Miscellaneous

Question 1

Trendelenburg Position

Answer 1

In this position, the body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. It is also used to improve the effects of spinal anesthesia and also to prevent air embolism during central venous cannulation.

Question 2

Prone

Answer 2

The prone position is when a patient is placed in a horizontal position with the face oriented down. A prone position is often used during surgical procedures, especially for those needing access to the spine and the back. It is also used to increase oxygenation in patients with respiratory distress.

Question 3

supine

Answer 3

he supine position is when a patient is placed in a horizontal position with the face oriented up. A supine position is often used during surgical procedures, especially for those needing access to the thoracic area/ cavity.

Question 4

Sims position

Answer 4

A Sim’s position is when a patient lies on his/her left side, left hip and lower extremity straight, and right hip and knee bent. It is also called a lateral recumbent position. Sim’s status is usually used for rectal exams, treatments, and enemas.

Question 5

Fowler’s position

Answer 5

Fowler’s position is another position an RN needs to be aware of since it has many implications during nursing care. This is when a patient is seated in a “semi-sitting” position when the head of the bed is elevated at a 45 to 60 degrees angle. There are variations in Fowler position: Low ( 15-30 degrees), Semi-Fowler (30-45 degrees), Standard (45-60 degrees), and High Fowler’s (60-90 degrees).
Fowler has been used as a way to help with peritonitis. Fowler’s can be used:-

To promote oxygenation during respiratory distress because it allows maximum chest expansion and relaxation of abdominal muscles. E.g., infants with respiratory distress.
To increase comfort during eating and other activities.
To improve uterine drainage in post-partum women.
To minimize the risk of aspiration in patients with oral or nasal gastric feeding tubes. Fowler’s position aids Peristalsis and swallowing by the effect of gravitational pull.

Question 6

Nursing responsibilities prior to surgery

Answer 6

When preparing a client for surgery, the nursing responsibilities include:

Ensuring that all pre-procedure paperwork is completed, including consent and corresponding checklists.
Maintaining the client on “by mouth (NPO)” status, if appropriate.
Appropriate attire and hygiene, including preprocedural bath with specified soap, clean gown, and anti-embolism stockings or sequential compression devices (SCDs).
Recent laboratory data including CBC, CMP, UA, clotting factors (PTT, PT/INR), and HCG if the client is a female.

Question 7

Nurse-Initiated Interventions

Answer 7

Nurse-initiated interventions, also known as independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of client needs that are written on the nursing care plan, as well as other activities that nurses can initiate without the direction or supervision of another healthcare personnel. The nurse can take initiative independently by monitoring clients’ skin for breakdown, assisting a client to order an appropriate meal, and providing education to clients and family members.
A nurse-initiated intervention is an independent action based on the scientific rationale that a nurse executes in order to benefit the client in a predictable way that takes into account the nursing diagnosis and expected outcomes. Nursing interventions are actions performed by the nurse to:

Monitor client health status and response to treatment
Reduce risks
Resolve, prevent, or manage a problem
Promote independence with ADLs
Promote an optimum sense of physical, psychological, and spiritual well-being
Give clients the information they need to make informed decisions and be independent
Nurse-initiated interventions do not require a physician’s order. Instead, like client goals, they are derived from the nursing diagnosis.

Question 8

Five Constructs associated with cultural competence

Answer 8

The five concepts or constructs associated with cultural competence are cultural skills, cultural encounters, cultural desire, cultural awareness, and cultural knowledge. These five concepts put forth by Campinha-Bacote underscore the need for nurses and other healthcare providers to develop the knowledge, skills, and abilities to provide culturally competent care to individuals, families, and the community.

Question 9

what does hyperalgesia put the patient at risk for?

Answer 9

At risk for abnormal and irreversible pain related to hyperalgesia” is an appropriate nursing diagnosis for a client who is affected with hyperalgesia. Hyperalgesia, which is synonymous with hyperpathia, is abnormal pain processing that can lead to the appearance of neuropathic pain that is irreversible if left untreated.

Question 10

Amish Culture Considerations

Answer 10

Alternative medical choices and natural treatments are commonly used in this culture. The nurse should recognize this fact because standard therapies may be abandoned for treatments that may be unproven. Church and religion are fundamental in this community. If an individual in the community is ill, it is common for a religious leader to request updates about the client’s condition.
Amish families are typically quite large, and the male is considered the head of the household. This influence enables males to have more influence in making healthcare decisions. Individuals in the Amish culture generally do not participate in health insurance and may pool money together to pay for healthcare expenses. The Amish culture has no prohibition regarding organ transplantation or blood transfusion.
✓ The Amish community prides itself in taking a simple approach to their lifestyle

✓ The family structure is generally large, and family is important

✓ The male is considered the head of the household and generally makes key decisions

✓ Natural remedies and treatments are often pursued in this community

✓ Most of the community is rejects health insurance

✓ Organ transplantation and blood transfusion is not prohibited

Question 11

Education for a young teen with acne

Answer 11

Washing the skin removes oil and debris. Hair should be kept away from the face and washed daily to help prevent oil from the hair from getting on the forehead. Sunbathing should be avoided when using acne treatments. Acne is a condition that is characterized by clogged pores caused by dead skin cells and sebum sticking together in the orifice. Inside the pore, the bacteria have a perfect environment for multiplying very quickly. With a large number of bacteria inside, the pore becomes inflamed. If the inflammation goes deep into the skin, an acne cyst or nodule appears. Acne can appear on the face, back, chest, neck, shoulders, upper arms, and buttocks. Treatment includes avoiding squeezing or picking the infected areas, as this may spread the infection and cause scarring. The face should be washed twice daily with a mild cleanser and warm water. Oil-free, water-based moisturizers and make-up should be used.

Question 12

Purpose of performance appriasals/evaluations

Answer 12

Performance appraisals/evaluations serve a variety of functions, including:

Appraisals help the nurse manager in updating personnel records and making decisions on staffing, including hiring, scheduling, promotions, or termination
Sets expectations for what the employer will provide, such as fair treatment, acceptable working conditions, and feedback on their job performance.
Develops the nurse-manager relationship leading to increased employee retention and morale.
Ensures legal compliance if consequential decisions such as termination should occur.

Question 13

Authoritative Leadership Style

Answer 13

An authoritative leadership style is when one individual is in complete control. This would be useful during an emergency, and clear roles must be delegated.

Question 14

Laissez-Faire Leadership

Answer 14

Laissez-Faire leadership relies on staff to make decisions, and the nurse or manager is viewed as a consultant. This is often viewed as a hands-off approach to leadership.

Question 15

Situational Leadership

Answer 15

Situational leadership the leadership style changes on the needs of the situation. For example, it may start with authoritative and then transition to democratic.

Question 16

Democratic Leadership

Answer 16

Democratic leadership style encourages and assists in discussion and group decision-making. This leadership style encourages shared decision-making, increases staff morale, and brings more viewpoints to issues. For example, if the nurse manager wants to start a unit-based council where the decision-making is shared.

Question 17

transactional leadership

Answer 17

Transactional leadership is when rewards and consequences are based on the actions of an individual. This leadership style is a rigorous approach to managing a team.

Question 18

Crush Wound

Answer 18

A crush wound is a wound caused by force, which leads to compression or disruption of tissues. It is often associated with fractures. Usually, there is minimal to no break in the skin. While other external symptoms, such as bruising or edema, may be visible, nurses should also rely on subjective symptoms reported by the patient. Unrelieved pain is an indication of a complication. Patients who experience a crush injury are at risk for developing compartment syndrome. Therefore, asking the patient to be specific about the quality and intensity of pain will help the nurse re-evaluate her status.

Question 19

Preoperative Nursing Assessment

Answer 19

When performing a preoperative surgical assessment, the nurse assesses the client’s physical status and reviews elements such as
Adherence to nothing by mouth (NPO) status
Preoperative laboratory and diagnostic data
Basic understanding of the procedure
Discharge planning
Postoperative education

Question 20

Would you triage a paient with profuse bleeding with laceration to the chest and apnea first or a patient with a crushed leg who reports decreases sensation to the extremity?

Answer 20

a patient with a crushed leg who reports decreases sensation to the extremity because of their compromised circulation. Red tags require emergent care because of an immediate threat to their life.

Emergent (red tags) include life-threatening injuries, including obstruction to the airway, severe hemorrhage, or shock. Immediate treatment is necessary.
Urgent (yellow tags) include alterations in blood glucose (hypoglycemia), disorientation, and large wounds that need treatment within 30 minutes to 2 hours.
Nonurgent (green tags) include minor injuries such as strains, sprains, simple fractures, or abrasions. Treatment may be delayed up to four hours.

Question 21

Log Roling

Answer 21

Logrolling a client is utilized to keep the spinal column in straight alignment to prevent further injury. This turning technique is commonly used for clients with spinal cord injuries or who are recovering from neck, back, or spinal surgery. A minimum of three individuals is necessary to perform log rolling safely.
The procedure of logrolling a client:
Place a small pillow between the client’s knees.
Cross the client’s arm on their chest.
Position two nurses on the side where the client is to be turned and one nurse on the side where pillows are to be placed behind the patient’s back.
Fanfold drawsheet along the backside of the client.
One nurse should grasp the drawsheet at the lower hips and thighs, and the other nurse grasping the drawsheet at the client’s shoulders and lower back and roll the client as one unit in a smooth, continuous motion.
The nurse on the opposite side of the bed places pillows along length of client for support.
Gently lean the client as a unit back toward pillows for support.

Question 22

Treatment goals for type two diabetic

Answer 22

The treatment goals for a client with type II diabetes mellitus includes:
Maintaining a healthy weight (body mass index less than 25)
A hemoglobin A1C less than 7%
Dietary management with appropriate carbohydrate intake
Full adherence to the prescribed oral antidiabetics or insulin
Absence of complications (foot ulcers, nephropathy, retinopathy)

Question 23

which medications is the patient sure to take following parathyroidectomy?

Answer 23

Following a parathyroidectomy, aggressive calcium replacement typically commences. Two medications commonly prescribed include cholecalciferol (Vitamin D3) and calcium carbonate. Cholecalciferol is necessary to enhance the absorption of calcium carbonate. Calcium levels are monitored closely following this procedure. The parathyroid regulates calcium via the release of parathyroid hormone.

Question 24

Diverticulosis

Answer 24

Diverticulosis is a condition in which the client develops small herniations in the large bowel. A common cause of this condition is a low-fiber diet. The client is instructed to increase their fiber and water intake as these measures are key in promoting bowel motility. If the client should develop diverticulitis, the prescribed diet is NPO (nothing by mouth) status and slowly advanced to clear liquids.

Question 25

how might one experience metabolic acidosis?

Answer 25

Choice A is correct. Diarrheal stools are high in bicarbonate. The loss of this bicarbonate, which is a base, from diarrhea stools results in metabolic acidosis.

Choice C is correct. End-stage renal disease causes metabolic acidosis due to the inability of the kidneys to produce sufficient bicarbonate. Because bicarbonate is a base, and the kidneys cannot produce enough bicarbonate, acidosis occurs.

Choice D is correct. Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. This occurs when a client with type I diabetes mellitus has so little insulin, that the cells have no glucose reserves for energy and subsequently resort to breaking down fat to use for energy. A byproduct of this fat breakdown is ketones, which are acids, and cause acidosis.

Question 26

Direct Combs TEst

Answer 26

direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant’s red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis
✓ Assessment findings in the newborn may include rapid onset jaundice, anemia, and swelling
✓ A newborn experiencing erythroblastosis fetalis may require a blood exchange transfusion

Question 27

Atrial Fibrilation

Answer 27

Atrial fibrillation is an irregularly irregular arrhythmia that produces an irregular pulse. This pulse irregularity is often a clinical indicator that a client requires a cardiac evaluation. Atrial fibrillation is associated with atrial fibrosis and loss of muscle mass. These structural changes are common in heart diseases such as hypertension, heart failure, and coronary artery disease. Characteristically, atrial fibrillation is irregularly, irregular with no P-waves identified. The biggest complication associated with atrial fibrillation is stroke because of blood pooling in the atrium. Treatment options for atrial fibrillation include digoxin (not as commonly used), amiodarone, diltiazem, verapamil, or atenolol. The client may be prescribed an oral anticoagulant such as apixaban to prevent thrombosis. If medication is not desired, synchronized cardioversion may be prescribed.

Question 28

Treatment for HIT

Answer 28

Heparin-induced thrombocytopenia (HIT) may be a life-threatening complication of exposure to heparinoids. The treatment for HIT Is to discontinue exposure to the heparin product immediately and to continue the anticoagulation with a non-heparin product. Agents that may be safely used include apixaban, dabigatran, or rivaroxaban. HIT is an adverse response to heparinoids. This autoantibody reaction causes venous (deeper vein thrombosis, pulmonary embolism) and arterial thrombosis (thrombotic strokes, myocardial infarction, arterial thromboembolism)
The priority of HIT is to recognize it and stop the heparin product.
The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy.
The nurse must report this type of platelet reduction immediately to the primary healthcare physician (PHCP).
HIT treatment includes using an alternative anticoagulation agent such as fondaparinux, warfarin, rivaroxaban, dabigatran, and argatroban, inhibiting thrombin.
Note that anticoagulation must be pursued in HIT despite thrombocytopenia.

Question 29

Risk factors for testicular cancer

Answer 29

Risk factors for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and family history. Cryptorchidism (Choice A) refers to undescended testicle where the testicle fails to descend to its normal position in the scrotum. Undescended testicles are associated with decreased fertility, testicular torsion, inguinal hernias, and an increased risk of testicular germ cell tumors. HIV-positive ( Choice B) men are more likely to develop testicular cancer. Family history (Choice D) of testicular cancer is another risk factor, with 8-10 times increased risk if the man has a sibling with testicular cancer. Testicular cancer, if caught early, has a high cure rate. This cancer most likely occurs between ages 15-34. Risk factors for testicular cancer include Caucasian males, ages 15-34, HIV infection, cryptorchidism, and family history. Testicular cancer may manifest as a dull ache in the scrotum or abdomen, a solid mass on a testicle, scrotal swelling, or heaviness. A scrotal ultrasound is preferred if a primary healthcare provider suspects testicular cancer.

Question 30

During assessment of a 9-month-old infant, what should the nurse expect?

Answer 30

• imitate speech, sounds, non-speech sounds, actions, and gestures
• recognizes own name
• shifts gaze to objects being spoken aout
  -strings together sullabyls I series (ma-ma-ma; da-da-da)

Question 31

which medication would be prescribed for a patten with influenza

Answer 31

✓ Influenza is a highly contagious respiratory infection primarily spread by infected respiratory droplets
✓ Appropriate infection control includes isolating the client using droplet precautions. This includes staff and visitors wearing a surgical mask within three feet of the client. Meticulous hand hygiene should be reinforced, including alcohol-based hand sanitizers before and after client care.
✓ Medical management aims to provide symptomatic care by using prescribed antipyretics and encouraging PO (by mouth) fluids. Antivirals may be used to shorten the duration of the illness; the guideline is to initiate oseltamivir 48 hours within influenza symptom onset.

Question 32

sodium bicarbonate

Answer 32

Sodium bicarbonate is an alkaline agent used to correct severe acidosis. This medication is given in ampules via intravenous push or a continuous infusion.
Epinephrine is the drug of choice for anaphylaxis as it relieves upper airway obstruction and treats hypotension. The intramuscular (IM) route is preferred over IV.
Glucagon is an effective treatment for hypoglycemia as well as beta-blockers and calcium channel blocker toxicity. This medication is given intravenously (IV) or intramuscular (IM) along with other treatments such as epinephrine and calcium gluconate.
Magnesium sulfate is indicated in the treatment of severe asthma attacks, eclamptic seizures, and torsades de pointes which is a ventricular dysrhythmia that may be fatal if not treated.

Question 33

critical thinking

Answer 33

Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth.

There are many definitions of critical thinking. It is a complex concept and people think about it in different ways. Any situation that requires critical thinking is likely to have more than one “right” answer. You do not need critical thinking to add 2 + 2 and come up with the solution. However, you do need critical thinking to problem-solve essential decisions. A crucial aspect of critical thinking is the process of identifying and checking your assumption. This is also a necessary part of the research process. Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth.

Question 34

what contributes to hypokalemia

Answer 34

Hypokalemia is when the potassium level is less than 3.5 mEq/l. Conditions such as metabolic alkalosis, potassium wasting diuretics, Cushing’s syndrome, and alcoholism may all contribute to hypokalemia.
The normal potassium level is 3.5-5.0 mEq/l. Conditions causing hypokalemia include metabolic alkalosis, which causes an intracellular shift of potassium. Cushing’s syndrome or disease causes hypokalemia because of this increase in aldosterone (potassium elimination and sodium retention). Symptoms of hypokalemia include muscle weakness, cramping, and lethargy. Cardiac rhythm changes include flattened T-waves and the presence of U waves.

Question 35

Which conditions require droplet precautions?

Answer 35

Pneumonia Streptococcus, group A
Adenovirus pneumonia
Mumps (infectious parotitis)
Rubella
Pandemic influenza
Epiglottitis, due to Haemophilus influenzae type b
Mycoplasma pneumonia
Pharyngeal diphtheria
Rheumatic fever, infectious mononucleosis, and cryptococcosis meningitis require just standard precautions
Clostridium difficile, rotavirus, and scabies require contact precautions
Varicella zoster requires contact and airborne precautions until the lesions crust over

Question 36

which medication would be reconsidered following order for a bulimic patient?
a) fluoxtetine
b) bupropion
c) sertraline
d) fluvoxamine

Answer 36

Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Weight loss is not a treatment goal for a client with bulimia nervosa, and thus, this medication should not be utilized.Fluoxetine is an SSRI and is approved to treat bulimia nervosa. This medication is effective when treating this eating disorder, especially when coupled with psychotherapy. Major side effects of fluoxetine include weight gain, sexual dysfunction, insomnia, and agitation.

Question 37

Teaching for client being discharged with oxygen therapy

Answer 37

Have a pulse oximetry device readily available.
Avoiding any open flame or heat. This includes an oven, stovetop, candles, matches, and cigarettes. Flammable products such as alcohol and oil should be avoided.
Have working smoke detectors in the home as well as fire extinguishers.
Use a water-soluble jelly to lubricate the nasal passages and mouth to prevent drying.

Question 38

Pavlik Harness Considerations

Answer 38

The Pavlik harness is a treatment method for developmental dysplasia of the hip (DDH)
✓ Treatment before 2 months often achieves the highest rate of success
✓ Treatment involves the application of a harness, casting, or surgery
✓ For the newborn to 6 months, the Pavlik harness may be applied
✓ This harness is applied, adjusted, and removed by the PHCP - not the parents
✓ The goal of the harness is to prevent hip extension and adduction
✓ Skin care is important while a client is wearing the harness
✓ Skin should be checked frequently for any reddened areas or overt skin breakdown
✓ Lotions and powders should not be used because of the potential for fungal dermatitis
✓ The diaper should be placed under the straps
✓ The infant should be dressed in loose, stretchy clothing
✓ If the straps get soiled, gentle soap and water via a washcloth may be used
✓ Provide sponge baths to the infant while leaving the harness in place
✓ Frequent follow-up appointments are necessary because the infant is growing

Question 39

urinary retention

Answer 39

Urinary retention occurs when urine is produced normally but is not entirely emptied from the bladder. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman). Antihistaminic medications (such as diphenhydramine) tend to have anticholinergic side effects. Urinary retention can occur from the use of drugs with anticholinergic side effects. The bladder muscle’s (detrusor smooth muscle) primary function is to “contract” and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function and predispose to urinary retention. Excessive urinary retention eventually results in “overflow” incontinence.

Question 40

dietary needs for patient who is post-gastectomy dumping syndrome

Answer 40

The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body’s increased energy demands.

Question 41

post-myelogram, priority intervention is?

Answer 41

increase fluid oral intake

Question 42

Which assessment data requires immediate intervention?
A) irregular QRS complex
B) rapid, irregular pulse
C) reports of palpitations
D) lightheadedness

Answer 42

Lightheadedness/dizziness may be a sign that the patient’s rhythm has changed. The nurse should assess the patient and the rhythm as well as report any changes to the physician.

Question 43

Which finding is most concerning for a patient who overdosed on ASA?

Answer 43

✓ Aspirin (ASA) overdose is highly concerning because it causes many serious effects
✓ The Poison Control Center should always be consulted with ASA overdoses for guidance on the client’s care
✓ Manifestations of ASA overdose include
Tinnitus
Nausea and vomiting
Tachypnea
Metabolic acidosis
Respiratory alkalosis (they may be in a mixed state of both)
Tachycardia
Hypovolemia
Life-threatening pulmonary edema
✓ Treatment includes correcting the acid-based imbalance with sodium bicarbonate infusion(s), activated charcoal may be given if the ingestion was within two hours of presentation, cardiac monitoring, parenteral fluid replacement to correct hypotension, and glucose replacement

Question 44

A client with lung cancer recently had a left lower lobe removal. Which postoperative intervention will be performed as a priority in the care of this patient?
A. Tracheostomy
B. Mediastinal tube
C. Incentive spirometer
D. Closed chest drainage system

Answer 44

A patient with a recent lower lobe lung removal will have a chest tube drainage system to collect the blood and drainage and to prevent it from accumulating in the chest.`

Question 45

Nursing Care for Abdominal Paracentesis

Answer 45

Abdominal paracentesis is performed for clients with gross ascitic fluid due to liver cirrhosis. Nursing care for an abdominal paracentesis includes -

➢ Witnessing informed consent that the primary healthcare provider obtains

➢ Assisting the client to void before the procedure

➢ Obtaining baseline vital signs

➢ Measure the abdominal girth

➢ Gather appropriate supplies (suction, tubing, paracentesis kit)

➢ Position the client per the physician’s prescription. The positioning is likely upright to allow the fluid to settle in the lower abdominal quadrants.

➢ Monitor the client and the drainage

➢ Send the initial ascitic fluid to the lab for culture and sensitivity, as prescribed
Reposition the client, as needed to facilitate better drainage

➢ Monitor the client’s vital signs throughout and after the procedure

➢ Administer an infusion of albumin, as prescribed for large volume (> 5 liters) paracentesis

Question 46

Hypothermia

Answer 46

Hypothermia is defined as a core body temperature of less than 95° F ( 35°C). Hypothermia is staged into Mild, moderate, severe, and profound hypothermia ( stages I to IV). Staging helps guide the treatment recommendations.

Question 47

Mild hypothermia

Answer 47

A core body temperature between 90 to 95° F (32.2°C to 35°C) is considered mild hypothermia

Question 48

Moderate Hypothermia

Answer 48

a temperature between 82° F to 90° F (27.8°C to 32.2°C) is considered moderate hypothermia
Manifestations of moderate hypothermia include decreased level of consciousness (LOC), hypoventilation, bradycardia, atrial fibrillation, hypovolemia, cessation of shivering, and possible hyperglycemia.

Question 49

Severe Hypothermia

Answer 49

A core temperature less than 82° F (27.8°C) is severe. However, measuring the core body temperature accurately is challenging. Therefore, a model based on the vital signs and clinical symptoms called the “swiss staging model” is used to stage hypothermic patients.

Question 50

The client Bill of Rights

Answer 50

The Client Bill of Rights

To courtesy, respect, dignity, and timely, responsive attention to his or her needs.
To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment. Patients should be able to expect that their physicians will provide guidance about what they consider the optimal course of action for the patient based on the physician’s objective professional judgment.
Ask questions about their health status or recommended treatment when they do not fully understand what has been described and have their questions answered.
To make decisions about the care the physician recommends and to have those decisions respected. A patient who has decision-making capacity may accept or refuse any recommended medical intervention.
To have the physician and other staff respect the patient’s privacy and confidentiality.
To obtain copies or summaries of their medical records.
To obtain a second opinion.
To be advised of any conflicts of interest their physician may have in respect to their care.
To continuity of care. Patients should be able to expect that their physician will cooperate in coordinating medically indicated care with other health care professionals and that the physician will not discontinue treating them when further treatment is medically indicated without giving them sufficient notice and reasonable assistance in making alternative arrangements for care.

Question 51

A client in the medical ward is adamant to go home regardless of what the medical team is telling him. The nurse understands that in order for all healthcare team members to be protected from liability when the client goes home, the nurse must first initiate which action?

Answer 51

The nurse must first determine if the client is of sound mind and legally competent to make decisions regarding his care before letting him sign an ‘Against Medical Advice’ form. If he is deemed incompetent, the facility must keep the client involuntarily to prevent further harm or injury to himself.

Question 52

A client with a history of long-standing hypertension and hyperlipidemia is complaining of shortness of breath and weakness in the legs. What may be occurring?

Answer 52

Myocardial infarction (MI) may present with symptoms of shortness of breath and muscle weakness. Silent MI is something that may not occur with pain. Other symptoms of myocardial infarction include:

Chest discomfort. Most heart attacks involve pain in the center of the chest that lasts more than a few minutes – or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness, or pain.
Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, back, neck, jaw, or stomach.
Shortness of breath can occur with or without chest discomfort.
Other signs include breaking out in a cold sweat, nausea, or lightheadedness.
Since hyperlipidemia has no symptoms, it can cause damage before an individual realizes a problem. It can cause atherosclerosis and limit blood flow, increasing the risk of heart attack or stroke. Factors that can increase your risk of bad cholesterol include a poor diet. These foods are high in saturated fat (found in animal products), and trans fats (found in some commercially baked products) can contribute to an elevated cholesterol level. Additionally, obesity, lack of exercise, age, and history of diabetes can increase the chances of experiencing hyperlipidemia.

Question 53

The occupational health nurse is conducting an in-service on reducing back injuries. It would be correct for the nurse to identify the most common location of the injury is the

Answer 53

The most common area injured during lifting is the lumbar spine. This is because it supports the lower back.

Question 54

Back Injury Prevention Measures

Answer 54

Effective Measures to Prevent Back Injury Include

Have the necessary assistance to move the object.
Planning the move and communicating with the other individual who will assist you.
Using the shoulder, upper arms, hips, and thighs as the predominant muscles to help with the move.
Keep objects close to your body when lifting or carrying objects.
Avoid twisting by using your feet to turn your body.
Use a mechanical lift when necessary.

Question 55

A 53-year-old male presented to the emergency department (ED) with his wife because the client had become quite tired over the past several days. Today, he was difficult to arouse and spoke incoherently.

The client responds to his name during the assessment but does not respond to any other questions. His pulses were thready and slow. Obvious tenting was noted in the skin, which was warm and quite dry. No facial drooping was observed, and when asked to hold out his arms, he could not perform the task. In fact, he did not have many purposeful movements during the exam.

The client has a medical history of gout, bipolar disorder, and hypothyroidism, for which he takes levothyroxine, allopurinol, and quetiapine. She reports that he has been taking his medications as prescribed. However, she noted he was recently placed on Prednisone 20 mg PO BID for a gout flare. He self-discontinued the drug after taking it for two weeks and feeling better, and he did not taper as directed.
Temperature 98.0° F (37° C)

Pulse 121/minute

Respirations 16/minute

Blood Pressure 90/60 mm Hg

O2 saturation 95% on room air
12-lead electrocardiogram: sinus tachycardia with peaked T waves

Answer 55

This client is exhibiting signs and symptoms of an adrenal crisis because of the abrupt cessation of prednisone. Findings supporting the crisis include the client’s lethargy, altered mental status, hypotension, tachycardia, and peaked T waves on the electrocardiogram. The client’s hypotension and tachycardia are explained by the significant dehydration associated with an adrenal crisis. This is further supported by their dry skin and tenting. The peaked T waves on the ECG are evidence of hyperkalemia, a feature of an adrenal crisis. An adrenal crisis may be triggered by a sudden cessation of a corticosteroid (especially if it is a considerable dose and the duration is greater than two weeks). An adrenal crisis is a medical emergency manifested by hypovolemia which causes hypotension and tachycardia. Hypoglycemia is also a clinical feature along with hyponatremia. The client will have elevated potassium levels that may cause cardiac dysrhythmias. The priority treatment for a client with an adrenal crisis is prompt administration of intravenous hydrocortisone! Additional treatment includes intravenous fluids, glucose, and regular insulin to lower the potassium.

Question 56

myxoedema coma

Answer 56

Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate. Fortunately, it is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as a result of the widespread availability of thyroid-stimulating hormone (TSH) assays.
Early recognition and therapy of myxedema coma are essential. Treatment should be initiated on the basis of clinical suspicion without waiting for laboratory results. Important clues to the possible presence of myxedema coma in a poorly responsive patient are the presence of a thyroidectomy scar or a history of radioiodine therapy or hypothyroidism. A history obtained from family members often reveals antecedent symptoms of thyroid dysfunction followed by progressive lethargy, stupor, and coma.

Question 57

Immediately post-op Nursing Interventions

Answer 57

Immediately following a surgical procedure (such as total hip arthroplasty), immediate assessments should include:

Vital signs
Lung sounds
Cardiac rhythm
Incision status
Pain
Nausea and vomiting
Older adults are more at risk for complications, including suboptimal thermoregulation, urinary retention, wound disruption, and delirium.

Question 58

Factitious Disorder

Answer 58

Factitious disorder is characterized by an individual feigning their symptoms. The individual falsifies medical or psychiatric symptoms. This disorder may be imposed on themselves or others (by proxy). Nursing care for a client with this disorder includes –

Develop a therapeutic rapport with the patient.
Avoid confrontation or power struggles.
Focus on the patient’s disorder – not symptoms.
Investigate any new physical symptoms appropriately without them dominating the conversation.

Question 59

You are caring for a patient with blood clots in his lungs. He is receiving urokinase for treating pulmonary embolism. The urokinase has been infusing for the last 10 hours. As you assess the patient, you note that his blood pressure is 102/64, heart rate is 108, and his respiratory rate is 16 breaths per minute. The patient asks to use the bedpan. When he is finished, you notice that he has passed a medium-sized bloody stool. Your best intervention is to:

Answer 59

You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.

Question 60

Which of the following nursing diagnoses is the most appropriate for an immobilized client on complete bed rest who has a blood calcium level of 9.9 mg/dL and a urinary pH of 9.9?
A. Impaired urinary elimination related to an alkaline urinary pH
B. Demineralization related to immobilization and complete bed rest
C. At risk for impaired urinary elimination related to immobilization
D. At risk for hypocalcemia related to bone demineralization

Answer 60

“Impaired urinary elimination related to an alkaline urinary pH” is the most appropriate nursing diagnosis for an immobilized client on complete bed rest. A urinary pH of 9.9 is abnormal, as this is outside the normal urinary pH value range of 4.5 to 8.0. A urinary pH of less than 4.5 is considered acidic, while urinary pH values greater than 8.0 are considered alkaline. Abnormal alkalinity, a known complication of immobility, places the client at risk for the formation of renal calculi and urinary impairments.

Question 61

considerations for acidity of urine

Answer 61

Dietary factors often affect urine pH.
Alkaline urine is observed in clients who consume large quantities of citrus fruit and vegetables.
Acidic urine is observed in clients with high meat intake.
Elevated urine pH levels may be due to urinary tract infections, vomiting, kidney failure, metabolic alkalosis, respiratory alkalosis, etc.
Decreased urine pH levels may be due to diarrhea, diabetes mellitus, diabetic ketoacidosis, metabolic acidosis, starvation, etc.

Question 62

Considerations for Bronchoscopy

Answer 62

Bronchoscopy should only be performed by a pulmonologist or trained surgeon in an operating room or intensive care unit.
Patients should remain nothing by mouth for a minimum of six hours before a bronchoscopy and have IV access, intermittent blood pressure monitoring, continuous pulse oximetry, cardiac monitoring, and supplemental oxygen for the procedure.
Patients usually receive conscious sedation with short-acting benzodiazepines, opioids, or both before the procedure to decrease anxiety, discomfort, and cough.
General anesthesia is also commonly used.
The pharynx and vocal cords are anesthetized with nebulized or aerosolized lidocaine.

Question 63

Skinner’s Theory of Behavior

Answer 63

According to Skinner’s theory, changes in behavior result from an individual’s response(s) to the specific events, or stimuli, which occur in their respective environment. According to Skinner’s research, everything we do and are shaped by our experience of punishment and reward. More specifically, when a stimulus-response pattern is rewarded, the individual is conditioned to respond similarly in the future. The key to Skinner’s theory is reinforcement, or, more specifically, anything that strengthens the desired response. The central tenet of Skinner’s work is that positively reinforced behavior will reoccur. When an individual is rewarded for a specific behavior, that individual is more likely to repeat the behavior due to positive reinforcement. Conversely, under Skinner’s theory, negative reinforcement involves removing an undesirable stimulus to increase a behavior (not to be confused with a “negative punishment,” where one would remove a pleasant stimulus to decrease a behavior). Despite Skinner’s operant conditioning findings dating back to publications from the 1960s, many of these scientific theories continue to be implemented today. While Skinner’s research and findings greatly influence countless fields, education is one of the most notable. Education appears to have been affected by Skinner’s theories at all educational levels, having been integrated into all aspects of classroom management by instructors, instructional designers, administrators, etc., continuing to this day. Skinner’s theories relating to behavior management techniques and procedures continue to be cited and implemented today.

Question 64

Correct sequence for irrigation of NG tube

Answer 64

A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline (or the amount indicated on the order) into the syringe.
C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution.
E and F: After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container.

Question 65

Contraindications of Warfarin

Answer 65

Some of the contraindications for warfarin include:

✓ Active bleeding: Warfarin can increase the risk of bleeding and should not be used in people who are actively bleeding.

✓ Hemorrhagic stroke: People who have had a hemorrhagic stroke (a stroke caused by bleeding in the brain) should not use warfarin, as it can increase the risk of bleeding and worsen the stroke.

✓ Pregnancy: Warfarin is contraindicated in pregnancy, as it can cross the placenta and cause birth defects or bleeding in the fetus.

✓ Severe liver or kidney disease: Warfarin is metabolized in the liver and excreted by the kidneys, so people with severe liver or kidney disease may not be able to properly metabolize or excrete the drug. Hypersensitivity to warfarin: People who have had an allergic reaction to warfarin in the past should not use the medication.

Question 66

Risk factors for T2DM

Answer 66

Risk factors for type two diabetes include family history, gestational diabetes, overweight, and being over the age of 45. Metabolic syndrome is the common driver of diabetes (abdominal obesity, hypertension, hyperlipidemia, hyperglycemia). Diabetes mellitus has a much higher prevalence in non-Hispanic whites as it impacts Native Americans and Alaskan Indians more than any other population group.

Question 67

Plaster Cast Considerations

Answer 67

laster casts are not commonly used and have been widely replaced by fiberglass material. However, it is important for all types of casts that the client is taught:

➢ Plaster cast should be exposed to air until it is dry.

➢ Plaster cast should be handled with the palms instead of the fingers to avoid indentation.

➢ All casts should be kept dry and out of the shower.

➢ The affected extremity that is casted should be elevated for the first 24 hours (above the heart).

➢ Manifestations of compartment syndrome (paresthesias, unrelieved pain) should be taught to the client.

➢ Objects should not be inserted into the cast. If the skin itches, a hair dryer on the cool setting may be used.

Question 68

Labs to monitor for a patient on lithium

Answer 68

Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity).
Lithium levels should be maintained between 0.6 – 1.2 mEq/L. The client should be educated on the following points –

Lithium requires the client to maintain adequate fluid and salt. Failing for the client to do so may result in lithium toxicity.
Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use).
The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity.
Lithium levels should be drawn twelve hours following the client’s last dose. If not, this may falsely elevate the lithium level.
Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension.

Lithium inhibits both iodine uptake & thyroxine release -> Hypothyroidism
(monitor TSH; T4) * Lithium increases PTH & also, causes parathyroid hyperplasia -> Hyperparathyroidism
(monitor calcium)

Question 69

A patient presents with dizziness upon standing, bilateral hand tremors, inability to sleep, irritability, sweating, and a heart rate of 95. From what substance is the patient most likely experiencing these withdrawal symptoms?
A. Alprazolam
B. Nicotine
C. Aderall
D. Cocaine

Answer 69

Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia.

Question 70

The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting

A. bilateral flank pain who has two nephrostomy tubes.
B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD).
C. facial edema while being treated for nephrotic syndrome.
D. a localized rash following the administration of ciprofloxacin for cystitis.

Answer 70

This finding requires follow-up because flank pain when a client has a nephrostomy tube would suggest pyelonephritis, a serious infection. Common findings associated with pyelonephritis include cloudy urine, nausea, fever, and malaise. This infection must be treated promptly because it can lead to urosepsis.
✓ Nursing care for pyelonephritis is like that of cystitis, which includes the administration of prescribed antibiotics, educating the client to stay hydrated, and measures to prevent a recurrence.

✓ A nephrostomy tube increases the client’s risk for pyelonephritis because the catheter is directly threaded into the renal pelvis.

✓ A complication of pyelonephritis is sepsis. Thus, signs of sepsis, such as tachycardia and hypotension, should be reported to the primary healthcare provider.

Question 71

Which of the following nursing improvements follow the recommendations of the Institute of Medicine’s Committee on Quality Healthcare in America?

Select all that apply.

Basing patient care on continuous healing relationships

Customizing care to reflect the competencies of the staff

Using evidence-based decision making

Having a charge nurse as the source of control

Using safety as a system priority

Recognizing the need for secrecy to protect patient privacy

Answer 71

Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care:

Safe: Avoiding injury
Useful: Avoiding overuse and underuse
Patient-centered: Responding to patient preferences, needs, and values
Timely: Reducing waits and delays
Efficient: Avoiding waste
Equitable: Providing care that does not vary in quality to all recipients

Question 72

The nurse is assessing a group of clients prescribed lithium. The client at most significant risk for lithium toxicity is a client with

A. asthma taking both long- and short-acting bronchodilators.
B. chronic migraine headaches and was newly prescribed naproxen.
C. hypertension newly prescribed clonidine transdermal patch.
D. hypothyroidism and was recently prescribed levothyroxine.

Answer 72

NSAIDs (naproxen, ibuprofen), ACE inhibitors (lisinopril, enalapril), and diuretics (furosemide, hydrochlorothiazide) should be avoided while a client is taking lithium. ACE inhibitors promote sodium wasting, and low levels of sodium precipitate lithium toxicity. NSAIDs reduce renal blood flow, cause lithium retention and raise its serum level to a potentially toxic range. The client with aches and pains should be recommended acetaminophen.

Question 73

A nurse is caring for a client receiving digoxin. The client’s most recent digitalis level was 2.5 ng/mL. The nurse should take which action?

Answer 73

The client’s digitalis level of 2.5 ng/mL indicates toxicity. Digoxin has a narrow therapeutic index, which can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal corrective serum digoxin levels range from 0.5–2 ng/mL. A level higher than 2 ng/mL is considered toxic. The nurse is correct in withholding the scheduled dose and assessing the client’s heart rate and rhythm, as the client is likely to be experiencing bradycardia.
The normal therapeutic range for digitalis is 0.5-2 ng/dL. Hypokalemia is a significant cause of digitalis toxicity and may be induced by certain diuretics. The earliest manifestation of digoxin toxicity is lack of appetite, nausea, and vomiting.

Question 74

A nurse is caring for a client following a stroke diagnosis which rendered the client with stage I dysphagia. Which foods should the nurse feed the client based on the client’s dysphagia severity?

Answer 74

A client with stage I dysphagia has severe difficulty swallowing. These clients must be fed puréed foods. Stage I dysphagia clients are fed diets consisting of primarily puréed foods, including puréed fruits, vegetables, and meats. Additional foods include gravies, puddings, egg yolks, and baby foods.

Question 75

Oxaprozin

Answer 75

Oxaprozin is a non-steroidal anti-inflammatory drug (NSAID). This drug is effective in osteoarthritis because this disease causes significant pain, especially when the affected joint is used. Long-term NSAID use may cause renal insufficiency and increase the risk of a gastrointestinal ulcer.

Question 76

The nurse reviews the function of a prescribed beta-blocker in the cardiovascular system. It would be appropriate for the nurse to state that beta-blockers
block catecholamines from binding to the beta receptors.

reduce myocardial oxygen demand.

increase cardiac contractility.

increase cardiac output.

prevent sodium and water resorption by inhibiting aldosterone secretion.

Answer 76

Beta-blockers decrease blood pressure by causing vasodilation of the vessels. They block catecholamines from the beta receptor sites found in the heart and lungs. Beta-blockers decrease the heart’s workload through vasodilation and lowering the heart rate. This relaxation of the vasculature and reduction in heart rate will reduce the myocardial oxygen demand. This is why beta blockers (low doses) may be prescribed during an acute myocardial infarction and afterward.

Question 77

Beta Blockers

Answer 77

✓ Beta-adrenergic blockers, more commonly referred to as beta blockers

✓ Beta-blockers block catecholamines from binding to the receptors found in the heart and lungs

✓ These medications block the beta receptors, the rate at which the pacemaker (sinoatrial [SA] node) fires decreases, and the time it takes for the node to recover increases

✓ Some beta-blockers are more cardioselective (metoprolol and atenolol) compared to nonselective beta-blockers (propranolol)

✓ Underlying restrictive and obstructive respiratory illness may worsen when beta-blockers are given because the medication causes bronchoconstriction

✓ The nurse needs to assess the client’s pulse (P) and blood pressure (BP) before administration

✓ These medications may raise the client’s risk for falls because they may cause orthostatic hypotension

✓ Beta-blockers should not be administered if the client is experiencing any atrioventricular (AV) block or bradyarrhythmia

✓ Examples of beta-blockers include propranolol, metoprolol, and carvedilol

Question 78

Where would the nurse expect to assess tympany when performing percussion on a patient with ascites?

Answer 78

Patients with ascites present with tightly stretched skin over a rounded, distended abdomen due to accumulation of fluid in the peritoneal cavity typically related to liver disease, portal hypertension, tuberculosis, or nephritic syndrome. Upon percussion of the abdomen, the nurse would expect to note tympany over the top of the abdomen where the intestines float, and dullness over the sides where fluid settles (fluid shifts when the patient is turned to the side).

Question 79

scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up?
A. You will need to provide both a urine and blood sample for this test.
B. Drink plenty of water prior to this test and do not empty your bladder.
C. An ultrasound will be used during this procedure to guide the needle.
D. It is okay to eat and drink on the day of the procedure.

Answer 79

A CVS is a test utilized to determine the presence of chromosomal abnormalities and involves the aspiration of small samples of the placenta for prenatal genetic diagnosis. Maternal blood and urine specimens are not necessary for this test.
Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Chorionic villus sampling has drawbacks that preclude its use, including possible spontaneous abortion of the fetus and fetomaternal hemorrhage.

Question 80

The nurse is assigned the case manager role. She understands that case management uses which methods of patient care delivery and documentation?

Answer 80

Documentation is a written record of (1) the interactions between and among health care professionals, patients, and their families (2) tests, procedures, treatments, and patient education (3) test results or patient’s responses to treatment interventions. Several methods are used for documentation. These include narrative charting, source-oriented charting, problem-oriented charting, PIE charting, focus charting, charting by exception (CBE), computerized documentation, and critical pathway documentation. Case management refers to the process of organizing the patient care throughout an episode of illness so that certain clinical and financial outcomes are achieved within an assigned time frame. Case management uses a critical pathway documentation system as a form of patient care delivery and documentation. Critical pathways are time-oriented multidisciplinary plans of care that are established and approved by the interdisciplinary team. Variances are deviations from the expected course that are documented within the critical pathway system.

Question 81

Diltiazem

Answer 81

Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke.
✓ The primary goal for a client with atrial fibrillation is to maintain rate control (60-100) and to prevent stroke

✓ Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be used to control heart rate

✓ Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation

✓ Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin

Question 82

Fentanyl Patch

Answer 82

Fentanyl via a transdermal patch is an effective way to provide around-the-clock pain control. The medication establishes efficacy within 24 hours, and the patch should be kept on the client for 72 hours.

Question 83

Pregabalin

Answer 83

Pregabalin is a medication used to manage neuropathic pain (neuropathy, phantom limb pain). This medication may cause an individual to experience drowsiness.

Question 84

Ketoralac

Answer 84

Ketorolac is an anti-inflammatory medication that may be used short-term for individuals with mild to moderate pain. The client should have their doses limited as this medication may cause nephrotoxicity.

Question 85

Health Care Proxy

Answer 85

A health care proxy is an individual named in a written legal document designated to make medical decisions for the client when the client is no longer able to make decisions for themself.

Question 86

Power of Attorney

Answer 86

A power of attorney (POA) primarily authorizes the person you designate to make financial decisions for you. It cannot be used to make health care decisions. You must complete a health care proxy to enable someone else to make healthcare decisions for you when you can no longer do so.

Question 87

Onycomychosis

Answer 87

Onychomycosis is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque/yellow, and crumbling.

Since Onychomycosis is the most common cause of nail dystrophy presenting to the outpatient department, a nurse plays a crucial role in the diagnosis, management, and education of the clients.

Dermatophytes (Trichophyton) cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida).
The prevalence of onychomycosis in patients between 20 to 60 years of age is 20%, whereas prevalence in older adults > 70 years of age is about 50%.
The nurse should be aware of the risk factors and educate at-risk clients regarding foot care. Some common risk factors for onychomycosis include immunosuppression, diabetes mellitus, age greater than 70, persistently wet feet, repetitive nail trauma, tight-fitting footwear, HIV infection, prolonged steroid use, peripheral vascular disease, and genetics.
Often, patients are asymptomatic. But the quality of life can be substantially decreased because of onychomycosis. Clients may have low self-esteem and feel embarrassed about having thick, discolored nails. Also, they may report mild pain and discomfort.
Diagnosis is based on history and clinical exam. Diagnosis can be confirmed by demonstrating dermatophytes in KOH preparation of nail scrapings.
The condition is often challenging to treat. Recurrence and failures may be in the range of 20 to 50% (i.e., the cure rate is approximately 50%). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails.
Most antifungal treatments may have liver toxicity; therefore, liver function tests may have to be monitored. Terbinafine is contraindicated in clients with baseline liver disease.

Question 88

Onychomadesis

Answer 88

Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease.

Question 89

Onychomadesis

Answer 89

Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease.

Question 90

Onychorrhexis

Answer 90

Onychorrhexis is the formation of vertical ridges on the nails or brittle nails that tend to break easily. The pins are not thick and discolored, as shown in the exhibit. Onychorrhexis occurs due to disordered keratinization in the nail matrix. Causes include the normal aging process, recurrent nail trauma, anemia, hypothyroidism, and eating disorders.

Question 91

Onychia

Answer 91

Onychia is an inflammation of the nail folds. It does not appear in the exhibit provided. Onychia is not the infection of the nail itself, but rather a disease of the surrounding tissue of the nail plate.

Question 92

The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client’s VPA level is 40 mcg/mL(50-125 mcg/mL). Which action should the nurse take next?

Answer 92

The therapeutic VPA level is 50-125 mcg/mL. A 40 mcg/mL VPA level is considered sub-therapeutic and requires follow-up as the client is at risk of seizure. A cause of this level being subtherapeutic may be caused by non-adherence to the medication.

Question 93

Valproic Acid

Answer 93

✓ VPA is indicated in preventing seizures, treatment for bipolar disorder, and migraine headache prevention

✓ The most common adverse effects of VPA include nausea, vomiting, blood dyscrasias, hair loss, and metabolic syndrome

✓ The liver enzymes should be monitored while a client takes VPA, as hepatic injury may occur

✓ The therapeutic level of VPA is 50-125 mcg/mL

Question 94

The nurse has taught a client about a scheduled intravenous (IV) urography (pyelogram). What should be taught?

Answer 94

An IV urography (pyelogram) is a diagnostic test used to gather urinary tract imaging that views the collecting ducts and renal pelvis and outlines the ureters, bladder, and urethra. The client must perform a bowel cleansing the night before to ensure adequate visualization of the urinary tract. During this procedure, the client will empty their bladder, and then an intravenous injection of contrast medium is given, and a series of x-ray films and fluoroscopy is used to observe the passage of urine from the renal pelvis to the bladder. The use of this test has decreased because of computed tomography scans of the urinary tract.
✓ This procedure requires female clients to undergo a pregnancy test before the procedure because of the adverse effect radiation may have on the fetus

✓ The purpose of this test is to diagnose neoplasms of the urinary tract, urolithiasis, scars, and urinary strictures

✓ Laxatives may be prescribed the night before to cleanse the bowel effectively

✓ Anesthesia is not used for this procedure

✓ Contrast dye is used in this procedure, but the relationship between IV contrast dye and allergies to shellfish has been discredited

Question 95

How should the nurse assess for the presence of thrombophlebitis in a patient who reports having pain in the left lower leg?

Answer 95

Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs.

Question 96

The nurse is working at the triage desk in the emergency department when a client arrives and begins speaking in Spanish. The nurse asks if the client would like an interpreter, and the client says, “No.” What is the most appropriate action for the nurse to take?

Answer 96

It is most appropriate to request an interpreter from the hospital’s interpreter service. A certified medical interpreter has the proper training to quickly and accurately translate the conversation as well as protect client confidentiality. This is the appropriate action by the nurse.

Question 97

Emergent triage category

Answer 97

The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke.

Question 98

urgent triage category

Answer 98

The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C).

Question 99

non-urgent triage category

Answer 99

Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections.

Question 100

The nurse has provided medication instruction to a client who has been prescribed enalapril. Which teaching should be included?

Answer 100

Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening.
ACE inhibitors are central in the treatment of heart failure and hypertension. These medications inhibit the deleterious effects associated with Angiotensin II. Medications in this class include lisinopril, enalapril, and captopril. The most serious adverse effect is angioedema. A nagging, dry cough is a common side-effect associated with this medication, and if this should occur, a prescriber may switch the client to an ARB such as valsartan. Finally, these drugs may raise potassium and creatinine.

Question 101

As a nurse working in the emergency department, you are working with a client who was admitted with a magnesium level of 1.4 mEq/L(1.5-2.5 mEq/L), which falls below the normal range of 1.5-2.5 mEq/L(1.5-2.5 mEq/L). You need to create a list of foods that you recommend the patient should consume. What foods would you suggest to add to the list?

Answer 101

✓ Magnesium is an essential mineral that plays a vital role in various physiological functions, including muscle and nerve function, blood pressure regulation, and protein synthesis.

✓ The following are some dietary sources of magnesium recommended by the American Dietetic Association (ADA):

Green leafy vegetables
Nuts and seeds
Legumes
Whole grains
Seafood
Dairy products
✓ It is essential to note that the magnesium content of foods can vary depending on the soil in which they are grown and the processing methods used. Therefore, it is recommended to consume a variety of magnesium-rich foods to meet daily magnesium requirements.

✓ The ADA recommends a daily intake of 310-320 mg of magnesium for adult women and 400-420 mg for adult men.

Question 102

The nurse is caring for a client diagnosed with a myxedema coma. The nurse should anticipate a prescription for which medications?

Answer 102

When a client experiences a myxedema coma, it is because of severe hypothyroidism. These dangerously low levels of thyroid hormone produce symptoms such as altered level of consciousness, hyponatremia, hypothermia, hypoventilation, and hypoglycemia. Treatment is essential and is geared towards the prompt administration of intravenous levothyroxine and liothyronine. Glucocorticoids are usually added to the treatment to help mitigate the hypotension and potential overlook of adrenal dysfunction.
Myxedema coma is a rare but extremely serious complication associated with severe hypothyroidism.

✓ Manifestations of a myxedema coma include hyponatremia, hypothermia, hypoventilation, and hypoglycemia.

✓ The nurse must initiate medical and symptomatic treatment, such as intravenous levothyroxine and hydrocortisone.

✓ The nurse may also treat the client’s symptoms with passive rewarming.

Question 103

Pheochromocytoma

Answer 103

Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla. This causes a surge in catecholamine discharge resulting in headaches, palpitations, marked hypertension, and hyperglycemia. Treatment includes antihypertensives and removal of the tumor. The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure.

Question 104

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed?

Answer 104

A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient’s neck from flexing. A standard ICP is about 5 to 15 mmHg.

Question 105

Patient Controlled Analgesia

Answer 105

➢ PCAs can be used for individuals as early as seven years old.

➢ The settings on the PCA include on-demand dosing, basal, or both.

➢ The PHCP will prescribe the opioid (morphine, fentanyl, or hydromorphone) along with the amount, lockout period, and maximum dose.

➢ When initiating a PCA device, it is essential to have a second nurse verify the settings before the infusion.

➢ It is recommended that continuous pulse oximetry be applied to the client to detect early signs of opioid toxicity.

➢ If on-demand dosing is prescribed, the client must be cognitively aware of operating the device.

➢ When the basal setting is used, the client is at an increased risk of adverse events because this setting delivers continuous pain medication regardless of the client pushing the button.

Question 106

Macewen’s Sign

Answer 106

Macewen’s sign is a sign used to detect hydrocephalus. The examiner percusses on the skull at the junction of the frontal, temporal, and parietal bones and can auscultate a “cracked pot”, or hyper-resonant sound if hydrocephalus is present. Macewen’s sign is unrelated to congestive heart failure or chronic hypoxia.

Question 107

This nurse is caring for a client who is receiving prescribed sitagliptin. Which assessment findings indicate the client is experiencing a severe adverse effect?

Answer 107

Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. The most common adverse effect associated with this medication is pancreatitis. Pancreatitis is manifested by abdominal pain, nausea, and persistent vomiting.Sitagliptin is a treatment that may be prescribed for type II diabetes mellitus

✓ Persistent abdominal pain should be reported because pancreatitis is the major adverse effect of this medication.

✓ Other medications in this class include linagliptin, saxagliptin, and alogliptin.

Question 108

A client is seeking guidance on secondary prevention strategies to prevent cancer. Which strategies would be most appropriate for the nurse to include in the client’s educational plan?

Answer 108

Primary, secondary, and tertiary prevention are three levels of healthcare strategies used to prevent or manage diseases and injuries:

✓ Primary prevention: Primary prevention aims to prevent the onset of a disease or injury before it occurs.

✓ Secondary prevention aims to identify and treat a disease or injury in its early stages to prevent it from progressing or causing complications.

✓ Tertiary prevention: Tertiary prevention aims to prevent or reduce the long-term effects of a disease or injury that has already occurred.

Question 109

Serotonin Syndrome

Answer 109

✓ Serotonin syndrome (serotonin toxicity) is a serious condition that ranges from mild (most cases go unnoticed) to life-threatening.

✓ Most cases are caused by a client being on a serotonergic agent (such as an SSRI [citalopram, paroxetine, fluoxetine]) and then a newly prescribed (or over over-the-counter) medication taken by the client which causes a tremendous elevation in serotonin giving the client abdominal cramping, myoclonus, diarrhea, diaphoresis, agitation, fever, and tachycardia

✓ Treatment is withdrawing the serotonergic drug and administering prescribed aggressive dosing of benzodiazepines, intravenous fluids, seizure precautions, and cyproheptadine (a serotonin antagonist)

Question 110

The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?

Answer 110

A PET scan is primarily indicated to detect cancers and their response to treatment. Before a PET scan, the client is instructed to be nothing by mouth (NPO) four to six hours before the exam and have a glucose level below 150 mg/dL. The reasoning is that this exam primarily looks at cancerous tissue, which uses a substantial amount of glucose. If the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. Glucose greater than 150 mg/dL or less than 60 mg/dL will alter the results.
PET imaging is primarily used to detect cancers, assess the treatment response, and evaluate the extent of metastasis. F-18 fluorodeoxyglucose (FDG) is used during this exam and emits positrons, and the technique often produces images with higher contrast and spatial resolution. Malignant tissue uses a substantial amount of glucose, and if the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas.

The client is instructed to be NPO 4-6 hours before this exam.
The client should be instructed to refrain from vigorous exercise 24- hours before the exam.
After the injection of FDG, the client must lie in a quiet room for 60 minutes before the scan.

Question 111

The nurse observes a patient clutching her abdomen and complaining of cramping, which is accompanied by sharp pain. Which type of pain is the client experiencing?

Answer 111

Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing “sharp” pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the patient as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue).

Question 112

Very-Low-Calorie Diet Considerations

Answer 112

Very Low-Calorie Diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision.
Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3–5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and the risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3–4 months. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months and gaining all of the weight back in less than five years. Low-calorie diets (LCDs) are not as extreme and with almost twice as many calories allowed (1200–1500 kcal/day), the weight loss is modest.

Question 113

The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action?

Answer 113

Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client’s safety at the forefront and provide seizure precautions. This includes padding the side rails, ensuring that intravenous access has been established, oxygen is at the bedside, and suction is available.
✓ Delirium Tremens (DTs) are a medical emergency and may cause autonomic hyperactivity, resulting in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension.

✓ Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium.

✓ This may occur within 72 hours following the last alcoholic beverage consumed.

✓ Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation.

✓ These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure.

✓ Diazepam is given intravenously as a common treatment for withdrawal seizures.

Nursing care for DTs includes -

Rapid assessment of the client’s vital signs
Initiate seizure precautions and establish patent intravenous access
Obtain a prescription for benzodiazepines, such as lorazepam or diazepam
Administer intravenous fluids and electrolytes to replete the lost fluids
Assess the client using the CiWa-Ar scale to trend the severity of the symptoms

Question 114

Agnosia

Answer 114

Agnosia is a clinical feature associated with dementia. Agnosia is the inability to identify familiar objects or people, even a spouse.

Question 115

Dementia

Answer 115

✓ Alzheimer’s disease (AD) is the most common type of dementia.

✓ The progressive deterioration of cognitive functioning commonly characterizes AD.

✓ Initial deterioration may be so subtle and insidious that others may not notice it.

✓ In the early stages of the disease, the affected person may be able to compensate for and hide cognitive deficits.

✓ Manifestations of AD include impairment of recent memory which progresses to remote memory.

✓ As the disease progresses, the client may have impairment in executive functioning, including planning, organizing, and problem-solving.

✓ Additional clinical features of AD include the triple-A (agraphia, agnosia, and apraxia).

✓ Nursing care is aimed at maximizing function and promoting safety. The nurse should also provide caregiver/family support because of the emotional toll of this disorder.

Question 116

The RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury?

Answer 116

deviated tongue

Question 117

Osteoporosis

Answer 117

✓ Osteoporosis is a condition characterized by a decrease in bone mass

✓ Risk factors are postmenopausal women, Asian or White race, excessive use of alcohol, tobacco use, sedentary lifestyle, prolonged exposure to corticosteroids, hormone insufficiency (testosterone/estrogen)

✓ The biggest complication of osteoporosis is fracture

✓ Prevention is the best treatment by encouraging weight-bearing exercises to increase bone mass, adequate calcium and vitamin D intake, and smoking, and alcohol cessation

✓ Diagnosis is established by a bone density (DEXA) scan

✓ Nursing care is focused on mitigating risk factors, preventing falls, and encouraging the client to remain active to help with restoring bone mass

Question 118

Factors to reduce medical errors in hospital

Answer 118

Reducing medical errors is a continuous process,, and several proven factors may mitigate errors. These factors include:

Having nurse-to-nurse bedside handoff reporting. Not only does this process increase client satisfaction by having the client participate, but it allows for errors to be noted by two individuals instead of one. For example, if an infusion pump is malfunctioning or administering the wrong dose. Bedside handoff reporting also mitigates distractions from being in the hallway or at the desk where it may be loud.
A standardized handoff reporting (ISBAR) is helpful because it keeps communication concise to pertinent information. This standardized tool is useful because it keeps the communication process structured,, minimizing the risk of omission.
Fatigue is a common source of errors. One way to minimize fatigue is to ensure all staff is taking uninterrupted breaks.
Poor lighting and distractions continually contribute to errors, and increasing lighting around critical pieces of equipment, such as mediation dispensaries, may be helpful to reduce errors regarding reading product labels and drawing up accurate medication dosages.

Question 119

Halo Vest Immobilizer

Answer 119

A halo vest immobilizer is used to stabilize cervical spinal cord injuries. The goal is to stabilize the spinal cord using external fixation. Pin care should be completed every shift using sterile gauze and the prescribed solution. If the client should have the wrench taped to the front of the vest or at the head of the bed in case the device needs to be taken down for emergent cardiopulmonary resuscitation. Loosening of the pins is the most common complication and should be addressed immediately. The client should use a straw for drinking as moving the neck to swallow liquids is not permitted.
When caring for a client with a halo vest immobilizer, the nurse should instruct the client about pin care, signs of infections at the pin site, not driving while in the vest, and keeping the wrench affixed to the front of the vest. To perform CPR, the wrench may be necessary to let down the metal posts. Before discharge, a client with this type of device will need to meet with an occupational and speech therapist to learn how to perform ADLs safely.

Question 120

The nurse in the emergency department is preparing to receive a client exposed to inhalation anthrax. The nurse plans to implement which precautions?

Answer 120

Standard precautions are utilized in the management of inhalation anthrax. Inhalation anthrax is not transmitted from person to person, and its vector is contaminated materials, such as wool, hides, or hair.
✓ Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate.

✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium.

✓ Standard precautions are used for a client with inhalation anthrax.

✓ Nursing care is aimed at stabilizing the client’s breathing and promptly initiating treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

Question 121

Benchmarking

Answer 121

In Benchmarking, the nurse-manager compares best practices from top hospitals with her unit and adapts the unit’s methods to improve unit performance.

Question 122

Causes of metabolic alkalosis

Answer 122

✓ Metabolic alkalosis is a medical condition characterized by an elevation in blood pH above the normal range of 7.35-7.45, resulting from an accumulation of bicarbonate ions (HCO3-) in the body.

✓ Causes: The most common causes of metabolic alkalosis include excessive vomiting or gastric suction, diuretic use, hyperaldosteronism, and excess bicarbonate administration.

✓ Symptoms: The symptoms of metabolic alkalosis include confusion, twitching, muscle cramps, and tingling in the fingers and toes. Severe cases can lead to seizures, respiratory depression, and cardiac arrest. Diagnosis: Diagnosis of metabolic alkalosis involves measuring arterial blood gases, serum electrolytes, and urine pH.

✓ Treatment: Treatment depends on the underlying cause of metabolic alkalosis. It may involve fluid and electrolyte replacement, correction of acid-base imbalance, and addressing the underlying condition.

Question 123

Conditions requiring droplet precautions

Answer 123

Conditions requiring droplet precautions include:

Rubella
Influenza
Pertussis
Bacterial meningitis
Pneumonic plague
Diphtheria (Pharyngeal)
Mumps
Rhinovirus

Question 124

The nurse is caring for a neonate with a decreased cardiac output. If noted in this patient, which of the following is not a sign of decreased cardiac output?

A. Oliguria
B. Difficulty breastfeeding
C. Bradycardia
D. Hypotension

Answer 124

Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses.

Question 125

This nurse is caring for a client who is receiving prescribed tolvaptan. What finding would indicate a therapeutic response?

Answer 125

Tolvaptan is a vasopressin antagonist and is indicated in treating the syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the client retains water which causes fluid retention without edema. Classic manifestations of SIADH include polydipsia, hemodilution, and oliguria. This medication promotes free water excretion, normalizing sodium levels and increasing urine output. This urine-specific gravity is normal (1.005 - 1.025) and indicates that the medication is having its therapeutic effect because a client with SIADH would have a high USG from the limited water spilled into the urine.
✓ SIADH may be caused by pulmonary tuberculosis and certain lung malignancies.

✓ Clinical features of SIADH include hyponatremia because of excessive water. Other features include increased urine-specific gravity, oliguria, and hemodilution.

✓ Treatment includes prescribed fluid restrictions and tolvaptan.

✓ Tolvaptan causes the excretion of free water, which raises sodium levels.

✓ The client’s sodium needs to be monitored carefully while administering this medication because it may cause hypernatremia.

✓ This medication is very hepatotoxic, and the liver function tests should be monitored closely.

Question 126

The nurse is educating the client with urinary tract calculi regarding diet. Which of the following foods may the client have?

Answer 126

The client may have broccoli, lettuce, and apples. Lettuce and apples are low in calcium and oxalate. Broccoli is high in calcium. However, it is low in oxalate and high in potassium. Being high in potassium, broccoli reduces calcium excretion in urine and reduces the formation of kidney stones. Therefore, this is the reason that it need not be held back in renal calculi. Kidney stones in the urinary tract are formed in several ways. Calcium can combine with chemicals, such as oxalate or phosphorous, in the urine. This can happen if these substances become so concentrated that they solidify. Kidney stones can also be caused by a buildup of uric acid related to the metabolism of protein. Most urinary tract calculi, especially calcium oxalate stones, can be prevented by following dietary recommendations. Generally, clients should avoid high calcium and high oxalate-containing foods. Clients should also be instructed to avoid stone-forming, high oxalate foods such as beets, chocolate, spinach, rhubarb, and tea. Most nuts are rich in oxalate and colas are rich in phosphate, both of which can contribute to kidney stones. Fluids, especially water, help to dilute the chemicals that form stones. Patients should be encouraged to drink at least eight glasses of water every day.
✓Increasing fluid intake: Drinking plenty of water and other fluids can help dilute the urine and reduce the risk of stone formation.

✓Reducing sodium intake: Consuming too much salt can increase the amount of calcium in the urine, contributing to kidney stones’ formation.

✓Eating a balanced diet: Eating a diet that is high in fruits, vegetables, and whole grains and low in animal protein and refined sugars can help reduce the risk of kidney stones.

✓Avoiding certain foods: Some foods, such as those high in oxalates or purines, may increase the risk of kidney stones and should be avoided or limited.

Question 127

Meloxicam

Answer 127

Meloxicam is a COX-2 inhibitor and is indicated in treating chronic musculoskeletal conditions causing pain, such as osteoarthritis or rheumatoid arthritis.
COX-2 inhibitors are purported to provide pain control while decreasing the risk of gastrointestinal bleeding when compared to an NSAID such as naproxen.
The client’s vital signs are not concerning. The client has a temperature of 99° F (37° C), is commonly found with rheumatoid arthritis, and is not concerning.
The client’s pain does not require follow-up because the nurse has a prescription for pain control, meloxicam. Pain with RA is expected.
An allergy to doxycycline is not a contraindication to the administration of meloxicam.
NSAIDs, COX-2 inhibitors, and aspirin should be avoided in individuals with congestive heart failure because of their ability to worsen the condition. The nurse must clarify this point with the physician before administering the medication.
NSAIDs and COX-2 inhibitors are nephrotoxic and may cause an acute kidney injury. The client’s renal function tests are elevated and would prohibit the dosing of this medication.
✓ Pain control for an individual with rheumatoid arthritis (RA) is an essential aspect of the treatment plan

✓ Medications such as topical creams and alternating with ice and heat are plausible options

✓ Antiinflammatory medications such as naproxen or ketorolac may be used

✓ COX-2 inhibitors may be used in lieu of an NSAID because of their decreased risk of causing gastrointestinal bleeding

✓ COX-2 inhibitors include meloxicam and celecoxib

✓ Contraindications with COX-2 inhibitors include renal insufficiency, congestive heart failure, and stroke

Question 128

The nurse is in the screening room of a women’s health clinic. The nurse notices a particular woman complaining of back and leg pain, spotting after intercourse with her husband, and vaginal discharge for the past few months. The nurse suspects:

Answer 128

Signs and symptoms of cervical cancer include back and leg pain, spotting between menstrual periods and after intercourse, vaginal discharge, and lengthening of a menstrual period. A pap smear is needed to assess cellular changes (i.e. check for cancerous and precancerous conditions).

Question 129

HHS

Answer 129

Hyperglycemic-hyperosmolar state (HHS) is likely to develop in individuals with type II diabetes mellitus. The patient secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. Severe hyperglycemia causes an individual to experience significant diuresis, causing severe dehydration. Correcting fluid and electrolyte imbalances is essential for an individual with HHS. The clinical guideline is to infuse one liter of saline in one hour and reassess the client’s volume status thereafter.
HHS development is related to residual insulin secretion. The client secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. The hyperglycemia of HHS is more severe than that of DKA, greatly increasing blood osmolarity, leading to extreme diuresis with severe dehydration and electrolyte loss. HHS is a common complication associated with type II diabetes mellitus.

Treatment for HHS emphasizes fluid replacement. Neurological functional needs to be monitored closely as cerebral edema may consequently occur from rapid fluid replacement. Any alteration in mental status needs to be reported. Treatment goals aim to restore circulatory volume at a steady pace.

Question 130

The nurse has attended a staff education program about disseminated intravascular coagulation (DIC). Which of the following clients is at risk for DIC? A client

A. with iron deficiency anemia receiving parenteral iron sucrose infusion.
B. being treated for gram-negative sepsis with intravenous antibiotics.
C. with atrial fibrillation receiving prescribed rivaroxaban to reduce their risk for stroke.
D. taking a daily aspirin to reduce their risk for acute coronary syndrome

Answer 130

A client with gram-negative sepsis faces an array of complications, including DIC. The release of the endotoxin by the bacteria may cause excessive activation of the clotting cascade, leading to exhaustion by the clotting factors. Clients with sepsis need to be monitored for DIC as this condition is life-threatening. The risk for DIC caused by gram-negative sepsis is even higher for those with hypothermia and acidosis because the coagulation factors’ enzymatic functions are pH and temperature-dependent.
✓ DIC is a medical emergency and can be caused by an array of conditions, including eclampsia, gram-negative sepsis, and cancer

✓ Extensive, abnormal clotting occurs throughout the blood vessels of individuals with DIC. This widespread clotting depletes circulating clotting factors and platelets. As this happens, extensive bleeding occurs.

✓ Bleeding from many sites is the most common problem, ranging from oozing to fatal hemorrhage.

✓ Clots block blood vessels and decrease blood flow to major body organs, resulting in pain, ischemia, strokelike symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis.

✓ Treatment includes packed red blood cells and fresh frozen plasma transfusions. Heparin may be prescribed for any thrombi.

Question 131

The nurse has received an order to prepare a client for a water deprivation test. The nurse understands that this test is used to diagnose

A. hyperthyroidism
B. pheochromocytoma
C. diabetes insipidus (DI)
D. syndrome of inappropriate antidiuretic hormone (SIADH)

Answer 131

DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client’s urine volume and weight are meticulously measured hourly. If the client’s body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely.
✓ DI is a condition that may be central or nephrogenic

✓ The client is at risk for fluid volume deficit because the client may experience polyuria

✓ This may manifest as tachycardia, hypotension, and a thread pulse

✓ Common laboratory findings for an individual with DI include hypernatremia, decreased urine specific gravity (it is dilute), and increased hematocrit (hemoconcentration)

✓ Treatment for central diabetes insipidus is by administering desmopressin (intranasal or tablet)

✓ Nephrogenic diabetes insipidus is treated by withdrawing the offending agent (such as lithium) and administration of thiazide diuretics or NSAIDs

Question 132

The nurse is caring for a client with pneumonia receiving six liters a minute of nasal cannula oxygen. The client has a SpO2 of 81%, and the arterial blood gas (ABG) returns with a PaO2 of 68 mm Hg. Which immediate intervention should the nurse take?

A. Notify the rapid response team (RRT).
B. Obtain a prescription for a chest radiography
C. Increase nasal cannula oxygen to seven liters a minute.
D. Auscultate the lung fields for adventitious sounds.

Answer 132

This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client’s inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider.
Inflammation from pneumonia may cause a client to develop ARDS. A classic manifestation of ARDS is hypoxemia (PaO2 less than 80 mm Hg). Adventitious lung sounds are not normally auscultated initially with ARDS and are not a reliable assessment. Treatment for ARDS is correcting the underlying cause and maintaining adequate oxygenation and ventilation via invasive and non-invasive means. The normal PaO2 is 80-100 mm Hg, and the normal SpO2 is greater than 95%.

Question 133

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL (Male: 14-18 g/dL / Female: 12-16 g/dL) today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate?

A. “You’re off to a great start! Tea has much less caffeine than coffee.”
B. “A great addition to your cup of tea would be a little lemon. It’s going to help you absorb your iron pill better.”
C. “Right now your iron levels are low. Please eliminate all caffeine.”
D. “That’s alright. Drinking coffee or tea won’t affect the fetus.”

Answer 133

Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption.

Question 134

The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication?

A. valacyclovir
B. zidovudine
C. amphotericin b
D. metronidazole

Answer 134

Zidovudine (ZDV) is an antiretroviral medication that may be administered intrapartum to further reduce vertical transmission of HIV. This medication is commonly indicated for women who have a scheduled cesarean delivery or, in the rare instance of a vaginal delivery. This medication is preferred because it may be administered intravenously and can provide pre-exposure prophylaxis to the fetus. Whether this medication is prescribed and administered intrapartum depends on the mother’s viral load. The lower the viral load, the less likely of transmission to the fetus.
✓ Women should continue taking their antiretroviral therapy (ART) regimen as much as possible during labor and delivery or scheduled cesarean delivery

✓ Zidovudine is an intravenous antiretroviral that is administered intrapartum to reduce vertical transmission further

✓ To further reduce HIV transmission during labor and delivery, avoid fetal scalp electrode monitoring when possible

✓ To identify HIV infection in infants and young children (less than 18 months), HIV viral load (VL) testing must be performed using assays that detect HIV deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)

✓ Antibody tests are not accurate because the infant acquires maternal antibodies, which may cause a false positive

✓ Cord blood should not be used for testing because of the possibility of contamination of the sample with maternal blood

Question 135

What assessment tool is used to assess nutritional status?

Answer 135

x The Patient-Generated Subjective Global Assessment is a client-reported screening tool to assess nutritional status. The Patient-Generated Subjective Global Assessment, often referred to as the PG-SGA or the PG-SGA nutritional assessment, is well recognized in clinical research as the reference method for determining the nutrition status of clients with cancer.

Question 136

Examples of neuropathic pain

Answer 136

Neuropathic pain describes constant inflammation or irritation of nerve cells that causes pain sensation due to oversensitive nerve cells and a decrease in opioid receptors. Examples of neuropathic pain sources include CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and phantom limb pain.

Question 137

antiviral used for HSV

Answer 137

Valacyclovir is an antiviral and is effective in the management (and prevention) of outbreaks associated with herpes simplex virus (HSV). It is highly recommended that the client start valacyclovir at the earliest sign of an outbreak which is the prodromal symptoms of headache, fever, malaise, itching, and burning in the affected area. A client will either take this during an outbreak or daily to prevent an outbreak (suppressive therapy).

Question 138

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?

A. Administer PRN analgesic.
B. Obtain STAT EKG.
C. Encourage ambulation.
D. Discuss the pain with the patient.

Answer 138

Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient’s pain to determine the cause before administering medications or other interventions.

Question 139

A neonate is suspected of having a tracheoesophageal fistula. Which symptom would the nurse observe from the neonate?

Answer 139

cyanosis
A tracheoesophageal fistula is an abnormal passage or connection between the esophagus (typically the lower) and the trachea.
Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation.
Esophageal atresia and tracheoesophageal fistula often occur together. The two conditions are also frequently seen in children with other birth defects of the spine, heart, kidney, genitals, ears, and limbs and retardation of mental development, physical development, or both.