Test: bstrandable NCLEX Miscellaneous 8 (2022)

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This is a Free Service provided by Why Fund Inc. (a 501 C3 NonProfit) We thank you for your donation!(1. Click on the course Study Set you wish to learn.) (2. If you wish you can click on "Print" and print the test page.) (3. When you want to take a test...click on anyone of the tests for that Study Set.) (4. Click on "Check Answers" and it will score your test and correct your answers.) (5. You can take all the tests as many times as you choose until you get an "A"!) (6. Automated college courses created from lecture notes, class exams, text books, reading materials from many colleges and universities.)NAMEPrint test695 Matching questions The LPN/LVN is teaching Mr. Elbridge how to insert his new hearing aid. Arrange the following choices in the correct order for completing this task.(A) Turn the hearing aid on and turn the volume up(B) Line up the earmold with the corresponding parts of the ear(C) Slightly rotate the earmold forward(D) Rotate the earmold backward(E) Insert the ear canal portion of the earmold(F) Turn the hearing aid off and the volume all the way down Mrs. foster thinks she might be pregnant and visit's the physician's office. a urine sample pregnancy test is performed. The evaluation of which of the following hormones in the urine would indicate that Mrs. Foster is indeed pregnant?(A) Human growth hormone (hGH)(B) Human chorionic gonadotropin (hCG)(C) Estrogen(D) Oxytocin A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds an older client slapping at the flames on the bedspread with a pillow. Both hands have been burned. Which action should the nurse take first?1. Pull the nearest fire alarm2. Close the door to the room3. Remove the client from the room4. Run to get the nearest fire extinguisher MENINGITIS :disease discription 95.) The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which of the following significantly elevated results is noted? 1. Serum protein 2. Blood glucose 3. Serum amylase 4. Serum creatinine 120.) A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse advises the client to take which of the following products if needed for a headache? 1. Naprosyn (Aleve) 2. Ibuprofen (Advil) 3. Acetaminophen (Tylenol) 4. Acetylsalicylic acid (aspirin) 197.) Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication? 1. "I will apply the ointment once a day and leave it open to the air." 2. "I will apply the ointment twice a day and leave it open to the air." 3. "I will apply the ointment once a day and cover it with a sterile dressing." 4. "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing." 228.) A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse recognizes this complaint as a symptom of: 1. Cardiac dysrhythmias 2. Postural hypotension 3. Psychosomatic symptoms 4. Respiratory insufficiency While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to: A. Revise the client's care plan to show the need for the application of moisturizing lotion B. Assume personal responsibility to apply the moisturizing lotion daily to the client's skin C. Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin D. Inform the staff that the client's skin is showing signs of breakdown and moisturizing lotion needs to be applied daily Epidural hematoma A nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox Sequels) daily. Which of the following indicates to the nurse that the client is experiencing an adverse effect related to the medication? 1. Diarrhea 2. Lacrimation 3. Low back pain and dysuria 4. Irritability A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client?1. The nursing assistant is speaking in a normal tone2. The nursing assistant is speaking clearly to the client3. The nursing assistant is facing the client when speaking4. The nursing assistant is speaking directly into the impaired ear inflammation 195.) A nurse is caring for a client who is taking metoprolol (Lopressor). The nurse measures the client's blood pressure (BP) and apical pulse (AP) immediately before administration. The client's BP is 122/78 mm/Hg and the AP is 58 beats/min. Based on this data, which of the following is the appropriate action? 1. Withhold the medication. 2. Notify the registered nurse immediately. 3. Administer the medication as prescribed. 4. Administer half of the prescribed medication. What is "terminal insomnia"? NSAIDS: teaching 110.) A client taking lithium carbonate (Lithobid) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up and the level is 3.0 mEq/L. The nurse knows that this level is: 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal When is a lumbar puncture not indicated? A friend calls and states that he has taken three nitroglycerin tablets for his chest pain, but the pain is still there. The nurse advises him to:1. Call his doctor2. Drive to the nearest emergency room3. lie down and rest to see if the pain goes away4. Call 911 1. A patient has had a splenectomy to control bleeding from a lacerated spleen following an automobile accident. The nurse will teach the patient about the increased risk fora. lymphedema.b. infection.c. prolonged bleeding.d. chronic anemia. O2 toxicity 38.) An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations 48. Before discharge, the nurse discusses activity levels with a 61-year-old patient with COPD and pneumonia. Which of the following exercise goals is most appropriate once the patient is fully recovered from this episode of illness? A. Slightly increase activity over the current level. B. Walk for 20 minutes a day, keeping the pulse rate less than 130 beats per minute. C. Limit exercise to activities of daily living to conserve energy. D. Swim for 10 min/day, gradually increasing to 30 min/day. 8. While obtaining the admission assessment data, which of the following characteristics would a nurse expect a patient with anemia to report? A. Palpitations B. Blurred vision C. Increased appetite D. Feeling of warm flushing sensation dry powder inhaler A nurse is planning to give a subcutaneous injection of insulin. The nurse plans to do which of the following immediately after giving the injection?1. Break the needle2. Recap the needle3. Place the needle and syringe in a labeled cardboard box4. Place the needle and syringe in a labeled, rigid plastic container What are some expected changes that may be seen when assessing pts w/ Brain Herniation as a result of IICP? If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following? 1. Increased respiration with exertion. 2. Cough producing large amount of thick, yellow mucus. 3. Peripheral edema and anorexia. 4. Twitching of extremities. When administering a drug via a parenteral routes, the drug would be absorbed fastest if given per the IM route.a. Trueb. False Mr. Greene is a client in a long term nursing facility who requires tube feedings via his PEG (percutaneous endoscopic gastrostomy) tube. Which of the following would the LPN/LVN know to watch for as the most common complication of tube feedings?(A) Constipation(B) Loose, watery stools(C) Vomiting(D) Excessive belching tri-cuspid soudns are best heard at the ____ intercostal space 32. Which of the following test results identify that a patient with an asthma attack is responding to treatment? A. A decreased exhaled nitric oxide B. An increase in CO2 levels C. A decrease in white blood cell count D. An increase in serum bicarbonate levels The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?1) Closing the patient's door to limit room traffic while preparing the sterile field2) Using clean procedure gloves to handle sterile equipment3) Placing the nonsterile syringes containing flush solution on the sterile field4) Remaining 6 inches away from the sterile field during the procedure A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. The nurse assigned to care for the client plans to ensure that which of the following does not occur in the care of the client?1. Admitting the client to a semiprivate room2. Placing a mask on the client if the client leaves the room3. Removing a vase with fresh flowers left by a previous client4. Placing a "See the Nurse before Entering" sign on the door to the room which is more important in determining premature labor: REGULAR contractions or cervical effacement and dilation? The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?1) Prepare the patient for an abdominal flat plate.2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.3) Administer a laxative to prepare the patient for a colonoscopy.4) Test the patient's stool using a fecal occult test. Which of the following are conditions associated with Cushing's syndrome? Select all that apply.(A) Easy bruising(B) Buffalo hump(C) Hyperglycemia(D) Excessive scalp hair growth(E) Hyponatremia(F) Trunk obesity MULTIPLE RESPONSE 1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.)a. Alcohol useb. Physical activityc. Body weightd. Colorectal screeninge. Tobacco usef. Mammographyg. Pap testingh. Sunscreen use A client with a seizure disorder has been placed on a ketogenic diet. What would the nurse teach is this diet's benefit to prevent seizures?a. It has no effect on the prevention of seizures.b. It reduces stress, which increases seizure threshold.c. It lowers the potassium and decreases neuron firing.d. It decreases the excitability of the neurons. voncristine sulfate (Oncovin): class & Tx chylothorax The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx.a. trueb. false Fever An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. Mrs. Palmer, a client with Parkinson's disease, is admitted to an extended-stay nursing facility. Up until this point she has been living on her own. Which of the following assessments is the most significant in developing the plan of care?(A) Mrs. Palmer states she dislikes beef nut will eat it once in a while if it is cooked well(B) Mrs. Palmer talks frequently about how much she misses living on her own(C) Mrs. Palmer has a difficult time eating at dinner due to tremors(D) Mrs. Palmer states her only living relative is her daughter who lives across the state and seldom visits hemothorax Which of the following symptoms should the nurse assess with a client who is deprived of sleep?1. Elevated blood pressure and confusion2. Confusion and irritability3. Inappropriateness and rapid respirations4. Decreased temperature and talkativeness during CPR, depress the sternum ____ A nurse working on a medical nursing unit during an external disaster is called to assist with the care of clients coming into the emergency room and is asked to assist the triage nurse. Using principles of prioritizing, the nurse initiates care for a client with which of the following injuries first?1. Fractured tibia2. Penetrating abdominal injury3. Bright red bleeding from a neck wound4. Open severe head injury in a deep coma A nurse should advise a client who is receiving lorazepam (Ativan) about the adverse effects of this medication which include:1. tachypnea2. astigmatism3. ataxia4. euphoria What are the actions of calcium channel blockers? 3. A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate?a. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size."b. "Annual x-rays will increase your risk for cancer because of exposure to radiation."c. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer."d. "Frequent x-rays damage the lungs and make them more susceptible to cancer." Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter?1. Empty the drainage bag at least every 8 hours.2. Clean up the length of the catheter to the perineum.3. Use clean technique to obtain a specimen for culture and sensitivity.4. Place the drainage bag on the client's lap while transporting the client to testing. 83.) The client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept (Enbrel), it is most important for the nurse to check: 1. The injection site for itching and edema 2. The white blood cell counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. A metallic taste in the mouth, with a loss of appetite pleural friction rub Cholinergic Crisis Which of the following is an example of a patient suffering from anxiety due to the stress of being hospitalized? (Select all that apply)A) The patient responds appropriately to teaching, but then asks a question about the information just given.B) The patient watches the nurse demonstrate a procedure and then performs a return demonstration correctly.C) The patient stares into space while the nurse is talking and then asks, "What?"D) The patient has frequent bouts of crying and wants to be left alone.E) The patient uses the incentive spirometer and ambulates without being reminded. A licensed practical nurse (LPN) is assisting a registered nurse (RN) to develop a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following does the LPN suggest be included in the client's plan of care?1. Limit visitor's time to 60 minute visits2. Place a radiation sign on the door of the client's room3. Place the client in a private room close to the nurses' station4. Reinsert the implant into the vagina immediately if it becomes dislodged 2. Which of the following is a factor significant in the development of anemia in men? A. Condom use B. Large hemorrhoids C. A diet high in cholesterol D. Smoking one pack of cigarettes daily Erb's point is found at the ____ intercostal space 15. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is toa. teach about the importance of nutrition during treatment.b. have the patient eat large meals when nausea is not present.c. administer prescribed antiemetics 1 hour before the treatments.d. offer dry crackers and carbonated fluids during chemotherapy. A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side. 54.) A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will be certain to avoid alcohol consumption." 3. "I have already called my family to pick up a Medic-Alert bracelet." 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." temperature of toddler TELL (Delegation) The nurse knows that which of the following is a major disadvantage for the use of tacrine (Cognex) to treat the symptoms of early Alzheimer's disease? Select all that apply.a. Must be administered four times per day.b. Causes weight gain.c. May cause vision difficulties.d. May cause serious hepatic damage.e. Can be purchased over-the-counter The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if the state that they will:◦ A. Place objects in the client's impaired field of vision◦ B. Discourage the client from wearing eyeglasses.◦ C. Approach the client from the impaired field of vision◦ D. Remind the client to turn the head to scan the lost visual field. Quadriparesis or quadriplegia: The nursing assistant runs out of a hospital room yelling that the patient fell to the floor. The LPV/LVN is rehearsing in her mind the order of nursing actions that should be performed when at the client's side. Arrange the following into the correct order of priority, with the highest priority action listed first:(A) Assess airway patency(B) Assess for injury(C) Move the client into bed(D) Check heart rate and blood pressure(E) Call the client's physician chest percussion The physician diagnoses a client with septicemia. Which of the following assessment findings would support this diagnosis?(A) Bilateral knee pain(B) Reddened tissue surrounding an injury site(C) Drainage from an injury site(D) Temperature of 101 degrees F A nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine (Tegretol). The nurse determines that the client understands the use of the medication if the client knows to: 1. Drive as long as it is not at night. 2. Use sunscreen when outsides. 3. Discontinue the medication if fever or sore throat occurs. 4. Keep tissues handy because of excess salivation that may occur. what can hypercalcemia cause? troponin ↑ 0.1-0.2 ng/mL is consistent with what? 1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumorsa. do not cause damage to adjacent tissue.b. do not spread to other tissues and organs.c. are simply an overgrowth of normal cells.d. frequently recur in the same site. A client is scheduled to have insertion of an inferior vena cava (IVC) filter. The nurse should place highest priority on determining whether the surgeon wants which of the following medications held in the preoperative period?1. Furosemide (Lasix)2. Famotidine (Pepcid)3. Multivitamin with minerals4. Warfarin sodium (Coumadin) 244.) A client has a prescription for valproic acid (Depakene) orally once daily. The nurse plans to: 1. Administer the medication with an antacid. 2. Administer the medication with a carbonated beverage. 3. Ensure that the medication is administered at the same time each day. 4. Ensure that the medication is administered 2 hours before breakfast only, when the client's stomach is empty. When doing a corneal reflex, we need to remember what key factor? corticosteroids: lifespan consideration A nurse assisting in the care of a client who has been in a coma for more than a year is told by the physician to stop the tube feeding that is providing sustenance to the client. The nurse, who is aware of the legal basis needed for carrying out the order, first determines whether which of the following requirements has been met?1. Institutional Ethics Committee approval2. A court order to discontinue the treatment3. A written order by the physician to remove the tube4. Authorization by the family to discontinue the treatment why might you place a patch over an eye injury? Cranial nerve 7 comes out of the temple and runs all the way down to the corner of the mouth. If there are problems with this nerve, what might we see? 2. When caring for a patient after an abdominal surgery, the nurse will be most concerned about monitoring for wound dehiscence during which period?a. The first postoperative dayb. The third postoperative dayc. One week after the surgeryd. One month after the surgery One reason for medication problems in the elderly is that 1. Regular use of laxatives increases absorption of medications 2. Decreased renal function slows excretion of drugs 3. Enhanced sense of taste of medications 4. Increased perception of pain from injections hydrocortisone Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe. 2. Limit fluid intake. 3. Supply a high-carbohydrate diet. 4. Evaluate skin integrity. 146.) A client has begun therapy with theophylline (Theo-24). The nurse tells the client to limit the intake of which of the following while taking this medication? 1. Oranges and pineapple 2. Coffee, cola, and chocolate 3. Oysters, lobster, and shrimp 4. Cottage cheese, cream cheese, and dairy creamers chest physiotherapy 86.) A nurse is reinforcing discharge instructions to a client receiving baclofen (Lioresal). Which of the following would the nurse include in the instructions? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Stop the medication if diarrhea occurs. 4. Notify the health care provider if fatigue occurs. 1. When assessing a patient's nutritional-metabolic pattern related to hematologic health, the nurse would: A. Inspect the skin for petechiae. B. Ask the patient about joint pain. C. Assess for vitamin C deficiency. D. Determine if the patient can perform ADLs. 173.) A nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness? 1. "Do you have any joint pain?" 2. "Are you having any diarrhea?" 3. "Do you have frequent headaches?" 4. "Are you experiencing heartburn?" What are the normal chloride values? ecchymosis The three common conditions affecting cognition in the older adults are: A. Stroke, MI, Cancer B. Cancer, Alzheimer's disease, Stroke C. Delirium, Depression, Dementia D. Blindness, Hearing loss, Stroke The patient with metastatic cancer tells the nurse "I am tired and do not want to be put on a breathing machine." The patient's out-of-town son wants "everything done for my mother" when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply)A) AutonomyB) NonmaleficenceC) JusticeD) BeneficenceE) Fidelity Which of the following nursing activities is of highest priority for maintaining medical asepsis?1) Washing hands2) Donning gloves3) Applying sterile drapes4) Wearing a gown A licensed practical nurse (LPN) is assisting a registered nurse (RN) in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this client because it is unsafe?1. Resume prescribed medications2. Have the client sit upright for a meal3. Encourage the client to drink extra fluids4. Ask the client to wiggle the toes when collecting data about neurovascular status 31. The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information thata. to give adequate doses of IV insulin, a centrally located IV catheter is needed.b. blood glucose testing is more accurate when samples are obtained from a central line.c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose.d. the 50% dextrose is less likely to produce infection when given through a PICC line. A client has been taught to apply capsaicin to increase mobility and relieve pain. Which educational intervention is most important for the client to learn?a. Apply the medication liberally above and below the site of pain.b. Apply with a gloved hand only to the site of pain.c. Apply to areas of redness and irritation.d. Apply liberally with a bare hand. What do we do to check function of the optic nerve? The client is receiving levodopa/carbidopa for parkinsonism. Which drug would the nurse expect to be added to the client's drug regimen to help control tremors?a. Amantadine (Symmetrel)b. Benztropine (Cogentin)c. Haloperidol (Haldol)d. Donepezil (Aricept) J. Cramer is a 17 year old client with sickle cell anemia. Which of the following is NOT a common treatment and care modality for a client with this condition?(A) Pain management(B) Preventing infection(C) Fluid restriction(D) Red blood cell transfusion Which cranial nerve is our sense of smell or Olfactory? What are sources of vitamin D? 46.) A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse checks the client for: 1. Pupillary changes 2. Scattered lung wheezes 3. Sudden increase in pain 4. Sudden episodes of diarrhea thoracotomy What is stroke volume? 217.) A health care provider prescribes auranofin (Ridaura) for a client with rheumatoid arthritis. Which of the following would indicate to the nurse that the client is experiencing toxicity related to the medication? 1. Joint pain 2. Constipation 3. Ringing in the ears 4. Complaints of a metallic taste in the mouth What is typically the most reliable indicator of pain?1) Patient's self-report2) Past medical history3) Description by caregiver(s)4) Behavioral cues The telemetry unit nurse is reviewing lab results for an operative procedure later in the day. The nurse notes on the lab report that the pt has a serum potassium level of 6.5 mEq/L. The nurse informs the physician of this lab result because the nurse recognizes this increases the pts risk for which of the following?a. infectionb. cardiac problemsc. bleeding and anemiad. fluid imbalances true A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following? 1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child after a DPaT immunization. 3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours. 4. The child's high fever is a direct response to the DPaT immunization and should be treated. A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day. 2. External catheters are uncomfortable. 3. The catheter would drain into a bag at the bedside or on the wheelchair. 4. The external condom catheter is easy to apply. An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following? 1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues. 2. Cool, moist skin; fine hand tremors; and mental confusion. 3. Headache, apprehension, and lethargy. 4. Shortness of breath, chest pain, and anxiety. What class of drugs are prescribed first line in children? Poison Control The nurse is teaching a client about a new eyedrop prescription for timolol (Timoptic) for treatment of open-angle glaucoma. The client has a history of seasonal allergies and hypertension. What is an important administration technique to stress for this client?a. Take any eyedrops for allergies 5 minutes before administering the timolol dropsb. Do not use the timolol drops while concurrently taking allergy medication.c. The timolol drops may temporarily worsen seasonal allergies.d. Gently put pressure on the inner canthus (tear duct) for 1 minute after instilling the timolol drop. Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding. When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan. 216.) A nurse is caring for a client with gout who is taking Colcrys (colchicine). The client has been instructed to restrict the diet to low-purine foods. Which of the following foods should the nurse instruct the client to avoid while taking this medication? 1. Spinach 2. Scallops 3. Potatoes 4. Ice cream 17. A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient willa. be free from injury.b. maintain intact perineal skin.c. have adequate oxygenation.d. receive immunizations. wheezes The Dub sound of Lub-Dub is closure of which heart valves? 7. When teaching a patient with chronic SIADH about long-term management of the disorder, the nurse determines that additional instruction is needed when the patient says,a. "I need to shop for foods that are low in sodium and avoid adding salt to foods."b. "I should weigh myself daily and report any sudden weight loss or gain."c. "I need to limit my fluid intake to no more than 1 quart of liquids a day."d. "I will eat foods high in potassium because the diuretics cause potassium loss." A 10-year-old child has been evaluated for a learning disability and has been diagnosed with absence seizures. Ethosuximide (Zarontin) has been ordered and the nurse is teaching the client and family about the drug. Because of the client's age, it is important to include instructions to:a. Curtail afterschool sports activities, because the drug's metabolism may be increased with physical activity.b. Increase intake of calcium-rich foods and vitamin D to prevent bone loss.c. Monitor height and weight weekly to be sure GI side effects are not hindering nutrition and normal growth.d. Increase fluid intake to avoid dehydration caused by the drug. A 22-year-old client who has been treated for 10 years for a seizure disorder has discussed pregnancy with her health care provider. Which drug therapy would the nurse expect to be added to the client's drug regimen prior to conception?a. Clomiphene (Clomid)b. Vitamin Kc. Calcium (Caltrate)d. Folic acid (Folgard) The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. "That must have been a real shock to you." 2. "You should be tested for hepatitis B." 3. "You'll receive the hepatitis B immune globulin (HBIG)." 4. "Have you had unprotected sex with your boyfriend?" What is "intermittent insomnia"? pre-eclampsia Sx The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement. lung abscess The LPN/LVN assigned to a homosexual male is responsible for relaying positive HIV test results to the client. Which of the following responses would the nurse expect initially?(A) Disbelief(B) Acceptance(C) Anger(D) Depression 19. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor isa. peripheral pulses.b. lung sounds.c. peripheral edema.d. urinary output. Breath Sounds Limiting bladder catherization to once every 12 hours Normal Potassium values What does vitamin C do? Upon removing a breakfast tray from a room, the LPN/LVN calculates the client's intake. The client consumed the following: 4 oz of pudding, 6 oz of coffee, half of a 6 oz container of grape juice and used 4 oz of milk over cold cereal. In milliliters, what should the nurse record as the client's intake for this meal?(A) 480 mL(B) 390 mL(C) 510 mL(D) 600 mL 226.) A client receiving lithium carbonate (Lithobid) complains of loose, watery stools and difficulty walking. The nurse would expect the serum lithium level to be which of the following? 1. 0.7 mEq/L 2. 1.0 mEq/L 3. 1.2 mEq/L 4. 1.7 mEq/L 24. After neck surgery, a patient develops hypoparathyroidism. The nurse should plan to teach the patient abouta. calcium supplementation to normalize serum calcium levels.b. including whole grains in the diet to prevent constipation.c. use of bisphosphonates to reduce bone demineralization.d. having a high fluid intake to decrease risk for nephrolithiasis. A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room?1. Draw the shades closed2. Give the client a bedpan3. Put up the side rails on the bed4. Turn the volume on the television set down The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips. 7.) Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Platelet count 2. Triglyceride level 3. Complete blood count 4. White blood cell count 96.) The nurse is caring for a postrenal transplant client taking cyclosporine (Sandimmune, Gengraf, Neoral). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. What is the vital sign that is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry 29. A patient with Cushing syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the highest priority toa. monitoring for infection.b. protecting the patient's skin.c. maintaining fluid and electrolyte status.d. preventing severe emotional disturbances. A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a crisis from occurring?1. Maintain strict hand washing technique2. Give the client reassurance and encouragement 3. Ensure that the client uses oxygen during labor4. Remind the client not to bear down for more than 3 seconds The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following? 1. Increased pulse rate. 2. Decreased temperature. 3. Fine tremors. 4. Increased radioactive iodine uptake level. A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side and the nurse plans to use the hemiplegic transfer technique. The client is sitting upright in bed with the legs dangling over the side. For the safest transfer, where should the wheelchair be positioned?1. Next to either leg2. Near the client's left leg3. Near the client's right leg4. As space in the room permits 6. A nurse is working on a respiratory care unit where many of the patients are affected by asthma. Which of the following actions by the nurse would most likely increase respiratory difficulty for the patients? A. Wearing perfume to work B. Encouraging patients to ambulate daily C. Allowing the patients to eat green leafy vegetables D. Withholding antibiotic therapy until cultures are obtained Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? (Select all that apply.)1) Blood pressure decreases less than heart rate and respiratory rate.2) Respiratory rate remains fairly stable throughout a person's life.3) Blood pressure increases; heart rate and respiratory rate decline.4) Men have higher blood pressure than women until after menopause. A client with vascular headaches is taking ergotamine (Ergomar). The nurse would monitor the client for: 1. Constipation 2. Hypotension 3. Dependent edema 4. Cool, numb fingers and toes A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to: 1. Baker's yeast 2. Eggs 3. Penicillin 4. Sulfonamides 36. The nurse is assisting a patient to learn self-administration of beclomethasone two puffs inhalation q6hr. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques? A. Chew a hard candy before the first puff of medication. B. Ask for a breath mint following the second puff of medication. C. Rinse the mouth with water before each puff of medication. D. Rinse the mouth with water following the second puff of medication. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?1) Reassure the patient by entering the room alone.2) Ask the patient if he is carrying any weapons.3) Stay between the patient and the door; keep the door open.4) Make eye contact while stating firmly "I will not tolerate cursing and threats." PART - LPN (delegation) blood pressure for adolescent 143.) A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of: 1. Heartburn 2. Constipation 3. Abdominal pain 4. Nausea and vomiting A manic-depressive client is placed on Lithium. The LPN/LVN provides instruction to the client regarding this medication. Which of the following is an appropriate statement by the nurse regarding this medication?(A) "You will need to restrict fluid intake while on this medication."(B) "You may skip your dose if you feel well when you wake up in the morning."(C) "You will need to visit your doctor regularly for laboratory blood testing."(D) "This medication may cause you to lose weight. So be sure to eat enough throughout the day." 13. The health care provider orders transfusion with packed RBCs for a patient who is hospitalized with severe anemia. The most important action by the nurse to prevent a transfusion reaction when administering the blood is toa. verify the patient identification according to hospital policy.b. administer the blood as soon as it arrives on the nursing unit.c. initiate the blood transfusion at a rate of no more than 2 ml/min.d. stay with the patient during the first 15 minutes of the transfusion. 17. The first nursing action indicated when a patient returns to the surgical nursing unit following a thyroidectomy is toa. check the dressing for bleeding.b. assess respiratory rate and effort.c. support the patient's head with pillows.d. take the blood pressure and pulse. bradykinesia dyspnea 14.) The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level Which sign is bluish coloration of the vagina? when might benztropine (Cogentin) be used other than to tx Parkinson's disease? The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Reddened area or red streaks at the site. 4. Leaking of fluid around the IV catheter. Which of the following represents an action demonstrating the Healthy Work Environment Initiative for Effective Recognition? (Select all that apply)A) A plaque on the wall that lists all the nurses with CCRN certificationB) A bulletin board listing all the charting deficits in the unit for the weekC) A banner in the hall to state the unit had no VAPs reported for the previous quarterD) A clinical ladder program that includes merit raises and opportunities for scholarships to national conferencesE) A newsletter article that talks about the projects completed by the shared governance committees in the department ALS: AMYOTROPHIC LATERAL SCLEROSIS :disease discription emphysema histamine nystagmus stage 3 inflammation What does vitamin K do? 161.) A nurse is caring for a client with severe back pain, and codeine sulfate has been prescribed for the client. Which of the following would the nurse include in the plan of care while the client is taking this medication? 1. Restrict fluid intake. 2. Monitor bowel activity. 3. Monitor for hypertension. 4. Monitor peripheral pulses. 16. When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is toa. stop the infusion if swelling is observed at the site.b. infuse the medication over a short period.c. administer the chemotherapy through small-bore catheter.d. hold the medication unless a central venous line is available. respirations of newborn The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting:A. Chest excursion B. Spinal curvatures C. The respiratory patternD. The fingernail and its base A nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. The nurse plans to administer this vaccine: 1. Intramuscularly in the anterolateral aspect of the thigh 2. Intramuscularly in the deltoid muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Subcutaneously in the gluteal muscle 19. Which of the following statements made by a nurse would indicate proper teaching principles regarding feeding and tracheostomies? A. "Follow each spoon of food consumed with a drink of fluid." B. "Thin your foods to a liquid consistency whenever possible." C. "Tilt your chin forward toward the chest when swallowing your food." D. "Make sure your cuff is overinflated before eating if you have swallowing problems." 14. Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding A. a gastrostomy tube that is clamped. B. the patient coughing blood-tinged secretions from the tracheostomy. C. the patient positioned in a lateral position with the head of the bed flat. D. 200 ml of serosanguineous drainage in the patient's portable drainage device. Eighty year old Mr. Lewis visits the physician at the clinic for his routine check-up. Following the doctor's orders, Mr. Lewis has been taking Amphogel for the past two weeks. Which of the following side effects should the LPN/LVN assess for?(A) Constipation(B) Diarrhea(C) Dizziness(D) Pruritis A client is receiving anticonvulsant therapy with phenytoin (Dilantin). The nurse plans to monitor the results of which laboratory test closely? 1. Serum sodium 2. Serum potassium 3. Blood urea nitrogen 4. Complete blood cell count 155.) Mycophenolate mofetil (CellCept) is prescribed for a client as prophylaxis for organ rejection following an allogeneic renal transplant. Which of the following instructions does the nurse reinforce regarding administration of this medication? 1. Administer following meals. 2. Take the medication with a magnesium-type antacid. 3. Open the capsule and mix with food for administration. 4. Contact the health care provider (HCP) if a sore throat occurs. 2. A patient who has been told by the health care provider that the cells in a bowel tumor are poorly differentiated asks the nurse what is meant by "poorly differentiated." Which response should the nurse make?a. "The cells in your tumor do not look very different from normal bowel cells."b. "The tumor cells have DNA that is different from your normal bowel cells."c. "Your tumor cells look more like immature fetal cells than normal bowel cells."d. "The cells in your tumor have mutated from the normal bowel cells." GUILLIAN-BARRE' SYNDROME :disease discription A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. re-establishes a trusting relationship with his/her other parent. 3. verbalizes that he/she is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:1. Uses a banister or wall for support when descending2. Uses one crutch for support while going up and down3. Advances the crutches first to ascend the stairs4. Advances the affected leg after moving the crutches to descend the stairs 41. Select all that apply. During initial assessment, a nurse should record which of the following manifestations of respiratory distress? A. Tachypnea B. Nasal flaring C. Thready pulse D. Panting or grunting E. Use of intercostal muscles F. An inspiratory-to-expiratory ratio of 1:2 The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty?1. "When do you usually retire for the night?"2. "What do you do to help yourself fall asleep?"3. "How much time does it usually take for you to fall asleep?"4. "Have you changed anything about your presleep ritual lately?" What is the body's only source of nitrogen? corticosteroids: teaching What is decorticate posturing? indomethacin A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume?1) White rice and toast2) Tomatoes and dried fruit3) Asparagus and melons4) Yogurt and parsley A client has been treated for cervical dystonia with an injection of botulinum toxin type A (Botox). Which of the following will the nurse teach the client to report immediately?a. Fever, aches, or chillsb. Difficulty swallowing, blurred vision, or ptosisc. Moderate levels of muscle weakness on the affected sided. Continuous spasms and pain on the affected side A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated?1) Apply an indwelling fecal drainage device.2) Apply an external fecal collection device.3) Place an incontinence garment on the patient.4) Place a waterproof pad under the patient's buttocks. 25. The nurse caring for a patient with hemophilia teaches the patient to seek immediate medical attention upon experiencinga. sore throat.b. skin abrasions.c. bleeding gums.d. dark tarry stools. A client has developed glaucoma. The nurse reviewing this client's medication history would identify long-term use of which drug as a potential contributor to glaucoma?a. Corticosteroidsb. Beta blockersc. Calcium channel blockersd. Insulin 157.) A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication? 1. Nausea 2. Diarrhea 3. Anorexia 4. Cough and chest pain 32. An excess of carbon dioxide in the blood causes an increased respiratory rate and volume because CO2 A. displaces oxygen on hemoglobin, leading to a decreased PaO2. B. causes an increase in the amount of hydrogen ions available in the body. C. combines with water to form carbonic acid, lowering the pH of cerebrospinal fluid. D. directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume. 5. Absorption of vitamin B12 may be decreased in older adults because of decreased A. intestinal motility. B. production of bile by the liver. C. production of intrinsic factor by the stomach. D. synthesis of cobalamin (vitamin B12) by intestinal bacteria. BELL'S PALSY :disease discription 117.) A nurse has given the client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client immediately reports: 1. Impaired sense of hearing 2. Distressing gastrointestinal side effects 3. Orange-red discoloration of body secretions 4. Difficulty discriminating the color red from green 36. The resurgence in TB resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis is primarily the result of A. a lack of effective means to diagnose TB. B. poor compliance with drug therapy in patients with TB. C. the increased population of immunosuppressed individuals with AIDS. D. indiscriminate use of antitubercular drugs in treatment of other infections. flail chest Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia. 2. Depression, disturbed sleep, restlessness, disorientation. 3. Nausea and vomiting, tachycardia, coarse tremors, seizures. 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea. Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted?1. A history of diabetes mellitus2. Use of phenelzine sulfate (Nardil)3. A history of myocardial infarction4. A history of irritable bowel syndrome 17. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is toa. check oxygen saturation q4hr.b. monitor fluid intake and output.c. place the patient on bed rest.d. administer iron supplements. The nurse knows that the results of a fecal occult blood test can be inaccurate ifa. the client has had an excessive intake of red meatb. the female client is menstruatingc. the client takes high doses of vitamin Cd. all of the above A client asks if convulsions and seizures are the same. The nurse's response is based on the knowledge that: Seizures involve muscle spasms on one side only. The terms can be used interchangeably. Seizure activity is more harmful than are convulsions. Convulsions always involve violent skeletal muscle activity. 18.) The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which of the following is documented in the client's history? 1. Pancreatitis 2. Diabetes mellitus 3. Myocardial infarction 4. Chronic obstructive pulmonary disease 18. A patient admitted to the hospital in preparation for a splenectomy for treatment of immune thrombocytopenia purpura (ITP) asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy isa. reduced destruction of platelets by macrophages.b. promotion of platelet sequesterization and release by the liver.c. increased production of platelets by the bone marrow.d. increased RBC production to compensate for blood loss. What are sources of vitamin B5? appropriate intervention for pt w/ presbycusis A client with obsessive-compulsive disorder (OCD) is admitted to the psychiatric facility for treatment. Select all of the following that are included in medical treatment of this disorder.(A) Prescription of selective serotonin reuptake inhibitors (SSRIs)(B) Behavior therapy(C) Prescription of benzodiazepines(D) Imagery(E) Distraction(F) Electroconvulsive therapy (ECT) 28. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?a. Fresh fruit saladb. Orange sherbetc. Strawberry yogurtd. French fries cor pulmonale What is the normal heart rate of an adult? 4. A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse would expect to finda. skin flushing.b. rising body temperature.c. decreasing blood pressure.d. muscle cramps. To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube? 1. Suction equipment. 2. Blood pressure cuff. 3. Levine tube. 4. Emesis basin. The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room. The nurse recognizes that several chemicals inhibit neurotransmitter function in the brain. The primary inhibitory transmitter in the brain is ______________. 55.) A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A health care provider prescribes a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? 1. 3 to 5 ng/mL 2. 0.5 to 2 ng/mL 3. 1.2 to 2.8 ng/mL 4. 3.5 to 5.5 ng/mL 25. A 75-year-old obese patient who is snoring loudly and having periods of apnea several times each night is most likely experiencing A. narcolepsy. B. sleep apnea. C. sleep deprivation. D. paroxysmal nocturnal dyspnea. hypercapnia The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/ana. Focused assessmentb. Initial assessmentc. Ongoing assessmentd. Special needs assessment Which of the following information provided by the client's bed partner is most associated with sleep apnea?1. Restlessness2. Talking during sleep3. Somnambulism4. Excessive snoring The client with a stroke has residual dysphagia. When the diet order is initiated, the nurse avoids doing which of the following?◦ A. Giving the client thin liquids◦ B. Thickening liquids to the consistency of oatmeal◦ C. Placing food on the unaffected side of the mouth◦ D. Allowing plenty of time for chewing and swallowing What are the dietary considerations for pancreatitis? When performing a comprehensive geriatric assessment of an older adult, focus of the nursing assessment is on the patient's: A. Physical signs of aging. B. Immunological function. C. Functional abilities. D. Chronic illness. 27. When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restricta. intake of green, leafy vegetables.b. the amount of high-fat foods.c. ingestion of dairy products.d. the quantity of fruits and juices. When feeding someone with a stroke or brain injury it may be better to have them ________________ while eating. hemianopsia What are the normal Creatinine Clearance values? Signs of IICP:(basic ideas) Prioritizing (FIRST) CVA: CEREBROVASCULAR ACCIDENT :disease discription 42. The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 1 mg/ml. How many milliliters should the nurse use to prepare the patient's dose?A. 0.2 B. 2.5 C. 3.75 D. 5.0 44.) A client is receiving acetylcysteine (Mucomyst), 20% solution diluted in 0.9% normal saline by nebulizer. The nurse should have which item available for possible use after giving this medication? 1. Ambu bag 2. Intubation tray 3. Nasogastric tube 4. Suction equipment BELL'S PALSY :S/S ComplicationCrisis Loss of lens elasticity 14. The charge nurse observes a new graduate performing a dressing change on a stage III sacral pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline.d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide. Which of the following would be the most appropriate room assignment for a child with lymphatic leukemia who is being admitted to the unit?(A) A semiprivate room with another child with leukemia(B) A semiprivate room with a child who is diagnosed with FUO(C) A private room on the pediatric medical floor(D) A private room in the intensive care unit The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer? 1. A nurse with an upper respiratory infection. 2. A young nurse who is 8 weeks pregnant. 3. A male nurse who is CMV-negative. 4. An older nurse with 30 years of experience. 28. The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately?a. The patient reports feeling "sick to my stomach."b. The patellar and triceps reflexes are absent.c. The patient has been sleeping most of the day.d. The bibasilar breath sounds are decreased. 13. A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question?a. Administer 3% saline if serum sodium drops to less than 128 mEq/L.b. IV morphine sulfate 4 mg every 2 hours prn.c. Infuse 5% dextrose in water at 125 ml/hr.d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea. TRIGEMINAL NEURALGIA :disease discription 4. A patient is suspected of having a pituitary tumor causing panhypopituitarism. During assessment of the patient, the nurse would expect to finda. elevated blood glucose.b. changes in secondary sex characteristics.c. high blood pressure.d. tachycardia and cardiac palpitations. 241.) A client with a history of simple partial seizures is taking clorazepate (Tranxene), and asks the nurse if there is a risk of addiction. The nurse's response is based on the understanding that clorazepate: 1. Is not habit forming, either physically or psychologically 2. Leads to physical tolerance, but only after 10 or more years of therapy 3. Leads to physical and psychological dependence with prolonged high-dose therapy 4. Can result in psychological dependence only, because of the nature of the medication What are the dietary considerations for Cushings? pneumothorax Wrap her hands in soft "mitten" restraints Which of the following is a correct initial nursing action to be performed by the LPN/LVN when a client with a physician-written DNR order goes into cardiac arrest?(A) Notify the physician(B) Initiate the emergency response system(C) Perform rescue breathing and chest compressions(D) Move the crash cart into the room beside the client's bed propantheline (Pro-Banthine): class, effect CNA's (delegation) CCANT Which sign is the softening of the cervix? 40. After receiving change-of-shift report about these four patients, which patient should the nurse assess first?a. A 22-year-old admitted with SIADH who has a serum sodium level of 130 mEq/L.b. A 31-year-old who has iatrogenic Cushing's syndrome with a capillary blood glucose level of 244 mg/dl.c. A 53-year-old who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef). d. A 70-year-old who recently started levothyroxine (Synthroid) to treat hypothyroidism and has an irregular pulse of 134. 43.) A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply. 1. Nizatidine (Axid) 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Cimetidine (Tagamet) 5. Esomeprazole (Nexium) 6. Lansoprazole (Prevacid) 37.) The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain What are the dietary considerations for Acute Renal Failure? 172.) A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse tells the client to avoid which food item? 1. Grapes 2. Spinach 3. Watermelon 4. Cottage cheese CN III Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult? A. 50% of older adults have two chronic health problems. B. Cancer is the most common cause of death among older adults. C. Nutritional needs for both younger and older adults are essentially the same. D. Adults older than 65 years of age are the greatest users of prescription medications. A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care?1. Limit visiting time to 60 minutes per visit2. Place the client in a private room near the nurse's station3. Reinsert the implant into the vagina immediately if it becomes dislodged4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering 162.) Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history, knowing that this medication is contraindicated if which of the following disorders is present? 1. Headaches 2. Liver disease 3. Hypothyroidism 4. Diabetes mellitus 166.) Alendronate (Fosamax) is prescribed for a client with osteoporosis. The client taking this medication is instructed to: 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning. Where are the Tricuspid heart sounds located? A licensed practical nurse (LPN) is reinforcing instructions given by a registered nurse (RN) to a client about how to take medications after discharge from the hospital. The LPN should use which of the following approaches to best ensure safe administration of medication in the home?1. Show the client the proper way to take prescribed medications2. Tell the client to double up on medications if a dose has been missed3. Count the number of pills remaining in the prescription bottle once a week4. Allow the client to verbalize and demonstrate correct administration procedure Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male? 1. Cognitive skills are starting to decline. 2. A balance is found among work, family, and social life. 3. Bone mass begins to increase at this age. 4. The client starts to measure life accomplishments against goals. dysgraphia Evaluate urine specific gravity 12. During the admission assessment of a patient who has an Hb of 7.6 g/dl (76 g/L), the nurse notes jaundice of the sclera. The nurse will plan to check the laboratory results fora. the stool occult blood test.b. the bilirubin level.c. the gastric analysis testing.d. the Schilling test. The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply.1) Bruxism2) Enuresis3) Daytime fatigue4) Snoring 236.) A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, the most important nursing intervention is: 1. Prescribing the client a tyramine-free diet 2. Checking the client for anticholinergic effects 3. Monitoring blood levels frequently because there is a narrow range between therapeutic and toxic blood levels of this medication 4. Getting baseline postural blood pressures before administering the medication and each time the medication is administered PD: PARKINSON'S DISEASE :S/S ComplicationCrisis When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should A. use a standardized geriatric nursing care plan. B. plan for likely long-term-care transfer to allow additional time for recovery. C. consider the preadmission functional abilities when setting patient goals. D. minimize activity level during hospitalization. when using crutches, follow the crutches w/ the weak|strong leg 222.) A nurse has administered a dose of diazepam (Valium) to a client. The nurse would take which important action before leaving the client's room? 1. Giving the client a bedpan 2. Drawing the shades or blinds closed 3. Turning down the volume on the television 4. Per agency policy, putting up the side rails on the bed 36. A patient with non-Hodgkin's lymphoma develops a platelet count of 10,000/l during chemotherapy. An appropriate nursing intervention for the patient, based on this finding, is toa. encourage fluids to 3000 ml/day.b. provide oral hygiene q2hr.c. check the temperature q4hr.d. check all stools for occult blood. 103.) A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client will the nurse specifically review to monitor for an adverse effect associated with the use of this medication? 1. Platelet count 2. Cholesterol level 3. White blood cell count 4. Blood urea nitrogen level Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of:1) Milk and cheese.2) Bread and pasta.3) Fruits and vegetables.4) Lean meats. Where is the location to listen to the Aortic valve? 10. When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include isa. monitor intake and output hourly.b. restrict oral free water intake.c. ambulate patient at least once per shift.d. use incentive spirometer every 2 hours. Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1. Remove the dressing layers one at a time. 2. Clean the wound with Betadine solution and hydrogen peroxide. 3. Clean the drain area first. 4. If the dressing adheres to the wound, pull gently and firmly. Which of the following pressure points is most likely to be at risk for developing a pressure wound while a client is in the prone position?(A) Occiput(B) Elbows(C) Toes(D) Coccyx School Age (6-12) Damage to cranial nerve I 200.) A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. The nurse tells the client to: 1. Apply a thick layer of cream to the entire body. 2. Apply the cream as prescribed for 2 days in a row. 3. Apply to the entire body and scalp, excluding the face. 4. Leave the cream on for 8 to 12 hours and then remove by washing. Peripheral Edema, bounding pulses, jugular vein distention, decreased or absent urinary output are signs of right or left sided heart failure? After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patient's pain?1) Encourage the client to ambulate to promote flow of spinal fluid.2) Offer caffeinated beverages to constrict blood vessels in his head.3) Encourage coughing and deep breathing to increase CSF pressure.4) Restrict oral fluid intake to prevent excess spinal pressure. A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk?1. Day shift2. Weekdays3. Shift change4. 8 am to 2 pm dysarthria 211.) A client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. A phenytoin blood level is drawn, and the results reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result? 1. Nystagmus 2. Tachycardia 3. Slurred speech 4. No symptoms, because this is a normal therapeutic level The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2. The nurse chases a patient who tries to run away while outside for a walk. 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison. Which of the following statements, made by the daughter of an older adult client concerning bringing her mother home to live with her family, presents the greatest concern for the nurse? A. "If this doesn't work out, she can always go to live with my sister." B. "I don't think she will react very well to me making decisions for her." C. "I'm afraid that mom will be depressed and miss her home." D. "My children will just have to adjust to having their grandmother with us." What conditions are contraindicated in the use of stimulants? 15. Fifteen minutes after a transfusion of packed red cells is started, a patient develops tachycardia and tachypnea and complains of back pain and feeling warm. The nurse first action should be toa. disconnect the transfusion and infuse normal saline.b. obtain a urine specimen to send to the laboratory.c. administer oxygen therapy at a high flow rate.d. notify the health care provider about the transfusion reaction. homonymous hemianopsia 73.) A client with myasthenia gravis is suspected of having cholinergic crisis. Which of the following indicate that this crisis exists? 1. Ataxia 2. Mouth sores 3. Hypotension 4. Hypertension What is Adjuvant chemotherapy and what is the purpose? What is the PPE transmission precaution for meningococcal meningitis? Mrs. Strachand was severely burned in an automobile accident. The burns cover her entire anterior chest and right arm. Using the Rule of Nines, the LPN/LVN would calculate the body surface area (BSA) that is burned to be:(A) 9%(B) 18%(C) 27%(D) 36% According to the American Heart Association (AHA), which of the following is the most prevalent form of cardiovascular disease?1. Stroke2. Coronary Artery Disease (CAD)3. Hypertension4. Rheumatic heart disease what are signs of right ventricular failure The critical care nurse is planning an interdisciplinary team conference regarding placement for a long-term ventilator patient. Which team members should be included? (Select all that apply)A) Staff nurseB) Respiratory therapistC) Case managerD) PhysicianE) Physical therapist 2. A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully fora. rapid and unexpected weight loss.b. increased total urinary output.c. decreased serum sodium level.d. elevation of serum hematocrit. alpha 1-antitrypsin 239.) Which of the following precautions will the nurse specifically take during the administration of ribavirin (Virazole) to a child with respiratory syncytial virus (RSV)? 1. Wearing goggles 2. Wearing a gown 3. Wearing a gown and a mask 4. Handwashing before administration Light sleep and slowing brain and body processes are associated with which stage of NREM sleep?a. Ib. IIc. IIId. IV 99.) The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The client develops a temperature of 101° F. The nurse does further monitoring of the client, knowing that this sign would most likely indicate: 1. The dose of the medication is too low. 2. The client is experiencing toxic effects of the medication. 3. The client has developed inadequacy of thermoregulation. 4. The result of another infection caused by leukopenic effects of the medication. The nurse is trying to communicate with a client with a stroke and aphasia. Which of the following actions by the nurse would be least helpful to the client?◦ A. Speaking to the client a slower rate◦ B. Allowing plenty of time for the client to respond◦ C. Completing the sentences that the client cannot finish◦ D. Looking directly at the client during attempts at speech MS: MULTIPLE SCLEROSIS :S/S ComplicationCrisis 0.9% sodium chloride is the same as what? 29. The nurse has identified the nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation in a patient with lung cancer who has had a 10% loss in weight. An appropriate nursing intervention that addresses the etiology of this problem is toa. provide foods that are highly spiced to stimulate the taste buds.b. avoid presenting foods for which the patient has a strong dislike.c. add strained baby meats to foods such as soups and casseroles.d. teach the patient to eat whatever is nutritious since food is tasteless. 16.) The clinic nurse is reviewing a teaching plan for the client receiving an antineoplastic medication. When implementing the plan, the nurse tells the client: 1. To take aspirin (acetylsalicylic acid) as needed for headache 2. Drink beverages containing alcohol in moderate amounts each evening 3. Consult with health care providers (HCPs) before receiving immunizations 4. That it is not necessary to consult HCPs before receiving a flu vaccine at the local health fair acetic acid "The lens is normally transparent 230.) A client is placed on chloral hydrate (Somnote) for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication? 1. Monitoring neurological signs every 2 hours 2. Monitoring the blood pressure every 4 hours 3. Instructing the client to call for ambulation assistance 4. Lowering the bed and clearing a path to the bathroom at bedtime What are characteristics of urge incontinence? The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction. 2. A 50-year-old with a diabetic foot ulcer. 3. A 62-year-old heart transplant with suspected rejection. 4. An 84-year-old with chronic obstructive pulmonary disease. Dopamine An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet. 2. Position client on unaffected side. 3. Exercise the client's arms and legs. 4. Encourage the client to cough and deep breathe. Equal pupillary constriction in response to light 11. In the patient who has had an intraoperative hemorrhage, the nurse would expect to find hematology results ofa. hematocrit of 45%.b. elevated reticulocyte count.c. decreased WBC count.d. hemoglobin 13.2 g/dl. 213.) A client is admitted to the hospital with complaints of back spasms. The client states, "I have been taking two or three aspirin every 4 hours for the past week and it hasn't helped my back." Aspirin intoxication is suspected. Which of the following complaints would indicate aspirin intoxication? 1. Tinnitus 2. Constipation 3. Photosensitivity 4. Abdominal cramps A nurse is assisting in the admission of a postoperative client from the postanesthesia care unit to the surgical nursing unit. The nurse should do which of the following for the safety of the client?1. Ask the client to slide from the stretcher to the bed2. Move the client rapidly from the stretcher to the bed3. Put the bed rails up after moving the client from the stretcher4. Uncover the client before transferring him or her from the stretcher to the bed A health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which of the following medications should the nurse expect to be prescribed and administered by this route? 1. Cyclobenzaprine hydrochloride (Flexeril) 2. Chlorzoxazone (Paraflex) 3. Dantrolene sodium (Dantrium) 4. Baclofen (Lioresal) A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client?1. Measuring the pH of gastric aspirate2. Submerging the NG tube in water to check for bubbling3. Aspirating the NG tube with a 50 mL syringe for gastric contents4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach 50. The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler. Which of the following instructions given by the nurse is most appropriate to help the patient learn proper inhalation technique? A. "Avoid shaking the inhaler before use." B. "Breathe out slowly before positioning the inhaler." C. "After taking a puff, hold the breath for 30 seconds before exhaling." D. "Using a spacer should be avoided for this type of medication." prolapse of the umbilical cord indicates what pt positioning? Hypogeusia What is the nursing process? 40. The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/ml. How many milliliters should the nurse use to prepare the patient's dose? A. 0.2 B. 2.5 C. 3.75 D. 5.0 respirations of 1 year old The nurse is making an occupied bed. Arrange the following steps in the order the nurse should perform them.A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. B. Lower the side rail on the side of the bed you are working on.C. Raise the side rail on the side of the bed you are working on.D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed. What percentage of the total daily caloric intake should be through saturated fat? 113.) A nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which of the following would be included in the plan of care for instructions? 1. Maintain a high fluid intake. 2. Discontinue the medication when feeling better. 3. If the urine turns dark brown, call the health care provider immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response. Positive Kernig's sign: 70.) Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness COX-2 inhibitor actions ibuprofen 11. A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stagea. I.b. II.c. III.d. IV. pulmonary edema The nurse knows an advantage to rivastigmine (Exelon) over other cholinesterase inhibitors is that it:a. Has no significant drug interactions.b. Does not cause cholinergic adverse effects.c. Is absorbed best on an empty stomach.d. Does not alter glucose control in clients with diabetes. The nurse is providing education to the patient concerning a new medication. Which of the following will have to be dealt with before the patient can effectively learn? (Select all that apply)A) The patient's blood sugar is 60.B) The patient's blood pressure is 120/70.C) The patient needs to use the bedpan.D) The patient has a new magazine.E) The patient has been sitting up in the chair for the first time and is tired. A client is admitted to a long-term care facility with a diagnosis of Parkinson's disease. The nurse gives information about the client's condition to a visitor assumed to be a family member. The nurse has violated which legal concept of the nurse-client relationship?1. Incompetency2. Invasion of privacy3. Communication techniques4. Teaching/Learning principles A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order?1. Monitor weight daily2. Monitor urine output hourly3. Maintain the nasogastric tube to intermittent suction4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn with an antiseptic soap and water. 2. Remove clothing, and wrap the victim in a clean sheet. 3. Leave the blisters intact and apply an ointment. 4. Take no action until the victim arrives in a burn unit. pleurisy (pleuritis) 97.) Amikacin (Amikin) is prescribed for a client with a bacterial infection. The client is instructed to contact the health care provider (HCP) immediately if which of the following occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches In preparation for a cerebral angiography, what do you need to ask the patient before the test? What are sources of vitamin B2? A nurse who is assisting a physician with insertion of a Miller-Abbott tube should do which of the following to ensure a safe environment and decrease the client's risk of aspiration?1. Place the client in a high-Fowler's position2. Assist with inserting the tube with the balloon inflated3. Instruct the client to bear down if there is an urge to gag4. Ask the client to cough when the tube reaches the nasopharynx The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL. 40.) The client who chronically uses nonsteroidal anti-inflammatory drugs has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count the rate of IV administration should be no faster than what? The nurse is teaching the client about his upcoming procedure and the client is very stressed. It would be most important for the nurse toa. Use humor first to decrease the client's stress levelb. Determine if the teaching should take place at a different timec. Introduce himself as the RN to give credibility to his messaged. Speak to the client when family members are there so they can teach the client A nurse has reinforced instructions to a parent regarding the safe methods to prevent Lyme disease. Which statement made by a parent would indicate the need for additional instructions?1. "We should wear hats when we go on our hiking trip."2. "Wearing long-sleeved tops and long pants is important."3. "We should wear closed shoes and socks that can be pulled over our pants."4. "We should avoid the use of insect repellents because they will attract the ticks." The nurse should question a health care provider's order of phenobarbital for the client with which conditions?a. Seizure disorderb. Panic disorderc. Prior to a bronchoscopyd. Prior to receiving a general anesthetic 7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the patient understands the purpose of a biopsy?a. "The biopsy will tell the doctor whether the cancer has spread to my other organs."b. "The biopsy will help the doctor decide what treatment to use for my enlarged prostate."c. "The biopsy will determine how much longer I have to live."d. "The biopsy will indicate the effect of the cancer on my life." fremitus During routine vital signs, the LPN/LVN auscultates a BP of 180/98. How long should the LPN/LVN wait before inflating the cuff to recheck this reading?(A) 15 seconds(B) 30 seconds(C) 1 minute(D) 2 minutes 18. A patient with hyperthyroidism is treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the nurse instructs the patienta. to monitor for symptoms of hypothyroidism, such as easy bruising and cold intolerance.b. to discontinue the antithyroid medications taken before the radioactive therapy.c. that symptoms of hyperthyroidism should be relieved in about a week.d. about radioactive precautions to take with urine, stool, and other body secretions. A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h." petechiae 34. A 45-year-old patient with chronic myelogenous leukemia (CML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT) from an HLA-matched sibling. To assist the patient with treatment decisions, the best approach for the nurse to use is toa. emphasize the positive outcomes of a bone marrow transplant.b. ask the patient whether there are any questions or concerns about HSCT.c. explain that a cure is not possible with any other treatment except HSCT.d. discuss the need for adequate insurance to cover post-HSCT care. 148.) A client is taking cetirizine hydrochloride (Zyrtec). The nurse checks for which of the following side effects of this medication? 1. Diarrhea 2. Excitability 3. Drowsiness 4. Excess salivation Which diagnostic test/exam would best measure a client's level of hypoxemia?a. chest x-rayb. pulse oximeter readingc. ABGd. peak expiratory flow rate What effect on a client's pulse rate would the LPV/LVN expect to occur from taking the medication propranolol (Inderal)? vecuronium bromide (Norcuron): common SE and RN priority Activity of the brain A client receives total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 ml/h. inflammation vs. infection Mr. Dwindell is admitted to the unit with severe dehydration caused by persistent nausea, vomiting and diarrhea. Which of the following fluids would the physician most likely start the client on?(A) 0.45% sodium chloride with added potassium(B) 0.9% sodium chloride with added potassium(C) 3% sodium chloride with added potassium(D) 0.9% sodium chloride Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?1. "I work with my ancillary staff to be able to determine what is abnormal." 2. "The skin is easy to observe for abnormalities when you are giving the bath."3. "I use the time to really look at my clients and determine what's normal and what's not."4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship." 8. When evaluating the red cell indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicatesa. small size of the red blood cells (RBCs).b. inadequate numbers of RBCs.c. low hemoglobin in the RBCs.d. hypochromic RBCs. What does vitamin B6 (pyridoxine) do? What does vitamin B3 (niacin) do? MENINGITIS :S/S ComplicationCrisis 3. Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is aa. weight gain of 2 pounds above the preoperative weight.b. an oral temperature of 100.1° F with bibasilar lung crackles.c. gradually decreasing level of consciousness (LOC).d. serum sodium level of 138 mEq/L (138 mmol/L). The LPN/LVN is teaching a male client how to perform a testicular self examination (TSE). Which of the following is NOT accurate for performing this procedure?(A) "It is best to perform the exam in the shower."(B) "The exam may hurt a little as you apply pressure to the testes."(C) "Use your thumb and first two fingers to palpate the area."(D) "If anything abnormal is detected, call your physician for further examination." During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following? 1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively. 2. Arrange all live plants received postoperatively in one section of the room. 3. Continue intermittent peritoneal dialysis for 3 months following surgery. 4. Limit consumption of sodium-free liquids for 1 year postoperatively. acute adrenal insufficiency A client on Lithium for antimanic effects comes to the clinic for regular testing of serum Lithium level. Which of the following indicates a therapeutic level of this medication in the blood?(A) 0.45mEq/L(B) 0.78mEq/L(C) 1.6mEq/L(D) 2.0mEq/L elderly with long term IV antibiotics may be r/t what? 31. A patient is admitted to the hospital in addisonian crisis 1 month after a diagnosis of Addison's disease. The nurse identifies the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of condition when the patient says,a. "I double my dose of hydrocortisone on the days that I go for a run."b. "I had the stomach flu earlier this week and couldn't take the hydrocortisone."c. "I frequently eat at restaurants, and so my food has a lot of added salt."d. "I do yoga exercises almost every day to help me reduce stress and relax." Tensilon Test 104.) Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. The nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? 1. A history of hyperthyroidism 2. A history of diabetes insipidus 3. When the last full meal was consumed 4. When the last alcoholic drink was consumed A client receiving digoxin (Lanoxin) therapy is being treated for status epilepticus with diazepam (Valium). The nurse places priority on: Holding the digoxin until the seizure has subsided. Monitoring the client for nausea and GI cramping. Keeping the client in a high Fowler's position. Instructing the client to eat foods high in potassium. what are signs of pulmonary edema A nurse is assigned to care for a client who has returned to the nursing unit after an oral cholecystogram. At this point in time, the nurse should question which of the following physician's orders in the medical record?1. Assess for nausea and vomiting2. Monitor the client's hydration status3. Maintain a clear liquid status for 72 hours4. Monitor the client for abdominal discomfort Which of the following would provide the best information as to whether hemodialysis (HD) has been effective therapy for a client with renal failure?(A) Checking the client's weight(B) Measuring intake and output(C) Checking the potassium level of the client's blood(D) Monitoring a client's tolerance to exercise A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?1. A client who had a below-the-knee amputation2. A client on a 24-hour urine collection who is on strict bed rest3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure4. A client scheduled to be transferred to the hospital for coronary artery bypass surgery 72.) Cinoxacin (Cinobac), a urinary antiseptic, is prescribed for the client. The nurse reviews the client's medical record and should contact the health care provider (HCP) regarding which documented finding to verify the prescription? Refer to chart. 1. Renal insufficiency 2. Chest x-ray: normal 3. Blood glucose, 102 mg/dL 4. Folic acid (vitamin B6) 0.5 mg, orally daily 27. A patient with Cushing syndrome is admitted to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the patient tells the nurse, "The worst thing about this disease is how terrible I look. I feel awful about it." The best response by the nurse isa. "Let me show you how to dress so that the changes are not so noticeable."b. "I do not think you look bad. Your appearance is just altered by your disease."c. "Most of the physical and mental changes caused by the disease will gradually improve after surgery."d. "You really should not worry about how you look in the hospital. We see many worse things." What are normal specific gravty values? Painless vaginal bleeding is a possible sign of what? 26.) Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. A nurse reinforces instructions for the client and tells the client to avoid which of the following while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages -Paresis: A client who is admitted to the labor and delivery unit in active labor has active genital herpes lesions present in the genital tract. The licensed practical nurse should reinforce teaching done by the registered nurse about which of the following immediate plans for the client?1. Placement on protective isolation2. Preparation for a cesarean delivery3. Preparation for spontaneous vaginal delivery4. Imminent artificial rupture of the membranes OTHER 1. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order will the nurse perform the following actions?a. Administer acetaminophen (Tylenol).b. Perform wet-to-dry dressing change.c. Administer intravenous antibiotics.d. Sponge patient with cool water. 3.) Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which of the following would indicate the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations 1 kg = how many liters of water? if a neck injury is suspected, what maneuver is used? In a small rural hospital they work with a wide variety of clients. Of this afternoon client's admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with:1) Burns2) Diabetes3) Pulmonary emphysema4) Peripheral vascular disease 34. A patient has an adrenocortical adenoma causing hyperaldosteronism and is scheduled for laparoscopic surgery to remove the tumor. During care before surgery, the nurse shoulda. monitor blood glucose level every 4 hours.b. provide a potassium-restricted diet.c. monitor the blood pressure every 4 hours.d. relieve edema by elevating the extremities. 237.) A client who is on lithium carbonate (Lithobid) will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse will instruct the client that it is most important to: 1. Avoid soy sauce, wine, and aged cheese. 2. Have the lithium level checked every week. 3. Take medication only as prescribed because it can become addicting. 4. Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications. The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply." 84.) Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse assists in planning care, knowing that the primary therapeutic effect of this medication is which of the following? 1. Increased muscle tone 2. Decreased muscle spasms 3. Increased range of motion 4. Decreased local pain and tenderness How many arteries and veins are in the umblical cord? The nurse is discussing a middle-age adult male client's report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.)1. An enlarged prostate gland2. Poorly controlled blood glucose3. Drinking a cup of tea before bed4. Possible side effect of his medication5. Taking his diuretic too close to bedtime6. Consuming too many liquids during the day Slow, irregular respirations A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device?1. Position the client in the center of the sling2. Have three staff members available to assist3. Lower the client rapidly once positioned over the chair4. Have the client grasp the chains attaching the cling to the lift 3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal. A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.) A. Falls asleep in the examination room B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which of the following items to perform the test?◦ A. Tuning fork and audiometer◦ B. Snellen chart, ophthalmoscope◦ C. Flashlight, pupil size chart or millimeter ruler◦ D. Safety pin, hot and cold water in test tubes, cotton wisp 14. Following a motor-vehicle accident, a patient is scheduled for an ultrasound of the spleen. Which patient education will be included in the teaching plan?a. "You will need to avoid eating or drinking anything for 6 hours before the exam."b. "An intravenous line will be started to administer fluids and medications during the exam."c. "A lubricated probe will be moved across your abdomen to check for any spleen injuries."d. "Iodine-based solution will be injected to help visualize the borders of your spleen." The physician has prescribed promethazine (Phenergan) 12.5 mg IM q 4 hours prn for a chemotherapy client with severe nausea. The vial reads 50 mg of medication per mL of solution. How much solution should the LPN/LVN draw into the syringe for IM administration?(A) 0.125 mL(B) 0.25 mL(C) 0.75 mL(D) 1 mL The name of the scale used globally to assess a person's consciousness A client who is taking clopidogrel (Plavix) to prevent another stroke asks the nurse how the medication works. The nurse's response should be based upon an understanding that Plavix:a. Inhibits platelet aggregation to prevent clot formation.b. Activates antithrombin III and subsequently inhibits thrombin.c. Inhibits enzymes involved in the formation of vitamin K.d. Converts plasminogen to plasmin to dissolve fibrin clots. 183.) A client who received a kidney transplant is taking azathioprine (Imuran), and the nurse provides instructions about the medication. Which statement by the client indicates a need for further instructions? 1. "I need to watch for signs of infection." 2. "I need to discontinue the medication after 14 days of use." 3. "I can take the medication with meals to minimize nausea." 4. "I need to call the health care provider (HCP) if more than one dose is missed." The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group? A. Suggest that he purchase an emergency in-home alert system. B. Arrange for the client to receive meals delivered to his home daily. C. Encourage the client to use a compartmentalized pill storage container for his daily medications. D. Provide only written document describing the medications the client is currently prescribed. A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that: A. Diet and exercise can slow the process considerably B. It usually progresses gradually with a deterioration of function C. Many individuals can be cured if the diagnosis is made early D. Few clients live more than 3 years after the diagnosis An older client who has not been hospitalized previously is extremely anxious after hospital admission. To provide a safe environment for the client and minimize the stress of hospitalization, the nurse should do which of the following?1. Keep visitors to the minimum number possible2. Keep the door open and room lights on at all times3. Admit the client to a room far away from the nurse's station4. Allow the client to have as many choices related to care as possible A PACU nurse has received a semiconscious patient form the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. in this situation, in what position will the nurse place the patient?a. supineb. pronec. side-lyingd. trendelenburg A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first?1. Aspirate the tube2. Flush the tube with warm water3. Prepare to remove and replace the tube4. Flush with a carbonated liquid such as cola Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function?1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."2. "Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines."3. "If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain."4. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure." What is the mechanism of stimulant use in ADHD? 11. Which action by a nursing assistant (NA) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene?a. The NA places the patient's bedding in the laundry container in the hallway.b. The NA flushes the toilet once after emptying the patient's bedpan.c. The NA stands by the patient's bed for an hour talking with the patient.d. The NA gives the patient an alcohol-containing mouthwash for oral care. 23.) A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which information should the nurse teach when carrying out plans for discharge? 1. Keep insulin vials refrigerated at all times. 2. Rotate the insulin injection sites systematically. 3. Increase the amount of insulin before unusual exercise. 4. Monitor the urine acetone level to determine the insulin dosage. 119.) A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which of the following is the most reliable indicator of hypoglycemia? 1. Sweating 2. Tachycardia 3. Nervousness 4. Low blood glucose level 142.) A health care provider has written a prescription for ranitidine (Zantac), once daily. The nurse should schedule the medication for which of the following times? 1. At bedtime 2. After lunch 3. With supper 4. Before breakfast The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients? 1. A client who had a total hip replacement and requires assistance with ambulation. 2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet. 3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine. 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder. A client is admitted to the unit with deep partial thickness burns on bilateral lower extremities. The LPN/LVN knows that deep partial thickness burns would exhibit which of the following characteristics?(A) The burns involve the epidermis and dermis(B) The burns involve the epidermis, dermis and subcutaneous tissue(C) The burns involve all skin layers and destruction of nerve endings(D) Necrosis is evident in the burned areas 2.) Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which best food item? 1. Milk 2. Water 3. Apple juice 4. Orange juice How do you determine which stimulant is a better tx? There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: A. Men have the greatest incidence of osteoporosis B. Muscle fibers increase in size and become tighter C. Weight-bearing exercise reduces the loss of bone mass D. Muscle strength does not diminish as much as muscle mass A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first?1) Remove the contaminated clothing immediately.2) Flood the contaminated area with lukewarm water.3) Wash the contaminated area with soap and water and rinse.4) Call the nearest poison control center immediately. A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use?1. Two-point2. Three-point3. Four-point4. Swing-through Your patient assigned to you has pneumonia. You are reviewing the age-related changed involved with the older adult. Select all age-related changes of the respiratory system that apply. 1. Decreased in residual lung volume 2. Decreased gas exchange 3. Decreased cough efficiency 4. Increased gas exchange To maintain proper posture, it is important toa. sleep on the softest mattress possible b. avoid arching shoulders forward when sittingc. keep your knees locked when standing uprightd. keep your stomach muscles relaxed to prevent back spasms The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection. 2. Fluid and electrolyte balance. 3. Seizure precautions. 4. Steroid replacement. The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy. CVA: CEREBROVASCULAR ACCIDENT :S/S ComplicationCrisis 63.) A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Select the appropriate actions that the nurse should take. Select all that apply. 1. Call a code blue. 2. Contact the registered nurse. 3. Contact the client's family. 4. Assess the client's pain level. 5. Check the client's blood pressure. 6. Administer a second nitroglycerin, 0.4 mg, sublingually. A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client?1. Mask and gloves2. Gown and gloves3. Mask, gown and gloves4. Gown, gloves and eyewear 21.) A nurse is assisting with caring for a client with cancer who is receiving cisplatin. Select the adverse effects that the nurse monitors for that are associated with this medication. Select all that apply. 1. Tinnitus 2. Ototoxicity 3. Hyperkalemia 4. Hypercalcemia 5. Nephrotoxicity 6. Hypomagnesemia NSAIDS: lifespan considerations An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:1. Confusion2. Impaired judgment3. Sensory deficits4. History of falls The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similar in type and dosages to those given before general surgery. 19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the patient about the procedure? A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas. B. This test will use special technology to examine cross sections of the chest with use of a contrast dye. C. This test will use magnetic fields to produce images of the lungs and chest. D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs. thrombocytopenia: sx Mrs. Fischner's physician diagnosed that she has rheumatoid arthritis. With this condition, the client's chief complaint is persistent joint pain and stiffness. Pain and stiffness associated with rheumatoid arthritis is most often first noticed in the joints of which of the following?(A) Hands(B) Arms(C) Legs(D) Neck A client with severe peptic ulcer disease undergoes a Billroth II surgical procedure. Which of the following best describes the alterations made to the gastrointestinal tract with this procedure?(A) Antrectomy with anastomosis to the duodenum(B) Antrectomy with anastomosis to the jejunum(C) Vagus nerves are severed(D) Resection of the large bowel The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?1) Continue to monitor the pump to see if the crack worsens.2) Place the pump back on the utility room shelf.3) A small crack poses no danger so continue using the pump.4) Clearly label the pump and send it for repair. 10. The nurse will plan to use wet-to-dry dressings when providing care for aa. full-thickness burn filled with dry, black material.b. surgical incision with pink, approximated edges.c. pressure ulcer with pink granulation tissue.d. wound with purulent drainage and dry brown areas. A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test?1. Shave the groin area for insertion of a femoral catheter2. Apply metal-tipped electrodes on the client's chest3. Remove all objects containing metal from the client4. Ensure that the client stays NPO for 24 hours before the test A nurse is caring for a client who is dying and is a potential organ donor. The nurse reviews the client's medical record and identifies a contraindication to organ donation if which of the following were documented in the client's record?1. Age of 38 years2. Hepatitis B infection3. Allergy to penicillin type antibiotics4. Negative rapid plasma reagin (RPR) laboratory result What are normal platelet count? 25. A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse?a. Arterial oxygen saturation 91%b. Serum potassium is 5.1 mEq/Lc. Arterial blood pH is 7.32d. Serum calcium is 18 mEq/L 196.) A client has been prescribed amikacin (Amikin). Which of the following priority baseline functions should be monitored? 1. Apical pulse 2. Liver function 3. Blood pressure 4. Hearing acuity A 2 month-old is admitted to the hospital. The nurse should take which of the following actions to maintain the infant's safety and to reduce the risk of sudden infant death syndrome (SIDS)?1. Make sure that only plastic bottles and toys are used2. Place the infant in a supine position in preparation for sleep3. Take the pacifier out of the mouth before the infant falls asleep4. Cover the crib with netting when the child is not being directly observed A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. Emotional trauma and stress. 2. Onset of menopause. 3. Presence of uterine fibroids. 4. Possible tubal pregnancy. A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when:1. Five sputum cultures are negative2. Three sputum cultures are negative3. The PPD and chest x-ray are negative4. A sputum culture and a PPD test are negative 6. A patient's 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse anticipate using for wound care?a. Transparent film dressing (Tegaderm)b. Dry gauze dressing (Kerlix)c. Hydrocolloid dressing (DuoDerm)d. Nonadherent dressing (Xeroform) A practical nurse student is preparing for an upcoming exam on the reproductive system. Arrange the following in order as they occur in the menstrual cycle and ovulation.(A) Ovulation occurs(B) Estrogen level peaks(C) Endometrium is shed(D) Progesterone level drops(E) Estrogen level drops sharply(F) Estrogen level is low 19.) Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that the primary action of this medication is to: 1. Increase DNA and RNA synthesis. 2. Promote the biosynthesis of nucleic acids. 3. Increase estrogen concentration and estrogen response. 4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors. A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure. Guillian-Barre S/S 1) A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client? 1. Calcium chloride 2. Calcium gluconate 3. Calcitonin (Miacalcin) 4. Large doses of vitamin D A client is receiving diazepam (Valium) for its skeletal muscle relaxant effects. The nurse should monitor this client for which side effect of this medication? 1. Urinary retention 2. Headache 3. Incoordination 4. Increased salivation adverse effects of corticosteroid use The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient? A. Show a colorful video about anticoagulation therapy. B. Present all the information in one session just before discharge. C. Give the patient pamphlets about the medications to read at home. D. Develop large-print handouts that reflect the verbal information presented. foods ↑ in K leading cause of disability and #1 inflammatory disease in US An adolescent asks a nurse about the procedure to become an organ donor. The nurse most accurately tells the adolescent that:1. Written consent is never required to become a donor2. A donor must be 18 years or older to provide consent3. An individual who is at least 16 years of age can sign to become a donor4. The family is responsible for making the decision about organ donation at the time of death The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart. 5.) Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action? 1. Notifying the registered nurse 2. Discontinuing the medication 3. Informing the client that this is normal 4. Applying a thinner film than prescribed to the burn site An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? A. "I don't seem to have problems with side effects, but I'll let my doctor know if something happens." B. "I'm lucky since my daughter is really good about keeping up with my medications." C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something." D. "It shouldn't be too hard to keep it straight since I don't have any really serious health issues." Diuretics are often prescribed for treatment of acute glomerulonephritis to treat fluid overload and hypertension. Which of the following is least likely to be prescribed for this purpose in glomerulonephritis?(A) Bumex(B) Lasix(C) Demadex(D) Aldactone 8. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?a. "I can have low-fat cheese."b. "I will have apple juice instead of orange juice."c. "I will drink at least 8 glasses of water every day."d. "I can use a salt substitute." A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to:1) Increased exercise.2) Nicotine withdrawal.3) Caffeine intake.4) Environmental changes. 42.) A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach." What is the normal PT value? The nurse plans care for a client who is receiving an ophthalmic anesthetic agent based on which priority for nursing care? a. Measures to increase tear secretionb. Measures to protect the eyec. Monitoring for conjunctivitisd. Assessing for level of consciousness A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient? 1. Oxycodone terephthalate (Percodan). 2. Ibuprofen (Motrin). 3. Enteric-coated aspirin. 4. Codeine phosphate (Paveral). hold NG tube feeding with residual amounts more than what? Bell's Palsy Nursing Interventions: 26. A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will includea. maintaining the patient on bedrest to prevent pathologic fractures.b. monitoring for Trousseau's and Chvostek's signs.c. encouraging fluid intake up to 4000 ml every day.d. auscultate breath sounds every 4 hours. STAR An older client in a long-term care facility is at risk for injury because of confusion. Because the client's gait is stable, which method of restraint, if prescribed, would be best used by the nurse to prevent injury to the client?1. Vest restraint2. Waist restraint3. Alarm-activating bracelet4. Chair with a locking lap-tray Carbohydrates are the main source of fuel for which body systems? A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding? 1. "I feel fine, but the bleeding scares me." 2. "I've been more nauseated during the past few weeks." 3. "The bleeding started after I carried four bags of groceries." 4. "I've been having severe abdominal cramps." A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse assigned to assist in caring for the client prepares to carry out which of the following orders that will maintain viability of the kidneys before organ donation?1. Checking respirations2. Monitoring temperature3. Frequent range of motion to extremities4. Administration of intravenous (IV) fluids The nurse is preparing a 42-year-old man for hospital discharge after an MI. Which of the following statements indicates the need for further teaching?1. "I will take my medications as prescribed"2. "I will follow a low-cholesterol, low-fat diet"3. "I can exercise as much as I want"4. "I can have a small glass of wine with the evening meal" A client is receiving a maintenance dose of oral dantrolene sodium (Dantrium) for the treatment of spasticity. The nurse reviews the medication record, expecting that which of the following doses would be prescribed? 1. 50 mg daily 2. 100 mg daily 3. 100 mg twice daily 4. 200 mg four times daily What is Ortilani's Sign Rapid dilantin administration can cause cardiac arrhythmias 4.) The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied: 1. Immediately before swimming 2. 15 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun 20. The nurse is caring for a patient ITP who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets?a. Petechiae are present on the chest and back.b. Blood pressure (BP) is 94/56 mm Hg.c. Platelet count is 42,000/l.d. Blood is oozing from the venipuncture site. how often should the incentive spirometer be used? 47.) A client has been taking isoniazid (INH) for 2 months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation vecuronium bromide (Norcuron): class and use What does vitamin A do? PD: PARKINSON'S DISEASE :disease discription 30. The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following? A. Adrenocortical dysfunction and hyperglycemia B. Elevation of blood glucose and calcium levelsC. Oropharyngeal candidiasis and hoarseness D. Hypertension and pulmonary edema Dilated non reactive pupils The LPN/LVN is evaluating a 6 second long electrocardiogram (ECG) strip. Which of the following represents depolarization of the ventricular muscle?(A) P wave(B) T wave(C) QRS complex(D) PR interval 22.) A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone. Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep. 38. A patient is admitted with possible SIADH. Which information obtained by the nurse is most important to communicate rapidly to the health care provider?a. The patient complains of a severe headache.b. The patient complains of severe thirst.c. The patient has a urine specific gravity of 1.025.d. The patient has a serum sodium level of 119 mEq/L. Do Myotic drops constrict or dilate the pupils? A nurse is giving a bed bath to a client who is on strict bed rest. To safely increase venous return, the nurse bathes the client's extremities by using:1. Long, firm strokes from distal to proximal areas2. Short, patting strokes from distal to proximal areas3. Firm, circular strokes from proximal to distal areas4. Smooth, light strokes back and forth from proximal to distal areas diphenhydramine The client with Parkinson's disease has a nursing diagnosis of falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait?◦ A. Unsteady and staggering◦ B. Shuffling and propulsive◦ C. Broad-based and waddling◦ D. Accelerating with walking on the toes 19. The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with PCP. Which is most important to administer at the right time?a. Nystatin (Mycostatin) tablet for vaginal candidiasisb. Aerosolized pentamadine (NebuPent) for PCP infectionc. Oral acyclovir ((Zovirax to treat systemic herpes simplexd. Oral saquinavir (Inverase) to suppress HIV infection 20. Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check fora. elevated serum potassium level.b. decreased thyroid hormone level.c. bleeding on the patient's dressing.d. the presence of Chvostek's sign. 26. Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider?a. Hemoglobin of 10 g/Lb. WBC count of 1700/µlc. Platelets of 65,000/µld. Serum creatinine level of 1.2 mg/dl A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following safe treatments with this client?1. Laser therapy2. Interferon therapy3. Cytotoxic medications4. No therapy is available What is the normal PaCO2 value? can a pt give consent if he has been drinking or is pre-medicated? What does sodium do in the body? hospital-acquired pneumonia . The nurse is instilling drops of phenylephrine (Neo-Synephrine) into the client's eye before cataract surgery. Phenylephrine is used prior to cataract surgery because it causes __________, allowing visualization of the operative area. 3. In preparing the preoperative teaching plan for a patient who is to undergo a total laryngectomy, a nurse should give highest priority to the A. tracheostomy being in place for 2 to 3 days. B. patient's not being able to speak normally again. C. insertion of a gastrostomy feeding tube during surgery. D. patient's not being able to perform deep-breathing exercises. 34.) A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). The nurse assisting in caring for the client should take which action to monitor the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed 245.) A client taking carbamazepine (Tegretol) asks the nurse what to do if he misses one dose. The nurse responds that the carbamazepine should be: 1. Withheld until the next scheduled dose 2. Withheld and the health care provider is notified immediately 3. Taken as long as it is not immediately before the next dose 4. Withheld until the next scheduled dose, which should then be doubled 39.) The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime community-acquired pneumonia 11.) The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication will permanently stain my skin." 4. "The medication should be applied directly to the wound." stage 1 inflammation A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing. 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air. 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry. 4. Soak in a warm tub three times a day, and rub the spots with a washcloth. The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. Cool skin, respiratory crackles, pulse 86 and bounding. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus. The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table. 2. The boy tries to grasp a toy just out of reach. 3. The boy turns his head to try to locate a sound. 4. The boy smiles spontaneously when he sees his mother. tuberculosis chemoreceptor 10. The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. The nurse should take which of the following actions to prevent an adverse effect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. C. Set up the Y-tubing of the blood set with dextrose in water as the flush solution. D. Infuse the blood slowly for the first 15 minutes of the transfusion. 14. While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently isa. perinatal transmission to the fetus.b. sharing equipment to inject illegal drugs.c. transfusions with HIV-contaminated blood.d. sexual contact with an infected partner. Immobilize the client's head and neck The nurse is teaching a client about the use of a hypnotic drug at home. What client teaching is needed related to this medication?a. "Take the medication with a caffeinated drink such as coffee."b. "Be sure to go to bed with a full stomach."c. "Train yourself to sleep with the lights and TV on."d. "Avoid the use of alcohol while taking this drug." The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions? 1. With the client's neck in a midline position and the head of the bed elevated 30°. 2. Side-lying with the client's head extended and the bed flat. 3. In high Fowler's position with the client's head maintained in a neutral position. 4. In semi-Fowler's position with the client's head turned to the side. Drugs ending in "olol" belong to which drug classification? When assisting with a bone marrow aspiration, the nurse should take which of the following actions? 1. Drop additional sterile supplies onto a sterile tray. 2. Unwrap all sterile packs for the procedure in case they are needed. 3. Reach over the tray, and remove contaminated supplies. 4. Place the bottle of sterile liquid on the sterile field so that it does not splash. Basilar skull fractures Place a tongue-blade in the patient's mouth to prevent blockage of the airway. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? A. Poor client compliance resulting from generalized diminished capacity B. Inadequate health insurance coverage for the group as a whole C. Insufficient research to provide a basis for effective geriatric health care D. Preconceived assumptions regarding the lifestyles and attitudes of this group 5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is toa. provide a diet high in vitamin K.b. isolate the patient from visitors.c. plan care to alternate periods of rest and activity.d. encourage increased intake of fluid and fiber in the diet. 7. Interventions such as promotion of nutrition, exercise, and stress reduction should be promoted by the nurse for patients who have HIV infection, primarily because these interventions willa. promote a feeling of well-being in the patient.b. prevent transmission of the virus to others.c. improve the patient's immune function.d. increase the patient's strength and self-care ability. elastic recoil 52.) A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? 1. Electrolyte levels 2. Coagulation times 3. Liver enzyme levels 4. Serum creatinine level children can sit in a regular adult seat in a car once they are ____ uretolithotomy What stimulant comes in the form of a patch? celecoxib 79.) Ibuprofen (Advil) is prescribed for a client. The nurse tells the client to take the medication: 1. With 8 oz of milk 2. In the morning after arising 3. 60 minutes before breakfast 4. At bedtime on an empty stomach 2. When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake ofa. eggs and muscle meats.b. nuts and cornmeal.c. milk and milk products.d. legumes and dried fruits. The LPN/LVN is providing blood pressure readings at a local convenience store for members of the community. For which of the following client should the nurse recommend follow-up with the client's primary doctor within a period of two months?(A) 114/78(B) 120/82(C) 134/97(D) 138/89 The physician has written an order for a client to receive 0.45% NaCl (1/2 normal saline) intravenously at a rate of 75mL per hour. The drop factor of the tubing set is 20 drops per mL. The LPN/LVN should calculate the flow rate to be: (A) 20(B) 25(C) 50(D) 75 5. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intakea. when the patient feels thirsty.b. in the late evening hours.c. as soon as changes in LOC occur.d. if the oral mucosa feels dry. MG: MYASTHENIA GRAVIS :S/S ComplicationCrisis The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions? 1. Use a new, sterile catheter each time the client performs a catheterization. 2. Perform the Valsalva maneuver before doing the catheterization. 3. Perform the catheterization procedure every 8 hours. 4. Limit oral fluids to reduce the number of times a catheterization is needed. A client is seen in the clinic for treatment of chronic back pain. The client mentions to the clinic nurse that at home he applies an ointment prepared from several different herbs that relieves his lower back pain. He asks the nurse, "Should I continue using it?" Which of the following responses by the nurse would be BEST? 1. "No. It might do you more harm than good." 2. "Yes. Continue using it, but I don't see how it could help your condition." 3. "You may think it works, but I don't believe home remedies work." 4. "Pain can be relieved in several ways. Consult your physician regarding this home remedy." The pregnant client is at full term. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the client that the baby is safe and that the baby's heart rate is within normal limits. The nurse bases this interpretation on which of the following data?1. FHR of 80 beats per minute2. FHR of 90 beats per minute3. FHR of 140 beats per minute4. FHR of 170 beats per minute when might doll's eye oculocephalic reflex be contra-indicated? 35.) The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage 46. Nursing assessment findings of jugular vein distention and pedal edema would be indicative of which of the following complications of emphysema? A. Acute respiratory failure B. Pulmonary edema caused by left-sided heart failureC. Fluid volume excess secondary to cor pulmonale D. Secondary respiratory infection Which cranial nerve is the Vagus? RACE Mrs. Fischner, a 55 year-old client, presents to her physician that she has stiffness and pain in her joints that "never seems to go away." After laboratory tests, the physician diagnoses rheumatoid arthritis. The results of which laboratory test most likely led to the physician's diagnosis?(A) Serum creatinine(B) Erythrocyte sedimentation rate (ESR)(C) International normalized ration (INR)(D) Fasting lipid panel ALS: AMYOTROPHIC LATERAL SCLEROSIS :S/S ComplicationCrisis apical heart rate for adolescent Which test is used to check Rh status? chronic bronchitis What does phosphorus do in the body? SHORT ANSWER 1. A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, calculate the total calories the patient should receive each day. NSAIDs: What to check after compliance The nurse is collaborating with the interdisciplinary team regarding the care of a client with a brain tumor. The nurse knows that the most common reason that subsequent rounds of chemotherapy may be delayed is what condition?a. Myelosuppressionb. Alopeciac. Mucositisd. Cachexia rhinoplasty blood pressure of newborn 25. A patient with hypoparathyroidism receives instructions from the nurse regarding symptoms of hypocalcemia and hypercalcemia. The nurse teaches the patient that if mild symptoms of hypocalcemia occur, the patient shoulda. increase the daily fluid intake to twice the usual amount.b. self-administer IM calcium before calling the doctor.c. call an ambulance because the symptoms will progress to seizures.d. rebreathe with a paper bag and then seek medical assistance. In which of the following positions should the patient who is receiving continuous nasogastric enteral feedings be placed to decrease the risk of aspiration?A) Semi-Fowler'sB) Right lateral decubitusC) TrendelenburgD) SupineE) Prone 17. When admitting a patient with a stage III pressure ulcers on both heels, which information obtained by the nurse is of most concern?a. The patient takes corticosteroids daily for rheumatoid arthritis.b. The patient has had the heel ulcers for the last 6 months.c. The patient has several old incisions that have formed keloids.d. The patient's admission oral temperature is 102° F. What genre of drugs should be used with precaution in combination with atomoxetine? The nurse is assessing the adaptation of the client to changes in the functional status after a stroke. The nurse assesses that the client is adapting most successfully if the client:◦ A. Gets angry with family if they interrupt a task◦ B. Experiences bouts of depression and irritability◦ C. Has difficulty with using modified feeding utensils◦ D. Consistently uses adaptive equipment in dressing self 138.) A daily dose of prednisone is prescribed for a client. A nurse reinforces instructions to the client regarding administration of the medication and instructs the client that the best time to take this medication is: 1. At noon 2. At bedtime 3. Early morning 4. Anytime, at the same time, each day 147.) A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further information about the medication if the client states that he or she will: 1. Drink at least 2 L of fluid per day. 2. Take the daily dose at bedtime. 3. Avoid changing brands of the medication without health care provider (HCP) approval. 4. Avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP. 26. Which of the following conditions is manifested by unexplained shortness of breath and a high mortality rate? A. Bleeding ulcer B. Transient ischemia C. Pulmonary embolism D. MI 233.) Diphenhydramine hydrochloride (Benadryl) is used in the treatment of allergic rhinitis for a hospitalized client with a chronic psychotic disorder. The client asks the nurse why the medication is being discontinued before hospital discharge. The nurse responds, knowing that: 1. Allergic symptoms are short in duration. 2. This medication promotes long-term extrapyramidal symptoms. 3. Addictive properties are enhanced in the presence of psychotropic medications. 4. Poor compliance causes this medication to fail to reach its therapeutic blood level. Diplopia What is a continuous seizure that must be interrupted by emergency measures? Mr. Peters is admitted to the unit for a cardiac arrhythmia. The LPN/LVN knows that this involves a malfunction in the electrical conduction of the heart. Arrange the following in the correct order to represent normal electrical conduction of the heart.(A) Atrioventricular (AV) node(B) Bundle of His (C) Bundle branches(D) Purkinje fibers(E) Sinoatrial (SA) node 156.) A nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication? 1. Blood glucose of 200 mg/dL 2. Potassium level of 3.8 mEq/L 3. Platelet count of 300,000 cells/mm3 4. White blood cell count of 6000 cells/mm3 What does vitamin B1 (thiamine) do? certain food allergies (i.e. bananas) may indicate an allergy to ___. The list includes ... Which of the following nursing interventions is most likely to prevent respiratory complications such as pneumonia and atelectasis in a post surgical patient?a. control of anxiety and agitationb. adequate nutrition and fluidsc. adequate pain controld. use of incentive spirometry The physician prescribes the following for a patient with rheumatoid arthritis: aspirin 5 g po daily. The pharmacy informs the LPN/LVN that the dosage strength of aspirin is 5 grains. How many tablets should be distributed for this patient in each 24-hour period?(A) 5(B) 10(C) 15(D) 20 The nurse is evaluation the respiratory outcomes for the client with Guillain-Barre syndrome. The nurse determines that which of the following is the least optimal outcome for the client?◦ A. Spontaneous breathing◦ B. Oxygen saturation of 98%◦ C. Adventitious breath sounds◦ D. Vital capacity within normal range Of the following, which describes dementia? A. Quick onset, irreversibleB. Slow onset, chronicC. Acute onset, reversibleD. Progressive, terminal 7. A patient is admitted to the hospital with idiopathic aplastic anemia. An appropriate collaborative problem for the nurse to identify for the patient isa. potential complication: hemorrhage.b. potential complication: neurogenic shock.c. potential complication: pulmonary edema.d. potential complication: seizures. Kerning's sign The LPN/LVN is preparing to insert a nasogastric tube into the client's gastrointestinal tract. Prior to insertion, the nurse would determine how far to insert the tube by marking the place on the tube that is equal to which of the following distances?(A) The distance from the tip of the nose to the belly button(B) The distance from the top of the head to the top of the ear, to the belly button(C) The distance from the tip of the earlobe to the belly button(D) The distance from the nose to the earlobe plus the earlobe to the sternum Neonates normal temperature ranges? What are characteristics of functional incontinence? A nurse is preparing to administer an I.M. injection in a client with a spinal cord injury. Which muscle is best to use in this case?1) Deltoid2) Dorsal gluteal3) Vastus lateralis4) Ventral gluteal The nurse should question the use of barbiturates for the treatment of seizure activity if prescribed for which of the following clients? 30-year-old pregnant female 24-year-old male with new diagnosis of seizures 55-year-old female with history of diabetes mellitus 45-year-old male with history of hypertension Diagnosis of meningitis 14. While assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon?a. The patient is complaining of 7/10 incisional pain.b. The patient's cardiac monitor shows a heart rate of 112.c. The patient has increasing swelling of the neck.d. The patient's voice is weak and hoarse sounding. tracheotomy 201.) A nurse is preparing to administer eardrops to an infant. The nurse plans to: 1. Pull up and back on the ear and direct the solution onto the eardrum. 2. Pull down and back on the ear and direct the solution onto the eardrum. 3. Pull down and back on the ear and direct the solution toward the wall of the canal. 4. Pull up and back on the ear lobe and direct the solution toward the wall of the canal. 26. The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment? A. Pulmonary function testing B. Systemic corticosteroids C. Biofeedback therapy D. Intravenous fluids From what stage of sleep are people typically most difficult to arouse?1) NREM, alpha waves2) NREM, sleep spindles3) NREM, delta waves4) REM prednisone A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her?1. Social worker2. Speech pathologist3. Recreational therapist4. Occupational therapist Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process? A. "I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it's hard to even walk." B. "I've given my grandchildren money for college so they can live a better life than I had." C. "Growing old certainly presents all sorts of challenges. I wish I knew then what I know now." D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough." The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action? 1. Remove reading material to decrease eyestrain. 2. Ask the client if he is nauseated. 3. Assess color of drainage from the affected eye. 4. Maintain sterility during q3h saline eye irrigations. 10. Which information obtained when caring for a patient who has just been admitted for evaluation of diabetes insipidus will be of greatest concern to the nurse?a. The patient has a urine output of 800 ml/hr.b. The patient's urine specific gravity is 1.003.c. The patient had a recent head injury.d. The patient is confused and lethargic. Carbamazepine (Tegretol) has been prescribed for a 24-year-old client for the control of partial seizures. The nurse will teach the client to immediately report:a. Blurred vision.b. Leg cramps.c. Blister-like rash.d. Lethargy. The nurse, who is monitoring a client taking phenytoin (Dilantin), has noted symptoms of nystagmus, confusion, and ataxia. Considering these findings, the nurse would suspect that the dose of the drug should be:a. Reduced.b. Increased.c. Maintained.d. Discontinued 187.) A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered? 1. Intramuscularly in the deltoid muscle 2. Subcutaneously in the gluteal muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Intramuscularly in the anterolateral aspect of the thigh 169.) Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that it is best to take the insulin: 1. 1 hour after each meal 2. Once daily, at the same time each day 3. 15 minutes before breakfast, lunch, and dinner 4. Before each meal, on the basis of the blood glucose level A male client with diagnosed bipolar disorder is hospitalized on the psychiatric unit. At a community activity, the client becomes disruptive and is seen flirting with female clients. Which of the following is the most appropriate intervention for this behavior?(A) Pull the client aside to remind him of the unit rules and set boundaries for his behavior(B) Tell the other clients to ignore the flirtatious actions of the male client(C) Avert the attention of the male client and lead him to his room(D) Have the client return to his room immediately because of his inappropriate behavior 12. If a nurse is assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations are measured at 32 breaths/min, which of the following is the most appropriate nursing assessment? A. The rapid breathing is causing the low pH. B. The nurse should sedate the patient to slow down respirations. C. The rapid breathing is an attempt to compensate for the low pH. D. The nurse should give the patient a paper bag to breathe into to correct the low pH. 29. The most appropriate nursing intervention to include in the care plan for a patient with neutropenia is toa. omit fresh fruits or vegetables from the diet.b. check the temperature q4hr.c. avoid any IM or subcutaneous injections.d. assess all wounds for redness and drainage. The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit:1. Severe flank pain and hematuria2. Pain and burning on urination3. A loss of the urge to void4. A feeling of pressure and voiding of small amounts The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?1) Decreased blood pressure (BP) after standing up2) Decreased temperature after a period of diaphoresis3) Increased heart rate after walking down the hall4) Increased respiratory rate when the heart rate increases When administering an enema, list the following steps in the order in which they should be performed. Label the steps from 1 to 6, with 1 being the first step to perform.A. Document the results of the procedure.B. Assess the patient for cramping. C. Insert the tubing about 3 to 4 inches into the rectum.D. Lubricate the tip of the enema tubing generously.E. Raise the container to the correct height and instill the solution at a slow rate.F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema. A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients on the unit. The licensed practical nurse (LPN) consults with the registered nurse knowing that which of the following changes should be made to the client's treatment plan? 1. Allow increased "in room" activities2. Increase the level of suicide precautions3. Allow the client to spend time off the unit4. Reduce the dosage of antidepressant medication Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home? 1. "Check your weight daily." 2. "Maintain clean technique at all times during the procedure." 3. "Milk the catheter to encourage extra fluid to be removed from the abdomen." 4. "Eat a well-balanced, low-protein diet." A nurse is caring for a child receiving carbamazepine (Tegretol) who has a carbamazepine level drawn. Which of the following results indicates a therapeutic level? 1. 1 mcg/mL 2. 3 mcg/mL 3. 6 mcg/mL 4. 15 mcg/mL pneumoconiosis The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. "Draw a picture of the eye to explain what will happen." 2. "Tell your daughter that the procedure will take 1 hour." 3. "Use dolls or puppets to explain how to get ready for surgery." 4. "Read an age-appropriate illustrated book about eye surgery to your daughter." The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse shoulda. be aware that confused clients don't feel as much pain due to their confusionb. observe the client carefully for changes in behavior or vital signsc. ask the client's family how much pain the client normally hasd. use only pain scales that feature numbers or "faces" the client can point to 18. A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement?a. Disconnect the nasogastric tube until the pH is within the normal range.b. Administer the prescribed sodium bicarbonate 50 mEq intravenously.c. Teach the patient about the importance of taking slow, deep breaths.d. Give the patient the ordered morphine sulfate 4 mg intravenously. A nurse notes that a child who has been diagnosed with intussusception has a formed brown bowel movement. The nurse should do which of the following at once to ensure that a safe plan of care is implemented for the child?1. Prepare the child for hydrostatic reduction2. Ask the child about any increase in abdominal pain3. Warn the child and her parents that surgery is imminent4. Report the passage of the normal stool to the registered nurse (RN) The LPN/LVN is preparing to give a subcutaneous injection of Procrit 5,000 units. Which of the following needles would be appropriate for this type of injection?(A) A 5/8 inch, 25 gauge needle(B) A 1 inch, 22 gauge needle(C) A 1.5 inch, 25 gauge needle(D) A 1.5 inch, 18 gauge needle 30. A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment upon findinga. decreasing serum sodium.b. decreasing serum potassium.c. decreasing blood glucose.d. increasing urinary output. What is the normal PTT value? SEIZURE :S/S ComplicationCrisis It is important for the nurse to have an understanding of anxiety and stress as they affect healing because: (Select all that apply)A) all patients respond the same way to stress.B) stress can impede healing.C) anxiety can cause powerlessness, which can lead to hopelessness.D) anxiety can intensify pain.E) critical care is a very stressful environment for the patients, family, and staff. A nurse is reviewing medications with the client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in: 1. Blood glucose 2. Blood pressure 3. Joint inflammation 4. Headaches respirations of preschooler direct light response COX-1 inhibitor actions 52. When assessing a patient's sleep-rest pattern related to respiratory health, the nurse would ask if the patient: (Select all that apply.) A. Has trouble falling asleep B. Awakens abruptly during the night C. Sleeps more than 8 hours per night D. Has to sleep with the head elevated 14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems. C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit?◦ A. Tells the client to scan the environment◦ B. Approaches the client from the unaffected side◦ C. Places the bedside articles on the affected side◦ D. Moves the commode and chair to the affected side what type of meat is ↑ in thymine? 231.) A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. What behaviors observed in the client would validate noncompliance with this medication? 1. Complaints of hunger 2. Complaints of insomnia 3. A pulse rate less than 60 beats per minute 4. Frequent handwashing with hot, soapy water Tonic Seizure Following a successful coronary artery bypass graft, a 71 year old male pt has been transferred to the PACU. What is the priority for the pt's nursing care during this stage of recovery?a. protecting and maintaining airwayb. positioning the pt to prevent skin breakdownc. treating the pts paind. preventing incisional infection and monitoring for s/s of infection COX-1 A client with paraplegia has a risk for injury related to spasticity of leg muscles. The nurse avoids which action that would be least helpful in dealing with this problem?1. Using restraints to immobilize the limbs2. Administering a PRN order for a muscle relaxant3. Removing potentially harmful objects placed near the client4. Performing range-of-motion exercises with the affected limb What drug is contraindicated with stimulants? NSAIDs: What to check BEFORE 25. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma? A. Anxiety and restlessness B. Effects of medications C. Fear of suffocation D. Work of breathing 10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which information will the nurse include?a. Drink only one or two caffeinated beverages daily.b. Take a daily multivitamin with iron.c. Limit fluids to 2 to 3 quarts a day.d. Avoid exposure to crowds as much as possible. Tonic Clonic (Grand-Mal) Seizure: The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?1. The client keeps the cane on the left side.2. Two points of support are kept on the floor at all times.3. There is a slight lean to the right when the client is walking.4. After advancing the cane, the client moves the right leg forward. 21. A 32-year-old male patient is to undergo radiation therapy to the pelvic area for Hodgkin's lymphoma. He expresses concern to the nurse about the effect of chemotherapy on his sexual function. The best response by the nurse to the patient's concerns isa. "Radiation does not cause the problems with sexual functioning that occur with chemotherapy or surgical procedures used to treat cancer."b. "It is possible you may have some changes in your sexual function, and you may want to consider pretreatment harvesting of sperm if you want children."c. "The radiation will make you sterile, but your ability to have sexual intercourse will not be changed by the treatment."d. "You may have some temporary impotence during the course of the radiation, but normal sexual function will return." A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods?1. Sneezing2. Shaking hands3. Contact with stool4. Contact with urine pleural effusion A nurse assigned to care for a 4-week-old infant who is scheduled for a pyloromyotomy. The nurse plans to do which of the following when caring for the infant?1. Restrain the infant in a high chair2. Feed the infant in a lying-down position3. Feed the infant 1 ounce of formula every hour4. Position the infant prone with the head of the bed elevated 25.) A home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse tells the client to: 1. Freeze the insulin. 2. Refrigerate the insulin. 3. Store the insulin in a dark, dry place. 4. Keep the insulin at room temperature. when using crutches, allow ___ inches clearance from the side of the feet A client who has been taking benzodiazepines for several years suddenly decides to stop taking the medication. For what symptoms of acute withdrawal will the nurse monitor?a. Weakness, delirium, seizuresb. Blurred vision, orthostatic hypotensionc. Sore throat, fever, jaundiced. Sleep disturbances The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:1. Physical abuse2. Accidental injury3. Contagious diseases4. Stranger abduction Adolescents (12-18) Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position the client on the abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist the client with heat application and ROM exercises. 109.) A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which of the following would indicate medication effectiveness? 1. No rapid heartbeats or anxiety 2. No paranoid thought processes 3. No thought broadcasting or delusions 4. No reports of alcohol withdrawal symptoms Thrombolytics are prescribed for each of the following clients. A nurse should question the order for the client with which condition?a. Myocardial infarctionb. Pulmonary embolismc. Acute ischemic strokesd. Closed head injury thoracentesis 45. The nurse reviews pursed lip breathing with a patient newly diagnosed with emphysema. The nurse reinforces that this technique will assist respiration by which of the following mechanisms? A. Preventing bronchial collapse and air trapping in the lungs during exhalation B. Increasing the respiratory rate and giving the patient control of respiratory patterns C. Loosening secretions so that they may be coughed up more easily D. Promoting maximal inhalation for better oxygenation of the lungs Follow a drop of blood as it circulates through the right side of the heart, using all of the following cardiac structures:(A) Tricuspid valve(B) Vena cava(C) Right ventricle(D) Right atrium(E) Pulmonic valve(F) Pulmonary artery A 49 year old, male client is admitted to the unit for alcohol withdrawal. The client insists that he had his last drink 4 hours prior. Which of the following medications would the LPN/LVN expect to administer to the client?(A) Naloxone hydrochloride (Narcan)(B) Chlordiazepoxide hydrochloride (Librium)(C) Disulfiram (Antabuse)(D) Chlorpromazine (Thorazine) A nurse is assisting in the care of a child who underwent surgical repair of a cleft lip the previous day. The nurse should implement which safe nursing intervention when caring for the surgical incision?1. Clean the incision only if serous exudate forms2. Remove the Logan bar carefully to clean the incision3. Rub the incision gently with a sterile cotton-tipped swab4. Rinse the incision with sterile water after using diluted hydrogen peroxide 1. The arterial blood gas (ABG) readings that indicate compensated respiratory acidosis are a PaCO2 of A. 30 mm Hg and bicarbonate level of 24 mEq/L. B. 30 mm Hg and bicarbonate level of 30 mEq/L. C. 50 mm Hg and bicarbonate level of 20 mEq/L.D. 50 mm Hg and bicarbonate level of 30 mEq/L. The chambers on the left side of the heart receive oxygenated or unoxygenated blood? A nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium (Dilantin). Which of the following should be included in the plan of care for this child? 1. Monitoring intake and output 2. Checking the heart rate before administering the phenytoin 3. Providing oral hygiene especially care of the gums 4. Administering medications 1 hour before food intake A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the prescription if the client had concurrent prescriptions to take: 1. Ibuprofen (Advil) 2. Furosemide (Lasix) 3. Valproic acid (Depakene) 4. Tranylcypromine (Parnate) 39. When developing a plan of care for a patient with SIADH, which interventions will the nurse include?a. Encourage fluids to 2000 ml/day.b. Offer patient hard candies to suck on.c. Monitor for increased peripheral edema.d. Keep head of bed elevated to 30 degrees. Check the fluid for dextrose with a dipstick NSAID: adverse effects What are sources of vitamin A? Monoparesis or Monoplegia: Imipramime (Tofranil): class & indication 171.) A nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. The most important laboratory test result for the nurse to check before administering this medication is: 1. Potassium level 2. Creatinine level 3. Cholesterol level 4. Blood urea nitrogen Methicillin-Resistant Staphylococcus Aureus (MRSA) A licensed practical nurse (LPN) employed in a long-term care facility is observing a nursing assistant ambulating a client with right-sided weakness. The LPN determines that the nursing assistant is performing the procedure safely if the LPN observes the nursing assistant:1. Standing behind the client2. Standing in front of the client3. Standing on the left side of the client4. Standing on the right side of the client Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning.2) The patient will rest quietly when undisturbed.3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.4) The patient will receive pain medication every 2 hours as prescribed. 33. A with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication?a. Blood urea nitrogen (BUN)b. Serum phosphatec. Serum potassiumd. Uric acid level 17. While caring for a patient with respiratory disease, a nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. The nurse should determine that A. supplemental oxygen should be used when the patient exercises. B. ABG determinations should be done to verify the oxygen saturation reading. C. this finding is a normal response to activity and that the patient should continue to be monitored. D. the oximetry probe should be moved from the finger to the earlobe for an accurate oxygen saturation measurement during activity. 190.) A child is hospitalized with a diagnosis of lead poisoning. The nurse assisting in caring for the child would prepare to assist in administering which of the following medications? 1. Activated charcoal 2. Sodium bicarbonate 3. Syrup of ipecac syrup 4. Dimercaprol (BAL in Oil) Which of the following actions violates a principle that is key to proper hand washing at the bedside?a. Washing your hands for 1 minuteb. Shaking your hands dry over the sinkc. Using warm, not very hot waterd. Using the soap provided by the agency Which of the following should the nurse include in the teaching plan for a client receiving subcutaneous heparin? Select all that apply.a. Inject medication in the deep fatty layer of the abdomen.b. When brushing your teeth, use a soft toothbrush.c. Hold direct pressure on any puncture sites for 15 minutes.d. Use dental floss daily after brushing.e. Take a daily aspirin tablet, 325 mg, to prevent inflammation at the injection sitea Difficulty swallowing, blurred vision, or ptosis Rationale: Dysphagia (difficulty swallowing), blurred vision, and ptosis are all symptoms of possible botulism toxicity and should be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated adverse effects of this drug. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur, because the drug blocks muscle contraction.b 2. Two points of support are kept on the floor at all times.Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the client's right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the client's left leg, forward to the cane.c BRationale: Clinical manifestations of Addison's disease include hyperkalemia and a decrease in potassium level indicates improvement. Decreasing serum sodium and decreasing blood glucose indicate that treatment has not been effective. Changes in urinary output are not an effective way of monitoring treatment for Addison's disease.Cognitive Level: Application Text Reference: pp. 1313, 1316Nursing Process: Evaluation NCLEX: Physiological Integrityd the tendency for the lungs to recoil or reduce in volume after being stretched or expanded.e 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 ml of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.f Classic s/s: tremor at rest, muscle rigidity, bradykinesia.Complications: risk for fall, aspiration, urinary retention/UTI, dysphagia, oculogyric crisis: fixed lateral and upward gaze.g 3. Remove all objects containing metal from the clientRationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed to determine if the client has any internal metallic devices such as orthopedic hardware, pacemakers and shrapnel. A femoral catheter is not inserted. For an abdominal MRI, the client is usually NPO, but this is not necessary for an MRI of the head. In addition, an NPO status for 24 hours is unnecessary and may be harmful to the client. Metal-tipped electrodes are not used for this test.h A. Preventing bronchial collapse and air trapping in the lungs during exhalation The focus of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation.i reduces pain, suppresses inflammation, affects renal functionj You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal?k AD Manifestations of respiratory distress include tachypnea, grunting and panting on respiration, central cyanosis, use of accessory muscles, and flaring nares.l CRationale: Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted.Cognitive Level: Application Text Reference: p. 331Nursing Process: Implementation NCLEX: Physiological Integritym 3. Leads to physical and psychological dependence with prolonged high-dose therapyRationale:Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative-hypnotic (benzodiazepine). One of the concerns with clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted. *Eliminate options 2 and 4 first because of the closed-ended word "only"*n 4. A feeling of pressure and voiding of small amountso B. 2.5p Oxygenatedq diagnosed by lumbar puncture where the CSF is analyzed for organisms.r (A) The burns involve the epidermis and dermisRationale: Deep partial thickness burns involve the epidermis and dermis. The client will experience sever pain due to nerve injury, but the burns do not penetrate deep enough to destroy nerve endings. Vesicles will develop from deep burns. Superficial partial thickness burns, such as sunburns, affect only the epidermis. Full thickness burns involve the epidermis, dermis, subcutaneous tissue and destroy nerve endings. Necrosis is seen in full thickness burns.s GOOD: protects GI, decreases stomach acid and increases mucus, lowers fever, platelet aggregation, maintains renal functioningt (1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder(2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization(3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours(4) should encourage fluids...u only give peds ibuprofenpregnancy: category c for 6 mos, avoid anything for last threeolder: cardiac problemsv 3. Ensure that the client uses oxygen during laborRationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. Option 1 is a safe nursing action, but it does nothing to prevent sickling crisis. Option 4 is not realistic and would not prevent sickling crisis. Option 2 is another generally helpful nursing measure but again is not related to prevention of sickling crisis.w Right-sidedx D, F, G, HRationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.Cognitive Level: Application Text Reference: p. 282Nursing Process: Implementation NCLEX: Health Promotion and Maintenancey vibration of the chest wall produced by vocalization.z kidney damage, induction of asthma/allergiesaa 1ab 1. Withhold the medication.Rationale:Metoprolol (Lopressor) is classified as a beta-adrenergic blocker and is used in the treatment of hypertension, angina, and myocardial infarction. Baseline nursing assessments include measurement of BP and AP immediately before administration. If the systolic BP is below 90 mm/Hg and the AP is below 60 beats/min, the nurse should withhold the medication and document this action. Although the registered nurse should be informed of the client's vital signs, it is not necessary to do so immediately. The medication should not be administered because the data is outside of the prescribed parameters for this medication. The nurse should not administer half of the medication, or alter any dosages at any point in time.ac A) Semi-Fowler'sTo decrease the risk of aspiration, the patient should have the head of the bed elevated 30-45 degrees (Semi-Fowlers). Right lateral decubitus helps promote gastric emptying. Supine, Trendelenburg, and prone positions are contraindicated because they increase the risk of aspiration.ad 4) Yogurt and parsleyYogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.ae Monitoring the client for nausea and GI cramping. Objective: Explain the importance of client drug compliance in the pharmacotherapy of epilepsy.Rationale: Valium is a benzodiazepine, which can potentate the action of digoxin and raise blood levels. Nausea, vomiting, GI cramping, blurred vision, and bigeminy are signs of digoxin toxicity. The digoxin should not be held unless symptoms of toxicity are seen. Positioning should protect the client from injury during the seizure-most likely recumbent and on the side, if possible. Potassium is not indicated.Cognitive Level: AnalysisClient Need: Physiological Integrity: Pharmacological and Parenteral TherapiesNursing Process: Planningaf Strategy: Determine the least stable situation(1) important issue that needs to be addressed after tending to the client who is bleeding(2) patients take priority over personnel issues(3) can be delegated to another staff member(4) correct—should assess client to determine amount and cause of bleedingag inflammation of the pleura.ah antineoplastic to treat cancerai 150,000 - 400,000aj 4. Occupational therapistRationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems.ak Trendelenburgal Constrict = myotiC (c for constrict)am 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.an 2. Monitor bowel activity.Rationale:While the client is taking codeine sulfate, an opioid analgesic, the nurse would monitor vital signs and monitor for hypotension. The nurse should also increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency (codeine can cause constipation). The nurse should monitor respiratory status and initiate breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication.ao non specific response to infection, ischemia, antigen-antibody, thermal/physical injury. immediate but short term protection.ap Mydriasis Phenylephrine causes mydriasis, allowing better visualization of the area of the lens during cataract surgery.aq A. Revise the client's care plan to show the need for the application of moisturizing lotionar 3. Sudden increase in painRationale:Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced. Options 1, 2, and 4 are not associated with this medication.as 3. Liver enzyme levelsRationale:INH therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.at Strategy: Think about growth and development.(1) appropriate for school-aged child(2) preschooler can't relate to the concept of 1 hour(3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel(4) appropriate for school-aged childau c. Ongoing assessmentThis type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.av inflammation is a normal rxn to injury or infection (can be environmental or pathogenic). infection is when invading microorganisms disturb normal environment and cause harm; often accompanies inflammationaw a serum protein produced by the liver normally found in the lungs that inhibits proteolytic enzymes of white cells from lysing lung tissue; genetic deficiency of this protein can cause emphysema.ax Absorption of glucoseTransport of fatty acidsEnergy metabolismay ARationale: Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole-grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium level further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.Cognitive Level: Application Text Reference: p. 1311Nursing Process: Planning NCLEX: Health Promotion and Maintenanceaz 3. Calcitonin (Miacalcin)Rationale:The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.ba 2. "What do you do to help yourself fall asleep?"As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.bb 4. Take the medication with a full glass of water after rising in the morning.Rationale:Precautions need to be taken with administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.bc 1.5" - 2"bd a surgical incision into the trachea for the purpose of establishing an airway; performed below a blockage by a foreign body, tumor, or edema of the glottis.be take with food, dont stop suddenly, avoid crowdsbf 30-year-old pregnant female Objective: Use the nursing process to care for clients receiving drug therapy for epilepsy.Rationale: Barbiturates cross the placental barrier and are excreted in breast milk, and are not recommended for women who are pregnant or nursing. Folic acid absorption also is decreased, and congenital malformations can occur if barbiturates are taken during the first trimester.Cognitive Level: ApplicationClient Need: Physiological Integrity: Pharmacological and Parenteral TherapiesNursing Process: Analysisbg Closed head injury Rationale: A closed head injury is one contraindication for the use of thrombolytic drugs. If a blood clot is in the brain, disturbing it may have a deleterious effect on the neurological system. Options 1, 2, and 3 are incorrect. Thrombolytics are drugs that dissolve blood clots. They are frequently used in the care of clients with heart attacks. Pulmonary embolism is another use for these drugs, as thrombolytics will dissolve any clots in the lungs. Only strokes (CVAs) that are known to be caused by thrombus or emboli will be treated with these drugs.bh Orange fruits and veggiesDark green leafy veggiesButterFortified milkEggsBeef liverbi A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?bj 4. Allow the client to have as many choices related to care as possibleRationale: Several general interventions will reduce the hospitalized client's level of stress. These include acknowledging the client's feelings, offering information, providing social support, and letting the client have control over choices related to care. Options 1 and 3 could increase anxiety, whereas option 2 could add to the disruption created by the hospitalization and interfere with the client's sleep pattern.bk Strategy: "Question which of the following orders" indicates an incorrect order.(1) H1 receptor blocker, used as an antiemetic(2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure(3) stool softener, used for an immobilized patient(4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcersbl Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?(1) soaps and ointments should not be applied to second-degree burns in an emergency situation(2) correct—after fire is out, remove clothing and cover victim with a clean sheet(3) soaps and ointments should not be applied to second-degree burns in an emergency situation(4) does not prevent infectionbm 121/70bn BRationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.Cognitive Level: Application Text Reference: p. 326Nursing Process: Planning NCLEX: Physiological Integritybo Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes.(1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias(2) assess cause of problem before implementing(3) assess cause of problem before implementing(4) more important to assess what is happening nowbp the amount of blood ejected by the heart in any one contractionbq 35-45br Respiratory Isolation = Droplet precautions: Gloves, Gown, Mask within 3 ft of pt.bs CRationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.Cognitive Level: Application Text Reference: pp. 295, 297Nursing Process: Planning NCLEX: Physiological Integritybt Blister-like rash. Carbamazepine is associated with an increased risk of Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis in genetically susceptible individuals. Sunburning and a reddish-purple rash, especially associated with blisters, are possible symptoms of severe dermatologic reactions and should be evaluated immediately. Options 1, 2, and 4 are incorrect. Blurred vision, leg cramping, and lethargy are all possible side effects of carbamazepine but tolerance to these effects usually develops over time.bu 2. The white blood cell counts and platelet countsRationale:Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed before and during drug treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste with loss of appetite are not common signs of side effects of this medication.bv 3. Subcutaneously in the outer aspect of the upper armRationale:The MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is most often used for intramuscular injections. The MMR vaccine is not administered by the intramuscular route.bw 3. Providing oral hygiene especially care of the gumsRationale:Phenytoin sodium causes gum bleeding and hypertrophy, and therefore oral hygiene is important. Soft toothbrushes and gum massage should be instituted to reduce the risk of complications and prevent further trauma. Options 1 and 2 are incorrect because the intake and output as well as heart rate are not affected by this medication. Option 4 is incorrect because directions for administration of this medication include administering with food to minimize gastrointestinal upset.bx (E) Sinoatrial (SA) node(A) Atrioventricular (AV) node(B) Bundle of His(C) Bundle branches(D) Purkinje fibersRationale: Normal electrical conduction within the heart begins with stimulation of the SA node. The SA node is called the heart's pacemaker because it maintains the normal heart rate of 60 to 100 bpm for an adult. The SA node sends the electrical impulse to the AV node, which transmits the electrical impulse through the bundle of His to the right and left bundle branches. The signal ends in the Purkinje fibers, located in the outside muscle layers of the heart.by Inhibits platelet aggregation to prevent clot formation. Rationale: Clopidogrel is an antiplatelet drug used to prevent blood clots from forming inside arteries by inhibiting platelet aggregation. Options 2, 3, and 4 are incorrect. Heparin is an anticoagulant that blocks the formation of blood clots by activating antithrombin III. Warfarin is a vitamin K antagonist used to prevent the blood from clotting. The drug alteplase is a tissue plasminogen activator that dissolves fibrin clots.bz 3. Maintain a clear liquid status for 72 hoursRationale: The client should be able to resume the usual diet once the nurse assured is assured the client that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting. The nurse would also assess the client's hydration status as part of routine care for the client undergoing a GI diagnostic test.ca Caused by overmedication with anticholinesterase. Treatment: hold medication and give atropine if ordered.cb Amino acid and fatty acid metabolismRed blood cell productioncc creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.cd BRationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.Cognitive Level: Comprehension Text Reference: pp. 274-275Nursing Process: Implementation NCLEX: Physiological Integrityce C- Completing the sentences that the client cannot finish.Rationale: Note that the question asks which is least helpful. These words indicate a negative event query and ask you to select an option that is and incorrect action.cf 4. Baclofen (Lioresal)Rationale:Baclofen is the only skeletal muscle relaxant that can be administered intrathecally. Therefore options 1, 2, and 3 are incorrect.cg protect the eyes. Eyes can be excessively dry or teary.ch can cause stomach ulcers, prevents blood clotting, affects renal functionci affecting all four limbscj DRationale: Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.Cognitive Level: Application Text Reference: p. 1306Nursing Process: Planning NCLEX: Physiological Integrityck Supports energy metabolismSkin healthNervous systemDigestive systemcl Fortified milkFishEgg yolksLiverFortified cerealcm b. avoid arching shoulders forward when sittingArching shoulders forward when sitting alters the curvature of the spine and contributes to poor body alignment.cn 4. Cough and chest painRationale:Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions, manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on the x-ray, would indicate the need to stop the treatment. These symptoms resolve in 2 to 4 days following discontinuation of this medication.*Eliminate options 1, 2, and 3 because they are similar GI-related side effects. Also, use the ABCs— airway, breathing, and circulation*co latex (commonly used in surgery); grapes, cherries, apricots, passion fruits, avocados, chestnuts, peaches and tomatoescp ...(1) should remain in the seclusion room(2) should have meal at regular time(3) should have meal at regular time(4) correct—should eat at regular time; remain in the seclusion room for client's safetycq 3. Taken as long as it is not immediately before the next doseRationale:Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not immediately before the next dose. The medication should not be double dosed. If more than one dose is omitted, the client should call the health care provider.cr Acs (1) closed statement(2) closed statement; casts doubt on efficiency of alternative therapy(3) focus should be on client, not on nurse's beliefs(4) correct—herbal medication can interact with other medication...ct A) Staff nurseB) Respiratory therapistC) Case managerD) PhysicianE) Physical therapistcu bruisecv rapid cell division: growth of new blood vessels and scar tissuecw 1. Laser therapyRationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis, although the exact route of perinatal transmission is unknown. Options 2, 3 and 4 are incorrect.cx tuck their chin.cy (1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges(2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent(3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity(4) caused by subcutaneous bleeding, common during first few exchanges...cz 60-100 per minuteda BRationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.Cognitive Level: Application Text Reference: p. 1304Nursing Process: Implementation NCLEX: Physiological Integritydb 2. Invasion of privacyRationale: Discussing a client's condition without the client's permission violates the client's right and places the nurse in legal jeopardy. This is an invasion of privacy and affects client's confidentiality. Incompetence could lead to negligence, but this legal concept is not related to the subject identified in the question. Communication techniques relate to the nurse-client relationship. Teaching/learning principles are considered concepts of standard practice.dc CRationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines.Cognitive Level: Application Text Reference: p. 340Nursing Process: Implementation NCLEX: Physiological Integritydd ARationale: There is a high incidence of post-radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.Cognitive Level: Application Text Reference: pp. 1304-1305Nursing Process: Implementation NCLEX: Physiological Integrityde Weakness, delirium, seizures Rationale: The client may experience symptoms similar to alcohol withdrawal, such as weakness, delirium, or seizures, if benzodiazepines are abruptly discontinued. Options 2, 3, and 4 are incorrect because they do not occur with abrupt withdrawal of benzodiazepines.df A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?dg CRationale: Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation prior to surgery. Edema does not usually occur with hyperaldosteronism.Cognitive Level: Application Text Reference: pp. 1319-1320Nursing Process: Implementation NCLEX: Physiological Integritydh Increase carbsLimit proteindecrease sodiumfluid restrictiondi Strategy: Think about each answer choice.(1) nurse should follow the policies of the institution(2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian(3) correct—the need for restraints is based on patient's behavioral status and condition, not the patient's voluntary/involuntary status(4) must first try less restrictive means to control patient before using restraintsdj 2. Checking the frequency and consistency of bowel movementsRationale:The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.dk A. Wearing perfume to work People with asthma should avoid extrinsic allergens and irritants (e.g., dust, pollen, smoke, certain foods, colognes and perfumes, certain types of medications) because their airways become inflamed, producing shortness of breath, chest tightness, and wheezing. Many green leafy vegetables are rich in vitamins, minerals, and proteins, which incorporate healthy lifestyle patterns into the patients' daily living routines. Routine exercise is a part of a prudent lifestyle, and for patients with asthma the physical and psychosocial effects of ambulation can incorporate feelings of well-being, strength, and enhancement of physical endurance. Antibiotic therapy is always initiated after cultures are obtained so that the sensitivity to the organism can be readily identified.dl 2. Near the client's left legRationale: Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is affected and the client is sitting on the edge of the bed, the wheelchair is positioned next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.dm C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.dn (B) Vena cave(D) Right atrium(A) Tricuspid valve(C) Right ventricle(E) Pulmonic valve(F) Pulmonary arteryRationale: The blood enters the right atrium of the heart via the superior vena cava. From the right atrium, blood goes through the tricuspid valve to the right ventricle. The blood then continues out of the right side of the heart into the pulmonary artery by way of the pulmonic valve.do s/s: Risk complications: Swallowing/ArrestPtosis, diplopiaWeakness, dysarthria, dysphagia, difficulty sitting up, Respiratory distressEye and periorbital muscles most affected- manifested by diplopia, ptosis, ocular palsiesSx least evident in the AM and most evident w/effort as the day proceedsCrisis: Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration:Pneumonia & MYASTHENIC CRISIS: Respiratory, and swallowing muscles too weak. Risk complications: Swallowing/ArrestTHYMOMA-A rare neoplasm, usually found in the anterior mediastinum and originating in the epithelial cells of the thymus.Assess an maintain respiratory, swallowing, atelectasis.CHOLINERGIC CRISIS:Flaccid paralysis, respiratory failure, GI symptoms, severe muscle weakness, vertigo. Tx: Atropinedp 4. A rescue squad is best equipped to give emergency treatment.dq Folic acid (Folgard) Rationale: Prior to conception, folic acid should be recommended to women who are required to continue with AED therapy. This will decrease the incidence of birth defects associated with the drugs. Options 1, 2 and 3 are incorrect. It would be inappropriate for the client to take Clomid, a drug used for infertility, unless it is determined that the client is suffering from infertility. The administration of vitamin K will increase the risk of blood clotting. The administration of calcium is important due to the development of osteomalacia, but it will not have the effect of folic acid in the prevention of neurological deficits in pregnancy.dr Strategy: Think about the cause of each symptom and how it relates to narcotic withdrawal.(1) describes cocaine withdrawal(2) describes amphetamine withdrawal(3) describes barbiturate withdrawal(4) correct—narcotic withdrawal is very much like the symptoms of the fluds visual field cut both eyesdt A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?du 3. 6 mcg/mLRationale:When carbamazepine is administered, blood levels need to be drawn periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum level for this medication is 4 to 12 mcg/mL.dv 3. Slurred speechRationale:The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appear. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.dw Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Think about what the assessments mean.(1) implementation; would be ineffective(2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired(3) assessment; refers to an eye infection, would be important after initial operative day(4) implementation; eye irrigations are not commonly done following this procedure...dx (A) A 5/8 inch, 25 gauge needleRationale: An all gauge needle is used to administer a subcutaneous injection to decrease the trauma caused by the needle puncture. The length of the needle selected for subcutaneous administration of a medication should be less than one inch, depending on the client's body mass. Needles most commonly come in 3/8 inch and 5/8 inch lengths.dy A) The patient's blood sugar is 60.C) The patient needs to use the bedpan.E) The patient has been sitting up in the chair for the first time and is tired.The blood sugar level and the need to use the bedpan are physiological needs that will interfere with teaching. Being tired will interfere with the teaching due to patient's lack of concentration. Blood pressure is normal, and the magazine is a higher-level need that can wait until after the teaching has occurred.dz rhythmic percussion of a patient's chest with cupped hands to loosen retained respiratory secretions.ea B. Lower the side rail on the side of the bed you are working on.A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him. D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.C. Raise the side rail on the side of the bed you are working on.First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient (in step 1). Position patient laterally near far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the "hump," and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side.eb C. Fluid volume excess secondary to cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow due to lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.ec - positive when the leg is fully bent in the hip and knee, and subsequent extension in the knee is painful (leading to resistance)ed 2. A donor must be 18 years or older to provide consentRationale: Any person 18 years of age or older may become an organ donor by indicating his or her consent in writing. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs.ee C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something."ef 4. Dimercaprol (BAL in Oil)Rationale:Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.eg surgical opening into the thoracic cavity.eh 1. Wearing gogglesRationale:Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A gown is not necessary. A mask may be worn. Handwashing is to be performed before and after any child contact.ei CRationale: The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Vocal hoarseness is expected after surgery due to edema.Cognitive Level: Application Text Reference: p. 1304Nursing Process: Assessment NCLEX: Physiological Integrityej CRationale: The primary goal for the patient with HIV infection is to increase immune function, and these interventions will promote a healthy immune system. They may also promote a feeling of well-being and increase strength, but these are not the priority goals for HIV-positive patients. These activities will not prevent the risk for transmission to others because the patient will still be HIV positive.Cognitive Level: Comprehension Text Reference: p. 265Nursing Process: Planning NCLEX: Physiological Integrityek CRationale: The patient is at risk for dehiscence during the granulation phase of wound healing, which lasts from the fifth postoperative day to 3 weeks after surgery. The other times are not high-risk periods for dehiscence.Cognitive Level: Application Text Reference: pp. 198-199Nursing Process: Assessment NCLEX: Physiological Integrityel 4. HypertensionRationale:Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.em Ataxia. Rationale: Ataxia, weakness, restlessness, dizziness, or other motor problems can occur with lorazepam. Options 1, 2, and 4 are incorrect. These are not adverse effects associated with lorazepam.en A) AutonomyB) NonmaleficenceD) BeneficenceE) FidelityThe patient's autonomy is in danger. Harm (nonmaleficence), in the form of complications due to a treatment that the patient does not want, is also involved. Doing the right thing (beneficence) for the patient is in question, owing to the patient's wishes and the prognosis of her illness. Keeping "a promise to the patient" (fidelity) is involved. This scenario does not involve the principle of justice.eo 3. Addictive properties are enhanced in the presence of psychotropic medications.Rationale:The addictive properties of diphenhydramine hydrochloride are enhanced when used with psychotropic medications. Allergic symptoms may not be short term and will occur if allergens are present in the environment. Poor compliance may be a problem with psychotic clients but is not the subject of the question. Diphenhydramine hydrochloride may be used for extrapyramidal symptoms and mild medication-induced movement disorders.ep 4. Advances the affected leg after moving the crutches to descend the stairsTo descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.eq b. falseThe term for this sound of respiratory distress is "stridor."er Placenta Previaes 4) Clearly label the pump and send it for repair.Label it and take it out of service - all organizations have labels which indicate the equipment is not working. Evaluate the policy to determine if Clinical engineering or biomed needs to be contacted.et accumulation of blood in the pleural space.eu (1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection(2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma(3) correct—important to keep the skin clean and prevent secondary skin infection(4) increases risk of secondary skin infection...ev dyspneaorthopneafatigueparoxysmal nocturnal dyspneanocturiaew (C) 15Rationale: One gram (g) contains approximately 15 grains. Therefore, 5 grams contain 75 grains (5 X 15 = 75). Solve for x tablets using the following ratio method:1 tablet/5 grams = x tablets/75 grains 5x = 75 x = 75/5x = 15 tabletsex 4. Administer morphine sulfate intramuscularly every 3 hours as needed for painRationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid balance is stabilized, oral narcotic agents can be used. Options 1, 2 and 3 are all appropriate interventions for the client with a burn.ey Relapsing/Remitting: Difficulty chewing, speaking, walking. Shakiness, muscle weakness, tinnitus, visual problems, incontinent,Ataxia, Nystagmus, Spasticity, tremors, dysphagia, speech impaired, fatigueHelp pts identify triggers: illness, stressez 95 - 105fa (B) 25Rationale: The formula to calculate this problem is: x gtt/min = volume/time (in minutes X drop factor.x gtt/min = 75mL/60 min X 20 gtt/min75/60 = 1.25 1.25 X 20 = 25 gtt/minfb 3. The AHA states the most prevalent form of cardivascular disease is hypertention, followed in descending order by CAD, rheumatic heart disease, and stroke.fc 1.010 - 1.030fd 2. Relief of epigastric painRationale:The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication, but is not an intended effect. Options 3 and 4 are incorrect.fe b. IIThese are characteristics of a person in Stage II of NREM sleep.ff loss of consciousness and falling to floor. Signs: aura, cries, loss of consciousness, fall, tonic clonic movements, incontinence, cyanosis, excessive salvation, tongue or cheek biting. Posticatal period: need 1-2hr for sleep after.fg Difficulty going back to sleepfh 1) Decreased blood pressure (BP) after standing upOrthostatic Hypotensionfi Supports energy metabolismSupports nerve functionfj released in response to stimulacauses changes that lead to inflammatory response: main mediator of dilation and increased permeability of capillaries.fk porkfl obstructive pulmonary disease characterized by excessive production of mucus and chronic inflammatory changes in the bronchi, resulting in a cough with expectoration for at least 3 months of the year for more than 2 consecutive years.fm BRationale: The impact on sperm count and erectile function depends on the patient's pretreatment status and on the amount of exposure to radiation. The patient should consider sperm donation before radiation. Radiation (like chemotherapy or surgery) may affect both sexual function and fertility either temporarily or permanently.Cognitive Level: Application Text Reference: p. 301Nursing Process: Implementation NCLEX: Physiological Integrityfn a surgical procedure done to remove fluid from the pleural space.fo (1) pulse will decrease(2) correct—with myxedema there is a slowing of all body functions(3) associated with hyperthyroidism(4) associated with hyperthyroidism...fp 3. An episode of diarrheaRationale:Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.fq Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?(1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area(2) should splint incision before coughing to reduce discomfort and increase efficiency(3) partial answer, should take three deep breaths before coughing(4) implies coughing routine is adequate, incision needs to be splintedfr instability of the chest wall resulting from multiple rib fractures.fs BRationale: Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Problems with tissue oxygenation in polycythemia vera are due to increased blood viscosity and poor perfusion, not to poor oxygen saturation. (Oxygen is useful in secondary polycythemia.) The patient should be encouraged to ambulate to prevent DVT. Iron is contraindicated for polycythemia vera.Cognitive Level: Application Text Reference: p. 701Nursing Process: Planning NCLEX: Physiological Integrityft B. It usually progresses gradually with a deterioration of functionfu Strategy: Determine the significance of each answer choice.(1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever(2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL(3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin(4) symptoms of CHF, chest x-ray clear, no other information providedfv BRationale: A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching.Cognitive Level: Application Text Reference: p. 283Nursing Process: Evaluation NCLEX: Physiological Integrityfw 3. Reduction of steatorrheaRationale:Pancrelipase (Pancrease MT) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.fx 3. "The medications will kill the bacteria and stop the acid production."Rationale:Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.fy seizures are divided into two broad categories: generalized and partial (also called local or focal).fz D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."ga 1. Maintain a high fluid intake.Rationale:Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark brown or red. This does not indicate the need to notify the health care provider.gb 2. Rotate the insulin injection sites systematically.Rationale:Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.gc 3. Informing the client that this is normalRationale:Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction; therefore options 1, 2, and 4 are incorrectgd It decreases the excitability of the neurons. Rationale: The ketogenic diet consists of a high-fat and low-carbohydrate diet. The diet produces ketone metabolism in the brain, which decreases the excitability of the neurons. Options 1, 2, and 3 are incorrect. The ketogenic diet does have an effect on the prevention of seizures. It does not reduce stress or alter the potassium level.ge Beta-Blockers = particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction (heart attack), and hypertensiongf 1.67 - 2.5gg (1) correct—describes esophageal speech(2) describes electric larynx(3) method of speech for patient with a tracheostomy(4) describes tracheoesophageal fistula (TEF)...gh CRationale: The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. The response beginning "Let me show you how to dress" indicates that the changes are permanent and that the patient's appearance needs disguising. The response beginning, "I do not think you look bad" does not acknowledge the patient's feelings and also fails to communicate that the changes will be resolved after surgery. And the response beginning "You really should not worry about how you look in the hospital" implies that the patient's appearance is not good.Cognitive Level: Application Text Reference: p. 1314Nursing Process: Implementation NCLEX: Psychosocial Integritygi c. ABGThe term "hypoxemia" means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured.gj C. Delirium, Depression, Dementiagk Uncontrolled contraction/spasm of bladder results in leakage before reaching bathroomgl Difficulty remaining asleepgm 20 - 45 secondsgn double visiongo Widespread in foodsgp (B) "The exam may hurt a little as you apply pressure to the testes."Rationale: Testicular self examinations should be performed once a month. The best place to perform the exam is in the shower, while scrotal sac is warm and relaxed. Using the thumb and first two fingers, the testicles should be palpated. The testicle is movable and egg shaped. Any lump, hard area, or enlargement of a testicle, whether painful or painless, should be reported to a physician. The examination should be painless. If pain is experienced, too much pressure is being applied.gq P- Plan and isolation of RN LPN's collaborate with RN's , The current LPN standard is not to push IV meds.A- Asses initially LPN's will participate in ongoing assessments but the RN is responsible for the initial assessment Analyze LPN's do not make nursing diagnosis or analyze nursing careR- Review and evaluate and isolate the RN The LPN is responsible for collaborating with the RN during the evaluation processT- Teach initially while LPN's maybe involved in the teaching process the RN is responsible for the initial teaching the LPN may reinforce teachinggr DRationale: The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.Cognitive Level: Analysis Text Reference: pp. 330-331Nursing Process: Assessment NCLEX: Physiological Integritygs 1. Aspirate the tubeRationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful.gt DRationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.Cognitive Level: Application Text Reference: p. 706Nursing Process: Planning NCLEX: Physiological Integritygu 2. SpinachRationale:Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables, fish, liver, coffee, and tea.gv D. Rinse the mouth with water following the second puff of medication. The patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.gw BrainPeripheral nervesWBCsRBCsHealing woundsgx (1) correct—assessment; daily weight necessary with peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by physician(2) implementation; strict aseptic technique required to prevent contamination, sterile = aseptic, clean = antiseptic(3) implementation; don't milk catheter, drainage by gravity only(4) implementation; encouraged to eat a high-protein diet because of protein loss with CAPD...gy oral corticosteroid immunosupressant used to treat inflammatory diseases; reduce signs of inflammation, improve functiongz 4. Complaints of a metallic taste in the mouthRationale:Ridaura is the one gold preparation that is given orally rather than by injection. Gastrointestinal reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy, but these usually subside in the first 3 months of therapy. Early symptoms of toxicity include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth.ha D. Work of breathingWhen the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity.hb topical or parenteral corticosteroid; generally safer bc given locally.hc BRationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.Cognitive Level: Analysis Text Reference: pp. 332-333Nursing Process: Assessment NCLEX: Physiological Integrityhd 4. Low blood glucose levelRationale:β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Option 4 is the most reliable indicator of hypoglycemia.he a form of rhonchus characterized by continuous high-pitched squeaking sound caused by rapid vibration of bronchial walls.hf Strategy: Identify the least stable client.(1) no indication of hemorrhage, will require a tetanus shot(2) correct—disoriented, requires immediate assessment to determine underlying cause(3) splint; cover wound with sterile dressing; check temperature, color, sensation; give narcotic(4) hyperglycemic, give IV fluid, regular insulin...hg 1. Two-pointThe two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client.hh Polyneuritis: peripheral nerve disease; autoimmune inflammatory response to prior infection.Acute immune-mediated polyneuropathy d/t damage to myelin sheath of Peripheral Nerves.hi Age slows down the reflex. Contact lenses can affect the corneal reflex as well.hj 1. Potassium levelRationale:Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 2 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.hk greater than normal amounts of carbon dioxide in the blood (PaCO2 > 45 mm Hg); also called hypercarbia.hl example of acetic acidNSAID COX1hm The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted = hip dyslpasiahn B. patient's not being able to speak normally again. Patients who have a total laryngectomy have a permanent tracheostomy and will need to learn how to speak using alternative methods, such as an artificial larynx. The tracheostomy will be permanent to allow normal breathing patterns and air exchange. After surgery, the patient's nutrition is supplemented with enteral feedings, and when the patient can swallow secretions, oral feedings can begin. Deep-breathing exercises should be performed with the patient at least every 2 hours to prevent further pulmonary complications.ho Bhp 3. Put up the side rails on the bedRationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure himself or herself. The most frequent side effects of this medication are dizziness, drowsiness and lethargy. Therefore the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2 and 4 may be helpful measures that provide a comfortable, restful environment; however, option 3 is the only one that provides for the client's safety needs.hq CRationale: The wound requires debridement of the necrotic areas; absorption of the yellow-green slough and a hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.Cognitive Level: Application Text Reference: pp. 200, 204, 205Nursing Process: Implementation NCLEX: Physiological Integrityhr H1 histamine blocker"benadryl"hs 3. Remove the client from the roomRationale: In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The next steps are: activate the alarm, contain the fire, and then extinguish as needed. This is a universal standard that may be applied to any type of fire emergency. Option 3 is correct because it removes the victim from the area. Option 1 would be the next step (alarm). The fire is next contained (option 2) and then extinguished (option 4).ht in darkened room w/ other eye covered, move bright light towards the midline of the face and into the open eye: pupil should shrink immediately; establishes intact reflexhu A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF.hv 3. Serum amylaseRationale:Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.hw b. observe the client carefully for changes in behavior or vital signsThe nurse should observe the confused client for nonverbal cues to pain.hx DRationale: Patients with diabetes insipidus compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.Cognitive Level: Analysis Text Reference: p. 1297Nursing Process: Assessment NCLEX: Physiological Integrityhy 1) Burnshz (1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation(2) describes normal mild withdrawal symptoms(3) would contraindicate giving more sedation(4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the bodyia When the patient has a possible brain tumor.ib 3. Low back pain and dysuriaRationale:Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark urine and stools, jaundice, pain in the lower back, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. The remaining options are not adverse effects of the medication.ic 4. The result of another infection caused by leukopenic effects of the medication.Rationale:Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.id drug can cross placenta and enter breastmilk; old must watch out for infection and monitor blood glucose (can raise glucose levels)ie CRationale: An undifferentiated cell has an appearance more like a stem cell or fetal cell and less like the normal cells of the organ or tissue. The DNA in cancer cells is always different from normal cells, whether the cancer cells are well differentiated or not. All tumor cells are mutations form the normal cells of the tissue.Cognitive Level: Application Text Reference: p. 274Nursing Process: Implementation NCLEX: Physiological Integrityif CATEGORY: NSAID, 2nd gen COX-2 inhibitorACTION: inhibits cox-2 onlyUSE: arthritis, pain, dysmenorrhea, polyposisADVERSE EFFECTS: dyspepsia, abdominal pain, renal toxicity, sulfonamide allergyig GABA Objective: Recognize the causes of epilepsy.Rationale: GABA drugs mimic GABA by stimulating the influx of chloride ions into the neuron, leading to the suppression of neuron firing.Cognitive Level: ComprehensionClient Need: Physiological Integrity: Pharmacological and Parenteral TherapiesNursing Process: Assessmentih .(1) correct—being free from any drain bags during the day would appeal to a 13-year-old(2) is negative(3) would be embarrassing to a 13-year-old(4) it would be impossible for a teen with muscular weakness to put on an external catheter..ii Slow dose drug form of stimulants will ↑ the NE and DA tone in prefrontal cortex and nucleus accumbens and change the communication flow.ij Coombs Testik 1. Place the client in a high-Fowler's positionRationale: A miller-Abbott tube is a nasoenteric tube used to correct a bowel obstruction and decompress the intestine. A high-Fowler position decreases the risk of aspiration if vomiting occurs. A physician inserts the tube with the balloon deflated in a manner similar to that used with a nasogastric tube. The client usually sips water to facilitate passage of the tube through the correct nasopharynx and esophagus. Options 2, 3 and 4 are incorrect actions.il Muscle stiffness, rigidityim 3. Joint inflammationRationale:Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Colchicine has no effect on the client's blood glucose or blood pressure; it is not used to treat a headache.in B. "I don't think she will react very well to me making decisions for her."io 73/55ip 3.5 - 5.0iq 4. One hour before meals and at bedtimeRationale:Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.ir (1) correct—stable patient with expected outcome(2) requires the assessment skills of the RN(3) requires assessment and teaching(4) requires assessment skills of RN...is abnormal slowness of voluntary movements and speechit 3. DrowsinessRationale:A frequent side effect of cetirizine hydrochloride (Zyrtec), an antihistamine, is drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating.iu 3. ConfusionRationale:Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.iv 2. Uric acid levelRationale:Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute renal failure. Options 1, 3, and 4 are not specifically related to this medication.iw A. A decreased exhaled nitric oxide. Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma.ix 2. Decreased renal function slows excretion of drugsiy B- Approaches the client from the unaffected side.Rationale: The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client form the affected side to increase awareness further.iz RATIONALE: 1) IM injections should be give in the deltoid muscle in clients with spinal cord injuries. These clients exhibit reduced use of - and consequently reduced blood flow to - muscles in the buttocks (dorsal gluteal and ventral gluteal) and legs (vastus lateralis). Decreased blood flow results in decreased drug absorption.ja Monitor height and weight weekly to be sure GI side effects are not hindering nutrition and normal growth. Rationale: GI effects such as nausea, anorexia, and abdominal pain are common with ethosuximide. Because the client is still growing, improper nutrition may affect normal growth. Monitoring height and weight weekly will assist in tracking normal growth. Options 1, 2, and 4 are incorrect. Physical activity will not affect the drug's metabolism, and activity is normal and needed for healthy growth and development. Ethosuximide is not known to cause bone loss or dehydration.jb a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization.jc 2. Take the daily dose at bedtime.Rationale:The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. In addition, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the physician before changing brands of the medication. The client also checks with the HCP before taking OTC cough, cold, or other respiratory preparations because they could cause interactive effects, increasing the side effects of theophylline and causing dysrhythmias.jd 4. Leave the cream on for 8 to 12 hours and then remove by washing.Rationale:Lindane is applied in a thin layer to the entire body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. Usually, only one application is required.je 1. Using restraints to immobilize the limbsRationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose a risk to the client's safety. Removing potentially harmful objects is a good basic safety measure. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity.jf (C) Avert the attention of the male client and lead him to his roomRationale: The most appropriate response to this behavior would be to avoid confronting and/or threatening the client while removing the inappropriate behavior. Distraction is a good approach to ease removal of the client, making answer (C) correct. Averting the client's attention and escorting him to his room is neither confrontational nor threatening. Pulling the client aside and/or reprimanding him, as in answers (A) and (D), are both confrontational and threatening to a client. This could cause agitation. Having the other clients ignore the behavior will not remove the potentially hazardous situation.jg > 4' 9" in heightjh CRationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of breath sounds, although these would be assessed every shift.Cognitive Level: Application Text Reference: p. 330Nursing Process: Planning NCLEX: Physiological Integrityji (1) correct—to avoid dislodging drain, remove the dressing layers one at a time(2) do not clean a wound with both Betadine solution and hydrogen peroxide(3) cleansing of the wound is from the center outward to the edges and from the top to the bottom(4) incorrect; may dislodge drain...jj (1) restraining a client to prevent injury to self or others is appropriate(2) appropriate behavior(3) restraining a client to prevent injury to self or others is appropriate(4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychoticjk BRationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Fruits and vegetables that are peeled are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). Redness and drainage may not occur even with severe wound infections because these symptoms of infections are dependent on neutrophils.Cognitive Level: Application Text Reference: pp. 714-716Nursing Process: Assessment NCLEX: Physiological Integrityjl 1) Patient's self-reportjm 3. Acetaminophen (Tylenol)Rationale:Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory drugs (ibuprofen). The client should be advised to take acetaminophen for headache.*Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options 1 and 2 first.*jn (C) ToesRationale: Prone position involves the client lying with the anterior surface of the body compressed against the bed or lying area. The occiput, elbow and coccyx (also called the tailbone) are all pressure points that would be compromised if the client were to lay with the posterior surface against the bed or lying area. The toes would be compressed against the lying area with the client in the prone position. Therefore, the correct answer is (C).jo A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?jp 4. Cool, numb fingers and toesRationale:Ergotamine produces vasoconstriction, which suppresses vascular headaches when given at a therapeutic dose range. The nurse monitors for hypertension; cool, numb fingers and toes; muscle pain; and nausea and vomiting. *first recall that vascular headaches are caused by vasodilatation of the blood vessels in the head. Following this train of thought, you then recall that this medication must cause vasoconstriction. The only side effect consistent with vasoconstriction is option 4, the cool, numb fingers and toes.*jq arthritisjr D. Lubricate the tip of the enema tubing generously.C. Insert the tubing about 3 to 4 inches into the rectum.E. Raise the container to the correct height and instill the solution at a slow rate.B. Assess the patient for cramping. F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.A. Document the results of the procedure.You must lubricate the tip before inserting the tubing. You would then begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.js Myelosuppression Rationale: Myelosuppression is the most common dose-limiting adverse effect of chemotherapy, and the one that most often causes discontinuation or delays of chemotherapy. Options 2, 3, and 4 are incorrect. Although alopecia may be distressing for the client, its presence does not determine when the next round of chemotherapy can be administered. Mucositis is not a reason that subsequent rounds of chemotherapy should be delayed. Cachexia is the physical wasting with loss of weight and muscle mass caused by disease. Although it is considered, it is not the most common reason for delaying chemotherapy.jt Strategy: Determine if the answer choice relates to Valium.(1) more indicative of preoperative complications, should be reported before medications are given(2) more indicative of preoperative complications, should be reported before medications are given(3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight)(4) hostility may be treated best by ventilating feelings...ju DRationale: An alert elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age, and is not an accurate indicator of volume depletion. Many prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.Cognitive Level: Application Text Reference: p. 321Nursing Process: Implementation NCLEX: Health Promotion and Maintenancejv (A) ConstipationRationale: Aluminum hydroxide (Amphogel) is used for the treatment of ulcers by neutralizing gastric acid. A frequent side effect of this medication is constipation, answer (A). It is uncommon for clients to experience diarrhea, dizziness, or pruritis (itching) from the use of Amphogel.jw B) stress can impede healing.C) anxiety can cause powerlessness, which can lead to hopelessness.D) anxiety can intensify pain.E) critical care is a very stressful environment for the patients, family, and staff.jx B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healingjy 4. Standing on the right side of the clientRationale: When working with a client, the nurse should stand on the client's affected side. The nurse should position the free hand on the client's shoulder so that the client can be pulled toward the nurse in the event that the client falls forward. The client should be instructed to look up and outward rather than at his or her feet. Options 1, 2 and 3 are incorrect.jz b. FalseAbsorption refers to the "movement" of the drug from the site of administration into the blood stream. Therefore, the intravenous, parenteral route leads to "instant" absorption.ka 3. FHR of 140 beats per minuteRationale: The average FHR is 140 beats per minute. The normal range is 110 to 160 beats per minute; therefore option 3 is the only correct option.kb 2. Once daily, at the same time each dayRationale:Insulin glargine is a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, at the same time each day.kc 4. Rinse the incision with sterile water after using diluted hydrogen peroxideRationale: The incision should be rinsed with sterile water when it is cleaned with a solution other than water or saline. The Logan bar is intended to maintain integrity of the suture line; removing the Logan bar on the first postoperative day is incorrect because removal would increase tension on the surgical incision. The incision is cleaned after every feeding and when serous exudate forms. The incision should be dabbed and not rubbed to maintain its integrity.kd (B) 0.25 mLRationale: Solve for x mL using the following ration method. 50mg/1mL = 12.5mg/xmL50x = 12.5x = 12.5/50x = 0.25mLOr use desired over available:12.5mg/50mg X 1mL = x mL12.5 divided by 50 = 0.250.25 X 1 mL = 0.25 MLke Must be administered four times per day. May cause serious hepatic damage.Rationale: it is difficult to remember to take a medication four times a day, and as the client's cognitive functioning declines, it may be increasingly difficult to administer it. Serious liver damage is a possibility with tacrine, which decreases its usefulness. Options 2, 3, and 5 are incorrect. Tacrine may cause weight loss, rather than gain, and does not cause vision difficulties. Tacrine is available by prescription only and cannot be purchased over the counter.kf DRationale: Sexual contact with an infected partner is currently the most common mode of transmission, although HIV is also spread through perinatal transmission, through sharing drug injection equipment, and through transfusions with HIV-infected blood.Cognitive Level: Comprehension Text Reference: p. 250Nursing Process: Assessment NCLEX: Health Promotion and Maintenancekg 2. Decreased muscle spasmsRationale:Baclofen is a skeletal muscle relaxant and central nervous system depressant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases and in clients with multiple sclerosis. Options 1, 3, and 4 are incorrect.kh Right second intercostal spaceki 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."Rationale:Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information.kj 9.5 - 12.0 secondskk A) The patient responds appropriately to teaching, but then asks a question about the information just given.C) The patient stares into space while the nurse is talking and then asks, "What?"D) The patient has frequent bouts of crying and wants to be left alone.kl 4. Report the passage of the normal stool to the registered nurse (RN)Rationale: Passage of a formed brown bowel movement usually indicates that an intussusception has reduced itself. The nurse immediately reports this data to the RN, who will in turn report it to the physician. This finding may change the course of the plan of care. Increased abdominal pain is not expected because the child's gastrointestinal tract is more functional. The finding does not indicate the need for immediate surgery.km A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?kn CRationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.Cognitive Level: Application Text Reference: pp. 322-325, 338Nursing Process: Assessment NCLEX: Physiological Integrityko (D) Temperature of 101 degrees FRationale: Septicemia is the invasion of pathogenic bacteria into the blood stream. Symptoms of septicemia include temperature elevation, backache, headache, elevated pulse, elevated respiratory rate, nausea, vomiting, diarrhea, chills and general malaise. The correct answer is (D), temperature 101 degrees F. Pain, redness or drainage from an injury site suggests local, rather than systemic, infection or inflammation.kp D- Remind the client to turn the head to scan the lost visual fieldRationale: Homonymous hemianopsia is loss of half of the visual field. The client with Homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision: The nurse encourages the use of personal eye glasses, if they are available.kq Corticosteroids Rationale: The long-term use of corticosteroids may contribute to the development of glaucoma. Options 2, 3, and 4 are incorrect. Beta blockers are used for the treatment of glaucoma; they do not cause it. Calcium channel blockers and insulin play no role in the development of glaucoma.kr BRationale: The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.Cognitive Level: Application Text Reference: pp. 196-197Nursing Process: Assessment NCLEX: Physiological Integrityks Tonic Phase: Loss of consciousness; muscles contract 10-20 secClonic Phase: rhythmic contraction <2minAura: warning sxCrisis Preventions: HAVE SUCTION, AIRWAY, O2 AT BEDSIDE!Protect pt: lower to floor, pad siderails, pillow under head, don't restrain, allow post-ictal rest.Prevent Aspiration: turn side, loosen neck clothing, suction.Ongoing: Monitor VS, LOC, O2 saturation, Glasgow coma scale, reassure & orient pt after seizurekt Inject medication in the deep fatty layer of the abdomen. When brushing your teeth, use a soft toothbrush. Hold direct pressure on any puncture sites for 15 minutes. Rationale: The client should be taught proper injection technique, including the need to inject the heparin into the deep subcutaneous fat layer. A soft toothbrush should be used for oral hygiene. Puncture wounds or cuts will require longer-than-normal pressure held at the site to stop bleeding—15 minutes or longer. Options 4 and 5 are incorrect. Dental flossing should be avoided while the client is receiving anticoagulants. The flossing can cause gum irritation and excessive bleeding. Aspirin has antiplatelet effects, and concurrent use may increase the risk of bleeding or hemorrhage.ku b. Shaking your hands dry over the sinkShaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area.kv CRationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia.Cognitive Level: Application Text Reference: p. 688Nursing Process: Implementation NCLEX: Physiological Integritykw 3. Bright red bleeding from a neck woundRationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. According to the triage process, the client in this classification would be issued a red tag. The client with the penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia; this client requires intervention but can provide self care if needed. A designation of "expectant" and color code "black" would be applied to the client with massive injuries and a minimal chance of survival. These clients are given definitive treatment last.kx 4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.Rationale:Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.ky Which of the following respiratory patterns indicate increasing ICP in the brain stem?kz normal salinela A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior?lb 4. Place a sign on the door of the client's room indicating the need to speak to the nurse before enteringRationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of exposure to radiation when in the client's room. The client should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. A lead container and long handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should be pick up the implant with long handled forceps and place it in the lead container. The nurse does not reinsert it. Visiting time is limited to 30 minutes per visit.lc Gently put pressure on the inner canthus (tear duct) for 1 minute after instilling the timolol drop. Rationale: Timolol is a beta-adrenergic blocker. To prevent swallowing and systemic absorption, pressure should be applied to the inner canthus of the eye for 1 minute after instilling the drop. Options 1, 2, and 3 are incorrect. No other eyedrops or ointments should be used when taking timolol or other drops for glaucoma without the approval of the provider. Eye solutions for allergies may contain adrenergic drugs that may worsen glaucoma. Timolol is not contraindicated during seasonal allergies. It is not known to worsen seasonal allergies, although it may cause bronchoconstriction in the sensitive individual or if swallowed and systemic effects occur.ld petechiae or ecchymoses, large blood filled bullae in mouthle 3) Fruits and vegetables.The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.lf Which of the following physiologic changes would be expected in a patient with presbyopia?lg removal of calculi (stone) from ureterlh C. "Tilt your chin forward toward the chest when swallowing your food." A nurse should instruct a patient to tilt the chin toward the chest, which will close the glottis and allow food to enter the normal passageway. Ideally, foods should be of a thick consistency to enable effective swallowing and reduce the risk of aspiration. Overinflation of the cuff causes swallowing difficulties. Fluids should be consumed in small amounts after swallowing to prevent the risk of aspiration.li F-Find Hypoxia O2 is an always immediate concern can be a result of cardiac or respiratory complications VS skin color or capillary refill are a few assessments a nurse would anticipate, also increased anxiety and confusion.I-Imunno Compromised receiving kimo, or has aidsR-Real Bleeding Hemmer age from trauma or surgery changes in VS skin color temperature and urine output will result in alteration in organ or tissue confusionS-Safety at risk for injury from IICP or confusion form delirium or dementiaT- Try Infection client who is septic with a high fever and has order for blood cultures and antibiotics, obtain blood cultures before starting antibioticslj 2) Offer caffeinated beverages to constrict blood vessels in his head.lk 2. Preparation for a cesarean deliveryRationale: Cesarean delivery reduces the risk of neonatal infection with a mother in labor who has either herpetic genital lesions or ruptured membranes. Options 3 and 4 would expose the fetus to the virus. Standard Precautions are necessary, not protective isolation.ll (B) 390 mLRationale: Oral fluid intake is being calculated. Oral fluid intake for this meal would include any consumed fluid or solid food that becomes liquid at room temperature. Pudding does not fit the category for oral intake. Oral Fluid Intake Calculation:6 oz of coffee, 3 oz of grape juice, 4 oz of milk multiplied by 30 mL/oz = (6=3=4) X30 = 390lm BRationale: Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.Cognitive Level: Comprehension Text Reference: pp. 667, 680Nursing Process: Assessment NCLEX: Physiological Integrityln 3. White blood cell countRationale:Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are unrelated to this medication.lo Has no significant drug interactions. Rationale: rivastigmine has no significant drug interactions. This is thought to be true because there is no interaction with enzymes in the liver that metabolize drugs. Options 2, 3, and 4 are incorrect because they do not apply to rivastigminelp 4. Orange juiceRationale:Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Milk may affect absorption of the iron. Water will not assist in absorption. Orange juice contains a greater amount of vitamin C than apple juice.lq shrinking of adrenal gland resulting in poor output of cortisol (life threatening); caused by not tapering off corticosteroidslr BRationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.Cognitive Level: Application Text Reference: pp. 326-327Nursing Process: Implementation NCLEX: Health Promotion and Maintenancels ARationale: Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.Cognitive Level: Application Text Reference: p. 694Nursing Process: Diagnosis NCLEX: Physiological Integritylt 2140Cognitive Level: Application Text Reference: pp. 202-204Nursing Process: Implementation NCLEX: Physiological Integritylu NSAID, COX 1 drug classex: indomethacin, nabumetone, ketorolac**unlike aspirin... inhibition of cyclooxygenase is reversible, does not protect against MI/stroke (Increase in thrombocytic events is concern)lv Increase protein and potassiumDecrease sodium and calorieslw pin-point hemorrhageslx 4thly BRationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.Cognitive Level: Application Text Reference: pp. 339-340Nursing Process: Assessment NCLEX: Physiological Integritylz (1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision(2) fluids should be encouraged(3) will not prevent complications(4) does not address a common complication...ma "Avoid the use of alcohol while taking this drug." Rationale: Alcohol is a CNS depressant, so taking two CNS depressants concurrently may cause over-sedation, or even coma. Options 1, 2, and 3 are incorrect, and are not recommended to improve sleep; they may only worsen the sleep problems.mb pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.mc the inability to extend legsmd 2. Confusion and irritabilityPsychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.me nomf BRationale: Neutropenia places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy.Cognitive Level: Application Text Reference: p. 297Nursing Process: Assessment NCLEX: Physiological Integritymg d. all of the abovemh A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli.mi 20-40mj The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?mk 3. Instructing the client to call for ambulation assistanceRationale:Chloral hydrate (a sedative-hypnotic) causes sedation and impairment of motor coordination; therefore, safety measures need to be implemented. The client is instructed to call for assistance with ambulation. Options 1 and 2 are not specifically associated with the use of this medication. Although option 4 is an appropriate nursing intervention, it is most important to instruct the client to call for assistance with ambulation.ml 1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain.mm (C) Until the degree of leukemia involvement is determined in the child, it is best to keep the child away from other children as much as possible. The white blood cells of a client with leukemia are ineffective. This causes decreased immunity. Infection from another child or person could be detrimental to a child with this condition. A semiprivate room is not recommended at this time. Unless the child is in critical condition, assignment to an intensive care bed is not necessary.mn (A) Checking the client's weightRationale: Hemodialysis (HD) is indicated for clients with excess and electrolyte imbalances. Fluid loss or gain is assessed by checking the client's weight at least once a day as well as before and after HD sessions. The amount of weight loss or gain at these times is used to monitor effectiveness of or further need for HD. Measuring intake and output is important to ensure limited fluid intake for clients with renal failure, but this will not indicate HD effectiveness. Clients with renal failure often experience fatigue with exercise, but factors other than those associated with renal failure could cause fatigue. HD is used to regulate serum electrolyte levels (i.e., potassium), but these levels will not indicate overall effectiveness of HD.mo 4. At least 30 minutes before exposure to the sunRationale:Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.mp visual field cut; defective vision or blindness 1/2 visual fieldmq 2. "I need to discontinue the medication after 14 days of use."Rationale:Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the HCP. The client should also call the HCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.mr 5th intercostal space, left side, sternal borderms 3. Treat hypocalcemic tetany.Rationale:Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes or muscle spasms or twitching, the health care provider is notified immediately. Calcium gluconate should be kept at the bedside.mt D. 50 mm Hg and bicarbonate level of 30 mEq/L. If compensation is present, carbon dioxide and bicarbonate are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and the other alkalotic).mu Abnormal flexion: Hands pulled to chest and hyper-extended.Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers."flexor - toward the cord"mv difficulty writingmw B. Walk for 20 minutes a day, keeping the pulse rate less than 130 beats per minute. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 minus patient's age).mx D. Preconceived assumptions regarding the lifestyles and attitudes of this groupmy 3. Early morningRationale:Corticosteroids (glucocorticoids) should be administered before 9:00 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning. *Note the suffix "-sone," and recall that medication names that end with these letters are corticosteroids.*mz allergies to Iodine - contrast media (dye)na BRationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. Treatment of CML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.Cognitive Level: Application Text Reference: pp. 721-722Nursing Process: Implementation NCLEX: Psychosocial Integritynb face pt and speak slowly w/ a slightly lower voicenc 2. Submerging the NG tube in water to check for bubblingRationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.nd 4. Complete blood cell countRationale:The nurse would monitor the client's complete blood cell counts because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other values that warrant monitoring include serum calcium levels and the results of urinalysis, hepatic, and thyroid function tests.ne a condition of oxygen overdosage caused by prolonged exposure to a high levels of oxygen; may inactivate pulmonary surfactant and lead to development of acute respiratory distress syndrome.nf MIng ARationale: The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient's BP. The other actions are also needed but are not the highest priority.Cognitive Level: Application Text Reference: pp. 732-733Nursing Process: Implementation NCLEX: Physiological Integritynh Panic disorder Rationale: Panic disorder is not an appropriate use for phenobarbital. Options 1, 3, and 4 are incorrect. Treatment of status epilepticus, use prior to diagnostic testing, and use prior to receiving general anesthesia are all appropriate for phenobarbital.ni CRationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as circulatory collapse.Cognitive Level: Application Text Reference: p. 1315Nursing Process: Planning NCLEX: Physiological Integritynj No more than 10%nk 1. PancreatitisRationale:Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.nl 4. Getting baseline postural blood pressures before administering the medication and each time the medication is administeredRationale:Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.nm Adolescents (12-18)P- peer group- select activities involving their peers. Individualize if on isolation or on bedrestA- altered body image dont want to be seen as different. PEER PRESSURE. Health promotion. Ex drugs and STDsI- identity/image struggle with their identity and make choices regarding college or careerR- role diffusion who are they and what r their goals. Educate families to help with strugglesS- separation from peers encourage peers to visit while in the hospitalnn b. Determine if the teaching should take place at a different timeClients who are stressed may be unable to listen fully and will not receive/understand the intended message.no jaw thrustnp a measure of the ease of expansion of the lungs and thorax.nq Avoid aldoholbland foodssmall, frequent mealsdecrease fatnr methylphenidate hydrochloridens Goodell'snt 1. An enlarged prostate gland2. Poorly controlled blood glucose3. Drinking a cup of tea before bed5. Taking his diuretic too close to bedtimenu 2. Avoid the use of alcohol.Rationale:Baclofen is a central nervous system (CNS) depressant. The client should be cautioned against the use of alcohol and other CNS depressants, because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect of baclofen. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the health care provider if fatigue occurs.nv 4. Contact the health care provider (HCP) if a sore throat occurs.Rationale:Mycophenolate mofetil should be administered on an empty stomach. The capsules should not be opened or crushed. The client should contact the HCP if unusual bleeding or bruising, sore throat, mouth sores, abdominal pain, or fever occurs because these are adverse effects of the medication. Antacids containing magnesium and aluminum may decrease the absorption of the medication and therefore should not be taken with the medication. The medication may be given in combination with corticosteroids and cyclosporine.*neutropenia can occur with this medication*nw an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs caused most commonly by heart failure; an acute, life-threatening situation in which the lung alveoli become filled with serous or serosanguineous fluid caused most commonly by heart failure.nx DRationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they do not indicate the need for immediate intervention.Cognitive Level: Analysis Text Reference: p. 330Nursing Process: Assessment NCLEX: Physiological Integrityny Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.nz DRationale: It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.Cognitive Level: Application Text Reference: pp. 258, 264-265Nursing Process: Implementation NCLEX: Physiological Integrityoa anticholinergic that inhibits gastric secretions and decr GI motilityob decrease oxygen demanddecrease conductivitydecrease HR and PVRblock calcium access to the cellsdecrease force of myocardial contractilityoc hyperthyroidism, hypertensionod BRationale: The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.Cognitive Level: Application Text Reference: pp. 1316, 1319Nursing Process: Diagnosis NCLEX: Physiological Integrityoe ARationale: Chronic corticosteroid use will interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. An admission temperature of 102° F requires assessment of the cause and treatment, but is not necessarily a concern for wound healing.Cognitive Level: Application Text Reference: pp. 201-202Nursing Process: Assessment NCLEX: Health Promotion and Maintenanceof BRationale: Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy.Cognitive Level: Application Text Reference: p. 670Nursing Process: Implementation NCLEX: Physiological Integrityog 1) Increased exercise.oh 3) NREM, delta wavesoi Ischemia of brain tissue: Hemorrhage, thrombus, embolus.Medical Emergencyoj DRationale: A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.Cognitive Level: Application Text Reference: p. 1295Nursing Process: Assessment NCLEX: Physiological Integrityok 4. Position the infant prone with the head of the bed elevatedRationale: Before surgery the infant's status is nothing by mouth (NPO), and the infant is stabilized with intravenous fluids and electrolytes. The head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Options 2 and 3 are not accurate during the preoperative period because the infant is kept NPO. An infant is not restrained in a high chair.ol (C) 134/97Rationale: Normal blood pressure readings range between 100 to 140 systolic and 60 to 90 diastolic. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (2003) recommends that if either a systolic reading between 140 and 149 or a diastolic reading of 90 to 99 is obtained, the client's blood pressure should e rechecked in 2 months following the initial reading. The correct answer is (C). In this answer the diastolic reading is above the normal range. All other answers are within normal blood pressure range.om Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?(1) diet should be high residue to prevent constipation due to inactivity(2) may be positioned on affected side after incision heals(3) foot flexion exercises should be done every hour to prevent complications(4) correct—prevents respiratory complications due to immobility following surgeryon 1) Apply an indwelling fecal drainage device.An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.oo (A) Assess airway patency(D) Check heart rate and blood pressure(B) Assess for injury(C) Move the client into bed(E) Call the client's physicianRationale: Assessing airway patency is the primary concern upon initiating emergency actions. If the airway is obstructed, CPR steps would be continued (i.e. Heimlich maneuver, rescue breathing, chest compressions, etc.). If the airway is patent, cardiopulmonary stability status is stable, the client can be assessed for any injuries caused by the fall. Moving the client to bed is not a top priority above assessing cardiopulmonary status. If the client could be further injured during the transfer process, this should be avoided until the safest transfer method is available. The physician should be notified once assessment and necessary interventions have been initiated.op 2. Peripheral neuritisRationale:A common side effect of the TB drug INH is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized by pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are incorrect.oq (1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area(2) sterile packs should be opened only as needed(3) never reach an unsterile arm over a sterile field(4) outside of a bottle containing sterile liquid is not considered to be sterile...or Strategy: Remember the positioning strategy.(1) head of bed not elevated enough(2) correct—facilitates swallowing and movement of tube through gastrointestinal tract(3) not the best position(4) not the best positionos 4. When the last alcoholic drink was consumedRationale:Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.ot 3) Blood pressure increases; heart rate and respiratory rate decline.4) Men have higher blood pressure than women until after menopause.ou (A) 0.45% sodium chloride with added potassiumRationale: The client in this case needs a hypotonic solution to help the dehydrated cells pull in and regain fluid. 0.45% sodium chloride or 1/2 normal saline is an example of a hypotonic solution. Potassium is lost along with the body fluids expelled through diarrhea and vomiting. Adding this to the fluid solution will replenish the body with this essential electrolyte. 0,9% sodium chloride or normal saline is an isotonic solution. The constituents in isotonic solutions are similar to the fluid in the blood. Using this type of solution would not change the dehydrated state since it will not add or remove fluid from the body cells. 3% sodium solution would lead to further dehydration by pulling fluid from the cells.ov C- Cant irrigate a Foley the CNA's should not conduct this interventionC- Cant make clinical decisions CNA's but can make observationsA- Anticipate Clinical ChangesN- No Invasive Procedures CNA's should not be accountable for any invasive procedures or specialized proceduresT- Teach CNA's are not responsible for teachingow Strategy: Think about each answer choice.(1) inaccurate; low-grade fever is expected within 24 to 48 hours(2) inaccurate; low-grade fever is expected within 24 to 48 hours(3) correct—low-grade fever and irritability frequent response to immunization(4) symptoms should be reported to physician, antipyretic usually prescribedox 3. "I will apply the ointment once a day and cover it with a sterile dressing."Rationale:Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing.oy an infectious disease caused by Mycobacterium tuberculosis; usually involves the lungs but also occurs in the larynx, kidneys, bones, adrenal glands, lymph nodes, and meninges and can be disseminated throughout the body.oz Status Epilepticuspa D- Consistently uses adaptive equipment in dressing selfRationale: Client's are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.pb Chadwickspc 3. IncoordinationRationale:Diazepam is a centrally acting skeletal muscle relaxant. Incoordination and drowsiness are common side effects resulting from this medication. The other options are incorrect.pd 4. Authorization by the family to discontinue the treatmentRationale: The family or a legal guardian can make treatment decisions, generally in collaboration with physicians, other health care workers, and other trusted advisors. The nurse first checks for family authorization to discontinue the treatment. Next, option 3 would be appropriate. Although options 1 and 2 may be necessary in some events, these options are not the first actions in this event.pe C. Functional abilities.pf DimpleD- death bogeyman. Be honest with them about death and funerals. Encourage ventilation of thoughts and feelingsI- industry vs inferiority/immunizations "chum" may enjoy collecting things and playing sportsM- modesty more concerned with modesty and privacy. Pull curtains and close doors.P- peers begin to mix with opposite sexL- loss of control hospitalization is seen as loss of control. Let them help with decision makingE- explain procedures use terms they can understandpg 2. Decreased gas exchange 3. Decreased cough efficiencyph 4. Tranylcypromine (Parnate)Rationale:The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) or phenelzine (Nardil) within the past 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, or death.pi 3. "I use the time to really look at my clients and determine what's normal and what's not."Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question.pj (A) Easy bruising(B) Buffalo hump(C) Hyperglycemia(F) Trunk obesityRationale: Clinical manifestations associated with Cushing's syndrome include: easy bruising, moon face, buffalo hump, hyperglycemia, hypokalemia, sodium retention, thinning of scalp hair, increased body and facial hair, acne, muscle wasting, poor wound healing, and mood changes. Excessive scalp hair growth and hyponatremia are not associated with Cushing's syndrome.pk 10 - gag reflex, swallowing, talkingpl (1) expected at 3 months(2) correct—unexpected until 6 months of age(3) expected at 3 months of age(4) expected at 3 months of agepm 4. Administration of intravenous (IV) fluidsRationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse prepares to infuse IV fluids as ordered and to continue monitoring urine output. Checking respirations and temperature and frequent range of motion to extremities will not maintain viability of the kidneys.pn Apply with a gloved hand only to the site of pain. Rationale: Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 1, 3, and 4 are incorrect. Capsaicin should only be applied to the site of pain, not proximal or distal to the pain. If capsaicin begins to irritate and cause redness, it should be discontinued. Capsaicin should not be applied with a bare hand.po Unilateral weakness of facial musclesPain around earUnilateral inability to close eyeDrooping of mouthInability to smile, frown, whistleparalysis that distorts smiling, eye closure, salivation, and tear formation on the affected side.Distinguishing it from the facial paralysis associated with some strokes, which affect the muscles of the mouth more than those of the eye or forehead.Complication: Corneal abrasion or ulcerationResidual facial weaknesspp shortness of breath; difficulty breathing that may be caused by certain heart conditions, strenuous exercise, or anxiety.pq MAO inhibitorsDrugs that use/block CYP 2D6pr 1) Washing handsps ...pt (1) has an acute trauma, is not immunocompromised(2) has a bacterial infection, is not immunocompromised(3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus(4) has chronic disease, is not immunocompromised...pu BRationale: Changes in secondary sex characteristics are associated with decreases in FSH and LH. Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in ACTH and cortisol. Bradycardia is likely due to the decrease in TSH and thyroid hormones associated with panhypopituitarism.Cognitive Level: Application Text Reference: p. 1294Nursing Process: Assessment NCLEX: Physiological Integritypv 1. TinnitusRationale:Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is commonly experienced when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequently occurring effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways involved with oxygen consumption and heat production. Options 2, 3, and 4 are incorrect.pw 2. A client on a 24-hour urine collection who is on strict bed rest.Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a below-the-knee amputation, is scheduled for an invasive procedure, or is scheduled to be transferred to the hospital for coronary artery bypass surgery has both physiological and psychological needs. The nursing assistant has been trained to care for a client on bed rest and urine collections. The nurse provides instructions, but the tasks required are within the role of a nursing assistant.px 2 arteries, 1 veinpy A,B,D The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health.pz 2. Increase the level of suicide precautionsRationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase in the level of suicide precautions is indicated to keep the client safe. The other options are not indicated (option 1) or could place the client at increases risk (options 3 and 4).qa a general term for lung diseases caused by inhalation and retention of dust particles.qb dry powdered drug delivered by inhalation.qc (1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens(2) CMV is fetotoxic; should inform client of risks(3) this nurse is at increased risk for developing the disease(4) correct—most appropriate option due to decreased risk...qd 16-22qe the surgical reconstruction of the nose.qf P- Promote Stability asses condition and provide airway support and provide IV site if necessaryO- Off / Out wash off if radioactive remove contaminated clothing if has pill in mouth take out eyes may need to be flushed out antidotes may be necessary for drug overdose ingested substances may be taken out of body by emisis, lavadge, absorbant (activated charcoal) catharticis Emithis is contra indicated if a person is comatose in shock experience a seizure or has loss of gag reflex. If a low viscosity hydrocarbon or strong corrosive (acid or alcheine ) has been ingested immises is contra indicatedI- Identify the toxinS- Support the client both physically and psychologically parents may feel guilty support is imperativeO- Ongoing safety education regarding poison controlN- Notify they poison control center facility or provider care for immediate consolation.qg 1. Nizatidine (Axid) 2. Ranitidine (Zantac) 3. Famotidine (Pepcid) 4. Cimetidine (Tagamet)Rationale:H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.H2-receptor antagonists medication names end with -dine.Proton pump inhibitors medication names end with -zole.qh B. poor compliance with drug therapy in patients with TB. Drug-resistant strains of TB have developed because TB patients' compliance to drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of TB treatment. Antitubercular drugs are almost exclusively used for TB infections. TB can be effectively diagnosed with sputum cultures. The incidence of TB is at epidemic proportions in patients with HIV, but this does not account for drug-resistant strains of TB.qi DRationale: Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.Cognitive Level: Application Text Reference: p. 308Nursing Process: Evaluation NCLEX: Physiological Integrityqj (B) Human chorionic gonadotropin (hCG)Rationale: Human chorionic gonadotropin (hCG) is released by the trophoblast, outer cell layer of the developing fetus in the zygote stage. hCG can be detected in the blood and urine as early as 10 to 14 days after conception, indicating early pregnancy. Human growth hormone (hGH) is responsible for the growth of bones, muscles and other organs. Estrogen is important for maintaining pregnancy, but it is not used to diagnose pregnancy. Estrogen elevation does not occur until the seventh week of gestation. Oxytocin promotes uterine contractility and the stimulation of milk ejection from the breasts. During pregnancy oxytocin assists the labor process that results in birth.qk 3. Shift changeRationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of increased risk for suicides are weekends (not weekdays), and the night shift (not day shift).ql Strategy: Think about the action of each medication.(1) contains aspirin, contraindicated for persons with bleeding disorders(2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders(3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders(4) correct—analgesic used for moderate to severe painqm (F) Turn the hearing aid off and the volume all the way down(B) Line up the earmold with the corresponding parts of the ear(C) Slightly rotate the earmold forward(E) Insert the ear canal portion of the earmold(D) Rotate the earmold backward(A) Turn the hearing aid on and turn the volume upRationale: Prior to inserting the hearing aid, it should be turned off with the volume all the way down. Next, locate the parts of the ear and the corresponding parts of the hearing aid and align them. Prior to inserting the ear canal portion of the earmold, it should be slightly rotated forward. As the earmold is guided into the ear canal, it is rotated backward. Once the earmold is snugly in place, turn the eharing aid on and volume according to the client's needs.qn 4. Warfarin (Coumadin)Rationale: The nurse is careful to question the surgeon about whether warfarin sodium should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld during the preoperative period to minimize the risk of hemorrhage during surgery. The other medications may also be withheld if specifically ordered, but usually they are discontinued as part of an NPO (nothing by mouth) after midnight order.qo Closure of the pulmonic and aortic valves (Distole) = Dubqp 30-60qq 1. Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous return.qr B. Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient.qs (1) indicates dehydration(2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement(3) symptoms could be from causes other than volume overload(4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seenqt A) A plaque on the wall that lists all the nurses with CCRN certificationC) A banner in the hall to state the unit had no VAPs reported for the previous quarterD) A clinical ladder program that includes merit raises and opportunities for scholarships to national conferencesE) A newsletter article that talks about the projects completed by the shared governance committees in the departmentqu A. supplemental oxygen should be used when the patient exercises.An oxygen saturation lower than 90% indicates inadequate oxygenation. If the drop is related to activity of some type, supplemental oxygen is indicated.qv MAO inhibitorsqw 1. Admitting the client to a semiprivate roomRationale: The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a single room on the nursing unit. A sign indicating "See the Nurse before Entering" should be placed on the door to the client's room so that the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room.qx (C) "You will need to visit your doctor regularly for laboratory blood testing."Rationale: Lithium is a medication used to decrease or prevent acute manic episodes. To ensure therapeutic effects and prevent toxicity, a client on this medication will need to have regular serum Lithium levels drawn. Initially this test is drawn twice weekly. Once therapeutic levels are reached the test is performed every 2 to 3 months. While on this medication, a client is informed to drink a lot of fluid and consume a moderate amount of sodium in the diet. This prevents low sodium levels, which can lead to Lithium toxicity. The client should be instructed never to skip a dose in order to maintain therapeutic levels. Weight gain, not weight loss, is a side effect of this medication.qy (A) Prescription of selective serotonin reuptake inhibitors(B) Behavior therapyRationale: Treatment of obsessive-compulsive disorder (OCD) includes use of selective serotonin reuptake inhibitors (SSRIs) and behavior therapy. OCD is thought to be caused partially by low levels of serotonin in the brain. SSRIs increase serotonin levels. Behavior therapy involves exposure to a feared object or situation and prevention of carrying out compulsive behavior. Benzodiazepines are not prescribed to treat OCD. Imagery and distraction are relaxation techniques usually used as pain relief measures. Electroconvulsive therapy is used to treat severe depression when other treatment modalities are ineffective.qz M-many cultures must be done to id the problem. Pathogens such as respiratory,skin,and urinary infections. The nurse is not always able to tell the client is infected.R- requires gown, gloves,goggles should be worn (standard precaution) gloves must be worn when touching substances, mucous membranes, non-intact skin, and items that are contaminated. Linen should be changed frequently after contact with infected material. Gowns should be worn if soiling is likely. mask/face shield should be worn if splashing is to occur. Hand washing before and aftercare.S-social isolation if infections is in the respiratory tract Private room is necessary (droplet precaution). There should be 3 feet of space between client/resident and visitors. Client must ware mask when transporting in the hospital. Linen must be bagged to prevent contamination. trash must be discarded to prevent contamination to self, environment, or outside a bag. masks/face shild for staff and visitors who are within 3 feet of client. Noncritical care equipment should be limited to a single client.A- active infection treatment is tetracycline, bactrim, bacamycin,MRSA is a common drug resistant organism found in health care facilities. Is spreed primarily by direct and indirect contact. Sometimes transmitted thru thr respiratory and urinary tracts. Standard precaution will prevent the spread particularly in the skin and urine infections. If in the wound or urine contact precaution are used and if in the respiratory tract then droplet precautions are used. Hands must always be washed after the gown,gloves, ect have been removed.Trash and linen stays in room (special bagging). Leave stethoscope in room.patient will have ^ tempt, ^ WBC(initally when given drug)I&O(renal function) 30 mins prior to 3rd doserudolph the redneck reindeerhad an adverse side effectfrom the drug vancomycingot to do peak and trough or go deafmust keep all labs in checkcaution with renal failurehearing loss and allergiestake a temp and blood culturesspecially a CBCra D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.rb 4. "We should avoid insect repellents because they will attract the ticks."Rationale: To prevent Lyme disease, individuals should be instructed to use insect repellent on the skin and clothes in areas where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over pant legs to prevent ticks from entering under clothing.rc C. production of intrinsic factor by the stomach. Older persons are at risk for deficiency of cobalamin (pernicious anemia) because of a naturally occurring reduction of the intrinsic factor by the stomach mucosa. Absorption of cobalamin relies on intrinsic factor. Both must be present for absorption. Megaloblastic anemia is related to folate dysfunction. Intestinal motility (peristalsis) is the motion that moves food down the GI tract. The rhythmic contractions of muscles cause wave-like motions. Lack of peristalsis is called "paralytic ileus." Bile is produced in the liver, is stored and concentrated in the gallbladder, and is released into the duodenum when fat is eaten. Bile emulsifies fats and prepares them for enzyme digestion in order for the nutrient to be absorbed into lymph and eventually into blood vessels to the liver. Vitamin K (the blood-clotting vitamin) is synthesized by intestinal bacteria.rd .(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it(2) outcome that would be positive but usually is not an initial result of treatment(3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse"(4) expected outcome..re 4. Allow the client to verbalize and demonstrate correct administration procedureRationale: The most effective method of teaching to ensure safe self-administration of medications in the home setting is to have the client verbalize and also demonstrate how to take medications. This ensures that the client has both the knowledge and the physical ability to comply with medication therapy. Option 1 is useful early in the teaching or learning process but is not the best method because it does not allow the client to demonstrate his or her own ability. Option 2 is incorrect because it is dangerous and incorrect statement. Option 3 is unrealistic and does not enhance self-care.rf ARationale: Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.Cognitive Level: Application Text Reference: p. 1296Nursing Process: Evaluation NCLEX: Health Promotion and Maintenancerg a collection of air or gas in the pleural space causing the lung to collapse.rh slow, progressive disorder of the nervous system that affects movement.Characterized by tremor at rest, muscle rigidity and akinesia due to lack of dopamine.ri Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa.(1) correct—placenta previa is characterized by painless vaginal bleeding(2) nausea not a symptom of placenta previa(3) bleeding is not necessarily related to activity(4) pain not characteristic of placenta previarj (D) The distance from the nose to the earlobe plus the earlobe to the sternumRationale: The length of the nasogastric tubing necessary fro each individual client is measured by using the tube to mark off the distance from the tip of the client's nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the sternum. This is approximately the distance from the nares to the stomach, which varies from client to client. The distances of the other answers would not provide an accurate measurement for the desired length.rk DRationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.Cognitive Level: Application Text Reference: p. 335Nursing Process: Implementation NCLEX: Physiological Integrityrl 3. Hearing lossRationale:Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.*(most aminoglycoside medication names end in the letters -cin)*rm 2. Use of phenelzine sulfate (Nardil)Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI) such as phenelzine sulfate, MAOIs should be stopped at least 14 days before sertraline therapy. Conversely, sertraline should be at least 14 days before MAOI therapy. Options 1, 3, and 4 are not concerns of use of this medication.rn 3. Alarm-activating braceletRationale: If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing him or her from leaving the premises. A vest or waist restraint or a chair with a locking lap tray is more intrusive than an alarm-activating bracelet.ro 2. Hepatitis B infectionRationale: A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 (kidney donation), 55 (pancreas and liver), or 40 (heart) years old. The client should be free of communicable disease such as human immunodeficiency virus or hepatitis, and the involved organ may not be diseased. Another contraindication to transplant is malignancy, with the exception of noninvolved skin and cornea.rp 2. Accidental injuryInjuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined.rq Rationale:MMR is administered subcutaneously in the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years.*Knowledge that MMR is administered subcutaneously will assist in eliminating options 1 and 2. Knowing that the gluteal muscle is not incorporated in the subcutaneous tissue will eliminate option 4.*rr CRationale: Platelet transfusions are not usually indicated until the platelet count is below 20,000/l unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.Cognitive Level: Application Text Reference: p. 704Nursing Process: Assessment NCLEX: Physiological Integrityrs 3. Put the bed rails up after moving the client from the stretcherRationale: Because the client may still be experiencing residual effects of anesthesia, the nurse should raise the side rails after transferring the client from the stretcher to the bed. It is not realistic to ask the client to slide from the stretcher to the bed because of the effects of anesthesia and postoperative pain. Hurried movements and rapid changes in position should be avoided since these predispose the client to hypotension. During the transfer of the client after surgery, the nurse should avoid exposing the client because of potential heat loss, respiratory infection and shock.rt a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions.ru 4) Remaining 6 inches away from the sterile field during the procedurerv s/s: Weakness, dysarthria, dysphagiaNo loss of cognitive functionComplications/Crisis: respiratory failure.Assess Respiratory function: ABC's, clear lungs. Swallowing: proper food choices & eventual NG tube. Mobility. Skin. Suctioning: difficult chewing, swallowing, drooling, choking. Communication.rw BRationale: Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.Cognitive Level: Application Text Reference: p. 686Nursing Process: Assessment NCLEX: Physiological Integrityrx don't take on empty stomach!!ry trial and errorrz (B) Billroth II, also known as gastrojejunostomy, begins with the removal of the lower section of the antral portion of the stomach. This is the part of the stomach that secretes gastrin, which stimulates the secretion of gastric acid. A small portion of the duodenum and pylorus are also removed. The remaining stomach is then attached with an opening (anastomosed to the jejunum of the small intestines. Answer (A) represents a Billroth I procedure. The severing of vagus nerves, answer (C), describes a vagotomy. Answer (D) describes a colon resection.sa (B) Chlordiazepoxide hydrochloride (Librium)Rationale: Chlordiazepoxide hydrochloride (Librium) is an antianxiety agent that is used in the treatment of alcohol withdrawal. Naloxone hydrochloride (Narcan) is an antidote for opioids. Narcan is used to reverse the effects of opioid overdose. Disulfiram (Antabuse) is an alcohol deterrent used to treat alcoholism. Antabuse cannot be taken if the client has ingested alcohol in the past 12 hours. Among other uses, chlorpromazine (Thorazine) is most often used to treat psychosis or control nausea and vomiting.sb (A) HandsRationale: Clients with rheumatoid arthritis usually experience discomfort in the proximal finger joints of the hands before any other joints of the body. Although rheumatoid arthritis can eventually spread to any or every joint, the symptoms of rheumatoid arthritis usually are noticed in the finger and hand joints prior to the joints of the arms, legs and neck.sc (1) correct—transplant clients require protective isolation following surgery(2) can't have live plants in the room at all(3) no need for dialysis following transplant(4) need to force fluids, not restrict them...sd Reduced. Rationale: High doses of phenytoin can cause nystagmus, confusion, ataxia, coma, and seizures, and should be reduced. Options 2, 3, and 4 are incorrect. Increasing or maintaining the same dose will continue the symptoms of toxicity or exacerbate them. The drug should not be discontinued abruptly, because seizure activity may occur.se CRationale: Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.Cognitive Level: Analysis Text Reference: pp. 326, 338-340Nursing Process: Diagnosis NCLEX: Physiological Integritysf 8-10"sg (C) QRS complexRationale: Depolarization of the ventricular muscle of the heart is represented by the QRS complex on the electrocardiogram (ECG) strip. The P wave represents atrial depolarization. The T wave represents ventricle muscle repolarization. The PR interval is the distance from the beginning of the P wave to the center of the R wave in the QRS complex. This interval represents the time used to stimulate the SA node, depolarize the atria, and conduct the impulse through the AV node prior to ventricular depolarization.sh 55-90 bpmsi neuromuscular blocking agent used to promote skeletal relaxation while pt under mechanical ventilationsj 4. Hearing acuityRationale:Amikacin (Amikin) is an antibiotic. This medication can cause ototoxicity and nephrotoxicity; therefore, hearing acuity tests and kidney function studies should be performed before the initiation of therapy. Apical pulse, liver function studies, and blood pressure are not specifically related to the use of this medication.sk is the admin of antineoplastic drugs after surgery or radiation therapy.The purpose is to rid the body of any cancerous cells that were not removed during the surgery or to treat any micrometastases that may be developing.sl ARationale: Improper identification is responsible 90% of hemolytic transfusion reactions. The nurse should also administer the blood within 30 minutes of its arrival on the unit, transfuse the blood at 2 ml/min during the first 15 minutes, and stay with the patient during the first 15 minutes; however, these measures will not prevent a transfusion reaction if the person is receiving the wrong blood.Cognitive Level: Comprehension Text Reference: p. 731Nursing Process: Implementation NCLEX: Safe and Effective Care Environmentsm A client has been pronounced brain dead. Which findings would the nurse assess?sn D. 5.0so C. combines with water to form carbonic acid, lowering the pH of cerebrospinal fluid. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of the cerebrospinal fluid and stimulates an increase in the respiratory rate. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid.sp Glasgow Coma Scalesq (1) not enough information given in question to assume that symptoms are caused by stress(2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old(3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea(4) usually see history of missed periods or spotting with abdominal pain...sr TCA used to tx panic attackss 96° to 99.5° Fst 4. Suction equipmentRationale:Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.su 1. Blood glucose of 200 mg/dLRationale:A blood glucose level of 200 mg/dL is elevated above the normal range of 70 to 110 mg/dL and suggests an adverse effect. Other adverse effects include neurotoxicity evidenced by headache, tremor, insomnia; gastrointestinal (GI) effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.sv Supports:VisionSkinBone and tooth growthImmunityReproductionsw Vessel dilation and capillary leak; WBCs flood the areasx 2. Place a radiation sign on the door of the client's roomRationale: The client's room should be marked with appropriate signs stating the presence of radiation. Visitors are limited to 30 minutes. The client should be placed in a private room at the end of the hall because this location provides less a chance of radiation exposure to others. A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. It is not reinserted by the nurse.sy C. Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.sz DRationale: Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.Cognitive Level: Application Text Reference: p. 209Nursing Process: Evaluation NCLEX: Safe and Effective Care Environmentta D. Adults older than 65 years of age are the greatest users of prescription medications. Rationale: Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adultstb B. "Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication thus enhancing the effectiveness of the dose.tc 2. Have the client sit upright for a mealRationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. This means that having the client sit upright would be contraindicated. The precatheterization medications are generally resumed after the procedure. Asking the client to wiggle the toes to determine neurovascular status is acceptable and should be done because vascular status could be impaired if a hematoma or thrombus were developing. Fluids should be increased to aid in eliminating the contrast medium through the kidneys.td T- Taught Has the person been taught the skill treatment or assessmentE- Evaluate You have to evaluate just because they were taught how to do something does not mean they are competent to do it, has there return demonstration been performed and documented.L- Licensee Does the individual have or need a licensee to do this task and is this in the scope of there practice.L- Lists What lists of standards of cares (agency policies are written regarding this task)te 1. No rapid heartbeats or anxietyRationale:Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.tf 2.) 0.5 to 2 ng/mLRationale:Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Therefore, options 1, 3, and 4 are incorrect.tg CRationale: During an abdominal ultrasound, a noninvasive probe is lubricated and moved across the abdomen while sound waves are bounced off abdominal structures. There is no need for the patient to be NPO, for an IV line, or for injection of contrast solution.Cognitive Level: Application Text Reference: p. 682Nursing Process: Planning NCLEX: Physiological Integrityth DRationale: Legumes and dried fruits are high in iron and low in fat and cholesterol. Eggs and muscle meats are high in iron but also high in fat and cholesterol. Nuts and milk products will improve amino acid intake but are not high in iron. Cornmeal would be an appropriate choice for a vitamin B6 deficiency.Cognitive Level: Application Text Reference: p. 689Nursing Process: Implementation NCLEX: Physiological Integrityti strong (so that if you falter, the strong leg is already in motion to help regain balance)tj 1. ToxicRationale:The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A level of 3 mEq/L indicates toxicity.tk affecting one limbtl incoordinationtm they are catagorized by intensity pitch and duration of the inspatory and the expetory phase bronchial sounds are heard manubirum (if heard at all) exportation sounds are longer louder and higher pitch than inspatory sounds. If heard in the minubrium they are considered abnormal and may be considerded low bar pneumonia. Broncular vassicular sounds are heard in the first or second interspaces interially between the scapula. The intspulatory and explatory sounds are equal in length and are intermediate. Pitch and intensity differences are easilly assesd during exporation if heard in any other location then air fillled long may have been replaced by fluid or solid lung tissue..Vassicular sounds are heard over most of the lungss. Inspatory sounds are longer than expatory sounds. Vassicular sounds are soft and low pitch. Breast sounds should be soft pitchRight side has 3 lobes and let side has 2Egophony (EE) Bronchaophony (99)Whispered 99 or 123 lung sound is normal and filled with air words are indistinct and muffled. EE is heard when airless lungs with pneumonia 99 are lowder and clearer EE is heard as AY whisper words are louder and clearer.tn C. consider the preadmission functional abilities when setting patient goals. Rationale: The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.to C- Adventitious breath soundstp (1) tenderness at the IV site is common(2) increased swelling at the insertion site may indicate infiltration(3) correct—characterized by inflammation and reddened areas around site and up length of vein(4) not indicative of phlebitis...tq 4. Per agency policy, putting up the side rails on the bedRationale:Diazepam is a sedative-hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure herself or himself. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2, and 3 may be helpful measures that provide a comfortable, restful environment, but option 4 is the one that provides for the client's safety needs.tr (A) DisbeliefRationale: Initial response to receiving sad or bad news is disbelief or denial. Grief is a normal response to loss or feelings of powerlessness. When people experiencing grief, they must work through the stages of changing emotions, which usually progress as follows: disbelief, anger, bargaining, depression, and eventually acceptance.ts (C) 27%Rationale: The Rules of Nines is a method that uses percentages to calculate the amount of body surface area (BSA) that has been burned. The body is divided into nine sections, each calculated as a percentage that is a multiple of nine. Together, the head and neck make up 9% of the BSA. Each arm is 9% of the BSA. Each leg is 18% of the BSA. The posterior chest (including the back and buttocks) is 18% of the BSA. The perineum, the only exception to the "nine" rules, is 1% of the BSA. Using this information, the correct answer is 27% or answer (C). The right arm is 9% and the anterior chest is 18%.tt 3. Blood pressureRationale:Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral), and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.tu S- Strength to grow help and allow others to growT- The happiness factor comfortable in her own shoes is not a victim and does not blameA- A visionary that can think out of the boxR- Reactive last Proactive first.tv (1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program(2) not of primary importance in designing an effective behavior modification program(3) not of primary importance in designing an effective behavior modification program(4) not of primary importance in designing an effective behavior modification programtw Degeneration of motor neurons in brain stem and spinal cord: brain's messages don't reach the musclesNo cure.tx 4. Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications.Rationale:Lithium is the medication of choice to treat manic-depressive illness. Many OTC medications interact with lithium, and the client is instructed to avoid OTC medications while taking lithium. Lithium is not addicting, and, although serum lithium levels need to be monitored, it is not necessary to check these levels every week. A tyramine-free diet is associated with monoamine oxidase inhibitors.ty q1-2hrs qdaytz to counter Parkinsonian-like SE of antipsychotics/anti-depressants (recall antipsychotics/anti-depressants (i.e. Thorazine) can cause extra-pyramidal Sx, and benztropine (Cogentin) can help to reverse these)ua A. Inspect the skin for petechiae. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presences of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes.ub 100 mLuc 1. AlcoholRationale:When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.ud (A) Notify the physicianRationale: A DNR or "Do Not Resuscitate" order indicates that in the case of cardiac or respiratory arrest, no lifesaving treatment will be initiated. I order for DNR procedures to stand, a written physician's order must be documented in the medical record. Initiating the emergency response system is not necessary for a client with a DNR order. Emergency actions, such as rescue breathing and chest compressions, will not be performed. A crash cart containing emergency medications and a defibrillator will not be used on this client. The physician should be notified of the client's status.ue 1. SneezingRationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine.uf rapid shaking of the eyesug 4. History of fallsAccording to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.uh BRationale: The patient will eat more if disliked foods are avoided and foods that patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. Patients will not improve intake by eating foods that are beneficial but have unpleasant taste.Cognitive Level: Application Text Reference: p. 307Nursing Process: Planning NCLEX: Physiological Integrityui 1. "Do you have any joint pain?"Rationale:Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. The other options are unrelated to medication effectiveness.uj BRationale: The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc) associated with HIV infection.Cognitive Level: Analysis Text Reference: p. 255Nursing Process: Planning NCLEX: Physiological Integrityuk (B) Erythrocyte sedimentation rate (ESR)Rationale: Erythrocyte sedimentation rate (ESR) is the best diagnostic indicator of rheumatoid arthritis. ESR is a nonspecific test that indicates the presence of an inflammatory disease when elevated. Rheumatoid arthritis is one of a number of disease processes that will elevate this serum level. Serum creatinine is used to evaluate kidney function. International normalized ratio (INR) tests the effectiveness of anticoagulation therapy, usually with the drug Warfarin (Coumadin). A fasting lipid panel measures the cholesterol and lipid levels and ratios that are present in the blood when the levels are not affected by recent food ingestion.ul 3rdum Strategy: Determine how each answer choice relates to cor pulmonale.(1) common assessment finding of the patient with chronic lung disease(2) describes a complication of pneumonia(3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites(4) is not seen with this client...un Axillary; 97.5-98.6 Fuo 2. Postural hypotensionRationale:Anxiolytic medications can cause postural hypotension. The client needs to be taught to rise to a sitting position and get out of bed slowly because of this adverse effect related to the medication. Options 1, 3, and 4 are unrelated to the use of this medication.up C. the patient positioned in a lateral position with the head of the bed flat. After total laryngectomy and radical neck dissection, a patient should be placed in a semi-Fowler's position to decrease edema and limit tension on the suture line.uq ARationale: Because sequesterization of platelets and platelet destruction by macrophages occurs in the spleen, splenectomy will increase the platelet count. Splenectomy does not promote sequesterization or release of platelets by the liver, increase platelet production, or increase RBC production.Cognitive Level: Application Text Reference: p. 703Nursing Process: Implementation NCLEX: Physiological Integrityur a sensory nerve cell that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it.us CRationale: A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.Cognitive Level: Application Text Reference: p. 207Nursing Process: Assessment NCLEX: Physiological Integrityut a pus-containing lesion of the lung parenchyma that results in a cavity formed by necrosis of lung tissue.uu 4. The nursing assistant is speaking directly into the impaired earRationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may improve communication, but the nurse should avoid talking directly into the impaired ear.uv Encourage the client to use a compartmentalized pill storage container for his daily medications.uw 4. RestlessnessRationale:Toxicity (overdosage) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage.ux A patient has a normal sensory change that results in diminished sense of taste. How would this be documenteduy Collagen synthesisAmino acid metabolismHelps iron absorptionImmunityAntioxidantuz C. Weight-bearing exercise reduces the loss of bone massva B- Shuffling and propulsivevb ARationale: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.Cognitive Level: Application Text Reference: p. 276Nursing Process: Implementation NCLEX: Health Promotion and Maintenancevc 1) Remove the contaminated clothing immediately.Remove contaminated clothing immediately - then wash with water - irrigate it and contact poison control.vd (B) 0.78mEq/LRationale: The range that indicates therapeutic serum Lithium level is 0.5 to 1.5mEq/L. Any level below this range may not be producing desired effects. A level higher than this is toxic and lethal to a client. 0.45 mEq/L is below therapeutic range. The client's dosage should be increased. Answers C and D indicate toxic levels of Lithium. The medication should be held, and the client should be monitored closely for adverse effects.ve 3. Although exercise is recommended after MI, it is usually done in a cardiac rehabilitation program where the client is monitored. Exercise is gradually increased over several weeks.vf Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.(1) nurse is interjecting own feelings(2) will require testing; not best response initially(3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine(4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implementvg CRationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.Cognitive Level: Application Text Reference: pp. 319, 322, 325-326Nursing Process: Assessment NCLEX: Physiological Integrityvh D- Safety pin, hot and cold water in test tubes, cotton wispvi AssessForming nursing diagnosisPlanning and Goal SettingImplementationEvaluationvj A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?vk Cvl inability to blink, requiring eye care to avoid corneal abrasionvm Drooping of the corner of the mouth (Bell's Palsy)vn MeatEggsLegumesNutsDairy productsGreen leafy veggiesBroccoliAsparagusMushroomsOystersClamsEnriched grainsvo example of propionic acidCOX 1 NSAID**unlike aspirin... inhibition of cyclooxygenase is reversible, does not protect against MI/stroke (Increase in thrombocytic events is concern)vp Trigeminal Nerve- degeneration/ pressure.Chronic disease of trigeminal nerve (cranial nerve V) causing severe facial painThe maxillary and mandibular divisions of nerve are effectedvq 2. Contact the registered nurse. 4. Assess the client's pain level. 5. Check the client's blood pressure. 6. Administer a second nitroglycerin, 0.4 mg, sublingually.Rationale:The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. The registered nurse should be notified of the client's condition, who will then notify the health care provider as appropriate. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.vr CRationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.Cognitive Level: Application Text Reference: p. 294Nursing Process: Implementation NCLEX: Safe and Effective Care Environmentvs Convulsions always involve violent skeletal muscle activity. Objective: Compare and contrast the terms epilepsy, seizures, and convulsions.Rationale: Convulsions specifically refer to involuntary, violent spasms of the large muscles of the face, neck, arms, and legs. Seizure activity does not always involve these characteristics.Cognitive Level: ComprehensionClient Need: Physiological Integrity: Physiological AdaptationNursing Process: Implementationvt Caused by a blow to the back of the head, characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyesvu (1) not most important(2) not most important(3) not most important(4) correct—steroid replacement is the most important information the client needs to know...vv B. Slow onset, chronicvw 1. Position the client in the center of the slingRationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised from the bed into a sitting position. The lift raises the client off the mattress and lowers the client slowly once the sling is positioned over the chair.vx starts with weakness of lower extremities and gradually progresses to upper extremities and facial muscles. Recovery is slow and can take years. "ground to brain"vy 2. Coffee, cola, and chocolateRationale:Theophylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These include coffee, cola, and chocolate.vz (B) The most frequent complication of tube feedings, whether through nasogastric or PEG (percutaneous endoscopic gastrostomy) tube, is diarrhea or loose, watery stools. This is a reaction caused by intolerance to the formula solution or the rate that the formula is being given. Constipation can occur any time food is passed through the gastrointestinal tract, but it is not the most common condition caused by tube feedings. Vomiting could also indicate intolerance to the tube feeding rate, but it is less common than diarrhea. Belching is not a side effect known to be caused by tube feeding.wa DRationale: Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.Cognitive Level: Application Text Reference: p. 204Nursing Process: Planning NCLEX: Physiological Integritywb 20 mEq/hwc A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?wd 3. "The medication will permanently stain my skin."Rationale:Silver sulfadiazine (Silvadene) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin.we spinal injurywf C. Pulmonary embolism A high mortality rate is associated with a pulmonary embolism. A pulmonary embolism is an obstruction of the pulmonary artery caused by an embolus. It presents with hypoxia, anxiety, restlessness, and shortness of breath. Bleeding ulcers, MI, and transient ischemia are not associated with such a high mortality rate.wg 4. Nausea and vomitingRationale:Trimethobenzamide is an antiemetic agent used in the treatment of nausea and vomiting. The other options are incorrect.wh C. The rapid breathing is an attempt to compensate for the low pH. The respiratory system influences pH (acidity) through control of carbon dioxide exhalation. Thus, rapid breathing increases the pH. Breathing into a paper bag aids a patient who is hyperventilating; in respiratory alkalosis, it aids in lowering the pH. The use of sedation can cause respiratory depression and hypoventilation, resulting in an even lower pH.wi 1. Empty the drainage bag at least every 8 hours.wj (C) Mrs. Palmer has a difficult time eating at dinner due to tremorsRationale: Although it is important to consider all client needs holistically, the highest concern in establishing a plan of care is the physiological needs of the client. Physiological needs include ADLs (activities of daily living). ADLs are basic needs, such as eating, moving, dressing, toileting and other personal hygiene. Answer (C) is the correct answer because it is the only assessment that indicates a physical hindrance to a physiological need.wk a condition marked by lymphatic fluid in the pleural space caused by a leak in the thoracic duct.wl 3. 100 mg twice dailyRationale:For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg two to four times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued.wm bleeding, sensitivity reactionwn an abnormal condition of the pulmonary system, characterized by overinflation and destructive changes in alveolar walls.wo DRationale: Melena is a sign of gastrointestinal bleeding and requires further assessment. A sore throat does not indicate bleeding, although neck swelling requires rapid medical care. The patient can apply pressure to abrasions or gum bleeding rather than immediately seeking medical attention.Cognitive Level: Application Text Reference: pp. 708, 710Nursing Process: Implementation NCLEX: Health Promotion and Maintenancewp DRationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.Cognitive Level: Application Text Reference: p. 697Nursing Process: Planning NCLEX: Physiological Integritywq 2. ScallopsRationale:Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Uric acid is produced when purine is catabolized. Clients are instructed to modify their diet and limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast.wr (1) would result in contractures due to the strength of flexor muscles(2) should encourage range of motion in all joints, not just hip flexors(3) massaging inflamed joints will add to inflammation and pain(4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility...ws weakness or incomplete loss of muscle functionwt ARationale: The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH).Cognitive Level: Comprehension Text Reference: p. 678Nursing Process: Assessment NCLEX: Physiological Integritywu Adrenal gland atrophy, masking of infection, delayed wound healingwv (D) AldactoneRationale: Loop diuretics are most commonly used to treat fluid overload and hypertension because of their effectiveness. Bumex, Lasix and Demadex are all loop diuretics. Aldactone, a potassium sparing diuretic, is very weak in comparison to loop diuretics. Unless the client's potassium level is dangerously low, this medication is not usually prescribed. Sometimes potassium sparing diuretics are used along with lower doses of other diuretics to help conserve the body's potassium levels.ww Facial nerve inflammation;Peripheral facial paralysis due to CN VII motor dysruption; affects one side of face.Inflammation, edema, ischemia, demyelination of nerve, causing sensory and motor loss.Outbreak of herpes vesicles in or around ear; Caused by a reactivation of herpes simplex virus, although other infections (e.g., syphilis or Lyme disease) are sometimes implicatedwx 1. At bedtimeRationale:A single daily dose of ranitidine is usually scheduled to be given at bedtime. This allows for a prolonged effect, and the greatest protection of the gastric mucosa. *recall that ranitidine suppresses secretions of gastric acids*wy Proteinwz Strategy: Think about each answer choice.(1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration(2) not a high priority(3) not a high priority(4) not a high priorityxa A. Palpitations Patients experiencing moderate anemia (hemoglobin [Hb] 6 to 10 g/dL) may experience dyspnea (shortness of breath), palpitations, diaphoresis (profound perspiration) with exertion, and chronic fatigue. Blurred vision is associated in patients experiencing profound anemia states. Anorexia is common in patients with severe anemia, as well. Patients with anemia often appear pale and complain of feeling cold because of compensatory vasoconstriction of the subcutaneous capillaries.xb hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension.xc an abnormal accumulation of fluid in the intrapleural spaces of the lungs.xd 2. Gown and glovesRationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In this instance, the nurse should wear gloves and a gown to protect the hands and uniform from contamination.xe Strategy: Think about each answer choice.(1) inaccurate for the situation(2) incorrectly stated(3) incorrectly stated(4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clientsxf 4. Excessive snoringPartners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).xg hypertension, 4+ proteinuria and edema; severe: BP > 150/100, headache, epigastric painxh Benztropine (cogentin) Rationale: benztropine, a cholinergic antagonist, is frequently used as combination therapy with other antiparkinson drugs to decrease tremors. Options 1, 3, and 4 are incorrect. Amantadine acts to increase dopamine's release, but only as long as dopamine is available. Haloperidol is a phenothiazine antipsychotic that may lead to pseudo-parkinson's disease in many persons. Donepezil prolongs the time between diagnosis and the institutionalization of the client with alzheimer's disease and is not used for parkinson's disease.xi Answer: The client's heart rate should be slower than it was prior to taking the medication.Rationale: Propranolol (Inderal) is a beta-adrenergic blocker. "Beta blockers" interfere with the effects of the naturally occurring epinephrine in the body. These medications reduce the heart rate. Therefore, once the client has started taking propranolol (Inderal), the client's heart rate should slow down compared to the rate prior to taking the medication.xj (C) Fluid restrictionRationale: Acute pain can be very severe during a sickle cell crisis due to hypoxia caused by inadequate blood flow to various tissues or organs. Pain management during crisis includes analgesics, relaxation techniques and distraction. Techniques are used to prevent reoccurrence of symptoms once acute pain is controlled. Clients with sickle cell anemia are usually susceptible to infection. Fluid is encouraged for sickle cell clients in order to promote dilution of the blood, which prevents clumping of sickled cells. Red blood cell transfusions are common therapy used to prevent complications from sickle cell anemia.xk 2. Use sunscreen when outsides.Rationale:Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because it could cause return of seizures or status epilepticus. Fever and sore throat (leukopenia) should be reported to the health care provider (HCP).xl 3. Consult with health care providers (HCPs) before receiving immunizationsRationale:Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without a HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side effects.xm Which neurotransmitter is responsible for may of the functions of the frontal lobe?xn B. sleep apnea. Sleep apnea is most common in obese patients. Typical symptoms include snoring and periods of apnea. Narcolepsy is when a patient falls asleep unexpectedly. Sleep deprivation could result from sleep apnea. Paroxysmal nocturnal dyspnea occurs when a patient has shortness of breath during the night.xo (1) if the pulse rate increases, may indicate fluid overload(2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume(3) temperature should remain within normal limits(4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels...xp A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a "blown pupil" (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disruption of which cranial nerve?xq stimulantsxr (D) 2 minutesRationale: The American Heart Association (AHA) recommends waiting 2 minutes before repeating a blood pressure reading at the same site. This is to decrease venous congestion. The correct answer is (D). All of the other answers give too short of a time span between cuff inflations.xs DRationale: Rebreathing may help alleviate mild symptoms, but it will only temporarily increase ionized calcium level, so the patient should call the health care provider. There is no need to increase fluid intake. Calcium is not given IM but is given slowly through the IV route. Mild hypocalcemia is unlikely to progress to seizures.Cognitive Level: Application Text Reference: p. 1311Nursing Process: Implementation NCLEX: Health Promotion and Maintenancext Snellen's Chart: Field of vision, visual acuity and structures (external, internal, red reflex and optic disc.)Reading a newspaper or magazine. Holding up fingersxu 3. Pull down and back on the ear and direct the solution toward the wall of the canal.Rationale:When administering eardrops to an infant, the nurse pulls the ear down and straight back. In the adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum.xv 3) Daytime fatigue4) Snoringxw Dxx peripheral edemahepatomegalysplenomegalyascitiesJVDhepatojugular refluxincreased central venous pressurepulmonary hypertensionxy 1. TinnitusRationale:Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.xz blood pressure, given with meals and glass of h20 or milk, previous problemsya IICP Brain Herniation:- Unilateral dilated pupil.- sluggish, equal pupil response.yb 1. Tinnitus 2. Ototoxicity 5. Nephrotoxicity 6. HypomagnesemiaRationale:Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity.yc (1) does not occur(2) occurs earlier in development(3) at age 40, bone mass begins to decrease(4) correct—may precipitate a mid-life crisis...yd (F) Estrogen level is low(C) Endometrium is shed(B) Estrogen level peaks(A) Ovulation occurs(E) Estrogen level drops sharply(D) Progesterone level dropsRationale: As the menstrual phase (days 1 to 6) begins, estrogen levels are low. During this phase the endometrium of the uterus is shed. During the proliferative phase 7 to 14 days), the endometrium thickens, estrogen rises and peaks, and the ovum is released (ovulation). The secretory phase (days 15 to 26) involves preparing the uterus for implantation. At this stage, estrogen drops sharply and progesterone dominates. During the final stage, the e=ischemic phase (days 27 to 28), progesterone levels begin to decrease, estrogen levels continue to decrease, blood vessels rupture, and blood escapes into the cells of the uterus in preparation for the cycle to begin again.ye Acute infection of the meninges. Bacterial meningitis is an infection of the ventricular system and the CSF.yf 2. Place the infant in a supine position in preparation for sleepRationale: The American Academy of Pediatrics recommends the supine position for sleep to reduce the risk of SIDS. Plastic bottles and toys are not needed yet because a 2 month-old cannot hold them. Pacifiers are considered safe and appropriate at this age. Safety netting is not necessary for a 2 month-old because the infant cannot roll over or stand alone.yg 1. Baker's yeastRationale:A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to common baker's yeast. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.yh 2. Triglyceride levelRationale:Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.yi s/s: Severe HA, fever, delirium, Nuchal Rigidity: stiff neckKernig's Sign: from bent leg/knee to strait is painfulBrudzinski's Sign: pain; resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supinePhoto/Phonophobia;Increased ICPEdema and inflammation of the optic nervePurpuric rash on the skin and mucous membranesAssess for IICP: LOC, VS, Eyes, Motor functionCrisis: COMA- Acute complication from IICPSEIZURES- Acute cerebral edema/ IICPyj A- Giving the client thin liquidsRationale: before the client with dyshagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.yk D. Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 ml/min and remain with the patient for the first 15 minutes after hanging a unit of blood.yl BRationale: Sucking on hard candies decreases thirst for patient on a fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 ml/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease ADH release.Cognitive Level: Application Text Reference: p. 1296Nursing Process: Planning NCLEX: Physiological Integrityym ARationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication should generally be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.Cognitive Level: Application Text Reference: pp. 286-288Nursing Process: Implementation NCLEX: Physiological Integrityyn 3. Ensure that the medication is administered at the same time each day.Rationale:Valproic acid is an anticonvulsant, antimanic, and antimigraine medication. It may be administered with or without food. It should not be taken with an antacid or carbonated beverage because these products will affect medication absorption. The medication is administered at the same time each day to maintain therapeutic serum levels.*Use general pharmacology guidelines to assist in eliminating options 1 and 2. Eliminate option 4 because of the closed-ended word "only."*yo 1. With 8 oz of milkRationale:Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation. Options 2, 3, and 4 are incorrect.yp 2. Refrigerate the insulin.Rationale:Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.yq Strategy: Think about the action of the medications.(1) decreased dosage of narcotics are used(2) dosages of sedatives and hypnotics will be similar(3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant(4) dosages of narcotics are reducedyr 4. Difficulty discriminating the color red from greenRationale:Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin).ys 1 Lyt C, A, D, BRationale: The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.Cognitive Level: Application Text Reference: p. 202Nursing Process: Planning NCLEX: Physiological Integrityyu Water balanceAcid-base balanceNormal muscle irritabilityGlycogen formationProtein synthesisNerve transmissionyv A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?yw Synthesis of blood clotting proteinsRegulates blood calciumyx 1. Renal insufficiencyRationale:Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. Therefore the nurse would verify the prescription if the client had a documented history of renal insufficiency. The laboratory and diagnostic test results are normal findings. Folic acid (vitamin B6) may be prescribed for a client with renal insufficiency to prevent anemia.yy R- RescueA- Activate AlarmC- Confine the fireE- Evacuate / Extinguishyz REGULAR contractionsza to minimize eye movt until a surgeon is availablezb 3) Stay between the patient and the door; keep the door open.Make sure you do not get trapped. You should never enter the room alone if someone is threatening, the nurse must be calm and reassuring. Asking about weapons and setting limits may escalate the situation.zc 1) changes in LOC2) changes in Vital Signs3) changes in Eyes4) decreased motor function5) HAzd 4. Frequent handwashing with hot, soapy waterRationale:Clomipramine is commonly used in the treatment of obsessive-compulsive disorder. Handwashing is a common obsessive-compulsive behavior. Weight gain is a common side effect of this medication. Tachycardia and sedation are side effects. Insomnia may occur but is seldom a side effect.ze Motor changes: opposite side, balance, coordination, gait, proprioceptionSensory Changes: Aphasia, Agnosia, Apraxia, Visual problems, hemianopsiaCognitive Changes: impaired memory, disorientedParalysis, difficulty swallowing, talking, memory, pain.Assessment includes: glasgow coma scale/LOCzf Not due to organic reasonsI.E. - impaired mobility prevents client from reaching bathroom in timezg D. Develop large-print handouts that reflect the verbal information presented. Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.zh Fever is the point heat production passes heat lossIce pack on the head contemplate a temped bathTake acetaminophen or ibuprofen to prevent a rapid rise that may cause seizureIf none of these work at 100.4 F can be tolerated can rise to dangerous levels especially in the afternoon. F-Fahrenheit Greater 100.4-100.8(38C)E-Endogenous Pyrogens Reset the hyperventilate systemV-Volume needs increase secondary to heat loss ex; increase metabolism shivering sweating evaporation and vazo dilationE-Evaluate the source via labs; CBC with differential a urinalysis a blood culture and chest x-rayR-Risk factors viral or bacterial illness environmental factors tissue damage and biological agents and endocrine system disorders Greater than 107F equals death or irreversible brain damage. These patients are at high risk of dehydration due to sweating. Give a lot of fluids fever peaks in late afternoonzi 2. Three sputum cultures are negativeRationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary.zj 4. Place the needle and syringe in a labeled, rigid plastic containerRationale: Standard precautions include specific guidelines for handling of sharps. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container that is specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing needlestick injury. Needles should always be properly discarded after use.zk 2. Liver diseaseRationale:Carbamazepine (Tegretol) is contraindicated in liver disease, and liver function tests are routinely prescribed for baseline purposes and are monitored during therapy. It is also contraindicated if the client has a history of blood dyscrasias. It is not contraindicated in the conditions noted in the incorrect options.zl A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?zm CRationale: Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. French fries are high in calories from fat but low in protein.Cognitive Level: Application Text Reference: p. 306Nursing Process: Evaluation NCLEX: Physiological Integrityzn bananas, cantaloupe, orangeszo Measures to protect the eye Rationale. Protecting the client's eye from injury is a priority of care when a topical eye anesthetic agent is administered, as the corneal reflex is lost when it is given. Options 1, 3, and 4 are incorrect. Measures to increase tear secretion are unnecessary. The nurse will monitor for the local effect of conjunctivitis, but this is not the priority of care. Since the medication is local and not general, there should be no need to monitor the client's level of consciousness.zp B. Large hemorrhoids Gastrointestinal (GI) tract bleeding is a common etiologic factor in men and may result from peptic ulcers, hiatal hernia, gastritis, cancer, hemorrhoids, diverticula, ulcerative colitis, or salicylate poisoning.zq c. diffzr 4. 1.7 mEq/LRationale:The therapeutic serum level of lithium ranges from 0.6 to 1.2 mEq/L. Serum lithium levels above the therapeutic level will produce signs of toxicity.zs (1) correct—decreases intracranial pressure(2) decreases venous blood return(3) too elevated, would increase intracranial pressure(4) head should be maintained in neutral position...Create Study SetBack to your sets 695 Matching questions

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Test: bstrandable NCLEX Miscellaneous 8 (2)

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695 Matching questions

  1. The LPN/LVN is teaching Mr. Elbridge how to insert his new hearing aid. Arrange the following choices in the correct order for completing this task.
    (A) Turn the hearing aid on and turn the volume up
    (B) Line up the earmold with the corresponding parts of the ear
    (C) Slightly rotate the earmold forward
    (D) Rotate the earmold backward
    (E) Insert the ear canal portion of the earmold
    (F) Turn the hearing aid off and the volume all the way down
  2. Mrs. foster thinks she might be pregnant and visit's the physician's office. a urine sample pregnancy test is performed. The evaluation of which of the following hormones in the urine would indicate that Mrs. Foster is indeed pregnant?
    (A) Human growth hormone (hGH)
    (B) Human chorionic gonadotropin (hCG)
    (C) Estrogen
    (D) Oxytocin
  3. A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds an older client slapping at the flames on the bedspread with a pillow. Both hands have been burned. Which action should the nurse take first?
    1. Pull the nearest fire alarm
    2. Close the door to the room
    3. Remove the client from the room
    4. Run to get the nearest fire extinguisher
  4. MENINGITIS :
    disease discription
  5. 95.) The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine (Videx). The nurse interprets that the client may have the medication discontinued by the health care provider if which of the following significantly elevated results is noted?
    1. Serum protein
    2. Blood glucose
    3. Serum amylase
    4. Serum creatinine
  6. 120.) A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. The nurse advises the client to take which of the following products if needed for a headache?
    1. Naprosyn (Aleve)
    2. Ibuprofen (Advil)
    3. Acetaminophen (Tylenol)
    4. Acetylsalicylic acid (aspirin)
  7. 197.) Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client indicates an accurate understanding of the use of this medication?
    1. "I will apply the ointment once a day and leave it open to the air."
    2. "I will apply the ointment twice a day and leave it open to the air."
    3. "I will apply the ointment once a day and cover it with a sterile dressing."
    4. "I will apply the ointment at bedtime and in the morning and cover it with a sterile dressing."
  8. 228.) A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse recognizes this complaint as a symptom of:
    1. Cardiac dysrhythmias
    2. Postural hypotension
    3. Psychosomatic symptoms
    4. Respiratory insufficiency
  9. While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to:

    A. Revise the client's care plan to show the need for the application of moisturizing lotion
    B. Assume personal responsibility to apply the moisturizing lotion daily to the client's skin
    C. Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin
    D. Inform the staff that the client's skin is showing signs of breakdown and moisturizing lotion needs to be applied daily

  10. Epidural hematoma
  11. A nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox Sequels) daily. Which of the following indicates to the nurse that the client is experiencing an adverse effect related to the medication?
    1. Diarrhea
    2. Lacrimation
    3. Low back pain and dysuria
    4. Irritability
  12. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client?
    1. The nursing assistant is speaking in a normal tone
    2. The nursing assistant is speaking clearly to the client
    3. The nursing assistant is facing the client when speaking
    4. The nursing assistant is speaking directly into the impaired ear
  13. inflammation
  14. 195.) A nurse is caring for a client who is taking metoprolol (Lopressor). The nurse measures the client's blood pressure (BP) and apical pulse (AP) immediately before administration. The client's BP is 122/78 mm/Hg and the AP is 58 beats/min. Based on this data, which of the following is the appropriate action?
    1. Withhold the medication.
    2. Notify the registered nurse immediately.
    3. Administer the medication as prescribed.
    4. Administer half of the prescribed medication.
  15. What is "terminal insomnia"?
  16. NSAIDS: teaching
  17. 110.) A client taking lithium carbonate (Lithobid) reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up and the level is 3.0 mEq/L. The nurse knows that this level is:
    1. Toxic
    2. Normal
    3. Slightly above normal
    4. Excessively below normal
  18. When is a lumbar puncture not indicated?
  19. A friend calls and states that he has taken three nitroglycerin tablets for his chest pain, but the pain is still there. The nurse advises him to:
    1. Call his doctor
    2. Drive to the nearest emergency room
    3. lie down and rest to see if the pain goes away
    4. Call 911
  20. 1. A patient has had a splenectomy to control bleeding from a lacerated spleen following an automobile accident. The nurse will teach the patient about the increased risk for
    a. lymphedema.
    b. infection.
    c. prolonged bleeding.
    d. chronic anemia.
  21. O2 toxicity
  22. 38.) An older client recently has been taking cimetidine (Tagamet). The nurse monitors the client for which most frequent central nervous system side effect of this medication?
    1. Tremors
    2. Dizziness
    3. Confusion
    4. Hallucinations
  23. 48. Before discharge, the nurse discusses activity levels with a 61-year-old patient with COPD and pneumonia. Which of the following exercise goals is most appropriate once the patient is fully recovered from this episode of illness?
    A. Slightly increase activity over the current level.
    B. Walk for 20 minutes a day, keeping the pulse rate less than 130 beats per minute. C. Limit exercise to activities of daily living to conserve energy.
    D. Swim for 10 min/day, gradually increasing to 30 min/day.
  24. 8. While obtaining the admission assessment data, which of the following characteristics would a nurse expect a patient with anemia to report?
    A. Palpitations
    B. Blurred vision
    C. Increased appetite
    D. Feeling of warm flushing sensation
  25. dry powder inhaler
  26. A nurse is planning to give a subcutaneous injection of insulin. The nurse plans to do which of the following immediately after giving the injection?
    1. Break the needle
    2. Recap the needle
    3. Place the needle and syringe in a labeled cardboard box
    4. Place the needle and syringe in a labeled, rigid plastic container
  27. What are some expected changes that may be seen when assessing pts w/ Brain Herniation as a result of IICP?
  28. If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following?

    1. Increased respiration with exertion.
    2. Cough producing large amount of thick, yellow mucus.
    3. Peripheral edema and anorexia.
    4. Twitching of extremities.

  29. When administering a drug via a parenteral routes, the drug would be absorbed fastest if given per the IM route.
    a. True
    b. False
  30. Mr. Greene is a client in a long term nursing facility who requires tube feedings via his PEG (percutaneous endoscopic gastrostomy) tube. Which of the following would the LPN/LVN know to watch for as the most common complication of tube feedings?
    (A) Constipation
    (B) Loose, watery stools
    (C) Vomiting
    (D) Excessive belching
  31. tri-cuspid soudns are best heard at the ____ intercostal space
  32. 32. Which of the following test results identify that a patient with an asthma attack is responding to treatment?
    A. A decreased exhaled nitric oxide
    B. An increase in CO2 levels
    C. A decrease in white blood cell count
    D. An increase in serum bicarbonate levels
  33. The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique?
    1) Closing the patient's door to limit room traffic while preparing the sterile field
    2) Using clean procedure gloves to handle sterile equipment
    3) Placing the nonsterile syringes containing flush solution on the sterile field
    4) Remaining 6 inches away from the sterile field during the procedure
  34. A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. The nurse assigned to care for the client plans to ensure that which of the following does not occur in the care of the client?
    1. Admitting the client to a semiprivate room
    2. Placing a mask on the client if the client leaves the room
    3. Removing a vase with fresh flowers left by a previous client
    4. Placing a "See the Nurse before Entering" sign on the door to the room
  35. which is more important in determining premature labor: REGULAR contractions or cervical effacement and dilation?
  36. The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?
    1) Prepare the patient for an abdominal flat plate.
    2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.
    3) Administer a laxative to prepare the patient for a colonoscopy.
    4) Test the patient's stool using a fecal occult test.
  37. Which of the following are conditions associated with Cushing's syndrome? Select all that apply.
    (A) Easy bruising
    (B) Buffalo hump
    (C) Hyperglycemia
    (D) Excessive scalp hair growth
    (E) Hyponatremia
    (F) Trunk obesity
  38. MULTIPLE RESPONSE

    1. A 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg) tells the nurse that she has a glass of wine two or three times a week. The patient works for the post office and has a 5-mile mail-delivery route. This is her first contact with the health care system in 20 years. Which of these topics will the nurse plan to include in patient teaching about cancer? (Select all that apply.)
    a. Alcohol use
    b. Physical activity
    c. Body weight
    d. Colorectal screening
    e. Tobacco use
    f. Mammography
    g. Pap testing
    h. Sunscreen use

  39. A client with a seizure disorder has been placed on a ketogenic diet. What would the nurse teach is this diet's benefit to prevent seizures?
    a. It has no effect on the prevention of seizures.
    b. It reduces stress, which increases seizure threshold.
    c. It lowers the potassium and decreases neuron firing.
    d. It decreases the excitability of the neurons.
  40. voncristine sulfate (Oncovin): class & Tx
  41. chylothorax
  42. The term "Kussmaul" refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx.
    a. true
    b. false
  43. Fever
  44. An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse?

    1. The client complains of pain during the inflow of the dialysate.
    2. The client complains of constipation.
    3. The dialysate outflow is cloudy.
    4. There is blood-tinged fluid around the intra-abdominal catheter.

    An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse?

    1. The client complains of pain during the inflow of the dialysate.
    2. The client complains of constipation.
    3. The dialysate outflow is cloudy.
    4. There is blood-tinged fluid around the intra-abdominal catheter.

  45. Mrs. Palmer, a client with Parkinson's disease, is admitted to an extended-stay nursing facility. Up until this point she has been living on her own. Which of the following assessments is the most significant in developing the plan of care?
    (A) Mrs. Palmer states she dislikes beef nut will eat it once in a while if it is cooked well
    (B) Mrs. Palmer talks frequently about how much she misses living on her own
    (C) Mrs. Palmer has a difficult time eating at dinner due to tremors
    (D) Mrs. Palmer states her only living relative is her daughter who lives across the state and seldom visits
  46. hemothorax
  47. Which of the following symptoms should the nurse assess with a client who is deprived of sleep?
    1. Elevated blood pressure and confusion
    2. Confusion and irritability
    3. Inappropriateness and rapid respirations
    4. Decreased temperature and talkativeness
  48. during CPR, depress the sternum ____
  49. A nurse working on a medical nursing unit during an external disaster is called to assist with the care of clients coming into the emergency room and is asked to assist the triage nurse. Using principles of prioritizing, the nurse initiates care for a client with which of the following injuries first?
    1. Fractured tibia
    2. Penetrating abdominal injury
    3. Bright red bleeding from a neck wound
    4. Open severe head injury in a deep coma
  50. A nurse should advise a client who is receiving lorazepam (Ativan) about the adverse effects of this medication which include:
    1. tachypnea
    2. astigmatism
    3. ataxia
    4. euphoria
  51. What are the actions of calcium channel blockers?
  52. 3. A patient who smokes tells the nurse, "I want to have a yearly chest x-ray so that if I get cancer, it will be detected early." Which response by the nurse is most appropriate?
    a. "Chest x-rays do not detect cancer until tumors are already at least a half-inch in size."
    b. "Annual x-rays will increase your risk for cancer because of exposure to radiation."
    c. "Insurance companies do not authorize yearly x-rays just to detect early lung cancer."
    d. "Frequent x-rays damage the lungs and make them more susceptible to cancer."
  53. Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter?
    1. Empty the drainage bag at least every 8 hours.
    2. Clean up the length of the catheter to the perineum.
    3. Use clean technique to obtain a specimen for culture and sensitivity.
    4. Place the drainage bag on the client's lap while transporting the client to testing.
  54. 83.) The client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept (Enbrel), it is most important for the nurse to check:
    1. The injection site for itching and edema
    2. The white blood cell counts and platelet counts
    3. Whether the client is experiencing fatigue and joint pain
    4. A metallic taste in the mouth, with a loss of appetite
  55. pleural friction rub
  56. Cholinergic Crisis
  57. Which of the following is an example of a patient suffering from anxiety due to the stress of being hospitalized? (Select all that apply)

    A) The patient responds appropriately to teaching, but then asks a question about the information just given.
    B) The patient watches the nurse demonstrate a procedure and then performs a return demonstration correctly.
    C) The patient stares into space while the nurse is talking and then asks, "What?"
    D) The patient has frequent bouts of crying and wants to be left alone.
    E) The patient uses the incentive spirometer and ambulates without being reminded.

  58. A licensed practical nurse (LPN) is assisting a registered nurse (RN) to develop a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following does the LPN suggest be included in the client's plan of care?
    1. Limit visitor's time to 60 minute visits
    2. Place a radiation sign on the door of the client's room
    3. Place the client in a private room close to the nurses' station
    4. Reinsert the implant into the vagina immediately if it becomes dislodged
  59. 2. Which of the following is a factor significant in the development of anemia in men?
    A. Condom use
    B. Large hemorrhoids
    C. A diet high in cholesterol
    D. Smoking one pack of cigarettes daily
  60. Erb's point is found at the ____ intercostal space
  61. 15. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to
    a. teach about the importance of nutrition during treatment.
    b. have the patient eat large meals when nausea is not present.
    c. administer prescribed antiemetics 1 hour before the treatments.
    d. offer dry crackers and carbonated fluids during chemotherapy.
  62. A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?

    1. Head of bed elevated 30-45°.
    2. Head of bed elevated 60-90°.
    3. Side-lying with head elevated 15°.
    4. Lying flat with head turned to the left side.

  63. 54.) A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?
    1. "I will take my pills every day at the same time."
    2. "I will be certain to avoid alcohol consumption."
    3. "I have already called my family to pick up a Medic-Alert bracelet."
    4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."
  64. temperature of toddler
  65. TELL (Delegation)
  66. The nurse knows that which of the following is a major disadvantage for the use of tacrine (Cognex) to treat the symptoms of early Alzheimer's disease? Select all that apply.
    a. Must be administered four times per day.
    b. Causes weight gain.
    c. May cause vision difficulties.
    d. May cause serious hepatic damage.
    e. Can be purchased over-the-counter
  67. The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if the state that they will:

    ◦ A. Place objects in the client's impaired field of vision
    ◦ B. Discourage the client from wearing eyeglasses.
    ◦ C. Approach the client from the impaired field of vision
    ◦ D. Remind the client to turn the head to scan the lost visual field.

  68. Quadriparesis or quadriplegia:
  69. The nursing assistant runs out of a hospital room yelling that the patient fell to the floor. The LPV/LVN is rehearsing in her mind the order of nursing actions that should be performed when at the client's side. Arrange the following into the correct order of priority, with the highest priority action listed first:
    (A) Assess airway patency
    (B) Assess for injury
    (C) Move the client into bed
    (D) Check heart rate and blood pressure
    (E) Call the client's physician
  70. chest percussion
  71. The physician diagnoses a client with septicemia. Which of the following assessment findings would support this diagnosis?
    (A) Bilateral knee pain
    (B) Reddened tissue surrounding an injury site
    (C) Drainage from an injury site
    (D) Temperature of 101 degrees F
  72. A nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine (Tegretol). The nurse determines that the client understands the use of the medication if the client knows to:
    1. Drive as long as it is not at night.
    2. Use sunscreen when outsides.
    3. Discontinue the medication if fever or sore throat occurs.
    4. Keep tissues handy because of excess salivation that may occur.
  73. what can hypercalcemia cause?
  74. troponin ↑ 0.1-0.2 ng/mL is consistent with what?
  75. 1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse what the difference is between a benign tumor and a malignant tumor. The nurse explains that a benign tumor differs from a malignant tumor in that benign tumors
    a. do not cause damage to adjacent tissue.
    b. do not spread to other tissues and organs.
    c. are simply an overgrowth of normal cells.
    d. frequently recur in the same site.
  76. A client is scheduled to have insertion of an inferior vena cava (IVC) filter. The nurse should place highest priority on determining whether the surgeon wants which of the following medications held in the preoperative period?
    1. Furosemide (Lasix)
    2. Famotidine (Pepcid)
    3. Multivitamin with minerals
    4. Warfarin sodium (Coumadin)
  77. 244.) A client has a prescription for valproic acid (Depakene) orally once daily. The nurse plans to:
    1. Administer the medication with an antacid.
    2. Administer the medication with a carbonated beverage.
    3. Ensure that the medication is administered at the same time each day.
    4. Ensure that the medication is administered 2 hours before breakfast only, when the client's stomach is empty.
  78. When doing a corneal reflex, we need to remember what key factor?
  79. corticosteroids: lifespan consideration
  80. A nurse assisting in the care of a client who has been in a coma for more than a year is told by the physician to stop the tube feeding that is providing sustenance to the client. The nurse, who is aware of the legal basis needed for carrying out the order, first determines whether which of the following requirements has been met?
    1. Institutional Ethics Committee approval
    2. A court order to discontinue the treatment
    3. A written order by the physician to remove the tube
    4. Authorization by the family to discontinue the treatment
  81. why might you place a patch over an eye injury?
  82. Cranial nerve 7 comes out of the temple and runs all the way down to the corner of the mouth. If there are problems with this nerve, what might we see?
  83. 2. When caring for a patient after an abdominal surgery, the nurse will be most concerned about monitoring for wound dehiscence during which period?
    a. The first postoperative day
    b. The third postoperative day
    c. One week after the surgery
    d. One month after the surgery
  84. One reason for medication problems in the elderly is that

    1. Regular use of laxatives increases absorption of medications
    2. Decreased renal function slows excretion of drugs
    3. Enhanced sense of taste of medications
    4. Increased perception of pain from injections

  85. hydrocortisone
  86. Which nursing intervention is a priority in preventing complications after a cesarean birth?

    1. Turn, cough, and deep breathe.
    2. Limit fluid intake.
    3. Supply a high-carbohydrate diet.
    4. Evaluate skin integrity.

  87. 146.) A client has begun therapy with theophylline (Theo-24). The nurse tells the client to limit the intake of which of the following while taking this medication?
    1. Oranges and pineapple
    2. Coffee, cola, and chocolate
    3. Oysters, lobster, and shrimp
    4. Cottage cheese, cream cheese, and dairy creamers
  88. chest physiotherapy
  89. 86.) A nurse is reinforcing discharge instructions to a client receiving baclofen (Lioresal). Which of the following would the nurse include in the instructions?
    1. Restrict fluid intake.
    2. Avoid the use of alcohol.
    3. Stop the medication if diarrhea occurs.
    4. Notify the health care provider if fatigue occurs.
  90. 1. When assessing a patient's nutritional-metabolic pattern related to hematologic health, the nurse would:
    A. Inspect the skin for petechiae.
    B. Ask the patient about joint pain.
    C. Assess for vitamin C deficiency.
    D. Determine if the patient can perform ADLs.
  91. 173.) A nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness?
    1. "Do you have any joint pain?"
    2. "Are you having any diarrhea?"
    3. "Do you have frequent headaches?"
    4. "Are you experiencing heartburn?"
  92. What are the normal chloride values?
  93. ecchymosis
  94. The three common conditions affecting cognition in the older adults are:

    A. Stroke, MI, Cancer
    B. Cancer, Alzheimer's disease, Stroke
    C. Delirium, Depression, Dementia
    D. Blindness, Hearing loss, Stroke

  95. The patient with metastatic cancer tells the nurse "I am tired and do not want to be put on a breathing machine." The patient's out-of-town son wants "everything done for my mother" when his mother later develops respiratory distress. Which ethical principles are involved in this dilemma? (Select all that apply)

    A) Autonomy
    B) Nonmaleficence
    C) Justice
    D) Beneficence
    E) Fidelity

  96. Which of the following nursing activities is of highest priority for maintaining medical asepsis?
    1) Washing hands
    2) Donning gloves
    3) Applying sterile drapes
    4) Wearing a gown
  97. A licensed practical nurse (LPN) is assisting a registered nurse (RN) in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this client because it is unsafe?
    1. Resume prescribed medications
    2. Have the client sit upright for a meal
    3. Encourage the client to drink extra fluids
    4. Ask the client to wiggle the toes when collecting data about neurovascular status
  98. 31. The IV therapy nurse is inserting a peripherally inserted central catheter (PICC) so that a patient can receive an IV solution containing 50% dextrose. When explaining the need for the PICC, the nurse will include the information that
    a. to give adequate doses of IV insulin, a centrally located IV catheter is needed.
    b. blood glucose testing is more accurate when samples are obtained from a central line.
    c. infusion of the IV solution through a PICC line will allow rapid dilution of 50% dextrose.
    d. the 50% dextrose is less likely to produce infection when given through a PICC line.
  99. A client has been taught to apply capsaicin to increase mobility and relieve pain. Which educational intervention is most important for the client to learn?
    a. Apply the medication liberally above and below the site of pain.
    b. Apply with a gloved hand only to the site of pain.
    c. Apply to areas of redness and irritation.
    d. Apply liberally with a bare hand.
  100. What do we do to check function of the optic nerve?
  101. The client is receiving levodopa/carbidopa for parkinsonism. Which drug would the nurse expect to be added to the client's drug regimen to help control tremors?
    a. Amantadine (Symmetrel)
    b. Benztropine (Cogentin)
    c. Haloperidol (Haldol)
    d. Donepezil (Aricept)
  102. J. Cramer is a 17 year old client with sickle cell anemia. Which of the following is NOT a common treatment and care modality for a client with this condition?
    (A) Pain management
    (B) Preventing infection
    (C) Fluid restriction
    (D) Red blood cell transfusion
  103. Which cranial nerve is our sense of smell or Olfactory?
  104. What are sources of vitamin D?
  105. 46.) A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse checks the client for:
    1. Pupillary changes
    2. Scattered lung wheezes
    3. Sudden increase in pain
    4. Sudden episodes of diarrhea
  106. thoracotomy
  107. What is stroke volume?
  108. 217.) A health care provider prescribes auranofin (Ridaura) for a client with rheumatoid arthritis. Which of the following would indicate to the nurse that the client is experiencing toxicity related to the medication?
    1. Joint pain
    2. Constipation
    3. Ringing in the ears
    4. Complaints of a metallic taste in the mouth
  109. What is typically the most reliable indicator of pain?
    1) Patient's self-report
    2) Past medical history
    3) Description by caregiver(s)
    4) Behavioral cues
  110. The telemetry unit nurse is reviewing lab results for an operative procedure later in the day. The nurse notes on the lab report that the pt has a serum potassium level of 6.5 mEq/L. The nurse informs the physician of this lab result because the nurse recognizes this increases the pts risk for which of the following?
    a. infection
    b. cardiac problems
    c. bleeding and anemia
    d. fluid imbalances
  111. true
  112. A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following?

    1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours.
    2. An elevated temperature is very rarely seen in a child after a DPaT immunization.
    3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours.
    4. The child's high fever is a direct response to the DPaT immunization and should be treated.

  113. A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements?

    1. The catheter can be removed during the day.
    2. External catheters are uncomfortable.
    3. The catheter would drain into a bag at the bedside or on the wheelchair.
    4. The external condom catheter is easy to apply.

  114. An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following?

    1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues.
    2. Cool, moist skin; fine hand tremors; and mental confusion.
    3. Headache, apprehension, and lethargy.
    4. Shortness of breath, chest pain, and anxiety.

  115. What class of drugs are prescribed first line in children?
  116. Poison Control
  117. The nurse is teaching a client about a new eyedrop prescription for timolol (Timoptic) for treatment of open-angle glaucoma. The client has a history of seasonal allergies and hypertension. What is an important administration technique to stress for this client?
    a. Take any eyedrops for allergies 5 minutes before administering the timolol drops
    b. Do not use the timolol drops while concurrently taking allergy medication.
    c. The timolol drops may temporarily worsen seasonal allergies.
    d. Gently put pressure on the inner canthus (tear duct) for 1 minute after instilling the timolol drop.
  118. Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae?

    1. Infection related to obstetrical trauma.
    2. Potential for fetal injury related to abruptio placentae.
    3. Potential alteration in tissue perfusion related to depletion of fibrinogen.
    4. Fluid volume deficit related to bleeding.

  119. When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse's actions during this intervention?

    1. The restraints/seclusion policies set forth by the institution.
    2. The patient's competence.
    3. The patient's voluntary/involuntary status.
    4. The patient's nursing care plan.

  120. 216.) A nurse is caring for a client with gout who is taking Colcrys (colchicine). The client has been instructed to restrict the diet to low-purine foods. Which of the following foods should the nurse instruct the client to avoid while taking this medication?
    1. Spinach
    2. Scallops
    3. Potatoes
    4. Ice cream
  121. 17. A patient with HIV infection has developed Mycobacterium avium complex infection. An appropriate outcome for the patient is that the patient will
    a. be free from injury.
    b. maintain intact perineal skin.
    c. have adequate oxygenation.
    d. receive immunizations.
  122. wheezes
  123. The Dub sound of Lub-Dub is closure of which heart valves?
  124. 7. When teaching a patient with chronic SIADH about long-term management of the disorder, the nurse determines that additional instruction is needed when the patient says,
    a. "I need to shop for foods that are low in sodium and avoid adding salt to foods."
    b. "I should weigh myself daily and report any sudden weight loss or gain."
    c. "I need to limit my fluid intake to no more than 1 quart of liquids a day."
    d. "I will eat foods high in potassium because the diuretics cause potassium loss."
  125. A 10-year-old child has been evaluated for a learning disability and has been diagnosed with absence seizures. Ethosuximide (Zarontin) has been ordered and the nurse is teaching the client and family about the drug. Because of the client's age, it is important to include instructions to:
    a. Curtail afterschool sports activities, because the drug's metabolism may be increased with physical activity.
    b. Increase intake of calcium-rich foods and vitamin D to prevent bone loss.
    c. Monitor height and weight weekly to be sure GI side effects are not hindering nutrition and normal growth.
    d. Increase fluid intake to avoid dehydration caused by the drug.
  126. A 22-year-old client who has been treated for 10 years for a seizure disorder has discussed pregnancy with her health care provider. Which drug therapy would the nurse expect to be added to the client's drug regimen prior to conception?
    a. Clomiphene (Clomid)
    b. Vitamin K
    c. Calcium (Caltrate)
    d. Folic acid (Folgard)
  127. The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST?

    1. "That must have been a real shock to you."
    2. "You should be tested for hepatitis B."
    3. "You'll receive the hepatitis B immune globulin (HBIG)."
    4. "Have you had unprotected sex with your boyfriend?"

  128. What is "intermittent insomnia"?
  129. pre-eclampsia Sx
  130. The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

    1. Confirm that all staff members understand and comply with the treatment plan.
    2. Establish mutually agreed-upon, realistic goals.
    3. Ensure that the potent reinforcers (rewards) are important to the client.
    4. Establish a fixed interval schedule for reinforcement.

  131. lung abscess
  132. The LPN/LVN assigned to a homosexual male is responsible for relaying positive HIV test results to the client. Which of the following responses would the nurse expect initially?
    (A) Disbelief
    (B) Acceptance
    (C) Anger
    (D) Depression
  133. 19. A patient is receiving 3% NaCl solution for correction of hyponatremia. During administration of the solution, the most important assessment for the nurse to monitor is
    a. peripheral pulses.
    b. lung sounds.
    c. peripheral edema.
    d. urinary output.
  134. Breath Sounds
  135. Limiting bladder catherization to once every 12 hours
  136. Normal Potassium values
  137. What does vitamin C do?
  138. Upon removing a breakfast tray from a room, the LPN/LVN calculates the client's intake. The client consumed the following: 4 oz of pudding, 6 oz of coffee, half of a 6 oz container of grape juice and used 4 oz of milk over cold cereal. In milliliters, what should the nurse record as the client's intake for this meal?
    (A) 480 mL
    (B) 390 mL
    (C) 510 mL
    (D) 600 mL
  139. 226.) A client receiving lithium carbonate (Lithobid) complains of loose, watery stools and difficulty walking. The nurse would expect the serum lithium level to be which of the following?
    1. 0.7 mEq/L
    2. 1.0 mEq/L
    3. 1.2 mEq/L
    4. 1.7 mEq/L
  140. 24. After neck surgery, a patient develops hypoparathyroidism. The nurse should plan to teach the patient about
    a. calcium supplementation to normalize serum calcium levels.
    b. including whole grains in the diet to prevent constipation.
    c. use of bisphosphonates to reduce bone demineralization.
    d. having a high fluid intake to decrease risk for nephrolithiasis.
  141. A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room?
    1. Draw the shades closed
    2. Give the client a bedpan
    3. Put up the side rails on the bed
    4. Turn the volume on the television set down
  142. The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective?

    1. The client swallows air and then eructates it while forming words with his mouth.
    2. The client places a battery-powered device against the side of his neck.
    3. The client places a finger over the tracheostomy, forcing air up through the vocal cords.
    4. The client covers the stoma in the tracheoesophageal fistula and moves his lips.

  143. 7.) Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
    1. Platelet count
    2. Triglyceride level
    3. Complete blood count
    4. White blood cell count
  144. 96.) The nurse is caring for a postrenal transplant client taking cyclosporine (Sandimmune, Gengraf, Neoral). The nurse notes an increase in one of the client's vital signs, and the client is complaining of a headache. What is the vital sign that is most likely increased?
    1. Pulse
    2. Respirations
    3. Blood pressure
    4. Pulse oximetry
  145. 29. A patient with Cushing syndrome returns to the surgical unit following an adrenalectomy. During the initial postoperative period, the nurse gives the highest priority to
    a. monitoring for infection.
    b. protecting the patient's skin.
    c. maintaining fluid and electrolyte status.
    d. preventing severe emotional disturbances.
  146. A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a crisis from occurring?
    1. Maintain strict hand washing technique
    2. Give the client reassurance and encouragement
    3. Ensure that the client uses oxygen during labor
    4. Remind the client not to bear down for more than 3 seconds
  147. The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following?

    1. Increased pulse rate.
    2. Decreased temperature.
    3. Fine tremors.
    4. Increased radioactive iodine uptake level.

  148. A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side and the nurse plans to use the hemiplegic transfer technique. The client is sitting upright in bed with the legs dangling over the side. For the safest transfer, where should the wheelchair be positioned?
    1. Next to either leg
    2. Near the client's left leg
    3. Near the client's right leg
    4. As space in the room permits
  149. 6. A nurse is working on a respiratory care unit where many of the patients are affected by asthma. Which of the following actions by the nurse would most likely increase respiratory difficulty for the patients?
    A. Wearing perfume to work
    B. Encouraging patients to ambulate daily C. Allowing the patients to eat green leafy vegetables
    D. Withholding antibiotic therapy until cultures are obtained
  150. Comparing the changes in vital signs as a person ages, which statement(s) is/are correct? (Select all that apply.)
    1) Blood pressure decreases less than heart rate and respiratory rate.
    2) Respiratory rate remains fairly stable throughout a person's life.
    3) Blood pressure increases; heart rate and respiratory rate decline.
    4) Men have higher blood pressure than women until after menopause.
  151. A client with vascular headaches is taking ergotamine (Ergomar). The nurse would monitor the client for:
    1. Constipation
    2. Hypotension
    3. Dependent edema
    4. Cool, numb fingers and toes
  152. A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to:
    1. Baker's yeast
    2. Eggs
    3. Penicillin
    4. Sulfonamides
  153. 36. The nurse is assisting a patient to learn self-administration of beclomethasone two puffs inhalation q6hr. The nurse explains that the best way to prevent oral infection while taking this medication is to do which of the following as part of the self-administration techniques?
    A. Chew a hard candy before the first puff of medication.
    B. Ask for a breath mint following the second puff of medication.
    C. Rinse the mouth with water before each puff of medication.
    D. Rinse the mouth with water following the second puff of medication.
  154. A patient in the emergency department is angry, yelling, cursing, and waving his arms when the nurse comes to the treatment cubicle. Which action(s) by the nurse are advisable?
    1) Reassure the patient by entering the room alone.
    2) Ask the patient if he is carrying any weapons.
    3) Stay between the patient and the door; keep the door open.
    4) Make eye contact while stating firmly "I will not tolerate cursing and threats."
  155. PART - LPN (delegation)
  156. blood pressure for adolescent
  157. 143.) A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:
    1. Heartburn
    2. Constipation
    3. Abdominal pain
    4. Nausea and vomiting
  158. A manic-depressive client is placed on Lithium. The LPN/LVN provides instruction to the client regarding this medication. Which of the following is an appropriate statement by the nurse regarding this medication?
    (A) "You will need to restrict fluid intake while on this medication."
    (B) "You may skip your dose if you feel well when you wake up in the morning."
    (C) "You will need to visit your doctor regularly for laboratory blood testing."
    (D) "This medication may cause you to lose weight. So be sure to eat enough throughout the day."
  159. 13. The health care provider orders transfusion with packed RBCs for a patient who is hospitalized with severe anemia. The most important action by the nurse to prevent a transfusion reaction when administering the blood is to
    a. verify the patient identification according to hospital policy.
    b. administer the blood as soon as it arrives on the nursing unit.
    c. initiate the blood transfusion at a rate of no more than 2 ml/min.
    d. stay with the patient during the first 15 minutes of the transfusion.
  160. 17. The first nursing action indicated when a patient returns to the surgical nursing unit following a thyroidectomy is to
    a. check the dressing for bleeding.
    b. assess respiratory rate and effort.
    c. support the patient's head with pillows.
    d. take the blood pressure and pulse.
  161. bradykinesia
  162. dyspnea
  163. 14.) The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value would the nurse specifically monitor during treatment with this medication?
    1. Clotting time
    2. Uric acid level
    3. Potassium level
    4. Blood glucose level
  164. Which sign is bluish coloration of the vagina?
  165. when might benztropine (Cogentin) be used other than to tx Parkinson's disease?
  166. The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis?

    1. Tenderness at the IV site.
    2. Increased swelling at the insertion site.
    3. Reddened area or red streaks at the site.
    4. Leaking of fluid around the IV catheter.

  167. Which of the following represents an action demonstrating the Healthy Work Environment Initiative for Effective Recognition? (Select all that apply)

    A) A plaque on the wall that lists all the nurses with CCRN certification
    B) A bulletin board listing all the charting deficits in the unit for the week
    C) A banner in the hall to state the unit had no VAPs reported for the previous quarter
    D) A clinical ladder program that includes merit raises and opportunities for scholarships to national conferences
    E) A newsletter article that talks about the projects completed by the shared governance committees in the department

  168. ALS: AMYOTROPHIC LATERAL SCLEROSIS :
    disease discription
  169. emphysema
  170. histamine
  171. nystagmus
  172. stage 3 inflammation
  173. What does vitamin K do?
  174. 161.) A nurse is caring for a client with severe back pain, and codeine sulfate has been prescribed for the client. Which of the following would the nurse include in the plan of care while the client is taking this medication?
    1. Restrict fluid intake.
    2. Monitor bowel activity.
    3. Monitor for hypertension.
    4. Monitor peripheral pulses.
  175. 16. When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to
    a. stop the infusion if swelling is observed at the site.
    b. infuse the medication over a short period.
    c. administer the chemotherapy through small-bore catheter.
    d. hold the medication unless a central venous line is available.
  176. respirations of newborn
  177. The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting:
    A. Chest excursion
    B. Spinal curvatures
    C. The respiratory pattern
    D. The fingernail and its base
  178. A nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5-year-old child. The nurse plans to administer this vaccine:
    1. Intramuscularly in the anterolateral aspect of the thigh
    2. Intramuscularly in the deltoid muscle
    3. Subcutaneously in the outer aspect of the upper arm
    4. Subcutaneously in the gluteal muscle
  179. 19. Which of the following statements made by a nurse would indicate proper teaching principles regarding feeding and tracheostomies?
    A. "Follow each spoon of food consumed with a drink of fluid."
    B. "Thin your foods to a liquid consistency whenever possible."
    C. "Tilt your chin forward toward the chest when swallowing your food."
    D. "Make sure your cuff is overinflated before eating if you have swallowing problems."
  180. 14. Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding
    A. a gastrostomy tube that is clamped.
    B. the patient coughing blood-tinged secretions from the tracheostomy.
    C. the patient positioned in a lateral position with the head of the bed flat.
    D. 200 ml of serosanguineous drainage in the patient's portable drainage device.
  181. Eighty year old Mr. Lewis visits the physician at the clinic for his routine check-up. Following the doctor's orders, Mr. Lewis has been taking Amphogel for the past two weeks. Which of the following side effects should the LPN/LVN assess for?
    (A) Constipation
    (B) Diarrhea
    (C) Dizziness
    (D) Pruritis
  182. A client is receiving anticonvulsant therapy with phenytoin (Dilantin). The nurse plans to monitor the results of which laboratory test closely?
    1. Serum sodium
    2. Serum potassium
    3. Blood urea nitrogen
    4. Complete blood cell count
  183. 155.) Mycophenolate mofetil (CellCept) is prescribed for a client as prophylaxis for organ rejection following an allogeneic renal transplant. Which of the following instructions does the nurse reinforce regarding administration of this medication?
    1. Administer following meals.
    2. Take the medication with a magnesium-type antacid.
    3. Open the capsule and mix with food for administration.
    4. Contact the health care provider (HCP) if a sore throat occurs.
  184. 2. A patient who has been told by the health care provider that the cells in a bowel tumor are poorly differentiated asks the nurse what is meant by "poorly differentiated." Which response should the nurse make?
    a. "The cells in your tumor do not look very different from normal bowel cells."
    b. "The tumor cells have DNA that is different from your normal bowel cells."
    c. "Your tumor cells look more like immature fetal cells than normal bowel cells."
    d. "The cells in your tumor have mutated from the normal bowel cells."
  185. GUILLIAN-BARRE' SYNDROME :
    disease discription
  186. A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client

    1. acknowledges willing participation in an incestuous relationship.
    2. re-establishes a trusting relationship with his/her other parent.
    3. verbalizes that he/she is not responsible for the sexual abuse.
    4. describes feelings of anxiety when speaking about sexual abuse.

  187. The client needs to use crutches at home, and will have to manage going up and down a short flight of stairs. The nurse evaluates the use of an appropriate technique if the client:
    1. Uses a banister or wall for support when descending
    2. Uses one crutch for support while going up and down
    3. Advances the crutches first to ascend the stairs
    4. Advances the affected leg after moving the crutches to descend the stairs
  188. 41. Select all that apply. During initial assessment, a nurse should record which of the following manifestations of respiratory distress?
    A. Tachypnea
    B. Nasal flaring
    C. Thready pulse
    D. Panting or grunting
    E. Use of intercostal muscles
    F. An inspiratory-to-expiratory ratio of 1:2
  189. The nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty?
    1. "When do you usually retire for the night?"
    2. "What do you do to help yourself fall asleep?"
    3. "How much time does it usually take for you to fall asleep?"
    4. "Have you changed anything about your presleep ritual lately?"
  190. What is the body's only source of nitrogen?
  191. corticosteroids: teaching
  192. What is decorticate posturing?
  193. indomethacin
  194. A patient with a colostomy complains to the nurse, "I am having really bad odors coming from my pouch." To help control odor, which foods should the nurse advise him to consume?
    1) White rice and toast
    2) Tomatoes and dried fruit
    3) Asparagus and melons
    4) Yogurt and parsley
  195. A client has been treated for cervical dystonia with an injection of botulinum toxin type A (Botox). Which of the following will the nurse teach the client to report immediately?
    a. Fever, aches, or chills
    b. Difficulty swallowing, blurred vision, or ptosis
    c. Moderate levels of muscle weakness on the affected side
    d. Continuous spasms and pain on the affected side
  196. A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated?
    1) Apply an indwelling fecal drainage device.
    2) Apply an external fecal collection device.
    3) Place an incontinence garment on the patient.
    4) Place a waterproof pad under the patient's buttocks.
  197. 25. The nurse caring for a patient with hemophilia teaches the patient to seek immediate medical attention upon experiencing
    a. sore throat.
    b. skin abrasions.
    c. bleeding gums.
    d. dark tarry stools.
  198. A client has developed glaucoma. The nurse reviewing this client's medication history would identify long-term use of which drug as a potential contributor to glaucoma?
    a. Corticosteroids
    b. Beta blockers
    c. Calcium channel blockers
    d. Insulin
  199. 157.) A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication?
    1. Nausea
    2. Diarrhea
    3. Anorexia
    4. Cough and chest pain
  200. 32. An excess of carbon dioxide in the blood causes an increased respiratory rate and volume because CO2
    A. displaces oxygen on hemoglobin, leading to a decreased PaO2.
    B. causes an increase in the amount of hydrogen ions available in the body.
    C. combines with water to form carbonic acid, lowering the pH of cerebrospinal fluid.
    D. directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume.
  201. 5. Absorption of vitamin B12 may be decreased in older adults because of decreased
    A. intestinal motility.
    B. production of bile by the liver.
    C. production of intrinsic factor by the stomach.
    D. synthesis of cobalamin (vitamin B12) by intestinal bacteria.
  202. BELL'S PALSY :
    disease discription
  203. 117.) A nurse has given the client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client immediately reports:
    1. Impaired sense of hearing
    2. Distressing gastrointestinal side effects
    3. Orange-red discoloration of body secretions
    4. Difficulty discriminating the color red from green
  204. 36. The resurgence in TB resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis is primarily the result of
    A. a lack of effective means to diagnose TB.
    B. poor compliance with drug therapy in patients with TB.
    C. the increased population of immunosuppressed individuals with AIDS. D. indiscriminate use of antitubercular drugs in treatment of other infections.
  205. flail chest
  206. Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin?

    1. Severe cravings, depression, fatigue, hypersomnia.
    2. Depression, disturbed sleep, restlessness, disorientation.
    3. Nausea and vomiting, tachycardia, coarse tremors, seizures.
    4. Runny nose, yawning, fever, muscle and joint pain, diarrhea.

  207. Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted?
    1. A history of diabetes mellitus
    2. Use of phenelzine sulfate (Nardil)
    3. A history of myocardial infarction
    4. A history of irritable bowel syndrome
  208. 17. During treatment of the patient with an acute exacerbation of polycythemia vera, a critical action by the nurse is to
    a. check oxygen saturation q4hr.
    b. monitor fluid intake and output.
    c. place the patient on bed rest.
    d. administer iron supplements.
  209. The nurse knows that the results of a fecal occult blood test can be inaccurate if
    a. the client has had an excessive intake of red meat
    b. the female client is menstruating
    c. the client takes high doses of vitamin C
    d. all of the above
  210. A client asks if convulsions and seizures are the same. The nurse's response is based on the knowledge that:

    Seizures involve muscle spasms on one side only.
    The terms can be used interchangeably.
    Seizure activity is more harmful than are convulsions.
    Convulsions always involve violent skeletal muscle activity.

  211. 18.) The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which of the following is documented in the client's history?
    1. Pancreatitis
    2. Diabetes mellitus
    3. Myocardial infarction
    4. Chronic obstructive pulmonary disease
  212. 18. A patient admitted to the hospital in preparation for a splenectomy for treatment of immune thrombocytopenia purpura (ITP) asks the nurse about the benefits of the splenectomy. The nurse explains that the expected effect of the splenectomy is
    a. reduced destruction of platelets by macrophages.
    b. promotion of platelet sequesterization and release by the liver.
    c. increased production of platelets by the bone marrow.
    d. increased RBC production to compensate for blood loss.
  213. What are sources of vitamin B5?
  214. appropriate intervention for pt w/ presbycusis
  215. A client with obsessive-compulsive disorder (OCD) is admitted to the psychiatric facility for treatment. Select all of the following that are included in medical treatment of this disorder.
    (A) Prescription of selective serotonin reuptake inhibitors (SSRIs)
    (B) Behavior therapy
    (C) Prescription of benzodiazepines
    (D) Imagery
    (E) Distraction
    (F) Electroconvulsive therapy (ECT)
  216. 28. The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
    a. Fresh fruit salad
    b. Orange sherbet
    c. Strawberry yogurt
    d. French fries
  217. cor pulmonale
  218. What is the normal heart rate of an adult?
  219. 4. A patient with a systemic bacterial infection has "goose pimples," feels cold, and has a shaking chill. At this stage of the febrile response, the nurse would expect to find
    a. skin flushing.
    b. rising body temperature.
    c. decreasing blood pressure.
    d. muscle cramps.
  220. To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube?

    1. Suction equipment.
    2. Blood pressure cuff.
    3. Levine tube.
    4. Emesis basin.

  221. The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

    1. Take the client to the dining room with 1:1 supervision.
    2. Inform the client that he may go to the dining room when he controls his behavior.
    3. Hold the meal until the client is able to come out of seclusion.
    4. Serve the meal to the client in the seclusion room.

  222. The nurse recognizes that several chemicals inhibit neurotransmitter function in the brain. The primary inhibitory transmitter in the brain is ______________.
  223. 55.) A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A health care provider prescribes a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin?
    1. 3 to 5 ng/mL
    2. 0.5 to 2 ng/mL
    3. 1.2 to 2.8 ng/mL
    4. 3.5 to 5.5 ng/mL
  224. 25. A 75-year-old obese patient who is snoring loudly and having periods of apnea several times each night is most likely experiencing
    A. narcolepsy.
    B. sleep apnea.
    C. sleep deprivation.
    D. paroxysmal nocturnal dyspnea.
  225. hypercapnia
  226. The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an
    a. Focused assessment
    b. Initial assessment
    c. Ongoing assessment
    d. Special needs assessment
  227. Which of the following information provided by the client's bed partner is most associated with sleep apnea?
    1. Restlessness
    2. Talking during sleep
    3. Somnambulism
    4. Excessive snoring
  228. The client with a stroke has residual dysphagia. When the diet order is initiated, the nurse avoids doing which of the following?

    ◦ A. Giving the client thin liquids
    ◦ B. Thickening liquids to the consistency of oatmeal
    ◦ C. Placing food on the unaffected side of the mouth
    ◦ D. Allowing plenty of time for chewing and swallowing

  229. What are the dietary considerations for pancreatitis?
  230. When performing a comprehensive geriatric assessment of an older adult, focus of the nursing assessment is on the patient's:

    A. Physical signs of aging.
    B. Immunological function.
    C. Functional abilities.
    D. Chronic illness.

  231. 27. When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict
    a. intake of green, leafy vegetables.
    b. the amount of high-fat foods.
    c. ingestion of dairy products.
    d. the quantity of fruits and juices.
  232. When feeding someone with a stroke or brain injury it may be better to have them ________________ while eating.
  233. hemianopsia
  234. What are the normal Creatinine Clearance values?
  235. Signs of IICP:
    (basic ideas)
  236. Prioritizing (FIRST)
  237. CVA: CEREBROVASCULAR ACCIDENT :
    disease discription
  238. 42. The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 1 mg/ml. How many milliliters should the nurse use to prepare the patient's dose?
    A. 0.2
    B. 2.5
    C. 3.75
    D. 5.0
  239. 44.) A client is receiving acetylcysteine (Mucomyst), 20% solution diluted in 0.9% normal saline by nebulizer. The nurse should have which item available for possible use after giving this medication?
    1. Ambu bag
    2. Intubation tray
    3. Nasogastric tube
    4. Suction equipment
  240. BELL'S PALSY :
    S/S
    Complication
    Crisis
  241. Loss of lens elasticity
  242. 14. The charge nurse observes a new graduate performing a dressing change on a stage III sacral pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care?
    a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer.
    b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer.
    c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline.
    d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
  243. Which of the following would be the most appropriate room assignment for a child with lymphatic leukemia who is being admitted to the unit?
    (A) A semiprivate room with another child with leukemia
    (B) A semiprivate room with a child who is diagnosed with FUO
    (C) A private room on the pediatric medical floor
    (D) A private room in the intensive care unit
  244. The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer?

    1. A nurse with an upper respiratory infection.
    2. A young nurse who is 8 weeks pregnant.
    3. A male nurse who is CMV-negative.
    4. An older nurse with 30 years of experience.

  245. 28. The nurse assesses a pregnant patient with eclampsia who is receiving IV magnesium sulfate and obtains all the following information. Which of these assessment data is most important to report to the health care provider immediately?
    a. The patient reports feeling "sick to my stomach."
    b. The patellar and triceps reflexes are absent.
    c. The patient has been sleeping most of the day.
    d. The bibasilar breath sounds are decreased.
  246. 13. A patient who has been NPO with gastric suction and IV fluid replacement for 3 days following surgery develops nausea and vomiting, weakness, and confusion and has a serum sodium level of 125 mEq/L (125 mmol/L). The nurse reviews the health care provider's postoperative medication and IV orders. Which health care provider order should the nurse question?
    a. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
    b. IV morphine sulfate 4 mg every 2 hours prn.
    c. Infuse 5% dextrose in water at 125 ml/hr.
    d. Give IV metoclopramide (Reglan) 10 mg every 6 hours prn nausea.
  247. TRIGEMINAL NEURALGIA :
    disease discription
  248. 4. A patient is suspected of having a pituitary tumor causing panhypopituitarism. During assessment of the patient, the nurse would expect to find
    a. elevated blood glucose.
    b. changes in secondary sex characteristics.
    c. high blood pressure.
    d. tachycardia and cardiac palpitations.
  249. 241.) A client with a history of simple partial seizures is taking clorazepate (Tranxene), and asks the nurse if there is a risk of addiction. The nurse's response is based on the understanding that clorazepate:
    1. Is not habit forming, either physically or psychologically
    2. Leads to physical tolerance, but only after 10 or more years of therapy
    3. Leads to physical and psychological dependence with prolonged high-dose therapy
    4. Can result in psychological dependence only, because of the nature of the medication
  250. What are the dietary considerations for Cushings?
  251. pneumothorax
  252. Wrap her hands in soft "mitten" restraints
  253. Which of the following is a correct initial nursing action to be performed by the LPN/LVN when a client with a physician-written DNR order goes into cardiac arrest?
    (A) Notify the physician
    (B) Initiate the emergency response system
    (C) Perform rescue breathing and chest compressions
    (D) Move the crash cart into the room beside the client's bed
  254. propantheline (Pro-Banthine): class, effect
  255. CNA's (delegation) CCANT
  256. Which sign is the softening of the cervix?
  257. 40. After receiving change-of-shift report about these four patients, which patient should the nurse assess first?
    a. A 22-year-old admitted with SIADH who has a serum sodium level of 130 mEq/L.
    b. A 31-year-old who has iatrogenic Cushing's syndrome with a capillary blood glucose level of 244 mg/dl.
    c. A 53-year-old who has Addison's disease and is due for a scheduled dose of hydrocortisone (Solu-Cortef).
    d. A 70-year-old who recently started levothyroxine (Synthroid) to treat hypothyroidism and has an irregular pulse of 134.
  258. 43.) A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-receptor antagonists? Select all that apply.
    1. Nizatidine (Axid)
    2. Ranitidine (Zantac)
    3. Famotidine (Pepcid)
    4. Cimetidine (Tagamet)
    5. Esomeprazole (Nexium)
    6. Lansoprazole (Prevacid)
  259. 37.) The client has begun medication therapy with pancrelipase (Pancrease MT). The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?
    1. Weight loss
    2. Relief of heartburn
    3. Reduction of steatorrhea
    4. Absence of abdominal pain
  260. What are the dietary considerations for Acute Renal Failure?
  261. 172.) A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse tells the client to avoid which food item?
    1. Grapes
    2. Spinach
    3. Watermelon
    4. Cottage cheese
  262. CN III
  263. Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult?

    A. 50% of older adults have two chronic health problems.
    B. Cancer is the most common cause of death among older adults.
    C. Nutritional needs for both younger and older adults are essentially the same.
    D. Adults older than 65 years of age are the greatest users of prescription medications.

  264. A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care?
    1. Limit visiting time to 60 minutes per visit
    2. Place the client in a private room near the nurse's station
    3. Reinsert the implant into the vagina immediately if it becomes dislodged
    4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering
  265. 162.) Carbamazepine (Tegretol) is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history, knowing that this medication is contraindicated if which of the following disorders is present?
    1. Headaches
    2. Liver disease
    3. Hypothyroidism
    4. Diabetes mellitus
  266. 166.) Alendronate (Fosamax) is prescribed for a client with osteoporosis. The client taking this medication is instructed to:
    1. Take the medication at bedtime.
    2. Take the medication in the morning with breakfast.
    3. Lie down for 30 minutes after taking the medication.
    4. Take the medication with a full glass of water after rising in the morning.
  267. Where are the Tricuspid heart sounds located?
  268. A licensed practical nurse (LPN) is reinforcing instructions given by a registered nurse (RN) to a client about how to take medications after discharge from the hospital. The LPN should use which of the following approaches to best ensure safe administration of medication in the home?
    1. Show the client the proper way to take prescribed medications
    2. Tell the client to double up on medications if a dose has been missed
    3. Count the number of pills remaining in the prescription bottle once a week
    4. Allow the client to verbalize and demonstrate correct administration procedure
  269. Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male?

    1. Cognitive skills are starting to decline.
    2. A balance is found among work, family, and social life.
    3. Bone mass begins to increase at this age.
    4. The client starts to measure life accomplishments against goals.

  270. dysgraphia
  271. Evaluate urine specific gravity
  272. 12. During the admission assessment of a patient who has an Hb of 7.6 g/dl (76 g/L), the nurse notes jaundice of the sclera. The nurse will plan to check the laboratory results for
    a. the stool occult blood test.
    b. the bilirubin level.
    c. the gastric analysis testing.
    d. the Schilling test.
  273. The patient is diagnosed with obstructive sleep apnea. Identify the symptoms you would expect the client to exhibit. Choose all that apply.
    1) Bruxism
    2) Enuresis
    3) Daytime fatigue
    4) Snoring
  274. 236.) A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, the most important nursing intervention is:
    1. Prescribing the client a tyramine-free diet
    2. Checking the client for anticholinergic effects
    3. Monitoring blood levels frequently because there is a narrow range between therapeutic and toxic blood levels of this medication
    4. Getting baseline postural blood pressures before administering the medication and each time the medication is administered
  275. PD: PARKINSON'S DISEASE :
    S/S
    Complication
    Crisis
  276. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should

    A. use a standardized geriatric nursing care plan.
    B. plan for likely long-term-care transfer to allow additional time for recovery.
    C. consider the preadmission functional abilities when setting patient goals.
    D. minimize activity level during hospitalization.

  277. when using crutches, follow the crutches w/ the weak|strong leg
  278. 222.) A nurse has administered a dose of diazepam (Valium) to a client. The nurse would take which important action before leaving the client's room?
    1. Giving the client a bedpan
    2. Drawing the shades or blinds closed
    3. Turning down the volume on the television
    4. Per agency policy, putting up the side rails on the bed
  279. 36. A patient with non-Hodgkin's lymphoma develops a platelet count of 10,000/l during chemotherapy. An appropriate nursing intervention for the patient, based on this finding, is to
    a. encourage fluids to 3000 ml/day.
    b. provide oral hygiene q2hr.
    c. check the temperature q4hr.
    d. check all stools for occult blood.
  280. 103.) A nurse is caring for a hospitalized client who has been taking clozapine (Clozaril) for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client will the nurse specifically review to monitor for an adverse effect associated with the use of this medication?
    1. Platelet count
    2. Cholesterol level
    3. White blood cell count
    4. Blood urea nitrogen level
  281. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of:
    1) Milk and cheese.
    2) Bread and pasta.
    3) Fruits and vegetables.
    4) Lean meats.
  282. Where is the location to listen to the Aortic valve?
  283. 10. When developing a care plan for a patient with syndrome of inappropriate antidiuretic hormone (SIADH), an intervention that will be important for the nurse to include is
    a. monitor intake and output hourly.
    b. restrict oral free water intake.
    c. ambulate patient at least once per shift.
    d. use incentive spirometer every 2 hours.
  284. Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain?

    1. Remove the dressing layers one at a time.
    2. Clean the wound with Betadine solution and hydrogen peroxide.
    3. Clean the drain area first.
    4. If the dressing adheres to the wound, pull gently and firmly.

  285. Which of the following pressure points is most likely to be at risk for developing a pressure wound while a client is in the prone position?
    (A) Occiput
    (B) Elbows
    (C) Toes
    (D) Coccyx
  286. School Age (6-12)
  287. Damage to cranial nerve I
  288. 200.) A client is seen in the clinic for complaints of skin itchiness that has been persistent over the past several weeks. Following data collection, it has been determined that the client has scabies. Lindane is prescribed, and the nurse is asked to provide instructions to the client regarding the use of the medication. The nurse tells the client to:
    1. Apply a thick layer of cream to the entire body.
    2. Apply the cream as prescribed for 2 days in a row.
    3. Apply to the entire body and scalp, excluding the face.
    4. Leave the cream on for 8 to 12 hours and then remove by washing.
  289. Peripheral Edema, bounding pulses, jugular vein distention, decreased or absent urinary output are signs of right or left sided heart failure?
  290. After undergoing dural puncture while receiving epidural pain medication, a patient complains of a headache. Which action can help alleviate the patient's pain?
    1) Encourage the client to ambulate to promote flow of spinal fluid.
    2) Offer caffeinated beverages to constrict blood vessels in his head.
    3) Encourage coughing and deep breathing to increase CSF pressure.
    4) Restrict oral fluid intake to prevent excess spinal pressure.
  291. A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk?
    1. Day shift
    2. Weekdays
    3. Shift change
    4. 8 am to 2 pm
  292. dysarthria
  293. 211.) A client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. A phenytoin blood level is drawn, and the results reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
    1. Nystagmus
    2. Tachycardia
    3. Slurred speech
    4. No symptoms, because this is a normal therapeutic level
  294. The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery?

    1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order.
    2. The nurse chases a patient who tries to run away while outside for a walk.
    3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance.
    4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.

  295. Which of the following statements, made by the daughter of an older adult client concerning bringing her mother home to live with her family, presents the greatest concern for the nurse?

    A. "If this doesn't work out, she can always go to live with my sister."
    B. "I don't think she will react very well to me making decisions for her."
    C. "I'm afraid that mom will be depressed and miss her home."
    D. "My children will just have to adjust to having their grandmother with us."

  296. What conditions are contraindicated in the use of stimulants?
  297. 15. Fifteen minutes after a transfusion of packed red cells is started, a patient develops tachycardia and tachypnea and complains of back pain and feeling warm. The nurse first action should be to
    a. disconnect the transfusion and infuse normal saline.
    b. obtain a urine specimen to send to the laboratory.
    c. administer oxygen therapy at a high flow rate.
    d. notify the health care provider about the transfusion reaction.
  298. homonymous hemianopsia
  299. 73.) A client with myasthenia gravis is suspected of having cholinergic crisis. Which of the following indicate that this crisis exists?
    1. Ataxia
    2. Mouth sores
    3. Hypotension
    4. Hypertension
  300. What is Adjuvant chemotherapy and what is the purpose?
  301. What is the PPE transmission precaution for meningococcal meningitis?
  302. Mrs. Strachand was severely burned in an automobile accident. The burns cover her entire anterior chest and right arm. Using the Rule of Nines, the LPN/LVN would calculate the body surface area (BSA) that is burned to be:
    (A) 9%
    (B) 18%
    (C) 27%
    (D) 36%
  303. According to the American Heart Association (AHA), which of the following is the most prevalent form of cardiovascular disease?
    1. Stroke
    2. Coronary Artery Disease (CAD)
    3. Hypertension
    4. Rheumatic heart disease
  304. what are signs of right ventricular failure
  305. The critical care nurse is planning an interdisciplinary team conference regarding placement for a long-term ventilator patient. Which team members should be included? (Select all that apply)

    A) Staff nurse
    B) Respiratory therapist
    C) Case manager
    D) Physician
    E) Physical therapist

  306. 2. A recently admitted patient has a small-cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for
    a. rapid and unexpected weight loss.
    b. increased total urinary output.
    c. decreased serum sodium level.
    d. elevation of serum hematocrit.
  307. alpha 1-antitrypsin
  308. 239.) Which of the following precautions will the nurse specifically take during the administration of ribavirin (Virazole) to a child with respiratory syncytial virus (RSV)?
    1. Wearing goggles
    2. Wearing a gown
    3. Wearing a gown and a mask
    4. Handwashing before administration
  309. Light sleep and slowing brain and body processes are associated with which stage of NREM sleep?
    a. I
    b. II
    c. III
    d. IV
  310. 99.) The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The client develops a temperature of 101° F. The nurse does further monitoring of the client, knowing that this sign would most likely indicate:
    1. The dose of the medication is too low.
    2. The client is experiencing toxic effects of the medication.
    3. The client has developed inadequacy of thermoregulation.
    4. The result of another infection caused by leukopenic effects of the medication.
  311. The nurse is trying to communicate with a client with a stroke and aphasia. Which of the following actions by the nurse would be least helpful to the client?

    ◦ A. Speaking to the client a slower rate
    ◦ B. Allowing plenty of time for the client to respond
    ◦ C. Completing the sentences that the client cannot finish
    ◦ D. Looking directly at the client during attempts at speech

  312. MS: MULTIPLE SCLEROSIS :
    S/S
    Complication
    Crisis
  313. 0.9% sodium chloride is the same as what?
  314. 29. The nurse has identified the nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation in a patient with lung cancer who has had a 10% loss in weight. An appropriate nursing intervention that addresses the etiology of this problem is to
    a. provide foods that are highly spiced to stimulate the taste buds.
    b. avoid presenting foods for which the patient has a strong dislike.
    c. add strained baby meats to foods such as soups and casseroles.
    d. teach the patient to eat whatever is nutritious since food is tasteless.
  315. 16.) The clinic nurse is reviewing a teaching plan for the client receiving an antineoplastic medication. When implementing the plan, the nurse tells the client:
    1. To take aspirin (acetylsalicylic acid) as needed for headache
    2. Drink beverages containing alcohol in moderate amounts each evening
    3. Consult with health care providers (HCPs) before receiving immunizations
    4. That it is not necessary to consult HCPs before receiving a flu vaccine at the local health fair
  316. acetic acid
  317. "The lens is normally transparent
  318. 230.) A client is placed on chloral hydrate (Somnote) for short-term treatment. Which nursing action indicates an understanding of the major side effect of this medication?
    1. Monitoring neurological signs every 2 hours
    2. Monitoring the blood pressure every 4 hours
    3. Instructing the client to call for ambulation assistance
    4. Lowering the bed and clearing a path to the bathroom at bedtime
  319. What are characteristics of urge incontinence?
  320. The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster?

    1. A 19-year-old with a broken tibia in Buck's traction.
    2. A 50-year-old with a diabetic foot ulcer.
    3. A 62-year-old heart transplant with suspected rejection.
    4. An 84-year-old with chronic obstructive pulmonary disease.

  321. Dopamine
  322. An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following?

    1. High-protein, low-residue diet.
    2. Position client on unaffected side.
    3. Exercise the client's arms and legs.
    4. Encourage the client to cough and deep breathe.

  323. Equal pupillary constriction in response to light
  324. 11. In the patient who has had an intraoperative hemorrhage, the nurse would expect to find hematology results of
    a. hematocrit of 45%.
    b. elevated reticulocyte count.
    c. decreased WBC count.
    d. hemoglobin 13.2 g/dl.
  325. 213.) A client is admitted to the hospital with complaints of back spasms. The client states, "I have been taking two or three aspirin every 4 hours for the past week and it hasn't helped my back." Aspirin intoxication is suspected. Which of the following complaints would indicate aspirin intoxication?
    1. Tinnitus
    2. Constipation
    3. Photosensitivity
    4. Abdominal cramps
  326. A nurse is assisting in the admission of a postoperative client from the postanesthesia care unit to the surgical nursing unit. The nurse should do which of the following for the safety of the client?
    1. Ask the client to slide from the stretcher to the bed
    2. Move the client rapidly from the stretcher to the bed
    3. Put the bed rails up after moving the client from the stretcher
    4. Uncover the client before transferring him or her from the stretcher to the bed
  327. A health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which of the following medications should the nurse expect to be prescribed and administered by this route?
    1. Cyclobenzaprine hydrochloride (Flexeril)
    2. Chlorzoxazone (Paraflex)
    3. Dantrolene sodium (Dantrium)
    4. Baclofen (Lioresal)
  328. A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client?
    1. Measuring the pH of gastric aspirate
    2. Submerging the NG tube in water to check for bubbling
    3. Aspirating the NG tube with a 50 mL syringe for gastric contents
    4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach
  329. 50. The nurse is teaching a patient how to self-administer ipratropium (Atrovent) via a metered dose inhaler. Which of the following instructions given by the nurse is most appropriate to help the patient learn proper inhalation technique?
    A. "Avoid shaking the inhaler before use." B. "Breathe out slowly before positioning the inhaler."
    C. "After taking a puff, hold the breath for 30 seconds before exhaling."
    D. "Using a spacer should be avoided for this type of medication."
  330. prolapse of the umbilical cord indicates what pt positioning?
  331. Hypogeusia
  332. What is the nursing process?
  333. 40. The patient has an order for albuterol 5 mg via nebulizer. Available is a solution containing 2 mg/ml. How many milliliters should the nurse use to prepare the patient's dose?
    A. 0.2
    B. 2.5
    C. 3.75
    D. 5.0
  334. respirations of 1 year old
  335. The nurse is making an occupied bed. Arrange the following steps in the order the nurse should perform them.
    A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him.
    B. Lower the side rail on the side of the bed you are working on.
    C. Raise the side rail on the side of the bed you are working on.
    D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.
  336. What percentage of the total daily caloric intake should be through saturated fat?
  337. 113.) A nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which of the following would be included in the plan of care for instructions?
    1. Maintain a high fluid intake.
    2. Discontinue the medication when feeling better.
    3. If the urine turns dark brown, call the health care provider immediately.
    4. Decrease the dosage when symptoms are improving to prevent an allergic response.
  338. Positive Kernig's sign:
  339. 70.) Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?
    1. Pallor
    2. Drowsiness
    3. Bradycardia
    4. Restlessness
  340. COX-2 inhibitor actions
  341. ibuprofen
  342. 11. A patient is admitted to the hospital with an infected pressure ulcer on the left buttock. The pressure ulcer is 5 cm long by 2.5 cm wide and is 1.5 cm deep. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage
    a. I.
    b. II.
    c. III.
    d. IV.
  343. pulmonary edema
  344. The nurse knows an advantage to rivastigmine (Exelon) over other cholinesterase inhibitors is that it:
    a. Has no significant drug interactions.
    b. Does not cause cholinergic adverse effects.
    c. Is absorbed best on an empty stomach.
    d. Does not alter glucose control in clients with diabetes.
  345. The nurse is providing education to the patient concerning a new medication. Which of the following will have to be dealt with before the patient can effectively learn? (Select all that apply)

    A) The patient's blood sugar is 60.
    B) The patient's blood pressure is 120/70.
    C) The patient needs to use the bedpan.
    D) The patient has a new magazine.
    E) The patient has been sitting up in the chair for the first time and is tired.

  346. A client is admitted to a long-term care facility with a diagnosis of Parkinson's disease. The nurse gives information about the client's condition to a visitor assumed to be a family member. The nurse has violated which legal concept of the nurse-client relationship?
    1. Incompetency
    2. Invasion of privacy
    3. Communication techniques
    4. Teaching/Learning principles
  347. A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order?
    1. Monitor weight daily
    2. Monitor urine output hourly
    3. Maintain the nasogastric tube to intermittent suction
    4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain
  348. During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection?

    1. Wash the burn with an antiseptic soap and water.
    2. Remove clothing, and wrap the victim in a clean sheet.
    3. Leave the blisters intact and apply an ointment.
    4. Take no action until the victim arrives in a burn unit.

  349. pleurisy (pleuritis)
  350. 97.) Amikacin (Amikin) is prescribed for a client with a bacterial infection. The client is instructed to contact the health care provider (HCP) immediately if which of the following occurs?
    1. Nausea
    2. Lethargy
    3. Hearing loss
    4. Muscle aches
  351. In preparation for a cerebral angiography, what do you need to ask the patient before the test?
  352. What are sources of vitamin B2?
  353. A nurse who is assisting a physician with insertion of a Miller-Abbott tube should do which of the following to ensure a safe environment and decrease the client's risk of aspiration?
    1. Place the client in a high-Fowler's position
    2. Assist with inserting the tube with the balloon inflated
    3. Instruct the client to bear down if there is an urge to gag
    4. Ask the client to cough when the tube reaches the nasopharynx
  354. The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST?

    1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can.
    2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time.
    3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain.
    4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.

  355. 40.) The client who chronically uses nonsteroidal anti-inflammatory drugs has been taking misoprostol (Cytotec). The nurse determines that the medication is having the intended therapeutic effect if which of the following is noted?
    1. Resolved diarrhea
    2. Relief of epigastric pain
    3. Decreased platelet count
    4. Decreased white blood cell count
  356. the rate of IV administration should be no faster than what?
  357. The nurse is teaching the client about his upcoming procedure and the client is very stressed. It would be most important for the nurse to
    a. Use humor first to decrease the client's stress level
    b. Determine if the teaching should take place at a different time
    c. Introduce himself as the RN to give credibility to his message
    d. Speak to the client when family members are there so they can teach the client
  358. A nurse has reinforced instructions to a parent regarding the safe methods to prevent Lyme disease. Which statement made by a parent would indicate the need for additional instructions?
    1. "We should wear hats when we go on our hiking trip."
    2. "Wearing long-sleeved tops and long pants is important."
    3. "We should wear closed shoes and socks that can be pulled over our pants."
    4. "We should avoid the use of insect repellents because they will attract the ticks."
  359. The nurse should question a health care provider's order of phenobarbital for the client with which conditions?
    a. Seizure disorder
    b. Panic disorder
    c. Prior to a bronchoscopy
    d. Prior to receiving a general anesthetic
  360. 7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the patient understands the purpose of a biopsy?
    a. "The biopsy will tell the doctor whether the cancer has spread to my other organs."
    b. "The biopsy will help the doctor decide what treatment to use for my enlarged prostate."
    c. "The biopsy will determine how much longer I have to live."
    d. "The biopsy will indicate the effect of the cancer on my life."
  361. fremitus
  362. During routine vital signs, the LPN/LVN auscultates a BP of 180/98. How long should the LPN/LVN wait before inflating the cuff to recheck this reading?
    (A) 15 seconds
    (B) 30 seconds
    (C) 1 minute
    (D) 2 minutes
  363. 18. A patient with hyperthyroidism is treated with radioactive iodine (RAI) at a clinic. Before the patient is discharged, the nurse instructs the patient
    a. to monitor for symptoms of hypothyroidism, such as easy bruising and cold intolerance.
    b. to discontinue the antithyroid medications taken before the radioactive therapy.
    c. that symptoms of hyperthyroidism should be relieved in about a week.
    d. about radioactive precautions to take with urine, stool, and other body secretions.
  364. A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders?

    1. "Promethazine (Phenergan) 25 mg IM 3 h."
    2. "Morphine sulfate 10 mg IM q3 4h."
    3. "Docusate sodium (Colace) 50 mg PO bid."
    4. "Ranitidine (Zantac) 50 mg IVPB q12h."

  365. petechiae
  366. 34. A 45-year-old patient with chronic myelogenous leukemia (CML) is considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT) from an HLA-matched sibling. To assist the patient with treatment decisions, the best approach for the nurse to use is to
    a. emphasize the positive outcomes of a bone marrow transplant.
    b. ask the patient whether there are any questions or concerns about HSCT.
    c. explain that a cure is not possible with any other treatment except HSCT.
    d. discuss the need for adequate insurance to cover post-HSCT care.
  367. 148.) A client is taking cetirizine hydrochloride (Zyrtec). The nurse checks for which of the following side effects of this medication?
    1. Diarrhea
    2. Excitability
    3. Drowsiness
    4. Excess salivation
  368. Which diagnostic test/exam would best measure a client's level of hypoxemia?
    a. chest x-ray
    b. pulse oximeter reading
    c. ABG
    d. peak expiratory flow rate
  369. What effect on a client's pulse rate would the LPV/LVN expect to occur from taking the medication propranolol (Inderal)?
  370. vecuronium bromide (Norcuron): common SE and RN priority
  371. Activity of the brain
  372. A client receives total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess which of the following?

    1. A significant increase in pulse rate.
    2. A decrease in diastolic blood pressure.
    3. Temperature in excess of 98.6°F (37°C).
    4. Urine output of at least 30 ml/h.

  373. inflammation vs. infection
  374. Mr. Dwindell is admitted to the unit with severe dehydration caused by persistent nausea, vomiting and diarrhea. Which of the following fluids would the physician most likely start the client on?
    (A) 0.45% sodium chloride with added potassium
    (B) 0.9% sodium chloride with added potassium
    (C) 3% sodium chloride with added potassium
    (D) 0.9% sodium chloride
  375. Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process?
    1. "I work with my ancillary staff to be able to determine what is abnormal."
    2. "The skin is easy to observe for abnormalities when you are giving the bath."
    3. "I use the time to really look at my clients and determine what's normal and what's not."
    4. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship."
  376. 8. When evaluating the red cell indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicates
    a. small size of the red blood cells (RBCs).
    b. inadequate numbers of RBCs.
    c. low hemoglobin in the RBCs.
    d. hypochromic RBCs.
  377. What does vitamin B6 (pyridoxine) do?
  378. What does vitamin B3 (niacin) do?
  379. MENINGITIS :
    S/S
    Complication
    Crisis
  380. 3. Following bowel surgery 2 days ago, a patient has been receiving normal saline intravenously at 100 ml/hr, has a nasogastric tube to low, intermittent suction, and is NPO. An assessment finding that indicates a need to contact the health care provider immediately is a
    a. weight gain of 2 pounds above the preoperative weight.
    b. an oral temperature of 100.1° F with bibasilar lung crackles.
    c. gradually decreasing level of consciousness (LOC).
    d. serum sodium level of 138 mEq/L (138 mmol/L).
  381. The LPN/LVN is teaching a male client how to perform a testicular self examination (TSE). Which of the following is NOT accurate for performing this procedure?
    (A) "It is best to perform the exam in the shower."
    (B) "The exam may hurt a little as you apply pressure to the testes."
    (C) "Use your thumb and first two fingers to palpate the area."
    (D) "If anything abnormal is detected, call your physician for further examination."
  382. During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following?

    1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively.
    2. Arrange all live plants received postoperatively in one section of the room.
    3. Continue intermittent peritoneal dialysis for 3 months following surgery.
    4. Limit consumption of sodium-free liquids for 1 year postoperatively.

  383. acute adrenal insufficiency
  384. A client on Lithium for antimanic effects comes to the clinic for regular testing of serum Lithium level. Which of the following indicates a therapeutic level of this medication in the blood?
    (A) 0.45mEq/L
    (B) 0.78mEq/L
    (C) 1.6mEq/L
    (D) 2.0mEq/L
  385. elderly with long term IV antibiotics may be r/t what?
  386. 31. A patient is admitted to the hospital in addisonian crisis 1 month after a diagnosis of Addison's disease. The nurse identifies the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of condition when the patient says,
    a. "I double my dose of hydrocortisone on the days that I go for a run."
    b. "I had the stomach flu earlier this week and couldn't take the hydrocortisone."
    c. "I frequently eat at restaurants, and so my food has a lot of added salt."
    d. "I do yoga exercises almost every day to help me reduce stress and relax."
  387. Tensilon Test
  388. 104.) Disulfiram (Antabuse) is prescribed for a client who is seen in the psychiatric health care clinic. The nurse is collecting data on the client and is providing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication?
    1. A history of hyperthyroidism
    2. A history of diabetes insipidus
    3. When the last full meal was consumed
    4. When the last alcoholic drink was consumed
  389. A client receiving digoxin (Lanoxin) therapy is being treated for status epilepticus with diazepam (Valium). The nurse places priority on:

    Holding the digoxin until the seizure has subsided.
    Monitoring the client for nausea and GI cramping.
    Keeping the client in a high Fowler's position.
    Instructing the client to eat foods high in potassium.

  390. what are signs of pulmonary edema
  391. A nurse is assigned to care for a client who has returned to the nursing unit after an oral cholecystogram. At this point in time, the nurse should question which of the following physician's orders in the medical record?
    1. Assess for nausea and vomiting
    2. Monitor the client's hydration status
    3. Maintain a clear liquid status for 72 hours
    4. Monitor the client for abdominal discomfort
  392. Which of the following would provide the best information as to whether hemodialysis (HD) has been effective therapy for a client with renal failure?
    (A) Checking the client's weight
    (B) Measuring intake and output
    (C) Checking the potassium level of the client's blood
    (D) Monitoring a client's tolerance to exercise
  393. A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?
    1. A client who had a below-the-knee amputation
    2. A client on a 24-hour urine collection who is on strict bed rest
    3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure
    4. A client scheduled to be transferred to the hospital for coronary artery bypass surgery
  394. 72.) Cinoxacin (Cinobac), a urinary antiseptic, is prescribed for the client. The nurse reviews the client's medical record and should contact the health care provider (HCP) regarding which documented finding to verify the prescription? Refer to chart.
    1. Renal insufficiency
    2. Chest x-ray: normal
    3. Blood glucose, 102 mg/dL
    4. Folic acid (vitamin B6) 0.5 mg, orally daily
  395. 27. A patient with Cushing syndrome is admitted to the hospital to have laparoscopic adrenalectomy. During the admission assessment, the patient tells the nurse, "The worst thing about this disease is how terrible I look. I feel awful about it." The best response by the nurse is
    a. "Let me show you how to dress so that the changes are not so noticeable."
    b. "I do not think you look bad. Your appearance is just altered by your disease."
    c. "Most of the physical and mental changes caused by the disease will gradually improve after surgery."
    d. "You really should not worry about how you look in the hospital. We see many worse things."
  396. What are normal specific gravty values?
  397. Painless vaginal bleeding is a possible sign of what?
  398. 26.) Glimepiride (Amaryl) is prescribed for a client with diabetes mellitus. A nurse reinforces instructions for the client and tells the client to avoid which of the following while taking this medication?
    1. Alcohol
    2. Organ meats
    3. Whole-grain cereals
    4. Carbonated beverages
  399. -Paresis:
  400. A client who is admitted to the labor and delivery unit in active labor has active genital herpes lesions present in the genital tract. The licensed practical nurse should reinforce teaching done by the registered nurse about which of the following immediate plans for the client?
    1. Placement on protective isolation
    2. Preparation for a cesarean delivery
    3. Preparation for spontaneous vaginal delivery
    4. Imminent artificial rupture of the membranes
  401. OTHER

    1. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order will the nurse perform the following actions?
    a. Administer acetaminophen (Tylenol).
    b. Perform wet-to-dry dressing change.
    c. Administer intravenous antibiotics.
    d. Sponge patient with cool water.

  402. 3.) Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which of the following would indicate the presence of systemic toxicity from this medication?
    1. Tinnitus
    2. Diarrhea
    3. Constipation
    4. Decreased respirations
  403. 1 kg = how many liters of water?
  404. if a neck injury is suspected, what maneuver is used?
  405. In a small rural hospital they work with a wide variety of clients. Of this afternoon client's admitted, the nurse acknowledges the client with the highest susceptibility to infection is the individual with:
    1) Burns
    2) Diabetes
    3) Pulmonary emphysema
    4) Peripheral vascular disease
  406. 34. A patient has an adrenocortical adenoma causing hyperaldosteronism and is scheduled for laparoscopic surgery to remove the tumor. During care before surgery, the nurse should
    a. monitor blood glucose level every 4 hours.
    b. provide a potassium-restricted diet.
    c. monitor the blood pressure every 4 hours.
    d. relieve edema by elevating the extremities.
  407. 237.) A client who is on lithium carbonate (Lithobid) will be discharged at the end of the week. In formulating a discharge teaching plan, the nurse will instruct the client that it is most important to:
    1. Avoid soy sauce, wine, and aged cheese.
    2. Have the lithium level checked every week.
    3. Take medication only as prescribed because it can become addicting.
    4. Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications.
  408. The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST?

    1. "Take three deep breaths, hold your incision, and then cough."
    2. "That was good. Do that again and soon it won't hurt as much."
    3. "It won't hurt as much if you hold your incision when you cough."
    4. "Take another deep breath, hold it, and then cough deeply."

  409. 84.) Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse assists in planning care, knowing that the primary therapeutic effect of this medication is which of the following?
    1. Increased muscle tone
    2. Decreased muscle spasms
    3. Increased range of motion
    4. Decreased local pain and tenderness
  410. How many arteries and veins are in the umblical cord?
  411. The nurse is discussing a middle-age adult male client's report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.)
    1. An enlarged prostate gland
    2. Poorly controlled blood glucose
    3. Drinking a cup of tea before bed
    4. Possible side effect of his medication
    5. Taking his diuretic too close to bedtime
    6. Consuming too many liquids during the day
  412. Slow, irregular respirations
  413. A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device?
    1. Position the client in the center of the sling
    2. Have three staff members available to assist
    3. Lower the client rapidly once positioned over the chair
    4. Have the client grasp the chains attaching the cling to the lift
  414. 3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should:
    A. test the drainage for the presence of glucose.
    B. suction the nose to maintain airway clearance.
    C. document the findings and continue monitoring.
    D. apply a drip pad and reassure the patient this is normal.
  415. A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.)

    A. Falls asleep in the examination room
    B. Repeatedly states, "Don't hurt me."
    C. Chafing around wrists and ankles
    D. Bruises in various stages of healing

  416. The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which of the following items to perform the test?

    ◦ A. Tuning fork and audiometer
    ◦ B. Snellen chart, ophthalmoscope
    ◦ C. Flashlight, pupil size chart or millimeter ruler
    ◦ D. Safety pin, hot and cold water in test tubes, cotton wisp

  417. 14. Following a motor-vehicle accident, a patient is scheduled for an ultrasound of the spleen. Which patient education will be included in the teaching plan?
    a. "You will need to avoid eating or drinking anything for 6 hours before the exam."
    b. "An intravenous line will be started to administer fluids and medications during the exam."
    c. "A lubricated probe will be moved across your abdomen to check for any spleen injuries."
    d. "Iodine-based solution will be injected to help visualize the borders of your spleen."
  418. The physician has prescribed promethazine (Phenergan) 12.5 mg IM q 4 hours prn for a chemotherapy client with severe nausea. The vial reads 50 mg of medication per mL of solution. How much solution should the LPN/LVN draw into the syringe for IM administration?
    (A) 0.125 mL
    (B) 0.25 mL
    (C) 0.75 mL
    (D) 1 mL
  419. The name of the scale used globally to assess a person's consciousness
  420. A client who is taking clopidogrel (Plavix) to prevent another stroke asks the nurse how the medication works. The nurse's response should be based upon an understanding that Plavix:
    a. Inhibits platelet aggregation to prevent clot formation.
    b. Activates antithrombin III and subsequently inhibits thrombin.
    c. Inhibits enzymes involved in the formation of vitamin K.
    d. Converts plasminogen to plasmin to dissolve fibrin clots.
  421. 183.) A client who received a kidney transplant is taking azathioprine (Imuran), and the nurse provides instructions about the medication. Which statement by the client indicates a need for further instructions?
    1. "I need to watch for signs of infection."
    2. "I need to discontinue the medication after 14 days of use."
    3. "I can take the medication with meals to minimize nausea."
    4. "I need to call the health care provider (HCP) if more than one dose is missed."
  422. The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group?

    A. Suggest that he purchase an emergency in-home alert system.
    B. Arrange for the client to receive meals delivered to his home daily.
    C. Encourage the client to use a compartmentalized pill storage container for his daily medications.
    D. Provide only written document describing the medications the client is currently prescribed.

  423. A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that:

    A. Diet and exercise can slow the process considerably
    B. It usually progresses gradually with a deterioration of function
    C. Many individuals can be cured if the diagnosis is made early
    D. Few clients live more than 3 years after the diagnosis

  424. An older client who has not been hospitalized previously is extremely anxious after hospital admission. To provide a safe environment for the client and minimize the stress of hospitalization, the nurse should do which of the following?
    1. Keep visitors to the minimum number possible
    2. Keep the door open and room lights on at all times
    3. Admit the client to a room far away from the nurse's station
    4. Allow the client to have as many choices related to care as possible
  425. A PACU nurse has received a semiconscious patient form the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. in this situation, in what position will the nurse place the patient?
    a. supine
    b. prone
    c. side-lying
    d. trendelenburg
  426. A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first?
    1. Aspirate the tube
    2. Flush the tube with warm water
    3. Prepare to remove and replace the tube
    4. Flush with a carbonated liquid such as cola
  427. Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function?
    1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."
    2. "Please take his pulse and blood pressure, and let me know if they are elevated above his normal baselines."
    3. "If his pulse and blood pressure are above his normal baseline, let me know, and I will medicate him for pain."
    4. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure."
  428. What is the mechanism of stimulant use in ADHD?
  429. 11. Which action by a nursing assistant (NA) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene?
    a. The NA places the patient's bedding in the laundry container in the hallway.
    b. The NA flushes the toilet once after emptying the patient's bedpan.
    c. The NA stands by the patient's bed for an hour talking with the patient.
    d. The NA gives the patient an alcohol-containing mouthwash for oral care.
  430. 23.) A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which information should the nurse teach when carrying out plans for discharge?
    1. Keep insulin vials refrigerated at all times.
    2. Rotate the insulin injection sites systematically.
    3. Increase the amount of insulin before unusual exercise.
    4. Monitor the urine acetone level to determine the insulin dosage.
  431. 119.) A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol (Tenormin) for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which of the following is the most reliable indicator of hypoglycemia?
    1. Sweating
    2. Tachycardia
    3. Nervousness
    4. Low blood glucose level
  432. 142.) A health care provider has written a prescription for ranitidine (Zantac), once daily. The nurse should schedule the medication for which of the following times?
    1. At bedtime
    2. After lunch
    3. With supper
    4. Before breakfast
  433. The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients?

    1. A client who had a total hip replacement and requires assistance with ambulation.
    2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet.
    3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine.
    4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder.

  434. A client is admitted to the unit with deep partial thickness burns on bilateral lower extremities. The LPN/LVN knows that deep partial thickness burns would exhibit which of the following characteristics?
    (A) The burns involve the epidermis and dermis
    (B) The burns involve the epidermis, dermis and subcutaneous tissue
    (C) The burns involve all skin layers and destruction of nerve endings
    (D) Necrosis is evident in the burned areas
  435. 2.) Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse instructs the mother to administer the iron with which best food item?
    1. Milk
    2. Water
    3. Apple juice
    4. Orange juice
  436. How do you determine which stimulant is a better tx?
  437. There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age:

    A. Men have the greatest incidence of osteoporosis
    B. Muscle fibers increase in size and become tighter
    C. Weight-bearing exercise reduces the loss of bone mass
    D. Muscle strength does not diminish as much as muscle mass

  438. A nurse is teaching a group of mothers about first aid. Should poison come in contact with their child's clothing and skin, which action should the nurse instruct the mothers to take first?
    1) Remove the contaminated clothing immediately.
    2) Flood the contaminated area with lukewarm water.
    3) Wash the contaminated area with soap and water and rinse.
    4) Call the nearest poison control center immediately.
  439. A client with a fractured left femur has been using crutches for the past 4 weeks. The physician tells the client to begin putting a little weight on the left foot when walking. Which of the following gaits should the client be taught to use?
    1. Two-point
    2. Three-point
    3. Four-point
    4. Swing-through
  440. Your patient assigned to you has pneumonia. You are reviewing the age-related changed involved with the older adult. Select all age-related changes of the respiratory system that apply.

    1. Decreased in residual lung volume
    2. Decreased gas exchange
    3. Decreased cough efficiency
    4. Increased gas exchange

  441. To maintain proper posture, it is important to
    a. sleep on the softest mattress possible
    b. avoid arching shoulders forward when sitting
    c. keep your knees locked when standing upright
    d. keep your stomach muscles relaxed to prevent back spasms
  442. The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following?

    1. Signs and symptoms of infection.
    2. Fluid and electrolyte balance.
    3. Seizure precautions.
    4. Steroid replacement.

  443. The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST?

    1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
    2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
    3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab.
    4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.

  444. CVA: CEREBROVASCULAR ACCIDENT :
    S/S
    Complication
    Crisis
  445. 63.) A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Select the appropriate actions that the nurse should take. Select all that apply.
    1. Call a code blue.
    2. Contact the registered nurse.
    3. Contact the client's family.
    4. Assess the client's pain level.
    5. Check the client's blood pressure.
    6. Administer a second nitroglycerin, 0.4 mg, sublingually.
  446. A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client?
    1. Mask and gloves
    2. Gown and gloves
    3. Mask, gown and gloves
    4. Gown, gloves and eyewear
  447. 21.) A nurse is assisting with caring for a client with cancer who is receiving cisplatin. Select the adverse effects that the nurse monitors for that are associated with this medication. Select all that apply.
    1. Tinnitus
    2. Ototoxicity
    3. Hyperkalemia
    4. Hypercalcemia
    5. Nephrotoxicity
    6. Hypomagnesemia
  448. NSAIDS: lifespan considerations
  449. An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is:
    1. Confusion
    2. Impaired judgment
    3. Sensory deficits
    4. History of falls
  450. The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section

    1. contains a lower overall dosage of medication than is given before general surgery.
    2. contains lower amounts of sedatives and hypnotics than are given before general surgery.
    3. contains lower amounts of narcotics than are given before general surgery.
    4. contains medications similar in type and dosages to those given before general surgery.

  451. 19. The nurse is caring for a postoperative patient with sudden onset of respiratory distress. The physician orders a STAT ventilation-perfusion scan. Which of the following explanations should the nurse provide to the patient about the procedure?
    A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.
    B. This test will use special technology to examine cross sections of the chest with use of a contrast dye.
    C. This test will use magnetic fields to produce images of the lungs and chest. D. This test involves injecting contrast dye into a blood vessel to outline the blood vessels of the lungs.
  452. thrombocytopenia: sx
  453. Mrs. Fischner's physician diagnosed that she has rheumatoid arthritis. With this condition, the client's chief complaint is persistent joint pain and stiffness. Pain and stiffness associated with rheumatoid arthritis is most often first noticed in the joints of which of the following?
    (A) Hands
    (B) Arms
    (C) Legs
    (D) Neck
  454. A client with severe peptic ulcer disease undergoes a Billroth II surgical procedure. Which of the following best describes the alterations made to the gastrointestinal tract with this procedure?
    (A) Antrectomy with anastomosis to the duodenum
    (B) Antrectomy with anastomosis to the jejunum
    (C) Vagus nerves are severed
    (D) Resection of the large bowel
  455. The nurse notes that the electrical cord on an IV infusion pump is cracked. Which action by the nurse is best?
    1) Continue to monitor the pump to see if the crack worsens.
    2) Place the pump back on the utility room shelf.
    3) A small crack poses no danger so continue using the pump.
    4) Clearly label the pump and send it for repair.
  456. 10. The nurse will plan to use wet-to-dry dressings when providing care for a
    a. full-thickness burn filled with dry, black material.
    b. surgical incision with pink, approximated edges.
    c. pressure ulcer with pink granulation tissue.
    d. wound with purulent drainage and dry brown areas.
  457. A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test?
    1. Shave the groin area for insertion of a femoral catheter
    2. Apply metal-tipped electrodes on the client's chest
    3. Remove all objects containing metal from the client
    4. Ensure that the client stays NPO for 24 hours before the test
  458. A nurse is caring for a client who is dying and is a potential organ donor. The nurse reviews the client's medical record and identifies a contraindication to organ donation if which of the following were documented in the client's record?
    1. Age of 38 years
    2. Hepatitis B infection
    3. Allergy to penicillin type antibiotics
    4. Negative rapid plasma reagin (RPR) laboratory result
  459. What are normal platelet count?
  460. 25. A patient with advanced lung cancer is admitted to the ED with urinary retention caused by renal calculi. Which of these laboratory values will require the most immediate action by the nurse?
    a. Arterial oxygen saturation 91%
    b. Serum potassium is 5.1 mEq/L
    c. Arterial blood pH is 7.32
    d. Serum calcium is 18 mEq/L
  461. 196.) A client has been prescribed amikacin (Amikin). Which of the following priority baseline functions should be monitored?
    1. Apical pulse
    2. Liver function
    3. Blood pressure
    4. Hearing acuity
  462. A 2 month-old is admitted to the hospital. The nurse should take which of the following actions to maintain the infant's safety and to reduce the risk of sudden infant death syndrome (SIDS)?
    1. Make sure that only plastic bottles and toys are used
    2. Place the infant in a supine position in preparation for sleep
    3. Take the pacifier out of the mouth before the infant falls asleep
    4. Cover the crib with netting when the child is not being directly observed
  463. A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following?

    1. Emotional trauma and stress.
    2. Onset of menopause.
    3. Presence of uterine fibroids.
    4. Possible tubal pregnancy.

  464. A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when:
    1. Five sputum cultures are negative
    2. Three sputum cultures are negative
    3. The PPD and chest x-ray are negative
    4. A sputum culture and a PPD test are negative
  465. 6. A patient's 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse anticipate using for wound care?
    a. Transparent film dressing (Tegaderm)
    b. Dry gauze dressing (Kerlix)
    c. Hydrocolloid dressing (DuoDerm)
    d. Nonadherent dressing (Xeroform)
  466. A practical nurse student is preparing for an upcoming exam on the reproductive system. Arrange the following in order as they occur in the menstrual cycle and ovulation.
    (A) Ovulation occurs
    (B) Estrogen level peaks
    (C) Endometrium is shed
    (D) Progesterone level drops
    (E) Estrogen level drops sharply
    (F) Estrogen level is low
  467. 19.) Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that the primary action of this medication is to:
    1. Increase DNA and RNA synthesis.
    2. Promote the biosynthesis of nucleic acids.
    3. Increase estrogen concentration and estrogen response.
    4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.
  468. A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms?

    1. Agitation and decreased level of consciousness.
    2. Lethargy and decreased respiratory rate.
    3. Restlessness and increased heart rate.
    4. Hostility and increased blood pressure.

  469. Guillian-Barre S/S
  470. 1) A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client?
    1. Calcium chloride
    2. Calcium gluconate
    3. Calcitonin (Miacalcin)
    4. Large doses of vitamin D
  471. A client is receiving diazepam (Valium) for its skeletal muscle relaxant effects. The nurse should monitor this client for which side effect of this medication?
    1. Urinary retention
    2. Headache
    3. Incoordination
    4. Increased salivation
  472. adverse effects of corticosteroid use
  473. The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient?

    A. Show a colorful video about anticoagulation therapy.
    B. Present all the information in one session just before discharge.
    C. Give the patient pamphlets about the medications to read at home.
    D. Develop large-print handouts that reflect the verbal information presented.

  474. foods ↑ in K
  475. leading cause of disability and #1 inflammatory disease in US
  476. An adolescent asks a nurse about the procedure to become an organ donor. The nurse most accurately tells the adolescent that:
    1. Written consent is never required to become a donor
    2. A donor must be 18 years or older to provide consent
    3. An individual who is at least 16 years of age can sign to become a donor
    4. The family is responsible for making the decision about organ donation at the time of death
  477. The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST?

    1. Talk with the client about how the client is feeling.
    2. Instruct the nursing assistant to sit with the client while the client eats.
    3. Contacts the physician to obtain an order for an antacid.
    4. Evaluate the most recent vital signs recorded in the chart.

  478. 5.) Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?
    1. Notifying the registered nurse
    2. Discontinuing the medication
    3. Informing the client that this is normal
    4. Applying a thinner film than prescribed to the burn site
  479. An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications?

    A. "I don't seem to have problems with side effects, but I'll let my doctor know if something happens."
    B. "I'm lucky since my daughter is really good about keeping up with my medications."
    C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something."
    D. "It shouldn't be too hard to keep it straight since I don't have any really serious health issues."

  480. Diuretics are often prescribed for treatment of acute glomerulonephritis to treat fluid overload and hypertension. Which of the following is least likely to be prescribed for this purpose in glomerulonephritis?
    (A) Bumex
    (B) Lasix
    (C) Demadex
    (D) Aldactone
  481. 8. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?
    a. "I can have low-fat cheese."
    b. "I will have apple juice instead of orange juice."
    c. "I will drink at least 8 glasses of water every day."
    d. "I can use a salt substitute."
  482. A patient tells you that she has trouble falling asleep at night, even though she is very tired. A review of symptoms reveals no physical problems and she takes no medication. She has recently quit smoking, is trying to eat healthier foods, and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine, stress level, or environment. Based on this information, the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to:
    1) Increased exercise.
    2) Nicotine withdrawal.
    3) Caffeine intake.
    4) Environmental changes.
  483. 42.) A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medications prescribed, including clarithromycin (Biaxin), esomeprazole (Nexium), and amoxicillin (Amoxil). Which statement by the client indicates the best understanding of the medication regimen?
    1. "My ulcer will heal because these medications will kill the bacteria."
    2. "These medications are only taken when I have pain from my ulcer."
    3. "The medications will kill the bacteria and stop the acid production."
    4. "These medications will coat the ulcer and decrease the acid production in my stomach."
  484. What is the normal PT value?
  485. The nurse plans care for a client who is receiving an ophthalmic anesthetic agent based on which priority for nursing care?
    a. Measures to increase tear secretion
    b. Measures to protect the eye
    c. Monitoring for conjunctivitis
    d. Assessing for level of consciousness
  486. A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient?

    1. Oxycodone terephthalate (Percodan).
    2. Ibuprofen (Motrin).
    3. Enteric-coated aspirin.
    4. Codeine phosphate (Paveral).

  487. hold NG tube feeding with residual amounts more than what?
  488. Bell's Palsy Nursing Interventions:
  489. 26. A patient with hypercalcemia is being cared for on the medical unit. Nursing actions included on the care plan will include
    a. maintaining the patient on bedrest to prevent pathologic fractures.
    b. monitoring for Trousseau's and Chvostek's signs.
    c. encouraging fluid intake up to 4000 ml every day.
    d. auscultate breath sounds every 4 hours.
  490. STAR
  491. An older client in a long-term care facility is at risk for injury because of confusion. Because the client's gait is stable, which method of restraint, if prescribed, would be best used by the nurse to prevent injury to the client?
    1. Vest restraint
    2. Waist restraint
    3. Alarm-activating bracelet
    4. Chair with a locking lap-tray
  492. Carbohydrates are the main source of fuel for which body systems?
  493. A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding?

    1. "I feel fine, but the bleeding scares me."
    2. "I've been more nauseated during the past few weeks."
    3. "The bleeding started after I carried four bags of groceries."
    4. "I've been having severe abdominal cramps."

  494. A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse assigned to assist in caring for the client prepares to carry out which of the following orders that will maintain viability of the kidneys before organ donation?
    1. Checking respirations
    2. Monitoring temperature
    3. Frequent range of motion to extremities
    4. Administration of intravenous (IV) fluids
  495. The nurse is preparing a 42-year-old man for hospital discharge after an MI. Which of the following statements indicates the need for further teaching?
    1. "I will take my medications as prescribed"
    2. "I will follow a low-cholesterol, low-fat diet"
    3. "I can exercise as much as I want"
    4. "I can have a small glass of wine with the evening meal"
  496. A client is receiving a maintenance dose of oral dantrolene sodium (Dantrium) for the treatment of spasticity. The nurse reviews the medication record, expecting that which of the following doses would be prescribed?
    1. 50 mg daily
    2. 100 mg daily
    3. 100 mg twice daily
    4. 200 mg four times daily
  497. What is Ortilani's Sign
  498. Rapid dilantin administration can cause cardiac arrhythmias
  499. 4.) The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied:
    1. Immediately before swimming
    2. 15 minutes before exposure to the sun
    3. Immediately before exposure to the sun
    4. At least 30 minutes before exposure to the sun
  500. 20. The nurse is caring for a patient ITP who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets?
    a. Petechiae are present on the chest and back.
    b. Blood pressure (BP) is 94/56 mm Hg.
    c. Platelet count is 42,000/l.
    d. Blood is oozing from the venipuncture site.
  501. how often should the incentive spirometer be used?
  502. 47.) A client has been taking isoniazid (INH) for 2 months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing:
    1. Hypercalcemia
    2. Peripheral neuritis
    3. Small blood vessel spasm
    4. Impaired peripheral circulation
  503. vecuronium bromide (Norcuron): class and use
  504. What does vitamin A do?
  505. PD: PARKINSON'S DISEASE :
    disease discription
  506. 30. The nurse determines that a patient is experiencing common adverse effects from the inhaled corticosteroid beclomethasone (Beclovent) after noting which of the following?
    A. Adrenocortical dysfunction and hyperglycemia
    B. Elevation of blood glucose and calcium levels
    C. Oropharyngeal candidiasis and hoarseness
    D. Hypertension and pulmonary edema
  507. Dilated non reactive pupils
  508. The LPN/LVN is evaluating a 6 second long electrocardiogram (ECG) strip. Which of the following represents depolarization of the ventricular muscle?
    (A) P wave
    (B) T wave
    (C) QRS complex
    (D) PR interval
  509. 22.) A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to:
    1. Treat thyroid storm.
    2. Prevent cardiac irritability.
    3. Treat hypocalcemic tetany.
    4. Stimulate the release of parathyroid hormone.
  510. Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence?

    1. Steadily increasing vital signs.
    2. Mild tremors and irritability.
    3. Decreased respirations and disorientation.
    4. Stomach distress and inability to sleep.

  511. 38. A patient is admitted with possible SIADH. Which information obtained by the nurse is most important to communicate rapidly to the health care provider?
    a. The patient complains of a severe headache.
    b. The patient complains of severe thirst.
    c. The patient has a urine specific gravity of 1.025.
    d. The patient has a serum sodium level of 119 mEq/L.
  512. Do Myotic drops constrict or dilate the pupils?
  513. A nurse is giving a bed bath to a client who is on strict bed rest. To safely increase venous return, the nurse bathes the client's extremities by using:
    1. Long, firm strokes from distal to proximal areas
    2. Short, patting strokes from distal to proximal areas
    3. Firm, circular strokes from proximal to distal areas
    4. Smooth, light strokes back and forth from proximal to distal areas
  514. diphenhydramine
  515. The client with Parkinson's disease has a nursing diagnosis of falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait?

    ◦ A. Unsteady and staggering
    ◦ B. Shuffling and propulsive
    ◦ C. Broad-based and waddling
    ◦ D. Accelerating with walking on the toes

  516. 19. The nurse is preparing to give the following medications to an HIV-positive patient who is hospitalized with PCP. Which is most important to administer at the right time?
    a. Nystatin (Mycostatin) tablet for vaginal candidiasis
    b. Aerosolized pentamadine (NebuPent) for PCP infection
    c. Oral acyclovir ((Zovirax to treat systemic herpes simplex
    d. Oral saquinavir (Inverase) to suppress HIV infection
  517. 20. Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." The nurse will immediately check for
    a. elevated serum potassium level.
    b. decreased thyroid hormone level.
    c. bleeding on the patient's dressing.
    d. the presence of Chvostek's sign.
  518. 26. Which information noted by the nurse reviewing the laboratory results of a patient who is receiving chemotherapy is most important to report to the health care provider?
    a. Hemoglobin of 10 g/L
    b. WBC count of 1700/µl
    c. Platelets of 65,000/µl
    d. Serum creatinine level of 1.2 mg/dl
  519. A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following safe treatments with this client?
    1. Laser therapy
    2. Interferon therapy
    3. Cytotoxic medications
    4. No therapy is available
  520. What is the normal PaCO2 value?
  521. can a pt give consent if he has been drinking or is pre-medicated?
  522. What does sodium do in the body?
  523. hospital-acquired pneumonia
  524. . The nurse is instilling drops of phenylephrine (Neo-Synephrine) into the client's eye before cataract surgery. Phenylephrine is used prior to cataract surgery because it causes __________, allowing visualization of the operative area.
  525. 3. In preparing the preoperative teaching plan for a patient who is to undergo a total laryngectomy, a nurse should give highest priority to the
    A. tracheostomy being in place for 2 to 3 days.
    B. patient's not being able to speak normally again.
    C. insertion of a gastrostomy feeding tube during surgery.
    D. patient's not being able to perform deep-breathing exercises.
  526. 34.) A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). The nurse assisting in caring for the client should take which action to monitor the effectiveness of treatment?
    1. Monitoring the leukocyte count for 2 days after the infusion
    2. Checking the frequency and consistency of bowel movements
    3. Checking serum liver enzyme levels before and after the infusion
    4. Carrying out a Hematest on gastric fluids after the infusion is completed
  527. 245.) A client taking carbamazepine (Tegretol) asks the nurse what to do if he misses one dose. The nurse responds that the carbamazepine should be:
    1. Withheld until the next scheduled dose
    2. Withheld and the health care provider is notified immediately
    3. Taken as long as it is not immediately before the next dose
    4. Withheld until the next scheduled dose, which should then be doubled
  528. 39.) The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times?
    1. With meals and at bedtime
    2. Every 6 hours around the clock
    3. One hour after meals and at bedtime
    4. One hour before meals and at bedtime
  529. community-acquired pneumonia
  530. 11.) The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments?
    1. "The medication is an antibacterial."
    2. "The medication will help heal the burn."
    3. "The medication will permanently stain my skin."
    4. "The medication should be applied directly to the wound."
  531. stage 1 inflammation
  532. A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions?

    1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing.
    2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air.
    3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry.
    4. Soak in a warm tub three times a day, and rub the spots with a washcloth.

  533. The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload?

    1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready.
    2. Cool skin, respiratory crackles, pulse 86 and bounding.
    3. Complaints of a headache, abdominal pain, and lethargy.
    4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.

  534. The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED?

    1. The boy holds his head erect when sitting on the examination table.
    2. The boy tries to grasp a toy just out of reach.
    3. The boy turns his head to try to locate a sound.
    4. The boy smiles spontaneously when he sees his mother.

  535. tuberculosis
  536. chemoreceptor
  537. 10. The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. The nurse should take which of the following actions to prevent an adverse effect during this procedure?
    A. Immediately pick up both units of blood from the blood bank.
    B. Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
    C. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
    D. Infuse the blood slowly for the first 15 minutes of the transfusion.
  538. 14. While teaching community groups about AIDS, the nurse informs people that the most common method of transmission of the HIV virus currently is
    a. perinatal transmission to the fetus.
    b. sharing equipment to inject illegal drugs.
    c. transfusions with HIV-contaminated blood.
    d. sexual contact with an infected partner.
  539. Immobilize the client's head and neck
  540. The nurse is teaching a client about the use of a hypnotic drug at home. What client teaching is needed related to this medication?
    a. "Take the medication with a caffeinated drink such as coffee."
    b. "Be sure to go to bed with a full stomach."
    c. "Train yourself to sleep with the lights and TV on."
    d. "Avoid the use of alcohol while taking this drug."
  541. The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions?

    1. With the client's neck in a midline position and the head of the bed elevated 30°.
    2. Side-lying with the client's head extended and the bed flat.
    3. In high Fowler's position with the client's head maintained in a neutral position.
    4. In semi-Fowler's position with the client's head turned to the side.

  542. Drugs ending in "olol" belong to which drug classification?
  543. When assisting with a bone marrow aspiration, the nurse should take which of the following actions?

    1. Drop additional sterile supplies onto a sterile tray.
    2. Unwrap all sterile packs for the procedure in case they are needed.
    3. Reach over the tray, and remove contaminated supplies.
    4. Place the bottle of sterile liquid on the sterile field so that it does not splash.

  544. Basilar skull fractures
  545. Place a tongue-blade in the patient's mouth to prevent blockage of the airway.
  546. Of the following options, which is the greatest barrier to providing quality health care to the older-adult client?

    A. Poor client compliance resulting from generalized diminished capacity
    B. Inadequate health insurance coverage for the group as a whole
    C. Insufficient research to provide a basis for effective geriatric health care
    D. Preconceived assumptions regarding the lifestyles and attitudes of this group

  547. 5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. An appropriate nursing intervention for the patient is to
    a. provide a diet high in vitamin K.
    b. isolate the patient from visitors.
    c. plan care to alternate periods of rest and activity.
    d. encourage increased intake of fluid and fiber in the diet.
  548. 7. Interventions such as promotion of nutrition, exercise, and stress reduction should be promoted by the nurse for patients who have HIV infection, primarily because these interventions will
    a. promote a feeling of well-being in the patient.
    b. prevent transmission of the virus to others.
    c. improve the patient's immune function.
    d. increase the patient's strength and self-care ability.
  549. elastic recoil
  550. 52.) A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed?
    1. Electrolyte levels
    2. Coagulation times
    3. Liver enzyme levels
    4. Serum creatinine level
  551. children can sit in a regular adult seat in a car once they are ____
  552. uretolithotomy
  553. What stimulant comes in the form of a patch?
  554. celecoxib
  555. 79.) Ibuprofen (Advil) is prescribed for a client. The nurse tells the client to take the medication:
    1. With 8 oz of milk
    2. In the morning after arising
    3. 60 minutes before breakfast
    4. At bedtime on an empty stomach
  556. 2. When discussing appropriate food choices with a patient who has iron-deficiency anemia and follows a low-cholesterol diet, the nurse will encourage the patient to increase the dietary intake of
    a. eggs and muscle meats.
    b. nuts and cornmeal.
    c. milk and milk products.
    d. legumes and dried fruits.
  557. The LPN/LVN is providing blood pressure readings at a local convenience store for members of the community. For which of the following client should the nurse recommend follow-up with the client's primary doctor within a period of two months?
    (A) 114/78
    (B) 120/82
    (C) 134/97
    (D) 138/89
  558. The physician has written an order for a client to receive 0.45% NaCl (1/2 normal saline) intravenously at a rate of 75mL per hour. The drop factor of the tubing set is 20 drops per mL. The LPN/LVN should calculate the flow rate to be:
    (A) 20
    (B) 25
    (C) 50
    (D) 75
  559. 5. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake
    a. when the patient feels thirsty.
    b. in the late evening hours.
    c. as soon as changes in LOC occur.
    d. if the oral mucosa feels dry.
  560. MG: MYASTHENIA GRAVIS :
    S/S
    Complication
    Crisis
  561. The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions?

    1. Use a new, sterile catheter each time the client performs a catheterization.
    2. Perform the Valsalva maneuver before doing the catheterization.
    3. Perform the catheterization procedure every 8 hours.
    4. Limit oral fluids to reduce the number of times a catheterization is needed.

  562. A client is seen in the clinic for treatment of chronic back pain. The client mentions to the clinic nurse that at home he applies an ointment prepared from several different herbs that relieves his lower back pain. He asks the nurse, "Should I continue using it?" Which of the following responses by the nurse would be BEST?

    1. "No. It might do you more harm than good."
    2. "Yes. Continue using it, but I don't see how it could help your condition."
    3. "You may think it works, but I don't believe home remedies work."
    4. "Pain can be relieved in several ways. Consult your physician regarding this home remedy."

  563. The pregnant client is at full term. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the client that the baby is safe and that the baby's heart rate is within normal limits. The nurse bases this interpretation on which of the following data?
    1. FHR of 80 beats per minute
    2. FHR of 90 beats per minute
    3. FHR of 140 beats per minute
    4. FHR of 170 beats per minute
  564. when might doll's eye oculocephalic reflex be contra-indicated?
  565. 35.) The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition?
    1. Constipation
    2. Abdominal pain
    3. An episode of diarrhea
    4. Hematest-positive nasogastric tube drainage
  566. 46. Nursing assessment findings of jugular vein distention and pedal edema would be indicative of which of the following complications of emphysema? A. Acute respiratory failure
    B. Pulmonary edema caused by left-sided heart failure
    C. Fluid volume excess secondary to cor pulmonale
    D. Secondary respiratory infection
  567. Which cranial nerve is the Vagus?
  568. RACE
  569. Mrs. Fischner, a 55 year-old client, presents to her physician that she has stiffness and pain in her joints that "never seems to go away." After laboratory tests, the physician diagnoses rheumatoid arthritis. The results of which laboratory test most likely led to the physician's diagnosis?
    (A) Serum creatinine
    (B) Erythrocyte sedimentation rate (ESR)
    (C) International normalized ration (INR)
    (D) Fasting lipid panel
  570. ALS: AMYOTROPHIC LATERAL SCLEROSIS :
    S/S
    Complication
    Crisis
  571. apical heart rate for adolescent
  572. Which test is used to check Rh status?
  573. chronic bronchitis
  574. What does phosphorus do in the body?
  575. SHORT ANSWER

    1. A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, calculate the total calories the patient should receive each day.

  576. NSAIDs: What to check after
  577. compliance
  578. The nurse is collaborating with the interdisciplinary team regarding the care of a client with a brain tumor. The nurse knows that the most common reason that subsequent rounds of chemotherapy may be delayed is what condition?
    a. Myelosuppression
    b. Alopecia
    c. Mucositis
    d. Cachexia
  579. rhinoplasty
  580. blood pressure of newborn
  581. 25. A patient with hypoparathyroidism receives instructions from the nurse regarding symptoms of hypocalcemia and hypercalcemia. The nurse teaches the patient that if mild symptoms of hypocalcemia occur, the patient should
    a. increase the daily fluid intake to twice the usual amount.
    b. self-administer IM calcium before calling the doctor.
    c. call an ambulance because the symptoms will progress to seizures.
    d. rebreathe with a paper bag and then seek medical assistance.
  582. In which of the following positions should the patient who is receiving continuous nasogastric enteral feedings be placed to decrease the risk of aspiration?

    A) Semi-Fowler's
    B) Right lateral decubitus
    C) Trendelenburg
    D) Supine
    E) Prone

  583. 17. When admitting a patient with a stage III pressure ulcers on both heels, which information obtained by the nurse is of most concern?
    a. The patient takes corticosteroids daily for rheumatoid arthritis.
    b. The patient has had the heel ulcers for the last 6 months.
    c. The patient has several old incisions that have formed keloids.
    d. The patient's admission oral temperature is 102° F.
  584. What genre of drugs should be used with precaution in combination with atomoxetine?
  585. The nurse is assessing the adaptation of the client to changes in the functional status after a stroke. The nurse assesses that the client is adapting most successfully if the client:

    ◦ A. Gets angry with family if they interrupt a task
    ◦ B. Experiences bouts of depression and irritability
    ◦ C. Has difficulty with using modified feeding utensils
    ◦ D. Consistently uses adaptive equipment in dressing self

  586. 138.) A daily dose of prednisone is prescribed for a client. A nurse reinforces instructions to the client regarding administration of the medication and instructs the client that the best time to take this medication is:
    1. At noon
    2. At bedtime
    3. Early morning
    4. Anytime, at the same time, each day
  587. 147.) A client with a prescription to take theophylline (Theo-24) daily has been given medication instructions by the nurse. The nurse determines that the client needs further information about the medication if the client states that he or she will:
    1. Drink at least 2 L of fluid per day.
    2. Take the daily dose at bedtime.
    3. Avoid changing brands of the medication without health care provider (HCP) approval.
    4. Avoid over-the-counter (OTC) cough and cold medications unless approved by the HCP.
  588. 26. Which of the following conditions is manifested by unexplained shortness of breath and a high mortality rate?
    A. Bleeding ulcer
    B. Transient ischemia
    C. Pulmonary embolism
    D. MI
  589. 233.) Diphenhydramine hydrochloride (Benadryl) is used in the treatment of allergic rhinitis for a hospitalized client with a chronic psychotic disorder. The client asks the nurse why the medication is being discontinued before hospital discharge. The nurse responds, knowing that:
    1. Allergic symptoms are short in duration.
    2. This medication promotes long-term extrapyramidal symptoms.
    3. Addictive properties are enhanced in the presence of psychotropic medications.
    4. Poor compliance causes this medication to fail to reach its therapeutic blood level.
  590. Diplopia
  591. What is a continuous seizure that must be interrupted by emergency measures?
  592. Mr. Peters is admitted to the unit for a cardiac arrhythmia. The LPN/LVN knows that this involves a malfunction in the electrical conduction of the heart. Arrange the following in the correct order to represent normal electrical conduction of the heart.
    (A) Atrioventricular (AV) node
    (B) Bundle of His
    (C) Bundle branches
    (D) Purkinje fibers
    (E) Sinoatrial (SA) node
  593. 156.) A nurse is reviewing the laboratory results for a client receiving tacrolimus (Prograf). Which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
    1. Blood glucose of 200 mg/dL
    2. Potassium level of 3.8 mEq/L
    3. Platelet count of 300,000 cells/mm3
    4. White blood cell count of 6000 cells/mm3
  594. What does vitamin B1 (thiamine) do?
  595. certain food allergies (i.e. bananas) may indicate an allergy to ___. The list includes ...
  596. Which of the following nursing interventions is most likely to prevent respiratory complications such as pneumonia and atelectasis in a post surgical patient?
    a. control of anxiety and agitation
    b. adequate nutrition and fluids
    c. adequate pain control
    d. use of incentive spirometry
  597. The physician prescribes the following for a patient with rheumatoid arthritis: aspirin 5 g po daily. The pharmacy informs the LPN/LVN that the dosage strength of aspirin is 5 grains. How many tablets should be distributed for this patient in each 24-hour period?
    (A) 5
    (B) 10
    (C) 15
    (D) 20
  598. The nurse is evaluation the respiratory outcomes for the client with Guillain-Barre syndrome. The nurse determines that which of the following is the least optimal outcome for the client?

    ◦ A. Spontaneous breathing
    ◦ B. Oxygen saturation of 98%
    ◦ C. Adventitious breath sounds
    ◦ D. Vital capacity within normal range

  599. Of the following, which describes dementia?

    A. Quick onset, irreversible
    B. Slow onset, chronic
    C. Acute onset, reversible
    D. Progressive, terminal

  600. 7. A patient is admitted to the hospital with idiopathic aplastic anemia. An appropriate collaborative problem for the nurse to identify for the patient is
    a. potential complication: hemorrhage.
    b. potential complication: neurogenic shock.
    c. potential complication: pulmonary edema.
    d. potential complication: seizures.
  601. Kerning's sign
  602. The LPN/LVN is preparing to insert a nasogastric tube into the client's gastrointestinal tract. Prior to insertion, the nurse would determine how far to insert the tube by marking the place on the tube that is equal to which of the following distances?
    (A) The distance from the tip of the nose to the belly button
    (B) The distance from the top of the head to the top of the ear, to the belly button
    (C) The distance from the tip of the earlobe to the belly button
    (D) The distance from the nose to the earlobe plus the earlobe to the sternum
  603. Neonates normal temperature ranges?
  604. What are characteristics of functional incontinence?
  605. A nurse is preparing to administer an I.M. injection in a client with a spinal cord injury. Which muscle is best to use in this case?

    1) Deltoid
    2) Dorsal gluteal
    3) Vastus lateralis
    4) Ventral gluteal

  606. The nurse should question the use of barbiturates for the treatment of seizure activity if prescribed for which of the following clients?

    30-year-old pregnant female
    24-year-old male with new diagnosis of seizures
    55-year-old female with history of diabetes mellitus
    45-year-old male with history of hypertension

  607. Diagnosis of meningitis
  608. 14. While assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon?
    a. The patient is complaining of 7/10 incisional pain.
    b. The patient's cardiac monitor shows a heart rate of 112.
    c. The patient has increasing swelling of the neck.
    d. The patient's voice is weak and hoarse sounding.
  609. tracheotomy
  610. 201.) A nurse is preparing to administer eardrops to an infant. The nurse plans to:
    1. Pull up and back on the ear and direct the solution onto the eardrum.
    2. Pull down and back on the ear and direct the solution onto the eardrum.
    3. Pull down and back on the ear and direct the solution toward the wall of the canal.
    4. Pull up and back on the ear lobe and direct the solution toward the wall of the canal.
  611. 26. The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate which of the following is likely to be the next step in treatment?
    A. Pulmonary function testing
    B. Systemic corticosteroids
    C. Biofeedback therapy
    D. Intravenous fluids
  612. From what stage of sleep are people typically most difficult to arouse?
    1) NREM, alpha waves
    2) NREM, sleep spindles
    3) NREM, delta waves
    4) REM
  613. prednisone
  614. A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her?
    1. Social worker
    2. Speech pathologist
    3. Recreational therapist
    4. Occupational therapist
  615. Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process?

    A. "I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it's hard to even walk."
    B. "I've given my grandchildren money for college so they can live a better life than I had."
    C. "Growing old certainly presents all sorts of challenges. I wish I knew then what I know now."
    D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."

  616. The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action?

    1. Remove reading material to decrease eyestrain.
    2. Ask the client if he is nauseated.
    3. Assess color of drainage from the affected eye.
    4. Maintain sterility during q3h saline eye irrigations.

  617. 10. Which information obtained when caring for a patient who has just been admitted for evaluation of diabetes insipidus will be of greatest concern to the nurse?
    a. The patient has a urine output of 800 ml/hr.
    b. The patient's urine specific gravity is 1.003.
    c. The patient had a recent head injury.
    d. The patient is confused and lethargic.
  618. Carbamazepine (Tegretol) has been prescribed for a 24-year-old client for the control of partial seizures. The nurse will teach the client to immediately report:
    a. Blurred vision.
    b. Leg cramps.
    c. Blister-like rash.
    d. Lethargy.
  619. The nurse, who is monitoring a client taking phenytoin (Dilantin), has noted symptoms of nystagmus, confusion, and ataxia. Considering these findings, the nurse would suspect that the dose of the drug should be:
    a. Reduced.
    b. Increased.
    c. Maintained.
    d. Discontinued
  620. 187.) A clinic nurse prepares to administer an MMR (measles, mumps, rubella) vaccine to a child. How is this vaccine best administered?
    1. Intramuscularly in the deltoid muscle
    2. Subcutaneously in the gluteal muscle
    3. Subcutaneously in the outer aspect of the upper arm
    4. Intramuscularly in the anterolateral aspect of the thigh
  621. 169.) Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that it is best to take the insulin:
    1. 1 hour after each meal
    2. Once daily, at the same time each day
    3. 15 minutes before breakfast, lunch, and dinner
    4. Before each meal, on the basis of the blood glucose level
  622. A male client with diagnosed bipolar disorder is hospitalized on the psychiatric unit. At a community activity, the client becomes disruptive and is seen flirting with female clients. Which of the following is the most appropriate intervention for this behavior?
    (A) Pull the client aside to remind him of the unit rules and set boundaries for his behavior
    (B) Tell the other clients to ignore the flirtatious actions of the male client
    (C) Avert the attention of the male client and lead him to his room
    (D) Have the client return to his room immediately because of his inappropriate behavior
  623. 12. If a nurse is assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations are measured at 32 breaths/min, which of the following is the most appropriate nursing assessment?
    A. The rapid breathing is causing the low pH.
    B. The nurse should sedate the patient to slow down respirations.
    C. The rapid breathing is an attempt to compensate for the low pH.
    D. The nurse should give the patient a paper bag to breathe into to correct the low pH.
  624. 29. The most appropriate nursing intervention to include in the care plan for a patient with neutropenia is to
    a. omit fresh fruits or vegetables from the diet.
    b. check the temperature q4hr.
    c. avoid any IM or subcutaneous injections.
    d. assess all wounds for redness and drainage.
  625. The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit:
    1. Severe flank pain and hematuria
    2. Pain and burning on urination
    3. A loss of the urge to void
    4. A feeling of pressure and voiding of small amounts
  626. The nurse assesses the following changes in a client's vital signs. Which client situation should be reported to the primary care provider?
    1) Decreased blood pressure (BP) after standing up
    2) Decreased temperature after a period of diaphoresis
    3) Increased heart rate after walking down the hall
    4) Increased respiratory rate when the heart rate increases
  627. When administering an enema, list the following steps in the order in which they should be performed. Label the steps from 1 to 6, with 1 being the first step to perform.
    A. Document the results of the procedure.
    B. Assess the patient for cramping.
    C. Insert the tubing about 3 to 4 inches into the rectum.
    D. Lubricate the tip of the enema tubing generously.
    E. Raise the container to the correct height and instill the solution at a slow rate.
    F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.
  628. A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients on the unit. The licensed practical nurse (LPN) consults with the registered nurse knowing that which of the following changes should be made to the client's treatment plan?
    1. Allow increased "in room" activities
    2. Increase the level of suicide precautions
    3. Allow the client to spend time off the unit
    4. Reduce the dosage of antidepressant medication
  629. Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home?

    1. "Check your weight daily."
    2. "Maintain clean technique at all times during the procedure."
    3. "Milk the catheter to encourage extra fluid to be removed from the abdomen."
    4. "Eat a well-balanced, low-protein diet."

  630. A nurse is caring for a child receiving carbamazepine (Tegretol) who has a carbamazepine level drawn. Which of the following results indicates a therapeutic level?
    1. 1 mcg/mL
    2. 3 mcg/mL
    3. 6 mcg/mL
    4. 15 mcg/mL
  631. pneumoconiosis
  632. The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST?

    1. "Draw a picture of the eye to explain what will happen."
    2. "Tell your daughter that the procedure will take 1 hour."
    3. "Use dolls or puppets to explain how to get ready for surgery."
    4. "Read an age-appropriate illustrated book about eye surgery to your daughter."

  633. The nurse is assessing the confused client. In trying to determine the client's level of pain, the nurse should
    a. be aware that confused clients don't feel as much pain due to their confusion
    b. observe the client carefully for changes in behavior or vital signs
    c. ask the client's family how much pain the client normally has
    d. use only pain scales that feature numbers or "faces" the client can point to
  634. 18. A postoperative patient with a nasogastric tube connected to low, intermittent suction is complaining of anxiety and severe incisional pain. The patient has a respiratory rate of 32 breaths per minute. The arterial blood gases (ABG) are pH 7.50, PaO2 90 mm Hg, PaCO2 30 mm Hg, and HCO3 23 mm Hg. Which intervention is most appropriate for the nurse to implement?
    a. Disconnect the nasogastric tube until the pH is within the normal range.
    b. Administer the prescribed sodium bicarbonate 50 mEq intravenously.
    c. Teach the patient about the importance of taking slow, deep breaths.
    d. Give the patient the ordered morphine sulfate 4 mg intravenously.
  635. A nurse notes that a child who has been diagnosed with intussusception has a formed brown bowel movement. The nurse should do which of the following at once to ensure that a safe plan of care is implemented for the child?
    1. Prepare the child for hydrostatic reduction
    2. Ask the child about any increase in abdominal pain
    3. Warn the child and her parents that surgery is imminent
    4. Report the passage of the normal stool to the registered nurse (RN)
  636. The LPN/LVN is preparing to give a subcutaneous injection of Procrit 5,000 units. Which of the following needles would be appropriate for this type of injection?
    (A) A 5/8 inch, 25 gauge needle
    (B) A 1 inch, 22 gauge needle
    (C) A 1.5 inch, 25 gauge needle
    (D) A 1.5 inch, 18 gauge needle
  637. 30. A patient is hospitalized with acute adrenal insufficiency. The nurse determines that the patient is responding favorably to treatment upon finding
    a. decreasing serum sodium.
    b. decreasing serum potassium.
    c. decreasing blood glucose.
    d. increasing urinary output.
  638. What is the normal PTT value?
  639. SEIZURE :
    S/S
    Complication
    Crisis
  640. It is important for the nurse to have an understanding of anxiety and stress as they affect healing because: (Select all that apply)

    A) all patients respond the same way to stress.
    B) stress can impede healing.
    C) anxiety can cause powerlessness, which can lead to hopelessness.
    D) anxiety can intensify pain.
    E) critical care is a very stressful environment for the patients, family, and staff.

  641. A nurse is reviewing medications with the client receiving colchicine for the treatment of gout. The nurse determines that the medication is effective if the client reports a decrease in:
    1. Blood glucose
    2. Blood pressure
    3. Joint inflammation
    4. Headaches
  642. respirations of preschooler
  643. direct light response
  644. COX-1 inhibitor actions
  645. 52. When assessing a patient's sleep-rest pattern related to respiratory health, the nurse would ask if the patient: (Select all that apply.)
    A. Has trouble falling asleep
    B. Awakens abruptly during the night
    C. Sleeps more than 8 hours per night
    D. Has to sleep with the head elevated
  646. 14. A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient?
    A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems.
    C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
    D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions.
  647. A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit?

    ◦ A. Tells the client to scan the environment
    ◦ B. Approaches the client from the unaffected side
    ◦ C. Places the bedside articles on the affected side
    ◦ D. Moves the commode and chair to the affected side

  648. what type of meat is ↑ in thymine?
  649. 231.) A client admitted to the hospital gives the nurse a bottle of clomipramine (Anafranil). The nurse notes that the medication has not been taken by the client in 2 months. What behaviors observed in the client would validate noncompliance with this medication?
    1. Complaints of hunger
    2. Complaints of insomnia
    3. A pulse rate less than 60 beats per minute
    4. Frequent handwashing with hot, soapy water
  650. Tonic Seizure
  651. Following a successful coronary artery bypass graft, a 71 year old male pt has been transferred to the PACU. What is the priority for the pt's nursing care during this stage of recovery?
    a. protecting and maintaining airway
    b. positioning the pt to prevent skin breakdown
    c. treating the pts pain
    d. preventing incisional infection and monitoring for s/s of infection
  652. COX-1
  653. A client with paraplegia has a risk for injury related to spasticity of leg muscles. The nurse avoids which action that would be least helpful in dealing with this problem?
    1. Using restraints to immobilize the limbs
    2. Administering a PRN order for a muscle relaxant
    3. Removing potentially harmful objects placed near the client
    4. Performing range-of-motion exercises with the affected limb
  654. What drug is contraindicated with stimulants?
  655. NSAIDs: What to check BEFORE
  656. 25. The nurse identifies the nursing diagnosis of activity intolerance for a patient with asthma. The nurse assesses for which of the following etiologic factor for this nursing diagnosis in patients with asthma?
    A. Anxiety and restlessness
    B. Effects of medications
    C. Fear of suffocation
    D. Work of breathing
  657. 10. When planning discharge teaching for the patient who was admitted with a sickle cell crisis, which information will the nurse include?
    a. Drink only one or two caffeinated beverages daily.
    b. Take a daily multivitamin with iron.
    c. Limit fluids to 2 to 3 quarts a day.
    d. Avoid exposure to crowds as much as possible.
  658. Tonic Clonic (Grand-Mal) Seizure:
  659. The nurse is working with a client who has left-sided weakness. After instruction, the nurse observes the client ambulate in order to evaluate the use of the cane. Which action indicates that the client knows how to use the cane properly?
    1. The client keeps the cane on the left side.
    2. Two points of support are kept on the floor at all times.
    3. There is a slight lean to the right when the client is walking.
    4. After advancing the cane, the client moves the right leg forward.
  660. 21. A 32-year-old male patient is to undergo radiation therapy to the pelvic area for Hodgkin's lymphoma. He expresses concern to the nurse about the effect of chemotherapy on his sexual function. The best response by the nurse to the patient's concerns is
    a. "Radiation does not cause the problems with sexual functioning that occur with chemotherapy or surgical procedures used to treat cancer."
    b. "It is possible you may have some changes in your sexual function, and you may want to consider pretreatment harvesting of sperm if you want children."
    c. "The radiation will make you sterile, but your ability to have sexual intercourse will not be changed by the treatment."
    d. "You may have some temporary impotence during the course of the radiation, but normal sexual function will return."
  661. A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods?
    1. Sneezing
    2. Shaking hands
    3. Contact with stool
    4. Contact with urine
  662. pleural effusion
  663. A nurse assigned to care for a 4-week-old infant who is scheduled for a pyloromyotomy. The nurse plans to do which of the following when caring for the infant?
    1. Restrain the infant in a high chair
    2. Feed the infant in a lying-down position
    3. Feed the infant 1 ounce of formula every hour
    4. Position the infant prone with the head of the bed elevated
  664. 25.) A home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse tells the client to:
    1. Freeze the insulin.
    2. Refrigerate the insulin.
    3. Store the insulin in a dark, dry place.
    4. Keep the insulin at room temperature.
  665. when using crutches, allow ___ inches clearance from the side of the feet
  666. A client who has been taking benzodiazepines for several years suddenly decides to stop taking the medication. For what symptoms of acute withdrawal will the nurse monitor?
    a. Weakness, delirium, seizures
    b. Blurred vision, orthostatic hypotension
    c. Sore throat, fever, jaundice
    d. Sleep disturbances
  667. The nurse recognizes that the leading cause of death for the otherwise healthy 1-year-old is:
    1. Physical abuse
    2. Accidental injury
    3. Contagious diseases
    4. Stranger abduction
  668. Adolescents (12-18)
  669. Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis?

    1. Provide support to flexed joints with pillows and pads.
    2. Position the client on the abdomen several times a day.
    3. Massage the inflamed joints with creams and oils.
    4. Assist the client with heat application and ROM exercises.

  670. 109.) A client taking buspirone (BuSpar) for 1 month returns to the clinic for a follow-up visit. Which of the following would indicate medication effectiveness?
    1. No rapid heartbeats or anxiety
    2. No paranoid thought processes
    3. No thought broadcasting or delusions
    4. No reports of alcohol withdrawal symptoms
  671. Thrombolytics are prescribed for each of the following clients. A nurse should question the order for the client with which condition?
    a. Myocardial infarction
    b. Pulmonary embolism
    c. Acute ischemic strokes
    d. Closed head injury
  672. thoracentesis
  673. 45. The nurse reviews pursed lip breathing with a patient newly diagnosed with emphysema. The nurse reinforces that this technique will assist respiration by which of the following mechanisms?
    A. Preventing bronchial collapse and air trapping in the lungs during exhalation
    B. Increasing the respiratory rate and giving the patient control of respiratory patterns
    C. Loosening secretions so that they may be coughed up more easily
    D. Promoting maximal inhalation for better oxygenation of the lungs
  674. Follow a drop of blood as it circulates through the right side of the heart, using all of the following cardiac structures:
    (A) Tricuspid valve
    (B) Vena cava
    (C) Right ventricle
    (D) Right atrium
    (E) Pulmonic valve
    (F) Pulmonary artery
  675. A 49 year old, male client is admitted to the unit for alcohol withdrawal. The client insists that he had his last drink 4 hours prior. Which of the following medications would the LPN/LVN expect to administer to the client?
    (A) Naloxone hydrochloride (Narcan)
    (B) Chlordiazepoxide hydrochloride (Librium)
    (C) Disulfiram (Antabuse)
    (D) Chlorpromazine (Thorazine)
  676. A nurse is assisting in the care of a child who underwent surgical repair of a cleft lip the previous day. The nurse should implement which safe nursing intervention when caring for the surgical incision?
    1. Clean the incision only if serous exudate forms
    2. Remove the Logan bar carefully to clean the incision
    3. Rub the incision gently with a sterile cotton-tipped swab
    4. Rinse the incision with sterile water after using diluted hydrogen peroxide
  677. 1. The arterial blood gas (ABG) readings that indicate compensated respiratory acidosis are a PaCO2 of
    A. 30 mm Hg and bicarbonate level of 24 mEq/L.
    B. 30 mm Hg and bicarbonate level of 30 mEq/L.
    C. 50 mm Hg and bicarbonate level of 20 mEq/L.
    D. 50 mm Hg and bicarbonate level of 30 mEq/L.
  678. The chambers on the left side of the heart receive oxygenated or unoxygenated blood?
  679. A nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium (Dilantin). Which of the following should be included in the plan of care for this child?
    1. Monitoring intake and output
    2. Checking the heart rate before administering the phenytoin
    3. Providing oral hygiene especially care of the gums
    4. Administering medications 1 hour before food intake
  680. A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the prescription if the client had concurrent prescriptions to take:
    1. Ibuprofen (Advil)
    2. Furosemide (Lasix)
    3. Valproic acid (Depakene)
    4. Tranylcypromine (Parnate)
  681. 39. When developing a plan of care for a patient with SIADH, which interventions will the nurse include?
    a. Encourage fluids to 2000 ml/day.
    b. Offer patient hard candies to suck on.
    c. Monitor for increased peripheral edema.
    d. Keep head of bed elevated to 30 degrees.
  682. Check the fluid for dextrose with a dipstick
  683. NSAID: adverse effects
  684. What are sources of vitamin A?
  685. Monoparesis or Monoplegia:
  686. Imipramime (Tofranil): class & indication
  687. 171.) A nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. The most important laboratory test result for the nurse to check before administering this medication is:
    1. Potassium level
    2. Creatinine level
    3. Cholesterol level
    4. Blood urea nitrogen
  688. Methicillin-Resistant Staphylococcus Aureus (MRSA)
  689. A licensed practical nurse (LPN) employed in a long-term care facility is observing a nursing assistant ambulating a client with right-sided weakness. The LPN determines that the nursing assistant is performing the procedure safely if the LPN observes the nursing assistant:
    1. Standing behind the client
    2. Standing in front of the client
    3. Standing on the left side of the client
    4. Standing on the right side of the client
  690. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia?
    1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning.
    2) The patient will rest quietly when undisturbed.
    3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.
    4) The patient will receive pain medication every 2 hours as prescribed.
  691. 33. A with tumor lysis syndrome (TLS) is taking allopurinol (Xyloprim). Which laboratory value should the nurse monitor to determine the effectiveness of the medication?
    a. Blood urea nitrogen (BUN)
    b. Serum phosphate
    c. Serum potassium
    d. Uric acid level
  692. 17. While caring for a patient with respiratory disease, a nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. The nurse should determine that
    A. supplemental oxygen should be used when the patient exercises.
    B. ABG determinations should be done to verify the oxygen saturation reading.
    C. this finding is a normal response to activity and that the patient should continue to be monitored.
    D. the oximetry probe should be moved from the finger to the earlobe for an accurate oxygen saturation measurement during activity.
  693. 190.) A child is hospitalized with a diagnosis of lead poisoning. The nurse assisting in caring for the child would prepare to assist in administering which of the following medications?
    1. Activated charcoal
    2. Sodium bicarbonate
    3. Syrup of ipecac syrup
    4. Dimercaprol (BAL in Oil)
  694. Which of the following actions violates a principle that is key to proper hand washing at the bedside?
    a. Washing your hands for 1 minute
    b. Shaking your hands dry over the sink
    c. Using warm, not very hot water
    d. Using the soap provided by the agency
  695. Which of the following should the nurse include in the teaching plan for a client receiving subcutaneous heparin? Select all that apply.
    a. Inject medication in the deep fatty layer of the abdomen.
    b. When brushing your teeth, use a soft toothbrush.
    c. Hold direct pressure on any puncture sites for 15 minutes.
    d. Use dental floss daily after brushing.
    e. Take a daily aspirin tablet, 325 mg, to prevent inflammation at the injection site
  1. a Difficulty swallowing, blurred vision, or ptosis

    Rationale: Dysphagia (difficulty swallowing), blurred vision, and ptosis are all symptoms of possible botulism toxicity and should be reported immediately. Options 1, 3, and 4 are incorrect. Fever, aches, and chills are not anticipated adverse effects of this drug. Moderate levels of muscle weakness may occur after the drug is administered, and strengthening exercises may be needed on the affected side. Continuous muscle spasms and pain should not occur, because the drug blocks muscle contraction.

  2. b 2. Two points of support are kept on the floor at all times.

    Two points of support, such as both feet or one foot and the cane, should be on the floor at all times. The cane should be kept on the stronger side, the client's right side. The client should keep his or her body upright and midline. Leaning can cause the client to lose his or her balance and fall. After advancing the cane, the client should move the weaker leg, the client's left leg, forward to the cane.

  3. c B
    Rationale: Clinical manifestations of Addison's disease include hyperkalemia and a decrease in potassium level indicates improvement. Decreasing serum sodium and decreasing blood glucose indicate that treatment has not been effective. Changes in urinary output are not an effective way of monitoring treatment for Addison's disease.

    Cognitive Level: Application Text Reference: pp. 1313, 1316
    Nursing Process: Evaluation NCLEX: Physiological Integrity

  4. d the tendency for the lungs to recoil or reduce in volume after being stretched or expanded.
  5. e 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool.

    To confirm the diagnosis of an infection, the nurse should collect a liquid stool specimen that contains 20 to 30 ml of liquid stool. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis.

  6. f Classic s/s: tremor at rest, muscle rigidity, bradykinesia.
    Complications: risk for fall, aspiration, urinary retention/UTI, dysphagia, oculogyric crisis: fixed lateral and upward gaze.
  7. g 3. Remove all objects containing metal from the client
    Rationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed to determine if the client has any internal metallic devices such as orthopedic hardware, pacemakers and shrapnel. A femoral catheter is not inserted. For an abdominal MRI, the client is usually NPO, but this is not necessary for an MRI of the head. In addition, an NPO status for 24 hours is unnecessary and may be harmful to the client. Metal-tipped electrodes are not used for this test.
  8. h A. Preventing bronchial collapse and air trapping in the lungs during exhalation The focus of pursed lip breathing is to slow down the exhalation phase of respiration, which decreases bronchial collapse and subsequent air trapping in the lungs during exhalation.
  9. i reduces pain, suppresses inflammation, affects renal function
  10. j You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal?
  11. k AD Manifestations of respiratory distress include tachypnea, grunting and panting on respiration, central cyanosis, use of accessory muscles, and flaring nares.
  12. l C
    Rationale: Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables, high-fat foods, and fruits/juices are not high in phosphate and are not restricted.

    Cognitive Level: Application Text Reference: p. 331
    Nursing Process: Implementation NCLEX: Physiological Integrity

  13. m 3. Leads to physical and psychological dependence with prolonged high-dose therapy
    Rationale:
    Clorazepate is classified as an anticonvulsant, antianxiety agent, and sedative-hypnotic (benzodiazepine). One of the concerns with clorazepate therapy is that the medication can lead to physical or psychological dependence with prolonged therapy at high doses. For this reason, the amount of medication that is readily available to the client at any one time is restricted.
    *Eliminate options 2 and 4 first because of the closed-ended word "only"*
  14. n 4. A feeling of pressure and voiding of small amounts
  15. o B. 2.5
  16. p Oxygenated
  17. q diagnosed by lumbar puncture where the CSF is analyzed for organisms.
  18. r (A) The burns involve the epidermis and dermis
    Rationale: Deep partial thickness burns involve the epidermis and dermis. The client will experience sever pain due to nerve injury, but the burns do not penetrate deep enough to destroy nerve endings. Vesicles will develop from deep burns. Superficial partial thickness burns, such as sunburns, affect only the epidermis. Full thickness burns involve the epidermis, dermis, subcutaneous tissue and destroy nerve endings. Necrosis is seen in full thickness burns.
  19. s GOOD: protects GI, decreases stomach acid and increases mucus, lowers fever, platelet aggregation, maintains renal functioning
  20. t (1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder

    (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization

    (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours

    (4) should encourage fluids...

  21. u only give peds ibuprofen
    pregnancy: category c for 6 mos, avoid anything for last three
    older: cardiac problems
  22. v 3. Ensure that the client uses oxygen during labor
    Rationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. Option 1 is a safe nursing action, but it does nothing to prevent sickling crisis. Option 4 is not realistic and would not prevent sickling crisis. Option 2 is another generally helpful nursing measure but again is not related to prevention of sickling crisis.
  23. w Right-sided
  24. x D, F, G, H
    Rationale: The patient's age, gender, and history indicate a need for teaching about or screening or both for colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is healthy.

    Cognitive Level: Application Text Reference: p. 282
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  25. y vibration of the chest wall produced by vocalization.
  26. z kidney damage, induction of asthma/allergies
  27. aa 1
  28. ab 1. Withhold the medication.
    Rationale:
    Metoprolol (Lopressor) is classified as a beta-adrenergic blocker and is used in the treatment of hypertension, angina, and myocardial infarction. Baseline nursing assessments include measurement of BP and AP immediately before administration. If the systolic BP is below 90 mm/Hg and the AP is below 60 beats/min, the nurse should withhold the medication and document this action. Although the registered nurse should be informed of the client's vital signs, it is not necessary to do so immediately. The medication should not be administered because the data is outside of the prescribed parameters for this medication. The nurse should not administer half of the medication, or alter any dosages at any point in time.
  29. ac A) Semi-Fowler's

    To decrease the risk of aspiration, the patient should have the head of the bed elevated 30-45 degrees (Semi-Fowlers). Right lateral decubitus helps promote gastric emptying. Supine, Trendelenburg, and prone positions are contraindicated because they increase the risk of aspiration.

  30. ad 4) Yogurt and parsley

    Yogurt, cranberry juice, parsley, and buttermilk may help control odor. White rice and toast (also bananas and applesauce) help control diarrhea. Asparagus, peas, melons, and fish are known to cause odor. Tomatoes, pears, and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy.

  31. ae Monitoring the client for nausea and GI cramping.

    Objective: Explain the importance of client drug compliance in the pharmacotherapy of epilepsy.
    Rationale: Valium is a benzodiazepine, which can potentate the action of digoxin and raise blood levels. Nausea, vomiting, GI cramping, blurred vision, and bigeminy are signs of digoxin toxicity. The digoxin should not be held unless symptoms of toxicity are seen. Positioning should protect the client from injury during the seizure-most likely recumbent and on the side, if possible. Potassium is not indicated.
    Cognitive Level: Analysis
    Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
    Nursing Process: Planning

  32. af Strategy: Determine the least stable situation

    (1) important issue that needs to be addressed after tending to the client who is bleeding

    (2) patients take priority over personnel issues

    (3) can be delegated to another staff member

    (4) correct—should assess client to determine amount and cause of bleeding

  33. ag inflammation of the pleura.
  34. ah antineoplastic to treat cancer
  35. ai 150,000 - 400,000
  36. aj 4. Occupational therapist
    Rationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems.
  37. ak Trendelenburg
  38. al Constrict = myotiC (c for constrict)
  39. am 3) On a scale of 0 to 10, the patient will rate pain as a 3 while in bed or as a 4 during ambulation.
  40. an 2. Monitor bowel activity.
    Rationale:
    While the client is taking codeine sulfate, an opioid analgesic, the nurse would monitor vital signs and monitor for hypotension. The nurse should also increase fluid intake, palpate the bladder for urinary retention, auscultate bowel sounds, and monitor the pattern of daily bowel activity and stool consistency (codeine can cause constipation). The nurse should monitor respiratory status and initiate breathing and coughing exercises. In addition, the nurse monitors the effectiveness of the pain medication.
  41. ao non specific response to infection, ischemia, antigen-antibody, thermal/physical injury. immediate but short term protection.
  42. ap Mydriasis

    Phenylephrine causes mydriasis, allowing better visualization of the area of the lens during cataract surgery.

  43. aq A. Revise the client's care plan to show the need for the application of moisturizing lotion
  44. ar 3. Sudden increase in pain
    Rationale:
    Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced. Options 1, 2, and 4 are not associated with this medication.
  45. as 3. Liver enzyme levels
    Rationale:
    INH therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.
  46. at Strategy: Think about growth and development.

    (1) appropriate for school-aged child

    (2) preschooler can't relate to the concept of 1 hour

    (3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel

    (4) appropriate for school-aged child

  47. au c. Ongoing assessment

    This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.

  48. av inflammation is a normal rxn to injury or infection (can be environmental or pathogenic). infection is when invading microorganisms disturb normal environment and cause harm; often accompanies inflammation
  49. aw a serum protein produced by the liver normally found in the lungs that inhibits proteolytic enzymes of white cells from lysing lung tissue; genetic deficiency of this protein can cause emphysema.
  50. ax Absorption of glucose
    Transport of fatty acids
    Energy metabolism
  51. ay A
    Rationale: Oral calcium supplements are used to maintain the serum calcium in normal range and prevent the complications of hypocalcemia. Whole-grain foods decrease calcium absorption and will not be recommended. Bisphosphonates will lower serum calcium level further by preventing calcium from being reabsorbed from bone. Kidney stones are not a complication of hypoparathyroidism and low calcium levels.

    Cognitive Level: Application Text Reference: p. 1311
    Nursing Process: Planning
    NCLEX: Health Promotion and Maintenance

  52. az 3. Calcitonin (Miacalcin)
    Rationale:
    The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.
  53. ba 2. "What do you do to help yourself fall asleep?"

    As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.

  54. bb 4. Take the medication with a full glass of water after rising in the morning.
    Rationale:
    Precautions need to be taken with administration of alendronate to prevent gastrointestinal side effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.
  55. bc 1.5" - 2"
  56. bd a surgical incision into the trachea for the purpose of establishing an airway; performed below a blockage by a foreign body, tumor, or edema of the glottis.
  57. be take with food, dont stop suddenly, avoid crowds
  58. bf 30-year-old pregnant female

    Objective: Use the nursing process to care for clients receiving drug therapy for epilepsy.
    Rationale: Barbiturates cross the placental barrier and are excreted in breast milk, and are not recommended for women who are pregnant or nursing. Folic acid absorption also is decreased, and congenital malformations can occur if barbiturates are taken during the first trimester.
    Cognitive Level: Application
    Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
    Nursing Process: Analysis

  59. bg Closed head injury

    Rationale: A closed head injury is one contraindication for the use of thrombolytic drugs. If a blood clot is in the brain, disturbing it may have a deleterious effect on the neurological system. Options 1, 2, and 3 are incorrect. Thrombolytics are drugs that dissolve blood clots. They are frequently used in the care of clients with heart attacks. Pulmonary embolism is another use for these drugs, as thrombolytics will dissolve any clots in the lungs. Only strokes (CVAs) that are known to be caused by thrombus or emboli will be treated with these drugs.

  60. bh Orange fruits and veggies
    Dark green leafy veggies
    Butter
    Fortified milk
    Eggs
    Beef liver
  61. bi A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
  62. bj 4. Allow the client to have as many choices related to care as possible
    Rationale: Several general interventions will reduce the hospitalized client's level of stress. These include acknowledging the client's feelings, offering information, providing social support, and letting the client have control over choices related to care. Options 1 and 3 could increase anxiety, whereas option 2 could add to the disruption created by the hospitalization and interfere with the client's sleep pattern.
  63. bk Strategy: "Question which of the following orders" indicates an incorrect order.

    (1) H1 receptor blocker, used as an antiemetic

    (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure

    (3) stool softener, used for an immobilized patient

    (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers

  64. bl Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

    (1) soaps and ointments should not be applied to second-degree burns in an emergency situation

    (2) correct—after fire is out, remove clothing and cover victim with a clean sheet

    (3) soaps and ointments should not be applied to second-degree burns in an emergency situation

    (4) does not prevent infection

  65. bm 121/70
  66. bn B
    Rationale: SIADH causes water retention, which leads to hyponatremia, so water intake is restricted. Intake and output are measured, but hourly monitoring is not required. Ambulation and incentive spirometer use may be included in the care plan but are not indicated for the diagnosis of SIADH.

    Cognitive Level: Application Text Reference: p. 326
    Nursing Process: Planning NCLEX: Physiological Integrity

  67. bo Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes.

    (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias

    (2) assess cause of problem before implementing

    (3) assess cause of problem before implementing

    (4) more important to assess what is happening now

  68. bp the amount of blood ejected by the heart in any one contraction
  69. bq 35-45
  70. br Respiratory Isolation = Droplet precautions: Gloves, Gown, Mask within 3 ft of pt.
  71. bs C
    Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.

    Cognitive Level: Application Text Reference: pp. 295, 297
    Nursing Process: Planning NCLEX: Physiological Integrity

  72. bt Blister-like rash.

    Carbamazepine is associated with an increased risk of Stevens-Johnson syndrome (SJS) and toxic epidermal necrosis in genetically susceptible individuals. Sunburning and a reddish-purple rash, especially associated with blisters, are possible symptoms of severe dermatologic reactions and should be evaluated immediately. Options 1, 2, and 4 are incorrect. Blurred vision, leg cramping, and lethargy are all possible side effects of carbamazepine but tolerance to these effects usually develops over time.

  73. bu 2. The white blood cell counts and platelet counts
    Rationale:
    Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed before and during drug treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste with loss of appetite are not common signs of side effects of this medication.
  74. bv 3. Subcutaneously in the outer aspect of the upper arm
    Rationale:
    The MMR vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is most often used for intramuscular injections. The MMR vaccine is not administered by the intramuscular route.
  75. bw 3. Providing oral hygiene especially care of the gums
    Rationale:
    Phenytoin sodium causes gum bleeding and hypertrophy, and therefore oral hygiene is important. Soft toothbrushes and gum massage should be instituted to reduce the risk of complications and prevent further trauma. Options 1 and 2 are incorrect because the intake and output as well as heart rate are not affected by this medication. Option 4 is incorrect because directions for administration of this medication include administering with food to minimize gastrointestinal upset.
  76. bx (E) Sinoatrial (SA) node
    (A) Atrioventricular (AV) node
    (B) Bundle of His
    (C) Bundle branches
    (D) Purkinje fibers
    Rationale: Normal electrical conduction within the heart begins with stimulation of the SA node. The SA node is called the heart's pacemaker because it maintains the normal heart rate of 60 to 100 bpm for an adult. The SA node sends the electrical impulse to the AV node, which transmits the electrical impulse through the bundle of His to the right and left bundle branches. The signal ends in the Purkinje fibers, located in the outside muscle layers of the heart.
  77. by Inhibits platelet aggregation to prevent clot formation.

    Rationale: Clopidogrel is an antiplatelet drug used to prevent blood clots from forming inside arteries by inhibiting platelet aggregation. Options 2, 3, and 4 are incorrect. Heparin is an anticoagulant that blocks the formation of blood clots by activating antithrombin III. Warfarin is a vitamin K antagonist used to prevent the blood from clotting. The drug alteplase is a tissue plasminogen activator that dissolves fibrin clots.

  78. bz 3. Maintain a clear liquid status for 72 hours
    Rationale: The client should be able to resume the usual diet once the nurse assured is assured the client that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting. The nurse would also assess the client's hydration status as part of routine care for the client undergoing a GI diagnostic test.
  79. ca Caused by overmedication with anticholinesterase.
    Treatment: hold medication and give atropine if ordered.
  80. cb Amino acid and fatty acid metabolism
    Red blood cell production
  81. cc creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together, evident during inspiration, expiration, or both and no change with coughing; usually uncomfortable, especially on deep inspiration.
  82. cd B
    Rationale: The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. Both types of tumors may cause damage to adjacent tissues. The cells differ from normal in both benign and malignant tumors. Benign tumors usually do not recur.

    Cognitive Level: Comprehension Text Reference: pp. 274-275
    Nursing Process: Implementation NCLEX: Physiological Integrity

  83. ce C- Completing the sentences that the client cannot finish.
    Rationale: Note that the question asks which is least helpful. These words indicate a negative event query and ask you to select an option that is and incorrect action.
  84. cf 4. Baclofen (Lioresal)
    Rationale:
    Baclofen is the only skeletal muscle relaxant that can be administered intrathecally. Therefore options 1, 2, and 3 are incorrect.
  85. cg protect the eyes.
    Eyes can be excessively dry or teary.
  86. ch can cause stomach ulcers, prevents blood clotting, affects renal function
  87. ci affecting all four limbs
  88. cj D
    Rationale: Initiation of thyroid replacement in older adults may cause angina and cardiac dysrhythmias. The patient's high pulse rate needs rapid investigation by the nurse to assess for and intervene with any cardiac problems. The other patients also require nursing assessment and/or actions but are not at risk for life-threatening complications.

    Cognitive Level: Application Text Reference: p. 1306
    Nursing Process: Planning NCLEX: Physiological Integrity

  89. ck Supports energy metabolism
    Skin health
    Nervous system
    Digestive system
  90. cl Fortified milk
    Fish
    Egg yolks
    Liver
    Fortified cereal
  91. cm b. avoid arching shoulders forward when sitting

    Arching shoulders forward when sitting alters the curvature of the spine and contributes to poor body alignment.

  92. cn 4. Cough and chest pain
    Rationale:
    Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions, manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on the x-ray, would indicate the need to stop the treatment. These symptoms resolve in 2 to 4 days following discontinuation of this medication.
    *Eliminate options 1, 2, and 3 because they are similar GI-related side effects. Also, use the ABCs— airway, breathing, and circulation*
  93. co latex (commonly used in surgery); grapes, cherries, apricots, passion fruits, avocados, chestnuts, peaches and tomatoes
  94. cp ...(1) should remain in the seclusion room

    (2) should have meal at regular time

    (3) should have meal at regular time

    (4) correct—should eat at regular time; remain in the seclusion room for client's safety

  95. cq 3. Taken as long as it is not immediately before the next dose
    Rationale:
    Carbamazepine is an anticonvulsant that should be taken around the clock, precisely as directed. If a dose is omitted, the client should take the dose as soon as it is remembered, as long as it is not immediately before the next dose. The medication should not be double dosed. If more than one dose is omitted, the client should call the health care provider.
  96. cr A
  97. cs (1) closed statement

    (2) closed statement; casts doubt on efficiency of alternative therapy

    (3) focus should be on client, not on nurse's beliefs

    (4) correct—herbal medication can interact with other medication

    ...

  98. ct A) Staff nurse
    B) Respiratory therapist
    C) Case manager
    D) Physician
    E) Physical therapist
  99. cu bruise
  100. cv rapid cell division: growth of new blood vessels and scar tissue
  101. cw 1. Laser therapy
    Rationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis, although the exact route of perinatal transmission is unknown. Options 2, 3 and 4 are incorrect.
  102. cx tuck their chin.
  103. cy (1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges

    (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent

    (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity

    (4) caused by subcutaneous bleeding, common during first few exchanges

    ...

  104. cz 60-100 per minute
  105. da B
    Rationale: Airway obstruction is a possible complication after thyroidectomy because of swelling or bleeding at the site or tetany, and the priority nursing action is to assess the airway. The other actions are also part of the standard nursing care post-thyroidectomy but are not as high in priority.

    Cognitive Level: Application Text Reference: p. 1304
    Nursing Process: Implementation NCLEX: Physiological Integrity

  106. db 2. Invasion of privacy
    Rationale: Discussing a client's condition without the client's permission violates the client's right and places the nurse in legal jeopardy. This is an invasion of privacy and affects client's confidentiality. Incompetence could lead to negligence, but this legal concept is not related to the subject identified in the question. Communication techniques relate to the nurse-client relationship. Teaching/learning principles are considered concepts of standard practice.
  107. dc C
    Rationale: Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered intravenously. Insulin can be administered intravenously through the peripheral catheter. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines.

    Cognitive Level: Application Text Reference: p. 340
    Nursing Process: Implementation NCLEX: Physiological Integrity

  108. dd A
    Rationale: There is a high incidence of post-radiation hypothyroidism after RAI, and the patient should be monitored for symptoms of hypothyroidism. RAI has a delayed response, with the maximum effect not seen for 2 to 3 months, and the patient will continue to take antithyroid medications during this time. The therapeutic dose of radioactive iodine is low enough that no radiation safety precautions are needed.

    Cognitive Level: Application Text Reference: pp. 1304-1305
    Nursing Process: Implementation NCLEX: Physiological Integrity

  109. de Weakness, delirium, seizures

    Rationale: The client may experience symptoms similar to alcohol withdrawal, such as weakness, delirium, or seizures, if benzodiazepines are abruptly discontinued. Options 2, 3, and 4 are incorrect because they do not occur with abrupt withdrawal of benzodiazepines.

  110. df A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
  111. dg C
    Rationale: Hypertension caused by sodium retention is a common complication of hyperaldosteronism. Hyperaldosteronism does not cause elevation in blood glucose. The patient will be hypokalemic and require potassium supplementation prior to surgery. Edema does not usually occur with hyperaldosteronism.

    Cognitive Level: Application Text Reference: pp. 1319-1320
    Nursing Process: Implementation NCLEX: Physiological Integrity

  112. dh Increase carbs
    Limit protein
    decrease sodium
    fluid restriction
  113. di Strategy: Think about each answer choice.

    (1) nurse should follow the policies of the institution

    (2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian

    (3) correct—the need for restraints is based on patient's behavioral status and condition, not the patient's voluntary/involuntary status

    (4) must first try less restrictive means to control patient before using restraints

  114. dj 2. Checking the frequency and consistency of bowel movements
    Rationale:
    The principal manifestations of Crohn's disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Options 1, 3, and 4 are unrelated to this medication.
  115. dk A. Wearing perfume to work People with asthma should avoid extrinsic allergens and irritants (e.g., dust, pollen, smoke, certain foods, colognes and perfumes, certain types of medications) because their airways become inflamed, producing shortness of breath, chest tightness, and wheezing. Many green leafy vegetables are rich in vitamins, minerals, and proteins, which incorporate healthy lifestyle patterns into the patients' daily living routines. Routine exercise is a part of a prudent lifestyle, and for patients with asthma the physical and psychosocial effects of ambulation can incorporate feelings of well-being, strength, and enhancement of physical endurance. Antibiotic therapy is always initiated after cultures are obtained so that the sensitivity to the organism can be readily identified.
  116. dl 2. Near the client's left leg
    Rationale: Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is affected and the client is sitting on the edge of the bed, the wheelchair is positioned next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.
  117. dm C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed once the patient's acute respiratory distress is being managed.
  118. dn (B) Vena cave
    (D) Right atrium
    (A) Tricuspid valve
    (C) Right ventricle
    (E) Pulmonic valve
    (F) Pulmonary artery
    Rationale: The blood enters the right atrium of the heart via the superior vena cava. From the right atrium, blood goes through the tricuspid valve to the right ventricle. The blood then continues out of the right side of the heart into the pulmonary artery by way of the pulmonic valve.
  119. do s/s: Risk complications: Swallowing/Arrest
    Ptosis, diplopia
    Weakness, dysarthria, dysphagia, difficulty sitting up,
    Respiratory distress

    Eye and periorbital muscles most affected- manifested by diplopia, ptosis, ocular palsies
    Sx least evident in the AM and most evident w/effort as the day proceeds

    Crisis: Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration:
    Pneumonia &
    MYASTHENIC CRISIS: Respiratory, and swallowing muscles too weak. Risk complications: Swallowing/Arrest
    THYMOMA-A rare neoplasm, usually found in the anterior mediastinum and originating in the epithelial cells of the thymus.
    Assess an maintain respiratory, swallowing, atelectasis.
    CHOLINERGIC CRISIS:
    Flaccid paralysis, respiratory failure, GI symptoms, severe muscle weakness, vertigo. Tx: Atropine

  120. dp 4. A rescue squad is best equipped to give emergency treatment.
  121. dq Folic acid (Folgard)

    Rationale: Prior to conception, folic acid should be recommended to women who are required to continue with AED therapy. This will decrease the incidence of birth defects associated with the drugs. Options 1, 2 and 3 are incorrect. It would be inappropriate for the client to take Clomid, a drug used for infertility, unless it is determined that the client is suffering from infertility. The administration of vitamin K will increase the risk of blood clotting. The administration of calcium is important due to the development of osteomalacia, but it will not have the effect of folic acid in the prevention of neurological deficits in pregnancy.

  122. dr Strategy: Think about the cause of each symptom and how it relates to narcotic withdrawal.

    (1) describes cocaine withdrawal

    (2) describes amphetamine withdrawal

    (3) describes barbiturate withdrawal

    (4) correct—narcotic withdrawal is very much like the symptoms of the flu

  123. ds visual field cut both eyes
  124. dt A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
  125. du 3. 6 mcg/mL
    Rationale:
    When carbamazepine is administered, blood levels need to be drawn periodically to check for the child's absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum level for this medication is 4 to 12 mcg/mL.
  126. dv 3. Slurred speech
    Rationale:
    The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appear. At a level higher than 30 mcg/mL, ataxia and slurred speech occur.
  127. dw Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Think about what the assessments mean.

    (1) implementation; would be ineffective

    (2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired

    (3) assessment; refers to an eye infection, would be important after initial operative day

    (4) implementation; eye irrigations are not commonly done following this procedure

    ...

  128. dx (A) A 5/8 inch, 25 gauge needle
    Rationale: An all gauge needle is used to administer a subcutaneous injection to decrease the trauma caused by the needle puncture. The length of the needle selected for subcutaneous administration of a medication should be less than one inch, depending on the client's body mass. Needles most commonly come in 3/8 inch and 5/8 inch lengths.
  129. dy A) The patient's blood sugar is 60.
    C) The patient needs to use the bedpan.
    E) The patient has been sitting up in the chair for the first time and is tired.

    The blood sugar level and the need to use the bedpan are physiological needs that will interfere with teaching. Being tired will interfere with the teaching due to patient's lack of concentration. Blood pressure is normal, and the magazine is a higher-level need that can wait until after the teaching has occurred.

  130. dz rhythmic percussion of a patient's chest with cupped hands to loosen retained respiratory secretions.
  131. ea B. Lower the side rail on the side of the bed you are working on.
    A. Position the patient laterally near the side rail farthest from you (that side rail is up); roll the soiled linens under him.
    D. After placing clean linens and tucking them under the soiled linens, roll the patient over the "hump" and position him facing you on the near side of the bed.
    C. Raise the side rail on the side of the bed you are working on.

    First lower the side rail on your side of the bed. This allows you to maintain good body mechanics while positioning the patient (in step 1). Position patient laterally near far side rail, and roll soiled linens under him. Then place clean linens on the side nearest you, and tuck them under soiled linens. Next, roll the patient over the "hump," and position him on his other side, facing you. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side.

  132. eb C. Fluid volume excess secondary to cor pulmonale Cor pulmonale is a right-sided heart failure caused by resistance to right ventricular outflow due to lung disease. With failure of the right ventricle, the blood emptying into the right atrium and ventricle would be slowed, leading to jugular venous distention and pedal edema.
  133. ec - positive when the leg is fully bent in the hip and knee, and subsequent extension in the knee is painful (leading to resistance)
  134. ed 2. A donor must be 18 years or older to provide consent
    Rationale: Any person 18 years of age or older may become an organ donor by indicating his or her consent in writing. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs.
  135. ee C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something."
  136. ef 4. Dimercaprol (BAL in Oil)
    Rationale:
    Dimercaprol is a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine. Sodium bicarbonate may be used in salicylate poisoning. Syrup of ipecac is used in the hospital setting in poisonings to induce vomiting. Activated charcoal is used to decrease absorption in certain poisoning situations. Note that dimercaprol is prepared with peanut oil, and hence should be avoided by clients with known or suspected peanut allergy.
  137. eg surgical opening into the thoracic cavity.
  138. eh 1. Wearing goggles
    Rationale:
    Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin. Specific to this medication is the use of goggles. A gown is not necessary. A mask may be worn. Handwashing is to be performed before and after any child contact.
  139. ei C
    Rationale: The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Vocal hoarseness is expected after surgery due to edema.

    Cognitive Level: Application Text Reference: p. 1304
    Nursing Process: Assessment NCLEX: Physiological Integrity

  140. ej C
    Rationale: The primary goal for the patient with HIV infection is to increase immune function, and these interventions will promote a healthy immune system. They may also promote a feeling of well-being and increase strength, but these are not the priority goals for HIV-positive patients. These activities will not prevent the risk for transmission to others because the patient will still be HIV positive.

    Cognitive Level: Comprehension Text Reference: p. 265
    Nursing Process: Planning NCLEX: Physiological Integrity

  141. ek C
    Rationale: The patient is at risk for dehiscence during the granulation phase of wound healing, which lasts from the fifth postoperative day to 3 weeks after surgery. The other times are not high-risk periods for dehiscence.

    Cognitive Level: Application Text Reference: pp. 198-199
    Nursing Process: Assessment NCLEX: Physiological Integrity

  142. el 4. Hypertension
    Rationale:
    Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.
  143. em Ataxia.

    Rationale: Ataxia, weakness, restlessness, dizziness, or other motor problems can occur with lorazepam. Options 1, 2, and 4 are incorrect. These are not adverse effects associated with lorazepam.

  144. en A) Autonomy
    B) Nonmaleficence
    D) Beneficence
    E) Fidelity

    The patient's autonomy is in danger. Harm (nonmaleficence), in the form of complications due to a treatment that the patient does not want, is also involved. Doing the right thing (beneficence) for the patient is in question, owing to the patient's wishes and the prognosis of her illness. Keeping "a promise to the patient" (fidelity) is involved. This scenario does not involve the principle of justice.

  145. eo 3. Addictive properties are enhanced in the presence of psychotropic medications.
    Rationale:
    The addictive properties of diphenhydramine hydrochloride are enhanced when used with psychotropic medications. Allergic symptoms may not be short term and will occur if allergens are present in the environment. Poor compliance may be a problem with psychotic clients but is not the subject of the question. Diphenhydramine hydrochloride may be used for extrapyramidal symptoms and mild medication-induced movement disorders.
  146. ep 4. Advances the affected leg after moving the crutches to descend the stairs

    To descend stairs, the crutches are placed on the stairs and the client moves the affected leg, then the unaffected leg to the stairs with the crutches. The client should continue to use the crutches for support, not the banister or wall. The client should continue to use both crutches for support when going up or down stairs. When ascending stairs, the client moves the unaffected leg up the stair, then the crutches and affected leg.

  147. eq b. false

    The term for this sound of respiratory distress is "stridor."

  148. er Placenta Previa
  149. es 4) Clearly label the pump and send it for repair.

    Label it and take it out of service - all organizations have labels which indicate the equipment is not working. Evaluate the policy to determine if Clinical engineering or biomed needs to be contacted.

  150. et accumulation of blood in the pleural space.
  151. eu (1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection

    (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma

    (3) correct—important to keep the skin clean and prevent secondary skin infection

    (4) increases risk of secondary skin infection

    ...

  152. ev dyspnea
    orthopnea
    fatigue
    paroxysmal nocturnal dyspnea
    nocturia
  153. ew (C) 15
    Rationale: One gram (g) contains approximately 15 grains. Therefore, 5 grams contain 75 grains (5 X 15 = 75). Solve for x tablets using the following ratio method:
    1 tablet/5 grams = x tablets/75 grains
    5x = 75
    x = 75/5
    x = 15 tablets
  154. ex 4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain
    Rationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid balance is stabilized, oral narcotic agents can be used. Options 1, 2 and 3 are all appropriate interventions for the client with a burn.
  155. ey Relapsing/Remitting:
    Difficulty chewing, speaking, walking. Shakiness, muscle weakness, tinnitus, visual problems, incontinent,
    Ataxia, Nystagmus, Spasticity, tremors, dysphagia, speech impaired, fatigue
    Help pts identify triggers: illness, stress
  156. ez 95 - 105
  157. fa (B) 25
    Rationale: The formula to calculate this problem is: x gtt/min = volume/time (in minutes X drop factor.
    x gtt/min = 75mL/60 min X 20 gtt/min
    75/60 = 1.25
    1.25 X 20 = 25 gtt/min
  158. fb 3. The AHA states the most prevalent form of cardivascular disease is hypertention, followed in descending order by CAD, rheumatic heart disease, and stroke.
  159. fc 1.010 - 1.030
  160. fd 2. Relief of epigastric pain
    Rationale:
    The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication, but is not an intended effect. Options 3 and 4 are incorrect.
  161. fe b. II

    These are characteristics of a person in Stage II of NREM sleep.

  162. ff loss of consciousness and falling to floor.
    Signs: aura, cries, loss of consciousness, fall, tonic clonic movements, incontinence, cyanosis, excessive salvation, tongue or cheek biting. Posticatal period: need 1-2hr for sleep after.
  163. fg Difficulty going back to sleep
  164. fh 1) Decreased blood pressure (BP) after standing up

    Orthostatic Hypotension

  165. fi Supports energy metabolism
    Supports nerve function
  166. fj released in response to stimula
    causes changes that lead to inflammatory response: main mediator of dilation and increased permeability of capillaries.
  167. fk pork
  168. fl obstructive pulmonary disease characterized by excessive production of mucus and chronic inflammatory changes in the bronchi, resulting in a cough with expectoration for at least 3 months of the year for more than 2 consecutive years.
  169. fm B
    Rationale: The impact on sperm count and erectile function depends on the patient's pretreatment status and on the amount of exposure to radiation. The patient should consider sperm donation before radiation. Radiation (like chemotherapy or surgery) may affect both sexual function and fertility either temporarily or permanently.

    Cognitive Level: Application Text Reference: p. 301
    Nursing Process: Implementation NCLEX: Physiological Integrity

  170. fn a surgical procedure done to remove fluid from the pleural space.
  171. fo (1) pulse will decrease

    (2) correct—with myxedema there is a slowing of all body functions

    (3) associated with hyperthyroidism

    (4) associated with hyperthyroidism

    ...

  172. fp 3. An episode of diarrhea
    Rationale:
    Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4.
  173. fq Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

    (1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area

    (2) should splint incision before coughing to reduce discomfort and increase efficiency

    (3) partial answer, should take three deep breaths before coughing

    (4) implies coughing routine is adequate, incision needs to be splinted

  174. fr instability of the chest wall resulting from multiple rib fractures.
  175. fs B
    Rationale: Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Problems with tissue oxygenation in polycythemia vera are due to increased blood viscosity and poor perfusion, not to poor oxygen saturation. (Oxygen is useful in secondary polycythemia.) The patient should be encouraged to ambulate to prevent DVT. Iron is contraindicated for polycythemia vera.

    Cognitive Level: Application Text Reference: p. 701
    Nursing Process: Planning NCLEX: Physiological Integrity

  176. ft B. It usually progresses gradually with a deterioration of function
  177. fu Strategy: Determine the significance of each answer choice.

    (1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever

    (2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL

    (3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin

    (4) symptoms of CHF, chest x-ray clear, no other information provided

  178. fv B
    Rationale: A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. Biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life; the three remaining statements indicate a need for patient teaching.

    Cognitive Level: Application Text Reference: p. 283
    Nursing Process: Evaluation NCLEX: Physiological Integrity

  179. fw 3. Reduction of steatorrhea
    Rationale:
    Pancrelipase (Pancrease MT) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion.
  180. fx 3. "The medications will kill the bacteria and stop the acid production."
    Rationale:
    Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.
  181. fy seizures are divided into two broad categories: generalized and partial (also called local or focal).
  182. fz D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."
  183. ga 1. Maintain a high fluid intake.
    Rationale:
    Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark brown or red. This does not indicate the need to notify the health care provider.
  184. gb 2. Rotate the insulin injection sites systematically.
    Rationale:
    Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.
  185. gc 3. Informing the client that this is normal
    Rationale:
    Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction; therefore options 1, 2, and 4 are incorrect
  186. gd It decreases the excitability of the neurons.

    Rationale: The ketogenic diet consists of a high-fat and low-carbohydrate diet. The diet produces ketone metabolism in the brain, which decreases the excitability of the neurons. Options 1, 2, and 3 are incorrect. The ketogenic diet does have an effect on the prevention of seizures. It does not reduce stress or alter the potassium level.

  187. ge Beta-Blockers = particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction (heart attack), and hypertension
  188. gf 1.67 - 2.5
  189. gg (1) correct—describes esophageal speech

    (2) describes electric larynx

    (3) method of speech for patient with a tracheostomy

    (4) describes tracheoesophageal fistula (TEF)

    ...

  190. gh C
    Rationale: The most reassuring communication to the patient is that the physical and emotional changes caused by the Cushing syndrome will resolve after hormone levels return to normal postoperatively. The response beginning "Let me show you how to dress" indicates that the changes are permanent and that the patient's appearance needs disguising. The response beginning, "I do not think you look bad" does not acknowledge the patient's feelings and also fails to communicate that the changes will be resolved after surgery. And the response beginning "You really should not worry about how you look in the hospital" implies that the patient's appearance is not good.

    Cognitive Level: Application Text Reference: p. 1314
    Nursing Process: Implementation NCLEX: Psychosocial Integrity

  191. gi c. ABG

    The term "hypoxemia" means low blood oxygen level. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured.

  192. gj C. Delirium, Depression, Dementia
  193. gk Uncontrolled contraction/spasm of bladder results in leakage before reaching bathroom
  194. gl Difficulty remaining asleep
  195. gm 20 - 45 seconds
  196. gn double vision
  197. go Widespread in foods
  198. gp (B) "The exam may hurt a little as you apply pressure to the testes."
    Rationale: Testicular self examinations should be performed once a month. The best place to perform the exam is in the shower, while scrotal sac is warm and relaxed. Using the thumb and first two fingers, the testicles should be palpated. The testicle is movable and egg shaped. Any lump, hard area, or enlargement of a testicle, whether painful or painless, should be reported to a physician. The examination should be painless. If pain is experienced, too much pressure is being applied.
  199. gq P- Plan and isolation of RN
    LPN's collaborate with RN's , The current LPN standard is not to push IV meds.
    A- Asses initially LPN's will participate in ongoing assessments but the RN is responsible for the initial assessment Analyze LPN's do not make nursing diagnosis or analyze nursing care
    R- Review and evaluate and isolate the RN
    The LPN is responsible for collaborating with the RN during the evaluation process
    T- Teach initially while LPN's maybe involved in the teaching process the RN is responsible for the initial teaching the LPN may reinforce teaching
  200. gr D
    Rationale: The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

    Cognitive Level: Analysis Text Reference: pp. 330-331
    Nursing Process: Assessment NCLEX: Physiological Integrity

  201. gs 1. Aspirate the tube
    Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful.
  202. gt D
    Rationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

    Cognitive Level: Application Text Reference: p. 706
    Nursing Process: Planning NCLEX: Physiological Integrity

  203. gu 2. Spinach
    Rationale:
    Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables, fish, liver, coffee, and tea.
  204. gv D. Rinse the mouth with water following the second puff of medication. The patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.
  205. gw Brain
    Peripheral nerves
    WBCs
    RBCs
    Healing wounds
  206. gx (1) correct—assessment; daily weight necessary with peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by physician

    (2) implementation; strict aseptic technique required to prevent contamination, sterile = aseptic, clean = antiseptic

    (3) implementation; don't milk catheter, drainage by gravity only

    (4) implementation; encouraged to eat a high-protein diet because of protein loss with CAPD

    ...

  207. gy oral corticosteroid
    immunosupressant used to treat inflammatory diseases; reduce signs of inflammation, improve function
  208. gz 4. Complaints of a metallic taste in the mouth
    Rationale:
    Ridaura is the one gold preparation that is given orally rather than by injection. Gastrointestinal reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy, but these usually subside in the first 3 months of therapy. Early symptoms of toxicity include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth.
  209. ha D. Work of breathingWhen the patient does not have sufficient gas exchange to engage in activity, the etiologic factor is often the work of breathing. When patients with asthma do not have effective respirations, they use all available energy to breathe and have little left over for purposeful activity.
  210. hb topical or parenteral corticosteroid; generally safer bc given locally.
  211. hc B
    Rationale: The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy are also side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis.

    Cognitive Level: Analysis Text Reference: pp. 332-333
    Nursing Process: Assessment NCLEX: Physiological Integrity

  212. hd 4. Low blood glucose level
    Rationale:
    β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Option 4 is the most reliable indicator of hypoglycemia.
  213. he a form of rhonchus characterized by continuous high-pitched squeaking sound caused by rapid vibration of bronchial walls.
  214. hf Strategy: Identify the least stable client.

    (1) no indication of hemorrhage, will require a tetanus shot

    (2) correct—disoriented, requires immediate assessment to determine underlying cause

    (3) splint; cover wound with sterile dressing; check temperature, color, sensation; give narcotic

    (4) hyperglycemic, give IV fluid, regular insulin

    ...

  215. hg 1. Two-point

    The two-point gait requires at least partial weight bearing on each foot. The client moves a crutch at the same time as the opposing leg, so that the crutch movements are similar to arm motion during normal walking. In a three-point gait, weight is borne on both crutches and then on the uninvolved leg. The four-point gait gives stability to the client but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. This client is only supposed to use partial weight bearing, so this gait would not be appropriate. Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. It would not be appropriate for this client.

  216. hh Polyneuritis: peripheral nerve disease; autoimmune inflammatory response to prior infection.
    Acute immune-mediated polyneuropathy d/t damage to myelin sheath of Peripheral Nerves.
  217. hi Age slows down the reflex. Contact lenses can affect the corneal reflex as well.
  218. hj 1. Potassium level
    Rationale:
    Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 2 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.
  219. hk greater than normal amounts of carbon dioxide in the blood (PaCO2 > 45 mm Hg); also called hypercarbia.
  220. hl example of acetic acid
    NSAID COX1
  221. hm The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted = hip dyslpasia
  222. hn B. patient's not being able to speak normally again. Patients who have a total laryngectomy have a permanent tracheostomy and will need to learn how to speak using alternative methods, such as an artificial larynx. The tracheostomy will be permanent to allow normal breathing patterns and air exchange. After surgery, the patient's nutrition is supplemented with enteral feedings, and when the patient can swallow secretions, oral feedings can begin. Deep-breathing exercises should be performed with the patient at least every 2 hours to prevent further pulmonary complications.
  223. ho B
  224. hp 3. Put up the side rails on the bed
    Rationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure himself or herself. The most frequent side effects of this medication are dizziness, drowsiness and lethargy. Therefore the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2 and 4 may be helpful measures that provide a comfortable, restful environment; however, option 3 is the only one that provides for the client's safety needs.
  225. hq C
    Rationale: The wound requires debridement of the necrotic areas; absorption of the yellow-green slough and a hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

    Cognitive Level: Application Text Reference: pp. 200, 204, 205
    Nursing Process: Implementation NCLEX: Physiological Integrity

  226. hr H1 histamine blocker
    "benadryl"
  227. hs 3. Remove the client from the room
    Rationale: In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The next steps are: activate the alarm, contain the fire, and then extinguish as needed. This is a universal standard that may be applied to any type of fire emergency. Option 3 is correct because it removes the victim from the area. Option 1 would be the next step (alarm). The fire is next contained (option 2) and then extinguished (option 4).
  228. ht in darkened room w/ other eye covered, move bright light towards the midline of the face and into the open eye: pupil should shrink immediately; establishes intact reflex
  229. hu A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF.
  230. hv 3. Serum amylase
    Rationale:
    Didanosine (Videx) can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.
  231. hw b. observe the client carefully for changes in behavior or vital signs

    The nurse should observe the confused client for nonverbal cues to pain.

  232. hx D
    Rationale: Patients with diabetes insipidus compensate for fluid losses by drinking copious amounts of fluids, but a patient who is lethargic will be unable to drink enough fluids and will become hypovolemic. A high urine output, low urine specific gravity, and history of a recent head injury are consistent with diabetes insipidus, but they do not require immediate nursing action to avoid life-threatening complications.

    Cognitive Level: Analysis Text Reference: p. 1297
    Nursing Process: Assessment NCLEX: Physiological Integrity

  233. hy 1) Burns
  234. hz (1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation

    (2) describes normal mild withdrawal symptoms

    (3) would contraindicate giving more sedation

    (4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the body

  235. ia When the patient has a possible brain tumor.
  236. ib 3. Low back pain and dysuria
    Rationale:
    Acetazolamide is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and are manifested by dark urine and stools, jaundice, pain in the lower back, dysuria, crystalluria, renal colic, and calculi. Bone marrow depression also may occur. The remaining options are not adverse effects of the medication.
  237. ic 4. The result of another infection caused by leukopenic effects of the medication.
    Rationale:
    Frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. Options 1, 2, and 3 are inaccurate interpretations.
  238. id drug can cross placenta and enter breastmilk; old must watch out for infection and monitor blood glucose (can raise glucose levels)
  239. ie C
    Rationale: An undifferentiated cell has an appearance more like a stem cell or fetal cell and less like the normal cells of the organ or tissue. The DNA in cancer cells is always different from normal cells, whether the cancer cells are well differentiated or not. All tumor cells are mutations form the normal cells of the tissue.

    Cognitive Level: Application Text Reference: p. 274
    Nursing Process: Implementation NCLEX: Physiological Integrity

  240. if CATEGORY: NSAID, 2nd gen COX-2 inhibitor
    ACTION: inhibits cox-2 only
    USE: arthritis, pain, dysmenorrhea, polyposis
    ADVERSE EFFECTS: dyspepsia, abdominal pain, renal toxicity, sulfonamide allergy
  241. ig GABA

    Objective: Recognize the causes of epilepsy.
    Rationale: GABA drugs mimic GABA by stimulating the influx of chloride ions into the neuron, leading to the suppression of neuron firing.
    Cognitive Level: Comprehension
    Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
    Nursing Process: Assessment

  242. ih .(1) correct—being free from any drain bags during the day would appeal to a 13-year-old

    (2) is negative

    (3) would be embarrassing to a 13-year-old

    (4) it would be impossible for a teen with muscular weakness to put on an external catheter

    ..

  243. ii Slow dose drug form of stimulants will ↑ the NE and DA tone in prefrontal cortex and nucleus accumbens and change the communication flow.
  244. ij Coombs Test
  245. ik 1. Place the client in a high-Fowler's position
    Rationale: A miller-Abbott tube is a nasoenteric tube used to correct a bowel obstruction and decompress the intestine. A high-Fowler position decreases the risk of aspiration if vomiting occurs. A physician inserts the tube with the balloon deflated in a manner similar to that used with a nasogastric tube. The client usually sips water to facilitate passage of the tube through the correct nasopharynx and esophagus. Options 2, 3 and 4 are incorrect actions.
  246. il Muscle stiffness, rigidity
  247. im 3. Joint inflammation
    Rationale:
    Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Colchicine has no effect on the client's blood glucose or blood pressure; it is not used to treat a headache.
  248. in B. "I don't think she will react very well to me making decisions for her."
  249. io 73/55
  250. ip 3.5 - 5.0
  251. iq 4. One hour before meals and at bedtime
    Rationale:
    Sucralfate is a gastric protectant. The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation. The other options are incorrect.
  252. ir (1) correct—stable patient with expected outcome

    (2) requires the assessment skills of the RN

    (3) requires assessment and teaching

    (4) requires assessment skills of RN

    ...

  253. is abnormal slowness of voluntary movements and speech
  254. it 3. Drowsiness
    Rationale:
    A frequent side effect of cetirizine hydrochloride (Zyrtec), an antihistamine, is drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating.
  255. iu 3. Confusion
    Rationale:
    Cimetidine is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.
  256. iv 2. Uric acid level
    Rationale:
    Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute renal failure. Options 1, 3, and 4 are not specifically related to this medication.
  257. iw A. A decreased exhaled nitric oxide. Nitric oxide levels are increased in the breath of people with asthma. A decrease in the exhaled nitric oxide concentration suggests that the treatment may be decreasing the lung inflammation associated with asthma.
  258. ix 2. Decreased renal function slows excretion of drugs
  259. iy B- Approaches the client from the unaffected side.
    Rationale: The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client form the affected side to increase awareness further.
  260. iz RATIONALE: 1) IM injections should be give in the deltoid muscle in clients with spinal cord injuries. These clients exhibit reduced use of - and consequently reduced blood flow to - muscles in the buttocks (dorsal gluteal and ventral gluteal) and legs (vastus lateralis). Decreased blood flow results in decreased drug absorption.
  261. ja Monitor height and weight weekly to be sure GI side effects are not hindering nutrition and normal growth.

    Rationale: GI effects such as nausea, anorexia, and abdominal pain are common with ethosuximide. Because the client is still growing, improper nutrition may affect normal growth. Monitoring height and weight weekly will assist in tracking normal growth. Options 1, 2, and 4 are incorrect. Physical activity will not affect the drug's metabolism, and activity is normal and needed for healthy growth and development. Ethosuximide is not known to cause bone loss or dehydration.

  262. jb a lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization.
  263. jc 2. Take the daily dose at bedtime.
    Rationale:
    The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. In addition, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the physician before changing brands of the medication. The client also checks with the HCP before taking OTC cough, cold, or other respiratory preparations because they could cause interactive effects, increasing the side effects of theophylline and causing dysrhythmias.
  264. jd 4. Leave the cream on for 8 to 12 hours and then remove by washing.
    Rationale:
    Lindane is applied in a thin layer to the entire body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. Usually, only one application is required.
  265. je 1. Using restraints to immobilize the limbs
    Rationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose a risk to the client's safety. Removing potentially harmful objects is a good basic safety measure. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity.
  266. jf (C) Avert the attention of the male client and lead him to his room
    Rationale: The most appropriate response to this behavior would be to avoid confronting and/or threatening the client while removing the inappropriate behavior. Distraction is a good approach to ease removal of the client, making answer (C) correct. Averting the client's attention and escorting him to his room is neither confrontational nor threatening. Pulling the client aside and/or reprimanding him, as in answers (A) and (D), are both confrontational and threatening to a client. This could cause agitation. Having the other clients ignore the behavior will not remove the potentially hazardous situation.
  267. jg > 4' 9" in height
  268. jh C
    Rationale: To decrease the risk for renal calculi, the patient should have an intake of 3000 to 4000 ml daily. Ambulation helps to decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of breath sounds, although these would be assessed every shift.

    Cognitive Level: Application Text Reference: p. 330
    Nursing Process: Planning NCLEX: Physiological Integrity

  269. ji (1) correct—to avoid dislodging drain, remove the dressing layers one at a time

    (2) do not clean a wound with both Betadine solution and hydrogen peroxide

    (3) cleansing of the wound is from the center outward to the edges and from the top to the bottom

    (4) incorrect; may dislodge drain

    ...

  270. jj (1) restraining a client to prevent injury to self or others is appropriate

    (2) appropriate behavior

    (3) restraining a client to prevent injury to self or others is appropriate

    (4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychotic

  271. jk B
    Rationale: The earliest sign of infection in a neutropenic patient is an elevation in temperature. Fruits and vegetables that are peeled are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). Redness and drainage may not occur even with severe wound infections because these symptoms of infections are dependent on neutrophils.

    Cognitive Level: Application Text Reference: pp. 714-716
    Nursing Process: Assessment NCLEX: Physiological Integrity

  272. jl 1) Patient's self-report
  273. jm 3. Acetaminophen (Tylenol)
    Rationale:
    Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory drugs (ibuprofen). The client should be advised to take acetaminophen for headache.
    *Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate options 1 and 2 first.*
  274. jn (C) Toes
    Rationale: Prone position involves the client lying with the anterior surface of the body compressed against the bed or lying area. The occiput, elbow and coccyx (also called the tailbone) are all pressure points that would be compromised if the client were to lay with the posterior surface against the bed or lying area. The toes would be compressed against the lying area with the client in the prone position. Therefore, the correct answer is (C).
  275. jo A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
  276. jp 4. Cool, numb fingers and toes
    Rationale:
    Ergotamine produces vasoconstriction, which suppresses vascular headaches when given at a therapeutic dose range. The nurse monitors for hypertension; cool, numb fingers and toes; muscle pain; and nausea and vomiting.
    *first recall that vascular headaches are caused by vasodilatation of the blood vessels in the head. Following this train of thought, you then recall that this medication must cause vasoconstriction. The only side effect consistent with vasoconstriction is option 4, the cool, numb fingers and toes.*
  277. jq arthritis
  278. jr D. Lubricate the tip of the enema tubing generously.
    C. Insert the tubing about 3 to 4 inches into the rectum.
    E. Raise the container to the correct height and instill the solution at a slow rate.
    B. Assess the patient for cramping.
    F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.
    A. Document the results of the procedure.

    You must lubricate the tip before inserting the tubing. You would then begin instilling the solution before assessing for cramping that the instillation might produce. Only after the solution is instilled would you ask the patient to hold the solution. The last action is to document the results of the procedure, after the procedure is finished.

  279. js Myelosuppression

    Rationale: Myelosuppression is the most common dose-limiting adverse effect of chemotherapy, and the one that most often causes discontinuation or delays of chemotherapy. Options 2, 3, and 4 are incorrect. Although alopecia may be distressing for the client, its presence does not determine when the next round of chemotherapy can be administered. Mucositis is not a reason that subsequent rounds of chemotherapy should be delayed. Cachexia is the physical wasting with loss of weight and muscle mass caused by disease. Although it is considered, it is not the most common reason for delaying chemotherapy.

  280. jt Strategy: Determine if the answer choice relates to Valium.

    (1) more indicative of preoperative complications, should be reported before medications are given

    (2) more indicative of preoperative complications, should be reported before medications are given

    (3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight)

    (4) hostility may be treated best by ventilating feelings

    ...

  281. ju D
    Rationale: An alert elderly patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age, and is not an accurate indicator of volume depletion. Many prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in LOC occur.

    Cognitive Level: Application Text Reference: p. 321
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  282. jv (A) Constipation
    Rationale: Aluminum hydroxide (Amphogel) is used for the treatment of ulcers by neutralizing gastric acid. A frequent side effect of this medication is constipation, answer (A). It is uncommon for clients to experience diarrhea, dizziness, or pruritis (itching) from the use of Amphogel.
  283. jw B) stress can impede healing.
    C) anxiety can cause powerlessness, which can lead to hopelessness.
    D) anxiety can intensify pain.
    E) critical care is a very stressful environment for the patients, family, and staff.
  284. jx B. Repeatedly states, "Don't hurt me."
    C. Chafing around wrists and ankles
    D. Bruises in various stages of healing
  285. jy 4. Standing on the right side of the client
    Rationale: When working with a client, the nurse should stand on the client's affected side. The nurse should position the free hand on the client's shoulder so that the client can be pulled toward the nurse in the event that the client falls forward. The client should be instructed to look up and outward rather than at his or her feet. Options 1, 2 and 3 are incorrect.
  286. jz b. False

    Absorption refers to the "movement" of the drug from the site of administration into the blood stream. Therefore, the intravenous, parenteral route leads to "instant" absorption.

  287. ka 3. FHR of 140 beats per minute
    Rationale: The average FHR is 140 beats per minute. The normal range is 110 to 160 beats per minute; therefore option 3 is the only correct option.
  288. kb 2. Once daily, at the same time each day
    Rationale:
    Insulin glargine is a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, at the same time each day.
  289. kc 4. Rinse the incision with sterile water after using diluted hydrogen peroxide
    Rationale: The incision should be rinsed with sterile water when it is cleaned with a solution other than water or saline. The Logan bar is intended to maintain integrity of the suture line; removing the Logan bar on the first postoperative day is incorrect because removal would increase tension on the surgical incision. The incision is cleaned after every feeding and when serous exudate forms. The incision should be dabbed and not rubbed to maintain its integrity.
  290. kd (B) 0.25 mL
    Rationale: Solve for x mL using the following ration method.
    50mg/1mL = 12.5mg/xmL
    50x = 12.5
    x = 12.5/50
    x = 0.25mL
    Or use desired over available:
    12.5mg/50mg X 1mL = x mL
    12.5 divided by 50 = 0.25
    0.25 X 1 mL = 0.25 ML
  291. ke Must be administered four times per day.
    May cause serious hepatic damage.

    Rationale: it is difficult to remember to take a medication four times a day, and as the client's cognitive functioning declines, it may be increasingly difficult to administer it. Serious liver damage is a possibility with tacrine, which decreases its usefulness. Options 2, 3, and 5 are incorrect. Tacrine may cause weight loss, rather than gain, and does not cause vision difficulties. Tacrine is available by prescription only and cannot be purchased over the counter.

  292. kf D
    Rationale: Sexual contact with an infected partner is currently the most common mode of transmission, although HIV is also spread through perinatal transmission, through sharing drug injection equipment, and through transfusions with HIV-infected blood.

    Cognitive Level: Comprehension Text Reference: p. 250
    Nursing Process: Assessment
    NCLEX: Health Promotion and Maintenance

  293. kg 2. Decreased muscle spasms
    Rationale:
    Baclofen is a skeletal muscle relaxant and central nervous system depressant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases and in clients with multiple sclerosis. Options 1, 3, and 4 are incorrect.
  294. kh Right second intercostal space
  295. ki 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."
    Rationale:
    Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information.
  296. kj 9.5 - 12.0 seconds
  297. kk A) The patient responds appropriately to teaching, but then asks a question about the information just given.
    C) The patient stares into space while the nurse is talking and then asks, "What?"
    D) The patient has frequent bouts of crying and wants to be left alone.
  298. kl 4. Report the passage of the normal stool to the registered nurse (RN)
    Rationale: Passage of a formed brown bowel movement usually indicates that an intussusception has reduced itself. The nurse immediately reports this data to the RN, who will in turn report it to the physician. This finding may change the course of the plan of care. Increased abdominal pain is not expected because the child's gastrointestinal tract is more functional. The finding does not indicate the need for immediate surgery.
  299. km A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
  300. kn C
    Rationale: The patient's history and change in LOC could be indicative of several fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the health care provider to determine the cause of the change in LOC and the appropriate interventions. A weight gain of 2 pounds (<1 kg) since surgery would not be clinically significant unless associated with other symptoms. The oral temperature elevation and crackles would initially be addressed by having the patient cough and deep breathe. The sodium level is within the normal range of 135 to 145 mEq/L.

    Cognitive Level: Application Text Reference: pp. 322-325, 338
    Nursing Process: Assessment NCLEX: Physiological Integrity

  301. ko (D) Temperature of 101 degrees F
    Rationale: Septicemia is the invasion of pathogenic bacteria into the blood stream. Symptoms of septicemia include temperature elevation, backache, headache, elevated pulse, elevated respiratory rate, nausea, vomiting, diarrhea, chills and general malaise. The correct answer is (D), temperature 101 degrees F. Pain, redness or drainage from an injury site suggests local, rather than systemic, infection or inflammation.
  302. kp D- Remind the client to turn the head to scan the lost visual field
    Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with Homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision: The nurse encourages the use of personal eye glasses, if they are available.
  303. kq Corticosteroids

    Rationale: The long-term use of corticosteroids may contribute to the development of glaucoma. Options 2, 3, and 4 are incorrect. Beta blockers are used for the treatment of glaucoma; they do not cause it. Calcium channel blockers and insulin play no role in the development of glaucoma.

  304. kr B
    Rationale: The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with rising temperatures.

    Cognitive Level: Application Text Reference: pp. 196-197
    Nursing Process: Assessment NCLEX: Physiological Integrity

  305. ks Tonic Phase: Loss of consciousness; muscles contract 10-20 sec
    Clonic Phase: rhythmic contraction <2min
    Aura: warning sx
    Crisis Preventions:
    HAVE SUCTION, AIRWAY, O2 AT BEDSIDE!
    Protect pt: lower to floor, pad siderails, pillow under head, don't restrain, allow post-ictal rest.
    Prevent Aspiration: turn side, loosen neck clothing, suction.
    Ongoing: Monitor VS, LOC, O2 saturation, Glasgow coma scale, reassure & orient pt after seizure
  306. kt Inject medication in the deep fatty layer of the abdomen.
    When brushing your teeth, use a soft toothbrush.
    Hold direct pressure on any puncture sites for 15 minutes.

    Rationale: The client should be taught proper injection technique, including the need to inject the heparin into the deep subcutaneous fat layer. A soft toothbrush should be used for oral hygiene. Puncture wounds or cuts will require longer-than-normal pressure held at the site to stop bleeding—15 minutes or longer. Options 4 and 5 are incorrect. Dental flossing should be avoided while the client is receiving anticoagulants. The flossing can cause gum irritation and excessive bleeding. Aspirin has antiplatelet effects, and concurrent use may increase the risk of bleeding or hemorrhage.

  307. ku b. Shaking your hands dry over the sink

    Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area.

  308. kv C
    Rationale: Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. High vitamin K diets might be used for a patient with a bleeding disorder. There is no indication that the patient is neutropenic, so isolation is not needed. Increased intake of fluid and fiber will not improve the anemia.

    Cognitive Level: Application Text Reference: p. 688
    Nursing Process: Implementation NCLEX: Physiological Integrity

  309. kw 3. Bright red bleeding from a neck wound
    Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. According to the triage process, the client in this classification would be issued a red tag. The client with the penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia; this client requires intervention but can provide self care if needed. A designation of "expectant" and color code "black" would be applied to the client with massive injuries and a minimal chance of survival. These clients are given definitive treatment last.
  310. kx 4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.
    Rationale:
    Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.
  311. ky Which of the following respiratory patterns indicate increasing ICP in the brain stem?
  312. kz normal saline
  313. la A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior?
  314. lb 4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering
    Rationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of exposure to radiation when in the client's room. The client should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. A lead container and long handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should be pick up the implant with long handled forceps and place it in the lead container. The nurse does not reinsert it. Visiting time is limited to 30 minutes per visit.
  315. lc Gently put pressure on the inner canthus (tear duct) for 1 minute after instilling the timolol drop.

    Rationale: Timolol is a beta-adrenergic blocker. To prevent swallowing and systemic absorption, pressure should be applied to the inner canthus of the eye for 1 minute after instilling the drop. Options 1, 2, and 3 are incorrect. No other eyedrops or ointments should be used when taking timolol or other drops for glaucoma without the approval of the provider. Eye solutions for allergies may contain adrenergic drugs that may worsen glaucoma. Timolol is not contraindicated during seasonal allergies. It is not known to worsen seasonal allergies, although it may cause bronchoconstriction in the sensitive individual or if swallowed and systemic effects occur.

  316. ld petechiae or ecchymoses, large blood filled bullae in mouth
  317. le 3) Fruits and vegetables.

    The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

  318. lf Which of the following physiologic changes would be expected in a patient with presbyopia?
  319. lg removal of calculi (stone) from ureter
  320. lh C. "Tilt your chin forward toward the chest when swallowing your food." A nurse should instruct a patient to tilt the chin toward the chest, which will close the glottis and allow food to enter the normal passageway. Ideally, foods should be of a thick consistency to enable effective swallowing and reduce the risk of aspiration. Overinflation of the cuff causes swallowing difficulties. Fluids should be consumed in small amounts after swallowing to prevent the risk of aspiration.
  321. li F-Find Hypoxia
    O2 is an always immediate concern can be a result of cardiac or respiratory complications VS skin color or capillary refill are a few assessments a nurse would anticipate, also increased anxiety and confusion.
    I-Imunno Compromised
    receiving kimo, or has aids
    R-Real Bleeding
    Hemmer age from trauma or surgery changes in VS skin color temperature and urine output will result in alteration in organ or tissue confusion
    S-Safety
    at risk for injury from IICP or confusion form delirium or dementia
    T- Try Infection
    client who is septic with a high fever and has order for blood cultures and antibiotics, obtain blood cultures before starting antibiotics
  322. lj 2) Offer caffeinated beverages to constrict blood vessels in his head.
  323. lk 2. Preparation for a cesarean delivery
    Rationale: Cesarean delivery reduces the risk of neonatal infection with a mother in labor who has either herpetic genital lesions or ruptured membranes. Options 3 and 4 would expose the fetus to the virus. Standard Precautions are necessary, not protective isolation.
  324. ll (B) 390 mL
    Rationale: Oral fluid intake is being calculated. Oral fluid intake for this meal would include any consumed fluid or solid food that becomes liquid at room temperature. Pudding does not fit the category for oral intake.
    Oral Fluid Intake Calculation:
    6 oz of coffee, 3 oz of grape juice, 4 oz of milk multiplied by 30 mL/oz = (6=3=4) X30 = 390
  325. lm B
    Rationale: Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

    Cognitive Level: Comprehension Text Reference: pp. 667, 680
    Nursing Process: Assessment NCLEX: Physiological Integrity

  326. ln 3. White blood cell count
    Rationale:
    Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options 1, 2, and 4 are unrelated to this medication.
  327. lo Has no significant drug interactions.

    Rationale: rivastigmine has no significant drug interactions. This is thought to be true because there is no interaction with enzymes in the liver that metabolize drugs. Options 2, 3, and 4 are incorrect because they do not apply to rivastigmine

  328. lp 4. Orange juice
    Rationale:
    Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Milk may affect absorption of the iron. Water will not assist in absorption. Orange juice contains a greater amount of vitamin C than apple juice.
  329. lq shrinking of adrenal gland resulting in poor output of cortisol (life threatening); caused by not tapering off corticosteroids
  330. lr B
    Rationale: Spironolactone is a potassium-sparing diuretic. Patients should be taught to choose low-potassium foods such as apple juice rather than foods that have higher levels of potassium, such as citrus fruits. Cheese is high in sodium; the fat content of the cheese is not relevant. Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Patients are taught to avoid salt substitutes, which are high in potassium.

    Cognitive Level: Application Text Reference: pp. 326-327
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  331. ls A
    Rationale: Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

    Cognitive Level: Application Text Reference: p. 694
    Nursing Process: Diagnosis NCLEX: Physiological Integrity

  332. lt 2140

    Cognitive Level: Application Text Reference: pp. 202-204
    Nursing Process: Implementation NCLEX: Physiological Integrity

  333. lu NSAID, COX 1 drug class
    ex: indomethacin, nabumetone, ketorolac
    **unlike aspirin... inhibition of cyclooxygenase is reversible, does not protect against MI/stroke (Increase in thrombocytic events is concern)
  334. lv Increase protein and potassium
    Decrease sodium and calories
  335. lw pin-point hemorrhages
  336. lx 4th
  337. ly B
    Rationale: Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are the most serious of the symptoms of fluid excess listed. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.

    Cognitive Level: Application Text Reference: pp. 339-340
    Nursing Process: Assessment NCLEX: Physiological Integrity

  338. lz (1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision

    (2) fluids should be encouraged

    (3) will not prevent complications

    (4) does not address a common complication...

  339. ma "Avoid the use of alcohol while taking this drug."

    Rationale: Alcohol is a CNS depressant, so taking two CNS depressants concurrently may cause over-sedation, or even coma. Options 1, 2, and 3 are incorrect, and are not recommended to improve sleep; they may only worsen the sleep problems.

  340. mb pneumonia occurring 48 hours or longer after hospital admission and not incubating at the time of hospitalization.
  341. mc the inability to extend legs
  342. md 2. Confusion and irritability

    Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.

  343. me no
  344. mf B
    Rationale: Neutropenia places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that white blood cell (WBC) growth factors such as filgrastim (Neupogen) are needed. The other laboratory data do not indicate any immediate life-threatening adverse effects of the chemotherapy.

    Cognitive Level: Application Text Reference: p. 297
    Nursing Process: Assessment NCLEX: Physiological Integrity

  345. mg d. all of the above
  346. mh A. This test involves injection of a radioisotope to outline the blood vessels in the lungs, followed by inhalation of a radioisotope gas.A ventilation-perfusion scan has two parts. In the perfusion portion, a radioisotope is injected into the blood and the pulmonary vasculature is outlined. In the ventilation part, the patient inhales a radioactive gas that outlines the alveoli.
  347. mi 20-40
  348. mj The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
  349. mk 3. Instructing the client to call for ambulation assistance
    Rationale:
    Chloral hydrate (a sedative-hypnotic) causes sedation and impairment of motor coordination; therefore, safety measures need to be implemented. The client is instructed to call for assistance with ambulation. Options 1 and 2 are not specifically associated with the use of this medication. Although option 4 is an appropriate nursing intervention, it is most important to instruct the client to call for assistance with ambulation.
  350. ml 1. "His pulse and blood pressure are within his normal baseline limits, so I'm sure the pain medication is working."

    Except in cases of severe traumatic pain, which sends a person into shock, most people reach a level of adaptation in which physical signs return to normal. Thus clients in pain will not always have changes in their vital signs. Changes in vital signs are more often indicative of problems other than pain. Although the remaining options recognize the phenomena, they are not assuming that no elevation of vital signs means the absence of pain.

  351. mm (C) Until the degree of leukemia involvement is determined in the child, it is best to keep the child away from other children as much as possible. The white blood cells of a client with leukemia are ineffective. This causes decreased immunity. Infection from another child or person could be detrimental to a child with this condition. A semiprivate room is not recommended at this time. Unless the child is in critical condition, assignment to an intensive care bed is not necessary.
  352. mn (A) Checking the client's weight
    Rationale: Hemodialysis (HD) is indicated for clients with excess and electrolyte imbalances. Fluid loss or gain is assessed by checking the client's weight at least once a day as well as before and after HD sessions. The amount of weight loss or gain at these times is used to monitor effectiveness of or further need for HD. Measuring intake and output is important to ensure limited fluid intake for clients with renal failure, but this will not indicate HD effectiveness. Clients with renal failure often experience fatigue with exercise, but factors other than those associated with renal failure could cause fatigue. HD is used to regulate serum electrolyte levels (i.e., potassium), but these levels will not indicate overall effectiveness of HD.
  353. mo 4. At least 30 minutes before exposure to the sun
    Rationale:
    Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.
  354. mp visual field cut; defective vision or blindness 1/2 visual field
  355. mq 2. "I need to discontinue the medication after 14 days of use."
    Rationale:
    Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the HCP. The client should also call the HCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.
  356. mr 5th intercostal space, left side, sternal border
  357. ms 3. Treat hypocalcemic tetany.
    Rationale:
    Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes or muscle spasms or twitching, the health care provider is notified immediately. Calcium gluconate should be kept at the bedside.
  358. mt D. 50 mm Hg and bicarbonate level of 30 mEq/L. If compensation is present, carbon dioxide and bicarbonate are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and the other alkalotic).
  359. mu Abnormal flexion:
    Hands pulled to chest and hyper-extended.
    Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers.

    "flexor - toward the cord"

  360. mv difficulty writing
  361. mw B. Walk for 20 minutes a day, keeping the pulse rate less than 130 beats per minute. The patient will benefit from mild aerobic exercise that does not stress the cardiorespiratory system. The patient should be encouraged to walk for 20 min/day, keeping the pulse rate less than 75% to 80% of maximum heart rate (220 minus patient's age).
  362. mx D. Preconceived assumptions regarding the lifestyles and attitudes of this group
  363. my 3. Early morning
    Rationale:
    Corticosteroids (glucocorticoids) should be administered before 9:00 AM. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning.
    *Note the suffix "-sone," and recall that medication names that end with these letters are corticosteroids.*
  364. mz allergies to Iodine - contrast media (dye)
  365. na B
    Rationale: Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. Treatment of CML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

    Cognitive Level: Application Text Reference: pp. 721-722
    Nursing Process: Implementation NCLEX: Psychosocial Integrity

  366. nb face pt and speak slowly w/ a slightly lower voice
  367. nc 2. Submerging the NG tube in water to check for bubbling
    Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.
  368. nd 4. Complete blood cell count
    Rationale:
    The nurse would monitor the client's complete blood cell counts because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other values that warrant monitoring include serum calcium levels and the results of urinalysis, hepatic, and thyroid function tests.
  369. ne a condition of oxygen overdosage caused by prolonged exposure to a high levels of oxygen; may inactivate pulmonary surfactant and lead to development of acute respiratory distress syndrome.
  370. nf MI
  371. ng A
    Rationale: The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient's BP. The other actions are also needed but are not the highest priority.

    Cognitive Level: Application Text Reference: pp. 732-733
    Nursing Process: Implementation NCLEX: Physiological Integrity

  372. nh Panic disorder

    Rationale: Panic disorder is not an appropriate use for phenobarbital. Options 1, 3, and 4 are incorrect. Treatment of status epilepticus, use prior to diagnostic testing, and use prior to receiving general anesthesia are all appropriate for phenobarbital.

  373. ni C
    Rationale: After adrenalectomy, the patient is at risk for circulatory instability caused by fluctuating hormone levels, and the focus of care is to assess and maintain fluid and electrolyte status through the use of IV fluids and corticosteroids. The other goals are also important for the patient but are not as immediately life-threatening as circulatory collapse.

    Cognitive Level: Application Text Reference: p. 1315
    Nursing Process: Planning NCLEX: Physiological Integrity

  374. nj No more than 10%
  375. nk 1. Pancreatitis
    Rationale:
    Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.
  376. nl 4. Getting baseline postural blood pressures before administering the medication and each time the medication is administered
    Rationale:
    Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.
  377. nm Adolescents (12-18)

    P- peer group- select activities involving their peers. Individualize if on isolation or on bedrest
    A- altered body image dont want to be seen as different. PEER PRESSURE. Health promotion. Ex drugs and STDs
    I- identity/image struggle with their identity and make choices regarding college or career
    R- role diffusion who are they and what r their goals. Educate families to help with struggles
    S- separation from peers encourage peers to visit while in the hospital

  378. nn b. Determine if the teaching should take place at a different time

    Clients who are stressed may be unable to listen fully and will not receive/understand the intended message.

  379. no jaw thrust
  380. np a measure of the ease of expansion of the lungs and thorax.
  381. nq Avoid aldohol
    bland foods
    small, frequent meals
    decrease fat
  382. nr methylphenidate hydrochloride
  383. ns Goodell's
  384. nt 1. An enlarged prostate gland
    2. Poorly controlled blood glucose
    3. Drinking a cup of tea before bed
    5. Taking his diuretic too close to bedtime
  385. nu 2. Avoid the use of alcohol.
    Rationale:
    Baclofen is a central nervous system (CNS) depressant. The client should be cautioned against the use of alcohol and other CNS depressants, because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is an adverse effect of baclofen. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary that the client notify the health care provider if fatigue occurs.
  386. nv 4. Contact the health care provider (HCP) if a sore throat occurs.
    Rationale:
    Mycophenolate mofetil should be administered on an empty stomach. The capsules should not be opened or crushed. The client should contact the HCP if unusual bleeding or bruising, sore throat, mouth sores, abdominal pain, or fever occurs because these are adverse effects of the medication. Antacids containing magnesium and aluminum may decrease the absorption of the medication and therefore should not be taken with the medication. The medication may be given in combination with corticosteroids and cyclosporine.
    *neutropenia can occur with this medication*
  387. nw an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs caused most commonly by heart failure; an acute, life-threatening situation in which the lung alveoli become filled with serous or serosanguineous fluid caused most commonly by heart failure.
  388. nx D
    Rationale: The serum calcium is well above the normal level (4.5-5.5 mEq/L) and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they do not indicate the need for immediate intervention.

    Cognitive Level: Analysis Text Reference: p. 330
    Nursing Process: Assessment NCLEX: Physiological Integrity

  389. ny Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.
  390. nz D
    Rationale: It is important that antiretrovirals be taken at the prescribed time every day to avoid developing drug-resistant HIV. The other medications should also be given as close as possible to the correct time, but they are not as essential to receive at the same time every day.

    Cognitive Level: Application Text Reference: pp. 258, 264-265
    Nursing Process: Implementation NCLEX: Physiological Integrity

  391. oa anticholinergic that inhibits gastric secretions and decr GI motility
  392. ob decrease oxygen demand
    decrease conductivity
    decrease HR and PVR
    block calcium access to the cells
    decrease force of myocardial contractility
  393. oc hyperthyroidism, hypertension
  394. od B
    Rationale: The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.

    Cognitive Level: Application Text Reference: pp. 1316, 1319
    Nursing Process: Diagnosis NCLEX: Physiological Integrity

  395. oe A
    Rationale: Chronic corticosteroid use will interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. An admission temperature of 102° F requires assessment of the cause and treatment, but is not necessarily a concern for wound healing.

    Cognitive Level: Application Text Reference: pp. 201-202
    Nursing Process: Assessment NCLEX: Health Promotion and Maintenance

  396. of B
    Rationale: Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy.

    Cognitive Level: Application Text Reference: p. 670
    Nursing Process: Implementation NCLEX: Physiological Integrity

  397. og 1) Increased exercise.
  398. oh 3) NREM, delta waves
  399. oi Ischemia of brain tissue: Hemorrhage, thrombus, embolus.
    Medical Emergency
  400. oj D
    Rationale: A serum sodium of less than 120 mEq/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.

    Cognitive Level: Application Text Reference: p. 1295
    Nursing Process: Assessment NCLEX: Physiological Integrity

  401. ok 4. Position the infant prone with the head of the bed elevated
    Rationale: Before surgery the infant's status is nothing by mouth (NPO), and the infant is stabilized with intravenous fluids and electrolytes. The head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Options 2 and 3 are not accurate during the preoperative period because the infant is kept NPO. An infant is not restrained in a high chair.
  402. ol (C) 134/97
    Rationale: Normal blood pressure readings range between 100 to 140 systolic and 60 to 90 diastolic. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (2003) recommends that if either a systolic reading between 140 and 149 or a diastolic reading of 90 to 99 is obtained, the client's blood pressure should e rechecked in 2 months following the initial reading. The correct answer is (C). In this answer the diastolic reading is above the normal range. All other answers are within normal blood pressure range.
  403. om Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

    (1) diet should be high residue to prevent constipation due to inactivity

    (2) may be positioned on affected side after incision heals

    (3) foot flexion exercises should be done every hour to prevent complications

    (4) correct—prevents respiratory complications due to immobility following surgery

  404. on 1) Apply an indwelling fecal drainage device.

    An indwelling fecal drainage device is contraindicated for children; for more than 30 consecutive days of use; and for patients who have severe hemorrhoids, recent bowel, rectal, or anal surgery or injury; rectal or anal tumors; or stricture or stenosis. External devices are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. Even with absorbent products or an external collection device, the nurse should place a waterproof pad under the patient to protect the bed linens.

  405. oo (A) Assess airway patency
    (D) Check heart rate and blood pressure
    (B) Assess for injury
    (C) Move the client into bed
    (E) Call the client's physician
    Rationale: Assessing airway patency is the primary concern upon initiating emergency actions. If the airway is obstructed, CPR steps would be continued (i.e. Heimlich maneuver, rescue breathing, chest compressions, etc.). If the airway is patent, cardiopulmonary stability status is stable, the client can be assessed for any injuries caused by the fall. Moving the client to bed is not a top priority above assessing cardiopulmonary status. If the client could be further injured during the transfer process, this should be avoided until the safest transfer method is available. The physician should be notified once assessment and necessary interventions have been initiated.
  406. op 2. Peripheral neuritis
    Rationale:
    A common side effect of the TB drug INH is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized by pyridoxine (vitamin B6) intake. Options 1, 3, and 4 are incorrect.
  407. oq (1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area

    (2) sterile packs should be opened only as needed

    (3) never reach an unsterile arm over a sterile field

    (4) outside of a bottle containing sterile liquid is not considered to be sterile

    ...

  408. or Strategy: Remember the positioning strategy.

    (1) head of bed not elevated enough

    (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract

    (3) not the best position

    (4) not the best position

  409. os 4. When the last alcoholic drink was consumed
    Rationale:
    Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.
  410. ot 3) Blood pressure increases; heart rate and respiratory rate decline.
    4) Men have higher blood pressure than women until after menopause.
  411. ou (A) 0.45% sodium chloride with added potassium
    Rationale: The client in this case needs a hypotonic solution to help the dehydrated cells pull in and regain fluid. 0.45% sodium chloride or 1/2 normal saline is an example of a hypotonic solution. Potassium is lost along with the body fluids expelled through diarrhea and vomiting. Adding this to the fluid solution will replenish the body with this essential electrolyte. 0,9% sodium chloride or normal saline is an isotonic solution. The constituents in isotonic solutions are similar to the fluid in the blood. Using this type of solution would not change the dehydrated state since it will not add or remove fluid from the body cells. 3% sodium solution would lead to further dehydration by pulling fluid from the cells.
  412. ov C- Cant irrigate a Foley
    the CNA's should not conduct this intervention
    C- Cant make clinical decisions
    CNA's but can make observations
    A- Anticipate Clinical Changes
    N- No Invasive Procedures
    CNA's should not be accountable for any invasive procedures or specialized procedures
    T- Teach
    CNA's are not responsible for teaching
  413. ow Strategy: Think about each answer choice.

    (1) inaccurate; low-grade fever is expected within 24 to 48 hours

    (2) inaccurate; low-grade fever is expected within 24 to 48 hours

    (3) correct—low-grade fever and irritability frequent response to immunization

    (4) symptoms should be reported to physician, antipyretic usually prescribed

  414. ox 3. "I will apply the ointment once a day and cover it with a sterile dressing."
    Rationale:
    Collagenase is used to promote debridement of dermal lesions and severe burns. It is usually applied once daily and covered with a sterile dressing.
  415. oy an infectious disease caused by Mycobacterium tuberculosis; usually involves the lungs but also occurs in the larynx, kidneys, bones, adrenal glands, lymph nodes, and meninges and can be disseminated throughout the body.
  416. oz Status Epilepticus
  417. pa D- Consistently uses adaptive equipment in dressing self
    Rationale: Client's are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
  418. pb Chadwicks
  419. pc 3. Incoordination
    Rationale:
    Diazepam is a centrally acting skeletal muscle relaxant. Incoordination and drowsiness are common side effects resulting from this medication. The other options are incorrect.
  420. pd 4. Authorization by the family to discontinue the treatment
    Rationale: The family or a legal guardian can make treatment decisions, generally in collaboration with physicians, other health care workers, and other trusted advisors. The nurse first checks for family authorization to discontinue the treatment. Next, option 3 would be appropriate. Although options 1 and 2 may be necessary in some events, these options are not the first actions in this event.
  421. pe C. Functional abilities.
  422. pf Dimple
    D- death bogeyman. Be honest with them about death and funerals. Encourage ventilation of thoughts and feelings
    I- industry vs inferiority/immunizations "chum" may enjoy collecting things and playing sports
    M- modesty more concerned with modesty and privacy. Pull curtains and close doors.
    P- peers begin to mix with opposite sex
    L- loss of control hospitalization is seen as loss of control. Let them help with decision making
    E- explain procedures use terms they can understand
  423. pg 2. Decreased gas exchange
    3. Decreased cough efficiency
  424. ph 4. Tranylcypromine (Parnate)
    Rationale:
    The client should not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors (MAOIs) such as tranylcypromine (Parnate) or phenelzine (Nardil) within the past 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, or death.
  425. pi 3. "I use the time to really look at my clients and determine what's normal and what's not."

    Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. It also provides an opportunity to assess other systems (e.g., circulatory, respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities, the ancillary staff should be instructed to report any suspicious factors they note. Answer 3 is the most thorough statement regarding the question.

  426. pj (A) Easy bruising
    (B) Buffalo hump
    (C) Hyperglycemia
    (F) Trunk obesity
    Rationale: Clinical manifestations associated with Cushing's syndrome include: easy bruising, moon face, buffalo hump, hyperglycemia, hypokalemia, sodium retention, thinning of scalp hair, increased body and facial hair, acne, muscle wasting, poor wound healing, and mood changes. Excessive scalp hair growth and hyponatremia are not associated with Cushing's syndrome.
  427. pk 10 - gag reflex, swallowing, talking
  428. pl (1) expected at 3 months

    (2) correct—unexpected until 6 months of age

    (3) expected at 3 months of age

    (4) expected at 3 months of age

  429. pm 4. Administration of intravenous (IV) fluids
    Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse prepares to infuse IV fluids as ordered and to continue monitoring urine output. Checking respirations and temperature and frequent range of motion to extremities will not maintain viability of the kidneys.
  430. pn Apply with a gloved hand only to the site of pain.

    Rationale: Capsaicin should be applied to the site of pain with a gloved hand to avoid introducing the capsaicin to the eyes or other parts of the body not under treatment. Options 1, 3, and 4 are incorrect. Capsaicin should only be applied to the site of pain, not proximal or distal to the pain. If capsaicin begins to irritate and cause redness, it should be discontinued. Capsaicin should not be applied with a bare hand.

  431. po Unilateral weakness of facial muscles
    Pain around ear
    Unilateral inability to close eye
    Drooping of mouth
    Inability to smile, frown, whistle
    paralysis that distorts smiling, eye closure, salivation, and tear formation on the affected side.
    Distinguishing it from the facial paralysis associated with some strokes, which affect the muscles of the mouth more than those of the eye or forehead.
    Complication: Corneal abrasion or ulceration
    Residual facial weakness
  432. pp shortness of breath; difficulty breathing that may be caused by certain heart conditions, strenuous exercise, or anxiety.
  433. pq MAO inhibitors
    Drugs that use/block CYP 2D6
  434. pr 1) Washing hands
  435. ps ...
  436. pt (1) has an acute trauma, is not immunocompromised

    (2) has a bacterial infection, is not immunocompromised

    (3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus

    (4) has chronic disease, is not immunocompromised

    ...

  437. pu B
    Rationale: Changes in secondary sex characteristics are associated with decreases in FSH and LH. Fasting hypoglycemia and hypotension occur in panhypopituitarism as a result of decreases in ACTH and cortisol. Bradycardia is likely due to the decrease in TSH and thyroid hormones associated with panhypopituitarism.

    Cognitive Level: Application Text Reference: p. 1294
    Nursing Process: Assessment NCLEX: Physiological Integrity

  438. pv 1. Tinnitus
    Rationale:
    Mild intoxication with acetylsalicylic acid (aspirin) is called salicylism and is commonly experienced when the daily dosage is higher than 4 g. Tinnitus (ringing in the ears) is the most frequently occurring effect noted with intoxication. Hyperventilation may occur because salicylate stimulates the respiratory center. Fever may result because salicylate interferes with the metabolic pathways involved with oxygen consumption and heat production. Options 2, 3, and 4 are incorrect.
  439. pw 2. A client on a 24-hour urine collection who is on strict bed rest.
    Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a below-the-knee amputation, is scheduled for an invasive procedure, or is scheduled to be transferred to the hospital for coronary artery bypass surgery has both physiological and psychological needs. The nursing assistant has been trained to care for a client on bed rest and urine collections. The nurse provides instructions, but the tasks required are within the role of a nursing assistant.
  440. px 2 arteries, 1 vein
  441. py A,B,D The patient with sleep apnea may have insomnia and/or abrupt awakenings. Patients with cardiovascular disease (e.g., heart failure that may affect respiratory health) may need to sleep with the head elevated on several pillows (orthopnea). Sleeping more than 8 hours per night is not indicative of impaired respiratory health.
  442. pz 2. Increase the level of suicide precautions
    Rationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase in the level of suicide precautions is indicated to keep the client safe. The other options are not indicated (option 1) or could place the client at increases risk (options 3 and 4).
  443. qa a general term for lung diseases caused by inhalation and retention of dust particles.
  444. qb dry powdered drug delivered by inhalation.
  445. qc (1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens

    (2) CMV is fetotoxic; should inform client of risks

    (3) this nurse is at increased risk for developing the disease

    (4) correct—most appropriate option due to decreased risk

    ...

  446. qd 16-22
  447. qe the surgical reconstruction of the nose.
  448. qf P- Promote Stability asses condition and provide airway support and provide IV site if necessary
    O- Off / Out wash off if radioactive remove contaminated clothing if has pill in mouth take out eyes may need to be flushed out antidotes may be necessary for drug overdose ingested substances may be taken out of body by emisis, lavadge, absorbant (activated charcoal) catharticis Emithis is contra indicated if a person is comatose in shock experience a seizure or has loss of gag reflex. If a low viscosity hydrocarbon or strong corrosive (acid or alcheine ) has been ingested immises is contra indicated
    I- Identify the toxin
    S- Support the client both physically and psychologically parents may feel guilty support is imperative
    O- Ongoing safety education regarding poison control
    N- Notify they poison control center facility or provider care for immediate consolation.
  449. qg 1. Nizatidine (Axid)
    2. Ranitidine (Zantac)
    3. Famotidine (Pepcid)
    4. Cimetidine (Tagamet)
    Rationale:
    H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist in preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions. The other medications listed are proton pump inhibitors.
    H2-receptor antagonists medication names end with -dine.
    Proton pump inhibitors medication names end with -zole.
  450. qh B. poor compliance with drug therapy in patients with TB. Drug-resistant strains of TB have developed because TB patients' compliance to drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of TB treatment. Antitubercular drugs are almost exclusively used for TB infections. TB can be effectively diagnosed with sputum cultures. The incidence of TB is at epidemic proportions in patients with HIV, but this does not account for drug-resistant strains of TB.
  451. qi D
    Rationale: Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.

    Cognitive Level: Application Text Reference: p. 308
    Nursing Process: Evaluation NCLEX: Physiological Integrity

  452. qj (B) Human chorionic gonadotropin (hCG)
    Rationale: Human chorionic gonadotropin (hCG) is released by the trophoblast, outer cell layer of the developing fetus in the zygote stage. hCG can be detected in the blood and urine as early as 10 to 14 days after conception, indicating early pregnancy. Human growth hormone (hGH) is responsible for the growth of bones, muscles and other organs. Estrogen is important for maintaining pregnancy, but it is not used to diagnose pregnancy. Estrogen elevation does not occur until the seventh week of gestation. Oxytocin promotes uterine contractility and the stimulation of milk ejection from the breasts. During pregnancy oxytocin assists the labor process that results in birth.
  453. qk 3. Shift change
    Rationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of increased risk for suicides are weekends (not weekdays), and the night shift (not day shift).
  454. ql Strategy: Think about the action of each medication.

    (1) contains aspirin, contraindicated for persons with bleeding disorders

    (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders

    (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders

    (4) correct—analgesic used for moderate to severe pain

  455. qm (F) Turn the hearing aid off and the volume all the way down
    (B) Line up the earmold with the corresponding parts of the ear
    (C) Slightly rotate the earmold forward
    (E) Insert the ear canal portion of the earmold
    (D) Rotate the earmold backward
    (A) Turn the hearing aid on and turn the volume up
    Rationale: Prior to inserting the hearing aid, it should be turned off with the volume all the way down. Next, locate the parts of the ear and the corresponding parts of the hearing aid and align them. Prior to inserting the ear canal portion of the earmold, it should be slightly rotated forward. As the earmold is guided into the ear canal, it is rotated backward. Once the earmold is snugly in place, turn the eharing aid on and volume according to the client's needs.
  456. qn 4. Warfarin (Coumadin)
    Rationale: The nurse is careful to question the surgeon about whether warfarin sodium should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld during the preoperative period to minimize the risk of hemorrhage during surgery. The other medications may also be withheld if specifically ordered, but usually they are discontinued as part of an NPO (nothing by mouth) after midnight order.
  457. qo Closure of the pulmonic and aortic valves (Distole) = Dub
  458. qp 30-60
  459. qq 1. Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous return.
  460. qr B. Systemic corticosteroids Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient.
  461. qs (1) indicates dehydration

    (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement

    (3) symptoms could be from causes other than volume overload

    (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen

  462. qt A) A plaque on the wall that lists all the nurses with CCRN certification
    C) A banner in the hall to state the unit had no VAPs reported for the previous quarter
    D) A clinical ladder program that includes merit raises and opportunities for scholarships to national conferences
    E) A newsletter article that talks about the projects completed by the shared governance committees in the department
  463. qu A. supplemental oxygen should be used when the patient exercises.An oxygen saturation lower than 90% indicates inadequate oxygenation. If the drop is related to activity of some type, supplemental oxygen is indicated.
  464. qv MAO inhibitors
  465. qw 1. Admitting the client to a semiprivate room
    Rationale: The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a single room on the nursing unit. A sign indicating "See the Nurse before Entering" should be placed on the door to the client's room so that the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room.
  466. qx (C) "You will need to visit your doctor regularly for laboratory blood testing."
    Rationale: Lithium is a medication used to decrease or prevent acute manic episodes. To ensure therapeutic effects and prevent toxicity, a client on this medication will need to have regular serum Lithium levels drawn. Initially this test is drawn twice weekly. Once therapeutic levels are reached the test is performed every 2 to 3 months. While on this medication, a client is informed to drink a lot of fluid and consume a moderate amount of sodium in the diet. This prevents low sodium levels, which can lead to Lithium toxicity. The client should be instructed never to skip a dose in order to maintain therapeutic levels. Weight gain, not weight loss, is a side effect of this medication.
  467. qy (A) Prescription of selective serotonin reuptake inhibitors
    (B) Behavior therapy
    Rationale: Treatment of obsessive-compulsive disorder (OCD) includes use of selective serotonin reuptake inhibitors (SSRIs) and behavior therapy. OCD is thought to be caused partially by low levels of serotonin in the brain. SSRIs increase serotonin levels. Behavior therapy involves exposure to a feared object or situation and prevention of carrying out compulsive behavior. Benzodiazepines are not prescribed to treat OCD. Imagery and distraction are relaxation techniques usually used as pain relief measures. Electroconvulsive therapy is used to treat severe depression when other treatment modalities are ineffective.
  468. qz M-many cultures must be done to id the problem. Pathogens such as respiratory,skin,and urinary infections. The nurse is not always able to tell the client is infected.
    R- requires gown, gloves,goggles should be worn (standard precaution) gloves must be worn when touching substances, mucous membranes, non-intact skin, and items that are contaminated. Linen should be changed frequently after contact with infected material. Gowns should be worn if soiling is likely. mask/face shield should be worn if splashing is to occur. Hand washing before and aftercare.
    S-social isolation if infections is in the respiratory tract Private room is necessary (droplet precaution). There should be 3 feet of space between client/resident and visitors. Client must ware mask when transporting in the hospital. Linen must be bagged to prevent contamination. trash must be discarded to prevent contamination to self, environment, or outside a bag. masks/face shild for staff and visitors who are within 3 feet of client. Noncritical care equipment should be limited to a single client.
    A- active infection treatment is tetracycline, bactrim, bacamycin,
    MRSA is a common drug resistant organism found in health care facilities. Is spreed primarily by direct and indirect contact. Sometimes transmitted thru thr respiratory and urinary tracts. Standard precaution will prevent the spread particularly in the skin and urine infections. If in the wound or urine contact precaution are used and if in the respiratory tract then droplet precautions are used. Hands must always be washed after the gown,gloves, ect have been removed.
    Trash and linen stays in room (special bagging). Leave stethoscope in room.
    patient will have ^ tempt, ^ WBC(initally when given drug)
    I&O(renal function) 30 mins prior to 3rd dose
    rudolph the redneck reindeer
    had an adverse side effect
    from the drug vancomycin
    got to do peak and trough or go deaf
    must keep all labs in check
    caution with renal failure
    hearing loss and allergies
    take a temp and blood cultures
    specially a CBC
  469. ra D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger.
  470. rb 4. "We should avoid insect repellents because they will attract the ticks."
    Rationale: To prevent Lyme disease, individuals should be instructed to use insect repellent on the skin and clothes in areas where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over pant legs to prevent ticks from entering under clothing.
  471. rc C. production of intrinsic factor by the stomach. Older persons are at risk for deficiency of cobalamin (pernicious anemia) because of a naturally occurring reduction of the intrinsic factor by the stomach mucosa. Absorption of cobalamin relies on intrinsic factor. Both must be present for absorption. Megaloblastic anemia is related to folate dysfunction. Intestinal motility (peristalsis) is the motion that moves food down the GI tract. The rhythmic contractions of muscles cause wave-like motions. Lack of peristalsis is called "paralytic ileus." Bile is produced in the liver, is stored and concentrated in the gallbladder, and is released into the duodenum when fat is eaten. Bile emulsifies fats and prepares them for enzyme digestion in order for the nutrient to be absorbed into lymph and eventually into blood vessels to the liver. Vitamin K (the blood-clotting vitamin) is synthesized by intestinal bacteria.
  472. rd .(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it

    (2) outcome that would be positive but usually is not an initial result of treatment

    (3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse"

    (4) expected outcome

    ..

  473. re 4. Allow the client to verbalize and demonstrate correct administration procedure
    Rationale: The most effective method of teaching to ensure safe self-administration of medications in the home setting is to have the client verbalize and also demonstrate how to take medications. This ensures that the client has both the knowledge and the physical ability to comply with medication therapy. Option 1 is useful early in the teaching or learning process but is not the best method because it does not allow the client to demonstrate his or her own ability. Option 2 is incorrect because it is dangerous and incorrect statement. Option 3 is unrealistic and does not enhance self-care.
  474. rf A
    Rationale: Patients with SIADH are at risk for hyponatremia, and a sodium supplement may be prescribed. The other patient statements are correct and indicate successful teaching has occurred.

    Cognitive Level: Application Text Reference: p. 1296
    Nursing Process: Evaluation
    NCLEX: Health Promotion and Maintenance

  475. rg a collection of air or gas in the pleural space causing the lung to collapse.
  476. rh slow, progressive disorder of the nervous system that affects movement.
    Characterized by tremor at rest, muscle rigidity and akinesia due to lack of dopamine.
  477. ri Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa.

    (1) correct—placenta previa is characterized by painless vaginal bleeding

    (2) nausea not a symptom of placenta previa

    (3) bleeding is not necessarily related to activity

    (4) pain not characteristic of placenta previa

  478. rj (D) The distance from the nose to the earlobe plus the earlobe to the sternum
    Rationale: The length of the nasogastric tubing necessary fro each individual client is measured by using the tube to mark off the distance from the tip of the client's nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the sternum. This is approximately the distance from the nares to the stomach, which varies from client to client. The distances of the other answers would not provide an accurate measurement for the desired length.
  479. rk D
    Rationale: The ABGs indicate respiratory alkalosis, which is caused by the increased respiratory rate. Because the increased respirations are most likely caused by the incisional pain, the first action by the nurse should be to medicate the patient for pain. The nasogastric tube is needed for postoperative gastric decompression and should remain connected to suction. Sodium bicarbonate administration will further increase the pH. Teaching the patient to take slow, deep breaths may be helpful, but it is unlikely to be effective until the pain level is decreased.

    Cognitive Level: Application Text Reference: p. 335
    Nursing Process: Implementation NCLEX: Physiological Integrity

  480. rl 3. Hearing loss
    Rationale:
    Amikacin (Amikin) is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified.
    *(most aminoglycoside medication names end in the letters -cin)*
  481. rm 2. Use of phenelzine sulfate (Nardil)
    Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI) such as phenelzine sulfate, MAOIs should be stopped at least 14 days before sertraline therapy. Conversely, sertraline should be at least 14 days before MAOI therapy. Options 1, 3, and 4 are not concerns of use of this medication.
  482. rn 3. Alarm-activating bracelet
    Rationale: If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing him or her from leaving the premises. A vest or waist restraint or a chair with a locking lap tray is more intrusive than an alarm-activating bracelet.
  483. ro 2. Hepatitis B infection
    Rationale: A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 (kidney donation), 55 (pancreas and liver), or 40 (heart) years old. The client should be free of communicable disease such as human immunodeficiency virus or hepatitis, and the involved organ may not be diseased. Another contraindication to transplant is malignancy, with the exception of noninvolved skin and cornea.
  484. rp 2. Accidental injury

    Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined.

  485. rq Rationale:
    MMR is administered subcutaneously in the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years.
    *Knowledge that MMR is administered subcutaneously will assist in eliminating options 1 and 2. Knowing that the gluteal muscle is not incorporated in the subcutaneous tissue will eliminate option 4.*
  486. rr C
    Rationale: Platelet transfusions are not usually indicated until the platelet count is below 20,000/l unless the patient is actively bleeding, so the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.

    Cognitive Level: Application Text Reference: p. 704
    Nursing Process: Assessment NCLEX: Physiological Integrity

  487. rs 3. Put the bed rails up after moving the client from the stretcher
    Rationale: Because the client may still be experiencing residual effects of anesthesia, the nurse should raise the side rails after transferring the client from the stretcher to the bed. It is not realistic to ask the client to slide from the stretcher to the bed because of the effects of anesthesia and postoperative pain. Hurried movements and rapid changes in position should be avoided since these predispose the client to hypotension. During the transfer of the client after surgery, the nurse should avoid exposing the client because of potential heat loss, respiratory infection and shock.
  488. rt a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions.
  489. ru 4) Remaining 6 inches away from the sterile field during the procedure
  490. rv s/s: Weakness, dysarthria, dysphagia
    No loss of cognitive function
    Complications/Crisis: respiratory failure.
    Assess Respiratory function: ABC's, clear lungs.
    Swallowing: proper food choices & eventual NG tube. Mobility. Skin. Suctioning: difficult chewing, swallowing, drooling, choking. Communication.
  491. rw B
    Rationale: Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia.

    Cognitive Level: Application Text Reference: p. 686
    Nursing Process: Assessment NCLEX: Physiological Integrity

  492. rx don't take on empty stomach!!
  493. ry trial and error
  494. rz (B) Billroth II, also known as gastrojejunostomy, begins with the removal of the lower section of the antral portion of the stomach. This is the part of the stomach that secretes gastrin, which stimulates the secretion of gastric acid. A small portion of the duodenum and pylorus are also removed. The remaining stomach is then attached with an opening (anastomosed to the jejunum of the small intestines. Answer (A) represents a Billroth I procedure. The severing of vagus nerves, answer (C), describes a vagotomy. Answer (D) describes a colon resection.
  495. sa (B) Chlordiazepoxide hydrochloride (Librium)
    Rationale: Chlordiazepoxide hydrochloride (Librium) is an antianxiety agent that is used in the treatment of alcohol withdrawal. Naloxone hydrochloride (Narcan) is an antidote for opioids. Narcan is used to reverse the effects of opioid overdose. Disulfiram (Antabuse) is an alcohol deterrent used to treat alcoholism. Antabuse cannot be taken if the client has ingested alcohol in the past 12 hours. Among other uses, chlorpromazine (Thorazine) is most often used to treat psychosis or control nausea and vomiting.
  496. sb (A) Hands
    Rationale: Clients with rheumatoid arthritis usually experience discomfort in the proximal finger joints of the hands before any other joints of the body. Although rheumatoid arthritis can eventually spread to any or every joint, the symptoms of rheumatoid arthritis usually are noticed in the finger and hand joints prior to the joints of the arms, legs and neck.
  497. sc (1) correct—transplant clients require protective isolation following surgery

    (2) can't have live plants in the room at all

    (3) no need for dialysis following transplant

    (4) need to force fluids, not restrict them

    ...

  498. sd Reduced.

    Rationale: High doses of phenytoin can cause nystagmus, confusion, ataxia, coma, and seizures, and should be reduced. Options 2, 3, and 4 are incorrect. Increasing or maintaining the same dose will continue the symptoms of toxicity or exacerbate them. The drug should not be discontinued abruptly, because seizure activity may occur.

  499. se C
    Rationale: Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction.

    Cognitive Level: Analysis Text Reference: pp. 326, 338-340
    Nursing Process: Diagnosis NCLEX: Physiological Integrity

  500. sf 8-10"
  501. sg (C) QRS complex
    Rationale: Depolarization of the ventricular muscle of the heart is represented by the QRS complex on the electrocardiogram (ECG) strip. The P wave represents atrial depolarization. The T wave represents ventricle muscle repolarization. The PR interval is the distance from the beginning of the P wave to the center of the R wave in the QRS complex. This interval represents the time used to stimulate the SA node, depolarize the atria, and conduct the impulse through the AV node prior to ventricular depolarization.
  502. sh 55-90 bpm
  503. si neuromuscular blocking agent used to promote skeletal relaxation while pt under mechanical ventilation
  504. sj 4. Hearing acuity
    Rationale:
    Amikacin (Amikin) is an antibiotic. This medication can cause ototoxicity and nephrotoxicity; therefore, hearing acuity tests and kidney function studies should be performed before the initiation of therapy. Apical pulse, liver function studies, and blood pressure are not specifically related to the use of this medication.
  505. sk is the admin of antineoplastic drugs after surgery or radiation therapy.
    The purpose is to rid the body of any cancerous cells that were not removed during the surgery or to treat any micrometastases that may be developing.
  506. sl A
    Rationale: Improper identification is responsible 90% of hemolytic transfusion reactions. The nurse should also administer the blood within 30 minutes of its arrival on the unit, transfuse the blood at 2 ml/min during the first 15 minutes, and stay with the patient during the first 15 minutes; however, these measures will not prevent a transfusion reaction if the person is receiving the wrong blood.

    Cognitive Level: Comprehension Text Reference: p. 731
    Nursing Process: Implementation
    NCLEX: Safe and Effective Care Environment

  507. sm A client has been pronounced brain dead. Which findings would the nurse assess?
  508. sn D. 5.0
  509. so C. combines with water to form carbonic acid, lowering the pH of cerebrospinal fluid. A combination of excess CO2 and H2O results in carbonic acid, which lowers the pH of the cerebrospinal fluid and stimulates an increase in the respiratory rate. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO2 to stimulate the respiratory center. Excess CO2 does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid.
  510. sp Glasgow Coma Scale
  511. sq (1) not enough information given in question to assume that symptoms are caused by stress

    (2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old

    (3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea

    (4) usually see history of missed periods or spotting with abdominal pain

    ...

  512. sr TCA used to tx panic attack
  513. ss 96° to 99.5° F
  514. st 4. Suction equipment
    Rationale:
    Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.
  515. su 1. Blood glucose of 200 mg/dL
    Rationale:
    A blood glucose level of 200 mg/dL is elevated above the normal range of 70 to 110 mg/dL and suggests an adverse effect. Other adverse effects include neurotoxicity evidenced by headache, tremor, insomnia; gastrointestinal (GI) effects such as diarrhea, nausea, and vomiting; hypertension; and hyperkalemia.
  516. sv Supports:
    Vision
    Skin
    Bone and tooth growth
    Immunity
    Reproduction
  517. sw Vessel dilation and capillary leak; WBCs flood the area
  518. sx 2. Place a radiation sign on the door of the client's room
    Rationale: The client's room should be marked with appropriate signs stating the presence of radiation. Visitors are limited to 30 minutes. The client should be placed in a private room at the end of the hall because this location provides less a chance of radiation exposure to others. A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. It is not reinserted by the nurse.
  519. sy C. Oropharyngeal candidiasis and hoarseness Oropharyngeal candidiasis and hoarseness are common adverse effects from the use of inhaled corticosteroids because the medication can lead to overgrowth of organisms and local irritation if the patient does not rinse the mouth following each dose.
  520. sz D
    Rationale: Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.

    Cognitive Level: Application Text Reference: p. 209
    Nursing Process: Evaluation
    NCLEX: Safe and Effective Care Environment

  521. ta D. Adults older than 65 years of age are the greatest users of prescription medications.

    Rationale: Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults

  522. tb B. "Breathe out slowly before positioning the inhaler." It is important to breathe out slowly before positioning the inhaler. This allows the patient to take a deeper breath while inhaling the medication thus enhancing the effectiveness of the dose.
  523. tc 2. Have the client sit upright for a meal
    Rationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. This means that having the client sit upright would be contraindicated. The precatheterization medications are generally resumed after the procedure. Asking the client to wiggle the toes to determine neurovascular status is acceptable and should be done because vascular status could be impaired if a hematoma or thrombus were developing. Fluids should be increased to aid in eliminating the contrast medium through the kidneys.
  524. td T- Taught
    Has the person been taught the skill treatment or assessment
    E- Evaluate
    You have to evaluate just because they were taught how to do something does not mean they are competent to do it, has there return demonstration been performed and documented.
    L- Licensee
    Does the individual have or need a licensee to do this task and is this in the scope of there practice.
    L- Lists
    What lists of standards of cares (agency policies are written regarding this task)
  525. te 1. No rapid heartbeats or anxiety
    Rationale:
    Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.
  526. tf 2.) 0.5 to 2 ng/mL
    Rationale:
    Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Therefore, options 1, 3, and 4 are incorrect.
  527. tg C
    Rationale: During an abdominal ultrasound, a noninvasive probe is lubricated and moved across the abdomen while sound waves are bounced off abdominal structures. There is no need for the patient to be NPO, for an IV line, or for injection of contrast solution.

    Cognitive Level: Application Text Reference: p. 682
    Nursing Process: Planning NCLEX: Physiological Integrity

  528. th D
    Rationale: Legumes and dried fruits are high in iron and low in fat and cholesterol. Eggs and muscle meats are high in iron but also high in fat and cholesterol. Nuts and milk products will improve amino acid intake but are not high in iron. Cornmeal would be an appropriate choice for a vitamin B6 deficiency.

    Cognitive Level: Application Text Reference: p. 689
    Nursing Process: Implementation NCLEX: Physiological Integrity

  529. ti strong (so that if you falter, the strong leg is already in motion to help regain balance)
  530. tj 1. Toxic
    Rationale:
    The therapeutic serum level of lithium is 0.6 to 1.2 mEq/L. A level of 3 mEq/L indicates toxicity.
  531. tk affecting one limb
  532. tl incoordination
  533. tm they are catagorized by intensity pitch and duration of the inspatory and the expetory phase bronchial sounds are heard manubirum (if heard at all) exportation sounds are longer louder and higher pitch than inspatory sounds. If heard in the minubrium they are considered abnormal and may be considerded low bar pneumonia. Broncular vassicular sounds are heard in the first or second interspaces interially between the scapula. The intspulatory and explatory sounds are equal in length and are intermediate. Pitch and intensity differences are easilly assesd during exporation if heard in any other location then air fillled long may have been replaced by fluid or solid lung tissue..Vassicular sounds are heard over most of the lungss. Inspatory sounds are longer than expatory sounds. Vassicular sounds are soft and low pitch.
    Breast sounds should be soft pitch
    Right side has 3 lobes and let side has 2
    Egophony (EE) Bronchaophony (99)
    Whispered 99 or 123 lung sound is normal and filled with air words are indistinct and muffled. EE is heard when airless lungs with pneumonia 99 are lowder and clearer EE is heard as AY whisper words are louder and clearer.
  534. tn C. consider the preadmission functional abilities when setting patient goals.

    Rationale: The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

  535. to C- Adventitious breath sounds
  536. tp (1) tenderness at the IV site is common

    (2) increased swelling at the insertion site may indicate infiltration

    (3) correct—characterized by inflammation and reddened areas around site and up length of vein

    (4) not indicative of phlebitis

    ...

  537. tq 4. Per agency policy, putting up the side rails on the bed
    Rationale:
    Diazepam is a sedative-hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure herself or himself. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2, and 3 may be helpful measures that provide a comfortable, restful environment, but option 4 is the one that provides for the client's safety needs.
  538. tr (A) Disbelief
    Rationale: Initial response to receiving sad or bad news is disbelief or denial. Grief is a normal response to loss or feelings of powerlessness. When people experiencing grief, they must work through the stages of changing emotions, which usually progress as follows: disbelief, anger, bargaining, depression, and eventually acceptance.
  539. ts (C) 27%
    Rationale: The Rules of Nines is a method that uses percentages to calculate the amount of body surface area (BSA) that has been burned. The body is divided into nine sections, each calculated as a percentage that is a multiple of nine. Together, the head and neck make up 9% of the BSA. Each arm is 9% of the BSA. Each leg is 18% of the BSA. The posterior chest (including the back and buttocks) is 18% of the BSA. The perineum, the only exception to the "nine" rules, is 1% of the BSA. Using this information, the correct answer is 27% or answer (C). The right arm is 9% and the anterior chest is 18%.
  540. tt 3. Blood pressure
    Rationale:
    Hypertension can occur in a client taking cyclosporine (Sandimmune, Gengraf, Neoral), and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitoring most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication.
  541. tu S- Strength
    to grow help and allow others to grow
    T- The happiness factor
    comfortable in her own shoes is not a victim and does not blame
    A- A visionary that can think out of the box
    R- Reactive last Proactive first.
  542. tv (1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

    (2) not of primary importance in designing an effective behavior modification program

    (3) not of primary importance in designing an effective behavior modification program

    (4) not of primary importance in designing an effective behavior modification program

  543. tw Degeneration of motor neurons in brain stem and spinal cord: brain's messages don't reach the muscles
    No cure.
  544. tx 4. Check with the psychiatrist before using any over-the-counter (OTC) medications or prescription medications.
    Rationale:
    Lithium is the medication of choice to treat manic-depressive illness. Many OTC medications interact with lithium, and the client is instructed to avoid OTC medications while taking lithium. Lithium is not addicting, and, although serum lithium levels need to be monitored, it is not necessary to check these levels every week. A tyramine-free diet is associated with monoamine oxidase inhibitors.
  545. ty q1-2hrs qday
  546. tz to counter Parkinsonian-like SE of antipsychotics/anti-depressants (recall antipsychotics/anti-depressants (i.e. Thorazine) can cause extra-pyramidal Sx, and benztropine (Cogentin) can help to reverse these)
  547. ua A. Inspect the skin for petechiae. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presences of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes.
  548. ub 100 mL
  549. uc 1. Alcohol
    Rationale:
    When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. The items in options 2, 3, and 4 do not need to be avoided.
  550. ud (A) Notify the physician
    Rationale: A DNR or "Do Not Resuscitate" order indicates that in the case of cardiac or respiratory arrest, no lifesaving treatment will be initiated. I order for DNR procedures to stand, a written physician's order must be documented in the medical record. Initiating the emergency response system is not necessary for a client with a DNR order. Emergency actions, such as rescue breathing and chest compressions, will not be performed. A crash cart containing emergency medications and a defibrillator will not be used on this client. The physician should be notified of the client's status.
  551. ue 1. Sneezing
    Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine.
  552. uf rapid shaking of the eyes
  553. ug 4. History of falls

    According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.

  554. uh B
    Rationale: The patient will eat more if disliked foods are avoided and foods that patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. Patients will not improve intake by eating foods that are beneficial but have unpleasant taste.

    Cognitive Level: Application Text Reference: p. 307
    Nursing Process: Planning NCLEX: Physiological Integrity

  555. ui 1. "Do you have any joint pain?"
    Rationale:
    Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. The other options are unrelated to medication effectiveness.
  556. uj B
    Rationale: The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc) associated with HIV infection.

    Cognitive Level: Analysis Text Reference: p. 255
    Nursing Process: Planning NCLEX: Physiological Integrity

  557. uk (B) Erythrocyte sedimentation rate (ESR)
    Rationale: Erythrocyte sedimentation rate (ESR) is the best diagnostic indicator of rheumatoid arthritis. ESR is a nonspecific test that indicates the presence of an inflammatory disease when elevated. Rheumatoid arthritis is one of a number of disease processes that will elevate this serum level. Serum creatinine is used to evaluate kidney function. International normalized ratio (INR) tests the effectiveness of anticoagulation therapy, usually with the drug Warfarin (Coumadin). A fasting lipid panel measures the cholesterol and lipid levels and ratios that are present in the blood when the levels are not affected by recent food ingestion.
  558. ul 3rd
  559. um Strategy: Determine how each answer choice relates to cor pulmonale.

    (1) common assessment finding of the patient with chronic lung disease

    (2) describes a complication of pneumonia

    (3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites

    (4) is not seen with this client...

  560. un Axillary; 97.5-98.6 F
  561. uo 2. Postural hypotension
    Rationale:
    Anxiolytic medications can cause postural hypotension. The client needs to be taught to rise to a sitting position and get out of bed slowly because of this adverse effect related to the medication. Options 1, 3, and 4 are unrelated to the use of this medication.
  562. up C. the patient positioned in a lateral position with the head of the bed flat. After total laryngectomy and radical neck dissection, a patient should be placed in a semi-Fowler's position to decrease edema and limit tension on the suture line.
  563. uq A
    Rationale: Because sequesterization of platelets and platelet destruction by macrophages occurs in the spleen, splenectomy will increase the platelet count. Splenectomy does not promote sequesterization or release of platelets by the liver, increase platelet production, or increase RBC production.

    Cognitive Level: Application Text Reference: p. 703
    Nursing Process: Implementation NCLEX: Physiological Integrity

  564. ur a sensory nerve cell that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it.
  565. us C
    Rationale: A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

    Cognitive Level: Application Text Reference: p. 207
    Nursing Process: Assessment NCLEX: Physiological Integrity

  566. ut a pus-containing lesion of the lung parenchyma that results in a cavity formed by necrosis of lung tissue.
  567. uu 4. The nursing assistant is speaking directly into the impaired ear
    Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may improve communication, but the nurse should avoid talking directly into the impaired ear.
  568. uv Encourage the client to use a compartmentalized pill storage container for his daily medications.
  569. uw 4. Restlessness
    Rationale:
    Toxicity (overdosage) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage.
  570. ux A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
  571. uy Collagen synthesis
    Amino acid metabolism
    Helps iron absorption
    Immunity
    Antioxidant
  572. uz C. Weight-bearing exercise reduces the loss of bone mass
  573. va B- Shuffling and propulsive
  574. vb A
    Rationale: A tumor must be at least 1 cm large before it is detectable by an x-ray and may already have metastasized by that time. Radiographs have low doses of radiation, and an annual x-ray alone is not likely to increase lung cancer risk. Insurance companies do not usually authorize x-rays for this purpose, but it would not be appropriate for the nurse to give this as the reason for not doing an x-ray. A yearly x-ray is not a risk factor for lung cancer.

    Cognitive Level: Application Text Reference: p. 276
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  575. vc 1) Remove the contaminated clothing immediately.

    Remove contaminated clothing immediately - then wash with water - irrigate it and contact poison control.

  576. vd (B) 0.78mEq/L
    Rationale: The range that indicates therapeutic serum Lithium level is 0.5 to 1.5mEq/L. Any level below this range may not be producing desired effects. A level higher than this is toxic and lethal to a client. 0.45 mEq/L is below therapeutic range. The client's dosage should be increased. Answers C and D indicate toxic levels of Lithium. The medication should be held, and the client should be monitored closely for adverse effects.
  577. ve 3. Although exercise is recommended after MI, it is usually done in a cardiac rehabilitation program where the client is monitored. Exercise is gradually increased over several weeks.
  578. vf Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

    (1) nurse is interjecting own feelings

    (2) will require testing; not best response initially

    (3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine

    (4) correct—assessment; transmitted through parenteral drug abuse and sexual contact; determine exposure before implement

  579. vg C
    Rationale: SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased urine output, and elevated serum hematocrit may be associated with excessive loss of water, but not with SIADH and water retention.

    Cognitive Level: Application Text Reference: pp. 319, 322, 325-326
    Nursing Process: Assessment NCLEX: Physiological Integrity

  580. vh D- Safety pin, hot and cold water in test tubes, cotton wisp
  581. vi Assess
    Forming nursing diagnosis
    Planning and Goal Setting
    Implementation
    Evaluation
  582. vj A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
  583. vk C
  584. vl inability to blink, requiring eye care to avoid corneal abrasion
  585. vm Drooping of the corner of the mouth (Bell's Palsy)
  586. vn Meat
    Eggs
    Legumes
    Nuts
    Dairy products
    Green leafy veggies
    Broccoli
    Asparagus
    Mushrooms
    Oysters
    Clams
    Enriched grains
  587. vo example of propionic acid
    COX 1 NSAID
    **unlike aspirin... inhibition of cyclooxygenase is reversible, does not protect against MI/stroke (Increase in thrombocytic events is concern)
  588. vp Trigeminal Nerve- degeneration/ pressure.
    Chronic disease of trigeminal nerve (cranial nerve V) causing severe facial pain
    The maxillary and mandibular divisions of nerve are effected
  589. vq 2. Contact the registered nurse.
    4. Assess the client's pain level.
    5. Check the client's blood pressure.
    6. Administer a second nitroglycerin, 0.4 mg, sublingually.
    Rationale:
    The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. The registered nurse should be notified of the client's condition, who will then notify the health care provider as appropriate. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.
  590. vr C
    Rationale: Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

    Cognitive Level: Application Text Reference: p. 294
    Nursing Process: Implementation
    NCLEX: Safe and Effective Care Environment

  591. vs Convulsions always involve violent skeletal muscle activity.

    Objective: Compare and contrast the terms epilepsy, seizures, and convulsions.
    Rationale: Convulsions specifically refer to involuntary, violent spasms of the large muscles of the face, neck, arms, and legs. Seizure activity does not always involve these characteristics.
    Cognitive Level: Comprehension
    Client Need: Physiological Integrity: Physiological Adaptation
    Nursing Process: Implementation

  592. vt Caused by a blow to the back of the head, characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
  593. vu (1) not most important

    (2) not most important

    (3) not most important

    (4) correct—steroid replacement is the most important information the client needs to know

    ...

  594. vv B. Slow onset, chronic
  595. vw 1. Position the client in the center of the sling
    Rationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised from the bed into a sitting position. The lift raises the client off the mattress and lowers the client slowly once the sling is positioned over the chair.
  596. vx starts with weakness of lower extremities and gradually progresses to upper extremities and facial muscles.
    Recovery is slow and can take years.
    "ground to brain"
  597. vy 2. Coffee, cola, and chocolate
    Rationale:
    Theophylline is a xanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These include coffee, cola, and chocolate.
  598. vz (B) The most frequent complication of tube feedings, whether through nasogastric or PEG (percutaneous endoscopic gastrostomy) tube, is diarrhea or loose, watery stools. This is a reaction caused by intolerance to the formula solution or the rate that the formula is being given. Constipation can occur any time food is passed through the gastrointestinal tract, but it is not the most common condition caused by tube feedings. Vomiting could also indicate intolerance to the tube feeding rate, but it is less common than diarrhea. Belching is not a side effect known to be caused by tube feeding.
  599. wa D
    Rationale: Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

    Cognitive Level: Application Text Reference: p. 204
    Nursing Process: Planning NCLEX: Physiological Integrity

  600. wb 20 mEq/h
  601. wc A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
  602. wd 3. "The medication will permanently stain my skin."
    Rationale:
    Silver sulfadiazine (Silvadene) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin.
  603. we spinal injury
  604. wf C. Pulmonary embolism A high mortality rate is associated with a pulmonary embolism. A pulmonary embolism is an obstruction of the pulmonary artery caused by an embolus. It presents with hypoxia, anxiety, restlessness, and shortness of breath. Bleeding ulcers, MI, and transient ischemia are not associated with such a high mortality rate.
  605. wg 4. Nausea and vomiting
    Rationale:
    Trimethobenzamide is an antiemetic agent used in the treatment of nausea and vomiting. The other options are incorrect.
  606. wh C. The rapid breathing is an attempt to compensate for the low pH. The respiratory system influences pH (acidity) through control of carbon dioxide exhalation. Thus, rapid breathing increases the pH. Breathing into a paper bag aids a patient who is hyperventilating; in respiratory alkalosis, it aids in lowering the pH. The use of sedation can cause respiratory depression and hypoventilation, resulting in an even lower pH.
  607. wi 1. Empty the drainage bag at least every 8 hours.
  608. wj (C) Mrs. Palmer has a difficult time eating at dinner due to tremors
    Rationale: Although it is important to consider all client needs holistically, the highest concern in establishing a plan of care is the physiological needs of the client. Physiological needs include ADLs (activities of daily living). ADLs are basic needs, such as eating, moving, dressing, toileting and other personal hygiene. Answer (C) is the correct answer because it is the only assessment that indicates a physical hindrance to a physiological need.
  609. wk a condition marked by lymphatic fluid in the pleural space caused by a leak in the thoracic duct.
  610. wl 3. 100 mg twice daily
    Rationale:
    For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg two to four times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued.
  611. wm bleeding, sensitivity reaction
  612. wn an abnormal condition of the pulmonary system, characterized by overinflation and destructive changes in alveolar walls.
  613. wo D
    Rationale: Melena is a sign of gastrointestinal bleeding and requires further assessment. A sore throat does not indicate bleeding, although neck swelling requires rapid medical care. The patient can apply pressure to abrasions or gum bleeding rather than immediately seeking medical attention.

    Cognitive Level: Application Text Reference: pp. 708, 710
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  614. wp D
    Rationale: Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

    Cognitive Level: Application Text Reference: p. 697
    Nursing Process: Planning NCLEX: Physiological Integrity

  615. wq 2. Scallops
    Rationale:
    Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Uric acid is produced when purine is catabolized. Clients are instructed to modify their diet and limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast.
  616. wr (1) would result in contractures due to the strength of flexor muscles

    (2) should encourage range of motion in all joints, not just hip flexors

    (3) massaging inflamed joints will add to inflammation and pain

    (4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility

    ...

  617. ws weakness or incomplete loss of muscle function
  618. wt A
    Rationale: The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH).

    Cognitive Level: Comprehension Text Reference: p. 678
    Nursing Process: Assessment NCLEX: Physiological Integrity

  619. wu Adrenal gland atrophy, masking of infection, delayed wound healing
  620. wv (D) Aldactone
    Rationale: Loop diuretics are most commonly used to treat fluid overload and hypertension because of their effectiveness. Bumex, Lasix and Demadex are all loop diuretics. Aldactone, a potassium sparing diuretic, is very weak in comparison to loop diuretics. Unless the client's potassium level is dangerously low, this medication is not usually prescribed. Sometimes potassium sparing diuretics are used along with lower doses of other diuretics to help conserve the body's potassium levels.
  621. ww Facial nerve inflammation;
    Peripheral facial paralysis due to CN VII motor dysruption; affects one side of face.
    Inflammation, edema, ischemia, demyelination of nerve, causing sensory and motor loss.
    Outbreak of herpes vesicles in or around ear; Caused by a reactivation of herpes simplex virus, although other infections (e.g., syphilis or Lyme disease) are sometimes implicated
  622. wx 1. At bedtime
    Rationale:
    A single daily dose of ranitidine is usually scheduled to be given at bedtime. This allows for a prolonged effect, and the greatest protection of the gastric mucosa.
    *recall that ranitidine suppresses secretions of gastric acids*
  623. wy Protein
  624. wz Strategy: Think about each answer choice.

    (1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration

    (2) not a high priority

    (3) not a high priority

    (4) not a high priority

  625. xa A. Palpitations Patients experiencing moderate anemia (hemoglobin [Hb] 6 to 10 g/dL) may experience dyspnea (shortness of breath), palpitations, diaphoresis (profound perspiration) with exertion, and chronic fatigue. Blurred vision is associated in patients experiencing profound anemia states. Anorexia is common in patients with severe anemia, as well. Patients with anemia often appear pale and complain of feeling cold because of compensatory vasoconstriction of the subcutaneous capillaries.
  626. xb hypertrophy of the right side of the heart, with or without heart failure, resulting from pulmonary hypertension.
  627. xc an abnormal accumulation of fluid in the intrapleural spaces of the lungs.
  628. xd 2. Gown and gloves
    Rationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In this instance, the nurse should wear gloves and a gown to protect the hands and uniform from contamination.
  629. xe Strategy: Think about each answer choice.

    (1) inaccurate for the situation

    (2) incorrectly stated

    (3) incorrectly stated

    (4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients

  630. xf 4. Excessive snoring

    Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).

  631. xg hypertension, 4+ proteinuria and edema; severe: BP > 150/100, headache, epigastric pain
  632. xh Benztropine (cogentin)

    Rationale: benztropine, a cholinergic antagonist, is frequently used as combination therapy with other antiparkinson drugs to decrease tremors. Options 1, 3, and 4 are incorrect. Amantadine acts to increase dopamine's release, but only as long as dopamine is available. Haloperidol is a phenothiazine antipsychotic that may lead to pseudo-parkinson's disease in many persons. Donepezil prolongs the time between diagnosis and the institutionalization of the client with alzheimer's disease and is not used for parkinson's disease.

  633. xi Answer: The client's heart rate should be slower than it was prior to taking the medication.
    Rationale: Propranolol (Inderal) is a beta-adrenergic blocker. "Beta blockers" interfere with the effects of the naturally occurring epinephrine in the body. These medications reduce the heart rate. Therefore, once the client has started taking propranolol (Inderal), the client's heart rate should slow down compared to the rate prior to taking the medication.
  634. xj (C) Fluid restriction
    Rationale: Acute pain can be very severe during a sickle cell crisis due to hypoxia caused by inadequate blood flow to various tissues or organs. Pain management during crisis includes analgesics, relaxation techniques and distraction. Techniques are used to prevent reoccurrence of symptoms once acute pain is controlled. Clients with sickle cell anemia are usually susceptible to infection. Fluid is encouraged for sickle cell clients in order to promote dilution of the blood, which prevents clumping of sickled cells. Red blood cell transfusions are common therapy used to prevent complications from sickle cell anemia.
  635. xk 2. Use sunscreen when outsides.
    Rationale:
    Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because it could cause return of seizures or status epilepticus. Fever and sore throat (leukopenia) should be reported to the health care provider (HCP).
  636. xl 3. Consult with health care providers (HCPs) before receiving immunizations
    Rationale:
    Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without a HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side effects.
  637. xm Which neurotransmitter is responsible for may of the functions of the frontal lobe?
  638. xn B. sleep apnea. Sleep apnea is most common in obese patients. Typical symptoms include snoring and periods of apnea. Narcolepsy is when a patient falls asleep unexpectedly. Sleep deprivation could result from sleep apnea. Paroxysmal nocturnal dyspnea occurs when a patient has shortness of breath during the night.
  639. xo (1) if the pulse rate increases, may indicate fluid overload

    (2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume

    (3) temperature should remain within normal limits

    (4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels

    ...

  640. xp A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a "blown pupil" (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disruption of which cranial nerve?
  641. xq stimulants
  642. xr (D) 2 minutes
    Rationale: The American Heart Association (AHA) recommends waiting 2 minutes before repeating a blood pressure reading at the same site. This is to decrease venous congestion. The correct answer is (D). All of the other answers give too short of a time span between cuff inflations.
  643. xs D
    Rationale: Rebreathing may help alleviate mild symptoms, but it will only temporarily increase ionized calcium level, so the patient should call the health care provider. There is no need to increase fluid intake. Calcium is not given IM but is given slowly through the IV route. Mild hypocalcemia is unlikely to progress to seizures.

    Cognitive Level: Application Text Reference: p. 1311
    Nursing Process: Implementation
    NCLEX: Health Promotion and Maintenance

  644. xt Snellen's Chart:
    Field of vision, visual acuity and structures (external, internal, red reflex and optic disc.)

    Reading a newspaper or magazine.
    Holding up fingers

  645. xu 3. Pull down and back on the ear and direct the solution toward the wall of the canal.
    Rationale:
    When administering eardrops to an infant, the nurse pulls the ear down and straight back. In the adult or a child older than 3 years, the ear is pulled up and back to straighten the auditory canal. The medication is administered by aiming it at the wall of the canal rather than directly onto the eardrum.
  646. xv 3) Daytime fatigue
    4) Snoring
  647. xw D
  648. xx peripheral edema
    hepatomegaly
    splenomegaly
    ascities
    JVD
    hepatojugular reflux
    increased central venous pressure
    pulmonary hypertension
  649. xy 1. Tinnitus
    Rationale:
    Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.
  650. xz blood pressure, given with meals and glass of h20 or milk, previous problems
  651. ya IICP Brain Herniation:
    - Unilateral dilated pupil.
    - sluggish, equal pupil response.
  652. yb 1. Tinnitus
    2. Ototoxicity
    5. Nephrotoxicity
    6. Hypomagnesemia
    Rationale:
    Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity.
  653. yc (1) does not occur

    (2) occurs earlier in development

    (3) at age 40, bone mass begins to decrease

    (4) correct—may precipitate a mid-life crisis

    ...

  654. yd (F) Estrogen level is low
    (C) Endometrium is shed
    (B) Estrogen level peaks
    (A) Ovulation occurs
    (E) Estrogen level drops sharply
    (D) Progesterone level drops
    Rationale: As the menstrual phase (days 1 to 6) begins, estrogen levels are low. During this phase the endometrium of the uterus is shed. During the proliferative phase 7 to 14 days), the endometrium thickens, estrogen rises and peaks, and the ovum is released (ovulation). The secretory phase (days 15 to 26) involves preparing the uterus for implantation. At this stage, estrogen drops sharply and progesterone dominates. During the final stage, the e=ischemic phase (days 27 to 28), progesterone levels begin to decrease, estrogen levels continue to decrease, blood vessels rupture, and blood escapes into the cells of the uterus in preparation for the cycle to begin again.
  655. ye Acute infection of the meninges.
    Bacterial meningitis is an infection of the ventricular system and the CSF.
  656. yf 2. Place the infant in a supine position in preparation for sleep
    Rationale: The American Academy of Pediatrics recommends the supine position for sleep to reduce the risk of SIDS. Plastic bottles and toys are not needed yet because a 2 month-old cannot hold them. Pacifiers are considered safe and appropriate at this age. Safety netting is not necessary for a 2 month-old because the infant cannot roll over or stand alone.
  657. yg 1. Baker's yeast
    Rationale:
    A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to common baker's yeast. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.
  658. yh 2. Triglyceride level
    Rationale:
    Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.
  659. yi s/s: Severe HA, fever, delirium,
    Nuchal Rigidity: stiff neck
    Kernig's Sign: from bent leg/knee to strait is painful
    Brudzinski's Sign: pain; resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
    Photo/Phonophobia;
    Increased ICP
    Edema and inflammation of the optic nerve
    Purpuric rash on the skin and mucous membranes

    Assess for IICP: LOC, VS, Eyes, Motor function
    Crisis: COMA- Acute complication from IICP
    SEIZURES- Acute cerebral edema/ IICP

  660. yj A- Giving the client thin liquids
    Rationale: before the client with dyshagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
  661. yk D. Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 ml/min and remain with the patient for the first 15 minutes after hanging a unit of blood.
  662. yl B
    Rationale: Sucking on hard candies decreases thirst for patient on a fluid restriction. Patients with SIADH are on fluid restrictions of 800 to 1000 ml/day. Peripheral edema is not seen with SIADH. The head of the bed is elevated no more than 10 degrees to increase left atrial filling pressure and decrease ADH release.

    Cognitive Level: Application Text Reference: p. 1296
    Nursing Process: Planning NCLEX: Physiological Integrity

  663. ym A
    Rationale: Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication should generally be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices (CVADs) are preferred.

    Cognitive Level: Application Text Reference: pp. 286-288
    Nursing Process: Implementation NCLEX: Physiological Integrity

  664. yn 3. Ensure that the medication is administered at the same time each day.
    Rationale:
    Valproic acid is an anticonvulsant, antimanic, and antimigraine medication. It may be administered with or without food. It should not be taken with an antacid or carbonated beverage because these products will affect medication absorption. The medication is administered at the same time each day to maintain therapeutic serum levels.
    *Use general pharmacology guidelines to assist in eliminating options 1 and 2. Eliminate option 4 because of the closed-ended word "only."*
  665. yo 1. With 8 oz of milk
    Rationale:
    Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation. Options 2, 3, and 4 are incorrect.
  666. yp 2. Refrigerate the insulin.
    Rationale:
    Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, and 4 are incorrect.
  667. yq Strategy: Think about the action of the medications.

    (1) decreased dosage of narcotics are used

    (2) dosages of sedatives and hypnotics will be similar

    (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant

    (4) dosages of narcotics are reduced

  668. yr 4. Difficulty discriminating the color red from green
    Rationale:
    Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin).
  669. ys 1 L
  670. yt C, A, D, B
    Rationale: The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.

    Cognitive Level: Application Text Reference: p. 202
    Nursing Process: Planning NCLEX: Physiological Integrity

  671. yu Water balance
    Acid-base balance
    Normal muscle irritability
    Glycogen formation
    Protein synthesis
    Nerve transmission
  672. yv A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
  673. yw Synthesis of blood clotting proteins
    Regulates blood calcium
  674. yx 1. Renal insufficiency
    Rationale:
    Cinoxacin should be administered with caution in clients with renal impairment. The dosage should be reduced, and failure to do so could result in accumulation of cinoxacin to toxic levels. Therefore the nurse would verify the prescription if the client had a documented history of renal insufficiency. The laboratory and diagnostic test results are normal findings. Folic acid (vitamin B6) may be prescribed for a client with renal insufficiency to prevent anemia.
  675. yy R- Rescue
    A- Activate Alarm
    C- Confine the fire
    E- Evacuate / Extinguish
  676. yz REGULAR contractions
  677. za to minimize eye movt until a surgeon is available
  678. zb 3) Stay between the patient and the door; keep the door open.

    Make sure you do not get trapped. You should never enter the room alone if someone is threatening, the nurse must be calm and reassuring. Asking about weapons and setting limits may escalate the situation.

  679. zc 1) changes in LOC
    2) changes in Vital Signs
    3) changes in Eyes
    4) decreased motor function
    5) HA
  680. zd 4. Frequent handwashing with hot, soapy water
    Rationale:
    Clomipramine is commonly used in the treatment of obsessive-compulsive disorder. Handwashing is a common obsessive-compulsive behavior. Weight gain is a common side effect of this medication. Tachycardia and sedation are side effects. Insomnia may occur but is seldom a side effect.
  681. ze Motor changes: opposite side, balance, coordination, gait, proprioception
    Sensory Changes: Aphasia, Agnosia, Apraxia, Visual problems, hemianopsia
    Cognitive Changes: impaired memory, disoriented
    Paralysis, difficulty swallowing, talking, memory, pain.
    Assessment includes: glasgow coma scale/LOC
  682. zf Not due to organic reasons
    I.E. - impaired mobility prevents client from reaching bathroom in time
  683. zg D. Develop large-print handouts that reflect the verbal information presented.

    Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.

  684. zh Fever is the point heat production passes heat loss
    Ice pack on the head contemplate a temped bath
    Take acetaminophen or ibuprofen to prevent a rapid rise that may cause seizure
    If none of these work at 100.4 F can be tolerated can rise to dangerous levels especially in the afternoon.
    F-Fahrenheit Greater 100.4-100.8(38C)
    E-Endogenous Pyrogens Reset the hyperventilate system
    V-Volume needs increase secondary to heat loss ex; increase metabolism shivering sweating evaporation and vazo dilation
    E-Evaluate the source via labs; CBC with differential a urinalysis a blood culture and chest x-ray
    R-Risk factors viral or bacterial illness environmental factors tissue damage and biological agents and endocrine system disorders Greater than 107F equals death or irreversible brain damage. These patients are at high risk of dehydration due to sweating. Give a lot of fluids fever peaks in late afternoon
  685. zi 2. Three sputum cultures are negative
    Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary.
  686. zj 4. Place the needle and syringe in a labeled, rigid plastic container
    Rationale: Standard precautions include specific guidelines for handling of sharps. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container that is specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing needlestick injury. Needles should always be properly discarded after use.
  687. zk 2. Liver disease
    Rationale:
    Carbamazepine (Tegretol) is contraindicated in liver disease, and liver function tests are routinely prescribed for baseline purposes and are monitored during therapy. It is also contraindicated if the client has a history of blood dyscrasias. It is not contraindicated in the conditions noted in the incorrect options.
  688. zl A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
  689. zm C
    Rationale: Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than yogurt. French fries are high in calories from fat but low in protein.

    Cognitive Level: Application Text Reference: p. 306
    Nursing Process: Evaluation NCLEX: Physiological Integrity

  690. zn bananas, cantaloupe, oranges
  691. zo Measures to protect the eye

    Rationale. Protecting the client's eye from injury is a priority of care when a topical eye anesthetic agent is administered, as the corneal reflex is lost when it is given. Options 1, 3, and 4 are incorrect. Measures to increase tear secretion are unnecessary. The nurse will monitor for the local effect of conjunctivitis, but this is not the priority of care. Since the medication is local and not general, there should be no need to monitor the client's level of consciousness.

  692. zp B. Large hemorrhoids Gastrointestinal (GI) tract bleeding is a common etiologic factor in men and may result from peptic ulcers, hiatal hernia, gastritis, cancer, hemorrhoids, diverticula, ulcerative colitis, or salicylate poisoning.
  693. zq c. diff
  694. zr 4. 1.7 mEq/L
    Rationale:
    The therapeutic serum level of lithium ranges from 0.6 to 1.2 mEq/L. Serum lithium levels above the therapeutic level will produce signs of toxicity.
  695. zs (1) correct—decreases intracranial pressure

    (2) decreases venous blood return

    (3) too elevated, would increase intracranial pressure

    (4) head should be maintained in neutral position

    ...

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