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88 terms

LVN hesi practice

predisposition for dig tox
low potassium (correct answer)
cefadroxil (Duricef) allergy alert
penicillins (correct answer)
phenytoin (Dilantin)
diazapam (Valium) (correct answer)
benztropine (Cogentin) and chlorpromazine HCI (Thorazine)
benztropine (Cogentin) is used to control extrapyramidal symptoms (correct answer)
dinitrate (Isordil)
for angina one tab and stop activity (correct answer)
angiotensin II receptor antagonist losartan (Cozaar) data to indicate desired effect?
used to treat high BP (correct answer)
dalteparin (Fragmin)
hold dose if blood in stool (correct answer)
glipizide (Glucotrol)
Category: Sulfonylurea, Antidiabetic, Use: Type 2 DM, Precautions: Monitor for hypoglycemia; Stimulates insulin release from pancreatic beta cells, reduces glucose output from liver, increases insulin sensitivity (correct answer)
conjugated estrogens (Premarin)
cigarette smoking increases risk for CV complications (correct answer)
guaifenesin (Robitussin)
notify the heath care provider if cough lasts more than 7 days (correct answer)
dont stop med suddenly (correct answer)
brush and floss teeth daily (correct answer)
ampicillin sodium (Omnipen)
most common adverse effect of all penicillins (correct answer)
haloperidol (Haldol)
changes in client behavior noted on a weekly basis provide the best evidence of the medication's effectiveness (correct answer)
Coumadin with ginger
dr wants to know all meds and herbs a client is taking
HR (correct answer)
metronidazole (Flagyl)
avoid alcohol because protozoa often proliferate in an acidic vaginal flora (correct answer)
7:30 NPH insulin time of potential hypoglycemic reaction?
3:30 - 7:30 pm (correct answer)
depress the immune system (correct answer)
emesis should be induced
for a child who drank the large dose of acetaminophen (Tylenol) elixir because the med is hepatotoxic (correct answer)
lanoxin (Digoxin)
answer is always HR/pulse (correct answer)
may be used in conjunction with artificial tears as long as they are administered 15 min apart (correct answer)
Isoniazid (INH)
is highly specific for Mycobacterium tuberculosis and is the drug of choice for clients with positive PPD skin tests (correct answer)
gentamicin sulfate (Garamycin)
hard of hearing
complications of gentamicin sulfate (Garamycin) are ototoxicity, nephrotoxicity, and neurotoxicity determining if the client is hard of hearing before initiation of this aminoglycoside will be helpful as the treatment progresses and ototoxicity is identified as a possible compllication
A client is to receive a glycerin suppository. When inserting the suppository, the nurse should advance it approximately how far into the client's rectum?
3"; The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. In an adult, this distance is approximately 3".
Following a fall from a horse during rodeo practice, an 18-year-old client is seen in the emergency department. He has a large, dirty laceration on his leg. The wound is vigorously cleaned, closed, and dressed. In the past, the client has received the full immunization regimen for tetanus toxoid. The nurse asks the client about his tetanus immunization history, and he says, "I had my last shot when I was 11 years old." The nurse should:
plan on administering a dose of tetanus vaccine.
Explanation: If a client has a wound contaminated with soil that may contain animal excrement and he has completed the full childhood tetanus immunization regimen, he should be given a dose of tetanus toxoid if it has been 3 or more years since the most recent dose. (It had been 7 years since the client's last dose.) Serum tetanus titer levels aren't used to determine whether tetanus toxoid should be administered. No available tetanus immunization confers life-long immunity.
After a client receives an I.M. injection, he complains of burning pain in the injection site. Which nursing action would be the best to take at this time?
Apply a warm compress to dilate the blood vessels.
Explanation: Applying heat increases blood flow to the area, which, in turn, increases the absorption of the medication. Cold decreases the pain but allows the medication to stay in the muscle longer. Massage is a good intervention, but applying a warm compress is better. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues.
After intentionally taking an overdose of amitriptyline (Elavil), a client is admitted to the emergency department. The nurse knows that the activated charcoal given to the client will:
bind with the ingested drug.
Explanation: Activated charcoal binds with the drug so that it isn't absorbed. It isn't given to promote vomiting or stimulate bowel motility, and it doesn't neutralize the drug.
A nurse is preparing the teaching plan for a client recently diagnosed with hepatitis A. Which teaching statement is correct?
The main route of transmission is feces
Explanation: The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.
A nurse is caring for a client with chronic pancreatitis. Which response by the client indicates that discharge teaching has been effective?
"I'll take pancreatic enzymes with each meal."
Explanation: Oral pancreatic enzymes are taken with each meal to aid digestion and control steatorrhea. The client should adhere to a low-fat, not low-carbohydrate, diet. The client should eliminate alcohol from his diet completely as it will continue to cause pancreatic damage.
A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?
I.M. - Explanation: With a platelet count of 22,000/μl, the client bleeds easily. Therefore, the nurse should avoid using the I.M. route because the area is highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. The client already has an I.V. access, so it would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subcutaneous routes are preferred over I.M., but they're less effective for acute pain management than I.V.
What instruction should be observed when administering a Mantoux test? (TB test)
Read the results within 72 hours
Explanation: The results of a Mantoux test should be read 48 to 72 hours after placement by measuring the diameter of the induration that develops at the site. The purified protein derivative test is injected intradermally on the volar surface of the forearm, not into the deltoid. Rubbing the site of an intradermal injection could cause leakage from the injection site.
To treat cervical cancer, a client has had an applicator of radioactive material placed in her vagina. Which observation by the nurse indicates a radiation hazard?
The client receives a complete bed bath each morning
Explanation: The client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because of the risk of radiation exposure to the nurse. During this treatment, the client should remain on strict bed rest with the head of the bed raised no higher than a 15-degree angle. The nurse should check the applicator's position every 4 hours to ensure that it remains in the proper place.
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which nursing intervention is appropriate?
Checking the fluid for glucose with a dipstick
Explanation: Clear liquid from the nose (rhinorrhea) or ear (otorrhea) can be determined to be cerebral spinal fluid or mucus by the presence of glucose. Glucose would be present in cerebral spinal fluid. Placing the client flat in bed may increase intracranial pressure and promote pulmonary aspiration. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection. The nose wouldn't be suctioned because of the risk of suctioning brain tissue through the sinuses.
Which statement is an example of passive acquired immunity?
A nurse who was accidentally exposed to hepatitis B virus from a needle stick receives hepatitis B immune globulin
Explanation: Immune globulin provides a temporary immunity that's passively acquired. Antibodies from one person are recovered and administered to another person to help prevent that person from being infected. Since the recipient's immune system didn't make the antibodies, the immunity is considered to be passively acquired. Immunizations and actual disease processes such as chickenpox cause the body to manufacture antibodies against future exposure to these specific antigens; this is called active immunity. Active immunity produces antibodies that are either permanent or longer lasting than passively acquired immunity. Shingles develops when latent varicella zoster virus is activated. Varicella zoster is the virus that causes chickenpox.
A 56-year-old client is suspected of having gastric cancer. The nurse expects which diagnostic test to aid in confirming the diag-nosis of gastric cancer?
Explanation: A gastroscopy will allow direct visualization of the tumor. A barium enema or colonoscopy would help to diagnose colon cancer. Serum chemistry levels don't contribute data useful to the assessment of gastric cancer.
What's the normal life span for healthy red blood cells (RBCs)?
120 days
A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?
Notify the charge nurse so she can notify the physician of the missed dose.
Explanation: An error was made that needs to be addressed by notifying the charge nurse. The charge nurse should then notify the physician to determine if the medication is still appropriate for the client, and then request the medication from the pharmacy if it's still needed. The physician might order a potassium level to see if the dose is sufficient for the client. It isn't appropriate to ask the client if the medication is still needed. After the charge nurse and physician have been notified, the nurse should document the incident according to facility policy.
While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?
Moist sterile saline gauze
Explanation: Sterile saline dressings support wound healing and are cost-effective; however, dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent; however, it can irritate epithelial cells, and is contraindicated for use on an open wound.
Which diagnostic test is definitive for tuberculosis?
Sputum culture
Explanation: Skin tests may be falsely positive or falsely negative. Lesions in the lung may not be big enough to be seen on X-ray. The sputum culture for Mycobacterium tuberculosis is the only method of confirming the diagnosis.
The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to:
protect the graft from direct sunlight.
Explanation: To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are helpful to the client and his recovery but are less important.
Which factor would have the most influence on the outcome of a crisis situation?
Previous coping skills
Explanation: Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, option 2 is the best answer. Age could have either a positive or negative effect during crisis, depending on previous experiences. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.
The nurse is checking a client's I.V. infusion rate at the beginning of her shift. The nursing Kardex states that the infusion should run at 125 ml/hour. To verify the I.V. drip rate, the nurse must know the drip factor, which is:
the number of drops in one milliliter.
Explanation: The drip factor is the number of drops in one milliliter, not the number of milliliters in one drop. The drip rate refers to the number of drops infused per minute. The flow rate is the number of milliliters, not the number of drops, infused per hour.
drip factor
drops in 1 mL
flow rate
# of mL infused p/hr
drip rate
# of drops infused p/min
A nurse must verify a client's identity before administering medication. The safest way to verify identity is to:
check armband
A patient is administered amiodarone (Cordarone) intravenously. Which of the following assessments is most important with this medication?
BP Q 5 min
A patient is brought to the Emergency Department after a motor vehicle accident. The patient is diagnosed with multiple injuries including a bladder injury. The patient is taken to surgery and develops a nonobstructive postoperative urinary retention. What drug would the nurse expect to be ordered for this patient?
Explanation: The agent bethanechol, which has an affinity for the cholinergic receptors in the urinary bladder, is available for use orally and subcutaneously to treat nonobstructive postoperative and postpartum urinary retention and to treat neurogenic bladder atony. Options A, C, and D are incorrect.
Which of the following planes divides the body longitudinally into anterior and posterior regions?
Frontal plane
Explanation: A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
A client is scheduled for an excretory urography at 10 a.m. An order states to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at:
7:30 a.m.
Explanation: It takes up to 2 hours for lidocaine-prilocaine cream (EMLA cream) reach its maximum effectiveness. Therefore, if the cannulation is scheduled for 9:30 a.m., EMLA cream should be applied at 7:30 a.m. Applying EMLA at 6:30 a.m. is too early. The other time options are too late for the local anesthetic to be effective.
Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child?
Explanation: Adjustment to the birth of a child is an example of a situational change, which arises from the interaction between individuals and the environment. Because pregnancy is a 9-month process, the change isn't unplanned. Adjustment to maturational change refers to that associated with puberty. Physiologic change refers to the events associated with aging and menopause.
A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?
Respiratory acidosis
Explanation: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.
A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. During the client's return visit to the physician's office, the nurse assesses his gait. Which finding indicates the need for further teaching about walker use?
The client's arms are fully extended when using the walker.
Explanation: When using a walker, the client's arms should be slightly bent at the elbow, allowing maximum support from the arms while ambulating. The weak leg is always moved forward first with the walker to provide the maximum support. When sitting, the client should always back up to the chair and feel the chair with his legs before sitting. The client should use the armrests of the chair for support because the armrests are more stable than the walker.
The nurse is collecting data on a client. She notes clubbed fingers. This finding indicates:
hypoxia: Explanation: Clubbing is a sign of prolonged hypoxia. Causes of clubbing include emphysema, chronic bronchitis, lung cancer, and heart failure. Beau's lines (transverse depressions in the nail that extend beyond the nail bed) occur with acute illness, malnutrition, and anemia. Koilonychia (thin, spoon-shaped nails with lateral edges that tilt upward) is associated with Raynaud's disease, malnutrition, chronic infections, and hypochromic anemia. Onycholysis (loosening of the nail plate with separation from the nail bed) is associated with hyperthyroidism, psoriasis, contact dermatitis, and Pseudomonas infections.
a very strong drive resulting from a deficiency of available oxygen in the blood and bodily tissues (short of anoxia)
A mother asks a nurse about measures for disciplining her toddler. Which recommendation by the nurse is best?
"When using a time-out, make sure your child knows the rules ahead of time."
Explanation: The mother should make sure that her child knows the rules before enforcing a time-out. The nurse should recommend the use of a time-out, but specify that time-out should be limited to 1 minute per each year of age. The child should be placed in a neutral, uninteresting environment for time-out. Children of this age-group require simple explanations of why the behavior requiring a time-out is unacceptable
A client with gangrene of the left foot is scheduled for below-knee amputation. When planning preoperative care, the nurse should assign highest priority to which nursing diagnosis?
Disturbed body image related to loss of body part
Explanation: Clients commonly fear amputation because it disturbs a familiar body image. To enhance postoperative recovery, the nurse should address such fears during the preoperative period. The client must accept body image changes before rehabilitation can occur. The other options may be appropriate but don't take precedence during the preoperative period
A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an I.V. line that's supplying hydration and antibiotics. The client has a vest restraint and bilateral soft wrist restraints. Which of the following actions by the nurse would be appropriate? Select all that apply.
• Perform a face-to-face behavior evaluation every hour.
• Tie the restraints in quick-release knots.
• Document the client's condition.
• Document alternative methods used before the restraints were applied.
• Document the client's response to the intervention.
Explanation: A face-to-face evaluation must be performed every hour. Restraints should be tied in knots that can be released quickly and easily. The nurse should document the client's condition, any alternative methods used before the restraints were applied, and the client's response to the interventions. Restraints should never be secured to side rails because doing so can cause injury if the side rail is lowered without untying the restraint.
A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on his life with satisfaction. According to Erickson, the nurse concludes that the client is in a stage of:
ego integrity.
Explanation: An adult at age 74 is in the stage of ego integrity versus despair. Intimacy, ego identity, and industry all apply to earlier stages of development.
The basis for building a strong therapeutic nurse-client relationship begins with the nurse's:
self-awareness and understanding.
Explanation: Although all of the options are desirable, knowledge of self is the basis for building a strong, therapeutic nurse-client relationship. Being aware of and understanding personal feelings and behavior are prerequisites for understanding and helping clients.
A client who delivered her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should:
help the client break down large tasks into smaller ones.
Explanation: If a client feels overwhelmed by the additional tasks brought on by her new role as a mother, the nurse should help her break down large tasks into smaller, more manageable ones. Encouraging her to work faster or reassuring her that her feelings will soon pass wouldn't address her needs. The nurse can't help the client accept her new role if the client feels overwhelmed
The physician orders nitroglycerin, 5 mg by mouth twice per day, for a client. The drug is dispensed in 2.5-mg tablets. How many tablets will the nurse administer twice per day?
Explanation: The nurse will administer two tablets twice per day. Using the ratio method, the equation to solve for X is: 5 mg : X tab :: 2.5 mg : 1 tab. Solving for X determines the quantity of the dosage form (two tablets, in this example).
The nurse is teaching a client about three medications he'll receive after discharge. While performing the discharge teaching, the nurse notices that the client suddenly becomes withdrawn and appears anxious. The nurse reviews the client's medical record and notes that he doesn't have a prescription plan and finances are limited. What action should the nurse take?
Inform the physician and request a social services consult.
Explanation: The nurse should inform the physician of the client's financial concerns and request a social services consult to help the client with these matters. The nurse shouldn't request that the prescriptions be changed because he's being discharged utilizing the treatment plan that was developed during hospitalization. Changing the treatment plan might jeopardize the client's health and unnecessarily prolong hospitalization. Treatment shouldn't be delayed by purchasing medications over a period of time. A delay in treatment could jeopardize the client's health.
Which type of solution, when administered I.V., would cause a shift of fluid from the interstitial space to the intravascular space?
Explanation: A hypertonic solution causes fluids to be absorbed into the intravascular space until equal pressure is established on both sides of the blood vessel. A hypotonic solution causes fluids to move from the intravascular space into the interstitial space. An isotonic solution has no effect on the cell. A sodium chloride solution can be isotonic, hypertonic, or hypotonic, depending on the concentration of sodium.
The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin (Coumadin), the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which of the following indicates the therapeutic range for this client?
2.0 to 3.0
Explanation: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy. For clients with mechanical prosthetic heart valves, an INR of 2.5 to 3.5 is suggested. An INR below 2.0 is subtherapeutic with warfarin therapy. An INR above 3.0 in a client without a prosthetic valve indicates the need to reduce the warfarin dose.
The nurse is to administer an I.M. injection into a client's left vastus lateralis muscle. How should the nurse position the client?
Lying supine
Explanation: To administer an I.M. injection into the vastus lateralis muscle, the nurse should position the client lying flat on the back (supine) or sitting upright to allow access to the muscle in the thigh. Lying on the stomach would allow access to the ventrogluteal or dorsogluteal site. Lying on the left or right side would allow access to the ventrogluteal site.
What is one disadvantage of using the rectal route for drug administration?
It can result in incomplete drug absorption.
Explanation: Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered, may cause orthostatic hypotension or hypersensitivity reactions. If inserted properly, drugs won't cause rectal tears.
A nurse is caring for a client with a history of GI bleeding, sickle cell disease, and a platelet count of 22,000/μl. The client is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour. He reports severe bone pain and is scheduled to receive a dose of morphine sulfate. In administering the medication, the nurse should avoid which route?
Explanation: With a platelet count of 22,000/μl, the client bleeds easily. Therefore, the nurse should avoid using the I.M. route because the area is highly vascular and can bleed readily when penetrated by a needle. The bleeding can be difficult to stop. The client already has an I.V. access, so it would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subcutaneous routes are preferred over I.M., but they're less effective for acute pain management than I.V.
After reconstituting a multidose vial of medication, the nurse writes the date and time of reconstitution on the vial label. What else should the nurse write on the label?
Strength of the medication
Explanation: After reconstituting a medication, the nurse should label any unused medication with the strength of the medication and the nurse's initials or signature, as well as the date and time of reconstitution. The expiration date on the order usually is written on the medication record. The administration route and prescriber's name are written on the order sheet.
A nurse is assessing a newly admitted client. In the family assessment, whom should the nurse consider to be a part of the client's family? Select all that apply.
• People whom the client views as family
• People who provide for the physical and emotional needs of the client
Explanation: When providing care to a client, the nurse should consider family members to be all the people whom the client views as family. Family members may also include those people who provide for the physical and emotional needs of the client. The traditional definition of a family has changed and may include people not related by blood or marriage, those of a different racial background, and those who may not live in the same house as the client. Family members are defined by the client, not by the nurse.
A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations of all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort?
Sleeping undisturbed for 3 hours
Explanation: Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions.
Victims of domestic violence should be assessed for what important information?
Readiness to leave the perpetrator and knowledge of resources
Explanation: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There is no evidence to suggest that previous victimization results in a person's seeking or causing abusive relationships.
The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness
Explanation: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30.
A female client taking antidepressant medication complains to the nurse that she has a decreased desire for sex, which is causing significant marital stress. Which response by the nurse would be the most appropriate?
"What are your thoughts on how you should handle this?"
Explanation: Encouraging the client to verbalize her thoughts will help her to problem-solve. Telling her not to stop taking the medication is too directive and doesn't encourage exploration on the part of the client. Asking the client if her husband understands the importance of taking the medication conveys negative judgment. Asking if the client has discussed the issue with her physician might be appropriate, but it may also give the impression that the nurse doesn't want to discuss the problem with the client.
A chronically ill school-age child is most vulnerable to which stressor?
Anxiety over school absences
Explanation: The school-age child is becoming industrious and attempts to master school-related activities. Therefore, school absences are likely to cause extreme anxiety for a school-age child who's chronically ill. Mutilation anxiety is more common in adolescents. Anticipatory grief is rare in a school-age child. Fear of hospital procedures is most pronounced in preschool-age children
preoperative drug that relaxes muscles and reduces secretion of saliva
A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?
Monitoring the client's weight every day
Explanation: By weighing the client every day, the nurse helps the team evaluate the client's response to TPN. Maintenance of the current weight is one indicator of adequate nutrition; weight loss may indicate inadequate nutrition, whereas weight gain may indicate adequate nutrition or fluid retention. The nurse shouldn't accelerate a TPN infusion that has fallen behind because this can cause wide fluctuations in the blood glucose level. Use of an in-line filter on TPN tubing traps bacteria and particles but has no effect on nutrition. The nurse records intake and output to evaluate fluid replacement — not the nutritional adequacy of TPN.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin sulfate (Mycifradin). The rationale for neomycin use in this client is to:
decrease the intestinal bacteria count.
Explanation: The antibiotic neomycin sulfate is prescribed to decrease the bacterial count and reduce the risk of fecal contamination during surgery. After surgery, the physician may prescribe an antiemetic — not an antibiotic — to control postoperative nausea and vomiting. Antibiotics have no relation to megacolon development. To prevent this complication, the client should avoid opioid analgesics, such as morphine (Duramorph), which can decrease intestinal motility and contribute to megacolon.
For a client with a sleep pattern disturbance, the nurse could use which measure to promote sleep?
Play soft or soothing music.
Explanation: By providing soft or soothing music, the nurse promotes relaxation, which fosters rest and sleep. To promote sleep, the nurse also should encourage the client to increase activity during the day, avoid providing stimulating beverages (such as caffeinated coffee) in the evening, and offer an evening snack with warm milk. Also, the nurse should encourage the client to decrease activity 2 hours before bedtime to promote sleep.
A client is diagnosed with diabetes mellitus. Which data collection finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?
Crying whenever diabetes is mentioned
Explanation: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.
The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness
Explanation: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30.
A client with left hemiparesis is having difficulty handling eating utensils. A nurse asks the physician to request a consult with which discipline?
Occupational therapy
Explanation: Occupational therapy is responsible for teaching the client how to eat using special utensils. Physical therapy assists with mobility, vocational rehabilitation supports job training, and speech therapy assists with swallowing.
A nurse is caring for a client with suspected upper GI bleeding. The nurse should monitor this client for:
black tarry stools
Explanation: As blood from the GI tract passes through the intestines, bacterial action causes it to become black. Hemoptysis involves coughing up blood from the lungs. Hematuria is blood in the urine. Bright red blood in the stools indicates bleeding from the lower GI tract.
A nurse is giving preoperative and postoperative instructions to a client who will undergo a liver biopsy the next morning. In this situation, patient-teaching information for which problem is most critical?
Explanation: Because the most common adverse effect of a liver biopsy is bleeding, the nurse should provide relevant information regarding the potential for hemorrhage. There's no reason to provide the client with information about a paralytic ileus. Renal shutdown isn't an expected complication after a liver biopsy. The nurse would have no reason to suspect that the client will have a problem with constipation after a liver biopsy.
Which factor associates chronic gastritis with pernicious anemia?
Inability to absorb vitamin B12
Explanation: With gastritis, the stomach lining becomes thin and atrophic, decreasing stomach acid secretion (the source of intrinsic factor). This decrease causes a reduction in the absorption of vitamin B12, leading to pernicious anemia.
A nurse is caring for a client with acute pancreatitis. The nurse knows that it's most important to monitor the client closely for which sign or symptom?
Explanation: Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is the primary concern. A client with acute pancreatitis may have increased pain on eating and is unlikely to demonstrate an increased appetite. A client with acute pancreatitis is at risk for hyperglycemia, not hypoglycemia. Although pain is an important concern, it's less significant than vomiting
When caring for a client with acute pancreatitis, the nurse should use which comfort measure?
Positioning the client on the side with the knees flexed
Explanation: The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and prescribed, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.
Aphthous stomatitis
canker sore