b. 0.5 to 2.

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

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

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

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

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

c. Stomach cramps d. Irregular pulse rate

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

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

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

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

d. Client stating that pain is 0 out of 10

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

c. Rapid IV bolus of Adenosine (Adenocard)
A client is admitted to the emergency department with paroxysmal supraventricular tachycardia. What intervention is the nurse's priority?

Decreased hemoglobin b. Blood pressure measurement b. BUN and creatinine c. Rapid IV bolus of Adenosine (Adenocard) d.) a. ECG d. Administration of digoxin IV push b. Heart rate 100 beats per minute b. Hypokalemia A client is taking hydrochlorothiazide 50 mg/day and digoxin 0. Hourly ECGs d. Which assessment is a priority for this client? a. Instructing client to "bear down" c. Presence of chest pain e. ECG A nurse is caring for a client who has been started on ibutilide (Corvert).25 mg/day.a. Hypokalemia . Crackles in the lungs Which assessment finding will alert the nurse to possible toxic effects of amiodarone? a. Presence of chest pain What must the nurse monitor when titrating intravenous nitroglycerin for a client? (Select all that apply. Serum nitroglycerin levels f. Continuous blood pressures c. Elevated blood urea nitrogen d. Hypocalcemia b. Visual acuity b. Administration of oxygen. What type of electrolyte imbalance does the nurse expect to occur? a. Lung sounds b. Continuous blood pressures d. Crackles in the lungs c. 2 lpm c. Continuous oxygen saturation b.

c. Hyperkalemia d. Hydrochlorothiazide What would cause the same client's electrolyte imbalance? a. Hypermagnesemia c. High-ceiling (loop) diuretic d. Osmotic diuretic c. Blood urea nitrogen (BUN) c. Potassium-sparing diuretic a. Thiazide diuretic b. Low dose of hydrochlorothiaizde d. Serum glucose (sugar) c. Arterial blood gases d. Hydrochlorothiazide d. Hypokalemia b. a combination such as triamterene and hydrochlorothiazide may be prescribed. Hemoglobin and hematocrit b. Serum glucose (sugar) A nurse teaching a client who has diabetes mellitus and is taking hydrochlorothiazide 50 mg/day. The teaching should include the importance of monitoring which levels? a. The nurse realizes that this combination is ordered for which purpose? . Hypokalemia The nurse acknowledges that which condition could occur when taking furosemide? a. Hyperkalemia c. Hypermagnesemia b. High dose of digoxin b. High-ceiling (loop) diuretic A client has heart failure and is prescribed Lasix. Hypoglycemia d. The nurse is aware that furosemide (Lasix) is what kind of drug? a. To increase the serum potassium level For the client taking a diuretic. Digoxin taken daily c.

Calcium level of 9 mg/dL d. Have the client lie down when taking a nitroglycerin sublingual tablet. Call the health care provider after taking 5 tablets if chest pain persists. Hypermagnesemia a." What is the best information for the nurse to provide to the client who is receiving spironolactone (Aldactone) and furosemide (Lasix) therapy? a. e. Apply Transderm-Nitro patch to a hairy area to protect skin from burning. "This combination promotes diuresis but decreases the risk of hypokalemia. c. Sodium level of 140 mEq/L b. Hyperkalemia The client has been receiving spironolactone (Aldactone) 50 mg/day for heart failure. To decrease the glucose level d. A client who has angina is prescribed nitroglycerin. Warn client against ingesting alcohol while taking nitroglycerin. Hypokalemia b. e. Chloride level of 100 mEq/L b.) a. Hypoglycemia d. The nurse should closely monitor the client for which condition? a." b. To decrease the serum potassium level b. The nurse reviews which appropriate nursing interventions for nitroglycerin (Select all that apply. d." . To increase the glucose level b. "This combination promotes diuresis but decreases the risk of hypokalemia. Fasting blood glucose level of 140 mg/dL c.a. To increase the serum potassium level c. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. Hyperkalemia c. b. b. "Moderate doses of two different diuretics are more effective than a large dose of one. Warn client against ingesting alcohol while taking nitroglycerin. Have the client lie down when taking a nitroglycerin sublingual tablet. Teach client to repeat taking a tablet in 5 minutes if chest pain persists. Fasting blood glucose level of 140 mg/dL Which laboratory value will the nurse report to the health care provider as a potential adverse response to hydrochlorothiazide (HydroDIURIL)? a. b.

A 67-year-old client with type 1 diabetes mellitus b. The fact that Lasix has shown efficacy in treating persons with renal insufficiency. That the medication will need to be given at a higher than normal dose owing to the client's medical problems. chloride is 90 mmol/L. Fish A client taking spironolactone (Aldactone) has been taught about the therapy. Administer PhosLo. two tablets three times per day. c. Mix 40 mEq of potassium in 250 mL D5W and infuse rapidly. b." c. d. b. Fish d. Which menu selection indicates that the client understands teaching related to this medication? a. A 47-year-old client with anuria Which client would the nurse need to assess first if the client is receiving mannitol (Osmitrol)? a. Administer Kayexalate. The fact that Lasix has shown efficacy in treating persons with renal insufficiency. That the medication will have to be monitored very carefully owing to the client's diagnosis of pneumonia. c. Bananas c. "This combination prevents dehydration and hypovolemia. and sodium is 140 mEq/L. The client has a history of chronic renal insufficiency.c. c. A 55-year-old client receiving cisplatin to treat ovarian cancer . A 21-year-old client with a head injury c." d. A nurse admits a client diagnosed with pneumonia. The fact that Lasix has been proven to decrease symptoms with pneumonia. "Using two drugs increases the osmolality of plasma and the glomerular filtration rate. The client's potassium level is 3. Apricots b. A 47-year-old client with anuria d. and the health care provider orders furosemide (Lasix) 40 mg twice a day. The nurse is assessing a client who is taking furosemide (Lasix). Administer 2 mEq potassium chloride per kilogram per day IV. What is the nurse's primary intervention? a. c. What is most important to include in the teaching plan for this client? a.4 mEq/L. d. Strawberries c. Administer 2 mEq potassium chloride per kilogram per day IV.

"Do not drink more than 10 ounces of fluid a day while on this medication. A decrease in bicarbonate level b. "Take this medication before bed each night. Assess blood pressure before and after administration." d. Assess blood pressure before and after administration. Decreased ankle edema c. Decreased crackles in the lung bases c.c." c." c. Maintain accurate intake and output record. A decrease in arterial pH A nurse is caring for a client receiving acetazolamide (Diamox).) a. c. A decrease in arterial pH d. What interventions should the nurse perform? (Select all that apply. c. Administer at a rate no faster than 20 mg/min. Which assessment finding will require immediate nursing intervention? a." b. Decreased aldosterone A client with hyperaldosteronism is prescribed spironolactone (Aldactone). . Decreased potassium level b. What is the most important information the nurse should teach the client? a. "Wear protective clothing and sunscreen while on this medication." A client is prescribed Thalitone (chlorthalidone). e. An increase in PaO2 b. "Wear protective clothing and sunscreen while on this medication. A client is ordered furosemide (Lasix) to be given via intravenous push. "Take this medication on an empty stomach. An increase in urinary output c. d. Monitor ECG continuously. Lungs clear. Assess lung sounds before and after administration. Decreased aldosterone d. Maintain accurate intake and output record. d. What assessment finding would the nurse evaluate as a positive outcome? a. b. f. Assess lung sounds before and after administration. d. Insert an arterial line for continuous blood pressure monitoring.

d. According to the guidelines for determining hypertension. c. b. Decreased serum osmolality c. Decreased intracranial pressure b. b. It decreases alkalinity of urine. to treat gout. Monitor for Hypernatremia. Output 30 mL/hr. It causes an acid urine. which facilitates the elimination of uric acid. a. Stage 1 hypertension d. Decreased intracranial pressure Which assessment indicates a therapeutic effect of mannitol (Osmitrol)? a. Decreased potassium c. c. Assess potassium levels. d. Assess urinary output hourly. a.5 mEq/L. Prehypertension c. Stage 1 hypertension A client's blood pressure (BP) is 145/90. Monitor for side effect of hypoglycemia. It increases alkalinity of urine. Assess potassium levels. d. a diuretic. Crackles auscultated in the bases.A client with acute pulmonary edema receives furosemide (Lasix). the nurse realizes that the client's BP is at which stage? a. which facilitates the elimination of uric acid.5 to 3. What is the nurse's best response? a. What assessment finding indicates that the intervention is working? a. It causes an alkaline urine. which facilitates the elimination of uric acid. The client asks the nurse why the health care provider prescribed acetazolamide (Diamox). c. Which intervention will the nurse perform when monitoring a client receiving triamterene (Dyrenium)? a. Stage 2 hypertension . It causes an alkaline urine. Increased urine osmolality d. thus decreasing the formation of uric acid. Lungs clear. Normal b. Potassium level decreased from 4. thus decreasing the formation of uric acid. c. b.

Diuretics b. ACE inhibitor d. Beta1 blocker b. The nurse teaches the client that ACE inhibitors have which common side effects? a. Alpha blocker c. Beta blockers and ACE inhibitors The nurse is aware that which group(s) of antihypertensive drugs are less effective in AfricanAmerican clients? a. Diuretic b. Calcium channel blockers and vasodilators c. potassium-sparing diuretic a.a. Constant. Beta1 blocker The nurse explains that which beta blocker category is preferred for treating hypertension? a. chlorthalidone b. hydrochlorothiazide The nurse knows that which diuretic is most frequently combined with an antihypertensive drug? a. hydrochlorothiazide c. Alpha/beta blocker c. Beta blockers and ACE inhibitors d. Beta2 blocker c. Beta1 and beta2 blockers d. Beta2 and beta3 blockers d. Dizziness and headaches . Nausea and vomiting b. Alpha blockers b. Diuretic The nurse acknowledges that the first-line drug for treating this client's blood pressure might be which drug? a. bendroflumethiazide d. irritating cough Captopril (Capoten) has been ordered for a client.

What is the nurse's priority action? . Headache d. Call the health care provider to switch the medication.) a. the client states that she takes amlodipine (Norvasc). Upset stomach d. Ankle edema During an admission assessment. The nurse wishes to determine whether or not the client has any common side effects of a calcium channel blocker. The nurse teaches the client that an angiotensin II receptor blocker (ARB) acts by doing what? a. Insomnia b. Ankle edema f. Constant. Headache e. Hacking cough a. Blocking angiotensin II from AT1 receptors A client is prescribed losartan (Cozaar)." c. "I will check my blood pressure daily and take my medication when it is over 140/90." b. Dizziness c. "I will change my position slowly to prevent feeling dizzy. "I will not mow my lawn until I see how this medication makes me feel. nonproductive cough. Promoting the release of aldosterone b." d. Angioedema e." Which statement indicates that the client needs additional instruction about antihypertensive treatment? a. Preventing the release of angiotensin I d. Inhibiting angiotensin-converting enzyme b. Blocking angiotensin II from AT1 receptors c. A nurse is caring for a client who is taking an angiotensin-converting enzyme inhibitor and develops a dry. The nurse asks the client if she has which signs and symptoms? (Select all that apply. "I will check my blood pressure daily and take my medication when it is over 140/90." a. Dizziness c. irritating cough b. "I will include rest periods during the day to help me tolerate the fatigue my medicine may cause.c.

c. Get up slowly from a sitting to a standing position. b. What nursing intervention is a priority for this client? a. docusate sodium (Colace) b. furosemide (Lasix) c. The nurse plans to contact the health care provider if the client is also taking which medication? a. d. The nurse is caring for a client with hypertension who is prescribed Clonidine transdermal preparation. The client who is taking a beta blocker and Lasix (furosemide). Call the health care provider to switch the medication. spironolactone (Aldactone) b.a. Assessment of blood glucose levels b. Instruct the client to take antitussive medication until the symptoms subside. The client who has stopped taking a beta blocker due to cost. The client who has been on beta blockers for 1 day. b. morphine sulfate d. Tell the client that the cough will subside in a few days. d. spironolactone (Aldactone) The nurse is reviewing a medication history on a client taking an ACE inhibitor. b. Notify the health care provider. b. d. Teaching about potential tachycardia c. Remove the patch before taking a shower or bath. . Respiratory assessment c. Which client will the nurse assess first? a. The client who has stopped taking a beta blocker due to cost. d. The client who is on a beta blocker and a thiazide diuretic. Do not take other antihypertensive medications while on this patch. d. Get up slowly from a sitting to a standing position. What is the correct information to teach this client? a. c. Assess the client for other symptoms of upper respiratory infection. Change the patch daily at the same time. c. Respiratory assessment A client is prescribed a noncardioselective beta1 blocker. Orthostatic blood pressure assessment d.

Increased intracranial pressure b. What is the nurse's best action? a. b. d. Notify the health care provider. c." c. Dysrhythmias c. Determine the client's history. "If you are having difficulty with the common side effect of drooling. c.The client taking Methyldopa (Aldomet) has elevated liver function tests. b. Call the health care provider. notify your health care provider so your dosage can be adjusted. Immediately stop the medication. Hypokalemia b. Hypotension A calcium channel blocker has been ordered for a client. Which condition in the client's history is a contraindication to this medication? a. To administer phentolamine (Regitine) During assessment of a client diagnosed with pheochromocytoma. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation. Which instruction will the nurse include when teaching this client? a. Weigh the client. Document the finding and continue care. Hold the medication." c. The client is complaining of swollen feet." b." A client who takes clonidine (Catapres) is to be discharged to home. the nurse auscultates a blood pressure of 210/110 mm Hg. "Your blood pressure should be checked by a health care provider at least once a year. Determine the client's history. d. c. "Increasing fluid and fiber in your diet can help prevent the side effect of constipation." d. A client taking prazosin has a blood pressure of 140/90. What is the nurse's best action? . "Intense exercise or prolonged standing is not a problem with clonidine as it can be with other antihypertensive agents. What is the nurse's best action? a. c. Change the client's diet. Hypotension d.

protamine sulfate A client who received heparin begins to bleed. Coronary thrombosis b. Deep vein thrombosis (DVT) d. Knowledge deficit related to medication regimen c. Acute myocardial infarction c.) a. Venous disorders a. Alteration in comfort related to nonproductive cough a.a. Cerebrovascular accident (CVA) (stroke) e. To administer phentolamine (Regitine) d. Acute myocardial infarction c. The nurse knows that which is the antidote for heparin? a. Alteration in cardiac output related to effects on the sympathetic nervous system b. protamine sulfate b. Alteration in cardiac output related to effects on the sympathetic nervous system Which is a priority nursing diagnosis for a client taking an antihypertensive medication? a. Venous disorders When a newly admitted client is placed on heparin. The nurse knows that low-molecular-weight heparin (LMWH) has what kind of half-life? . A longer half-life than heparin A client is prescribed enoxaparin (Lovenox). vitamin K c. To ask the client to lie down and rest b. vitamin C a. Cerebrovascular accident (CVA) (stroke) e. Coronary thrombosis b. and the physician calls for the antidote. To assess the client?s dietary intake of sodium and fluid c. Fatigue related to side effects of medication d. aminocaproic acid d. the nurse acknowledges that heparin is effective for preventing new clot formation in clients who have which disorder(s)? (Select all that apply. To administer nitroprusside (Nipride) a. Deep vein thrombosis (DVT) d.

b. Subcutaneously A client is prescribed dalteparin (Fragmin). Intramuscularly c. c. Which anticoagulant does the nurse realize is administered orally? a. A shorter half-life than heparin c. Intravenously b. warfarin (Coumadin) c. LMWH is administered via which route? a. Within normal range b. Normal dose is 25 mg tablet per day. Constipation may occur. Intradermally d. d. A four-times shorter half-life than heparin c. Elevated INR range A client is taking warfarin 5 mg/day for atrial fibrillation. To suppress platelet aggregation . What is important information to include? a. warfarin (Coumadin) A client is being changed from an injectable anticoagulant to an oral anticoagulant. The nurse would consider the INR to be what? a. Hypotension may occur.a. The same half-life as heparin d. Subcutaneously b. Bleeding may increase when taken with aspirin. Low INR range d. enoxaparin sodium (Lovenox) b. The nurse is teaching a client about clopidogrel (Plavix). bivalirudin (Angiomax) d. Bleeding may increase when taken with aspirin. The client's international normalized ration (INR) is 3. Elevated INR range c. d. lepirudin (Refludan) b. A longer half-life than heparin b.8. Low average INR range d.

Activated partial thromboplastin time (aPTT) of 120 seconds A client is receiving an intravenous heparin drip. To suppress platelet aggregation b. Administer vitamin K. Which drug category does the nurse expect to be given to the client early for the prevention of tissue necrosis following blood clot blockage in a coronary or cerebral artery? a. Administer vitamin K. What is the nurse's primary action? a.0 d. Thrombolytic agent d. streptokinase c. clopidogrel (Plavix) b. To inhibit hepatic synthesis of vitamin K d. INR of 1. A client who has been taking warfarin (Coumadin) is admitted with coffee-ground emesis. warfarin (Coumadin) d. Thrombolytic agent A client is admitted to the emergency department with an acute myocardial infarction. Platelet count of 150. Which laboratory value will require immediate action by the nurse? a. . b. The nurse acknowledges that which drug is used primarily for preventing reocclusion of coronary arteries following a coronary angioplasty? a. abciximab (ReoPro) c. Anticoagulant agent b. The nurse knows that which is the major purpose for antiplatelet drug therapy? a. To decrease tissue necrosis c. Blood urea nitrogen (BUN) level of 12 mg/dL b. Low-molecular-weight heparin (LMWH) b. To dissolve the blood clot b. Activated partial thromboplastin time (aPTT) of 120 seconds c.Cilostazol (Pletal) is being prescribed for a client with coronary artery disease. Administer vitamin E.000 b. Antiplatelet agent c. abciximab (ReoPro) A client is to undergo a coronary angioplasty.

Administer protamine sulfate. Administer the medication into subcutaneous tissue. "I take aspirin daily for headaches." A client is taking enoxaparin (Lovenox) daily. "I take my medicine first thing in the morning. c. Assess intake and output. "I take aspirin daily for headaches. The client is receiving tirofiban (Aggrastat). Administer calcium gluconate. Administer an additional dose of warfarin (Coumadin). c. Weigh the client before administration. What is an essential nursing intervention for this client? a." A client is receiving warfarin (Coumadin) for a chronic condition. "I will increase dark-green. "I will avoid contact sports. "Whenever I have a fever." d. leafy vegetables in my diet. a. Have vitamin K available in case of an overdose." b." c." b. Administer an additional dose of warfarin (Coumadin). leafy vegetables in my diet. I take acetaminophen (Tylenol). Which client statement requires immediate action by the nurse? a." c. . Hold the next dose of warfarin (Coumadin).c. "I will increase dark-green. d. "I take ibuprofen (Motrin) at least once a week for joint pain. d. "I will contact my health care provider if I develop excessive bruising. Administer protamine sulfate. The client has an international normalized ratio (INR) value of 1. b. Increase the heparin drip rate. Have protamine sulfate available in case of an overdose.5." d. Weigh the client before administration. d. What action will the nurse take? a. "I will take my medication in the early evening each day." b. c. Which client statement requires additional monitoring? a." a. c. b.

d. . "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding. "Dalteparin is a low-molecular-weight heparin that is more predictable in its effect and has a lower risk of bleeding." d. Teach the client about the phenytoin. Rub the administration site after injecting. b. b. Dalteparin is preferred because it is less expensive. Administer the medication into subcutaneous tissue." c. Administer vitamin K if bruising is observed. What is the nurse's best response? a. Teach the client of potential drug interactions with anticoagulants. The client has been receiving heparin. Administer vitamin K. Utilize the Z-track method to inject the medication.A nurse is preparing to administer enoxaparin sodium (Lovenox) to a client for prevention of deep vein thrombosis. What is the nurse's best response? a. Administer protamine sulfate." b. c. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic. What nursing intervention is essential for the client receiving alteplase? a. d." The client asks what the difference is between dalteparin (Fragmin) and heparin. Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 minutes. You should ask your doctor. Assess for reperfusion dysrhythmias. What is an essential nursing intervention? a. Draw up the medication in a syringe with a 22-gauge." b. Monitor liver enzymes. a. b. b. d. "There is no real difference. "I'm not sure why some health care providers choose dalteparin and some heparin. b. A client has been admitted through the emergency department and requires emergency surgery. 1-½ inch needle. c. "The only difference is that heparin dosing is based on the client's weight. Assess the INR before surgery. Administer protamine sulfate. A client who is taking warfarin (Coumadin) requests an aspirin for headache relief. c. Assess for reperfusion dysrhythmias. What nursing intervention is essential? a.

"It usually takes about 3 days to achieve a therapeutic effect for warfarin. d. What intervention is essential before the nurse administers tenecteplase (TNKase)? a. Perform all necessary venipunctures. Potential for pain c. b." d. Potential for body image disturbance . "I will double my dose if I forget to take it the day before. c. you have a higher risk of blood clots and therefore need to be on both medications. The client questions the nurse about the risk for bleeding. Have the client void." b. "I should use a soft toothbrush for dental hygiene. Assess for allergies to iodine. Risk for injury d. Explain that the headache is an expected side effect and will subside shortly. "I should keep taking ibuprofen for my arthritis. so the heparin is continued until the warfarin is therapeutic." d. so the heparin is continued until the warfarin is therapeutic. d.b." A client is started on warfarin (Coumadin) therapy while still receiving intravenous heparin. Teach the client of potential drug interactions with anticoagulants. Potential for fluid volume excess b. c. "Because of your valve replacement." The nurse evaluates that the client understood discharge teaching regarding warfarin (Coumadin) based on which statement? a." c. Perform all necessary venipunctures." a. b. "I should use a soft toothbrush for dental hygiene. "I should decrease the dose if I start bruising easily." c. How should the nurse respond? a." b. Risk for injury Which nursing diagnosis would be possible for a client receiving intravenous heparin therapy? a. "It usually takes about 3 days to achieve a therapeutic effect for warfarin. I will call the doctor to discontinue the heparin. Explain to the client that ASA is contraindicated and administer ibuprofen as ordered. "Your concern is valid. c. "Because you are now up and walking. Administer aminocaproic acid (Amicar). The heparin and warfarin together are more effective than one alone. it is especially important for you to be anticoagulated." d.

150 to 200 mg/dL b. It is the desired level of HDL. A client's high-density lipoprotein (HDL) is 60 mg/dL. Blood urea nitrogen b. c. It is lower than the desired level of HDL. b. Hypolipidemia b. Hyperlipidemia d. ceruloplasmin d. Alipidemia a. d. homocysteine The nurse realizes that which is the laboratory test ordered to determine the presence of the amino acid that can contribute to cardiovascular disease and stroke? a. Which serum level is most important for the nurse to monitor? a. It is the desired level of HDL. homocysteine c. What does the nurse acknowledge concerning this level? a. 225 to 250 mg/dL d. It is higher than the desired level of HDL. 150 to 200 mg/dL The nurse knows that the client's cholesterol level should be within which range? a. What do these serum levels indicate? a. Greater than 250 mg/dL b. 200 to 225 mg/dL c. triglyceride level of 235 mg/dL. and LDL of 180 mg/dL. Hyperlipidemia A client has a serum cholesterol level of 265 mg/dL. Complete blood count . b. Liver enzymes A client is taking lovastatin (Mevacor). It is a much lower HDL level than desired.c. cryoglobulin d. Normolipidemia c. antidiuretic hormone b.

Forms insoluble complexes and reduces circulating cholesterol in blood. Dyskinesia d.c. He is prescribed isoxsuprine (Vasodilan)." Which statement indicates the client understands discharge instructions regarding cholestyramine (Questran)? a. Cardiac enzymes d. "I will take Questran 1 hour before my other medications. The nurse acknowledges that isoxsuprine does what? (Select all that apply. "I will increase fiber in my diet. and palpitations c. "I will increase fiber in my diet. Relaxes the arterial walls within the skeletal muscles b. d. c. Agranulocytosis a. Inhibits HMG-CoA reductase. Commonly causes an adverse effect of rhabdomyolysis b. May cause hypotension. Increases the rigidity of arteriosclerotic blood vessels d.) a. Inhibits absorption of dietary cholesterol in the intestines." b. chest pain. she asks the nurse how it works. May increase intermittent claudication e. Relaxes the arterial walls within the skeletal muscles b. chest pain. Rhabdomyolysis The client is taking rosuvastatin (Crestor). Inhibits absorption of dietary cholesterol in the intestines. May cause hypotension. The nurse should explain that Zetia does what? a. and palpitations A client is diagnosed with peripheral arterial disease (PAD). Myasthenia gravis b. "I will weigh myself weekly. which is necessary for cholesterol production in the liver. a. "I will have my blood pressure checked weekly. b. What severe skeletal muscle adverse reaction should the nurse observe for? a. Rhabdomyolysis c. Binds with bile acids in the intestines to reduce LDL levels." . Liver enzymes b. May lead to hypertension and bradycardia f." c." d. When a client is taking ezetimibe (Zetia).

The nurse plans which intervention to decrease the flushing reaction of niacin? a." b." c. "Antihyperlipidemic medications will replace the other interventions I have been doing to try to decrease my cholesterol. "Take aspirin before the medication if you experience facial flushing. Which assessment finding will require immediate action by the nurse? . "You will need to have weekly blood drawn to assess for hyperkalemia. Administer aspirin 30 minutes before nicotinic acid. "It is important to double my dose if I miss one in order to maintain therapeutic blood levels. "I will continue my exercise program to help increase my high-density lipoprotein serum levels. "I will continue my exercise program to help increase my high-density lipoprotein serum levels. "Take this medication with breakfast." c." c." d. A client is prescribed ezetimibe (Zetia). What is important for the nurse to teach the client? a. Administer aspirin 30 minutes before nicotinic acid. "Cholesterol levels will need to be assessed daily for one week. "You may experience headaches with this medication. c.b. What information is essential for the nurse to include? a." The nurse is reviewing instructions for a client taking an HMG-CoA reductase inhibitor (statin). "Take this medication with an antacid. "I will stop taking the medication if it causes nausea and vomiting." b. Administer diphenhydramine hydrochloride (Benadryl) with niacin." b." A client is prescribed gemfibrozil (Lopid) for treatment of hyperlipidemia type IV. Apply cold compresses to the head and neck. "You may experience headaches with this medication. b." Which statement made by the client indicates understanding about discharge instructions on antihyperlipidemic medications? a. d. "Take this medication at the same time each day. "Take this medication on an empty stomach. b. Muscle pain. Administer niacin with an antacid." d." c." b." d. "Take this medication at the same time each day." d.

"This dose may lower your cholesterol too much. Decreased hemoglobin b. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication. d. d. b. What is essential information for the nurse to teach the client? a." Which statement indicates to the nurse that the client needs further medication instruction about colestipol (Colestid)? a. c. "I should stir the powder in as small an amount of fluid as possible to maintain potency of the medication." A 70-year-old client who is taking several cardiac antidysrhythmic medications has been prescribed simvastatin (Zocor) 80 mg/day. "The medication may cause constipation. "I might need to take fat-soluble vitamins to supplement my diet. Have the client increase fluids and fiber in his diet. Slight nausea. Muscle pain. "These factors may put you at higher risk for myopathy. A nurse is caring for a client taking cholestyramine (Questran)." b." d. c. Elevated LDL b. Elevated liver function tests Which assessment finding in a client taking an HMG-CoA reductase inhibitor will the nurse act on immediately? a. Headache. c. so I will increase fluid and fiber in my diet. Elevated HDL d. The client is complaining of constipation. "These factors may put you at higher risk for myopathy. Elevated liver function tests c. b. Administer an enema to the client." b. Tell the client to skip a dose of the medication." b." . Have the client increase fluids and fiber in his diet." c. d.a. Fatigue. Call the health care provider to change the medication. "I should take this medication 1 hour after or 4 hours before my other medications. What will the nurse do? a.

Hepatic disease A client diagnosed with hypercholesterolemia is prescribed lovastatin (Mevacor). "This combination will cause you to have nausea and vomiting. simvastatin (Zocor) a. Hepatic disease c." d. gemfibrozil (Lopid) d.c. Impaction The nurse would question an order for cholestyramine (Questran) if the client has which condition? a. Client takes herbal therapy including kava kava. cholestyramine (Questran) b. Hepatic disease d. What will the nurse act on immediately? a. Client takes medications with grape juice. The nurse reviews the history for a client taking atorvastatin (Lipitor). Client was started on penicillin for a respiratory infection. What medication will the nurse administer? a. Renal disease c." b. c. "You should not take this drug with cardiac medications. Client is on oral contraceptives. Chronic pulmonary disease b. Leukemia d. colestipol (Colestid) c. Glaucoma c. The nurse is reviewing the client's history and would contact the health care provider about which of these conditions in the client's history? a. Impaction b. . Renal disease c. gemfibrozil (Lopid) A nurse is caring for a client with elevated triglyceride levels who is unresponsive to HMG-CoA reductase inhibitors. b. d. Client is on oral contraceptives.

The nurse realizes that the purpose of the drug is to accomplish what? a. what is most important for the nurse to tell the client? a. Limit the drug to 5 days of use to prevent rebound nasal congestion. Acute pharyngitis. This drug may be used in maintenance treatment for asthma. c. d. To loosen bronchial secretions so they can be eliminated by coughing A client has been prescribed guaifenesin (Robitussin). Avoid driving a motor vehicle until stabilized on the drug. d. Do not to take this drug at bedtime to avoid insomnia. thus preventing a histamine response d. A client is prescribed the decongestant oxymetazoline (Afrin) nasal spray. c. To loosen bronchial secretions so they can be eliminated by coughing c. Acute sinusitis. b. Acute rhinitis. Limit use to 1 to 2 puffs/sprays 4 to 6 times per day to avoid rebound congestion. c. Directly spray away from the nasal septum and gently sniff. A client tells the nurse that he has started to take an OTC antihistamine. To stimulate alpha-adrenergic receptors. Nightmares and nervousness are more likely in an adult. In teaching him about side effects. The client complains of a sore throat and has been told it is due to beta-hemolytic streptococcal infection. The nurse realizes this condition is called what? a. The nurse teaches the client that which is the most common side effect from continuous use? . b. Acute rhinorrhea. b. Avoid driving a motor vehicle until stabilized on the drug. Dry nasal mucosa Beclomethasone (Beconase) has been prescribed for a client with allergic rhinitis. diphenhydramine. Take this drug at bedtime as a sleep aid. thus producing vascular constriction of capillaries in nasal mucosa d. Limit the drug to 5 days of use to prevent rebound nasal congestion. Acute pharyngitis. d. To treat allergic rhinitis and prevent motion sickness b.. To compete with histamine for receptor sites. d. c. b. What should the nurse teach the client? a.

"Take a lower dose than normal when you have to drive. e. Take medication with food to decrease gastric distress. Take sugarless candy." c." The nurse is caring for a client who is taking a first-generation antihistamine." The nurse is caring for a client in the clinic who states that he is afraid of taking antihistamines because he is a truck driver." d.a. Hallucinations d. you should not take antihistamines. b. "Take this medication on an empty stomach. gum." Administer guaifenesin. e." d. Avoid alcohol and other central nervous system depressants. What is the best information for the nurse to give this client? a." b. Which are topics to include? (Select all that apply. or ice chips for temporary relief of dry mouth. d. "Do not take this medication for more than 2 days. or ice chips for temporary relief of dry mouth. Take medication with food to decrease gastric distress. "Take the medication only when you are not driving. "You may be able to safely take a second-generation antihistamine. What is the most important fact for the nurse to teach the client? a. "Make sure you drink a lot of liquids while on this medication." d. The nurse is teaching a client about diphenhydramine (Benadryl). . Notify the health care provider if confusion or hypotension occurs. Avoid alcohol and other central nervous system depressants. Dizziness b. "Do not drive after taking this medication. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug.) a. a. "You are correct. "You may be able to safely take a second-generation antihistamine. Take sugarless candy. c." c. "Do not drive after taking this medication. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug. Dry nasal mucosa a. Rhinorrhea c. Notify the health care provider if confusion or hypotension occurs. gum. d. c. b." b.

" c. This medication has fewer sedative effects. b." . What should the nurse do? a. What is the nurse's best response? a. Administer fluticasone (Flonase). This medication causes less gastrointestinal upset. b. Administer dextromethorphan." A client is prescribed an antitussive medication. b. "This medication will help prevent the inflammatory response of my allergies. Administer guaifenesin. c. "This medication will help prevent the inflammatory response of my allergies. is coughing." b." Which statement indicates that the client understands the teaching about beclomethasone diproprionate (Beconase)? a." c. "I will need to taper off the medication to prevent acute adrenal crisis." a." d." b." A client complains of worsening nasal congestion despite the use of oxymetazoline (Afrin) nasal spray every 2 hours." b. "Oxymetazoline is not an effective nasal decongestant. c. b. d. "Overuse of nasal decongestants results in rebound congestion." b.The client tells the nurse that she has a bad cold. "Watch out for diarrhea and abdominal cramping. This medication has increased bronchodilating effects. What is the most important thing for the nurse to teach the client? a. d. and feels like she has "stuff" in her lungs. "This medication may cause drowsiness and dizziness. "Overuse of nasal decongestants results in rebound congestion. "Oxymetazoline should be administered every hour for severe congestion. This medication can potentially cause dysrhythmias. Encourage the client to drink fluids hourly. "This medication may cause drowsiness and dizziness. What is the most important thing for the nurse to teach a client who is switching allergy medications from diphenhydramine (Benadryl) to loratadine (Claritin)? a. This medication has fewer sedative effects." d. "I will need to monitor my blood sugar more closely because it may increase. "You are probably displaying an idiosyncratic reaction to oxymetazoline. "I need to take this medication only when my symptoms get bad.

Increase fluid intake in order to decrease viscosity of secretions. 10 to 20 mcg/mL ." c. Take the medication once a day only. Increased heart rate A client is taking aminophylline-theophylline ethylenediamine (Somophyllin). Drowsiness b. The nurse knows that which is the best medication for this emergency situation? a. Increase fiber and fluid intake to prevent constipation. epinephrine (Adrenalin) A client with COPD has an acute bronchospasm. The nurse understands that which is the client's most likely diagnosis? a. Hypoglycemia c. d. Increase fluid intake in order to decrease viscosity of secretions. Chronic bronchitis b.c. Bronchiectasis d. "This may cause tremors and anxiety. epinephrine (Adrenalin) c. a. zafirlukast (Accolate) b. Decreased white blood cell count b. Lungs tissue changes are normally reversible with this condition. Asthma b. oxtriphylline-theophyllinate (Choledyl) c. Increased heart rate d. b. Restrict fluids in order to decrease mucus production. Emphysema c. "Headache and hypertension are common side effects. For what should the nurse monitor the client? a. c. Asthma A client is diagnosed with a pulmonary disorder that causes COPD. at bedtime. dexamethasone (Decadron) d. Which is the best instruction for the nurse to include when teaching a client about the use of expectorants? a." d.

Treatment of an acute asthma attack c. Stop the IV for an hour then restart at lower rate. 30 to 40 mcg/mL a. d. 1 to 10 mcg/mL b. d. Maintenance treatment of asthma b. c. montelukast (Singulair). What is the priority nursing intervention? a. Continue to assess the client's oxygenation. Hypoglycemia b. St. 20 to 30 mcg/mL d.A client is prescribed theophylline to relax the smooth muscles of the bronchi. acetaminophen (Tylenol) b. Increase the IV drip rate. Continue to assess the client's oxygenation. echinacea . Maintenance treatment of asthma A client with COPD is taking a leukotriene antagonist. 10 to 20 mcg/mL c. Nonproductive cough c. Monitor the client for toxicity. Reversing bronchospasm associated with COPD d. John's wort The nurse instructs the client to avoid which over-the-counter products when taking theophylline (Theo-Dur)? a. The nurse monitors the client's theophylline serum levels to maintain which therapeutic range? a. Treatment of inflammation in chronic bronchitis c. Sedation d. Tachycardia Discharge teaching to a client receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. The nurse is caring for a client with a theophylline level of 14 mcg/mL. The nurse is aware that this medication is given for which purpose? a. Tachycardia d. b.

d. Assess daily for hyperkalemia. c." c. A nurse reviews a client's medication history and notes that the client is taking a nonselective adrenergic agonist bronchodilator and has a history of coronary artery disease. diphenhydramine (Benadryl) d.c. "This medication will prevent the inflammation that causes your asthma attack. "Take the medication as soon as you begin wheezing. . Salmeterol does not have any side effects." Client teaching regarding the use of antileukotriene agents such as zafirlukast (Accolate) should include which statement? a. What is a priority nursing intervention? a. Salmeterol has a longer duration of action. b. Administer a long-acting glucocorticoid. Monitor blood pressure continuously." d. b. Monitor client for potential chest pain. Salmeterol has a shorter onset of action. "I feel like I'm having an asthmatic attack. c. c." What is the nurse's best action? a. "Increase fiber and fluid in your diet to prevent the side effect of constipation. "This medication will prevent the inflammation that causes your asthma attack. Administer a beta2 adrenergic agonist. d." b. How will the nurse explain to the client the difference in these two medications? a. Monitor client for potential chest pain. A client with a history of asthma is short of breath and says. St. b. Administer a beta2 adrenergic agonist. Assess 12-lead ECG each shift. d. Albuterol has a longer onset of action. The nurse is instructing a client about the advantages of salmeterol (Serevent) over other beta2 agonists such as albuterol (Proventil). c. Ask the client to describe the symptoms. Call a code. Salmeterol has a longer duration of action. John's wort a. d. "It will take about 3 weeks before you notice a therapeutic effect." c.

Rinse his mouth with water after each use. and administer ipratropium bromide. The client with a history of emphysema b. d. A client has taken metaproterenol. A client demonstrates understanding of flunisolide (AeroBid) by saying that he will do what? a. and beclomethasone (Vanceril) inhalers for a client. Monitor for heart rate >100 beats/min. The client with atrial fibrillation with a rate of 100 b. Administer the albuterol first. d. wait 5 minutes. What is the nurse's best action? a. What is the nurse's best action? a. albuterol (Proventil). followed by beclomethasone several minutes later. Administer the albuterol first. b. Question the order. c. Rinse his mouth with water after each use. c.a. Monitor for sedation. The client with atrial fibrillation with a rate of 100 The nurse is caring for clients on the pulmonary unit. followed . and administer ipratropium bromide. Monitor for heart rate >100 beats/min. three inhalers should not be given at one time. d. Tell the client not to drive for 2 hours. Teach the child to use a spacer. What is the nurse's priority action? a. The client who is 16 years old d. b. Assess for elevated blood pressure. d. Tell the parent that young children should not use inhalers. Not use his albuterol inhaler while he is taking AeroBid. Which client should not receive epinephrine if ordered? a. Immediately stop taking his oral prednisone when he starts using AeroBid. Teach the child to use a spacer. The client with a history of type 2 diabetes c. d. Tell the parent to hold the inhaler for the child. The child is having difficulty using the inhaler. b. wait 5 minutes. b. b. The nurse is caring for a young child who has been prescribed an inhaler for control of her asthma. Take two puffs to treat an acute asthma attack. Ask the health care provider to switch to oral medications. The health care provider orders ipratropium bromide (Atrovent). c.

c. . wait 2 minutes." c. Administer beclomethasone first. "Take the ipratropium at least 5 minutes before the cromolyn. Monitor blood glucose levels every 4 hours when taking albuterol. An antianxiety agent may be prescribed to help with nervousness." c. "Hold your breath for 10 seconds if you can after you inhale the medication. followed by the albuterol several minutes later. c. c. b. d. Monitor blood glucose levels every 4 hours when taking albuterol." Which instruction will the nurse include when teaching a client about the proper use of metereddose inhalers? a." b. Administer each inhaler at 30-minute intervals." A client is prescribed ipratropium and cromolyn sodium." b. Relief of bronchospasms c. repeat until you obtain relief. take a deep breath. What will the nurse teach the client? a. "Do not take these medications within 4 hours of each other." d. What is the most important thing for the nurse to teach the client with a history of diabetes and asthma who has started on albuterol PRN? a. Hold the next dose of theophylline." c. and administer ipratropium bromide. Liquefying and loosening of bronchial secretions d." d. Monitor for orthostatic hypotension every 2 hours when taking albuterol. b. Take Tylenol for headaches when taking albuterol. "Make sure that you puff out air repeatedly after you inhale the medication. "Administer both medications together in a metered-dose inhaler. Decreased nasal secretions c. d. "Hold the inhaler in your mouth. "After you inhale the medication once." c. Decreased cough reflex b. "Take the ipratropium only in the mornings.by beclomethasone several minutes later. "Hold your breath for 10 seconds if you can after you inhale the medication. "Take the ipratropium at least 5 minutes before the cromolyn. Liquefying and loosening of bronchial secretions What will the nurse expect to find that would indicate a therapeutic effect of acetylcysteine (Mucomyst)? a. and then compress the inhaler.

Absorbs water into the intestines to increase bulk and peristalsis c. c. d. Acts on smooth intestinal muscle to gently increase peristalsis A client who has constipation is prescribed a bisacodyl suppository. Lack of exercise A client complains of constipation and requires a laxative. The nurse explains that bisacodyl does what? a. Vomiting . Dry mouth A client is using the scopolamine patch to prevent motion sickness. Block serotonin receptors in the CTZ c. Food intolerance d. Motion sickness b. the nurse reviews the common causes of constipation. b. Administer oxygen 2 lpm via nasal cannula. Lack of exercise c. Bacteria (Escherichia coli) b. In providing teaching to the client. The nurse explains that the action of this drug is what? a. Acts on smooth intestinal muscle to gently increase peristalsis b. Block dopamine receptors in the CTZ d. including which cause? a. Call the health care provider. Block serotonin receptors in the CTZ A client has nausea and is taking ondansetron (Zofran). Continue to monitor the client. b. Coat the wall of the GI tract and absorb bacteria a. Diarrhea b. Lowers surface tension and increases water accumulation in the intestines d. What is the best action for the nurse to take? a. Stimulate the CTZ b. Pulls hyperosmolar salts into the colon and increases water in the feces to increase bulk d. The nurse teaches the client that which is a common side effect of this drug? a. The client is irritable.A client taking an oral theophylline preparation is due for her next dose and has a blood pressure of 100/50 mm Hg and a heart rate of 110. Hold the next dose of theophylline.

Warn the client to avoid laxative abuse. c. MAOIs c. c. Dry mouth c. Record the frequency of bowel movements. Teach the client that the drug acts by drawing water into the intestine. Warn the client against taking sedatives concurrently. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. d. Client is complaining of gastric upset. d. Alcohol When metoclopramide (Raglan) is given for nausea. b. b. The nurse is administering opium tincture (paregoric) to a client.c.) a. Client taking magnesium-containing antacids who has renal failure. Insomnia d. d. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. b. Encourage the client to increase fluids. Which should be included in the client teaching regarding this medication? (Select all that apply. Alcohol d. Encourage the client to increase fluids. Client has trace edema in feet. Warn the client to avoid laxative abuse. Warn the client against taking sedatives concurrently. a. b. Record the frequency of bowel movements. Which assessment finding will need intervention and is related to the client's use of aluminum hydroxide (Amphojel)? a. Client has had one loose stool this week. Carbonated beverages a. . Which client needs immediate intervention? a. c. Client has not had a bowel movement in 3 days. e. c. the client is cautioned to avoid which substance? a. Milk b. Client taking aluminum-containing antacids with complaints of reflux. f. e. Client has not had a bowel movement in 3 days. Client taking calcium-containing antacids who is hypocalcemic.

d. "I should decrease bulk and fluids in my diet to prevent diarrhea. "I should take this medication 1 hour after each meal in order to decrease gastric acidity." c. Administer the medications and assess the client for relief. What assessment has the highest priority for a client using sodium bicarbonate to treat gastric hyperacidity? a. What is the nurse's best action? a. Assess for fluid volume deficit. Alteration in tissue perfusion related to hypertension b. Assess for metabolic alkalosis. Potential risk for bleeding related to thrombocytopenia Which nursing diagnoses is appropriate for a client receiving famotidine (Pepcid)? a. Increased risk for infection related to immunosuppression b. b. Administer the medications and assess the client for relief. Client taking magnesium-containing antacids who has renal failure. Assess for hyperkalemia. Only administer the Ativan if the client seems anxious. so I should look into cessation programs. c. Assess for hypercalcemia." d. "Smoking decreases the effects of this medication. b. d. b. Assess for metabolic alkalosis. A client is prescribed Lorazepam (Ativan) and a glucocorticoid during chemotherapy treatments. it is all right for me to eat spicy foods." Which statement demonstrates to the nurse that the client understands instructions regarding the use of histamine2-receptor antagonists? a. "Smoking decreases the effects of this medication. Call the health care provider and question the order. Potential risk for bleeding related to thrombocytopenia c. pantoprazole (Protonix) . "Since I am taking this medication.c. Client taking antacids who is older than 70 years. Administer the two medications at least 12 hours apart." b. a. c. Alteration in urinary elimination related to retention d." d. so I should look into cessation programs. d. d.

Administer 30 minutes before meals and at bedtime. esomeprazole (Nexium) b. "I will not drive while I am taking these medications because they may cause drowsiness. c. The nurse is planning to administer metoclopramide (Reglan). "I will apply the scopolamine patches to rotating sites on my arms. What assessment is essential for this client? a. Vascular assessment b. Increase in number of bowel movements c. Gastric assessment c." c. lansoprazole (Prevacid) c. b. "I should take my prescribed antiemetic before receiving my chemotherapy dose and continue afterwards.A nurse is caring for a client who is unable to tolerate oral medications." b. Give with a full glass of water first thing in the morning. Decrease in gastric motility d. Increase in bowel sounds b. Hourly blood pressure measurements d. Decrease in gastric motility Which outcome assessment is essential to monitor for the client taking diphenoxylate (Lomotil)? a. What is a primary intervention? a. d. Gastric assessment The nurse is administering loperamide (Imodium) to a client with diarrhea. ." d. Administer every 6 hours around the clock. omeprazole (Prilosec) d." Which client statement indicates that further teaching is needed? a. "I may take Tylenol to treat the headache caused by ondansetron (Zofran). Administer 30 minutes before meals and at bedtime. Decrease in urination c. White blood count c." b. "I will apply the scopolamine patches to rotating sites on my arms. The nurse anticipates that the client may be prescribed which proton pump inhibitor to be administered intravenously? a. Administer with food to decrease gastrointestinal upset. pantoprazole (Protonix) c.

Administer the medication at least 12 hours before the start of chemotherapy. What will the nurse teach the client about the reason for administering multiple medications for relief of nausea and vomiting? a. b. b. "Assess your stools for dark streaks." b. "Brush your teeth and gargle to help with dryness in your mouth. A client is starting cisplatin therapy for cancer. b." What instruction is most important for the nurse to teach a client who is taking an anticholinergic agent to treat nausea and vomiting? a. which nursing diagnosis would be of highest priority? a. Fluid volume deficit related to nausea and vomiting c. d. What intervention is appropriate for this client? ." c. What intervention is most appropriate for this client? a. Weigh the client before chemotherapy. Combination therapy blocks different vomiting pathways. Alteration in comfort related to nausea and vomiting c. Combination therapy blocks different vomiting pathways. Knowledge deficit regarding medication administration b. Combination therapy decreases the risk of constipation. Combination therapy decreases side effects due to lower doses of each drug. Fluid volume deficit related to nausea and vomiting In developing a plan of care for a client receiving an antihistamine antiemetic agent. Risk for injury related to side effects of medication d. Teach the client about the possibility of rebound nausea and vomiting once the drug is discontinued. c. A client is prescribed granisetron (Kytril) IV for relief of nausea and vomiting caused by cancer chemotherapy. b. b. Combination therapy is more cost-effective.c. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy. c. Weigh the client before chemotherapy. Check your heart rate and call the health care provider if it gets below 50 beats/min. "Do not take more than two doses of this medication. Assess baseline vital signs and monitor for tachycardia. d. "Brush your teeth and gargle to help with dryness in your mouth." d.

" b. Evaluate renal function. "Do not use this medication for longer than a day. Monitor bowel elimination daily. Helicobacter pylori b. Helicobacter pylori A client is diagnosed with peptic ulcer disease. hyposecretion of pepsin c. "Drowsiness is a concern while on this medication." e. Assess fluid and electrolyte balance. b. Administer granisetron (Kytril) 60 minutes before therapy and for several days after surgery. c." a. which nursing intervention is the priority? a. Which assessment is most important for the client who is taking stimulant laxatives? a. Monitor heart rate and blood pressure every 4 hours. c." f. "Do not take this medication if you are dizzy. What information will the nurse include on the teaching plan for this client? (Select all that apply. d." A client is prescribed scopolamine. b. Obtain a history of constipation and causes." e. b." f." c. switch patch to alternate ear. c. Evaluate renal function. c. "After 3 days. decreased number of parietal cells . "After 3 days. decreased hydrochloric acid d.a. "Apply patch 4 hours before effect is desired. "Drowsiness is a concern while on this medication. "Do not use laxatives while on this medication. c. Record baseline vital signs.) a. d." d. Before administering a stimulant laxative to a client. Administer metoclopramide (Reglan) PO. switch patch to alternate ear. Monitor intake and output. d. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy. The nurse realizes that which factor is a predisposing factor for this condition? a. Monitor signs and symptoms of fluid and electrolyte imbalance. Monitor signs and symptoms of fluid and electrolyte imbalance. Administer palonosetron (Aloxi) IV push. d. "Apply patch 4 hours before effect is desired.

Antacids decrease GI motility. To suppress gastric acid secretion by inhibiting the hydrogen/potassium ATPase enzyme d. The drug must always be administered with magnesium hydroxide e. The nurse who is teaching the client about this drug should include which information? (Select all that apply. Foods high in vitamin B12 should be increased in diet A client is taking ranitidine (Zantac). Diarrhea b. Aluminum hydroxide is a systemic antacid. b. The drug must be administered separate from an antacid by at least 1 hour e. Antacids decrease gastric acid secretion. Headaches . To combine with protein to form a viscous substance that forms a protective covering of ulcer When a client is given sucralfate (Carafate). To neutralize gastric acidity b. To inhibit gastric acid secretion by inhibiting histamine at H2 receptors in parietal cells c. Antacids neutralize HCl and reduce pepsin activity. To combine with protein to form a viscous substance that forms a protective covering of ulcer c.) a. Decreased libido A client is taking famotidine (Pepcid) to inhibit gastric secretions. Drug-induced impotence is irreversible b. c. The drug must be administered separate from an antacid by at least 1 hour d. Antacids neutralize HCl and reduce pepsin activity. b. What are the side effects of famotidine? (Select all that apply. Dry mouth d. Smoking should be avoided while taking this drug f. Dizziness d. d. When a client complains of pain accompanying a peptic ulcer. Smoking should be avoided while taking this drug f. Dizziness c.d. why should an antacid be given? a. the nurse knows that its mode of action is what? a. Headaches f.) a. Foods high in vitamin B12 should be increased in diet d. The drug must be administered 30 minutes before meals c.

e. . "I will drink 2 ounces of water after taking aluminum hydroxide. "I will drink 2 ounces of water after taking aluminum hydroxide." b. Administer during meals. "I will take a laxative if I develop constipation. The client is able to eat. "I will take aluminum hydroxide at mealtime. Sulcrate) for treatment of a duodenal ulcer." d. Blurred vision f. c. Administer just before meals. c. d." a. Which assessment indicates to the nurse that the medication has had a therapeutic effect? a. Absent bowel sounds. Calcium level 8. The client has no throat pain. hard abdomen The nurse is caring for a client who is taking sucralfate (Carafate. Alu-Tab) for peptic ulcer pain. The health care provider prescribes lansoprazole (Prevacid) to a client." A client has just been prescribed aluminum hydroxide (Amphojel. Absent bowel sounds. The client has no diarrhea. d. Allow the tablet to dissolve in water before administering. The nurse has provided instructions to the client. "I will take aluminum hydroxide within 30 minutes of my other medications. ALternaGEL. The client has no gastric pain. c. Administer 1 to 2 hours after meals. Which assessment requires action by the nurse? a. Decreased libido b." c. b. Urinary output 30 mL/hr d. b. What is a priority nursing intervention when administering ranitidine (Zantac)? a. b. Administer just before meals. Sodium level 140 mEq/L b. hard abdomen c. Which statement by the client indicates to the nurse that the client understands the instructions? a.5 mg/dL c. The client has no throat pain. Administer right after eating.

"Your gastric acid will be inhibited. Cyclopentolate The client is being prepared for an eye examination. Kidney stones c. Instruct the client to take omeprazole with the aspirin. a." d. Instruct the client to take the aspirin with milk. Administer misoprostol. what is an essential intervention? a. What drug might be used instead for the examination? . When the nurse takes the health history. Dehydration b. Administer with an antacid for maximum benefit. c. which includes mannitol." b. Dehydration The nurse reviews the client's list of medication. "This medication will form a protective barrier over the gastric mucosa. Gout c. d. c. What is the best intervention for this client? (Select all that apply. "This medication will neutralize gastric acid. "This medication will enhance gastric absorption of meals. d. b. Allow the tablet to dissolve in water before administering. Administer with a bolus tube feeding. Instruct the client to take omeprazole with the aspirin. The nurse is caring for a client who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. The nurse must be aware that which condition is a contraindication for use of this drug? a.) a. Crush the tablet into a fine powder before mixing it with water." b. the client says that she is sensitive to atropine sulfate. "This medication will form a protective barrier over the gastric mucosa. Eczema d. b." c.When administering sucralfate (Carafate) to a client with a nasogastric tube. c. Stop all aspirin therapy. Administer misoprostol." What information should the nurse include in a teaching plan for the client who is prescribed sucralfate (Carafate)? a. d.

travoprost The nurse reviews the African-American client's list of medications. not a combination. It is important for the nurse to be aware that the prostaglandin analogue more effective in African Americans than in nonAfrican Americans is wha? a. bimatoprost c. Electrolytes d. Hydrogen peroxide The camp nurse reviews the "shopping list" of supplies needed for the upcoming camping season. Electrolytes An 85-year-old client is taking acetazolamide. It is important to note what primary disadvantage of the use of combination products such as Cortisporin Otic? a. a carbonic anhydrase inhibitor. latanoprost b. What product is recommended to prevent and treat chronic impaction of cerumen? a. Hydrogen peroxide b. unoprostone d. Salt solution . d. Betaxolol HCl c. School-aged children may need only one drug. Complete blood count c. Suprofen c. Combination products are less effective for school-aged children. not a combination.a. Charcoal d. travoprost a. Weight b. a. Cyclopentolate d. Combination products may not have the desired dose for school-aged children. c. Rubbing alcohol c. School-aged children may need only one drug. b. There is increased cost in using combination products for school-aged children. Urine output d. The school nurse is preparing a presentation for the parent-teacher association meeting on medications commonly used in school-aged children. A nursing intervention associated with clients receiving this drug is to monitor what? a. Diclofenac b.

Instruct the client to report changes in vision and breathing. carbamide peroxide A client is complaining of excessive earwax that diminishes hearing ability. The pinna of an adult should be held down and back to administer eardrops. Client's pupils are dilated to 4 mm. d. Warm the eardrops to room temperature before administration. Client states that her eyes feel very dry." c. "I should rinse the eye dropper with tap water after each use. What medication will the nurse use to assist the client? . Eardrops may be warmed in the microwave before administration. "I will put pressure on the inside corner of my eye after I administer the drops." b. Wait 10 minutes to instill the second eye medication to be given at the same time. "I will turn my head slightly toward the outside of the eye I am putting the drops in. b. Which intervention is essential to include in the plan of care? a." b. Client's eyes appear clear. Eardrops should be cool when being administered. b. Warm the eardrops to room temperature before administration. "I should rinse the eye dropper with tap water after each use." d. Which assessment finding would indicate a therapeutic effect of the medication? a." Which statement. c.a. The nurse administers pilocarpine (Pilocar) to a client with glaucoma. Which important nursing intervention are included for this client? (Select all that apply. c. indicates to the nurse a need for further client teaching regarding proper administration of eye drops? a. b.) a. b. d. "I will be careful not to touch my eye with the dropper. d. The nurse is planning to administer eardrops. without drainage. Maintain sterile technique and prevent dropper contamination during administration of eyedrops. d. Include return demonstration only with geriatric clients. c. Client's pupils are constricted to 2 mm. made by a client. Client's pupils are constricted to 2 mm. Maintain sterile technique and prevent dropper The nurse prepares a health teaching plan for the client with glaucoma. Instruct the client to report changes in vision and breathing. c. b.

acetic acid b. b. Assess lesions The nurse is doing health teaching with a client with psoriasis. Nursing implications for health teaching with clients taking isotretinoin include which implications? (Select all that apply. d. d. Hair follicles a. glycerin b. A horny layer of epidermis The nurse reviews the client's list of medications and recalls that the purpose of keratolytic agents is to remove what? a.a. d. Avoid sunlight. and lipids. Continue to observe the client. Monitor CBC. c. A horny layer of dermis b. Instruct the client that one drop is optimal. b. Have the client irrigate his eye to remove excess medication. glucose. The nurse evaluates the client using eyedrops. Erythematous lesions d. carbamide peroxide c. and lipids. Instruct the client that one drop is optimal. What is the nurse's best action? a. Do not breastfeed or give blood. b. The client puts two drops into his eye. glucose. Monitor weight c. Monitor CBC. c. Have the client close his eye and rub to assist in absorption. c. hydrocortisone d.) a. Daily weight b. A horny layer of epidermis c. Do not breastfeed or give blood. Avoid sunlight. Monitor electrolytes . Which is a nursing implication of the new biologic agents for the management of psoriasis? a.

Metabolic acidosis c. Thinning of the skin c. Respiratory alkalosis d. A review of iPLEDGE educational materials c. Thinning of the skin d. what does the assessment include? (Select all that apply. finasteride a. That a negative pregnancy test is required before each monthly refill A 20-year-old woman comes to the clinic for follow-up related to isotretinoin use. Respiratory alkalosis The client has second.) a.) a. Obesity b. dexamethasone b. Purpura The nurse reviews the client's medication history." Which drug is used to treat male pattern baldness? a. PABA c. Erythematous lesions d.) a. Assess lesions d. minoxidil d.and third-degree burns over 25% of his body. Respiratory acidosis b. Based on the client's prolonged use of glucocorticoids. That an effective method of contraception must be used throughout treatment b. What acid-base imbalance can result from its use? (Select all that apply. Metabolic acidosis b. The nurse reviews the iPLEDGE program. Mafenide acetate has been ordered. Monitor CBC and T-cell count d. Purpura b. which includes which important information? (Select all that apply. Metabolic alkalosis c.c. A review of iPLEDGE educational materials . finasteride A 55-year-old man has a chief complaint: "I'm going bald.

IV dextrose infusion d. a. Silver sulfadiazine cream Which intervention is most appropriate for the client with second-degree burns? a. Isolation c. Sunscreen products should contain information about UVA and UVB SPF protection. d. d. b.8 meq/L c. Sunscreen products should contain information about UVA and UVB SPF protection. Perform pregnancy test. UVB radiation is greatest between 10 AM and 4 PM.c. so sunscreen is not needed on cloudy days. Potassium 3. Sodium 135 mmol/L d. b. d. SPF should be at least 15 in sunscreen products.) a.5 mg/dL . A 20-year-old client is starting isotretinoin (Accutane) therapy. c. Force fluids. Assess sputum cultures. Make sure IV is patent. d. b. Which assessment finding requires immediate intervention by the nurse? a. Clouds block radiation. That a negative pregnancy test is required before each monthly refill d. IV antibiotics b. c. Silver sulfadiazine cream a. Perform pregnancy test. UVB radiation is greatest between 10 AM and 4 PM. The school nurse prepares a program for junior high school students on sun safety. SPF should be at least 15 in sunscreen products. That informed consent is not required a. Calcium 12 mg/dL b. Calcium 12 mg/dL A client is prescribed calcipotriene (Dovonex) for treatment of psoriasis. Phosphorus 2. What is important information to include? (Select all that apply. What is an essential nursing intervention for this client? a.

Wash the skin. b. d. Do not take aspirin while on this medication. c. . Do not go out in the sun while on this medication. Shave and prepare the area. Call the health care provider if you have muscle weakness. b. Ask client if he or she has any allergies. b. Call the health care provider if you have muscle weakness. Ask client if he or she has any allergies. what is a primary nursing intervention? a. Before applying povidone-iodine (Betadine) to a client's skin. A client is prescribed isotretinoin (Accutane). Increase fluid intake while on this medication. Apply a cortisone cream. c.d. d. What is the most important instruction to teach the client before beginning this medication? a.

he nurse and a client are discussing possible behaviors that might be interfering with the client's ability to fall asleep. Which of the following assessment questions is most likely to identify possible problems with the client's sleep routine that possibly are contributing to the difficulty? 1. "When do you usually retire for the night?" 2. "What do you do to help yourself fall asleep?" 3. "How much time does it usually take for you to fall asleep?" 4. "Have you changed anything about your presleep ritual lately?"
2. "What do you do to help yourself fall asleep?" As people try to fall asleep, they close their eyes and assume relaxed positions. Stimuli to the RAS decline. If the room is dark and quiet, activation of the RAS further declines. At some point the BSR takes over, causing sleep. If the client engages in activities such as reading or watching television as a means of falling asleep, this could be causing the problem. Although the other questions are not inappropriate, they are not as directed toward the cause of the problem.

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

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

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

Which of the following information provided by the client's bed partner is most associated with sleep apnea? 1. Restlessness 2. Talking during sleep 3. Somnambulism 4. Excessive snoring
4. Excessive snoring Partners of clients with sleep apnea often complain that the client's snoring disturbs their sleep. Restlessness is not most associated with sleep apnea. Sleep talking is associated with sleep-wake transition disorders; somnambulism is associated with parasomnias (specifically, arousal disorders and sleep-wake transition disorders).

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

Which of the following symptoms should the nurse assess with a client who is deprived of sleep? 1. Elevated blood pressure and confusion 2. Confusion and irritability 3. Inappropriateness and rapid respirations 4. Decreased temperature and talkativeness
2. Confusion and irritability Psychological symptoms of sleep deprivation include confusion and irritability. Elevated blood pressure is not a symptom of sleep deprivation. Rapid respirations are not a symptom of sleep

deprivation. There may be a decreased ability of reasoning and judgment that could lead to inappropriateness. Decreased temperature is not a symptom of sleep deprivation. The client with sleep deprivation is often withdrawn, not talkative.

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

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

Which principle of body mechanics should the nurse incorporate into client care? 1. Advances the affected leg after moving the crutches to descend the stairs To descend stairs. Lower the client gently to the floor If the client has a syncopal episode or begins to fall.Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Lower the client gently to the floor 4. 1. then the unaffected leg to the stairs with the crutches. The nurse should be positioned close to the client and use the arms and legs. This will create a wide base of support. supporting the client's weight. Flex the knees and keep the feet wide apart. Facing the direction of movement prevents abnormal twisting of the spine. 2. allowing the client to slide against the leg while gently lowering the client to the floor and protecting the client's head. The nurse. Assume a position far enough away from the client. The client needs to use crutches at home. alert to a syncopal episode. Dividing balanced activity between arms and legs reduces the risk of back injury. providing greater stability for the nurse and reducing the risk of back injury. and will have to manage going up and down a short flight of stairs. the client complains of extreme dizziness. The nurse should not lean the client against a wall as the client may fall. The nurse evaluates the use of an appropriate technique if the client: 1. Lean the client against the wall until the episode passes 3. The correct answer is to flex the knees and keep the feet wide apart. 4. Advances the crutches first to ascend the stairs 4. Twist the body in the direction of movement. The client should continue to use the crutches . Go for help 3. Uses a banister or wall for support when descending 2. Use the strong back muscles for lifting or moving. the nurse should assume a wide base of support with one foot in front of the other. 3. Advances the affected leg after moving the crutches to descend the stairs 4. Uses one crutch for support while going up and down 3. and then extend the leg. The nurse should not leave the client alone and go for help. While ambulating in the hallway of a hospital. The nurse should not attempt to walk the client quickly back to the room. Support the client and walk quickly back to the room 2. should first: 1. the crutches are placed on the stairs and the client moves the affected leg. also reducing the risk of back injury. Flex the knees and keep the feet wide apart.

The client should keep his or her body upright and midline. "His pulse and blood pressure are within his normal baseline limits. 2. After instruction. and let me know if they are elevated . Paraplegics who wear weight-supporting braces on their legs use the swing-through gait. Leaning can cause the client to lose his or her balance and fall. There is a slight lean to the right when the client is walking. Two-point The two-point gait requires at least partial weight bearing on each foot. The client should continue to use both crutches for support when going up or down stairs. The client moves a crutch at the same time as the opposing leg. should be on the floor at all times. such as both feet or one foot and the cane. 4. then the crutches and affected leg. "Please take his pulse and blood pressure. Which action indicates that the client knows how to use the cane properly? 1. Two-point 2. 2. After advancing the cane. so this gait would not be appropriate. This client is only supposed to use partial weight bearing.for support. forward to the cane. so that the crutch movements are similar to arm motion during normal walking. A client with a fractured left femur has been using crutches for the past 4 weeks. Swing-through 1. Two points of support are kept on the floor at all times. Three-point 3. It would not be appropriate for this client. In a three-point gait. Which of the following statements by the nurse reflects a need for immediate follow-up regarding the physical effects of chronic pain on body function? 1. Which of the following gaits should the client be taught to use? 1. the client moves the unaffected leg up the stair. the nurse observes the client ambulate in order to evaluate the use of the cane. Two points of support are kept on the floor at all times. Four-point 4. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. the client's right side. Two points of support. the client should move the weaker leg. 3. The client keeps the cane on the left side. When ascending stairs. The four-point gait gives stability to the client but requires weight bearing on both legs. The nurse is working with a client who has left-sided weakness. The cane should be kept on the stronger side. the client's left leg. The physician tells the client to begin putting a little weight on the left foot when walking. so I'm sure the pain medication is working. weight is borne on both crutches and then on the uninvolved leg. After advancing the cane. not the banister or wall. the client moves the right leg forward." 2.

. "If his pulse and blood pressure are above his normal baseline.above his normal baselines. Bradypnea 3. The advantage for the client is that he or she may self-administer opioids with minimal risk for overdose. "Unmanaged pain usually manifests itself in both an elevated pulse and blood pressure. The health care provider prescribes the type of medication to be used." 1. Has control over the frequency of the intravenous (IV) analgesia 2. When a client's husband questions how a patient-controlled analgesia (PCA) pump works. Diaphoresis An expected assessment finding of a client experiencing acute pain would be diaphoresis resulting from sympathetic nerve stimulation. Controls the route for administering the medication 1. Additional assessment findings of a client experiencing acute pain would be an increased heart rate. they are not assuming that no elevation of vital signs means the absence of pain. Decreased muscle tension 3." 3." Except in cases of severe traumatic pain. and I will medicate him for pain. so I'm sure the pain medication is working. respiratory rate. let me know. The PCA system is designed to deliver no more than a specified number of doses. "His pulse and blood pressure are within his normal baseline limits. Thus clients in pain will not always have changes in their vital signs. The client does not control the route for administration. and muscle tension. which sends a person into shock. May request the type of medication received 4." 4. Bradycardia 2. the nurse explains that the client: 1. Has control over the frequency of the intravenous (IV) analgesia With a PCA system the client controls medication delivery. Although the remaining options recognize the phenomena. The client does not choose the dosage. Which of the following symptoms would the nurse expect with a client who is experiencing acute pain? 1. Can choose the dosage of the drug received 3. Changes in vital signs are more often indicative of problems other than pain. Systemic PCA typically involves IV drug administration but can also be given subcutaneously. Diaphoresis 4. most people reach a level of adaptation in which physical signs return to normal.

in which pain may be referred to the jaw. A priority nursing intervention when caring for a client who is receiving an epidural infusion for pain relief is to: 1. Label the port as an epidural catheter 3. such as with a myocardial infarction. Superficial or cutaneous 3. and pruritus. The nurse should describe pain that is causing the client a "burning sensation in the epigastric region" as: 1. 4. Deep or visceral Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation. such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation. Deep or visceral 4. A common complication of epidural anesthesia is hypotension. Use open-ended questions to find out about the sensation. Offer the client a pain scale to objectify the information. Use aseptic technique 2. 3. Superficial or cutaneous pain is of short duration and is localized as in a small cut. Referred pain is felt in a part of the body separate from the source of pain. but rather it is an assessment of the pain pattern. Radiating pain feels as though it travels down or along a body part. 2. the nurse may ask open-ended questions to find out about the sensation experienced. and left shoulder. respiratory depression. including assessment of respiratory rate. Referred 2. Radiating 3. monitoring occurs as often as every 15 minutes. Complications of epidural opioid use include nausea and vomiting. Offer the client a pain scale to objectify the information. Asking the client about the location of pain does not assess the intensity of the client's pain. urinary retention. Ask about what precipitates the pain. constipation. .Which of the following is most appropriate when the nurse assesses the intensity of the client's pain? 1. and skin color. Descriptive scales are a more objective means of measuring pain intensity. Asking the client what precipitates the pain does not assess intensity. 3. left arm. Monitor vital signs every 15 minutes 4. respiratory effort. Avoid supplemental doses of sedatives 3. Monitor vital signs every 15 minutes When clients are receiving epidural analgesia. To determine the quality of the client's pain. Question the client about the location of the pain.

have some juice with breakfast." 3." 4. "Let me get you some apple juice." 2. "I'll see about getting a different pain medication. "You might find the new flavored bulk laxatives helpful. and diarrhea is the result. have some juice with breakfast. To reduce the risk for accidental epidural injection of drugs intended for IV use.Assessing vital signs is the priority nursing intervention. antibiotics irritate the mucous lining of the intestines." A client who is 2 days' postoperative reports feeling "constipated" to the nurse." Supplemental doses of opioids or sedative/hypnotics are avoided because of possible additive central nervous system adverse effects. "The GI tract naturally rids itself of bacterial toxins by increasing peristalsis. causing decreased absorption and diarrhea." 1." 4. strict surgical asepsis is needed to prevent a serious and potentially fatal infection. "Increase your fluid intake. Which of the following interventions should the nurse try initially? 1." 4. "Have you tried foods like prunes and bran?" 2." 2. "For some. "Your health care provider might prescribe an enema if I call. your body is fighting off an infection." 3." 2. "What have you tried in the past that hasn't been helpful?" 4. and peristalsis is faster and so diarrhea occurs. Her pain is being controlled with an opioid analgesic. "Increase your fluid intake. The client has good bowel sounds in all four quadrants and has tolerated liquids well. "When you are taking an antibiotic. and diarrhea is the result." An adult client reports to the nurse that she has been experiencing constipation recently and is interested in any suggestions regarding dietary changes she might make. Which of the following suggestions provided by the nurse is most likely to minimize the client's complaint? 1. "The antibiotic is responsible for killing off the GI tract's normal bacterial. Because of the catheter location. "Let me get you some apple juice. and that causes diarrhea." . Which of the following statements made by a nurse discussing the effect of an antibiotic on the gastrointestinal system reflects the best understanding of the possible occurrence of diarrhea? 1." 3. the catheter should be clearly labeled "epidural catheter. "Ambulating may get your bowels moving. "The antibiotic is responsible for killing off the GI tract's normal bacterial.

"The more fiber I eat." 2. The client has diabetes that is managed with diet and exercise as well as hypertension . Advance the enema tubing 2 to 3 inches 4. the client complains of abdominal cramping. Paralytic ileus While undergoing a soapsuds enema.Which of the following statements made by an older adult reflects the best understanding of the role of fiber regarding bowel patterns? 1. Whole wheat bread 2. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly. Salmon 1. "Whole grain cereal and toast for breakfast keeps my bowels moving regularly. clients who have undergone general anesthesia may experience: 1." 3. Colitis 2." 2. Veal 4." The nurse instructs the client that before the fecal occult blood test (FOBT) she may eat: 1. Lower the height of the enema container 3. T-bone steak 3. "My wife makes whole grain muffins. they are really good and good for me too. Clamp the tubing 2. Gastrocolic reflex 3. The nurse should: 1. Lower the height of the enema container The nurse is discussing a middle-age adult male client's report of nocturia. A lean. Immediately stop the infusion 2." 4. Paralytic ileus 4. Whole wheat bread A nurse who is caring for postoperative clients on a surgical unit knows that for 24 to 48 hours postoperatively. the fewer problems I have with my bowels. "I use to have trouble with constipation until I started taking a fiber supplement. Stomatitis 3.

) 1. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. Pelvic tenderness or flank pain 6. An enlarged prostate gland 2. The 62-year-old Alzheimer's disease client diagnosed 8 years ago 4. Chills and fever 2. Frequency or urgency 4.) 1. The 25-year-old with Crohn's disease diagnosed 4 years ago 3. Consuming too many liquids during the day 1. An enlarged prostate gland 2. Cloudy or blood-tinged urine 6. Poorly controlled blood glucose 3.that is currently well-controlled with medication. Possible side effect of his medication 5. Drinking a cup of tea before bed 4. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. Chills and fever 2. Drinking a cup of tea before bed 5. Burning or pain when voiding 1. Nausea and vomiting 3. The 74-year-old diagnosed with parkinsonism 5 years ago 2. Frequency or urgency 4. Taking his diuretic too close to bedtime 6. The 69-year-old client diagnosed with type 2 diabetes 9 years ago 1. The 74-year-old diagnosed with parkinsonism 5 years ago 3. Cloudy or blood-tinged urine 5. Burning or pain when voiding Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply. Poorly controlled blood glucose 3.) 1. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago . Nausea and vomiting 3. The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago 5. Taking his diuretic too close to bedtime Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.

3. The impaired cognitive state the client will experience as the effects of the anesthesia wear off 2. 3. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder A timed urine specimen collection is ordered. The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago 6. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? 1. The nurse is visiting the client who has a nursing diagnosis of urinary retention. Apply sterile gloves for the procedure. Upon assessment the nurse anticipates that this client will exhibit: 1. The unit manager is evaluating the care of a new nursing staff member. Severe flank pain and hematuria 2. A feeling of pressure and voiding of small amounts . The decreased volume of orally ingested fluids before. A loss of the urge to void 4. The client voids in the toilet. The preservative is placed in the collection container. 4. Collect the specimen after the initial stream of urine has passed. The length of time the client was under the effects of general anesthesia required for the surgical procedure 4. Pain and burning on urination 3. The urine specimen is kept cold . The first voided urine is discarded. 4. The test will need to be restarted if which of the following occurs? 1. The 69-year-old client diagnosed with type 2 diabetes 9 years ago The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of: 1. Place the specimen in a clean urinalysis container. 2. during. Restrict fluids before the specimen collection. 2. 1.5. The client voids in the toilet. Collect the specimen after the initial stream of urine has passed. and after the surgical procedure 3. The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder 4. 4.

Distribution A low-protein diet may lead to an inadequate level of plasma proteins. 3. Excretion c. 4. Use a needle to withdraw urine from the catheter port Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? 1. 2. Distribution d. Catheterize the client 3.4. Disconnect the catheter from the drainage tubing 2. Use a needle to withdraw urine from the catheter port 4. which will affect availability of "free" drug. A therapeutic nursing intervention based on this diagnosis is to: 1. The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. Use clean technique to obtain a specimen for culture and sensitivity. Withdraw urine from a urinometer 3. This will most likely affect which pharmacokinetic process? a. Apply adult diapers 2. . Clean up the length of the catheter to the perineum. Teach Kegel exercises 4. Administer Urecholine 4. Teach Kegel exercises The client has been on a low-protein diet. Place the drainage bag on the client's lap while transporting the client to testing. Open the drainage bag and removing urine 4. Absorption b. Empty the drainage bag at least every 8 hours. Empty the drainage bag at least every 8 hours. Metabolism c. A feeling of pressure and voiding of small amounts When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: 1. 1.

The nurse is having difficulty deciphering what has been written. acute vs. so that he can educate the client thoroughly c. the nurse should a. so that he can develop an effective pain management plan ANS: C Different modalities are used in the treatment/ management of pain and are often based on how the pain is classified (e. Call the pharmacist and ask her to read the prescription. c. False Absorption refers to the "movement" of the drug from the site of administration into the blood stream. observe the client carefully for changes in behavior or vital signs c. b. Ask the patient what medication the provider prescribed. so that he can be clear in his communication with the physician c. use only pain scales that feature numbers or "faces" the client can point to .The primary provider has written a medication prescription.g. a. Call the provider and ask him to clarify the prescription. The nurse is assessing the confused client. so that he can document the client's pain using accurate terms b. parenteral route leads to "instant" absorption. It is most important for the nurse to understand the various ways in which pain is classified a. be aware that confused clients don't feel as much pain due to their confusion b. False b. Ask the nurse who knows the provider's handwriting to read the prescription. so that he can develop an effective pain management plan d. True b. All other answers increase the risk of a medication error. Therefore.. the drug would be absorbed fastest if given per the IM route. d. Call the provider and ask him to clarify the prescription. When administering a drug via a parenteral routes. ask the client's family how much pain the client normally has d. In trying to determine the client's level of pain. d. chronic). The best strategy to clarify the information is a. the intravenous.

" c." d. Zenobia's chronic cancer pain has recently increased. "I'm worried if we increase your dose that you will stop breathing. 2) The patient will rest quietly when undisturbed. 3) Check the skin frequently for extreme redness." b. which of the following is an appropriate response by the nurse? a. . "If you take more morphine. Which instruction should the nurse include in the teaching plan? 1) Place the cold pack directly on the skin over the ankle. Mr." There is no ceiling on the analgesic effect of opioid narcotics. 4) Keep the cold pack in place for at least 24 hours. it will not change your pain relief. Patients develop a tolerance to the effects. 3) On a scale of 0 to 10. the patient will rate pain as a 3 while in bed or as a 4 during ambulation. In relationship to his long-acting morphine. 2) Apply the cold pack to the ankle for 30 minutes at a time." b. observe the client carefully for changes in behavior or vital signs The nurse should observe the confused client for nonverbal cues to pain. Which expected outcome is best for the patient with a nursing diagnosis of Acute Pain related to movement and secondary to surgical resection of a ruptured spleen and possible inadequate analgesia? 1) The patient will verbalize a reduction in pain after receiving pain medication and repositioning. "I'll call the physician and ask for an increased dose. 3) Check the skin frequently for extreme redness. which often necessitates an increase in the dose. 4) The patient will receive pain medication every 2 hours as prescribed.b. When should the nurse assess pain? 1) Whenever a full set of vital signs is taken 2) During the admission interview 3) Every 4 hours for the first 2 days after surgery 4) Only when the patient complains of pain 1) Whenever a full set of vital signs is taken The nurse is teaching a client who sustained an ankle injury about cold application. "The amount you are taking now is all I can give you. and he asks the home health nurse what can be done. "I'll call the physician and ask for an increased dose.

2) Offer caffeinated beverages to constrict blood vessels in his head. 2) Offer caffeinated beverages to constrict blood vessels in his head. 3) Recalls pain at a later time than when it occurs. 4) Relies on caregiver to provide pain relief without asking. a patient complains of a headache. A patient with a history of mitral valve replacement. Which action can help alleviate the patient's pain? 1) Encourage the client to ambulate to promote flow of spinal fluid. 3) Encourage coughing and deep breathing to increase CSF pressure. What is typically the most reliable indicator of pain? 1) Patient's self-report 2) Past medical history 3) Description by caregiver(s) 4) Behavioral cues 1) Patient's self-report . Which factor contraindicates the use of epidural analgesia in this patient? 1) Anticoagulant therapy 2) Diabetes mellitus 3) Hypertension 4) Embolectomy 1) Anticoagulant therapy After undergoing dural puncture while receiving epidural pain medication.3) On a scale of 0 to 10. 4) Restrict oral fluid intake to prevent excess spinal pressure. 2) Cannot communicate the character of his pain effectively. 2) Cannot communicate the character of his pain effectively. hypertension. His bone cancer has progressed to an advanced stage. and type 2 diabetes mellitus undergoes emergency surgery to remove an embolus in her right leg. Why might the client fail to request pain medication as needed? The client: 1) Experiences less pain than in earlier stages of cancer. An older adult receiving hospice care has dementia as a result of metastasis to the brain. the patient will rate pain as a 3 while in bed or as a 4 during ambulation.

Washing your hands for 1 minute b. the nurse will implement a. contact precautions Contact precautions are used when "contact" with the infected drainage could lead to transmission of the infection. Using the soap provided by the agency b. the nurse acknowledges the client with the highest susceptibility to infection is the individual with: 1) Burns 2) Diabetes 3) Pulmonary emphysema 4) Peripheral vascular disease 1) Burns In preventing and controlling the transmission of infections. In caring for the client. Shaking your hands dry over the sink Shaking your hands will not completely remove the excess moisture. not very hot water d. allowing for the reacquisition of bacteria on the area. Of this afternoon client's admitted. the single most important technique is: 1) Hand hygiene 2) The use of disposable gloves 3) The use of isolation precautions 4) Sterilization of equipment 1) Hand hygiene . droplet precautions c. The client has a draining abdominal wound that has become infected. In a small rural hospital they work with a wide variety of clients. Using warm. contact precautions b. no precautions d. airborne precautions a. Shaking your hands dry over the sink c.Which of the following actions violates a principle that is key to proper hand washing at the bedside? a.

4) Carry the tray to an isolation trash receptacle located in the dirty utility room and dispose of it there. 1) Place the tray in a specially marked trash can inside the patient's room. 2) Place the tray in a special isolation bag held by a second healthcare worker at the patient's door. 3) Return the tray with a note to dietary services so it can be cleaned and reused for the next meal.) 1) While interviewing a client with a productive cough .Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown 1) Washing hands The nurse assists a surgeon with central venous catheter insertion. Which action is necessary to help maintain sterile technique? 1) Closing the patient's door to limit room traffic while preparing the sterile field 2) Using clean procedure gloves to handle sterile equipment 3) Placing the nonsterile syringes containing flush solution on the sterile field 4) Remaining 6 inches away from the sterile field during the procedure 4) Remaining 6 inches away from the sterile field during the procedure How should the nurse dispose of the breakfast tray of a patient who requires airborne isolation? 1) Place the tray in a specially marked trash can inside the patient's room. The nurse is removing personal protective equipment (PPE). Which item should be removed first? 1) Gown 2) Gloves 3) Face shield 4) Hair covering 4) Hair covering In which situation would using standard precautions be adequate? (Select all that apply.

Which of the following statements made by a nurse reflects the best understanding of the role of the bath in the nursing assessment process? 1. 3) Place a surgical mask on the patient and transport him to CT lab. 4) Notify the computed tomography department about precautions prior to transport. the nurse identifies a nursing diagnosis of: 1) Powerlessness 2) Self-care deficit 3) Tissue integrity impairment 4) Knowledge deficit of hygiene practices 2) Self-care deficit The client who is unable to complete bathing and grooming independently has a nursing diagnosis of self-care deficit. How should the nurse proceed? (Select all that apply. 2) Place an N-95 respirator mask on the patient and transport him to the test." . "I work with my ancillary staff to be able to determine what is abnormal. "The skin is easy to observe for abnormalities when you are giving the bath. 4) Notify the computed tomography department about precautions prior to transport.) 1) Question the order because the patient must remain in isolation." 3. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of powerlessness. 3) Place a surgical mask on the patient and transport him to CT lab. "Bath time is an excellent time to get to know your clients and form that nurse-client relationship. A client has severe right-sided weakness and is unable to complete bathing and grooming independently. There is no indication this client has a knowledge deficit of hygiene practices. Based on this observation." 4.2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter 2) While helping a client to perform his own hygiene care 3) While aiding a client to ambulate after surgery 4) While inserting a peripheral intravenous catheter A patient with tuberculosis is scheduled for computed tomography (CT). "I use the time to really look at my clients and determine what's normal and what's not." 2.

circulatory.g." 1) use an electric razor for shaving. "I use the time to really look at my clients and determine what's normal and what's not. some patients with severe bleeding risk may be told not to floss. The patient who sustained a closed head injury may develop increased intracranial pressure during care. Which instruction is most important for the nurse to include on the patient's care plan? "Teach the patient to: 1) use an electric razor for shaving. respiratory) and client behaviors as well. While the nurse is responsible for determining abnormalities. a risk for bleeding takes priority over a risk for dry skin. The patient takes anticoagulants. however. 1) 32-year-old admitted with a closed head injury 2) 76-year-old admitted with septic shock 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago 4) 23-year-old admitted with an exacerbation of asthma with dyspnea on exertion 3) 62-year-old who underwent surgical repair of a bowel obstruction 2 days ago Morning care for the patient who underwent surgical repair of a bowel 2 days ago can be safely delegated to the nursing assistive personnel because the patient should be stable. a registered nurse is required to provide his morning care safely..3. Everyone should be encouraged to floss their teeth daily. even if this patient is an older adult. For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP. he requires the critical thinking skills of a registered nurse to perform his morning care safely. It also provides an opportunity to assess other systems (e." The nurse should instruct the patient prescribed an anticoagulant to use an electric razor instead of a double-edge razor for shaving to prevent the risk of excess bleeding." Take this time to identify abnormalities and initiate appropriate actions to prevent further injury to sensitive tissues. Assume there are no complications other than the conditions stated." 4) floss teeth daily. Older adults should be encouraged to use skin moisturizers and use less soap while bathing to combat excess drying of the skin that occurs as a result of aging. . and base your decision on patient condition. the ancillary staff should be instructed to report any suspicious factors they note. The patient admitted with an exacerbation of asthma who becomes short of breath with activity also requires the critical thinking skills of a registered nurse to detect respiratory compromise quickly. The patient admitted with septic shock may easily become unstable with care." 3) use less soap when bathing. However." 2) apply skin moisturizer. Therefore. Answer 3 is the most thorough statement regarding the question. therefore.

Excoriation is a loss of the superficial layers of the skin caused by the digestive enzymes in feces. C. roll the soiled linens under him. The nurse is making an occupied bed. Then place clean linens on the side nearest you. After placing clean linens and tucking them under the soiled linens. First lower the side rail on your side of the bed. Maceration is the softening of skin from exposure to moisture. and tuck them under soiled linens. C. A client's vital signs at the beginning of the shift are as follows: oral temperature 99. A. roll the soiled linens under him. A. Position patient laterally near far side rail. The nurse documents that he now has excoriated skin on his buttocks. 3) Epidermal layer of skin was rubbed away. is often caused by friction or searing forces that occur when a patient moves in bed. respiratory rate 14 breaths per minute. Position the patient laterally near the side rail farthest from you (that side rail is up). D. the nurse should anticipate the client's heart rate would be how many beats per minute? Why? . a rubbing away of the epidermal layer of the skin. This allows you to maintain good body mechanics while positioning the patient (in step 1). D. heart rate 82 beats per minute. Do this before raising the near side rail so you do not have to reach across the side rail to help the patient roll and turn to his other side. Position the patient laterally near the side rail farthest from you (that side rail is up). Lower the side rail on the side of the bed you are working on.A patient with diarrhea is incontinent of liquid stool. roll the patient over the "hump. Lower the side rail on the side of the bed you are working on. facing you. B. Raise the side rail on the side of the bed you are working on. especially over bony areas. B. roll the patient over the "hump" and position him facing you on the near side of the bed. Raise the side rail on the side of the bed you are working on. Abrasion.2°F (39°C). Four hours later the client's oral temperature is 102. Pressure ulcers are lesions caused by tissue compression and inadequate perfusion that are a result of immobility.3°F (37°C). and blood pressure 118/76. 2) Superficial layers of skin were absent. Based on the temperature change. 2) Superficial layers of skin were absent. After placing clean linens and tucking them under the soiled linens." and position him on his other side. 4) Lesion caused by tissue compression was present. roll the patient over the "hump" and position him facing you on the near side of the bed. Arrange the following steps in the order the nurse should perform them. Which finding by the nurse led to this documentation? 1) Skin was softened from prolonged exposure to moisture. Next. and roll soiled linens under him.

ANS: 111 BPM." 3) "Your vital signs are stable. BP decreases.9 °F * (10 BPM / 1 °F) = ∆ 29 BPM + 82 BPM = 111 BPM The nurse assesses the following changes in a client's vital signs. that means I'm cured. Hypovolemia / shock." 3) "Your vital signs are stable." The nurse's best response would be: 1) "Your vital signs confirm that your infection is resolved. but there are other things to assess.8°F to obtain a rectal equivalent. 3) Lived at a high altitude and then moved to sea level. 2) Had surgery and lost a unit of blood intraoperatively.3 °F = 2." 4) "We still need to keep monitoring your temperature for a while. how do you feel?" 2) "I'll let your health care provider know so you can be discharged." A client's axillary temperature is 100. but there are other things to assess. What should the nurse do to obtain a good estimate of the core temperature? 1) Add 1°F to 100. 2) Had surgery and lost a unit of blood intraoperatively. 2) Add 2°F to 100.8°F to obtain an oral equivalent. and that axillary temperatures do not reflect core temperature. 4) Been exposed to the cold and is now hypothermic.99.2 °F . ∆ 1 °F = 10 BPM 102. Which client situation should be reported to the primary care provider? 1) Decreased blood pressure (BP) after standing up 2) Decreased temperature after a period of diaphoresis 3) Increased heart rate after walking down the hall 4) Increased respiratory rate when the heart rate increases 1) Decreased blood pressure (BP) after standing up Orthostatic Hypotension Which one of the following clients would probably have a higher than normal respiratory rate? A client who has: 1) Had surgery and is receiving a narcotic analgesic. The nurse realizes this is outside normal range for this client. . respiratory rate increases A client who has been hospitalized for an infection states. "The nursing assistant told me my vital signs are all within normal limits.8°F.

and blood pressure 120/66. High-pitched. c. 3) Blood pressure increases.2°F (38. Comparing the changes in vital signs as a person ages. 4) Take the temperature by a different route. 4) Obtain a tympanic membrane reading. continuous musical sound 3) High-pitched popping or low-pitched bubbling sounds 4) Low-pitched continuous sounds that clear with coughing 5) Labored. and blood pressure (BP) 118/60. respiratory rate 16. 3) Ask the client if he is feeling chilled. 1) High-pitched sound heard on inspiration in infants 2) High-pitched. continuous musical sound: Wheezes . High-pitched sound heard on inspiration in infants: Stridor 2. heart rate and respiratory rate decline.3) Obtain a rectal temperature reading. heart rate 76. Rhonchi c.7°C). 4) Men have higher blood pressure than women until after menopause. heart rate and respiratory rate decline. which statement(s) is/are correct? (Select all that apply. Crackles b. 2) Respiratory rate remains fairly stable throughout a person's life. Which should the nurse's first intervention be at this time? 1) Ask the client if he has had a warm drink in the last 30 minutes. Stertor 1. the vital signs are as follows: oral temperature 103. Match the breath sound with the appropriate description.5°C). d. heart rate 76 beats/minute.) 1) Blood pressure decreases less than heart rate and respiratory rate. Wheezes e. 3) Blood pressure increases. respiratory rate 14 breaths/minute. Stridor d. Four hours later. 3) Obtain a rectal temperature reading. At last measurement. 1) Ask the client if he has had a warm drink in the last 30 minutes. 2) Notify the primary care provider of the client's temperature. 4) Men have higher blood pressure than women until after menopause. the client's vital signs were as follows: oral temperature 98°F (36. snoring sound a.

An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimer's disease. According to the falls assessment tool. the greatest indicator of risk is a history of falls. Assessing when the client experiences severe pain G. . Impaired judgment 3. Assessing immediately after eating E. Confusion 2. e. sensory deficit is the fifth leading risk factor for falls. High-pitched popping or low-pitched bubbling sounds: Crackles 4. Blood pressure cuff too narrow: False Increase B. b. the second leading risk factor for falls is confusion. impaired judgment is the fourth leading risk factor for falls. In using a falls assessment tool. Low-pitched continuous sounds that clear with coughing: Rhonchi 5. Assessing when the client is in mild-to-moderate pain: Increase F. Sensory deficits 4. Labored. Assessing when the client experiences severe pain: Increase. History of falls 4. Assessing immediately after smoking D. According to the falls assessment tool. Blood pressure cuff too wide: False Decrease C. Blood pressure cuff too wide C. a. snoring sound: Stertor How do the following impact blood pressure? A.3. According to the falls assessment tool. Assessing immediately after eating: Increase E. Assessing immediately after exercise: Immediately upon stopping it is increased. the nurse knows that the greatest indicator of risk is: 1. Blood pressure cuff too narrow B. Eventually chronic pain modulates to decrease. Assessing immediately after exercise How do the following impact blood pressure? A. Assessing immediately after smoking: Increase D. Assessing when the client is in mild-to-moderate pain F. G. History of falls According to the falls assessment tool. but within 5 minutes decreases.

Accidental injury 3. Which action by the nurse is best? 1) Continue to monitor the pump to see if the crack worsens. 4) Call the nearest poison control center immediately. 2) Place the pump back on the utility room shelf. Contagious diseases 4. Label it and take it out of service . Evaluate the policy to determine if Clinical engineering or biomed needs to be contacted. 4) Clearly label the pump and send it for repair. Physiological changes associated with aging place the older adult especially at risk for which nursing diagnosis? 1) Risk for Falls 2) Risk for Ineffective Airway Clearance (choking) 3) Risk for Poisoning 4) Risk for Suffocation (drowning) 1) Risk for Falls Risk for Falls due to loss of muscle strength and joint mobility The nurse notes that the electrical cord on an IV infusion pump is cracked. Should poison come in contact with their child's clothing and skin. 3) Wash the contaminated area with soap and water and rinse. Accidental injury Injuries are the leading cause of death in children older than 1 year of age and cause more deaths and disabilities than do all diseases combined. which action should the nurse instruct the mothers to take first? 1) Remove the contaminated clothing immediately. 4) Clearly label the pump and send it for repair. 3) A small crack poses no danger so continue using the pump. Physical abuse 2. A nurse is teaching a group of mothers about first aid.all organizations have labels which indicate the equipment is not working.The nurse recognizes that the leading cause of death for the otherwise healthy 1year-old is: 1. Stranger abduction 2. . 2) Flood the contaminated area with lukewarm water.

B. B.irrigate it and contact poison control. D. keep the door open. cursing.A. contain.E. alarm. and exstinquish or evacuate . C. You should never enter the room alone if someone is threatening. Rank the following actions in the order they should be performed by the nurse.then wash with water . . Activate the fire alarm. R. Which is the most commonly reported "incident" in hospitals? 1) Equipment malfunction 2) Patient falls 3) Laboratory specimen errors 4) Treatment delays 2) Patient falls Patient falls.rescue. Close all doors and windows. Put out the fire using the proper extinguisher. Asking about weapons and setting limits may escalate the situation. keep the door open.1) Remove the contaminated clothing immediately. 3) Stay between the patient and the door. Move the patient out of the room. the nurse must be calm and reassuring. Activate the fire alarm. Which action(s) by the nurse are advisable? 1) Reassure the patient by entering the room alone. and waving his arms when the nurse comes to the treatment cubicle. 2) Ask the patient if he is carrying any weapons. usually in an attempt to go to the bathroom A patient in the emergency department is angry. Move the patient out of the room. Make sure you do not get trapped. yelling. When the nurse walks into the patient's room. A." 3) Stay between the patient and the door.C. D. Put out the fire using the proper extinguisher. Remove contaminated clothing immediately . A. C. Close all doors and windows. 4) Make eye contact while stating firmly "I will not tolerate cursing and threats. she notices fire coming from the patient's trash can.

all of the above Mrs. 3) Give the baby sterile water until the mother's milk comes in. "It sounds like you are really upset. "It sounds like you are really upset. Risk for Ineffective Therapeutic Regimen d. the client has had an excessive intake of red meat b." c. "I'm sure you will get used to taking care of it eventually. Diarrhea b. When changing a diaper. and the nurse would gather further assessment data related to the client's bowel pattern. What should the nurse do? 1) Notify the physician. Addie is 70 years old. . The client states. I'll never be able to touch this thing. Should I call the chaplain for you?" c." The nurse's best response is a. The nurse is assisting the client in caring for her ostomy. the client takes high doses of vitamin C d. the nurse observes that a 2-day-old infant has had a green black. this is so disgusting. 2) Do nothing. this is normal." b." This statement reflects the principles of therapeutic communication. the female client is menstruating c. all of the above d. "Yes. the patient states. Perceived Constipation Daily laxative use by the patient might suggest that she perceives she is constipated. "I've taken a tablespoon of Milk of Magnesia every day for 3 years." Which nursing diagnosis is most appropriate for the nurse to use in her plan of care? a. There is not enough data to infer actual constipation. so I'll take care of it for you today. tarry stool. "Oh. Perceived Constipation d." d.The nurse knows that the results of a fecal occult blood test can be inaccurate if a. it is pretty messy. Constipation c. 4) Apply a skin barrier cream to the buttocks to prevent irritation. "You sound very angry. While the nurse is gathering admission assessment data.

The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)? 1) 2 to 4 glasses a day 2) 4 to 6 glasses a day 3) 6 to 8 glasses a day 4) 8 to 10 glasses a day 3) 6 to 8 glasses a day A minimum of 6 to 8 glasses of fluid should be consumed each day to promote healthy bowel function. as well as milk. such as bread. thereby relieving constipation. Meconium stools are more irritating to the buttocks than other stools because they are so sticky and the skin usually must be rubbed to cleanse it.2) Do nothing. 4) Test the patient's stool using a fecal occult test. Stools transition to a yellow green color over the next few days. Low-fiber foods. 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. A nurse is teaching wellness to a women's group. 4) Lean meats. the appearance of stools depends upon the feedings the newborn receives. The healthcare team suspects that a patient has an intestinal infection. tarry stools known as meconium. The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation. cheese. Sterile water does nothing to alter this progression. After that. During the first few days of life. and other simple carbohydrates. pasta. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese. . a term newborn passes green black. 3) Administer a laxative to prepare the patient for a colonoscopy. 3) Fruits and vegetables. and lean meat. this is normal. 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool. slow peristalsis. 2) Bread and pasta. 3) Fruits and vegetables.

the nurse should place a waterproof pad under the patient to protect the bed linens. pears. parsley. External devices cannot be used effectively when the patient has Impaired Skin Integrity because they will not seal tightly. A patient with severe hemorrhoids is incontinent of liquid stool. A patient with a colostomy complains to the nurse. agitated. An abdominal flat plate and a fecal occult blood test cannot confirm the diagnosis. White rice and toast (also bananas and applesauce) help control diarrhea. or active in bed because the device may be dislodged. melons. for more than 30 consecutive days of use. 4) Place a waterproof pad under the patient's buttocks. Even with absorbent products or an external collection device. Which of the following interventions is contraindicated? 1) Apply an indwelling fecal drainage device. causing skin breakdown.To confirm the diagnosis of an infection. "I am having really bad odors coming from my pouch. rectal. and fish are known to cause odor. or anal surgery or injury. Asparagus. cranberry juice. 1) 2 inches 2) 3 inches . External devices are not typically used for patients who are ambulatory. the nurse should collect a liquid stool specimen that contains 20 to 30 ml of liquid stool. and dried fruit are high-fiber foods that might cause blockage in a patient with an ostomy. The nurse must administer an enema to an adult patient with constipation. Colonoscopy is not necessary to obtain a specimen to confirm the diagnosis. peas. 3) Place an incontinence garment on the patient. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Choose all that apply." To help control odor. An indwelling fecal drainage device is contraindicated for children. Tomatoes. or stricture or stenosis. and buttermilk may help control odor. Absorbent products are not contraindicated for this patient unless Impaired Skin Integrity occurs. and for patients who have severe hemorrhoids. 2) Apply an external fecal collection device. rectal or anal tumors. which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley 4) Yogurt and parsley Yogurt. recent bowel. 1) Apply an indwelling fecal drainage device.

A. Encourage the patient to hold the solution for 3 to 15 minutes. II These are characteristics of a person in Stage II of NREM sleep. list the following steps in the order in which they should be performed. Light sleep and slowing brain and body processes are associated with which stage of NREM sleep? a. You must lubricate the tip before inserting the tubing. Encourage the patient to hold the solution for 3 to 15 minutes. the nurse should insert the tubing about 3 to 4 inches into the patient's rectum. E.3) 4 inches 4) 5 inches 2) 3 inches 3) 4 inches When administering an enema. depending on the type of enema. after the procedure is finished. II c. C. Five inches is too much. . with 1 being the first step to perform. D. B. IV b. Assess the patient for cramping. Insert the tubing about 3 to 4 inches into the rectum. Insert the tubing about 3 to 4 inches into the rectum. E. B. C. I b. Only after the solution is instilled would you ask the patient to hold the solution. Raise the container to the correct height and instill the solution at a slow rate. A. F. Two inches would not be effective because it would not place the fluid high enough in the rectum. D. Label the steps from 1 to 6. Document the results of the procedure. F. III d. The last action is to document the results of the procedure. Raise the container to the correct height and instill the solution at a slow rate. Lubricate the tip of the enema tubing generously. Assess the patient for cramping. When administering an enema. Lubricate the tip of the enema tubing generously. Document the results of the procedure. You would then begin instilling the solution before assessing for cramping that the instillation might produce. depending on the type of enema.

The client states. The hospital routine has disrupted this normal pattern. For which sleep disorder would the nurse most likely need to include safety measures in the client's plan of care? a. Hypersomnia c. Snoring b." 3) "There has been a disruption in your circadian rhythm. What can I do to help you sleep better at night?" 4) "I will notify the doctor and ask him to prescribe a hypnotic medication to help you sleep. so it will be important for you to walk in the hall more often. Which of the following factors has the greatest positive effect on sleep quality? 1) Sleeping hours in synchrony with the person's circadian rhythm 2) Sleeping in a quiet environment 3) Spending additional time in stage IV of the sleep cycle 4) Napping on and off during the daytime 1) Sleeping hours in synchrony with the person's circadian rhythm Which is a major factor regulating sleep? 1) Electrical impulses transmitted to the cerebellum 2) Level of sympathetic nervous system stimulation 3) Amount of sleep a person has become accustomed 4) Amount of light received through the eyes .The nurse is caring for a hospitalized client who normally works the night shift at his job. Narcolepsy d. I have been napping all day and can't seem to think clearly." 3) "There has been a disruption in your circadian rhythm. This could put the person at risk for harm depending on the activity in which he is engaged. "I don't know what is wrong with me. but that will resolve in a few days. What can I do to help you sleep better at night?" The data suggests that the patient is used to being awake at night and sleeping during the day. Narcolepsy Narcolepsy can occur suddenly during the daytime hours when a person is involved in any type of activity. Enuresis c." 2) "You are experiencing hypersomnia." The nurse's best response is 1) "You are sleep deprived.

She has recently quit smoking. alpha waves 2) NREM. Which patient teaching would be most therapeutic for someone with sleep disturbance? 1) Give yourself at least 60 minutes to fall asleep. From what stage of sleep are people typically most difficult to arouse? 1) NREM. delta waves 4) REM 3) NREM. is trying to eat healthier foods. 1) Increased exercise. A review of symptoms reveals no physical problems and she takes no medication. Identify the symptoms you would expect the client to exhibit. 2) Avoid eating carbohydrates before going to sleep. sleep spindles 3) NREM. or environment. 4) Environmental changes. 2) Nicotine withdrawal. stress level. 3) Caffeine intake. 4) Do not go to bed feeling upset about a conflict. the most appropriate nursing diagnosis would be Disturbed Sleep Pattern related to: 1) Increased exercise. 3) Catch up on sleep by napping or sleeping in when possible. even though she is very tired. Based on this information. Choose all that apply. delta waves The patient is diagnosed with obstructive sleep apnea. 4) Do not go to bed feeling upset about a conflict. and has started a moderate-intensity exercise program. Her sleep history reveals no changes in bedtime routine. 1) Bruxism 2) Enuresis 3) Daytime fatigue 4) Snoring 3) Daytime fatigue 4) Snoring .3) Amount of sleep a person has become accustomed to A patient tells you that she has trouble falling asleep at night.

b. The NAP inadvertently empties one specimen into the toilet instead of the collection "hat. While performing a physical assessment. Dispose of the urine already collected and begin an entirely new 24-hour collection. Which statement by the instructor is best? "You should: . Which nurse's statement. Begin filling a new collection container and take both containers to the lab at the end of the collection period. I wet myself. c. the student nurse tells her instructor that she cannot palpate her patient's bladder. is incorrect? I am inserting this catheter to a. d. obtain a sterile urine specimen d. unconscious incontinence a. Make a note to the lab to inform them that one specimen was missed during the collection. d. Dispose of the urine already collected and begin an entirely new 24-hour collection. It seems like every time I laugh hard." The nurse should a. "I'm so distressed. Four nurses are inserting catheters in their clients. the results of the lab test will be inaccurate and the collection must be restarted. related to this intervention." The nurse knows that this condition is known as a. stress incontinence b. treat your problem of leaking urine Insertion of a urinary catheter is not a "treatment" for incontinence. functional incontinence d.The female client states to the nurse. Once one specimen is "missed" during a 24-hour urine collection. stress incontinence Stress incontinence results from increased pressure within the abdominal cavity. urge incontinence c. Continue with the collection of urine until the 24-hour time period is finished. treat your problem of leaking urine c. "Never event" by CMS CAUTI There is a 24-hour urine collection in process for a client. measure the amount of urine left after you emptied your bladder b. empty your bladder prior to your procedure b.

" 2) Palpate the patient's bladder only when it is distended by urine. The provider may hold the patient's scheduled dose of diuretic if he determines that the patient is experiencing deficient fluid volume. Patients who undergo abdominal surgery commonly require increased infusions of IV fluid during the immediate postoperative period. 3) Notify the provider about the patient's oliguria. It is not difficult to palpate the bladder when distended. The nurse should document her finding. the nurse should notify the provider when the patient shows diminished urine output (oliguria)." The bladder is not palpable unless it is distended by urine. The nurse cannot provide increased IV fluids without a provider's order. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. Which action should the nurse take? 1) Do nothing. such as when the patient has fluid overload (too much IV fluid) or when the kidneys fail to concentrate urine. The kidneys typically produce 60 ml of urine per hour.025. The nurse should not administer any medications before the scheduled time without a prescription. for example. Specific gravity greater than 1. Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1. it takes practice but you will locate it. 4) Administer the patient's routine diuretic dose early. 50 mL in two hours is not normal output. It is not necessary to notify the nurse assigned to the patient.030 4) 1." 2) Palpate the patient's bladder only when it is distended by urine." 3) Document this abnormal finding on the patient's chart. . this is normal postoperative urine output." 4) Immediately notify the nurse assigned to your patient. 3) Notify the provider about the patient's oliguria.010 indicates fluid volume excess. as a result of blood loss or dehydration. 2) Increase the infusion rate of the patient's IV fluids.002 2) 1.010 to 1.025 4) 1.030 Normal urine specific gravity ranges from 1. His urine output for the past 2 hours totals 50 mL.1) Try to palpate it again.025 is a sign of deficient fluid volume that occurs. but it is not an abnormal finding. Specific gravity less than 1.010 3) 1. Therefore.

but not when obtaining a clean catch urine specimen. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowler's . 2) Pour the urine into a graduated container." 3) "I will need to lie still while you put in a urinary catheter to obtain the specimen. clarity. the nurse should put on gloves and have the patient void directly into the bedpan. The nurse instructs a woman about providing a clean catch urine specimen. A 24-hour urine collection may be necessary to evaluate some disorders but a clean catch specimen is a one-time collection.The nurse measures the urine output of a patient who requires a bedpan to void." To obtain a clean catch urine specimen." 2) "I will cleanse my genital area from front to back before I collect the specimen midstream. She should observe the urine for color. A urinary catheter is required for a sterile urine specimen. the nurse should instruct the patient to cleanse the genital area from front to back and collect the specimen midstream." 4) "I will collect my urine each time I urinate for the next 24 hours. and read the amount at eye level. she should record the amount of urine voided on the patient's intake and output record." The nurse should have the ambulatory patient void into a "hat" (container for collecting the urine of an ambulatory patient) when monitoring urinary output. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. and odor. First. This follows the principle of going from "clean" to "dirty. 3) Read the volume with the bedpan on a flat surface at eye level. not a clean catch specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) "I will be sure to urinate into the 'hat' you placed on the toilet seat. 4) Observe color and clarity of the urine in the bedpan. Finally. Then. if no specimen is required. Next. she should pour the urine into a graduated container. place the measuring device on a flat surface. she should discard the urine in the toilet and clean the container and bedpan. 1) Have the patient void directly into the bedpan." 2) "I will cleanse my genital area from front to back before I collect the specimen midstream.

the nurse should help the patient to a side-lying position. However. chest x-ray b. a. Suddenly the patient's urine output drops to almost nothing. pulse oximeter reading c. true b. ABG d. If no blockage is detected.3) Dorsal recumbent The nurse should have the patient lie supine with knees flexed. Which diagnostic test/exam would best measure a client's level of hypoxemia? a. the nurse should not change a catheter in the immediate postoperative period without consulting with the surgeon. the nurse should notify the surgeon. Prone position is sometimes used to improve oxygenation in patients with adult respiratory distress syndrome. If the patient is unable to assume this position. The surgeon orders hourly urine output measurement for a patient after abdominal surgery. Modified Trendelenburg position is used for central venous catheter insertion. 2) Replace the patient's indwelling urinary catheter. peak expiratory flow rate c. false . The surgeon may request that the catheter be changed if irrigation does not help or if the tubing is not kinked. If the patient's urinary output suddenly ceases. the nurse should irrigate the urinary catheter to assess whether the catheter is blocked. crowing inspiratory sound that occurs due to partial obstruction of the larynx. The term "Kussmaul" refers to a high-pitched. Arterial blood gas sampling is the most direct way in which the level of oxygen in the blood can be measured. What should the nurse do first? 1) Irrigate the catheter with 30 ml of sterile solution. harsh. 4) Notify the surgeon immediately. 3) Infuse 500 ml of normal saline solution IV over 1 hour. feet flat on the bed (dorsal recumbent position). ABG The term "hypoxemia" means low blood oxygen level. 1) Irrigate the catheter with 30 ml of sterile solution. The patient's urine output has been greater than 60 ml/hour for the past 2 hours. Semi-Fowler's position is used to prevent aspiration in those receiving enteral feedings. The surgeon may prescribe an IV fluid bolus if the patient is suspected to have a deficient fluid volume.

Immediately cover the wound with sterile towels soaked in normal saline and call the surgeon. sterile 4 x 4 over the incision and monitor the drainage.b. decreased sensation d. The nurse's best action is to a. "Look. sterile 4 x 4 over the incision and monitor the drainage. my incision is popping open where they did my hip surgery!" The nurse notes that the wound edges have separated 1 cm at the center and there is straw-colored fluid leaking from one end. b. Place a clean. Impaired tissue integrity a. Wrap an ace bandage firmly around the area and have the client maintain bedrest. Anxiety related to suctioning c. decreased sensation Decreased sensation would greatly increase the risk for injury with a tear or break in the skin. dehydration c. Notify the surgeon STAT. Risk for ineffective airway clearance While other diagnoses may be applicable. Place a clean. c. Of the following factors. maintaining a patent airway by tending to excessive secretions is a priority. . the medication digoxin b. false The term for this sound of respiratory distress is "stridor. d. moisture c. Even if there were a large separation. b. there are no "internal viscera" to protrude. A 1 cm separation of wound edges only in the center of a surgical incision on the hip is too small to truly be termed dehiscence. the nurse would give priority to the nursing diagnosis of a. This could lead to a delay in seeking treatment due to lack of awareness. Social isolation related to altered body image d. which would put a client at greatest risk for impaired skin integrity? a. Risk for ineffective airway clearance b. The client calls the nurse to the room and states." In caring for a client with a tracheostomy.

avoid arching shoulders forward when sitting Arching shoulders forward when sitting alters the curvature of the spine and contributes to poor body alignment. Ongoing assessment d. keep your knees locked when standing upright d. Special needs assessment c. When gathering admission assessment data the nurse obtains a weight of 200 pounds. Initial assessment c. Explain to the client how weight gain occurs b. it is important to a. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift. The client states. the nurse will give priority to a. Focused assessment b. having the client use his incentive spirometer q2hrs d. Check the calibration and re-weigh the client c. Document the weight as 200 pounds d. administering the PRN medication for sleep c. encouraging a diet high in fiber and extra fluids b. massaging the client's legs every hour . keep your stomach muscles relaxed to prevent back spasms b. "I've never weighed that much!" The nurse should a. To maintain proper posture. This would be considered a/an a. Validating data often includes ensuring that equipment is functioning properly first. Instruct the UAP to re-weigh the client in 2 hours b. Ongoing assessment This type of assessment can be completed at any time after the initial assessment.The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. Check the calibration and re-weigh the client It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Of the following interventions for the client who is immobile. sleep on the softest mattress possible b. avoid arching shoulders forward when sitting c.

Use of the statements "Tell me more about. Introduce himself as the RN to give credibility to his message d.. The interpretation of the message by the receiver The nurse is teaching the client about his upcoming procedure and the client is very stressed. A cane should be used by the client to support the weakest side of the body." or "I see" encourage clients to continue talking and expressing themselves. Encouraging elaboration d. "decoding" is a. c. The method by which the message is given d. It would be most important for the nurse to a. Focusing d. Each crutch-walking "gait" begins with the client in the tripod position. a. Summarizing b. During the communication process.c.a priority need. The interpretation of the message by the receiver c. Open-ended questions c. which improves oxygenation . having the client use his incentive spirometer q2hrs Use of the incentive spirometer helps to prevent atelectasis. Encouraging elaboration . b. A transfer belt should be placed around the client's chest for maximum " lift.. Speak to the client when family members are there so they can teach the client b. Each crutch-walking "gait" begins with the client in the The tripod position is the basic crutch standing position from which the client then moves forward. Use humor first to decrease the client's stress level b. Identify the true statement about devices used when assisting clients to ambulate. The selection of words by the sender b. The way in which feedback is interpreted b. This is called: a. *d. The client should stand a foot back from the back legs of a walker. Determine if the teaching should take place at a different time Clients who are stressed may be unable to listen fully and will not receive/understand the intended message." d. Determine if the teaching should take place at a different time c.

This is not an example of an error in denotative meaning. Sits facing the client 2. discussing follow-up dietary needs would seem irrelevant. The client is less likely to be able to pay attention and comprehend instruction when in pain. For active listening. This posture conveys that the nurse is involved and interested in the interaction. Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in: 1. Pacing has to do with the speed of conversation. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture suggests that the nurse is "open" to what the client says. This is not an example of an error in pacing. . Keeps the arms and legs crossed 3. the nurse should establish and maintain intermittent eye contact. the nurse should lean toward the client. and immediately after surgery. Avoids eye contact as much as is physically possible 1. Leans back in the chair away from the client 4. For active listening. Sits facing the client Active listening means to be attentive to what the client is saying both verbally and nonverbally. This conveys the nurse's involvement in and willingness to listen to what the client is saying. Pacing 2. the arms and legs should be uncrossed. Denotative meaning is when a single word can have several meanings. Intonation is the tone of voice used. This posture gives the message that the nurse is there to listen and is interested in what the client is saying.Communication involves both active listening and body language working together. This is not an example of an error in intonation. Timing and relevance 4. Denotative meaning 3. For active listening. Intonation 3. The nurse actively listens to the client and: 1. Timing and relevance Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing and relevance.

Parkinson's disease type symptoms A patient has taken an overdose of aspirin. The patient asks how long to RBC's last in my body? The correct response is. What microorganism has noted been linked to meningitis in humans? The life span of RBC is 120 days. Start prophylactic AZT treatment A second year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. "My doctor recommended I increase my intake of folic acid. A nurse is administering blood to a patient who has a low hemoglobin count. What is the most important action that nursing student should take? IgG A 34 year old female has recently been diagnosed with an autoimmune disease. What clinical sign would most likely be present? Streptokinase A patient has recently experienced a (MI) within the last 4 hours. What medication would most like be administered? Green vegetables and liver A patient asks a nurse. Which is the only immunoglobulin that will provide protection to the fetus in the womb? . difficile A nurse is putting together a presentation on meningitis.RH negative. She has also recently discovered that she is pregnant. What should a nurse most closely monitor for during acute management of this patient? Weight gain A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. RH positive Rho gam is most often used to treat____ mothers that have a ____ infant. What type of foods contain folic acids?" Cl.

Bright sunshine may be irritating because of disease-related ophthalmopathy. overdose. chest pain. and a barking cough c) Pulmonary congestion. and barking cough that worsens at night are suggestive of croup." c) "A good blood level of the drug means the drug concentration has stabilized." d) "Eating too much watermelon will affect my lithium level. and fever along with nasal flaring. dyspnea. and crackles indicate pneumococcal pneumonia. and symptoms of lithium toxicity. severe sore throat. Pulmonary congestion. and inspiratory stridor b) Low-grade fever. hoarseness. Which clinical manifestations should the nurse expect to assess? a) Severe sore throat. A sore throat. drooling. I'll increase my dose of lithium. and general malaise point to viral pharyngitis. and inspiratory stridor Reason: A child with acute epiglottiditis appears acutely ill and clinical manifestations may include drooling (because of difficulty swallowing). Clients taking lithium don't need to limit their sodium intake. Reason: Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. c) Promote interactions with one friend instead of groups. fever. a fever. stridor. I'll increase my dose of lithium. stridor. Sweating is common and bathing should be encouraged." b) "When my moods fluctuate. Because of their high metabolic rate. b) Encourage plenty of outdoor activities. age 3. d) Limit bathing to prevent skin irritation. and severe inspiratory stridor.A child. A nurse is instructing a client with bipolar disorder on proper use of lithium carbonate (Eskalith). The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a) Keep their home warmer than usual. c) CORRECT ANSWER Promote interactions with one friend instead of groups. and renal failure. A low-sodium diet causes . and general malaise a) CORRECT ANSWER Severe sore throat." Reason: A client who states that he'll increase his dose of lithium if his mood fluctuates requires additional teaching because increasing the dose of lithium without evaluating the client's laboratory values can cause serious health problems." b) CORRECT ANSWER "When my moods fluctuate. is brought to the emergency department in respiratory distress caused by acute epiglottiditis. retractions. and a fever d) Sore throat. children with hyperthyroidism complain of being too warm. drooling. productive cough. Which client statement indicates that additional teaching is required? a) "I can still eat my favorite salty foods. decreased breath sounds. a productive cough. the drug's adverse effects. such as lithium toxicity. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. A low-grade fever. a high temperature.

This complication is called: a) a first-degree laceration. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. b) CORRECT ANSWER resolve the immediate problem. it isn't a major goal. "There are poison crystals hidden in the showerhead. The client demonstrates effective teaching by stating his lithium levels will be affected by foods that have a diuretic effect. A client has refused to take a shower since being admitted 4 days earlier. Providing support and safety are necessary interventions while working toward accomplishing the goal. and cranberry juice. Reason: Birth may extend an episiotomy incision to the anal sphincter (a third-degree laceration) or the anal canal (a fourth-degree laceration). They'll kill me if I take a shower. Reason: During a period of crisis. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him. A therapeutic lithium blood level indicates that the drug concentration has stabilized. cantaloupe. providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time.lithium retention. Because these fears are real to the client. c) CORRECT ANSWER a third-degree laceration. Birth extends the incision into the anal sphincter. Documentation is necessary for maintaining accurate records of treatment. d) provide documentation of events. the nurse can arrange to meet the client's hygiene needs in another way. such as watermelon. b) resolve the immediate problem. The client's anxiety will decrease after the immediate problem is resolved. the major goal is to resolve the immediate problem. The major goal of therapy in crisis intervention is to: a) withdraw from the stress. c) decrease anxiety. b) a second-degree laceration. d) a fourth-degree laceration. grapefruit juice." Which nursing action is most appropriate? a) Dismantling the showerhead and showing the client that there is nothing in it b) Explaining that other clients are complaining about the client's body odor c) Asking a security officer to assist in giving the client a shower d) Accepting these fears and allowing the client to take a sponge bath d) CORRECT ANSWER Accepting these fears and allowing the client to take a sponge bath Reason: By acknowledging the client's fears. . with hopes of getting the individual to the level of functioning that existed before the crisis or to a higher level of functioning. c) a third-degree laceration. He tells a nurse. A first-degree laceration involves the fourchette. A client has an episiotomy to widen her birth canal.

c) Striae that are silver in color. Which nursing diagnosis is most appropriate for the client? a) Ineffective denial related to a socially unacceptable infection b) Impaired parenting related to the neonate's transfer to the intensive care unit c) Deficient fluid volume related to severe edema d) Fear related to removal and loss of the neonate by statute b) CORRECT ANSWER Impaired parenting related to the neonate's transfer to the intensive care unit Reason: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit. Reason: By 4 to 6 weeks postpartum. is a problem associated with a uterus that is larger than expected at this time. and breasts that are soft without evidence of milk production (in a bottle-feeding mother). b) White. striae that are beginning to fade to silver.perineal skin. the client may have a nursing diagnosis of Impaired parenting related to the neonate's transfer to the neonatal intensive care unit. b) bradycardia. . thick vaginal discharge. thick vaginal discharge. a) CORRECT ANSWER Firm fundus at the symphysis. generalized edema. The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is: a) peripheral acrocyanosis. (Another pertinent nursing diagnosis may be Compromised family coping related to lack of opportunity for bonding. The mother is bottle feeding her baby. A second-degree laceration extends to the fasciae and muscle of the perineal body A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe. d) Soft breasts without milk. Subinvolution. Normal expectations include a white. caused by infection or retained placental fragments. c) lethargy. Rh isoimmunization doesn't lead to loss of the neonate by statute. Which client finding indicates a problem at this time? a) Firm fundus at the symphysis. the fundus should be deep in the pelvis and the size of a nonpregnant uterus. The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. This condition causes an excess fluid volume (not deficient) related to cardiac problems. d) jaundice. The neonate is immediately transferred to the neonatal intensive care unit. and vaginal mucous membranes.) Rh isoimmunization isn't a socially unacceptable infection.

" c) "We will refer you to a sex therapist because you will probably notice erectile dysfunction. you'll likely not notice much change in your sexual performance. Before discharge." d) "Take digoxin with meals. Jaundice isn't a sign of hypoglycemia. Peripheral acrocyanosis is normal in the neonate because of immature capillary function." c) "Call the physician if your pulse drops below 80 beats/minute." Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy." b) CORRECT ANSWER "Call the physician if your heart rate is above 90 beats/minute." Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. and in this crucial stage of life. you'll likely not notice much change in your sexual performance. which instruction should a nurse give to a client receiving digoxin (Lanoxin)? a) "Take an extra dose of digoxin if you miss one dose. To prevent toxicity. the loss of a gonad and testosterone may result in decreased libido and sterility." b) "Call the physician if your heart rate is above 90 beats/minute. The client shouldn't take digoxin with meals. A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. Tachycardia — not bradycardia — is seen with hypoglycemia." b) "You could have early ejaculation with this type of surgery. . Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy? a) "Most impotence resolves in a couple of months.c) CORRECT ANSWER lethargy. Remember. which is a normal pulse rate and doesn't warrant action. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. the population most affected by testicular cancer is generally young men ages 15 to 34. doing so slows the absorption rate." d) "Because your surgery does not involve other organs or tissues. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. sexual anxieties may be a large concern. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute." d) CORRECT ANSWER "Because your surgery does not involve other organs or tissues.

Avoid driving a motor vehicle until stabilized on the drug. what is most important for the nurse to tell the client? a. This drug may be used in maintenance treatment for asthma. Directly spray away from the nasal septum and gently sniff. A client tells the nurse that he has started to take an OTC antihistamine. Dry nasal mucosa Beclomethasone (Beconase) has been prescribed for a client with allergic rhinitis. Avoid driving a motor vehicle until stabilized on the drug. To compete with histamine for receptor sites. d. In teaching him about side effects. Acute pharyngitis. thus producing vascular constriction of capillaries in nasal mucosa d. Acute pharyngitis. To loosen bronchial secretions so they can be eliminated by coughing A client has been prescribed guaifenesin (Robitussin). To treat allergic rhinitis and prevent motion sickness b. The nurse realizes this condition is called what? a. To stimulate alpha-adrenergic receptors. What should the nurse teach the client? a. b. b. b. Nightmares and nervousness are more likely in an adult. To loosen bronchial secretions so they can be eliminated by coughing c. d. thus preventing a histamine response d. Take this drug at bedtime as a sleep aid. Limit the drug to 5 days of use to prevent rebound nasal congestion. Acute rhinorrhea. Acute sinusitis. c. c. d. The client complains of a sore throat and has been told it is due to beta-hemolytic streptococcal infection. b. The nurse realizes that the purpose of the drug is to accomplish what? a. d. Limit the drug to 5 days of use to prevent rebound nasal congestion. Acute rhinitis. c. diphenhydramine. c. Limit use to 1 to 2 puffs/sprays 4 to 6 times per day to avoid rebound congestion. Do not to take this drug at bedtime to avoid insomnia.b. The nurse teaches the client that which is the most common side effect from continuous use? . A client is prescribed the decongestant oxymetazoline (Afrin) nasal spray.

Take medication with food to decrease gastric distress. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug. or ice chips for temporary relief of dry mouth. Rhinorrhea c.) a. "You are correct." d. "Take this medication on an empty stomach. Dizziness b." d." b. gum. Take sugarless candy. What is the best information for the nurse to give this client? a." c. Which are topics to include? (Select all that apply." c. . "Do not take this medication for more than 2 days." d." Administer guaifenesin. Take medication with food to decrease gastric distress. Take sugarless candy. Notify the health care provider if confusion or hypotension occurs. d. d. a. "Take the medication only when you are not driving. "Take a lower dose than normal when you have to drive. "You may be able to safely take a second-generation antihistamine. Dry nasal mucosa a." b. c. e. e. Hallucinations d. you should not take antihistamines." The nurse is caring for a client who is taking a first-generation antihistamine.a. gum. Avoid alcohol and other central nervous system depressants. "Make sure you drink a lot of liquids while on this medication. Avoid alcohol and other central nervous system depressants. The nurse is teaching a client about diphenhydramine (Benadryl). "Do not drive after taking this medication. What is the most important fact for the nurse to teach the client? a. b." The nurse is caring for a client in the clinic who states that he is afraid of taking antihistamines because he is a truck driver. "You may be able to safely take a second-generation antihistamine. c. or ice chips for temporary relief of dry mouth. Avoid handling dangerous equipment or performing dangerous activities until stabilized on the drug. Notify the health care provider if confusion or hypotension occurs. b. "Do not drive after taking this medication.

What should the nurse do? a. "Oxymetazoline should be administered every hour for severe congestion. What is the most important thing for the nurse to teach a client who is switching allergy medications from diphenhydramine (Benadryl) to loratadine (Claritin)? a." c." a." A client is prescribed an antitussive medication.The client tells the nurse that she has a bad cold. This medication has fewer sedative effects. b." . d. "Oxymetazoline is not an effective nasal decongestant. "Overuse of nasal decongestants results in rebound congestion. b." c." b. Administer fluticasone (Flonase). What is the nurse's best response? a. d. "This medication will help prevent the inflammatory response of my allergies." d. This medication causes less gastrointestinal upset." A client complains of worsening nasal congestion despite the use of oxymetazoline (Afrin) nasal spray every 2 hours. "Overuse of nasal decongestants results in rebound congestion. This medication has increased bronchodilating effects. This medication has fewer sedative effects. "This medication will help prevent the inflammatory response of my allergies. and feels like she has "stuff" in her lungs. Administer dextromethorphan." b." b. "This medication may cause drowsiness and dizziness. "I will need to monitor my blood sugar more closely because it may increase. What is the most important thing for the nurse to teach the client? a. "This medication may cause drowsiness and dizziness. "I need to take this medication only when my symptoms get bad." Which statement indicates that the client understands the teaching about beclomethasone diproprionate (Beconase)? a. c. "You are probably displaying an idiosyncratic reaction to oxymetazoline. "Watch out for diarrhea and abdominal cramping. Administer guaifenesin. c. Encourage the client to drink fluids hourly." b. This medication can potentially cause dysrhythmias." d. b. is coughing. "I will need to taper off the medication to prevent acute adrenal crisis. b.

Asthma A client is diagnosed with a pulmonary disorder that causes COPD. Decreased white blood cell count b. epinephrine (Adrenalin) c. Bronchiectasis d. Asthma b. at bedtime. c. Drowsiness b. Increased heart rate d. zafirlukast (Accolate) b. epinephrine (Adrenalin) A client with COPD has an acute bronchospasm.c. d. 10 to 20 mcg/mL . Lungs tissue changes are normally reversible with this condition. Increase fiber and fluid intake to prevent constipation. Take the medication once a day only. oxtriphylline-theophyllinate (Choledyl) c. b. The nurse understands that which is the client's most likely diagnosis? a. Increased heart rate A client is taking aminophylline-theophylline ethylenediamine (Somophyllin). Restrict fluids in order to decrease mucus production." d. For what should the nurse monitor the client? a. The nurse knows that which is the best medication for this emergency situation? a. a. "This may cause tremors and anxiety. Increase fluid intake in order to decrease viscosity of secretions. Hypoglycemia c. dexamethasone (Decadron) d. Emphysema c." c. Increase fluid intake in order to decrease viscosity of secretions. Which is the best instruction for the nurse to include when teaching a client about the use of expectorants? a. Chronic bronchitis b. "Headache and hypertension are common side effects.

Treatment of an acute asthma attack c. Maintenance treatment of asthma b. Monitor the client for toxicity. Tachycardia Discharge teaching to a client receiving a beta-agonist bronchodilator should emphasize reporting which side effect? a. Continue to assess the client's oxygenation. 30 to 40 mcg/mL a. echinacea . 20 to 30 mcg/mL d. Sedation d. d.A client is prescribed theophylline to relax the smooth muscles of the bronchi. b. Maintenance treatment of asthma A client with COPD is taking a leukotriene antagonist. St. Treatment of inflammation in chronic bronchitis c. 10 to 20 mcg/mL c. John's wort The nurse instructs the client to avoid which over-the-counter products when taking theophylline (Theo-Dur)? a. c. Stop the IV for an hour then restart at lower rate. The nurse is aware that this medication is given for which purpose? a. The nurse monitors the client's theophylline serum levels to maintain which therapeutic range? a. Increase the IV drip rate. Nonproductive cough c. Continue to assess the client's oxygenation. acetaminophen (Tylenol) b. Hypoglycemia b. d. montelukast (Singulair). The nurse is caring for a client with a theophylline level of 14 mcg/mL. What is the priority nursing intervention? a. 1 to 10 mcg/mL b. Tachycardia d. Reversing bronchospasm associated with COPD d.

"It will take about 3 weeks before you notice a therapeutic effect. How will the nurse explain to the client the difference in these two medications? a. . Ask the client to describe the symptoms." c. A nurse reviews a client's medication history and notes that the client is taking a nonselective adrenergic agonist bronchodilator and has a history of coronary artery disease." d. Salmeterol has a longer duration of action. b. Salmeterol does not have any side effects. d. c. diphenhydramine (Benadryl) d. Salmeterol has a shorter onset of action." c. b. Albuterol has a longer onset of action. Monitor client for potential chest pain. "Take the medication as soon as you begin wheezing. c. c. "This medication will prevent the inflammation that causes your asthma attack. d. Call a code. c." Client teaching regarding the use of antileukotriene agents such as zafirlukast (Accolate) should include which statement? a. St. "This medication will prevent the inflammation that causes your asthma attack. "Increase fiber and fluid in your diet to prevent the side effect of constipation. d. Salmeterol has a longer duration of action. A client with a history of asthma is short of breath and says. The nurse is instructing a client about the advantages of salmeterol (Serevent) over other beta2 agonists such as albuterol (Proventil). Administer a long-acting glucocorticoid.c." b. Assess daily for hyperkalemia. b. Administer a beta2 adrenergic agonist. Monitor blood pressure continuously. "I feel like I'm having an asthmatic attack. d. Administer a beta2 adrenergic agonist. What is a priority nursing intervention? a." What is the nurse's best action? a. Assess 12-lead ECG each shift. Monitor client for potential chest pain. John's wort a.

Tell the client not to drive for 2 hours. wait 5 minutes. Assess for elevated blood pressure. Rinse his mouth with water after each use. Administer the albuterol first. d. d. Monitor for sedation. Tell the parent that young children should not use inhalers. Tell the parent to hold the inhaler for the child. The client with atrial fibrillation with a rate of 100 The nurse is caring for clients on the pulmonary unit. d. c. Immediately stop taking his oral prednisone when he starts using AeroBid. The nurse is caring for a young child who has been prescribed an inhaler for control of her asthma. Rinse his mouth with water after each use. b. Which client should not receive epinephrine if ordered? a. The client with a history of emphysema b. b. What is the nurse's priority action? a. and beclomethasone (Vanceril) inhalers for a client. three inhalers should not be given at one time. d. What is the nurse's best action? a. Teach the child to use a spacer. followed . Monitor for heart rate >100 beats/min. The client who is 16 years old d. Take two puffs to treat an acute asthma attack. c. The client with a history of type 2 diabetes c. Not use his albuterol inhaler while he is taking AeroBid. b. What is the nurse's best action? a. and administer ipratropium bromide. A client demonstrates understanding of flunisolide (AeroBid) by saying that he will do what? a. b. followed by beclomethasone several minutes later. The client with atrial fibrillation with a rate of 100 b. A client has taken metaproterenol. and administer ipratropium bromide. Teach the child to use a spacer. c. albuterol (Proventil). d. Monitor for heart rate >100 beats/min. wait 5 minutes. b. The child is having difficulty using the inhaler. Question the order. The health care provider orders ipratropium bromide (Atrovent). Ask the health care provider to switch to oral medications.a. Administer the albuterol first.

c. "Hold the inhaler in your mouth." c." c. Liquefying and loosening of bronchial secretions What will the nurse expect to find that would indicate a therapeutic effect of acetylcysteine (Mucomyst)? a. Decreased cough reflex b. wait 2 minutes. repeat until you obtain relief." d. Relief of bronchospasms c. "Administer both medications together in a metered-dose inhaler." b. "Hold your breath for 10 seconds if you can after you inhale the medication. Monitor blood glucose levels every 4 hours when taking albuterol." d. "Make sure that you puff out air repeatedly after you inhale the medication. . Administer beclomethasone first. Monitor blood glucose levels every 4 hours when taking albuterol. c.by beclomethasone several minutes later. take a deep breath." c. Hold the next dose of theophylline. "Take the ipratropium at least 5 minutes before the cromolyn. Liquefying and loosening of bronchial secretions d. d. "Hold your breath for 10 seconds if you can after you inhale the medication. b. followed by the albuterol several minutes later. Administer each inhaler at 30-minute intervals. Monitor for orthostatic hypotension every 2 hours when taking albuterol. d. What will the nurse teach the client? a. What is the most important thing for the nurse to teach the client with a history of diabetes and asthma who has started on albuterol PRN? a. "Take the ipratropium at least 5 minutes before the cromolyn. An antianxiety agent may be prescribed to help with nervousness. Take Tylenol for headaches when taking albuterol. Decreased nasal secretions c." Which instruction will the nurse include when teaching a client about the proper use of metereddose inhalers? a. b." b." A client is prescribed ipratropium and cromolyn sodium. and administer ipratropium bromide. "After you inhale the medication once. "Take the ipratropium only in the mornings." c. "Do not take these medications within 4 hours of each other. and then compress the inhaler. c.

Block serotonin receptors in the CTZ A client has nausea and is taking ondansetron (Zofran). d.A client taking an oral theophylline preparation is due for her next dose and has a blood pressure of 100/50 mm Hg and a heart rate of 110. including which cause? a. Vomiting . Lack of exercise A client complains of constipation and requires a laxative. Lack of exercise c. Pulls hyperosmolar salts into the colon and increases water in the feces to increase bulk d. c. The nurse teaches the client that which is a common side effect of this drug? a. Food intolerance d. Administer oxygen 2 lpm via nasal cannula. Block serotonin receptors in the CTZ c. Acts on smooth intestinal muscle to gently increase peristalsis b. The nurse explains that bisacodyl does what? a. Acts on smooth intestinal muscle to gently increase peristalsis A client who has constipation is prescribed a bisacodyl suppository. Continue to monitor the client. Bacteria (Escherichia coli) b. Stimulate the CTZ b. b. Absorbs water into the intestines to increase bulk and peristalsis c. Hold the next dose of theophylline. Lowers surface tension and increases water accumulation in the intestines d. b. Dry mouth A client is using the scopolamine patch to prevent motion sickness. Motion sickness b. The client is irritable. What is the best action for the nurse to take? a. In providing teaching to the client. Block dopamine receptors in the CTZ d. Call the health care provider. Diarrhea b. the nurse reviews the common causes of constipation. Coat the wall of the GI tract and absorb bacteria a. The nurse explains that the action of this drug is what? a.

c. Alcohol d.) a. d. MAOIs c. Client is complaining of gastric upset. e. . f. a. Which should be included in the client teaching regarding this medication? (Select all that apply. Dry mouth c. Alcohol When metoclopramide (Raglan) is given for nausea. Record the frequency of bowel movements. Warn the client against taking sedatives concurrently. b. Record the frequency of bowel movements. Teach the client that the drug acts by drawing water into the intestine. the client is cautioned to avoid which substance? a. The nurse is administering opium tincture (paregoric) to a client. b. d. b. Encourage the client to increase fluids. Client has not had a bowel movement in 3 days. Milk b. Encourage the client to increase fluids. Client has had one loose stool this week. Client taking magnesium-containing antacids who has renal failure. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. Warn the client against taking sedatives concurrently. e. c. Warn the client to avoid laxative abuse. Client taking aluminum-containing antacids with complaints of reflux. Client has trace edema in feet. c. Which client needs immediate intervention? a.c. Client has not had a bowel movement in 3 days. Client taking calcium-containing antacids who is hypocalcemic. Which assessment finding will need intervention and is related to the client's use of aluminum hydroxide (Amphojel)? a. Carbonated beverages a. Insomnia d. d. Warn the client to avoid laxative abuse. Instruct the client to avoid this drug if he or she has narrow-angle glaucoma. c. b.

"Smoking decreases the effects of this medication. c. so I should look into cessation programs. Client taking antacids who is older than 70 years. Only administer the Ativan if the client seems anxious. "I should take this medication 1 hour after each meal in order to decrease gastric acidity. Client taking magnesium-containing antacids who has renal failure. A client is prescribed Lorazepam (Ativan) and a glucocorticoid during chemotherapy treatments. Administer the medications and assess the client for relief. Assess for fluid volume deficit. d. Assess for metabolic alkalosis. "I should decrease bulk and fluids in my diet to prevent diarrhea. Alteration in urinary elimination related to retention d." d. "Since I am taking this medication." c. a." b. Administer the medications and assess the client for relief. so I should look into cessation programs. What is the nurse's best action? a. Potential risk for bleeding related to thrombocytopenia c. b. Alteration in tissue perfusion related to hypertension b.c. c. d. Administer the two medications at least 12 hours apart. Increased risk for infection related to immunosuppression b. pantoprazole (Protonix) . Potential risk for bleeding related to thrombocytopenia Which nursing diagnoses is appropriate for a client receiving famotidine (Pepcid)? a. it is all right for me to eat spicy foods. b." d. Assess for hyperkalemia. d. "Smoking decreases the effects of this medication. What assessment has the highest priority for a client using sodium bicarbonate to treat gastric hyperacidity? a. d." Which statement demonstrates to the nurse that the client understands instructions regarding the use of histamine2-receptor antagonists? a. Call the health care provider and question the order. Assess for metabolic alkalosis. b. Assess for hypercalcemia.

Increase in number of bowel movements c." b. The nurse anticipates that the client may be prescribed which proton pump inhibitor to be administered intravenously? a. "I may take Tylenol to treat the headache caused by ondansetron (Zofran)." Which client statement indicates that further teaching is needed? a. Administer 30 minutes before meals and at bedtime. omeprazole (Prilosec) d. Gastric assessment The nurse is administering loperamide (Imodium) to a client with diarrhea. White blood count c. What is a primary intervention? a. d. Increase in bowel sounds b. Administer 30 minutes before meals and at bedtime. Vascular assessment b." c. Gastric assessment c. Administer every 6 hours around the clock. "I will apply the scopolamine patches to rotating sites on my arms. Decrease in gastric motility d. Hourly blood pressure measurements d." b. Decrease in urination c. lansoprazole (Prevacid) c. Decrease in gastric motility Which outcome assessment is essential to monitor for the client taking diphenoxylate (Lomotil)? a. "I should take my prescribed antiemetic before receiving my chemotherapy dose and continue afterwards. esomeprazole (Nexium) b. The nurse is planning to administer metoclopramide (Reglan). . Give with a full glass of water first thing in the morning.A nurse is caring for a client who is unable to tolerate oral medications." d. Administer with food to decrease gastrointestinal upset. b. What assessment is essential for this client? a. pantoprazole (Protonix) c. "I will apply the scopolamine patches to rotating sites on my arms. c. "I will not drive while I am taking these medications because they may cause drowsiness.

"Do not take more than two doses of this medication. Weigh the client before chemotherapy. Weigh the client before chemotherapy. b. c. b. Fluid volume deficit related to nausea and vomiting In developing a plan of care for a client receiving an antihistamine antiemetic agent." d. Fluid volume deficit related to nausea and vomiting c. "Brush your teeth and gargle to help with dryness in your mouth. Knowledge deficit regarding medication administration b." b. Combination therapy is more cost-effective. What intervention is appropriate for this client? . b. which nursing diagnosis would be of highest priority? a. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy. c. d. d. "Assess your stools for dark streaks. b. What intervention is most appropriate for this client? a. Teach the client about the possibility of rebound nausea and vomiting once the drug is discontinued. Combination therapy blocks different vomiting pathways. Alteration in comfort related to nausea and vomiting c. Administer the medication at least 12 hours before the start of chemotherapy.c. Combination therapy decreases the risk of constipation. A client is starting cisplatin therapy for cancer. b. A client is prescribed granisetron (Kytril) IV for relief of nausea and vomiting caused by cancer chemotherapy. Assess baseline vital signs and monitor for tachycardia. "Brush your teeth and gargle to help with dryness in your mouth. Risk for injury related to side effects of medication d. Combination therapy blocks different vomiting pathways. Combination therapy decreases side effects due to lower doses of each drug." c. Check your heart rate and call the health care provider if it gets below 50 beats/min." What instruction is most important for the nurse to teach a client who is taking an anticholinergic agent to treat nausea and vomiting? a. What will the nurse teach the client about the reason for administering multiple medications for relief of nausea and vomiting? a.

c. "Do not use this medication for longer than a day." b. d. switch patch to alternate ear.a. Record baseline vital signs." e. Monitor intake and output. switch patch to alternate ear. hyposecretion of pepsin c. Assess fluid and electrolyte balance." c. Monitor heart rate and blood pressure every 4 hours. b. Helicobacter pylori b. Monitor signs and symptoms of fluid and electrolyte imbalance." e. Obtain a history of constipation and causes." d. c. "Apply patch 4 hours before effect is desired. b. which nursing intervention is the priority? a. d. Administer ondansetron HCL (Zofran) 30 minutes before therapy and two doses after therapy.) a. "Apply patch 4 hours before effect is desired. "After 3 days. Monitor bowel elimination daily. "Do not use laxatives while on this medication. Administer metoclopramide (Reglan) PO." f. Which assessment is most important for the client who is taking stimulant laxatives? a. "Drowsiness is a concern while on this medication. Monitor signs and symptoms of fluid and electrolyte imbalance. Before administering a stimulant laxative to a client. Evaluate renal function. b. c. Administer granisetron (Kytril) 60 minutes before therapy and for several days after surgery. d. c. Administer palonosetron (Aloxi) IV push. Evaluate renal function. The nurse realizes that which factor is a predisposing factor for this condition? a. decreased hydrochloric acid d. "Drowsiness is a concern while on this medication." f. c. decreased number of parietal cells ." a." A client is prescribed scopolamine. Helicobacter pylori A client is diagnosed with peptic ulcer disease. "Do not take this medication if you are dizzy. What information will the nurse include on the teaching plan for this client? (Select all that apply. "After 3 days. d.

Headaches f. Smoking should be avoided while taking this drug f. The drug must be administered separate from an antacid by at least 1 hour e. To inhibit gastric acid secretion by inhibiting histamine at H2 receptors in parietal cells c. why should an antacid be given? a. Foods high in vitamin B12 should be increased in diet d. The drug must be administered separate from an antacid by at least 1 hour d. Dizziness d. Antacids decrease GI motility. Headaches . Aluminum hydroxide is a systemic antacid. When a client complains of pain accompanying a peptic ulcer. To combine with protein to form a viscous substance that forms a protective covering of ulcer When a client is given sucralfate (Carafate). Antacids neutralize HCl and reduce pepsin activity. Foods high in vitamin B12 should be increased in diet A client is taking ranitidine (Zantac). d. The drug must be administered 30 minutes before meals c. To combine with protein to form a viscous substance that forms a protective covering of ulcer c. Decreased libido A client is taking famotidine (Pepcid) to inhibit gastric secretions. Antacids decrease gastric acid secretion. Dry mouth d. the nurse knows that its mode of action is what? a.) a. c. To suppress gastric acid secretion by inhibiting the hydrogen/potassium ATPase enzyme d. Antacids neutralize HCl and reduce pepsin activity. Diarrhea b. b. Smoking should be avoided while taking this drug f. Dizziness c. To neutralize gastric acidity b. Drug-induced impotence is irreversible b. The drug must always be administered with magnesium hydroxide e.d. b. The nurse who is teaching the client about this drug should include which information? (Select all that apply.) a. What are the side effects of famotidine? (Select all that apply.

The client has no gastric pain. Absent bowel sounds. hard abdomen The nurse is caring for a client who is taking sucralfate (Carafate. "I will drink 2 ounces of water after taking aluminum hydroxide. d. Which assessment requires action by the nurse? a." c.5 mg/dL c. c. Administer 1 to 2 hours after meals. Urinary output 30 mL/hr d. Blurred vision f. Calcium level 8. "I will take aluminum hydroxide at mealtime. Which statement by the client indicates to the nurse that the client understands the instructions? a. Administer just before meals. Which assessment indicates to the nurse that the medication has had a therapeutic effect? a. "I will drink 2 ounces of water after taking aluminum hydroxide. c. The client has no diarrhea. Administer during meals. "I will take a laxative if I develop constipation.e. What is a priority nursing intervention when administering ranitidine (Zantac)? a." b. "I will take aluminum hydroxide within 30 minutes of my other medications." a. b. b. Sodium level 140 mEq/L b. Allow the tablet to dissolve in water before administering. Administer right after eating. b. Administer just before meals. The client has no throat pain. Decreased libido b. . The client has no throat pain. The client is able to eat. Sulcrate) for treatment of a duodenal ulcer. hard abdomen c. d. Absent bowel sounds. Alu-Tab) for peptic ulcer pain. ALternaGEL. c. The health care provider prescribes lansoprazole (Prevacid) to a client." d." A client has just been prescribed aluminum hydroxide (Amphojel. The nurse has provided instructions to the client.

Dehydration The nurse reviews the client's list of medication. d. c. "This medication will neutralize gastric acid. Administer misoprostol. b. Allow the tablet to dissolve in water before administering. what is an essential intervention? a. "This medication will form a protective barrier over the gastric mucosa. Administer with a bolus tube feeding." What information should the nurse include in a teaching plan for the client who is prescribed sucralfate (Carafate)? a. Administer misoprostol. which includes mannitol. Dehydration b." b. What is the best intervention for this client? (Select all that apply." d. "This medication will form a protective barrier over the gastric mucosa. The nurse is caring for a client who is experiencing gastric distress from the long-term use of aspirin for treatment of arthritis. Kidney stones c. Instruct the client to take the aspirin with milk." b. The nurse must be aware that which condition is a contraindication for use of this drug? a. Instruct the client to take omeprazole with the aspirin." c. What drug might be used instead for the examination? . When the nurse takes the health history. c. Cyclopentolate The client is being prepared for an eye examination. "This medication will enhance gastric absorption of meals. Crush the tablet into a fine powder before mixing it with water. d. b. d.) a. Gout c. "Your gastric acid will be inhibited. Administer with an antacid for maximum benefit. c. Eczema d.When administering sucralfate (Carafate) to a client with a nasogastric tube. a. Instruct the client to take omeprazole with the aspirin. the client says that she is sensitive to atropine sulfate. Stop all aspirin therapy.

Rubbing alcohol c. a carbonic anhydrase inhibitor. Weight b. Hydrogen peroxide b. Salt solution . Charcoal d. Combination products may not have the desired dose for school-aged children. not a combination. Hydrogen peroxide The camp nurse reviews the "shopping list" of supplies needed for the upcoming camping season. a. Urine output d. Suprofen c. The school nurse is preparing a presentation for the parent-teacher association meeting on medications commonly used in school-aged children. latanoprost b. c. d. Electrolytes d. travoprost a. School-aged children may need only one drug. It is important to note what primary disadvantage of the use of combination products such as Cortisporin Otic? a. b. Electrolytes An 85-year-old client is taking acetazolamide. It is important for the nurse to be aware that the prostaglandin analogue more effective in African Americans than in nonAfrican Americans is wha? a. What product is recommended to prevent and treat chronic impaction of cerumen? a. A nursing intervention associated with clients receiving this drug is to monitor what? a.a. Diclofenac b. School-aged children may need only one drug. not a combination. Cyclopentolate d. Combination products are less effective for school-aged children. bimatoprost c. There is increased cost in using combination products for school-aged children. unoprostone d. Betaxolol HCl c. travoprost The nurse reviews the African-American client's list of medications. Complete blood count c.

a. b. b. "I should rinse the eye dropper with tap water after each use. d. "I will turn my head slightly toward the outside of the eye I am putting the drops in. Client's pupils are constricted to 2 mm. "I will put pressure on the inside corner of my eye after I administer the drops. b." b. d. Client's pupils are constricted to 2 mm. c. Client's eyes appear clear. Maintain sterile technique and prevent dropper contamination during administration of eyedrops. d. indicates to the nurse a need for further client teaching regarding proper administration of eye drops? a. The nurse administers pilocarpine (Pilocar) to a client with glaucoma. Which intervention is essential to include in the plan of care? a. Instruct the client to report changes in vision and breathing. without drainage. Eardrops should be cool when being administered. "I will be careful not to touch my eye with the dropper. c." c. Which assessment finding would indicate a therapeutic effect of the medication? a. Eardrops may be warmed in the microwave before administration. made by a client. b. Include return demonstration only with geriatric clients." b. The nurse is planning to administer eardrops. Maintain sterile technique and prevent dropper The nurse prepares a health teaching plan for the client with glaucoma. c. Warm the eardrops to room temperature before administration. Instruct the client to report changes in vision and breathing. The pinna of an adult should be held down and back to administer eardrops. c. d. "I should rinse the eye dropper with tap water after each use. What medication will the nurse use to assist the client? . Client's pupils are dilated to 4 mm. b." d.) a. Warm the eardrops to room temperature before administration. carbamide peroxide A client is complaining of excessive earwax that diminishes hearing ability. Which important nursing intervention are included for this client? (Select all that apply. Client states that her eyes feel very dry. Wait 10 minutes to instill the second eye medication to be given at the same time." Which statement.

What is the nurse's best action? a. Do not breastfeed or give blood. Monitor weight c. The client puts two drops into his eye. and lipids. Monitor CBC. glucose. glycerin b. c. A horny layer of epidermis c. b. Monitor electrolytes . c. Hair follicles a. acetic acid b. Do not breastfeed or give blood. A horny layer of dermis b. Monitor CBC. The nurse evaluates the client using eyedrops. Nursing implications for health teaching with clients taking isotretinoin include which implications? (Select all that apply.a. Avoid sunlight. d. Have the client irrigate his eye to remove excess medication. A horny layer of epidermis The nurse reviews the client's list of medications and recalls that the purpose of keratolytic agents is to remove what? a. Erythematous lesions d. d. b. Instruct the client that one drop is optimal. Avoid sunlight. glucose. carbamide peroxide c. Daily weight b. d. and lipids. Instruct the client that one drop is optimal. b. Assess lesions The nurse is doing health teaching with a client with psoriasis.) a. c. Continue to observe the client. hydrocortisone d. Have the client close his eye and rub to assist in absorption. Which is a nursing implication of the new biologic agents for the management of psoriasis? a.

Mafenide acetate has been ordered. Respiratory acidosis b. Thinning of the skin c. PABA c. That a negative pregnancy test is required before each monthly refill A 20-year-old woman comes to the clinic for follow-up related to isotretinoin use. What acid-base imbalance can result from its use? (Select all that apply. Purpura b. That an effective method of contraception must be used throughout treatment b. Assess lesions d. what does the assessment include? (Select all that apply. A review of iPLEDGE educational materials c. Based on the client's prolonged use of glucocorticoids.c. which includes which important information? (Select all that apply. Monitor CBC and T-cell count d. finasteride a. Respiratory alkalosis The client has second.and third-degree burns over 25% of his body. minoxidil d. Respiratory alkalosis d. Metabolic acidosis b. Metabolic acidosis c. dexamethasone b.) a. Obesity b. Erythematous lesions d.) a. Thinning of the skin d. The nurse reviews the iPLEDGE program.) a. Purpura The nurse reviews the client's medication history." Which drug is used to treat male pattern baldness? a. A review of iPLEDGE educational materials . finasteride A 55-year-old man has a chief complaint: "I'm going bald. Metabolic alkalosis c.

d. Isolation c. That a negative pregnancy test is required before each monthly refill d. Which assessment finding requires immediate intervention by the nurse? a. SPF should be at least 15 in sunscreen products. Perform pregnancy test. Perform pregnancy test.) a. d. b. Potassium 3. d.8 meq/L c.5 mg/dL . What is important information to include? (Select all that apply. IV dextrose infusion d. c. IV antibiotics b. UVB radiation is greatest between 10 AM and 4 PM. That informed consent is not required a. Clouds block radiation. Calcium 12 mg/dL A client is prescribed calcipotriene (Dovonex) for treatment of psoriasis. SPF should be at least 15 in sunscreen products. The school nurse prepares a program for junior high school students on sun safety. b. What is an essential nursing intervention for this client? a. d. so sunscreen is not needed on cloudy days. Silver sulfadiazine cream a. a. UVB radiation is greatest between 10 AM and 4 PM. Sunscreen products should contain information about UVA and UVB SPF protection.c. c. b. Sodium 135 mmol/L d. Force fluids. Phosphorus 2. Assess sputum cultures. Calcium 12 mg/dL b. Sunscreen products should contain information about UVA and UVB SPF protection. A 20-year-old client is starting isotretinoin (Accutane) therapy. Silver sulfadiazine cream Which intervention is most appropriate for the client with second-degree burns? a. Make sure IV is patent.

Increase fluid intake while on this medication. .d. Call the health care provider if you have muscle weakness. c. Apply a cortisone cream. Wash the skin. What is the most important instruction to teach the client before beginning this medication? a. Ask client if he or she has any allergies. Do not go out in the sun while on this medication. Before applying povidone-iodine (Betadine) to a client's skin. d. b. Ask client if he or she has any allergies. b. Shave and prepare the area. A client is prescribed isotretinoin (Accutane). c. what is a primary nursing intervention? a. b. Call the health care provider if you have muscle weakness.