b. 0.5 to 2.

0 ng/mL
A newly admitted client takes digoxin 0.25 mg/day. The nurse knows that which is the serum therapeutic range for digoxin? a. 0.1 to 1.5 ng/mL b. 0.5 to 2.0 ng/mL c. 1.0 to 2.5 ng/mL d. 2.0 to 4.0 ng/mL

a. It is in the high (elevated) range.

The client's serum digoxin level is 3.0 ng/mL. What does the nurse know about this serum digoxin level? a. It is in the high (elevated) range. b. It is in the low (decreased) range. c. It is within the normal range. d. It is in the low average range.

d. Pulse below 60 beats/min and irregular rate

The nurse is assessing the client for possible evidence of digitalis toxicity. The nurse acknowledges that which is included in the signs and symptoms for digitalis toxicity? a. Pulse (heart) rate of 100 beats/min b. Pulse of 72 with an irregular rate c. Pulse greater than 60 beats/min and irregular rate d. Pulse below 60 beats/min and irregular rate

a. Increase the serum digoxin sensitivity level

The client is also taking a diuretic that decreases her potassium level. The nurse expects that a low potassium level (hypokalemia) could have what effect on the digoxin? a. Increase the serum digoxin sensitivity level b. Decrease the serum digoxin sensitivity level c. Not have any effect on the serum digoxin sensitivity level d. Cause a low average serum digoxin sensitivity level

b. Headaches
When a client first takes a nitrate, the nurse expects which symptom that often occurs? a. Nausea and vomiting b. Headaches

c. Stomach cramps d. Irregular pulse rate

c. Decrease heart rate and decrease myocardial contractility.

The nurse acknowledges that beta blockers are as effective as antianginals because they do what? a. Increase oxygen to the systemic circulation. b. Maintain heart rate and blood pressure. c. Decrease heart rate and decrease myocardial contractility. d. Decrease heart rate and increase myocardial contractility.

b. The beta blocker should NOT be abruptly stopped; the dose should be tapered down.
The health care provider is planning to discontinue a client's beta blocker. What instruction should the nurse give the client regarding the beta blocker? a. The beta blocker should be abruptly stopped when another cardiac drug is prescribed. b. The beta blocker should NOT be abruptly stopped; the dose should be tapered down. c. The beta blocker dose should be maintained while taking another antianginal drug. d. Half the beta blocker dose should be taken for the next several weeks.

c. To block the beta1-adrenergic receptors in the cardiac tissues

The beta blocker acebutolol (Sectral) is prescribed for dysrhythmias. The nurse knows that what is the primary purpose of the drug? a. To increase the beta1 and beta2 receptors in the cardiac tissues b. To increase the flow of oxygen to the cardiac tissues c. To block the beta1-adrenergic receptors in the cardiac tissues d. To block the beta2-adrenergic receptors in the cardiac tissues

a. "Apply the patch to a nonhairy area of the upper torso or arm."

A client is to be discharged home with a transdermal nitroglycerin patch. Which instruction will the nurse include in the client's teaching plan? a. "Apply the patch to a nonhairy area of the upper torso or arm." b. "Apply the patch to the same site each day." c. "If you have a headache, remove the patch for 4 hours and then reapply." d. "If you have chest pain, apply a second patch next to the first patch."

d. Client stating that pain is 0 out of 10

A nurse is monitoring a client with angina for therapeutic effects of nitroglycerin. Which assessment finding indicates that the nitroglycerin has been effective? a. Blood pressure 120/80 mm Hg b. Heart rate 70 beats per minute c. ECG without evidence of ST changes d. Client stating that pain is 0 out of 10

d. Chest pain
The nurse is monitoring a client during IV nitroglycerin infusion. Which assessment finding will cause the nurse to take action? a. Blood pressure 110/90 mm Hg b. Flushing c. Headache d. Chest pain

d. "I can take up to five tablets at 3-minute intervals for chest pain if necessary."
Which statement made by the client demonstrates a need for further instruction regarding the use of nitroglycerin? a. "If I get a headache, I should keep taking nitroglycerin and use Tylenol for pain relief." b. "I should keep my nitroglycerin in a cool, dry place." c. "I should change positions slowly to avoid getting dizzy." d. "I can take up to five tablets at 3-minute intervals for chest pain if necessary."

a. Client states that she has no chest pain.

Which client assessment would assist the nurse in evaluating therapeutic effects of a calcium channel blocker? a. Client states that she has no chest pain. b. Client states that the swelling in her feet is reduced. c. Client states the she does not feel dizzy. d. Client states that she feels stronger.

d. "This medication will work for 24 hours and you will need to change the patch daily."
What statement is the most important for the nurse to include in the teaching plan for a client who has started on a transdermal nitroglycerin patch? a. "This medication works faster than sublingual nitroglycerin works." b. "This medication is the strongest of any nitroglycerin preparation available."

c. "This medication should be used only when you are experiencing chest pain." d. "This medication will work for 24 hours and you will need to change the patch daily."

c. Apply the nitroglycerin patch for 14 hours and remove it for 10 hours at night.
What will the nurse instruct the client to do to prevent the development of tolerance to nitroglycerin? a. Apply the nitroglycerin patch every other day. b. Switch to sublingual nitroglycerin when the client's systolic blood pressure elevates to more than 140 mm Hg. c. Apply the nitroglycerin patch for 14 hours and remove it for 10 hours at night. d. Use the nitroglycerin patch for acute episodes of angina only.

c. Assess blood pressure.

Before the nurse administers isosorbide mononitrate (Imdur), what is a priority nursing assessment? a. Assess serum electrolytes. b. Measure blood urea nitrogen and creatinine. c. Assess blood pressure. d. Monitor level of consciousness.

b. "It's best to keep it in its original container away from heat and light."
The client asks the nurse how nitroglycerin should be stored while traveling. What is the nurse's best response? a. "You can protect it from heat by placing the bottle in an ice chest." b. "It's best to keep it in its original container away from heat and light." c. "You can put a few tablets in a resealable bag and carry it in your pocket." d. "It's best to lock them in the glove compartment to keep them away from heat and light."

d. "I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness."
Which statement indicates to the nurse that the client understands sublingual nitroglycerin medication instructions? a. "I will take up to five doses every 3 minutes for chest pain." b. "I can chew the tablet for the quickest effect." c. "I will keep the tablets locked in a safe place until I need them." d. "I should sit or lie down after I take a nitroglycerin tablet to prevent dizziness."

b. Apply the ointment to a nonhairy part of the upper torso.

What instruction should the nurse provide to the client who needs to apply nitroglycerin ointment? a. Use the fingers to spread the ointment evenly over a 3-inch area. b. Apply the ointment to a nonhairy part of the upper torso. c. Massage the ointment into the skin. d. Cover the application paper with ointment before use.

b. Decrease the intravenous nitroglycerin by 10 mcg/min.

A client receiving intravenous nitroglycerin at 20 mcg/min complains of dizziness. Nursing assessment reveals a blood pressure of 85/40 mm Hg, heart rate of 110 beats/min, and respiratory rate of 16 breaths/min. What is the nurse's priority action? a. Assess the client's lung sounds. b. Decrease the intravenous nitroglycerin by 10 mcg/min. c. Stop the nitroglycerin infusion for 1 hour, and then restart. d. Recheck the client's vital signs in 15 minutes but continue the infusion.

b. Heart rate 58 beats per minute

The nurse is monitoring a client taking digoxin (Lanoxin) for treatment of heart failure. Which assessment finding indicates a therapeutic effect of the drug? a. Heart rate 110 beats per minute b. Heart rate 58 beats per minute c. Urinary output 40 mL/hr d. Blood pressure 90/50 mm Hg

a. Administer ordered dose of digoxin.

A client's serum digoxin level is drawn, and it is 0.4 ng/mL. What is the nurse's priority action? a. Administer ordered dose of digoxin. b. Hold future digoxin doses. c. Administer potassium. d. Call the health care provider.

a. Evaluate digoxin levels.

A client is taking digoxin (Lanoxin) 0.25 mg and furosemide (Lasix) 40 mg. When the nurse enters the room, the client states, "There are yellow halos around the lights." Which action will the nurse take? a. Evaluate digoxin levels. b. Withhold the furosemide

c. Administer potassium. d. Document the findings and reassess in 1 hour.

a. Loss of appetite with slight bradycardia

Which assessment finding will alert the nurse to suspect early digitalis toxicity? a. Loss of appetite with slight bradycardia b. Blood pressure 90/60 mm Hg c. Heart rate 110 beats per minute d. Confusion and diarrhea

b. To administer digoxin immune FAB

The nurse reviews a client's laboratory values and finds a digoxin level of 10 ng/mL and a serum potassium level of 5.9 mEq/L. What is the nurse's primary intervention? a. To administer atropine b. To administer digoxin immune FAB c. To administer epinephrine d. To administer Kayexalate

c. Monitor blood pressure continuously.

A client is to begin treatment for short-term management of heart failure with milrinone lactate (Primacor). What is the priority nursing action? a. Administer digoxin via IV infusion with the Primacor. b. Administer Lasix (furosemide) via IV infusion after the Primacor. c. Monitor blood pressure continuously. d. Maintain an infusion of lactated Ringers with Primacor infusion.

c. Continue to monitor the client.

A client's recently drawn serum lidocaine drug level is 3.0 mcg/mL. What is the nurse's priority intervention? a. Increase the lidocaine infusion. b. Decrease the lidocaine infusion. c. Continue to monitor the client. d. Stop the IV drip for 1 hour.

c. Rapid IV bolus of Adenosine (Adenocard)

A client is admitted to the emergency department with paroxysmal supraventricular tachycardia. What intervention is the nurse's priority?

a. Administration of digoxin IV push b. Administration of oxygen, 2 lpm c. Rapid IV bolus of Adenosine (Adenocard) d. Instructing client to "bear down"

c. ECG
A nurse is caring for a client who has been started on ibutilide (Corvert). Which assessment is a priority for this client? a. Blood pressure measurement b. BUN and creatinine c. ECG d. Lung sounds

b. Crackles in the lungs

Which assessment finding will alert the nurse to possible toxic effects of amiodarone? a. Heart rate 100 beats per minute b. Crackles in the lungs c. Elevated blood urea nitrogen d. Decreased hemoglobin

b. Continuous blood pressures d. Presence of chest pain

What must the nurse monitor when titrating intravenous nitroglycerin for a client? (Select all that apply.) a. Continuous oxygen saturation b. Continuous blood pressures c. Hourly ECGs d. Presence of chest pain e. Serum nitroglycerin levels f. Visual acuity

b. Hypokalemia
A client is taking hydrochlorothiazide 50 mg/day and digoxin 0.25 mg/day. What type of electrolyte imbalance does the nurse expect to occur? a. Hypocalcemia b. Hypokalemia

c. Hyperkalemia d. Hypermagnesemia

c. Hydrochlorothiazide
What would cause the same client's electrolyte imbalance? a. High dose of digoxin b. Digoxin taken daily c. Hydrochlorothiazide d. Low dose of hydrochlorothiaizde

d. Serum glucose (sugar)

A nurse teaching a client who has diabetes mellitus and is taking hydrochlorothiazide 50 mg/day. The teaching should include the importance of monitoring which levels? a. Hemoglobin and hematocrit b. Blood urea nitrogen (BUN) c. Arterial blood gases d. Serum glucose (sugar)

c. High-ceiling (loop) diuretic

A client has heart failure and is prescribed Lasix. The nurse is aware that furosemide (Lasix) is what kind of drug? a. Thiazide diuretic b. Osmotic diuretic c. High-ceiling (loop) diuretic d. Potassium-sparing diuretic

a. Hypokalemia
The nurse acknowledges that which condition could occur when taking furosemide? a. Hypokalemia b. Hyperkalemia c. Hypoglycemia d. Hypermagnesemia

b. To increase the serum potassium level

For the client taking a diuretic, a combination such as triamterene and hydrochlorothiazide may be prescribed. The nurse realizes that this combination is ordered for which purpose?

a. To decrease the serum potassium level b. To increase the serum potassium level c. To decrease the glucose level d. To increase the glucose level

b. Hyperkalemia
The client has been receiving spironolactone (Aldactone) 50 mg/day for heart failure. The nurse should closely monitor the client for which condition? a. Hypokalemia b. Hyperkalemia c. Hypoglycemia d. Hypermagnesemia

a. Have the client lie down when taking a nitroglycerin sublingual tablet. b. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. e. Warn client against ingesting alcohol while taking nitroglycerin.
A client who has angina is prescribed nitroglycerin. The nurse reviews which appropriate nursing interventions for nitroglycerin (Select all that apply.) a. Have the client lie down when taking a nitroglycerin sublingual tablet. b. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. c. Apply Transderm-Nitro patch to a hairy area to protect skin from burning. d. Call the health care provider after taking 5 tablets if chest pain persists. e. Warn client against ingesting alcohol while taking nitroglycerin.

b. Fasting blood glucose level of 140 mg/dL

Which laboratory value will the nurse report to the health care provider as a potential adverse response to hydrochlorothiazide (HydroDIURIL)? a. Sodium level of 140 mEq/L b. Fasting blood glucose level of 140 mg/dL c. Calcium level of 9 mg/dL d. Chloride level of 100 mEq/L

b. "This combination promotes diuresis but decreases the risk of hypokalemia."

What is the best information for the nurse to provide to the client who is receiving spironolactone (Aldactone) and furosemide (Lasix) therapy? a. "Moderate doses of two different diuretics are more effective than a large dose of one." b. "This combination promotes diuresis but decreases the risk of hypokalemia."

c. "This combination prevents dehydration and hypovolemia." d. "Using two drugs increases the osmolality of plasma and the glomerular filtration rate."

c. Administer 2 mEq potassium chloride per kilogram per day IV.

The nurse is assessing a client who is taking furosemide (Lasix). The client's potassium level is 3.4 mEq/L, chloride is 90 mmol/L, and sodium is 140 mEq/L. What is the nurse's primary intervention? a. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly. b. Administer Kayexalate. c. Administer 2 mEq potassium chloride per kilogram per day IV. d. Administer PhosLo, two tablets three times per day.

c. The fact that Lasix has shown efficacy in treating persons with renal insufficiency.
A nurse admits a client diagnosed with pneumonia. The client has a history of chronic renal insufficiency, and the health care provider orders furosemide (Lasix) 40 mg twice a day. What is most important to include in the teaching plan for this client? a. That the medication will have to be monitored very carefully owing to the client's diagnosis of pneumonia. b. The fact that Lasix has been proven to decrease symptoms with pneumonia. c. The fact that Lasix has shown efficacy in treating persons with renal insufficiency. d. That the medication will need to be given at a higher than normal dose owing to the client's medical problems.

c. Fish
A client taking spironolactone (Aldactone) has been taught about the therapy. Which menu selection indicates that the client understands teaching related to this medication? a. Apricots b. Bananas c. Fish d. Strawberries

c. A 47-year-old client with anuria

Which client would the nurse need to assess first if the client is receiving mannitol (Osmitrol)? a. A 67-year-old client with type 1 diabetes mellitus b. A 21-year-old client with a head injury c. A 47-year-old client with anuria d. A 55-year-old client receiving cisplatin to treat ovarian cancer

c. A decrease in arterial pH
A nurse is caring for a client receiving acetazolamide (Diamox). Which assessment finding will require immediate nursing intervention? a. A decrease in bicarbonate level b. An increase in urinary output c. A decrease in arterial pH d. An increase in PaO2

b. Assess lung sounds before and after administration. c. Assess blood pressure before and after administration. d. Maintain accurate intake and output record.
A client is ordered furosemide (Lasix) to be given via intravenous push. What interventions should the nurse perform? (Select all that apply.) a. Administer at a rate no faster than 20 mg/min. b. Assess lung sounds before and after administration. c. Assess blood pressure before and after administration. d. Maintain accurate intake and output record. e. Monitor ECG continuously. f. Insert an arterial line for continuous blood pressure monitoring.

d. "Wear protective clothing and sunscreen while on this medication."

A client is prescribed Thalitone (chlorthalidone). What is the most important information the nurse should teach the client? a. "Do not drink more than 10 ounces of fluid a day while on this medication." b. "Take this medication on an empty stomach." c. "Take this medication before bed each night." d. "Wear protective clothing and sunscreen while on this medication."

c. Decreased aldosterone
A client with hyperaldosteronism is prescribed spironolactone (Aldactone). What assessment finding would the nurse evaluate as a positive outcome? a. Decreased potassium level b. Decreased crackles in the lung bases c. Decreased aldosterone d. Decreased ankle edema

c. Lungs clear.

A client with acute pulmonary edema receives furosemide (Lasix). What assessment finding indicates that the intervention is working? a. Potassium level decreased from 4.5 to 3.5 mEq/L. b. Crackles auscultated in the bases. c. Lungs clear. d. Output 30 mL/hr.

a. Decreased intracranial pressure

Which assessment indicates a therapeutic effect of mannitol (Osmitrol)? a. Decreased intracranial pressure b. Decreased potassium c. Increased urine osmolality d. Decreased serum osmolality

c. Assess potassium levels.

Which intervention will the nurse perform when monitoring a client receiving triamterene (Dyrenium)? a. Assess urinary output hourly. b. Monitor for side effect of hypoglycemia. c. Assess potassium levels. d. Monitor for Hypernatremia.

a. It causes an alkaline urine, which facilitates the elimination of uric acid.

The client asks the nurse why the health care provider prescribed acetazolamide (Diamox), a diuretic, to treat gout. What is the nurse's best response? a. It causes an alkaline urine, which facilitates the elimination of uric acid. b. It increases alkalinity of urine, thus decreasing the formation of uric acid. c. It causes an acid urine, which facilitates the elimination of uric acid. d. It decreases alkalinity of urine, thus decreasing the formation of uric acid.

c. Stage 1 hypertension
A client's blood pressure (BP) is 145/90. According to the guidelines for determining hypertension, the nurse realizes that the client's BP is at which stage? a. Normal b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension

a. Diuretic
The nurse acknowledges that the first-line drug for treating this client's blood pressure might be which drug? a. Diuretic b. Alpha blocker c. ACE inhibitor d. Alpha/beta blocker

c. Beta blockers and ACE inhibitors

The nurse is aware that which group(s) of antihypertensive drugs are less effective in AfricanAmerican clients? a. Diuretics b. Calcium channel blockers and vasodilators c. Beta blockers and ACE inhibitors d. Alpha blockers

b. hydrochlorothiazide
The nurse knows that which diuretic is most frequently combined with an antihypertensive drug? a. chlorthalidone b. hydrochlorothiazide c. bendroflumethiazide d. potassium-sparing diuretic

a. Beta1 blocker
The nurse explains that which beta blocker category is preferred for treating hypertension? a. Beta1 blocker b. Beta2 blocker c. Beta1 and beta2 blockers d. Beta2 and beta3 blockers

d. Constant, irritating cough

Captopril (Capoten) has been ordered for a client. The nurse teaches the client that ACE inhibitors have which common side effects? a. Nausea and vomiting b. Dizziness and headaches

c. Upset stomach d. Constant, irritating cough

b. Blocking angiotensin II from AT1 receptors

A client is prescribed losartan (Cozaar). The nurse teaches the client that an angiotensin II receptor blocker (ARB) acts by doing what? a. Inhibiting angiotensin-converting enzyme b. Blocking angiotensin II from AT1 receptors c. Preventing the release of angiotensin I d. Promoting the release of aldosterone

b. Dizziness c. Headache e. Ankle edema

During an admission assessment, the client states that she takes amlodipine (Norvasc). The nurse wishes to determine whether or not the client has any common side effects of a calcium channel blocker. The nurse asks the client if she has which signs and symptoms? (Select all that apply.) a. Insomnia b. Dizziness c. Headache d. Angioedema e. Ankle edema f. Hacking cough

a. "I will check my blood pressure daily and take my medication when it is over 140/90."
Which statement indicates that the client needs additional instruction about antihypertensive treatment? a. "I will check my blood pressure daily and take my medication when it is over 140/90." b. "I will include rest periods during the day to help me tolerate the fatigue my medicine may cause." c. "I will change my position slowly to prevent feeling dizzy." d. "I will not mow my lawn until I see how this medication makes me feel."

a. Call the health care provider to switch the medication.

A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry, nonproductive cough. What is the nurse's priority action?

a. Call the health care provider to switch the medication. b. Assess the client for other symptoms of upper respiratory infection. c. Instruct the client to take antitussive medication until the symptoms subside. d. Tell the client that the cough will subside in a few days.

d. spironolactone (Aldactone)
The nurse is reviewing a medication history on a client taking an ACE inhibitor. The nurse plans to contact the health care provider if the client is also taking which medication? a. docusate sodium (Colace) b. furosemide (Lasix) c. morphine sulfate d. spironolactone (Aldactone)

b. Respiratory assessment
A client is prescribed a noncardioselective beta1 blocker. What nursing intervention is a priority for this client? a. Assessment of blood glucose levels b. Respiratory assessment c. Orthostatic blood pressure assessment d. Teaching about potential tachycardia

c. The client who has stopped taking a beta blocker due to cost.
Which client will the nurse assess first? a. The client who has been on beta blockers for 1 day. b. The client who is on a beta blocker and a thiazide diuretic. c. The client who has stopped taking a beta blocker due to cost. d. The client who is taking a beta blocker and Lasix (furosemide).

d. Get up slowly from a sitting to a standing position.

The nurse is caring for a client with hypertension who is prescribed Clonidine transdermal preparation. What is the correct information to teach this client? a. Change the patch daily at the same time. b. Remove the patch before taking a shower or bath. c. Do not take other antihypertensive medications while on this patch. d. Get up slowly from a sitting to a standing position.

b. Notify the health care provider.

The client taking Methyldopa (Aldomet) has elevated liver function tests. What is the nurse's best action? a. Document the finding and continue care. b. Notify the health care provider. c. Immediately stop the medication. d. Change the client's diet.

c. Determine the client's history.

A client taking prazosin has a blood pressure of 140/90. The client is complaining of swollen feet. What is the nurse's best action? a. Hold the medication. b. Call the health care provider. c. Determine the client's history. d. Weigh the client.

c. Hypotension
A calcium channel blocker has been ordered for a client. Which condition in the client's history is a contraindication to this medication? a. Hypokalemia b. Dysrhythmias c. Hypotension d. Increased intracranial pressure

b. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation."
A client who takes clonidine (Catapres) is to be discharged to home. Which instruction will the nurse include when teaching this client? a. "Your blood pressure should be checked by a health care provider at least once a year." b. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation." c. "Intense exercise or prolonged standing is not a problem with clonidine as it can be with other antihypertensive agents." d. "If you are having difficulty with the common side effect of drooling, notify your health care provider so your dosage can be adjusted."

c. To administer phentolamine (Regitine)

During assessment of a client diagnosed with pheochromocytoma, the nurse auscultates a blood pressure of 210/110 mm Hg. What is the nurse's best action?

a. To ask the client to lie down and rest b. To assess the client?s dietary intake of sodium and fluid c. To administer phentolamine (Regitine) d. To administer nitroprusside (Nipride)

a. Alteration in cardiac output related to effects on the sympathetic nervous system

Which is a priority nursing diagnosis for a client taking an antihypertensive medication? a. Alteration in cardiac output related to effects on the sympathetic nervous system b. Knowledge deficit related to medication regimen c. Fatigue related to side effects of medication d. Alteration in comfort related to nonproductive cough

a. Coronary thrombosis b. Acute myocardial infarction c. Deep vein thrombosis (DVT) d. Cerebrovascular accident (CVA) (stroke) e. Venous disorders
When a newly admitted client is placed on heparin, the nurse acknowledges that heparin is effective for preventing new clot formation in clients who have which disorder(s)? (Select all that apply.) a. Coronary thrombosis b. Acute myocardial infarction c. Deep vein thrombosis (DVT) d. Cerebrovascular accident (CVA) (stroke) e. Venous disorders

a. protamine sulfate
A client who received heparin begins to bleed, and the physician calls for the antidote. The nurse knows that which is the antidote for heparin? a. protamine sulfate b. vitamin K c. aminocaproic acid d. vitamin C

a. A longer half-life than heparin

A client is prescribed enoxaparin (Lovenox). The nurse knows that low-molecular-weight heparin (LMWH) has what kind of half-life?

a. A longer half-life than heparin b. A shorter half-life than heparin c. The same half-life as heparin d. A four-times shorter half-life than heparin

c. Bleeding may increase when taken with aspirin.

The nurse is teaching a client about clopidogrel (Plavix). What is important information to include? a. Constipation may occur. b. Hypotension may occur. c. Bleeding may increase when taken with aspirin. d. Normal dose is 25 mg tablet per day.

d. Subcutaneously
A client is prescribed dalteparin (Fragmin). LMWH is administered via which route? a. Intravenously b. Intramuscularly c. Intradermally d. Subcutaneously

b. warfarin (Coumadin)
A client is being changed from an injectable anticoagulant to an oral anticoagulant. Which anticoagulant does the nurse realize is administered orally? a. enoxaparin sodium (Lovenox) b. warfarin (Coumadin) c. bivalirudin (Angiomax) d. lepirudin (Refludan)

b. Elevated INR range

A client is taking warfarin 5 mg/day for atrial fibrillation. The client's international normalized ration (INR) is 3.8. The nurse would consider the INR to be what? a. Within normal range b. Elevated INR range c. Low INR range d. Low average INR range

d. To suppress platelet aggregation

Cilostazol (Pletal) is being prescribed for a client with coronary artery disease. The nurse knows that which is the major purpose for antiplatelet drug therapy? a. To dissolve the blood clot b. To decrease tissue necrosis c. To inhibit hepatic synthesis of vitamin K d. To suppress platelet aggregation

b. abciximab (ReoPro)
A client is to undergo a coronary angioplasty. The nurse acknowledges that which drug is used primarily for preventing reocclusion of coronary arteries following a coronary angioplasty? a. clopidogrel (Plavix) b. abciximab (ReoPro) c. warfarin (Coumadin) d. streptokinase

c. Thrombolytic agent
A client is admitted to the emergency department with an acute myocardial infarction. Which drug category does the nurse expect to be given to the client early for the prevention of tissue necrosis following blood clot blockage in a coronary or cerebral artery? a. Anticoagulant agent b. Antiplatelet agent c. Thrombolytic agent d. Low-molecular-weight heparin (LMWH)

b. Activated partial thromboplastin time (aPTT) of 120 seconds

A client is receiving an intravenous heparin drip. Which laboratory value will require immediate action by the nurse? a. Platelet count of 150,000 b. Activated partial thromboplastin time (aPTT) of 120 seconds c. INR of 1.0 d. Blood urea nitrogen (BUN) level of 12 mg/dL

b. Administer vitamin K.
A client who has been taking warfarin (Coumadin) is admitted with coffee-ground emesis. What is the nurse's primary action? a. Administer vitamin E. b. Administer vitamin K.

c. Administer protamine sulfate. d. Administer calcium gluconate.

a. Administer an additional dose of warfarin (Coumadin).

The client has an international normalized ratio (INR) value of 1.5. What action will the nurse take? a. Administer an additional dose of warfarin (Coumadin). b. Hold the next dose of warfarin (Coumadin). c. Increase the heparin drip rate. d. Administer protamine sulfate.

c. "I will increase dark-green, leafy vegetables in my diet."

A client is receiving warfarin (Coumadin) for a chronic condition. Which client statement requires immediate action by the nurse? a. "I will avoid contact sports." b. "I will take my medication in the early evening each day." c. "I will increase dark-green, leafy vegetables in my diet." d. "I will contact my health care provider if I develop excessive bruising."

a. "I take aspirin daily for headaches."

A client is taking enoxaparin (Lovenox) daily. Which client statement requires additional monitoring? a. "I take aspirin daily for headaches." b. "I take ibuprofen (Motrin) at least once a week for joint pain." c. "Whenever I have a fever, I take acetaminophen (Tylenol)." d. "I take my medicine first thing in the morning."

b. Weigh the client before administration.

The client is receiving tirofiban (Aggrastat). What is an essential nursing intervention for this client? a. Have protamine sulfate available in case of an overdose. b. Weigh the client before administration. c. Have vitamin K available in case of an overdose. d. Assess intake and output.

c. Administer the medication into subcutaneous tissue.

A nurse is preparing to administer enoxaparin sodium (Lovenox) to a client for prevention of deep vein thrombosis. What is an essential nursing intervention? a. Draw up the medication in a syringe with a 22-gauge, 1- inch needle. b. Utilize the Z-track method to inject the medication. c. Administer the medication into subcutaneous tissue. d. Rub the administration site after injecting.

b. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding."
The client asks what the difference is between dalteparin (Fragmin) and heparin. What is the nurse's best response? a. "There is no real difference. Dalteparin is preferred because it is less expensive." b. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." c. "I'm not sure why some health care providers choose dalteparin and some heparin. You should ask your doctor." d. "The only difference is that heparin dosing is based on the client's weight."

b. Administer protamine sulfate.

A client has been admitted through the emergency department and requires emergency surgery. The client has been receiving heparin. What nursing intervention is essential? a. Teach the client about the phenytoin. b. Administer protamine sulfate. c. Assess the INR before surgery. d. Administer vitamin K.

a. Assess for reperfusion dysrhythmias.

What nursing intervention is essential for the client receiving alteplase? a. Assess for reperfusion dysrhythmias. b. Monitor liver enzymes. c. Administer vitamin K if bruising is observed. d. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic.

b. Teach the client of potential drug interactions with anticoagulants.

A client who is taking warfarin (Coumadin) requests an aspirin for headache relief. What is the nurse's best response? a. Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 minutes.

b. Teach the client of potential drug interactions with anticoagulants. c. Explain to the client that ASA is contraindicated and administer ibuprofen as ordered. d. Explain that the headache is an expected side effect and will subside shortly.

b. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic."
A client is started on warfarin (Coumadin) therapy while still receiving intravenous heparin. The client questions the nurse about the risk for bleeding. How should the nurse respond? a. "Your concern is valid. I will call the doctor to discontinue the heparin." b. "It usually takes about 3 days to achieve a therapeutic effect for warfarin, so the heparin is continued until the warfarin is therapeutic." c. "Because of your valve replacement, it is especially important for you to be anticoagulated. The heparin and warfarin together are more effective than one alone." d. "Because you are now up and walking, you have a higher risk of blood clots and therefore need to be on both medications."

d. "I should use a soft toothbrush for dental hygiene."

The nurse evaluates that the client understood discharge teaching regarding warfarin (Coumadin) based on which statement? a. "I will double my dose if I forget to take it the day before." b. "I should keep taking ibuprofen for my arthritis." c. "I should decrease the dose if I start bruising easily." d. "I should use a soft toothbrush for dental hygiene."

a. Perform all necessary venipunctures.

What intervention is essential before the nurse administers tenecteplase (TNKase)? a. Perform all necessary venipunctures. b. Administer aminocaproic acid (Amicar). c. Have the client void. d. Assess for allergies to iodine.

c. Risk for injury

Which nursing diagnosis would be possible for a client receiving intravenous heparin therapy? a. Potential for fluid volume excess b. Potential for pain c. Risk for injury d. Potential for body image disturbance

c. Hyperlipidemia
A client has a serum cholesterol level of 265 mg/dL, triglyceride level of 235 mg/dL, and LDL of 180 mg/dL. What do these serum levels indicate? a. Hypolipidemia b. Normolipidemia c. Hyperlipidemia d. Alipidemia

a. 150 to 200 mg/dL

The nurse knows that the client's cholesterol level should be within which range? a. 150 to 200 mg/dL b. 200 to 225 mg/dL c. 225 to 250 mg/dL d. Greater than 250 mg/dL

b. It is the desired level of HDL.

A client's high-density lipoprotein (HDL) is 60 mg/dL. What does the nurse acknowledge concerning this level? a. It is lower than the desired level of HDL. b. It is the desired level of HDL. c. It is higher than the desired level of HDL. d. It is a much lower HDL level than desired.

b. homocysteine
The nurse realizes that which is the laboratory test ordered to determine the presence of the amino acid that can contribute to cardiovascular disease and stroke? a. antidiuretic hormone b. homocysteine c. ceruloplasmin d. cryoglobulin

d. Liver enzymes
A client is taking lovastatin (Mevacor). Which serum level is most important for the nurse to monitor? a. Blood urea nitrogen b. Complete blood count

c. Cardiac enzymes d. Liver enzymes

b. Rhabdomyolysis
The client is taking rosuvastatin (Crestor). What severe skeletal muscle adverse reaction should the nurse observe for? a. Myasthenia gravis b. Rhabdomyolysis c. Dyskinesia d. Agranulocytosis

a. Inhibits absorption of dietary cholesterol in the intestines.

When a client is taking ezetimibe (Zetia), she asks the nurse how it works. The nurse should explain that Zetia does what? a. Inhibits absorption of dietary cholesterol in the intestines. b. Binds with bile acids in the intestines to reduce LDL levels. c. Inhibits HMG-CoA reductase, which is necessary for cholesterol production in the liver. d. Forms insoluble complexes and reduces circulating cholesterol in blood.

a. Relaxes the arterial walls within the skeletal muscles b. May cause hypotension, chest pain, and palpitations
A client is diagnosed with peripheral arterial disease (PAD). He is prescribed isoxsuprine (Vasodilan). The nurse acknowledges that isoxsuprine does what? (Select all that apply.) a. Relaxes the arterial walls within the skeletal muscles b. May cause hypotension, chest pain, and palpitations c. Increases the rigidity of arteriosclerotic blood vessels d. May increase intermittent claudication e. May lead to hypertension and bradycardia f. Commonly causes an adverse effect of rhabdomyolysis

b. "I will increase fiber in my diet."

Which statement indicates the client understands discharge instructions regarding cholestyramine (Questran)? a. "I will take Questran 1 hour before my other medications." b. "I will increase fiber in my diet." c. "I will weigh myself weekly." d. "I will have my blood pressure checked weekly."

b. Administer aspirin 30 minutes before nicotinic acid.

The nurse plans which intervention to decrease the flushing reaction of niacin? a. Administer niacin with an antacid. b. Administer aspirin 30 minutes before nicotinic acid. c. Administer diphenhydramine hydrochloride (Benadryl) with niacin. d. Apply cold compresses to the head and neck.

b. "Take this medication at the same time each day."

The nurse is reviewing instructions for a client taking an HMG-CoA reductase inhibitor (statin). What information is essential for the nurse to include? a. "Take this medication on an empty stomach." b. "Take this medication at the same time each day." c. "Take this medication with breakfast." d. "Take this medication with an antacid."

b. "You may experience headaches with this medication."

A client is prescribed gemfibrozil (Lopid) for treatment of hyperlipidemia type IV. What is important for the nurse to teach the client? a. "Take aspirin before the medication if you experience facial flushing." b. "You may experience headaches with this medication." c. "You will need to have weekly blood drawn to assess for hyperkalemia." d. "Cholesterol levels will need to be assessed daily for one week."

d. "I will continue my exercise program to help increase my high-density lipoprotein serum levels."
Which statement made by the client indicates understanding about discharge instructions on antihyperlipidemic medications? a. "Antihyperlipidemic medications will replace the other interventions I have been doing to try to decrease my cholesterol." b. "It is important to double my dose if I miss one in order to maintain therapeutic blood levels." c. "I will stop taking the medication if it causes nausea and vomiting." d. "I will continue my exercise program to help increase my high-density lipoprotein serum levels."

c. Muscle pain.
A client is prescribed ezetimibe (Zetia). Which assessment finding will require immediate action by the nurse?

a. Headache. b. Slight nausea. c. Muscle pain. d. Fatigue.

c. Have the client increase fluids and fiber in his diet.

A nurse is caring for a client taking cholestyramine (Questran). The client is complaining of constipation. What will the nurse do? a. Call the health care provider to change the medication. b. Tell the client to skip a dose of the medication. c. Have the client increase fluids and fiber in his diet. d. Administer an enema to the client.

d. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication."
Which statement indicates to the nurse that the client needs further medication instruction about colestipol (Colestid)? a. "The medication may cause constipation, so I will increase fluid and fiber in my diet." b. "I should take this medication 1 hour after or 4 hours before my other medications." c. "I might need to take fat-soluble vitamins to supplement my diet." d. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication."

b. Elevated liver function tests

Which assessment finding in a client taking an HMG-CoA reductase inhibitor will the nurse act on immediately? a. Decreased hemoglobin b. Elevated liver function tests c. Elevated HDL d. Elevated LDL

b. "These factors may put you at higher risk for myopathy."

A 70-year-old client who is taking several cardiac antidysrhythmic medications has been prescribed simvastatin (Zocor) 80 mg/day. What is essential information for the nurse to teach the client? a. "This dose may lower your cholesterol too much." b. "These factors may put you at higher risk for myopathy."

c. "You should not take this drug with cardiac medications." d. "This combination will cause you to have nausea and vomiting."

b. Hepatic disease
A client diagnosed with hypercholesterolemia is prescribed lovastatin (Mevacor). The nurse is reviewing the client's history and would contact the health care provider about which of these conditions in the client's history? a. Chronic pulmonary disease b. Hepatic disease c. Leukemia d. Renal disease

c. gemfibrozil (Lopid)
A nurse is caring for a client with elevated triglyceride levels who is unresponsive to HMG-CoA reductase inhibitors. What medication will the nurse administer? a. cholestyramine (Questran) b. colestipol (Colestid) c. gemfibrozil (Lopid) d. simvastatin (Zocor)

a. Impaction
The nurse would question an order for cholestyramine (Questran) if the client has which condition? a. Impaction b. Glaucoma c. Hepatic disease d. Renal disease

c. Client is on oral contraceptives.

The nurse reviews the history for a client taking atorvastatin (Lipitor). What will the nurse act on immediately? a. Client takes medications with grape juice. b. Client takes herbal therapy including kava kava. c. Client is on oral contraceptives. d. Client was started on penicillin for a respiratory infection.

. Avoid driving a motor vehicle until stabilized on the drug.

A client tells the nurse that he has started to take an OTC antihistamine, diphenhydramine. In teaching him about side effects, what is most important for the nurse to tell the client? a. Do not to take this drug at bedtime to avoid insomnia. b. Avoid driving a motor vehicle until stabilized on the drug. c. Nightmares and nervousness are more likely in an adult. d. Limit use to 1 to 2 puffs/sprays 4 to 6 times per day to avoid rebound congestion.

c. Acute pharyngitis.
The client complains of a sore throat and has been told it is due to beta-hemolytic streptococcal infection. The nurse realizes this condition is called what? a. Acute rhinitis. b. Acute sinusitis. c. Acute pharyngitis. d. Acute rhinorrhea.

d. Limit the drug to 5 days of use to prevent rebound nasal congestion.

A client is prescribed the decongestant oxymetazoline (Afrin) nasal spray. What should the nurse teach the client? a. Take this drug at bedtime as a sleep aid. b. Directly spray away from the nasal septum and gently sniff. c. This drug may be used in maintenance treatment for asthma. d. Limit the drug to 5 days of use to prevent rebound nasal congestion.

b. To loosen bronchial secretions so they can be eliminated by coughing

A client has been prescribed guaifenesin (Robitussin). The nurse realizes that the purpose of the drug is to accomplish what? a. To treat allergic rhinitis and prevent motion sickness b. To loosen bronchial secretions so they can be eliminated by coughing c. To compete with histamine for receptor sites, thus preventing a histamine response d. To stimulate alpha-adrenergic receptors, thus producing vascular constriction of capillaries in nasal mucosa

d. Dry nasal mucosa

Beclomethasone (Beconase) has been prescribed for a client with allergic rhinitis. The nurse teaches the client that which is the most common side effect from continuous use?

a. Dizziness b. Rhinorrhea c. Hallucinations d. Dry nasal mucosa

a. Take medication with food to decrease gastric distress. b. Avoid alcohol and other central nervous system depressants. c. Notify the health care provider if confusion or hypotension occurs. d. Take sugarless candy, gum, or ice chips for temporary relief of dry mouth. e. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug.
The nurse is teaching a client about diphenhydramine (Benadryl). Which are topics to include? (Select all that apply.) a. Take medication with food to decrease gastric distress. b. Avoid alcohol and other central nervous system depressants. c. Notify the health care provider if confusion or hypotension occurs. d. Take sugarless candy, gum, or ice chips for temporary relief of dry mouth. e. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug.

a. "Do not drive after taking this medication."

The nurse is caring for a client who is taking a first-generation antihistamine. What is the most important fact for the nurse to teach the client? a. "Do not drive after taking this medication." b. "Make sure you drink a lot of liquids while on this medication." c. "Take this medication on an empty stomach." d. "Do not take this medication for more than 2 days."

d. "You may be able to safely take a second-generation antihistamine."

The nurse is caring for a client in the clinic who states that he is afraid of taking antihistamines because he is a truck driver. What is the best information for the nurse to give this client? a. "Take the medication only when you are not driving." b. "Take a lower dose than normal when you have to drive." c. "You are correct, you should not take antihistamines." d. "You may be able to safely take a second-generation antihistamine."

Administer guaifenesin.

The client tells the nurse that she has a bad cold, is coughing, and feels like she has "stuff" in her lungs. What should the nurse do? a. Administer dextromethorphan. b. Administer guaifenesin. c. Encourage the client to drink fluids hourly. d. Administer fluticasone (Flonase).

b. This medication has fewer sedative effects.

What is the most important thing for the nurse to teach a client who is switching allergy medications from diphenhydramine (Benadryl) to loratadine (Claritin)? a. This medication can potentially cause dysrhythmias. b. This medication has fewer sedative effects. c. This medication has increased bronchodilating effects. d. This medication causes less gastrointestinal upset.

b. "Overuse of nasal decongestants results in rebound congestion."

A client complains of worsening nasal congestion despite the use of oxymetazoline (Afrin) nasal spray every 2 hours. What is the nurse's best response? a. "Oxymetazoline is not an effective nasal decongestant." b. "Overuse of nasal decongestants results in rebound congestion." c. "Oxymetazoline should be administered every hour for severe congestion." d. "You are probably displaying an idiosyncratic reaction to oxymetazoline."

b. "This medication will help prevent the inflammatory response of my allergies."

Which statement indicates that the client understands the teaching about beclomethasone diproprionate (Beconase)? a. "I will need to taper off the medication to prevent acute adrenal crisis." b. "This medication will help prevent the inflammatory response of my allergies." c. "I will need to monitor my blood sugar more closely because it may increase." d. "I need to take this medication only when my symptoms get bad."

a. "This medication may cause drowsiness and dizziness."

A client is prescribed an antitussive medication. What is the most important thing for the nurse to teach the client? a. "This medication may cause drowsiness and dizziness." b. "Watch out for diarrhea and abdominal cramping."

c. "This may cause tremors and anxiety." d. "Headache and hypertension are common side effects."

c. Increase fluid intake in order to decrease viscosity of secretions.

Which is the best instruction for the nurse to include when teaching a client about the use of expectorants? a. Restrict fluids in order to decrease mucus production. b. Take the medication once a day only, at bedtime. c. Increase fluid intake in order to decrease viscosity of secretions. d. Increase fiber and fluid intake to prevent constipation.

a. Asthma
A client is diagnosed with a pulmonary disorder that causes COPD. Lungs tissue changes are normally reversible with this condition. The nurse understands that which is the client's most likely diagnosis? a. Asthma b. Emphysema c. Bronchiectasis d. Chronic bronchitis

b. epinephrine (Adrenalin)
A client with COPD has an acute bronchospasm. The nurse knows that which is the best medication for this emergency situation? a. zafirlukast (Accolate) b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. oxtriphylline-theophyllinate (Choledyl)

c. Increased heart rate

A client is taking aminophylline-theophylline ethylenediamine (Somophyllin). For what should the nurse monitor the client? a. Drowsiness b. Hypoglycemia c. Increased heart rate d. Decreased white blood cell count

b. 10 to 20 mcg/mL

A client is prescribed theophylline to relax the smooth muscles of the bronchi. The nurse monitors the client's theophylline serum levels to maintain which therapeutic range? a. 1 to 10 mcg/mL b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 40 mcg/mL

a. Maintenance treatment of asthma

A client with COPD is taking a leukotriene antagonist, montelukast (Singulair). The nurse is aware that this medication is given for which purpose? a. Maintenance treatment of asthma b. Treatment of an acute asthma attack c. Reversing bronchospasm associated with COPD d. Treatment of inflammation in chronic bronchitis

c. Continue to assess the client's oxygenation.

The nurse is caring for a client with a theophylline level of 14 mcg/mL. What is the priority nursing intervention? a. Increase the IV drip rate. b. Monitor the client for toxicity. c. Continue to assess the client's oxygenation. d. Stop the IV for an hour then restart at lower rate.

d. Tachycardia
Discharge teaching to a client receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. Hypoglycemia b. Nonproductive cough c. Sedation d. Tachycardia

d. St. John's wort

The nurse instructs the client to avoid which over-the-counter products when taking theophylline (Theo-Dur)? a. acetaminophen (Tylenol) b. echinacea

c. diphenhydramine (Benadryl) d. St. John's wort

a. Monitor client for potential chest pain.

A nurse reviews a client's medication history and notes that the client is taking a nonselective adrenergic agonist bronchodilator and has a history of coronary artery disease. What is a priority nursing intervention? a. Monitor client for potential chest pain. b. Monitor blood pressure continuously. c. Assess daily for hyperkalemia. d. Assess 12-lead ECG each shift.

d. Salmeterol has a longer duration of action.

The nurse is instructing a client about the advantages of salmeterol (Serevent) over other beta2 agonists such as albuterol (Proventil). How will the nurse explain to the client the difference in these two medications? a. Salmeterol has a shorter onset of action. b. Salmeterol does not have any side effects. c. Albuterol has a longer onset of action. d. Salmeterol has a longer duration of action.

c. "This medication will prevent the inflammation that causes your asthma attack."
Client teaching regarding the use of antileukotriene agents such as zafirlukast (Accolate) should include which statement? a. "Take the medication as soon as you begin wheezing." b. "It will take about 3 weeks before you notice a therapeutic effect." c. "This medication will prevent the inflammation that causes your asthma attack." d. "Increase fiber and fluid in your diet to prevent the side effect of constipation."

c. Administer a beta2 adrenergic agonist.

A client with a history of asthma is short of breath and says, "I feel like I'm having an asthmatic attack." What is the nurse's best action? a. Call a code. b. Ask the client to describe the symptoms. c. Administer a beta2 adrenergic agonist. d. Administer a long-acting glucocorticoid.

a. Monitor for heart rate >100 beats/min.

A client has taken metaproterenol. What is the nurse's priority action? a. Monitor for heart rate >100 beats/min. b. Tell the client not to drive for 2 hours. c. Monitor for sedation. d. Assess for elevated blood pressure.

b. Rinse his mouth with water after each use.

A client demonstrates understanding of flunisolide (AeroBid) by saying that he will do what? a. Take two puffs to treat an acute asthma attack. b. Rinse his mouth with water after each use. c. Immediately stop taking his oral prednisone when he starts using AeroBid. d. Not use his albuterol inhaler while he is taking AeroBid.

d. Teach the child to use a spacer.

The nurse is caring for a young child who has been prescribed an inhaler for control of her asthma. The child is having difficulty using the inhaler. What is the nurse's best action? a. Tell the parent to hold the inhaler for the child. b. Ask the health care provider to switch to oral medications. c. Tell the parent that young children should not use inhalers. d. Teach the child to use a spacer.

d. The client with atrial fibrillation with a rate of 100

The nurse is caring for clients on the pulmonary unit. Which client should not receive epinephrine if ordered? a. The client with a history of emphysema b. The client with a history of type 2 diabetes c. The client who is 16 years old d. The client with atrial fibrillation with a rate of 100

b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed by beclomethasone several minutes later.
The health care provider orders ipratropium bromide (Atrovent), albuterol (Proventil), and beclomethasone (Vanceril) inhalers for a client. What is the nurse's best action? a. Question the order; three inhalers should not be given at one time. b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed

by beclomethasone several minutes later. c. Administer each inhaler at 30-minute intervals. d. Administer beclomethasone first, wait 2 minutes, and administer ipratropium bromide, followed by the albuterol several minutes later.

c. "Hold your breath for 10 seconds if you can after you inhale the medication."
Which instruction will the nurse include when teaching a client about the proper use of metereddose inhalers? a. "After you inhale the medication once, repeat until you obtain relief." b. "Make sure that you puff out air repeatedly after you inhale the medication." c. "Hold your breath for 10 seconds if you can after you inhale the medication." d. "Hold the inhaler in your mouth, take a deep breath, and then compress the inhaler."

c. Liquefying and loosening of bronchial secretions

What will the nurse expect to find that would indicate a therapeutic effect of acetylcysteine (Mucomyst)? a. Decreased cough reflex b. Decreased nasal secretions c. Liquefying and loosening of bronchial secretions d. Relief of bronchospasms

c. Monitor blood glucose levels every 4 hours when taking albuterol.

What is the most important thing for the nurse to teach the client with a history of diabetes and asthma who has started on albuterol PRN? a. Take Tylenol for headaches when taking albuterol. b. Monitor for orthostatic hypotension every 2 hours when taking albuterol. c. Monitor blood glucose levels every 4 hours when taking albuterol. d. An antianxiety agent may be prescribed to help with nervousness.

b. "Take the ipratropium at least 5 minutes before the cromolyn."

A client is prescribed ipratropium and cromolyn sodium. What will the nurse teach the client? a. "Do not take these medications within 4 hours of each other." b. "Take the ipratropium at least 5 minutes before the cromolyn." c. "Administer both medications together in a metered-dose inhaler." d. "Take the ipratropium only in the mornings."

c. Hold the next dose of theophylline.

A client taking an oral theophylline preparation is due for her next dose and has a blood pressure of 100/50 mm Hg and a heart rate of 110. The client is irritable. What is the best action for the nurse to take? a. Continue to monitor the client. b. Call the health care provider. c. Hold the next dose of theophylline. d. Administer oxygen 2 lpm via nasal cannula.

b. Lack of exercise
A client complains of constipation and requires a laxative. In providing teaching to the client, the nurse reviews the common causes of constipation, including which cause? a. Motion sickness b. Lack of exercise c. Food intolerance d. Bacteria (Escherichia coli)

b. Block serotonin receptors in the CTZ

A client has nausea and is taking ondansetron (Zofran). The nurse explains that the action of this drug is what? a. Stimulate the CTZ b. Block serotonin receptors in the CTZ c. Block dopamine receptors in the CTZ d. Coat the wall of the GI tract and absorb bacteria

a. Acts on smooth intestinal muscle to gently increase peristalsis

A client who has constipation is prescribed a bisacodyl suppository. The nurse explains that bisacodyl does what? a. Acts on smooth intestinal muscle to gently increase peristalsis b. Absorbs water into the intestines to increase bulk and peristalsis c. Lowers surface tension and increases water accumulation in the intestines d. Pulls hyperosmolar salts into the colon and increases water in the feces to increase bulk

d. Dry mouth
A client is using the scopolamine patch to prevent motion sickness. The nurse teaches the client that which is a common side effect of this drug? a. Diarrhea b. Vomiting

c. Insomnia d. Dry mouth

c. Alcohol
When metoclopramide (Raglan) is given for nausea, the client is cautioned to avoid which substance? a. Milk b. MAOIs c. Alcohol d. Carbonated beverages

a. Warn the client to avoid laxative abuse. b. Record the frequency of bowel movements. c. Warn the client against taking sedatives concurrently. d. Encourage the client to increase fluids. e. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma.
The nurse is administering opium tincture (paregoric) to a client. Which should be included in the client teaching regarding this medication? (Select all that apply.) a. Warn the client to avoid laxative abuse. b. Record the frequency of bowel movements. c. Warn the client against taking sedatives concurrently. d. Encourage the client to increase fluids. e. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. f. Teach the client that the drug acts by drawing water into the intestine.

a. Client has not had a bowel movement in 3 days.

Which assessment finding will need intervention and is related to the client's use of aluminum hydroxide (Amphojel)? a. Client has not had a bowel movement in 3 days. b. Client has had one loose stool this week. c. Client is complaining of gastric upset. d. Client has trace edema in feet.

c. Client taking magnesium-containing antacids who has renal failure.

Which client needs immediate intervention? a. Client taking aluminum-containing antacids with complaints of reflux. b. Client taking calcium-containing antacids who is hypocalcemic.

c. Client taking magnesium-containing antacids who has renal failure. d. Client taking antacids who is older than 70 years.

a. Assess for metabolic alkalosis.

What assessment has the highest priority for a client using sodium bicarbonate to treat gastric hyperacidity? a. Assess for metabolic alkalosis. b. Assess for fluid volume deficit. c. Assess for hyperkalemia. d. Assess for hypercalcemia.

b. Potential risk for bleeding related to thrombocytopenia

Which nursing diagnoses is appropriate for a client receiving famotidine (Pepcid)? a. Increased risk for infection related to immunosuppression b. Potential risk for bleeding related to thrombocytopenia c. Alteration in urinary elimination related to retention d. Alteration in tissue perfusion related to hypertension

b. "Smoking decreases the effects of this medication, so I should look into cessation programs."
Which statement demonstrates to the nurse that the client understands instructions regarding the use of histamine2-receptor antagonists? a. "Since I am taking this medication, it is all right for me to eat spicy foods." b. "Smoking decreases the effects of this medication, so I should look into cessation programs." c. "I should take this medication 1 hour after each meal in order to decrease gastric acidity." d. "I should decrease bulk and fluids in my diet to prevent diarrhea."

d. Administer the medications and assess the client for relief.

A client is prescribed Lorazepam (Ativan) and a glucocorticoid during chemotherapy treatments. What is the nurse's best action? a. Call the health care provider and question the order. b. Only administer the Ativan if the client seems anxious. c. Administer the two medications at least 12 hours apart. d. Administer the medications and assess the client for relief.

d. pantoprazole (Protonix)

A nurse is caring for a client who is unable to tolerate oral medications. The nurse anticipates that the client may be prescribed which proton pump inhibitor to be administered intravenously? a. esomeprazole (Nexium) b. lansoprazole (Prevacid) c. omeprazole (Prilosec) d. pantoprazole (Protonix)

c. "I will apply the scopolamine patches to rotating sites on my arms."

Which client statement indicates that further teaching is needed? a. "I will not drive while I am taking these medications because they may cause drowsiness." b. "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." c. "I will apply the scopolamine patches to rotating sites on my arms." d. "I should take my prescribed antiemetic before receiving my chemotherapy dose and continue afterwards."

b. Gastric assessment
The nurse is administering loperamide (Imodium) to a client with diarrhea. What assessment is essential for this client? a. Vascular assessment b. Gastric assessment c. Hourly blood pressure measurements d. White blood count

c. Decrease in gastric motility

Which outcome assessment is essential to monitor for the client taking diphenoxylate (Lomotil)? a. Increase in bowel sounds b. Increase in number of bowel movements c. Decrease in gastric motility d. Decrease in urination

c. Administer 30 minutes before meals and at bedtime.

The nurse is planning to administer metoclopramide (Reglan). What is a primary intervention? a. Administer with food to decrease gastrointestinal upset. b. Administer every 6 hours around the clock. c. Administer 30 minutes before meals and at bedtime. d. Give with a full glass of water first thing in the morning.

c. Combination therapy blocks different vomiting pathways.

What will the nurse teach the client about the reason for administering multiple medications for relief of nausea and vomiting? a. Combination therapy decreases the risk of constipation. b. Combination therapy is more cost-effective. c. Combination therapy blocks different vomiting pathways. d. Combination therapy decreases side effects due to lower doses of each drug.

b. Fluid volume deficit related to nausea and vomiting

In developing a plan of care for a client receiving an antihistamine antiemetic agent, which nursing diagnosis would be of highest priority? a. Knowledge deficit regarding medication administration b. Fluid volume deficit related to nausea and vomiting c. Risk for injury related to side effects of medication d. Alteration in comfort related to nausea and vomiting

c. "Brush your teeth and gargle to help with dryness in your mouth."
What instruction is most important for the nurse to teach a client who is taking an anticholinergic agent to treat nausea and vomiting? a. "Assess your stools for dark streaks." b. "Do not take more than two doses of this medication." c. "Brush your teeth and gargle to help with dryness in your mouth." d. Check your heart rate and call the health care provider if it gets below 50 beats/min.

b. Weigh the client before chemotherapy.

A client is prescribed granisetron (Kytril) IV for relief of nausea and vomiting caused by cancer chemotherapy. What intervention is most appropriate for this client? a. Administer the medication at least 12 hours before the start of chemotherapy. b. Weigh the client before chemotherapy. c. Assess baseline vital signs and monitor for tachycardia. d. Teach the client about the possibility of rebound nausea and vomiting once the drug is discontinued.

b. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy.
A client is starting cisplatin therapy for cancer. What intervention is appropriate for this client?

a. Administer granisetron (Kytril) 60 minutes before therapy and for several days after surgery. b. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy. c. Administer palonosetron (Aloxi) IV push. d. Administer metoclopramide (Reglan) PO.

c. Evaluate renal function.

Before administering a stimulant laxative to a client, which nursing intervention is the priority? a. Obtain a history of constipation and causes. b. Record baseline vital signs. c. Evaluate renal function. d. Assess fluid and electrolyte balance.

c. Monitor signs and symptoms of fluid and electrolyte imbalance.

Which assessment is most important for the client who is taking stimulant laxatives? a. Monitor bowel elimination daily. b. Monitor intake and output. c. Monitor signs and symptoms of fluid and electrolyte imbalance. d. Monitor heart rate and blood pressure every 4 hours.

d. "After 3 days, switch patch to alternate ear." e. "Apply patch 4 hours before effect is desired." f. "Drowsiness is a concern while on this medication."
A client is prescribed scopolamine. What information will the nurse include on the teaching plan for this client? (Select all that apply.) a. "Do not take this medication if you are dizzy." b. "Do not use laxatives while on this medication." c. "Do not use this medication for longer than a day." d. "After 3 days, switch patch to alternate ear." e. "Apply patch 4 hours before effect is desired." f. "Drowsiness is a concern while on this medication."

a. Helicobacter pylori
A client is diagnosed with peptic ulcer disease. The nurse realizes that which factor is a predisposing factor for this condition? a. Helicobacter pylori b. hyposecretion of pepsin c. decreased hydrochloric acid d. decreased number of parietal cells

d. To combine with protein to form a viscous substance that forms a protective covering of ulcer
When a client is given sucralfate (Carafate), the nurse knows that its mode of action is what? a. To neutralize gastric acidity b. To inhibit gastric acid secretion by inhibiting histamine at H2 receptors in parietal cells c. To suppress gastric acid secretion by inhibiting the hydrogen/potassium ATPase enzyme d. To combine with protein to form a viscous substance that forms a protective covering of ulcer

c. The drug must be administered separate from an antacid by at least 1 hour e. Smoking should be avoided while taking this drug f. Foods high in vitamin B12 should be increased in diet
A client is taking ranitidine (Zantac). The nurse who is teaching the client about this drug should include which information? (Select all that apply.) a. Drug-induced impotence is irreversible b. The drug must be administered 30 minutes before meals c. The drug must be administered separate from an antacid by at least 1 hour d. The drug must always be administered with magnesium hydroxide e. Smoking should be avoided while taking this drug f. Foods high in vitamin B12 should be increased in diet

d. Antacids neutralize HCl and reduce pepsin activity.

When a client complains of pain accompanying a peptic ulcer, why should an antacid be given? a. Antacids decrease GI motility. b. Antacids decrease gastric acid secretion. c. Aluminum hydroxide is a systemic antacid. d. Antacids neutralize HCl and reduce pepsin activity.

b. Dizziness d. Headaches f. Decreased libido

A client is taking famotidine (Pepcid) to inhibit gastric secretions. What are the side effects of famotidine? (Select all that apply.) a. Diarrhea b. Dizziness c. Dry mouth d. Headaches

e. Blurred vision f. Decreased libido

b. "I will drink 2 ounces of water after taking aluminum hydroxide."

A client has just been prescribed aluminum hydroxide (Amphojel, ALternaGEL, Alu-Tab) for peptic ulcer pain. The nurse has provided instructions to the client. Which statement by the client indicates to the nurse that the client understands the instructions? a. "I will take aluminum hydroxide at mealtime." b. "I will drink 2 ounces of water after taking aluminum hydroxide." c. "I will take aluminum hydroxide within 30 minutes of my other medications." d. "I will take a laxative if I develop constipation."

a. Administer just before meals.

What is a priority nursing intervention when administering ranitidine (Zantac)? a. Administer just before meals. b. Administer right after eating. c. Administer 1 to 2 hours after meals. d. Administer during meals.

c. The client has no throat pain.

The health care provider prescribes lansoprazole (Prevacid) to a client. Which assessment indicates to the nurse that the medication has had a therapeutic effect? a. The client has no diarrhea. b. The client has no gastric pain. c. The client has no throat pain. d. The client is able to eat.

b. Absent bowel sounds, hard abdomen

The nurse is caring for a client who is taking sucralfate (Carafate, Sulcrate) for treatment of a duodenal ulcer. Which assessment requires action by the nurse? a. Sodium level 140 mEq/L b. Absent bowel sounds, hard abdomen c. Urinary output 30 mL/hr d. Calcium level 8.5 mg/dL

c. Allow the tablet to dissolve in water before administering.

When administering sucralfate (Carafate) to a client with a nasogastric tube, what is an essential intervention? a. Crush the tablet into a fine powder before mixing it with water. b. Administer with a bolus tube feeding. c. Allow the tablet to dissolve in water before administering. d. Administer with an antacid for maximum benefit.

c. "This medication will form a protective barrier over the gastric mucosa."
What information should the nurse include in a teaching plan for the client who is prescribed sucralfate (Carafate)? a. "This medication will neutralize gastric acid." b. "This medication will enhance gastric absorption of meals." c. "This medication will form a protective barrier over the gastric mucosa." d. "Your gastric acid will be inhibited."

b. Administer misoprostol. d. Instruct the client to take omeprazole with the aspirin.
The nurse is caring for a client who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. What is the best intervention for this client? (Select all that apply.) a. Stop all aspirin therapy. b. Administer misoprostol. c. Instruct the client to take the aspirin with milk. d. Instruct the client to take omeprazole with the aspirin.

a. Dehydration
The nurse reviews the client's list of medication, which includes mannitol. The nurse must be aware that which condition is a contraindication for use of this drug? a. Dehydration b. Kidney stones c. Eczema d. Gout

c. Cyclopentolate
The client is being prepared for an eye examination. When the nurse takes the health history, the client says that she is sensitive to atropine sulfate. What drug might be used instead for the examination?

a. Diclofenac b. Suprofen c. Cyclopentolate d. Betaxolol HCl

c. Electrolytes
An 85-year-old client is taking acetazolamide, a carbonic anhydrase inhibitor. A nursing intervention associated with clients receiving this drug is to monitor what? a. Weight b. Complete blood count c. Electrolytes d. Urine output

d. travoprost
The nurse reviews the African-American client's list of medications. It is important for the nurse to be aware that the prostaglandin analogue more effective in African Americans than in nonAfrican Americans is wha? a. latanoprost b. bimatoprost c. unoprostone d. travoprost

a. School-aged children may need only one drug, not a combination.

The school nurse is preparing a presentation for the parent-teacher association meeting on medications commonly used in school-aged children. It is important to note what primary disadvantage of the use of combination products such as Cortisporin Otic? a. School-aged children may need only one drug, not a combination. b. Combination products may not have the desired dose for school-aged children. c. There is increased cost in using combination products for school-aged children. d. Combination products are less effective for school-aged children.

a. Hydrogen peroxide
The camp nurse reviews the "shopping list" of supplies needed for the upcoming camping season. What product is recommended to prevent and treat chronic impaction of cerumen? a. Hydrogen peroxide b. Rubbing alcohol c. Charcoal d. Salt solution

a. Instruct the client to report changes in vision and breathing. b. Maintain sterile technique and prevent dropper
The nurse prepares a health teaching plan for the client with glaucoma. Which important nursing intervention are included for this client? (Select all that apply.) a. Instruct the client to report changes in vision and breathing. b. Maintain sterile technique and prevent dropper contamination during administration of eyedrops. c. Include return demonstration only with geriatric clients. d. Wait 10 minutes to instill the second eye medication to be given at the same time.

d. Client's pupils are constricted to 2 mm.

The nurse administers pilocarpine (Pilocar) to a client with glaucoma. Which assessment finding would indicate a therapeutic effect of the medication? a. Client's eyes appear clear, without drainage. b. Client states that her eyes feel very dry. c. Client's pupils are dilated to 4 mm. d. Client's pupils are constricted to 2 mm.

c. "I should rinse the eye dropper with tap water after each use."
Which statement, made by a client, indicates to the nurse a need for further client teaching regarding proper administration of eye drops? a. "I will put pressure on the inside corner of my eye after I administer the drops." b. "I will be careful not to touch my eye with the dropper." c. "I should rinse the eye dropper with tap water after each use." d. "I will turn my head slightly toward the outside of the eye I am putting the drops in."

b. Warm the eardrops to room temperature before administration.

The nurse is planning to administer eardrops. Which intervention is essential to include in the plan of care? a. Eardrops should be cool when being administered. b. Warm the eardrops to room temperature before administration. c. The pinna of an adult should be held down and back to administer eardrops. d. Eardrops may be warmed in the microwave before administration.

b. carbamide peroxide
A client is complaining of excessive earwax that diminishes hearing ability. What medication will the nurse use to assist the client?

a. acetic acid b. carbamide peroxide c. hydrocortisone d. glycerin

b. Instruct the client that one drop is optimal.

The nurse evaluates the client using eyedrops. The client puts two drops into his eye. What is the nurse's best action? a. Continue to observe the client. b. Instruct the client that one drop is optimal. c. Have the client irrigate his eye to remove excess medication. d. Have the client close his eye and rub to assist in absorption.

b. A horny layer of epidermis

The nurse reviews the client's list of medications and recalls that the purpose of keratolytic agents is to remove what? a. A horny layer of dermis b. A horny layer of epidermis c. Erythematous lesions d. Hair follicles

a. Avoid sunlight. c. Monitor CBC, glucose, and lipids. d. Do not breastfeed or give blood.
Nursing implications for health teaching with clients taking isotretinoin include which implications? (Select all that apply.) a. Avoid sunlight. b. Monitor weight c. Monitor CBC, glucose, and lipids. d. Do not breastfeed or give blood.

c. Assess lesions
The nurse is doing health teaching with a client with psoriasis. Which is a nursing implication of the new biologic agents for the management of psoriasis? a. Daily weight b. Monitor electrolytes

c. Assess lesions d. Monitor CBC and T-cell count

d. finasteride
A 55-year-old man has a chief complaint: "I'm going bald." Which drug is used to treat male pattern baldness? a. dexamethasone b. PABA c. minoxidil d. finasteride

a. Metabolic acidosis c. Respiratory alkalosis

The client has second- and third-degree burns over 25% of his body. Mafenide acetate has been ordered. What acid-base imbalance can result from its use? (Select all that apply.) a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Respiratory acidosis

b. Thinning of the skin d. Purpura

The nurse reviews the client's medication history. Based on the client's prolonged use of glucocorticoids, what does the assessment include? (Select all that apply.) a. Obesity b. Thinning of the skin c. Erythematous lesions d. Purpura

b. A review of iPLEDGE educational materials c. That a negative pregnancy test is required before each monthly refill
A 20-year-old woman comes to the clinic for follow-up related to isotretinoin use. The nurse reviews the iPLEDGE program, which includes which important information? (Select all that apply.) a. That an effective method of contraception must be used throughout treatment b. A review of iPLEDGE educational materials

c. That a negative pregnancy test is required before each monthly refill d. That informed consent is not required

a. Sunscreen products should contain information about UVA and UVB SPF protection. b. UVB radiation is greatest between 10 AM and 4 PM. d. SPF should be at least 15 in sunscreen products.
The school nurse prepares a program for junior high school students on sun safety. What is important information to include? (Select all that apply.) a. Sunscreen products should contain information about UVA and UVB SPF protection. b. UVB radiation is greatest between 10 AM and 4 PM. c. Clouds block radiation, so sunscreen is not needed on cloudy days. d. SPF should be at least 15 in sunscreen products.

d. Silver sulfadiazine cream

Which intervention is most appropriate for the client with second-degree burns? a. IV antibiotics b. Isolation c. IV dextrose infusion d. Silver sulfadiazine cream

a. Perform pregnancy test.

A 20-year-old client is starting isotretinoin (Accutane) therapy. What is an essential nursing intervention for this client? a. Perform pregnancy test. b. Assess sputum cultures. c. Make sure IV is patent. d. Force fluids.

a. Calcium 12 mg/dL
A client is prescribed calcipotriene (Dovonex) for treatment of psoriasis. Which assessment finding requires immediate intervention by the nurse? a. Calcium 12 mg/dL b. Potassium 3.8 meq/L c. Sodium 135 mmol/L d. Phosphorus 2.5 mg/dL

d. Ask client if he or she has any allergies.

Before applying povidone-iodine (Betadine) to a client's skin, what is a primary nursing intervention? a. Apply a cortisone cream. b. Wash the skin. c. Shave and prepare the area. d. Ask client if he or she has any allergies.

b. Call the health care provider if you have muscle weakness.

A client is prescribed isotretinoin (Accutane). What is the most important instruction to teach the client before beginning this medication? a. Do not go out in the sun while on this medication. b. Call the health care provider if you have muscle weakness. c. Increase fluid intake while on this medication. d. Do not take aspirin while on this medication.

he 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?"
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.

The nurse is completing an assessment of the client's sleep patterns. A specific question that the nurse should ask to determine the potential presence of sleep apnea is: 1. "How easily do you fall asleep?" 2. "Do you have vivid, lifelike dreams?" 3. "Do you ever experience loss of muscle control or falling?" 4. "Do you snore loudly or experience headaches?"
4. "Do you snore loudly or experience headaches?" To assess for sleep apnea (unlike assessing for narcolepsy or insomnia), the nurse may ask, "Do you snore loudly?" and "Do you experience headaches after awakening?" A positive response may indicate the client experiences sleep apnea.

The nurse knows that which of the following habits may interfere with a client's sleep? 1. Listening to classical music 2. Finishing office work 3. Reading novels 4. Drinking warm milk
2. Finishing office work At home a client should not try to finish office work or resolve family problems before bedtime. Noise should be kept to a minimum. Soft music may be used to mask noise if necessary. Reading a light novel, watching an enjoyable television program, or listening to music helps a person to

relax. Relaxation exercises can be useful at bedtime. A dairy product snack such as warm milk or cocoa that contains L-tryptophan may be helpful in promoting sleep.

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
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).

A 74-year-old client has been having sleeping difficulties. To have a better idea of the client's problem, the nurse should respond: 1. "What do you do just before going to bed?" 2. "Let's make sure that your bedroom is completely darkened at night." 3. "Why don't you try napping more during the daytime?" 4. "Do you eat a small snack before going to bed?"
1. "What do you do just before going to bed?" To assess the client's sleeping problem, the nurse should inquire about predisposing factors, such as by asking "What do you do just before going to bed?" Assessment is aimed at understanding the characteristics of any sleep problem and the client's usual sleep habits so that ways for promoting sleep can be incorporated into nursing care. Older adults sleep best in softly lit rooms. Napping more during the daytime is often not the best solution. The nurse should first assess the client's sleeping problem. The client does not always have to eat something before going to bed.

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
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.

When discussing the benefits of physical activity and exercise with a client, the nurse identifies which of the following as a positive outcome to the client? (Select all that apply.) 1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 5. Increased cognitive function 6. Increased musculoskeletal flexibility
1. Stress management 2. Enhanced cardiac output 3. Improved bone integrity 4. Facilitation of weight control 6. Increased musculoskeletal flexibility Regular physical activity and exercise enhances functioning of all body systems, including cardiopulmonary functioning (endurance), musculoskeletal fitness (flexibility and bone integrity), weight control and maintenance (body image), and psychological well-being. Effects on cognitive function are not consistent.

Following an assessment of the client, the nurse identifies the nursing diagnosis activity intolerance related to increased weight gain and inactivity. An outcome identified by the nurse should be: 1. Resting heart rate will be 90 to 100 beats/minute 2. Blood pressure will be maintained between 140/80 and 160/90 mm Hg 3. Exercise will be performed 3 to 4 times over the next 2 weeks 4. Achievement of a rating of 3 for activity endurance
3. Exercise will be performed 3 to 4 times over the next 2 weeks An appropriate outcome for activity intolerance related to increased weight gain and inactivity is that the client will perform exercise 3 to 4 times over the next 2 weeks. This outcome is realistic, measurable, and addresses the problem. A resting heart rate of 90-100 beats/minute is too high, and it does not address the need to increase activity. This outcome does not state whether this blood pressure is at rest or after exercising. It also does not address the need to increase activity. A more appropriate outcome is that the client will increase his or her activity (over the next 2 weeks).

Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care? 1. Flex the knees and keep the feet wide apart. 2. Assume a position far enough away from the client. 3. Twist the body in the direction of movement. 4. Use the strong back muscles for lifting or moving.
1. Flex the knees and keep the feet wide apart. The correct answer is to flex the knees and keep the feet wide apart. This will create a wide base of support, providing greater stability for the nurse and reducing the risk of back injury. The nurse should be positioned close to the client and use the arms and legs. Dividing balanced activity between arms and legs reduces the risk of back injury. Facing the direction of movement prevents abnormal twisting of the spine, also reducing the risk of back injury.

While ambulating in the hallway of a hospital, the client complains of extreme dizziness. The nurse, alert to a syncopal episode, should first: 1. Support the client and walk quickly back to the room 2. Lean the client against the wall until the episode passes 3. Lower the client gently to the floor 4. Go for help
3. Lower the client gently to the floor If the client has a syncopal episode or begins to fall, the nurse should assume a wide base of support with one foot in front of the other, supporting the client's weight, and then extend the leg, allowing the client to slide against the leg while gently lowering the client to the floor and protecting the client's head. The nurse should not attempt to walk the client quickly back to the room. The nurse should not lean the client against a wall as the client may fall. The nurse should not leave the client alone and go for help.

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
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.

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
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.

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.
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.

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."
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.

Which of the following symptoms would the nurse expect with a client who is experiencing acute pain? 1. Bradycardia 2. Bradypnea 3. Diaphoresis 4. Decreased muscle tension
3. Diaphoresis An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Additional assessment findings of a client experiencing acute pain would be an increased heart rate, respiratory rate, and muscle tension.

When a client's husband questions how a patient-controlled analgesia (PCA) pump works, the nurse explains that the client: 1. Has control over the frequency of the intravenous (IV) analgesia 2. Can choose the dosage of the drug received 3. May request the type of medication received 4. Controls the route for administering the medication
1. Has control over the frequency of the intravenous (IV) analgesia With a PCA system the client controls medication delivery. The PCA system is designed to deliver no more than a specified number of doses. The client does not choose the dosage. The health care provider prescribes the type of medication to be used. The advantage for the client is that he or she may self-administer opioids with minimal risk for overdose. The client does not control the route for administration. Systemic PCA typically involves IV drug administration but can also be given subcutaneously.

Which of the following is most appropriate when the nurse assesses the intensity of the client's pain? 1. Ask about what precipitates the pain. 2. Question the client about the location of the pain. 3. Offer the client a pain scale to objectify the information. 4. Use open-ended questions to find out about the sensation.
3. Offer the client a pain scale to objectify the information. Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity, but rather it is an assessment of the pain pattern. Asking the client about the location of pain does not assess the intensity of the client's pain. To determine the quality of the client's pain, the nurse may ask open-ended questions to find out about the sensation experienced.

The nurse should describe pain that is causing the client a "burning sensation in the epigastric region" as: 1. Referred 2. Radiating 3. Deep or visceral 4. Superficial or cutaneous
3. Deep or visceral Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder. Radiating pain feels as though it travels down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Superficial or cutaneous pain is of short duration and is localized as in a small cut.

A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to: 1. Use aseptic technique 2. Label the port as an epidural catheter 3. Monitor vital signs every 15 minutes 4. Avoid supplemental doses of sedatives
3. Monitor vital signs every 15 minutes When clients are receiving epidural analgesia, monitoring occurs as often as every 15 minutes, including assessment of respiratory rate, respiratory effort, and skin color. Complications of epidural opioid use include nausea and vomiting, urinary retention, constipation, respiratory depression, and pruritus. A common complication of epidural anesthesia is hypotension.

Assessing vital signs is the priority nursing intervention. Because of the catheter location, strict surgical asepsis is needed to prevent a serious and potentially fatal infection. To reduce the risk for accidental epidural injection of drugs intended for IV use, the catheter should be clearly labeled "epidural catheter." Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects.

Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea? 1. "The GI tract naturally rids itself of bacterial toxins by increasing peristalsis, and that causes diarrhea." 2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result." 3. "For some, antibiotics irritate the mucous lining of the intestines, causing decreased absorption and diarrhea." 4. "When you are taking an antibiotic, your body is fighting off an infection, and peristalsis is faster and so diarrhea occurs."
2. "The antibiotic is responsible for killing off the GI tract's normal bacterial, and diarrhea is the result."

A client who is 2 days' postoperative reports feeling "constipated" to the nurse. The client has good bowel sounds in all four quadrants and has tolerated liquids well. Her pain is being controlled with an opioid analgesic. Which of the following interventions should the nurse try initially? 1. "Let me get you some apple juice." 2. "Ambulating may get your bowels moving." 3. "I'll see about getting a different pain medication." 4. "Your health care provider might prescribe an enema if I call."
1. "Let me get you some apple juice."

An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the client's complaint? 1. "Have you tried foods like prunes and bran?" 2. "You might find the new flavored bulk laxatives helpful." 3. "What have you tried in the past that hasn't been helpful?" 4. "Increase your fluid intake; have some juice with breakfast."
4. "Increase your fluid intake; have some juice with breakfast."

Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns? 1. "The more fiber I eat, the fewer problems I have with my bowels." 2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly." 3. "My wife makes whole grain muffins; they are really good and good for me too." 4. "I use to have trouble with constipation until I started taking a fiber supplement."
2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly."

The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat: 1. Whole wheat bread 2. A lean, T-bone steak 3. Veal 4. Salmon
1. Whole wheat bread

A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively, clients who have undergone general anesthesia may experience: 1. Colitis 2. Stomatitis 3. Paralytic ileus 4. Gastrocolic reflex
3. Paralytic ileus

While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: 1. Immediately stop the infusion 2. Lower the height of the enema container 3. Advance the enema tubing 2 to 3 inches 4. Clamp the tubing
2. Lower the height of the enema container

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
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

Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.) 1. Chills and fever 2. Nausea and vomiting 3. Frequency or urgency 4. Cloudy or blood-tinged urine 5. Pelvic tenderness or flank pain 6. Burning or pain when voiding
1. Chills and fever 2. Nausea and vomiting 3. Frequency or urgency 4. Cloudy or blood-tinged urine 6. Burning or pain when voiding

Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply.) 1. The 74-year-old diagnosed with parkinsonism 5 years ago 2. The 25-year-old with Crohn's disease diagnosed 4 years ago 3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago 5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago
1. The 74-year-old diagnosed with parkinsonism 5 years ago 3. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago

5. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago

The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: 1. The impaired cognitive state the client will experience as the effects of the anesthesia wear off 2. The decreased volume of orally ingested fluids before, during, and after the surgical procedure 3. The length of time the client was under the effects of general anesthesia required for the surgical procedure 4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder
4. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs? 1. The client voids in the toilet. 2. The urine specimen is kept cold . 3. The first voided urine is discarded. 4. The preservative is placed in the collection container.
1. The client voids in the toilet.

The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? 1. Apply sterile gloves for the procedure. 2. Restrict fluids before the specimen collection. 3. Place the specimen in a clean urinalysis container. 4. Collect the specimen after the initial stream of urine has passed.
4. Collect the specimen after the initial stream of urine has passed.

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

4. A feeling of pressure and voiding of small amounts

When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: 1. Disconnect the catheter from the drainage tubing 2. Withdraw urine from a urinometer 3. Open the drainage bag and removing urine 4. Use a needle to withdraw urine from the catheter port
4. Use a needle to withdraw urine from the catheter port

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.
1. Empty the drainage bag at least every 8 hours.

The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to: 1. Apply adult diapers 2. Catheterize the client 3. Administer Urecholine 4. Teach Kegel exercises
4. Teach Kegel exercises

The client has been on a low-protein diet. This will most likely affect which pharmacokinetic process? a. Absorption b. Excretion c. Distribution d. Metabolism
c. Distribution A low-protein diet may lead to an inadequate level of plasma proteins, which will affect availability of "free" drug.

The primary provider has written a medication prescription. The nurse is having difficulty deciphering what has been written. The best strategy to clarify the information is a. Ask the patient what medication the provider prescribed. b. Call the pharmacist and ask her to read the prescription. c. Ask the nurse who knows the provider's handwriting to read the prescription. d. Call the provider and ask him to clarify the prescription.
d. Call the provider and ask him to clarify the prescription. All other answers increase the risk of a medication error.

When administering a drug via a parenteral routes, the drug would be absorbed fastest if given per the IM route. a. True b. False
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.

It is most important for the nurse to understand the various ways in which pain is classified a. so that he can document the client's pain using accurate terms b. so that he can be clear in his communication with the physician c. so that he can develop an effective pain management plan d. so that he can educate the client thoroughly
c. so that he can develop an effective pain management plan ANS: C Different modalities are used in the treatment/ management of pain and are often based on how the pain is classified (e.g., acute vs. chronic).

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

b. observe the client carefully for changes in behavior or vital signs The nurse should observe the confused client for nonverbal cues to pain.

Mr. Zenobia's chronic cancer pain has recently increased, and he asks the home health nurse what can be done. In relationship to his long-acting morphine, which of the following is an appropriate response by the nurse? a. "If you take more morphine, it will not change your pain relief." b. "I'll call the physician and ask for an increased dose." c. "The amount you are taking now is all I can give you." d. "I'm worried if we increase your dose that you will stop breathing."
b. "I'll call the physician and ask for an increased dose." There is no ceiling on the analgesic effect of opioid narcotics. Patients develop a tolerance to the effects, which often necessitates an increase in the dose.

When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain
1) Whenever a full set of vital signs is taken

The nurse is teaching a client who sustained an ankle injury about cold application. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. 2) Apply the cold pack to the ankle for 30 minutes at a time. 3) Check the skin frequently for extreme redness. 4) Keep the cold pack in place for at least 24 hours.
3) Check the skin frequently for extreme redness.

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.

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.

A patient with a history of mitral valve replacement, hypertension, and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy
1) Anticoagulant therapy

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.
2) Offer caffeinated beverages to constrict blood vessels in his head.

An older adult receiving hospice care has dementia as a result of metastasis to the brain. His bone cancer has progressed to an advanced stage. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. 2) Cannot communicate the character of his pain effectively. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking.
2) Cannot communicate the character of his pain effectively.

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
1) Patient's self-report

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
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.

The client has a draining abdominal wound that has become infected. In caring for the client, the nurse will implement a. contact precautions b. droplet precautions c. no precautions d. airborne precautions
a. contact precautions Contact precautions are used when "contact" with the infected drainage could lead to transmission of the infection.

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
1) Burns

In preventing and controlling the transmission of infections, the single most important technique is: 1) Hand hygiene 2) The use of disposable gloves 3) The use of isolation precautions 4) Sterilization of equipment
1) Hand hygiene

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
1) Washing hands

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
4) Remaining 6 inches away from the sterile field during the procedure

How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patient's room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal. 4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there.
1) Place the tray in a specially marked trash can inside the patient's room.

The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering
4) Hair covering

In which situation would using standard precautions be adequate? (Select all that apply.) 1) While interviewing a client with a productive cough

2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter
2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter

A patient with tuberculosis is scheduled for computed tomography (CT). How should the nurse proceed? (Select all that apply.) 1) Question the order because the patient must remain in isolation. 2) Place an N-95 respirator mask on the patient and transport him to the test. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.
3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport.

A client has severe right-sided weakness and is unable to complete bathing and grooming independently. Based on this observation, the nurse identifies a nursing diagnosis of: 1) Powerlessness 2) Self-care deficit 3) Tissue integrity impairment 4) Knowledge deficit of hygiene practices
2) Self-care deficit The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.

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."

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.

The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient's care plan? "Teach the patient to: 1) use an electric razor for shaving." 2) apply skin moisturizer." 3) use less soap when bathing." 4) floss teeth daily."
1) use an electric razor for shaving." The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. However, even if this patient is an older adult, a risk for bleeding takes priority over a risk for dry skin. Everyone should be encouraged to floss their teeth daily; however, some patients with severe bleeding risk may be told not to floss.

For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion
3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Therefore, he requires the critical thinking skills of a registered nurse to perform his morning care safely. The patient admitted with septic shock may easily become unstable with care; therefore, a registered nurse is required to provide his morning care safely. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly.

A patient with diarrhea is incontinent of liquid stool. The nurse documents that he now has excoriated skin on his buttocks. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. 2) Superficial layers of skin were absent. 3) Epidermal layer of skin was rubbed away. 4) Lesion caused by tissue compression was present.
2) Superficial layers of skin were absent. Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. Maceration is the softening of skin from exposure to moisture. Abrasion, a rubbing away of the epidermal layer of the skin, especially over bony areas, is often caused by friction or searing forces that occur when a patient moves in bed. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.

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.
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.

A client's vital signs at the beginning of the shift are as follows: oral temperature 99.3F (37C), heart rate 82 beats per minute, respiratory rate 14 breaths per minute, and blood pressure 118/76. Four hours later the client's oral temperature is 102.2F (39C). Based on the temperature change, the nurse should anticipate the client's heart rate would be how many beats per minute? Why?

ANS: 111 BPM. 1 F = 10 BPM 102.2 F - 99.3 F = 2.9 F * (10 BPM / 1 F) = 29 BPM + 82 BPM = 111 BPM

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
1) Decreased blood pressure (BP) after standing up Orthostatic Hypotension

Which one of the following clients would probably have a higher than normal respiratory rate? A client who has: 1) Had surgery and is receiving a narcotic analgesic. 2) Had surgery and lost a unit of blood intraoperatively. 3) Lived at a high altitude and then moved to sea level. 4) Been exposed to the cold and is now hypothermic.
2) Had surgery and lost a unit of blood intraoperatively. Hypovolemia / shock. BP decreases, respiratory rate increases

A client who has been hospitalized for an infection states, "The nursing assistant told me my vital signs are all within normal limits; that means I'm cured." The nurse's best response would be: 1) "Your vital signs confirm that your infection is resolved; how do you feel?" 2) "I'll let your health care provider know so you can be discharged." 3) "Your vital signs are stable, but there are other things to assess." 4) "We still need to keep monitoring your temperature for a while."
3) "Your vital signs are stable, but there are other things to assess."

A client's axillary temperature is 100.8F. The nurse realizes this is outside normal range for this client, and that axillary temperatures do not reflect core temperature. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1F to 100.8F to obtain an oral equivalent. 2) Add 2F to 100.8F to obtain a rectal equivalent.

3) Obtain a rectal temperature reading. 4) Obtain a tympanic membrane reading.

3) Obtain a rectal temperature reading.

At last measurement, the client's vital signs were as follows: oral temperature 98F (36.7C), heart rate 76, respiratory rate 16, and blood pressure (BP) 118/60. Four hours later, the vital signs are as follows: oral temperature 103.2F (38.5C), heart rate 76 beats/minute, respiratory rate 14 breaths/minute, and blood pressure 120/66. Which should the nurse's first intervention be at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 3) Ask the client if he is feeling chilled. 4) Take the temperature by a different route.
1) Ask the client if he has had a warm drink in the last 30 minutes.

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.
3) Blood pressure increases; heart rate and respiratory rate decline. 4) Men have higher blood pressure than women until after menopause.

Match the breath sound with the appropriate description. 1) High-pitched sound heard on inspiration in infants 2) High-pitched, continuous musical sound 3) High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored, snoring sound a. Crackles b. Rhonchi c. Stridor d. Wheezes e. Stertor
1. c. High-pitched sound heard on inspiration in infants: Stridor 2. d. High-pitched, continuous musical sound: Wheezes

3. a. High-pitched popping or low-pitched bubbling sounds: Crackles 4. b. Low-pitched continuous sounds that clear with coughing: Rhonchi 5. e. Labored, snoring sound: Stertor

How do the following impact blood pressure? A. Blood pressure cuff too narrow B. Blood pressure cuff too wide C. Assessing immediately after smoking D. Assessing immediately after eating E. Assessing when the client is in mild-to-moderate pain F. Assessing when the client experiences severe pain G. Assessing immediately after exercise
How do the following impact blood pressure? A. Blood pressure cuff too narrow: False Increase B. Blood pressure cuff too wide: False Decrease C. Assessing immediately after smoking: Increase D. Assessing immediately after eating: Increase E. Assessing when the client is in mild-to-moderate pain: Increase F. Assessing when the client experiences severe pain: Increase. Eventually chronic pain modulates to decrease. G. Assessing immediately after exercise: Immediately upon stopping it is increased, but within 5 minutes decreases.

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
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.

The nurse recognizes that the leading cause of death for the otherwise healthy 1year-old is: 1. Physical abuse 2. Accidental injury 3. Contagious diseases 4. Stranger abduction
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.

Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning)
1) Risk for Falls Risk for Falls due to loss of muscle strength and joint mobility

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.
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.

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.

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

Which is the most commonly reported "incident" in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays
2) Patient falls Patient falls, usually in an attempt to go to the bathroom

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."
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.

When the nurse walks into the patient's room, she notices fire coming from the patient's trash can. Rank the following actions in the order they should be performed by the nurse. A. Activate the fire alarm. B. Move the patient out of the room. C. Close all doors and windows. D. Put out the fire using the proper extinguisher.
B. Move the patient out of the room. A. Activate the fire alarm. C. Close all doors and windows. D. Put out the fire using the proper extinguisher. R.A.C.E. - rescue, alarm, contain, and exstinquish or evacuate

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
d. all of the above

Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data, the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years." Which nursing diagnosis is most appropriate for the nurse to use in her plan of care? a. Diarrhea b. Constipation c. Risk for Ineffective Therapeutic Regimen d. Perceived Constipation
d. Perceived Constipation Daily laxative use by the patient might suggest that she perceives she is constipated, and the nurse would gather further assessment data related to the client's bowel pattern. There is not enough data to infer actual constipation.

The nurse is assisting the client in caring for her ostomy. The client states, "Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's best response is a. "I'm sure you will get used to taking care of it eventually." b. "Yes, it is pretty messy, so I'll take care of it for you today." c. "It sounds like you are really upset." d. "You sound very angry. Should I call the chaplain for you?"
c. "It sounds like you are really upset." This statement reflects the principles of therapeutic communication.

When changing a diaper, the nurse observes that a 2-day-old infant has had a green black, tarry stool. What should the nurse do? 1) Notify the physician. 2) Do nothing; this is normal. 3) Give the baby sterile water until the mother's milk comes in. 4) Apply a skin barrier cream to the buttocks to prevent irritation.

2) Do nothing; this is normal. During the first few days of life, a term newborn passes green black, tarry stools known as meconium. Stools transition to a yellow green color over the next few days. After that, the appearance of stools depends upon the feedings the newborn receives. Sterile water does nothing to alter this progression. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it.

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.
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.

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)? 1) 2 to 4 glasses a day 2) 4 to 6 glasses a day 3) 6 to 8 glasses a day 4) 8 to 10 glasses a day
3) 6 to 8 glasses a day A minimum of 6 to 8 glasses of fluid should be consumed each day to promote healthy bowel function.

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.
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.

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
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.

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.
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.

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Choose all that apply. 1) 2 inches 2) 3 inches

3) 4 inches 4) 5 inches
2) 3 inches 3) 4 inches When administering an enema, the nurse should insert the tubing about 3 to 4 inches into the patient's rectum. Two inches would not be effective because it would not place the fluid high enough in the rectum. Five inches is too much.

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.
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.

Light sleep and slowing brain and body processes are associated with which stage of NREM sleep? a. I b. II c. III d. IV
b. II These are characteristics of a person in Stage II of NREM sleep.

The nurse is caring for a hospitalized client who normally works the night shift at his job. The client states, "I don't know what is wrong with me. I have been napping all day and can't seem to think clearly." The nurse's best response is 1) "You are sleep deprived, but that will resolve in a few days." 2) "You are experiencing hypersomnia, so it will be important for you to walk in the hall more often." 3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" 4) "I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep."
3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" The data suggests that the patient is used to being awake at night and sleeping during the day. The hospital routine has disrupted this normal pattern.

For which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care? a. Snoring b. Enuresis c. Narcolepsy d. Hypersomnia
c. Narcolepsy Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. This could put the person at risk for harm depending on the activity in which he is engaged.

Which of the following factors has the greatest positive effect on sleep quality? 1) Sleeping hours in synchrony with the person's circadian rhythm 2) Sleeping in a quiet environment 3) Spending additional time in stage IV of the sleep cycle 4) Napping on and off during the daytime
1) Sleeping hours in synchrony with the person's circadian rhythm

Which is a major factor regulating sleep? 1) Electrical impulses transmitted to the cerebellum 2) Level of sympathetic nervous system stimulation 3) Amount of sleep a person has become accustomed 4) Amount of light received through the eyes

3) Amount of sleep a person has become accustomed to

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.
1) Increased exercise.

Which patient teaching would be most therapeutic for someone with sleep disturbance? 1) Give yourself at least 60 minutes to fall asleep. 2) Avoid eating carbohydrates before going to sleep. 3) Catch up on sleep by napping or sleeping in when possible. 4) Do not go to bed feeling upset about a conflict.
4) Do not go to bed feeling upset about a conflict.

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
3) NREM, delta waves

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
3) Daytime fatigue 4) Snoring

The female client states to the nurse, "I'm so distressed. It seems like every time I laugh hard, I wet myself." The nurse knows that this condition is known as a. stress incontinence b. urge incontinence c. functional incontinence d. unconscious incontinence
a. stress incontinence Stress incontinence results from increased pressure within the abdominal cavity.

Four nurses are inserting catheters in their clients. Which nurse's statement, related to this intervention, is incorrect? I am inserting this catheter to a. empty your bladder prior to your procedure b. treat your problem of leaking urine c. obtain a sterile urine specimen d. measure the amount of urine left after you emptied your bladder
b. treat your problem of leaking urine Insertion of a urinary catheter is not a "treatment" for incontinence. "Never event" by CMS CAUTI

There is a 24-hour urine collection in process for a client. The NAP inadvertently empties one specimen into the toilet instead of the collection "hat." The nurse should a. Continue with the collection of urine until the 24-hour time period is finished. b. Make a note to the lab to inform them that one specimen was missed during the collection. c. Begin filling a new collection container and take both containers to the lab at the end of the collection period. d. Dispose of the urine already collected and begin an entirely new 24-hour collection.
d. Dispose of the urine already collected and begin an entirely new 24-hour collection. Once one specimen is "missed" during a 24-hour urine collection, the results of the lab test will be inaccurate and the collection must be restarted.

While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best? "You should:

1) Try to palpate it again; it takes practice but you will locate it." 2) Palpate the patient's bladder only when it is distended by urine." 3) Document this abnormal finding on the patient's chart." 4) Immediately notify the nurse assigned to your patient."
2) Palpate the patient's bladder only when it is distended by urine." The bladder is not palpable unless it is distended by urine. It is not difficult to palpate the bladder when distended. The nurse should document her finding, but it is not an abnormal finding. It is not necessary to notify the nurse assigned to the patient.

Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030
4) 1.030 Normal urine specific gravity ranges from 1.010 to 1.025. Specific gravity less than 1.010 indicates fluid volume excess, such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. Specific gravity greater than 1.025 is a sign of deficient fluid volume that occurs, for example, as a result of blood loss or dehydration.

The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patient's IV fluids. 3) Notify the provider about the patient's oliguria. 4) Administer the patient's routine diuretic dose early.
3) Notify the provider about the patient's oliguria. 50 mL in two hours is not normal output. The kidneys typically produce 60 ml of urine per hour. Therefore, the nurse should notify the provider when the patient shows diminished urine output (oliguria). Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. The nurse cannot provide increased IV fluids without a provider's order. The nurse should not administer any medications before the scheduled time without a prescription. The provider may hold the patient's scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume.

The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the bedpan on a flat surface at eye level. 4) Observe color and clarity of the urine in the bedpan.
1) Have the patient void directly into the bedpan. First, the nurse should put on gloves and have the patient void directly into the bedpan. Next, she should pour the urine into a graduated container, place the measuring device on a flat surface, and read the amount at eye level. She should observe the urine for color, clarity, and odor. Then, if no specimen is required, she should discard the urine in the toilet and clean the container and bedpan. Finally, she should record the amount of urine voided on the patient's intake and output record.

The nurse instructs a woman about providing a clean catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) "I will be sure to urinate into the 'hat' you placed on the toilet seat." 2) "I will cleanse my genital area from front to back before I collect the specimen midstream." 3) "I will need to lie still while you put in a urinary catheter to obtain the specimen." 4) "I will collect my urine each time I urinate for the next 24 hours."
2) "I will cleanse my genital area from front to back before I collect the specimen midstream." To obtain a clean catch urine specimen, the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream. This follows the principle of going from "clean" to "dirty." The nurse should have the ambulatory patient void into a "hat" (container for collecting the urine of an ambulatory patient) when monitoring urinary output, but not when obtaining a clean catch urine specimen. A urinary catheter is required for a sterile urine specimen, not a clean catch specimen. A 24-hour urine collection may be necessary to evaluate some disorders but a clean catch specimen is a one-time collection.

What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowler's

3) Dorsal recumbent The nurse should have the patient lie supine with knees flexed, feet flat on the bed (dorsal recumbent position). If the patient is unable to assume this position, the nurse should help the patient to a side-lying position. Modified Trendelenburg position is used for central venous catheter insertion. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. Semi-Fowler's position is used to prevent aspiration in those receiving enteral feedings.

The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patient's urine output has been greater than 60 ml/hour for the past 2 hours. Suddenly the patient's urine output drops to almost nothing. What should the nurse do first? 1) Irrigate the catheter with 30 ml of sterile solution. 2) Replace the patient's indwelling urinary catheter. 3) Infuse 500 ml of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately.
1) Irrigate the catheter with 30 ml of sterile solution. If the patient's urinary output suddenly ceases, the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. If no blockage is detected, the nurse should notify the surgeon. The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked. However, the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.

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
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.

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

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

In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of a. Risk for ineffective airway clearance b. Anxiety related to suctioning c. Social isolation related to altered body image d. Impaired tissue integrity
a. Risk for ineffective airway clearance While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.

Of the following factors, which would put a client at greatest risk for impaired skin integrity? a. the medication digoxin b. moisture c. decreased sensation d. dehydration
c. decreased sensation Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. This could lead to a delay in seeking treatment due to lack of awareness.

The client calls the nurse to the room and states, "Look, my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. The nurse's best action is to a. Notify the surgeon STAT. b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage. c. Wrap an ace bandage firmly around the area and have the client maintain bedrest. d. Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon.
b. Place a clean, sterile 4 x 4 over the incision and monitor the drainage. A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. Even if there were a large separation, there are no "internal viscera" to protrude.

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
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.

When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should a. Explain to the client how weight gain occurs b. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. Instruct the UAP to re-weigh the client in 2 hours
b. Check the calibration and re-weigh the client It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.

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

Of the following interventions for the client who is immobile, the nurse will give priority to a. encouraging a diet high in fiber and extra fluids b. administering the PRN medication for sleep c. having the client use his incentive spirometer q2hrs d. massaging the client's legs every hour

c. having the client use his incentive spirometer q2hrs Use of the incentive spirometer helps to prevent atelectasis, which improves oxygenation - a priority need.

Identify the true statement about devices used when assisting clients to ambulate. a. The client should stand a foot back from the back legs of a walker. b. A cane should be used by the client to support the weakest side of the body. c. A transfer belt should be placed around the client's chest for maximum " lift." d. Each crutch-walking "gait" begins with the client in the tripod position.
*d. Each crutch-walking "gait" begins with the client in the The tripod position is the basic crutch standing position from which the client then moves forward.

During the communication process, "decoding" is a. The selection of words by the sender b. The interpretation of the message by the receiver c. The method by which the message is given d. The way in which feedback is interpreted
b. The interpretation of the message by the receiver

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
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.

Use of the statements "Tell me more about..." or "I see" encourage clients to continue talking and expressing themselves. This is called: a. Summarizing b. Open-ended questions c. Focusing d. Encouraging elaboration
d. Encouraging elaboration

Communication involves both active listening and body language working together. The nurse actively listens to the client and: 1. Sits facing the client 2. Keeps the arms and legs crossed 3. Leans back in the chair away from the client 4. Avoids eye contact as much as is physically possible
1. Sits facing the client Active listening means to be attentive to what the client is saying both verbally and nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen and is interested in what the client is saying. For active listening, the arms and legs should be uncrossed. This posture suggests that the nurse is "open" to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved and interested in the interaction. For active listening, the nurse should establish and maintain intermittent eye contact. This conveys the nurse's involvement in and willingness to listen to what the client is saying.

Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in: 1. Pacing 2. Intonation 3. Timing and relevance 4. Denotative meaning
3. Timing and relevance Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance. The client is less likely to be able to pay attention and comprehend instruction when in pain, and immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning.

RH negative, RH positive
Rho gam is most often used to treat____ mothers that have a ____ infant.

Parkinson's disease type symptoms

A patient has taken an overdose of aspirin. What should a nurse most closely monitor for during acute management of this patient?

Weight gain
A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. What clinical sign would most likely be present?

Streptokinase
A patient has recently experienced a (MI) within the last 4 hours. What medication would most like be administered?

Green vegetables and liver

A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain folic acids?"

Cl. difficile
A nurse is putting together a presentation on meningitis. What microorganism has noted been linked to meningitis in humans?

The life span of RBC is 120 days.

A nurse is administering blood to a patient who has a low hemoglobin count. The patient asks how long to RBC's last in my body? The correct response is.

Start prophylactic AZT treatment

A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. What is the most important action that nursing student should take?

IgG
A 34 year old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which is the only immunoglobulin that will provide protection to the fetus in the womb?

A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess? a) Severe sore throat, drooling, and inspiratory stridor b) Low-grade fever, stridor, and a barking cough c) Pulmonary congestion, a productive cough, and a fever d) Sore throat, a fever, and general malaise
a) CORRECT ANSWER Severe sore throat, drooling, and inspiratory stridor Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing), severe sore throat, hoarseness, a high temperature, and severe inspiratory stridor. A low-grade fever, stridor, and barking cough that worsens at night are suggestive of croup. Pulmonary congestion, productive cough, and fever along with nasal flaring, retractions, chest pain, dyspnea, decreased breath sounds, and crackles indicate pneumococcal pneumonia. A sore throat, fever, and general malaise point to viral pharyngitis.

The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a) Keep their home warmer than usual. b) Encourage plenty of outdoor activities. c) Promote interactions with one friend instead of groups. d) Limit bathing to prevent skin irritation.
c) CORRECT ANSWER Promote interactions with one friend instead of groups. Reason: Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.

A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith), the drug's adverse effects, and symptoms of lithium toxicity. Which client statement indicates that additional teaching is required? a) "I can still eat my favorite salty foods." b) "When my moods fluctuate, I'll increase my dose of lithium." c) "A good blood level of the drug means the drug concentration has stabilized." d) "Eating too much watermelon will affect my lithium level."
b) CORRECT ANSWER "When my moods fluctuate, I'll increase my dose of lithium." Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems, such as lithium toxicity, overdose, and renal failure. Clients taking lithium don't need to limit their sodium intake. A low-sodium diet causes

lithium retention. A therapeutic lithium blood level indicates that the drug concentration has stabilized. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect, such as watermelon, cantaloupe, grapefruit juice, and cranberry juice.

The major goal of therapy in crisis intervention is to: a) withdraw from the stress. b) resolve the immediate problem. c) decrease anxiety. d) provide documentation of events.
b) CORRECT ANSWER resolve the immediate problem. Reason: During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn't a major goal.

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? a) Dismantling the showerhead and showing the client that there is nothing in it b) Explaining that other clients are complaining about the client's body odor c) Asking a security officer to assist in giving the client a shower d) Accepting these fears and allowing the client to take a sponge bath
d) CORRECT ANSWER Accepting these fears and allowing the client to take a sponge bath Reason: By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.

A client has an episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. This complication is called: a) a first-degree laceration. b) a second-degree laceration. c) a third-degree laceration. d) a fourth-degree laceration.
c) CORRECT ANSWER a third-degree laceration. Reason: Birth may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). A first-degree laceration involves the fourchette,

perineal skin, and vaginal mucous membranes. A second-degree laceration extends to the fasciae and muscle of the perineal body

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client? a) Ineffective denial related to a socially unacceptable infection b) Impaired parenting related to the neonate's transfer to the intensive care unit c) Deficient fluid volume related to severe edema d) Fear related to removal and loss of the neonate by statute
b) CORRECT ANSWER Impaired parenting related to the neonate's transfer to the intensive care unit Reason: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a) Firm fundus at the symphysis. b) White, thick vaginal discharge. c) Striae that are silver in color. d) Soft breasts without milk.
a) CORRECT ANSWER Firm fundus at the symphysis. Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a) peripheral acrocyanosis. b) bradycardia. c) lethargy. d) jaundice.

c) CORRECT ANSWER lethargy. Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia not bradycardia is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)? a) "Take an extra dose of digoxin if you miss one dose." b) "Call the physician if your heart rate is above 90 beats/minute." c) "Call the physician if your pulse drops below 80 beats/minute." d) "Take digoxin with meals."
b) CORRECT ANSWER "Call the physician if your heart rate is above 90 beats/minute." Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy? a) "Most impotence resolves in a couple of months." b) "You could have early ejaculation with this type of surgery." c) "We will refer you to a sex therapist because you will probably notice erectile dysfunction." d) "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."
d) CORRECT ANSWER "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance." Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.

b. Avoid driving a motor vehicle until stabilized on the drug.

A client tells the nurse that he has started to take an OTC antihistamine, diphenhydramine. In teaching him about side effects, what is most important for the nurse to tell the client? a. Do not to take this drug at bedtime to avoid insomnia. b. Avoid driving a motor vehicle until stabilized on the drug. c. Nightmares and nervousness are more likely in an adult. d. Limit use to 1 to 2 puffs/sprays 4 to 6 times per day to avoid rebound congestion.

c. Acute pharyngitis.
The client complains of a sore throat and has been told it is due to beta-hemolytic streptococcal infection. The nurse realizes this condition is called what? a. Acute rhinitis. b. Acute sinusitis. c. Acute pharyngitis. d. Acute rhinorrhea.

d. Limit the drug to 5 days of use to prevent rebound nasal congestion.

A client is prescribed the decongestant oxymetazoline (Afrin) nasal spray. What should the nurse teach the client? a. Take this drug at bedtime as a sleep aid. b. Directly spray away from the nasal septum and gently sniff. c. This drug may be used in maintenance treatment for asthma. d. Limit the drug to 5 days of use to prevent rebound nasal congestion.

b. To loosen bronchial secretions so they can be eliminated by coughing

A client has been prescribed guaifenesin (Robitussin). The nurse realizes that the purpose of the drug is to accomplish what? a. To treat allergic rhinitis and prevent motion sickness b. To loosen bronchial secretions so they can be eliminated by coughing c. To compete with histamine for receptor sites, thus preventing a histamine response d. To stimulate alpha-adrenergic receptors, thus producing vascular constriction of capillaries in nasal mucosa

d. Dry nasal mucosa

Beclomethasone (Beconase) has been prescribed for a client with allergic rhinitis. The nurse teaches the client that which is the most common side effect from continuous use?

a. Dizziness b. Rhinorrhea c. Hallucinations d. Dry nasal mucosa

a. Take medication with food to decrease gastric distress. b. Avoid alcohol and other central nervous system depressants. c. Notify the health care provider if confusion or hypotension occurs. d. Take sugarless candy, gum, or ice chips for temporary relief of dry mouth. e. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug.
The nurse is teaching a client about diphenhydramine (Benadryl). Which are topics to include? (Select all that apply.) a. Take medication with food to decrease gastric distress. b. Avoid alcohol and other central nervous system depressants. c. Notify the health care provider if confusion or hypotension occurs. d. Take sugarless candy, gum, or ice chips for temporary relief of dry mouth. e. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug.

a. "Do not drive after taking this medication."

The nurse is caring for a client who is taking a first-generation antihistamine. What is the most important fact for the nurse to teach the client? a. "Do not drive after taking this medication." b. "Make sure you drink a lot of liquids while on this medication." c. "Take this medication on an empty stomach." d. "Do not take this medication for more than 2 days."

d. "You may be able to safely take a second-generation antihistamine."

The nurse is caring for a client in the clinic who states that he is afraid of taking antihistamines because he is a truck driver. What is the best information for the nurse to give this client? a. "Take the medication only when you are not driving." b. "Take a lower dose than normal when you have to drive." c. "You are correct, you should not take antihistamines." d. "You may be able to safely take a second-generation antihistamine."

Administer guaifenesin.

The client tells the nurse that she has a bad cold, is coughing, and feels like she has "stuff" in her lungs. What should the nurse do? a. Administer dextromethorphan. b. Administer guaifenesin. c. Encourage the client to drink fluids hourly. d. Administer fluticasone (Flonase).

b. This medication has fewer sedative effects.

What is the most important thing for the nurse to teach a client who is switching allergy medications from diphenhydramine (Benadryl) to loratadine (Claritin)? a. This medication can potentially cause dysrhythmias. b. This medication has fewer sedative effects. c. This medication has increased bronchodilating effects. d. This medication causes less gastrointestinal upset.

b. "Overuse of nasal decongestants results in rebound congestion."

A client complains of worsening nasal congestion despite the use of oxymetazoline (Afrin) nasal spray every 2 hours. What is the nurse's best response? a. "Oxymetazoline is not an effective nasal decongestant." b. "Overuse of nasal decongestants results in rebound congestion." c. "Oxymetazoline should be administered every hour for severe congestion." d. "You are probably displaying an idiosyncratic reaction to oxymetazoline."

b. "This medication will help prevent the inflammatory response of my allergies."

Which statement indicates that the client understands the teaching about beclomethasone diproprionate (Beconase)? a. "I will need to taper off the medication to prevent acute adrenal crisis." b. "This medication will help prevent the inflammatory response of my allergies." c. "I will need to monitor my blood sugar more closely because it may increase." d. "I need to take this medication only when my symptoms get bad."

a. "This medication may cause drowsiness and dizziness."

A client is prescribed an antitussive medication. What is the most important thing for the nurse to teach the client? a. "This medication may cause drowsiness and dizziness." b. "Watch out for diarrhea and abdominal cramping."

c. "This may cause tremors and anxiety." d. "Headache and hypertension are common side effects."

c. Increase fluid intake in order to decrease viscosity of secretions.

Which is the best instruction for the nurse to include when teaching a client about the use of expectorants? a. Restrict fluids in order to decrease mucus production. b. Take the medication once a day only, at bedtime. c. Increase fluid intake in order to decrease viscosity of secretions. d. Increase fiber and fluid intake to prevent constipation.

a. Asthma
A client is diagnosed with a pulmonary disorder that causes COPD. Lungs tissue changes are normally reversible with this condition. The nurse understands that which is the client's most likely diagnosis? a. Asthma b. Emphysema c. Bronchiectasis d. Chronic bronchitis

b. epinephrine (Adrenalin)
A client with COPD has an acute bronchospasm. The nurse knows that which is the best medication for this emergency situation? a. zafirlukast (Accolate) b. epinephrine (Adrenalin) c. dexamethasone (Decadron) d. oxtriphylline-theophyllinate (Choledyl)

c. Increased heart rate

A client is taking aminophylline-theophylline ethylenediamine (Somophyllin). For what should the nurse monitor the client? a. Drowsiness b. Hypoglycemia c. Increased heart rate d. Decreased white blood cell count

b. 10 to 20 mcg/mL

A client is prescribed theophylline to relax the smooth muscles of the bronchi. The nurse monitors the client's theophylline serum levels to maintain which therapeutic range? a. 1 to 10 mcg/mL b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 40 mcg/mL

a. Maintenance treatment of asthma

A client with COPD is taking a leukotriene antagonist, montelukast (Singulair). The nurse is aware that this medication is given for which purpose? a. Maintenance treatment of asthma b. Treatment of an acute asthma attack c. Reversing bronchospasm associated with COPD d. Treatment of inflammation in chronic bronchitis

c. Continue to assess the client's oxygenation.

The nurse is caring for a client with a theophylline level of 14 mcg/mL. What is the priority nursing intervention? a. Increase the IV drip rate. b. Monitor the client for toxicity. c. Continue to assess the client's oxygenation. d. Stop the IV for an hour then restart at lower rate.

d. Tachycardia
Discharge teaching to a client receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. Hypoglycemia b. Nonproductive cough c. Sedation d. Tachycardia

d. St. John's wort

The nurse instructs the client to avoid which over-the-counter products when taking theophylline (Theo-Dur)? a. acetaminophen (Tylenol) b. echinacea

c. diphenhydramine (Benadryl) d. St. John's wort

a. Monitor client for potential chest pain.

A nurse reviews a client's medication history and notes that the client is taking a nonselective adrenergic agonist bronchodilator and has a history of coronary artery disease. What is a priority nursing intervention? a. Monitor client for potential chest pain. b. Monitor blood pressure continuously. c. Assess daily for hyperkalemia. d. Assess 12-lead ECG each shift.

d. Salmeterol has a longer duration of action.

The nurse is instructing a client about the advantages of salmeterol (Serevent) over other beta2 agonists such as albuterol (Proventil). How will the nurse explain to the client the difference in these two medications? a. Salmeterol has a shorter onset of action. b. Salmeterol does not have any side effects. c. Albuterol has a longer onset of action. d. Salmeterol has a longer duration of action.

c. "This medication will prevent the inflammation that causes your asthma attack."
Client teaching regarding the use of antileukotriene agents such as zafirlukast (Accolate) should include which statement? a. "Take the medication as soon as you begin wheezing." b. "It will take about 3 weeks before you notice a therapeutic effect." c. "This medication will prevent the inflammation that causes your asthma attack." d. "Increase fiber and fluid in your diet to prevent the side effect of constipation."

c. Administer a beta2 adrenergic agonist.

A client with a history of asthma is short of breath and says, "I feel like I'm having an asthmatic attack." What is the nurse's best action? a. Call a code. b. Ask the client to describe the symptoms. c. Administer a beta2 adrenergic agonist. d. Administer a long-acting glucocorticoid.

a. Monitor for heart rate >100 beats/min.

A client has taken metaproterenol. What is the nurse's priority action? a. Monitor for heart rate >100 beats/min. b. Tell the client not to drive for 2 hours. c. Monitor for sedation. d. Assess for elevated blood pressure.

b. Rinse his mouth with water after each use.

A client demonstrates understanding of flunisolide (AeroBid) by saying that he will do what? a. Take two puffs to treat an acute asthma attack. b. Rinse his mouth with water after each use. c. Immediately stop taking his oral prednisone when he starts using AeroBid. d. Not use his albuterol inhaler while he is taking AeroBid.

d. Teach the child to use a spacer.

The nurse is caring for a young child who has been prescribed an inhaler for control of her asthma. The child is having difficulty using the inhaler. What is the nurse's best action? a. Tell the parent to hold the inhaler for the child. b. Ask the health care provider to switch to oral medications. c. Tell the parent that young children should not use inhalers. d. Teach the child to use a spacer.

d. The client with atrial fibrillation with a rate of 100

The nurse is caring for clients on the pulmonary unit. Which client should not receive epinephrine if ordered? a. The client with a history of emphysema b. The client with a history of type 2 diabetes c. The client who is 16 years old d. The client with atrial fibrillation with a rate of 100

b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed by beclomethasone several minutes later.
The health care provider orders ipratropium bromide (Atrovent), albuterol (Proventil), and beclomethasone (Vanceril) inhalers for a client. What is the nurse's best action? a. Question the order; three inhalers should not be given at one time. b. Administer the albuterol first, wait 5 minutes, and administer ipratropium bromide, followed

by beclomethasone several minutes later. c. Administer each inhaler at 30-minute intervals. d. Administer beclomethasone first, wait 2 minutes, and administer ipratropium bromide, followed by the albuterol several minutes later.

c. "Hold your breath for 10 seconds if you can after you inhale the medication."
Which instruction will the nurse include when teaching a client about the proper use of metereddose inhalers? a. "After you inhale the medication once, repeat until you obtain relief." b. "Make sure that you puff out air repeatedly after you inhale the medication." c. "Hold your breath for 10 seconds if you can after you inhale the medication." d. "Hold the inhaler in your mouth, take a deep breath, and then compress the inhaler."

c. Liquefying and loosening of bronchial secretions

What will the nurse expect to find that would indicate a therapeutic effect of acetylcysteine (Mucomyst)? a. Decreased cough reflex b. Decreased nasal secretions c. Liquefying and loosening of bronchial secretions d. Relief of bronchospasms

c. Monitor blood glucose levels every 4 hours when taking albuterol.

What is the most important thing for the nurse to teach the client with a history of diabetes and asthma who has started on albuterol PRN? a. Take Tylenol for headaches when taking albuterol. b. Monitor for orthostatic hypotension every 2 hours when taking albuterol. c. Monitor blood glucose levels every 4 hours when taking albuterol. d. An antianxiety agent may be prescribed to help with nervousness.

b. "Take the ipratropium at least 5 minutes before the cromolyn."

A client is prescribed ipratropium and cromolyn sodium. What will the nurse teach the client? a. "Do not take these medications within 4 hours of each other." b. "Take the ipratropium at least 5 minutes before the cromolyn." c. "Administer both medications together in a metered-dose inhaler." d. "Take the ipratropium only in the mornings."

c. Hold the next dose of theophylline.

A client taking an oral theophylline preparation is due for her next dose and has a blood pressure of 100/50 mm Hg and a heart rate of 110. The client is irritable. What is the best action for the nurse to take? a. Continue to monitor the client. b. Call the health care provider. c. Hold the next dose of theophylline. d. Administer oxygen 2 lpm via nasal cannula.

b. Lack of exercise
A client complains of constipation and requires a laxative. In providing teaching to the client, the nurse reviews the common causes of constipation, including which cause? a. Motion sickness b. Lack of exercise c. Food intolerance d. Bacteria (Escherichia coli)

b. Block serotonin receptors in the CTZ

A client has nausea and is taking ondansetron (Zofran). The nurse explains that the action of this drug is what? a. Stimulate the CTZ b. Block serotonin receptors in the CTZ c. Block dopamine receptors in the CTZ d. Coat the wall of the GI tract and absorb bacteria

a. Acts on smooth intestinal muscle to gently increase peristalsis

A client who has constipation is prescribed a bisacodyl suppository. The nurse explains that bisacodyl does what? a. Acts on smooth intestinal muscle to gently increase peristalsis b. Absorbs water into the intestines to increase bulk and peristalsis c. Lowers surface tension and increases water accumulation in the intestines d. Pulls hyperosmolar salts into the colon and increases water in the feces to increase bulk

d. Dry mouth
A client is using the scopolamine patch to prevent motion sickness. The nurse teaches the client that which is a common side effect of this drug? a. Diarrhea b. Vomiting

c. Insomnia d. Dry mouth

c. Alcohol
When metoclopramide (Raglan) is given for nausea, the client is cautioned to avoid which substance? a. Milk b. MAOIs c. Alcohol d. Carbonated beverages

a. Warn the client to avoid laxative abuse. b. Record the frequency of bowel movements. c. Warn the client against taking sedatives concurrently. d. Encourage the client to increase fluids. e. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma.
The nurse is administering opium tincture (paregoric) to a client. Which should be included in the client teaching regarding this medication? (Select all that apply.) a. Warn the client to avoid laxative abuse. b. Record the frequency of bowel movements. c. Warn the client against taking sedatives concurrently. d. Encourage the client to increase fluids. e. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. f. Teach the client that the drug acts by drawing water into the intestine.

a. Client has not had a bowel movement in 3 days.

Which assessment finding will need intervention and is related to the client's use of aluminum hydroxide (Amphojel)? a. Client has not had a bowel movement in 3 days. b. Client has had one loose stool this week. c. Client is complaining of gastric upset. d. Client has trace edema in feet.

c. Client taking magnesium-containing antacids who has renal failure.

Which client needs immediate intervention? a. Client taking aluminum-containing antacids with complaints of reflux. b. Client taking calcium-containing antacids who is hypocalcemic.

c. Client taking magnesium-containing antacids who has renal failure. d. Client taking antacids who is older than 70 years.

a. Assess for metabolic alkalosis.

What assessment has the highest priority for a client using sodium bicarbonate to treat gastric hyperacidity? a. Assess for metabolic alkalosis. b. Assess for fluid volume deficit. c. Assess for hyperkalemia. d. Assess for hypercalcemia.

b. Potential risk for bleeding related to thrombocytopenia

Which nursing diagnoses is appropriate for a client receiving famotidine (Pepcid)? a. Increased risk for infection related to immunosuppression b. Potential risk for bleeding related to thrombocytopenia c. Alteration in urinary elimination related to retention d. Alteration in tissue perfusion related to hypertension

b. "Smoking decreases the effects of this medication, so I should look into cessation programs."
Which statement demonstrates to the nurse that the client understands instructions regarding the use of histamine2-receptor antagonists? a. "Since I am taking this medication, it is all right for me to eat spicy foods." b. "Smoking decreases the effects of this medication, so I should look into cessation programs." c. "I should take this medication 1 hour after each meal in order to decrease gastric acidity." d. "I should decrease bulk and fluids in my diet to prevent diarrhea."

d. Administer the medications and assess the client for relief.

A client is prescribed Lorazepam (Ativan) and a glucocorticoid during chemotherapy treatments. What is the nurse's best action? a. Call the health care provider and question the order. b. Only administer the Ativan if the client seems anxious. c. Administer the two medications at least 12 hours apart. d. Administer the medications and assess the client for relief.

d. pantoprazole (Protonix)

A nurse is caring for a client who is unable to tolerate oral medications. The nurse anticipates that the client may be prescribed which proton pump inhibitor to be administered intravenously? a. esomeprazole (Nexium) b. lansoprazole (Prevacid) c. omeprazole (Prilosec) d. pantoprazole (Protonix)

c. "I will apply the scopolamine patches to rotating sites on my arms."

Which client statement indicates that further teaching is needed? a. "I will not drive while I am taking these medications because they may cause drowsiness." b. "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." c. "I will apply the scopolamine patches to rotating sites on my arms." d. "I should take my prescribed antiemetic before receiving my chemotherapy dose and continue afterwards."

b. Gastric assessment
The nurse is administering loperamide (Imodium) to a client with diarrhea. What assessment is essential for this client? a. Vascular assessment b. Gastric assessment c. Hourly blood pressure measurements d. White blood count

c. Decrease in gastric motility

Which outcome assessment is essential to monitor for the client taking diphenoxylate (Lomotil)? a. Increase in bowel sounds b. Increase in number of bowel movements c. Decrease in gastric motility d. Decrease in urination

c. Administer 30 minutes before meals and at bedtime.

The nurse is planning to administer metoclopramide (Reglan). What is a primary intervention? a. Administer with food to decrease gastrointestinal upset. b. Administer every 6 hours around the clock. c. Administer 30 minutes before meals and at bedtime. d. Give with a full glass of water first thing in the morning.

c. Combination therapy blocks different vomiting pathways.

What will the nurse teach the client about the reason for administering multiple medications for relief of nausea and vomiting? a. Combination therapy decreases the risk of constipation. b. Combination therapy is more cost-effective. c. Combination therapy blocks different vomiting pathways. d. Combination therapy decreases side effects due to lower doses of each drug.

b. Fluid volume deficit related to nausea and vomiting

In developing a plan of care for a client receiving an antihistamine antiemetic agent, which nursing diagnosis would be of highest priority? a. Knowledge deficit regarding medication administration b. Fluid volume deficit related to nausea and vomiting c. Risk for injury related to side effects of medication d. Alteration in comfort related to nausea and vomiting

c. "Brush your teeth and gargle to help with dryness in your mouth."
What instruction is most important for the nurse to teach a client who is taking an anticholinergic agent to treat nausea and vomiting? a. "Assess your stools for dark streaks." b. "Do not take more than two doses of this medication." c. "Brush your teeth and gargle to help with dryness in your mouth." d. Check your heart rate and call the health care provider if it gets below 50 beats/min.

b. Weigh the client before chemotherapy.

A client is prescribed granisetron (Kytril) IV for relief of nausea and vomiting caused by cancer chemotherapy. What intervention is most appropriate for this client? a. Administer the medication at least 12 hours before the start of chemotherapy. b. Weigh the client before chemotherapy. c. Assess baseline vital signs and monitor for tachycardia. d. Teach the client about the possibility of rebound nausea and vomiting once the drug is discontinued.

b. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy.
A client is starting cisplatin therapy for cancer. What intervention is appropriate for this client?

a. Administer granisetron (Kytril) 60 minutes before therapy and for several days after surgery. b. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy. c. Administer palonosetron (Aloxi) IV push. d. Administer metoclopramide (Reglan) PO.

c. Evaluate renal function.

Before administering a stimulant laxative to a client, which nursing intervention is the priority? a. Obtain a history of constipation and causes. b. Record baseline vital signs. c. Evaluate renal function. d. Assess fluid and electrolyte balance.

c. Monitor signs and symptoms of fluid and electrolyte imbalance.

Which assessment is most important for the client who is taking stimulant laxatives? a. Monitor bowel elimination daily. b. Monitor intake and output. c. Monitor signs and symptoms of fluid and electrolyte imbalance. d. Monitor heart rate and blood pressure every 4 hours.

d. "After 3 days, switch patch to alternate ear." e. "Apply patch 4 hours before effect is desired." f. "Drowsiness is a concern while on this medication."
A client is prescribed scopolamine. What information will the nurse include on the teaching plan for this client? (Select all that apply.) a. "Do not take this medication if you are dizzy." b. "Do not use laxatives while on this medication." c. "Do not use this medication for longer than a day." d. "After 3 days, switch patch to alternate ear." e. "Apply patch 4 hours before effect is desired." f. "Drowsiness is a concern while on this medication."

a. Helicobacter pylori
A client is diagnosed with peptic ulcer disease. The nurse realizes that which factor is a predisposing factor for this condition? a. Helicobacter pylori b. hyposecretion of pepsin c. decreased hydrochloric acid d. decreased number of parietal cells

d. To combine with protein to form a viscous substance that forms a protective covering of ulcer
When a client is given sucralfate (Carafate), the nurse knows that its mode of action is what? a. To neutralize gastric acidity b. To inhibit gastric acid secretion by inhibiting histamine at H2 receptors in parietal cells c. To suppress gastric acid secretion by inhibiting the hydrogen/potassium ATPase enzyme d. To combine with protein to form a viscous substance that forms a protective covering of ulcer

c. The drug must be administered separate from an antacid by at least 1 hour e. Smoking should be avoided while taking this drug f. Foods high in vitamin B12 should be increased in diet
A client is taking ranitidine (Zantac). The nurse who is teaching the client about this drug should include which information? (Select all that apply.) a. Drug-induced impotence is irreversible b. The drug must be administered 30 minutes before meals c. The drug must be administered separate from an antacid by at least 1 hour d. The drug must always be administered with magnesium hydroxide e. Smoking should be avoided while taking this drug f. Foods high in vitamin B12 should be increased in diet

d. Antacids neutralize HCl and reduce pepsin activity.

When a client complains of pain accompanying a peptic ulcer, why should an antacid be given? a. Antacids decrease GI motility. b. Antacids decrease gastric acid secretion. c. Aluminum hydroxide is a systemic antacid. d. Antacids neutralize HCl and reduce pepsin activity.

b. Dizziness d. Headaches f. Decreased libido

A client is taking famotidine (Pepcid) to inhibit gastric secretions. What are the side effects of famotidine? (Select all that apply.) a. Diarrhea b. Dizziness c. Dry mouth d. Headaches

e. Blurred vision f. Decreased libido

b. "I will drink 2 ounces of water after taking aluminum hydroxide."

A client has just been prescribed aluminum hydroxide (Amphojel, ALternaGEL, Alu-Tab) for peptic ulcer pain. The nurse has provided instructions to the client. Which statement by the client indicates to the nurse that the client understands the instructions? a. "I will take aluminum hydroxide at mealtime." b. "I will drink 2 ounces of water after taking aluminum hydroxide." c. "I will take aluminum hydroxide within 30 minutes of my other medications." d. "I will take a laxative if I develop constipation."

a. Administer just before meals.

What is a priority nursing intervention when administering ranitidine (Zantac)? a. Administer just before meals. b. Administer right after eating. c. Administer 1 to 2 hours after meals. d. Administer during meals.

c. The client has no throat pain.

The health care provider prescribes lansoprazole (Prevacid) to a client. Which assessment indicates to the nurse that the medication has had a therapeutic effect? a. The client has no diarrhea. b. The client has no gastric pain. c. The client has no throat pain. d. The client is able to eat.

b. Absent bowel sounds, hard abdomen

The nurse is caring for a client who is taking sucralfate (Carafate, Sulcrate) for treatment of a duodenal ulcer. Which assessment requires action by the nurse? a. Sodium level 140 mEq/L b. Absent bowel sounds, hard abdomen c. Urinary output 30 mL/hr d. Calcium level 8.5 mg/dL

c. Allow the tablet to dissolve in water before administering.

When administering sucralfate (Carafate) to a client with a nasogastric tube, what is an essential intervention? a. Crush the tablet into a fine powder before mixing it with water. b. Administer with a bolus tube feeding. c. Allow the tablet to dissolve in water before administering. d. Administer with an antacid for maximum benefit.

c. "This medication will form a protective barrier over the gastric mucosa."
What information should the nurse include in a teaching plan for the client who is prescribed sucralfate (Carafate)? a. "This medication will neutralize gastric acid." b. "This medication will enhance gastric absorption of meals." c. "This medication will form a protective barrier over the gastric mucosa." d. "Your gastric acid will be inhibited."

b. Administer misoprostol. d. Instruct the client to take omeprazole with the aspirin.
The nurse is caring for a client who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. What is the best intervention for this client? (Select all that apply.) a. Stop all aspirin therapy. b. Administer misoprostol. c. Instruct the client to take the aspirin with milk. d. Instruct the client to take omeprazole with the aspirin.

a. Dehydration
The nurse reviews the client's list of medication, which includes mannitol. The nurse must be aware that which condition is a contraindication for use of this drug? a. Dehydration b. Kidney stones c. Eczema d. Gout

c. Cyclopentolate
The client is being prepared for an eye examination. When the nurse takes the health history, the client says that she is sensitive to atropine sulfate. What drug might be used instead for the examination?

a. Diclofenac b. Suprofen c. Cyclopentolate d. Betaxolol HCl

c. Electrolytes
An 85-year-old client is taking acetazolamide, a carbonic anhydrase inhibitor. A nursing intervention associated with clients receiving this drug is to monitor what? a. Weight b. Complete blood count c. Electrolytes d. Urine output

d. travoprost
The nurse reviews the African-American client's list of medications. It is important for the nurse to be aware that the prostaglandin analogue more effective in African Americans than in nonAfrican Americans is wha? a. latanoprost b. bimatoprost c. unoprostone d. travoprost

a. School-aged children may need only one drug, not a combination.

The school nurse is preparing a presentation for the parent-teacher association meeting on medications commonly used in school-aged children. It is important to note what primary disadvantage of the use of combination products such as Cortisporin Otic? a. School-aged children may need only one drug, not a combination. b. Combination products may not have the desired dose for school-aged children. c. There is increased cost in using combination products for school-aged children. d. Combination products are less effective for school-aged children.

a. Hydrogen peroxide
The camp nurse reviews the "shopping list" of supplies needed for the upcoming camping season. What product is recommended to prevent and treat chronic impaction of cerumen? a. Hydrogen peroxide b. Rubbing alcohol c. Charcoal d. Salt solution

a. Instruct the client to report changes in vision and breathing. b. Maintain sterile technique and prevent dropper
The nurse prepares a health teaching plan for the client with glaucoma. Which important nursing intervention are included for this client? (Select all that apply.) a. Instruct the client to report changes in vision and breathing. b. Maintain sterile technique and prevent dropper contamination during administration of eyedrops. c. Include return demonstration only with geriatric clients. d. Wait 10 minutes to instill the second eye medication to be given at the same time.

d. Client's pupils are constricted to 2 mm.

The nurse administers pilocarpine (Pilocar) to a client with glaucoma. Which assessment finding would indicate a therapeutic effect of the medication? a. Client's eyes appear clear, without drainage. b. Client states that her eyes feel very dry. c. Client's pupils are dilated to 4 mm. d. Client's pupils are constricted to 2 mm.

c. "I should rinse the eye dropper with tap water after each use."
Which statement, made by a client, indicates to the nurse a need for further client teaching regarding proper administration of eye drops? a. "I will put pressure on the inside corner of my eye after I administer the drops." b. "I will be careful not to touch my eye with the dropper." c. "I should rinse the eye dropper with tap water after each use." d. "I will turn my head slightly toward the outside of the eye I am putting the drops in."

b. Warm the eardrops to room temperature before administration.

The nurse is planning to administer eardrops. Which intervention is essential to include in the plan of care? a. Eardrops should be cool when being administered. b. Warm the eardrops to room temperature before administration. c. The pinna of an adult should be held down and back to administer eardrops. d. Eardrops may be warmed in the microwave before administration.

b. carbamide peroxide
A client is complaining of excessive earwax that diminishes hearing ability. What medication will the nurse use to assist the client?

a. acetic acid b. carbamide peroxide c. hydrocortisone d. glycerin

b. Instruct the client that one drop is optimal.

The nurse evaluates the client using eyedrops. The client puts two drops into his eye. What is the nurse's best action? a. Continue to observe the client. b. Instruct the client that one drop is optimal. c. Have the client irrigate his eye to remove excess medication. d. Have the client close his eye and rub to assist in absorption.

b. A horny layer of epidermis

The nurse reviews the client's list of medications and recalls that the purpose of keratolytic agents is to remove what? a. A horny layer of dermis b. A horny layer of epidermis c. Erythematous lesions d. Hair follicles

a. Avoid sunlight. c. Monitor CBC, glucose, and lipids. d. Do not breastfeed or give blood.
Nursing implications for health teaching with clients taking isotretinoin include which implications? (Select all that apply.) a. Avoid sunlight. b. Monitor weight c. Monitor CBC, glucose, and lipids. d. Do not breastfeed or give blood.

c. Assess lesions
The nurse is doing health teaching with a client with psoriasis. Which is a nursing implication of the new biologic agents for the management of psoriasis? a. Daily weight b. Monitor electrolytes

c. Assess lesions d. Monitor CBC and T-cell count

d. finasteride
A 55-year-old man has a chief complaint: "I'm going bald." Which drug is used to treat male pattern baldness? a. dexamethasone b. PABA c. minoxidil d. finasteride

a. Metabolic acidosis c. Respiratory alkalosis

The client has second- and third-degree burns over 25% of his body. Mafenide acetate has been ordered. What acid-base imbalance can result from its use? (Select all that apply.) a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Respiratory acidosis

b. Thinning of the skin d. Purpura

The nurse reviews the client's medication history. Based on the client's prolonged use of glucocorticoids, what does the assessment include? (Select all that apply.) a. Obesity b. Thinning of the skin c. Erythematous lesions d. Purpura

b. A review of iPLEDGE educational materials c. That a negative pregnancy test is required before each monthly refill
A 20-year-old woman comes to the clinic for follow-up related to isotretinoin use. The nurse reviews the iPLEDGE program, which includes which important information? (Select all that apply.) a. That an effective method of contraception must be used throughout treatment b. A review of iPLEDGE educational materials

c. That a negative pregnancy test is required before each monthly refill d. That informed consent is not required

a. Sunscreen products should contain information about UVA and UVB SPF protection. b. UVB radiation is greatest between 10 AM and 4 PM. d. SPF should be at least 15 in sunscreen products.
The school nurse prepares a program for junior high school students on sun safety. What is important information to include? (Select all that apply.) a. Sunscreen products should contain information about UVA and UVB SPF protection. b. UVB radiation is greatest between 10 AM and 4 PM. c. Clouds block radiation, so sunscreen is not needed on cloudy days. d. SPF should be at least 15 in sunscreen products.

d. Silver sulfadiazine cream

Which intervention is most appropriate for the client with second-degree burns? a. IV antibiotics b. Isolation c. IV dextrose infusion d. Silver sulfadiazine cream

a. Perform pregnancy test.

A 20-year-old client is starting isotretinoin (Accutane) therapy. What is an essential nursing intervention for this client? a. Perform pregnancy test. b. Assess sputum cultures. c. Make sure IV is patent. d. Force fluids.

a. Calcium 12 mg/dL
A client is prescribed calcipotriene (Dovonex) for treatment of psoriasis. Which assessment finding requires immediate intervention by the nurse? a. Calcium 12 mg/dL b. Potassium 3.8 meq/L c. Sodium 135 mmol/L d. Phosphorus 2.5 mg/dL

d. Ask client if he or she has any allergies.

Before applying povidone-iodine (Betadine) to a client's skin, what is a primary nursing intervention? a. Apply a cortisone cream. b. Wash the skin. c. Shave and prepare the area. d. Ask client if he or she has any allergies.

b. Call the health care provider if you have muscle weakness.

A client is prescribed isotretinoin (Accutane). What is the most important instruction to teach the client before beginning this medication? a. Do not go out in the sun while on this medication. b. Call the health care provider if you have muscle weakness. c. Increase fluid intake while on this medication.