication with food if it upsets my stomach." "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." Rationale: There is a need for further instruction when the client says "I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." Tolbutamide, a first-generation sulfonylurea, is used as an adjunct to calorie restriction and exercise to maintain glycemic control in clients with type 2 diabetes mellitus. When alcohol is combined with tolbutamide, a disulfiram-like reaction, including flushing, palpitations, and nausea, may occur. Alcohol also potentiates the hypoglycemic effects of tolbutamide. The client must be told about the dangers of alcohol consumption. The statements in the remaining options are correct. The nurse is reviewing the record of a client admitted with Cushing's syndrome due to ingestion of large doses of long-term glucocorticoids used to treat nonendocrine conditions. What signs/symptoms does the nurse expect to note? Select all that apply. Moon face Dizziness Osteoporosis Hyperkalemia Loss of weight Edema in the feet Moon face Dizziness Osteoporosis Edema in the feet Rationale: Signs/symptoms of clients with Cushing's syndrome include moon face, dizziness, osteoporosis, and swelling of the feet. Other signs/symptoms include puffy eyelids, increased bruising, bleeding, and menstrual irregularities. Hyperkalemia, not hypokalemia, also occurs, as well as gaining, not losing, weight. Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse is providing information to the client about the medication. What time of day does the nurse tell the client is best to take the medication? 96 | P a g e At bedtime With lunch In the evening, after 9 p.m. In the morning, before 9:00 a.m. In the morning, before 9:00 a.m. Rationale: The nurse tells the client that it is best to take glucocorticoids before 9 a.m. This schedule helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenals each morning. Prednisone, a glucocorticoid, may be prescribed to reduce inflammation and pain in acute exacerbations of rheumatoid arthritis. The time frames in the remaining options are incorrect. A child with growth hormone deficiency will be receiving somatropin. 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? Creatinine Hemoglobin Blood urea nitrogen (BUN) Thyroid-stimulating hormone (TSH) Thyroid-stimulating hormone (TSH) Rationale: TSH is the laboratory value the nurse tells the mother to monitor. Somatropin is a growth hormone. One adverse reaction to somatropin is hypothyroidism. Thyroid function is assessed before treatment and periodically thereafter. Creatinine and BUN are used to evaluate renal function, and hemoglobin reflects hematologic activity. Laboratory studies are performed on a client diagnosed with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? Low reticulocyte count Low total bilirubin level Increased hematocrit count Increased white blood cell (WBC) count Increased white blood cell (WBC) count Rationale: Sickle cell disease is a genetic disorder that results in chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. The WBC count is usually higher than normal in clients with sickle cell disease. Also, the red blood cells assume a sickle shape, become rigid, and clump together. The main laboratory finding associated with sickle cell disease is the large percentage of HbS present on electrophoresis. The reticulocyte count is increased, indicating anemia of long duration, and the total bilirubin level is increased. The hematocrit level is low and decreases during crisis, because the 97 | P a g e bone marrow fails to produce cells during stressful periods. It is believed that this increase is related to chronic inflammation resulting from tissue hypoxia and ischemia. A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the primary health care provider suspects iron-deficiency anemia. After reviewing the laboratory results, which finding indicative of this type of anemia does the nurse expect to note?. An increased RBC count An increased hematocrit level An increased hemoglobin level Microcytic red blood cells (RBCs) Microcytic red blood cells (RBCs) Rationale: The nurse expects to note a low RBC count and microcytic (small) RBCs. In iron-deficiency anemia, laboratory testing will reveal low hemoglobin and hematocrit levels. In iron-deficiency anemia, iron stores are depleted first, followed by hemoglobin stores. Alendronate 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? At bedtime With orange juice, to enhance absorption at night Every morning before breakfast, with a full glass of water Every morning after breakfast, after which the client should lie down for 30 minutes Every morning before breakfast, with a full glass of water Rationale: Alendronate should be taken in the morning before breakfast with a full glass of water and on an empty stomach to maximize its bioavailability. It is a medication used to treat postmenopausal osteoporesis, glucocorticoid-induced osteoporosis, and Paget's disease of bone. Proper administration is necessary to maximize bioavailability and minimize the risk of esophagitis. No food, including orange juice or coffee, should be consumed for at least 30 minutes after alendronate is taken. To minimize the risk of esophagitis, the client should take the medication with a full glass of water and remain upright (seated or standing) for at least 30 minutes. Therefore taking the medication at bedtime, with orange juice to help with absorption, and every morning after breakfast, followed by a 30-minute period of lying down, are all incorrect. Calcium carbonate is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication? Fish Milk Spinach Watermelon