RN Comprehensive Online Practice 2019 A with NGN Latest Update 2023/2024

RN Comprehensive Online Practice 2019 A with NGN A nurse is caring for a client who has hypertension and is taking captopril. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Obtain the client's blood pressure before the nurse administers medication. The nurse can delegate obtaining blood pressure before and after medication administration because this task is within the range of function for an AP. Initiate a referral with a dietitian for the client. Initiating a referral with a dietitian requires assessment skills and is the role of the nurse. Inform the client about the adverse effects of the medication. Informing the client about the adverse effects of a medication is the role of the nurse. Recommend a salt substitute to the client. Recommending a salt substitute to the client is the role of the nurse and is outside the range of function for an AP. A charge nurse assigns a newly licensed nurse to care for a client who has a chest tube. The nurse expresses concern about having limited experience with monitoring chest tube drainage. Which of the following actions should the charge nurse take first to provide teaching about chest tubes? Refer the nurse to the procedure manual. The charge nurse should instruct the newly licensed nurse to consult the procedure manual for further information. Use a diagram to explain the procedure to the nurse. The charge nurse should use a diagram to explain the procedure and enhance the nurse's understanding. Demonstrate the procedure to the nurse. The charge nurse should use a demonstration to model the procedure to the newly licensed nurse. Ask the nurse about their knowledge of the procedure. The first action the charge nurse should take using the nursing process is to assess the newly licensed nurse's knowledge about the procedure. By assessing the nurse's knowledge, the charge nurse can identify the nurse's learning needs. A home health nurse is assessing a 2-week-old newborn who had a birth weight of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding? The newborn nurses every 4 hr during the day and sleeps through the night. Measuring duration and frequency of nursing is not an effective way to evaluate the effectiveness of breastfeeding. The newborn has six to eight wet diapers per day. Measuring the number of wet diapers per day is an effective measurement of adequate intake. Six to eight wet diapers each day after the fourth day of life indicates effective breastfeeding. The newborn's current weight is 3.18 kg (7 lb). A newborn is expected to gain 20 to 28 g (0.04 to 0.06 lb) per day after the fourth or fifth day and surpass the birth weight in 10 to 14 days. Slow weight gain can be an indication of ineffective breastfeeding. The newborn has sticky, greenish stools. The breastfed newborn's stool should be yellow, soft, and seedy by the end of the first week of life. Newborns who continue to have meconium in their stools after the first week of life should be evaluated for ineffective breastfeeding. A nurse is caring for a client who is immediately postoperative following a total vaginal hysterectomy. Which of the following actions should the nurse take first? Measure the client's vital signs. The first action the nurse should take when using the nursing process is to assess the client. The nurse should monitor the client's vital signs every 15 min until stable and then every 4 hr for the next 48 hr. Reposition the client. The nurse should reposition the client every 2 hr to prevent postoperative complications such as atelectasis. Encourage the client to use an incentive spirometer. The nurse should encourage the client to turn, cough, deep breathe, and use an incentive spirometer every 2 hr for 24 hr to increase lung expansion and prevent pneumonia. Administer pain medication. The nurse should administer pain medication on a regular schedule for the first 48 hr for a client who is postoperative and has vital signs within the expected reference range following a total vaginal hysterectomy. A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Investigate environmental factors that might be contributing to client injury during these hours When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem. Review the performance evaluations of nurses who work during these hours. When conducting a root cause analysis, the nurse does not look at the individual performance of staff members. Implement a plan to transition from team nursing to primary care nursing during these hours. When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the problem. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours. When conducting a root cause analysis, the nurse should focus on identifying the cause of a problem, not potential solutions to the problem. A nurse is administering cyclophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication? Give an antiemetic 30 min after medication administration. The nurse should administer an antiemetic 30 min before administration of the medication to decrease gastrointestinal effects. Monitor blood glucose levels. Cyclophosphamide does not affect blood glucose levels. Maintain hydration with liberal fluid intake. The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication. Monitor for tumor lysis syndrome. Tumor lysis syndrome can occur in clients who are diagnosed with acute lymphoblastic leukemia, not neuroblastoma. A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first? Ensure that the staff nurse changes the dressing. It is the charge nurse's role to advocate for the client to receive the care the provider prescribed. Notify the nurse manager. The charge nurse should notify the nurse manager that the occurrence happened. Complete an incident report. The charge nurse should complete an incident report describing the occurrence. Gather more information about the staff nurse's actions. The first action the nurse should take when using the nursing process is to assess the reasons for the staff nurse's negligent actions. Therefore, the charge nurse should gather additional information and discuss the issue with the staff nurse before deciding on the next course of action. A nurse is teaching a client who has a new prescription for estradiol. For which of the following adverse effects of this medication should the nurse instruct the client to monitor and report to the provider? Hypotension The nurse should instruct the client to monitor for and report hypertension. Headaches The nurse should instruct the client to monitor for and report headaches. Headaches can be an indication of a thromboembolic stroke because estradiol increases the risk for adverse cardiovascular events. Bruising The nurse should instruct the client to monitor for swelling and tenderness of an extremity or fluid retention. Bruising is not an adverse effect of this medication. Oliguria The nurse should instruct the client to monitor for the development of genitourinary candidiasis. Oliguria is not an adverse effect of this medication. A nurse is preparing to administer enoxaparin to a client. Enoxaparin is administered subcutaneous tissue, specifically in the periumbilical area. B – Deltoid site, used for intramuscular injections. C – Ventrogluteal site, used for intramuscular injections. D – Anterior thigh for SQ injection, enoxaparin must be administered in a different area. A nurse is assessing a client who has skeletal traction for a femur fracture. Which of the following findings should the nurse identify as the priority? Muscle spasms of the affected extremity The nurse should reposition the client or check the weights to relieve the client's muscle spasms. A pain rating of 6 on a scale from 0 to 10 The nurse should provide analgesia to relieve the client's moderate pain level. Upper chest petechiae The greatest risk to this client is organ damage from fat embolism syndrome, a life-threatening complication of fractures. In fat embolism syndrome, a fat embolism enters the bloodstream and can obstruct blood vessels of a major organ, such as the lung, kidney, or brain. Manifestations include petechiae on the upper torso, dyspnea, hypoxia, headache, lethargy, and confusion. Therefore, the nurse should identify this as the priority finding. Ecchymosis over the fractured area The nurse should identify ecchymosis over the fractured area as an expected finding due to localized trauma and provide comfort measures. Nurses' Notes 1500: Infant admitted to the pediatric unit. Parent reports the infant has been irritable and has vomited after each feeding within the last 3 days. Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation anterior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive x 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting. 1600: Called to the room by the parents. Parents attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO. 1800: Infant crying. Soothed with a pacifier. History and Physical Birth weight 3,492.7 g (7.7 lb) Parent is breastfeeding. Newborn birthed vaginally at 38 weeks of gestation. Vital Signs | 1500: Temperature 37.1° C (98.8° F) Heart rate 120/min Respiratory rate 30/min Weight 3.62 kg (8 lb) Diagnostic Results | 1545: Hgb 20 g/dL (14 to 24 g/dL) Hct 60% (44% to 64%) Potassium 5.8 mEq/L (3.9 to 5.9 mEq/L) Sodium 132 mEq/L (134 to 150 mEq/L) Chloride 110 mEq/L (96 to 106 mEq/L) WBC count 16,000/mm3 (6,200 to 17,000/mm3) BUN 20 mg/dL (5 to 18 mg/dL) Creatinine 0.2 mg/dL (0.1 to 0.4 mg/dL) 1730: Abdominal ultrasound: Narrowing of pyloric canal. Thickening of pylorus. Consistent with hypertrophic pyloric stenosis. The infant is at highest risk for developing dehydration, as evidenced by the infant's vomiting. When prioritizing hypotheses and using the urgent vs. non urgent priority framework, the nurse should identify that the infant is at the greatest risk for developing dehydration due to a loss of gastric content from vomiting. An infant with pyloric stenosis presents with projectile vomiting after feeding, distended abdomen, and olive-shaped mass in the epigastrium. A community health nurse is preparing a health education program for a local rural community. Which of the following actions should the nurse plan to take first? Identify health-related issues within the community. The first action the nurse should take when using the nursing process is to assess the clients living in the community to identify the prevalent health problems. Develop measurable health goals for community residents. The nurse should develop measurable health goals for the community residents to use when evaluating the activities of the program. Create safety education classes for the program. The nurse should create safety education classes for the program to ensure the needs of the community residents are met. Enlist volunteers from the rural community to promote the program. The nurse should enlist volunteers from the rural community as a method of outreach to promote the program. A nurse in an emergency department is preparing to discharge a client who has experienced intimate partner violence. Which of the following actions should the nurse take first? Offer a referral to the client for social services. A client who has experienced intimate partner abuse can benefit from a referral to social services, but offering a referral is not the first action the nurse should take. Develop a safety plan with the client. The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client. Encourage the client to reach out to family and friends. The client can benefit from the support of family and friends when the client is ready, but encouraging this behavior is not the first action the nurse should take. Provide the client with a list of support groups. The client can benefit from attending a support group, but providing this information is not the first action the nurse should take. A client is receiving lorazepam IV for panic attacks and develops a respiratory rate of 6/min and a blood pressure of 90/44 mm Hg. Which of the following medications should the nurse anticipate administering? Naloxone The nurse should administer naloxone to counteract an opiate overdose, such as morphine. Flumazenil The nurse should anticipate administering flumazenil, a competitive benzodiazepine receptor antagonist, to reverse the sedative effects of lorazepam. In addition, the nurse should continue to support the client's respirations with a bag-valve mask. Acetylcysteine The nurse should administer acetylcysteine to counteract an acetaminophen overdose. Atropine The nurse should administer atropine to counteract a cholinesterase inhibitor overdose, such as neostigmine. A charge nurse overhears two staff nurses in the hallway discussing the nutritional status of a client who has anorexia nervosa. Which of the following actions should the charge nurse take? Apologize to the client for the nurses' actions. The charge nurse should not discuss the nurses' actions with the client. The nurse should report the situation to the nursing supervisor to investigate and take further action. Advise the nurses that they are being insubordinate. The nurses are not committing insubordination, because insubordination occurs when an employee disobeys a person in authority such as a manager or supervisor. Tell the nurses to stop the discussion. The nurses are violating client confidentiality by having the discussion in a public hallway. The charge nurse should tell the nurses to stop the discussion to prevent any further breach of confidentiality. Document the incident in the client's medical record. If the nurse needs to report the incident, the nurse should do so on an incident report, which is not included in the client's medical record. A nurse is caring for a client who is in the spinal cord injury (SCI) unit. Nurses' Notes Day 3 | 1700: Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations are easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, patella 0, and ankle 0 bilaterally. Client reports pain of 0 on a 0 to 10 scale. Day 4 | 0600: Client reports increased coughing and shortness of breath. Crackles auscultated in lower lobes bilaterally. Face and neck flushed. Skin is warm and moist. Client reports blurred vision and a headache as an 8 on a 0 to 10 pain scale. Abdomen soft and mildly distended. Hypoactive bowel sounds present. Urinary output 300 mL over the last 8 hr. Vital Signs Day 3|1700: Temperature 38.2° C (100.8° F) Heart rate 74/min Respiratory rate 20/min Blood pressure 108/60 mm Hg Oxygen saturation 96% on room air Day 4 |0600: Temperature 38.4° C (101.2° F) Heart rate 54/min Respiratory rate 26/min Blood pressure 142/90 mm Hg Oxygen saturation 91% on room air The nurse should analyze cues from the client’s manifestations and determine that the client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation to less than 92% can indicate pneumonia. The client’s sudden increase in blood pressure, bradycardia, flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-threatening condition. A nurse is caring for a newborn whose parent asks why the baby is receiving vitamin K. The nurse should explain to the parent that the newborn should receive vitamin K to prevent which of the following? Bleeding The nurse should explain to the parent that newborns are deficient in vitamin K and should receive it following birth because this deficiency can lead to bleeding. Potassium deficiency Vitamin K does not prevent potassium deficiency in a newborn. Infection Vitamin K does not prevent infection in a newborn. Hyperbilirubinemia Vitamin K does not prevent hyperbilirubinemia in a newborn. A case manager is reviewing the medical records of several clients. For which of the following clients should the nurse request an interprofessional care conference? A client who has diabetes mellitus and has had repeated hospitalizations for diabetic ketoacidosis A client who is having repeated episodes of a life-threatening complication requires an interprofessional care conference so team members can address the client's needs to provide care and support. A client who has alcohol use disorder and has decided to start attending Alcoholics Anonymous meetings A client who is being proactive in the management of their alcohol use disorder does not require an interprofessional care conference. A client who was admitted for dehydration and is receiving a continuous IV infusion A client who has dehydration, which is an acute condition, does not require an interprofessional care conference at the time of admission. A client who has a history of two prior miscarriages and has ruptured membranes at 38 weeks of gestation A client who has ruptured membranes at 38 weeks of gestation is not a complicated obstetrical client and does not require an interprofessional care conference. A nurse is caring for a client who has end-stage Alzheimer's disease. The adult child of the client says to the nurse, "I don't know why I bother to visit my mother anymore." Which of the following responses should the nurse make? "Your mother might still know you are here." This statement is nontherapeutic because the nurse is offering an opinion and is dismissing the adult child's concerns. "Why do you feel that way?" This statement is nontherapeutic because the nurse is asking a "why" question which can make the adult child feel the need to know why certain feelings occur and implies wrongdoing. This might cause the adult child to feel defensive. "It seems like you feel your visits are a waste of time." The nurse is using a clarifying technique that facilitates the nurse's understanding of the adult child's feelings. "Are you sure you would not want to see your mother again?" This statement is nontherapeutic because the nurse is showing disapproval, which can make the adult child feel as though feelings of sadness and frustration should not be expressed. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following statements by the client indicates an understanding of the teaching? "I can resume my daily aspirin therapy." The client should avoid taking aspirin because of its anticoagulant effect. "I will contact my provider if my eye feels itchy." The nurse should instruct the client to expect eye itching and recommend the use of a cool compress to ease the discomfort of the itching. "I will bend at my knees when picking an object up off the floor." The client should avoid bending at the waist, because this movement increases intraocular pressure. The nurse should instruct the client to bend at the knees when picking up an object. "It's okay for me to pick up my grandchild who weighs 20 pounds." The client should avoid lifting anything that weighs more than 4.5 kg (10 lb) because it can increase intraocular pressure and damage the suture of the new lens. A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs). Vital Signs 0900: Temperature 36.9° C (98.5° F) Heart rate 74/min Respiratory rate 16/min Blood pressure 112/68 mm Hg Pulse oximetry 98% 0915: Temperature 36.9° C (98.5° F) Heart rate 76/min Respiratory rate 16/min Blood pressure 120/68 mm Hg Pulse oximetry 98% 0930: Temperature 36.9° C (98.5° F) Heart rate 80/min Respiratory rate 18/min Blood pressure 116/70 mm Hg Pulse oximetry 98% Nurses' Notes 0900: Platelet count and Hgb unchanged from post-transfusion results yesterday. Infusion of 1 unit of packed RBCs started as ordered. Client alert and oriented to person, place, and time. 0930: Client requests pain medication for headache and reports pain level of 5 on a scale from 0 to 10. Client reports "arthritis must be acting up because my back and knees and ankles hurt." Asked if a nurse can assist in placing pillows behind back for low back pain. Reports back and joint pain as 4 on a scale of 0 to 10. States they did not have any concerns yesterday during transfusions but "starting to feel a little anxious about it now. I'm not really sure why I need this." Alert and oriented to person and place. Skin pale, cool, and dry to touch. Mucous membranes are pink and moist. Urine output: 150 mL of clear, yellow urine in the urinal. Diagnostic Results 0800: Hgb 5.6 g/dL (12 to 16 g/dL) Platelet count 18,000/mm3 (150,000 to 400,00/mm3) The nurse should suspect a transfusion reaction based on which of the following assessment findings? Urine output Vital signs Anxiety Back pain Skin Headache When analyzing cues, the nurse should identify that the assessment findings of back pain, headache, and anxiety can be indications of a possible hemolytic transfusion reaction. Other manifestations of a hemolytic transfusion reaction include fever, chills, chest pain, tachycardia, dyspnea, and hypotension. A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of the following defense mechanisms? Displacement Displacement occurs when a client transfers emotions of a particular situation to another nonthreatening situation. Regression Regression occurs when a client reverts to a childlike pattern of behavior that might have been exhibited previously. Suppression Suppression is the denial of a disturbing feeling or situation. Sublimation The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior. A nurse is assessing a 2-month-old infant during a well-baby examination. Which of the following actions should the nurse take to assess the infant's rooting reflex? Stroke the infant's cheek. The nurse should stroke the infant's cheek to assess the rooting reflex, should cause the infant to turn towards that side and suck. Depress the infant's tongue. The nurse should depress the infant's tongue to assess the extrusion reflex, which should cause the infant to stick out the tongue. Turn the infant's head to one side. The nurse should turn the infant's head to one side to assess the asymmetric tonic neck reflex, which should cause the infant to extend her arm and leg on that side and flex her arm and leg on the other side. Tap on the bridge of the infant's nose. The nurse should tap on the bridge of the infant's nose to assess the glabellar reflex, which should cause the infant to close her eyes tightly. A home health nurse is providing teaching to a client who has hepatitis A. Which of the following instructions should the nurse include? Use hydrogen peroxide to clean kitchen surfaces. The client should clean kitchen surfaces with hydrogen peroxide to kill the virus and prevent transmission. Seal non-washable items in a plastic bag for 2 weeks. A client who has pediculosis capitis should seal non washable items in a plastic bag for 2 weeks. Wear a surgical mask when in public. The client does not need to wear a surgical mask, because hepatitis A is not an airborne infection. Limit family visits to 30 min periods. Limiting family visits to 30 min does not reduce the risk of transmitting hepatitis A. Instead, the nurse should encourage safe food handling and appropriate hand hygiene techniques. A nurse in an outpatient mental health clinic is working with a client who has post-traumatic stress disorder (PTSD) and asks the nurse to recommend a nonpharmacological therapy to use to provide relief of the manifestations. Which of the following complementary therapies should the nurse teach the client to use to help alleviate the distress? Spinal manipulation Spinal manipulation is not a therapy the client can learn to self-perform to relieve manifestations of PTSD. Spinal manipulation involves adjusting and aligning the spine, which can help with back pain, asthma, and allergies. Acupuncture Performing acupuncture requires special training. It is not a therapy the client can self-perform to relieve manifestations of PTSD. Needle placement can alter and improve immune, neurologic, cardiac, and endocrine function. It can also help relieve pain and assist with substance withdrawal. Therapeutic touch Although touch therapies are helpful for inducing relaxation in general, therapeutic touch specifically addresses pain, depression, healing of body tissues, and physiological needs such as reducing blood pressure, fever, and nausea. It is not a therapy the client can learn to self-perform. Guided imagery Helping clients imagine themselves as strong and capable and in settings that are positive and therapeutic can assist clients who have PTSD by relieving anxiety and pain. A nurse is caring for a client who is on 24-hr observation. History and Physical Day 1 | 0600: Client admitted for 24-hr observation for alcohol intoxication. History of alcohol use disorder per family. Client alert and oriented to the person. Client appears lethargic. Diminished lung sounds auscultated in bilateral lower lobes. Heart is tachycardic. Nausea and vomiting for the last 2 days. Bowel sounds hypoactive in all 4 quadrants. Abdomen is distended and nontender. Client unable to verbalize last alcohol ingestion. Petechiae noted on forearms bilaterally. Client is diaphoretic. Laboratory Results Day 1 | 0600: Sodium 150 mEq/L (136 to 145 mEq/L) Potassium 5.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 105 mEq/L (98 to 106 mEq/L) BUN 17 mg/dL (10 to 20 mg/dL) Magnesium 1.2 mEq/L (1.3 to 2.1 mEq/L) Total calcium 10.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.0 mg/dL (3.0 to 4.5 mg/dL) Glucose 135 mg/dL (74 to 106 mg/dL) Platelet count 99,500/mm3 (150,000 to 400,000/mm3) WBC count 9,500/mm3 (5,000 to 10,000/mm3) Total protein 4.0 g/dL (6.4 to 8.3 g/dL) Albumin 1.5 g/dL (3.5 to 5.0 g/dL) Blood alcohol content (EtOH) 200 mg/dL (0 to 50 mg/dL) Nurses' Notes Day 1 | 0700: Client sleeping. No change in previous condition. 0810: Client awake. Lethargic. Bleeding noted from left nostril. Applied pressure to left nostril with cotton gauze. Provider notified. 0903: Client alert to person and place. Verbalized last drink was "last night.” Does not recall events from the previous night. Bleeding increased. Provider notified. Vital Signs Day 1 | 0600: Temperature 38.4° C (101.1° F) Heart rate 84/min Respiratory rate 18/min Blood pressure 132/68 mm Hg Oxygen saturation 98% on room air 0645: Temperature 37.7° C (99.9° F) Heart rate 90/min Respiratory rate 20/min Blood pressure 142/58 mm Hg Oxygen saturation 95% on room air 0800: Temperature 35.9° C (96.6° F) Heart rate 110/min Respiratory rate 20/min Blood pressure 110/76 mm Hg Oxygen saturation 92% on room air 0910: Temperature 37.6° C (99.7° F) Heart rate 116/min Respiratory rate 22/min Blood pressure 105/62 mm Hg Oxygen saturation 90% on room air Medication Administration Record Day 1 | 0700: 0.9% sodium chloride IV fluids at 150 mL/hr When analyzing cues, the nurse should recognize that the client is experiencing thrombocytopenia and is at risk for hemorrhage due to low platelet count. The client is experiencing bleeding from their nose that is not resolving with pressure being applied. Petechiae of the arms is a manifestation of thrombocytopenia. Chronic alcohol use disorder increases the risk for hemorrhaging due to the inability of the liver to assist with platelet formation A nurse in an emergency department is assessing a client who reports taking methylenedioxymethamphetamine (MDMA). Which of the following findings should the nurse expect? Lethargy Lethargy is not an expected finding of MDMA use. Diaphoresis Diaphoresis is an expected finding of MDMA use. Additionally, the client might experience increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects. Bradycardia Bradycardia is not an expected finding of MDMA use. Cough Cough is not an expected finding of MDMA use. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings is the priority for the nurse to report the provider? Temperature 39.4° C (102.9° F) The greatest risk to this client is injury from neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure. Therefore, the priority finding for the nurse report to the provider is a fever. Headache Headache is a common adverse effect of chlorpromazine. The nurse should report the client's headache to the provider and request analgesia. Constipation Constipation is a common adverse effect of chlorpromazine. The nurse should encourage the client to increase fiber and fluid intake as well as their activity level. Dry mouth Dry mouth is a common adverse effect of chlorpromazine. The nurse should encourage the client to chew sugarless gum to help moisten the mouth. A nurse is caring for a client who is pregnant in the acute care setting. Nurses' Notes 1400: Client reports a constant low dull backache and painless abdominal tightening for the past 3 hr. Denies any changes in vaginal discharge. External fetal monitor applied. 1430: Contraction pattern: contractions every 4 to 5 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 150 to 155 bpm, moderate variability, adequate accelerations present, no decelerations noted. Provider in to see client. Specimen obtained for fetal fibronectin. 1800: Client sleepy. Difficult to arouse. Respirations slow and shallow. Contraction pattern: contractions every 10 min, lasting 30 to 45 seconds, palpate mild in intensity. Fetal heart rate: 140 bpm, moderate variability, no accelerations present, no decelerations noted. History and Physical Gravida 2 para 1 30 weeks gestation Previously uncomplicated pregnancy Reported the onset of back pain and contractions 3 hr ago Vaginal examination: 3 cm dilated and 50% effaced. Amniotic membranes intact. Diagnosis: Preterm labor Plan: Administer tocolytics and glucocorticoids. Vital Signs 1400: Temperature 37° C (98.6° F) Heart rate 72/min Respiratory rate 20/min Blood pressure 115/75 mm Hg Oxygen saturation 98% on room air 1800: Heart rate 65/min Respiratory rate 10/min Blood pressure 100/60 mm Hg Oxygen saturation 88% on room air Medication Administration Record 1445: Administered magnesium sulfate 4 g IV bolus over 20 min. Initiated lactated Ringer's continuous infusion at 75 mL/hr. 1450: Administered betamethasone 12 mg IM. 1505: Initiated magnesium sulfate continuous infusion at 2 g/hr. Laboratory Results 1445: Fetal fibronectin: positive (negative) The nurse should first address the client’s respiratory rate, followed by the client's level of consciousness. When prioritizing hypotheses, the nurse should recognize that magnesium sulfate is a central nervous system depressant that can affect respirations, consciousness, and reflexes when toxic blood levels occur. Using the airway, breathing, circulation priority framework, the nurse should plan to first take action to support respirations, followed by action to increase the client's level of consciousness. The nurse should plan to discontinue the magnesium sulfate infusion and administer calcium gluconate as an antidote. A nurse is performing gastric lavage for a client who has gastrointestinal bleeding and an NG tube in place. Which of the following actions should the nurse take? Instill chilled lavage solution into the client's NG tube. The nurse should use a lavage solution that is at room temperature to reduce the risk of injury to the client. Attach the client's NG tube to low intermittent suction. After instilling the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube. Use 0.9% sodium chloride for irrigation of the NG tube. The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time. The nurse should instill the solution in volumes of 200 to 300 mL at a time to reduce the risk of injury to the client. A nurse in the delivery room is caring for a newborn immediately after birth. Which of the following actions should the nurse take first? Dry the newborn. The greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take is to dry the newborn. Assign the first Apgar score to the newborn. The Apgar score is an important assessment for determining the newborn's adjustment to extrauterine life. Place an identification bracelet on the newborn. Placing an identification bracelet on the newborn is an important safety measure. Obtain the newborn's weight. Obtaining the newborn's weight is important to help determine the health status of the newborn. A nurse is providing colostomy care for a client using a two-piece pouching system. Which of the following actions should the nurse take? Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. The nurse should cleanse the skin at the stoma site using a washcloth and warm water to reduce the risk of skin irritation. Dampen the skin before applying the skin barrier and ostomy pouch. Thoroughly dry the skin around the stoma – before applying the skin barrier to ensure the pouch adheres to the client's skin. Place the skin barrier over the stoma and hold it for 30 seconds. The nurse should activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. Cut the skin barrier opening 0.6 cm (0.25 in) larger than the stoma. The nurse should cut the skin barrier opening no more than 0.3 cm (0.13 in) larger to reduce the risk of skin irritation. A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestation of vaso-occlusive crisis? Diminished reflexes Painful swelling of the hands and feet, rather than diminished reflexes, is a manifestation of vaso-occlusive sickle cell crisis. Hematuria The nurse should identify hematuria as a manifestation of vaso-occlusive sickle cell crisis resulting from ischemia of the kidneys. Hyperglycemia Hyperglycemia is not a manifestation of vaso-occlusive sickle cell crisis. Hearing loss Visual disturbances, rather than hearing loss, are manifestations of vaso-occlusive sickle cell crisis. A nurse is reviewing the laboratory findings of a client who is experiencing chest pain. The nurse should identify that an elevation in which of the following laboratory values indicates cellular injury of myocardial tissue? Amylase An increase in amylase can indicate acute pancreatitis, cholecystitis, or renal failure. Troponin T Troponin T is a myocardial muscle protein that is released into circulation after cardiac injury. The nurse should expect increases in the client's troponin level within 2 to 3 hr following a myocardial injury. Low-density lipoprotein (LDL) Elevated LDL values indicate the risk of coronary artery disease and peripheral vascular disease, which can increase the client's risk for development of a myocardial infarction; however, levels do not increase with myocardial tissue injury. Homocysteine Elevated homocysteine levels indicate the client is at risk for the development of ischemic heart disease, cerebrovascular disease, and peripheral vascular disease; however, levels do not increase with myocardial tissue injury. A community health nurse is performing triage tagging following a mass casualty incident. On which of the following clients should the nurse place a black tag? A client who is alert and has a 2.5 cm (1 in) laceration on the forehead The nurse should place a green tag on a client who is alert and has a 2.5 cm (1 in) laceration on the forehead because this client has an injury that is nonurgent. A client who has significant head trauma and agonal respirations The nurse should place a black tag on a client who has significant head trauma and agonal respirations because this client is not likely to recover or will require extensive resources for care. A client who has an open fracture of the right forearm The nurse should place a yellow tag on a client who has an open fracture of the right forearm because this client has a major injury that requires attention within 30 min to 2 hr. A client who is unconscious and has a rapid, thready radial pulse The nurse should place a red tag on a client who is unconscious and has a rapid, thready radial pulse because this client has a life-threatening injury and requires immediate treatment. A nurse is teaching about total parenteral nutrition (TPN) and IV lipid emulsions with a client who has an extensive burn injury. Which of the following information should the nurse include? "This type of nutrition is more effective than eating by mouth." The client should receive oral or enteral nutrition whenever possible because it enhances the immune system and maintains intestinal motility. However, the client should receive TPN when nutritional needs are greater than oral or enteral nutrition can provide, such as in a client who has burn injuries. "You will receive fingersticks for blood glucose testing." A client who is receiving TPN is at risk for hyperglycemia due to the dextrose in the TPN solution. Therefore, the client will require blood glucose monitoring. "TPN is a way to provide vitamins and minerals without increased calories." TPN provides calories to clients who are unable to eat or who do not have a functioning gastrointestinal tract. A client who has a burn injury is in a hypermetabolic state and requires additional calories, carbohydrates, proteins, and fats. "Taking TPN can increase the risk of developing a latex allergy." The nurse should check the client for an egg allergy, because this can result in an intolerance of the lipid solution and many lipids are composed of egg phospholipids. A nurse is caring for a preschooler on the pediatric unit. Provider Prescriptions Day 1 | 2350: Admit for observation. Obtain vital signs every 4 hr and PRN. Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation above 95%. Initiate saline lock. Administer ceftriaxone 250 mg IV every 12 hr. Administer acetaminophen oral suspension 240 mg every 4 hr PRN for temperature greater than 38° C (100.4° F). Place on a regular diet and encourage oral fluids of the preschooler's choice. Monitor intake and output every 8 hr. History and Physical 2250: Admitted from the emergency department with a diagnosis of pneumonia on the right side with mild pleural effusion Medical history: Preschooler has a history of asthma Allergies: No known allergies Assessment Day 2 0030: Preschooler lying on bed, awake and alert. Breath sounds with wheezing auscultated on expiration on the right side. Nonproductive cough with no retractions or nasal flaring observed. Abdomen soft and nondistended, bowel sounds active in all four quadrants. Preschooler reports headache and pain in abdomen. Rates pain in abdomen as a 2 on a 0 to 10 FACES pain scale. Nurses' Notes Day 2 | 0100: Saline lock inserted on first attempt. Assisted preschooler to right side-lying position for splinting. Administered ceftriaxone IV. Caregiver at bedside. Day 2 | 0130: Preschooler sitting up in bed, appearing anxious and flushed. Lips swollen. Preschooler scratching hives that have appeared on both upper extremities. Vital Signs Day 2 0030: Temperature 38.1° C (100.6° F) Heart rate 122/min Respiratory rate 25/min Oxygen saturation 98% on oxygen at 2 L/min via nasal cannula Weight 17.3 kg (38 lb) Height 102.3 cm (40.3 in) After reviewing the assessment findings, which of the following actions should the nurse take? Monitor urinary output every 2 hr. Discontinue supplemental oxygen. Administer 0.9% sodium chloride IV. Administer epinephrine IM. Discontinue the IV medication. Monitor vital signs frequently When taking actions for a preschooler who is experiencing an anaphylactic reaction, the nurse should discontinue the IV medication, administer 0.9% sodium chloride IV, administer epinephrine IM, and monitor vital signs frequently. Because the nurse administered ceftriaxone, the nurse should discontinue the cause of the reaction; in this case, it is the IV medication. Administering 0.9% sodium chloride IV will help restore fluids, as fluid shifts can occur quickly during a reaction. Administering epinephrine IM is the first line of therapy for anaphylactic reactions because it constricts blood vessels and dilates bronchioles. Monitoring vital signs frequently will allow the nurse to monitor for signs of shock. A home health nurse is planning care for an older adult client who has impaired vision. Which of the following interventions should the nurse include in the plan of care to prevent injury in the home? Mark the edges of stairs for contrast. Marking the edges of stairs with paint or colored tape for contrast can help older adult clients who have impaired vision prevent injury by decreasing the risk of falls. Cover exposed extension cords with throw rugs. Extension cords should be removed from high-traffic areas in the home and placed along the edges of walls. Placing cords under throw rugs can increase an older adult client's risk for falls. Use 40-watt bulbs in lighting fixtures. The nurse should ensure that an older adult client's home has adequate lighting. This includes the use of light fixtures that use at least 75-watt bulbs to optimize the client's visibility. Instruct the client to obtain vision testing once every other year. The nurse should instruct older adult clients to receive vision testing at least once each year. For a client who has impaired vision, it might be necessary for the nurse to recommend vision testing more often. A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching? Constipation The nurse should inform the client that diarrhea, rather than constipation, is a manifestation of digoxin toxicity. Nausea The nurse should instruct the client to monitor for and report manifestations of digoxin toxicity, such as nausea, anorexia, abdominal pain, bradycardia, and visual changes. Wheezing The nurse should inform the client that wheezing is a manifestation of anaphylaxis, not digoxin toxicity. Muscle rigidity The nurse should inform the client that muscle weakness, rather than rigidity, is a manifestation of digoxin toxicity. A nurse is assessing a school-age child who has cystic fibrosis. Which of the following findings is the priority for the nurse to report to the provider? Decreased activity The nurse should report decreased activity to the provider because it can be an indication of pulmonary infection. Hemoptysis 275 mL/24 hr Hemoptysis greater than 250 mL/24 hr indicates that this child is at greatest risk for hemorrhage. Priority finding to report! Fever The nurse should report fever to the provider because it can be an indication of pulmonary infection. Weight loss 2.3 kg (5 lb) The nurse should report anorexia and weight loss to the provider because it can be an indication of pulmonary infection. A nurse is preparing to insert an indwelling urinary catheter for a client. The nurse should assess the client for which of the following conditions prior to starting the procedure? Ketonuria Ketonuria is the presence of ketones in the urine and occurs due to fatty acid catabolism caused by hyperglycemia, starvation, high-protein diets, and alcohol use disorder. Fecal impaction The nurse does not need to assess the client for a fecal impaction prior to the insertion of an indwelling urinary catheter. Latex allergy The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction. A nurse is caring for an adolescent in the emergency department (ED). Nurses' Notes 0700: Adolescent admitted to ED. Adolescent's parents are concerned about left leg injury that appears to be getting worse. Parents report adolescent has had fever, decreased appetite, and decreased energy within the past 2 days. Adolescent reports leg injury occurred while playing soccer. 0715: Alert and oriented to person, place, time, and situation. Adolescent reports left lower leg pain as 4 on a scale of 0 to 10. Heart rate is regular. Capillary refills in less than 3 seconds. Respirations even, unlabored. Lungs clear anterior/posterior. Abdomen soft, nondistended. Bowel sounds hyperactive in all 4 quadrants. Pedal pulses +2 bilaterally. Medial lateral aspect of left lower leg: 3 x 3 cm2 area of redness with small pustules present. Tenderness and warmth noted to the area. Vital Signs 0700: Temperature 38.7° C (101.7° F) Pulse 100/min Respiratory rate 18/min Blood pressure 110/60 mm Hg Laboratory Results 0730: Sodium 132 mEq/L (136 to 145 mEq/L) Potassium 5.0 mEq/L (3.4 to 4.7 mEq/L) BUN 16 mg/dL (5 to 18 mg/dL) WBC count 13,000/mm3 (5,000 to 10,000/mm3) Hgb 9.5 g/dL (10 to 15.5 g/dL) Hct 30% (32% to 44%) Casual blood glucose 250 mg/dL (less than 200 mg/dL) History and Physical Type 1 diabetes mellitus Skin assessment Temperature Pulse Blood pressure WBC count Abdominal assessment Pain Casual blood glucose Potassium After reviewing the information in the adolescent's EMR and recognizing cues, the nurse should identify that the adolescent has a potential skin infection, such as cellulitis. The skin assessment reveals that the medial lateral aspect of the left leg has a 3 x 3 cm2 area of redness with small pustules, tenderness, and warmth, which can indicate infection. The adolescent's temperature and WBC count are above the expected reference range, which can also indicate infection. The adolescent's casual blood glucose and potassium are above the expected reference range, which can indicate infection or a complication of type 1 diabetes mellitus. The nurse should immediately follow up on these findings because they can indicate infection or other complications. A nurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings should the nurse expect? Nystagmus The nurse should expect a client who has autonomic dysreflexia to experience spots in the visual field. Facial flushing The nurse should expect a client who has autonomic dysreflexia to have facial flushing. Flushing occurs from the point of the lesion upward. Diplopia The nurse should expect a client who has autonomic dysreflexia to have blurred vision. Nasal congestion The nurse should expect a client who has autonomic dysreflexia to have nasal congestion. Headache The nurse should expect a client who has autonomic dysreflexia to have a severe headache. A nurse is providing client education to a postpartum client who has decided to bottle feed the newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement? Allow the newborn to breastfeed temporarily. The nurse should instruct the client to avoid nipple stimulation, because it increases milk production, leading to engorgement. Relieve pressure by expressing milk daily. The nurse should instruct the client to avoid expressing milk to prevent further milk production, because this can lead to engorgement. Place ice packs on the breasts for 15 min several times per day. The client should place ice packs on the breasts to reduce swelling and relieve the pain caused by engorgement. Sleep with a loose-fitting bra to prevent nipple stimulation. The client should wear a tight-fitting, supportive bra or breast binder to decrease the discomfort caused by engorgement. A nurse is teaching a newly admitted client who has heart failure about advance directives. Which of the following statements should the nurse make? "You don't need advance directives now because you are competent and can make decisions for yourself." The nurse should instruct the client to complete advance directives while they are competent to make decisions. "You must wait for a period of 6 months after your diagnosis before initiating advance directives." The client has the right to acknowledge their preferences regarding medical decisions, which will be effective immediately without a waiting period. "You will have to speak to an expert who works in the social service department." The nurse has a responsibility to respond to any questions the client has about the purpose of advance directives. Informing the client about advance directives is within the scope of practice of the nurse. "You should complete advance directives in the event you cannot express your own wishes." The client should prepare advance directives to make their wishes known. Incase– unable to communicate in the future. A nurse is teaching a group of guardians about child safety measures. Which of the following statements by a guardian indicates an understanding of the teaching? "I will make sure my 4-year-old child wears a helmet when using a skateboard." Guardians should prevent children who are younger than 5 years old from skateboarding because they are not able to adequately protect themselves from skateboard-related injuries. "I should have my child avoid sun exposure between 10 am and 2 pm." To prevent sunburns, guardians should apply sunscreen, dress their child in protective clothing, and avoid sun exposure between 1000 and 1400. "I can give my 2-year-old child a whole hotdog on a bun." The guardians should cut a hotdog lengthwise for toddlers to prevent choking. "When my infant is in the carrier, I will place it on a raised, flat surface whenever possible." Guardians should avoid placing carriers on raised surfaces to reduce the risk for falls. A nurse is interviewing a client who is now without a home due to a natural disaster. After ensuring the client's safety, which of the following actions should the nurse take first? Assist the client with contacting individuals from the client's support system. The nurse should assist the client with contacting people for support and to get additional help. However, there is another action that the nurse should take first. Give the client information about available community resources for shelter. The nurse should assist the client with locating community resources to secure shelter. However, there is another action that the nurse should take first. Suggest the client obtain mental health counseling. The nurse should assist a client who recently experienced a natural disaster to obtain mental health counseling for further support. However, there is another action that the nurse should take first. Determine the client's perception of the personal impact of the crisis. The first action the nurse should take using the nursing process is to assess the client. Therefore, the first action the nurse should take is to determine the client's feelings and understanding of the natural disaster and its personal impact. A nurse is providing teaching to a parent of a child who has a permanent tracheostomy tube. Identify the sequence of steps the parent should follow to perform tracheostomy care. When teaching the parent to provide tracheostomy care, the nurse should instruct the parent to: ● First remove the inner cannula. ● Next, the nurse should instruct the parent to remove the soiled dressing ● Then clean the stoma with 0.9% sodium chloride irrigation. ● Finally, the nurse should instruct the parent to change the tracheostomy collar. A nurse is caring for a client who vomits on a reusable BP cuff. Which of the following actions should the nurse take? Place the BP cuff in a labeled bag to send it for decontamination. The nurse should place the BP cuff in a labeled bag before removing it from the client's room and sending it to the proper facility location for decontamination. Immediately rinse the BP cuff in hot running water. The nurse should rinse the BP cuff in cold running water prior to sending it for decontamination. Hot water can cause the vomitus to coagulate and stick to the cuff, which can make it difficult to remove. Dispose of the contaminated BP cuff in the bag lining the trash can. The nurse should not dispose of reusable facility equipment, such as a BP cuff. Clean the BP cuff with a chlorine bleach solution. The nurse should use a chlorine bleach solution to clean blood spills. A nurse is caring for a client who is in the manic-phase of bipolar disorder. Which of the following manifestations should the nurse expect? Hypersensitivity to criticism Clients who have avoidant personality disorder are typically hypersensitive to criticism and can exhibit feelings of inadequacy and a fear of rejection. Fears of abandonment Clients who have borderline personality disorder typically have a fear of real or imagined abandonment. Grandiose delusions Clients who are in the manic phase of bipolar disorder typically exhibit behaviors that appear to be euphoric. Clients can also have abrupt mood changes, expansiveness, unlimited energy, poor impulse control, and grandiose delusions. Reclusive behavior Clients who have schizoid personality disorder demonstrate reclusive behavior or social withdrawal. A nurse in a provider's office is caring for a client. Nurses' Notes Day 1 | 0900: Client is 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x 3. Bilateral breath sounds clear. Respirations even and unlabored. S3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air The nurse is assessing the client. Which of the following assessment findings should the nurse report to the provider? Oxygen saturation Dysuria Frequency Urgency Blood pressure Edema When recognizing cues, the nurse should identify that the client's report of frequency, dysuria, and urgency are manifestations of a UTI and should be reported to the provider. These manifestations occur due to bacteria invading the urinary tract through the urethra. A nurse in a provider’s office is caring for a client. Which of the following provider prescriptions should the nurse anticipate. Educate client on new prescription for sulfamethoxazole/trimethoprim. Educate client on new prescription for furosemide. Collect urine specimen for urinalysis. Collect urine specimen for urine culture. Educate client on new prescription for phenazopyridine. Initiate home oxygen therapy regimen. When analyzing cues, the nurse should anticipate provider prescriptions to collect urine specimens for urinalysis and urine culture and to educate the client on new prescriptions for sulfamethoxazole/trimethoprim and phenazopyridine. The nurse should identify that the client is most likely experiencing a urinary tract infection (UTI). UTIs are diagnosed through urinalysis and urine culture. Clients experiencing a UTI should be prescribed an antibiotic and an analgesic for urinary pain relief and frequency. Provider Prescriptions Day 1 | 0930: Collect urine specimen for urinalysis and urine culture and sensitivity. Trimethoprim/sulfamethoxazole 160/800 mg PO twice daily for 10 days. Phenazopyridine 200 mg PO every 6 hr for 2 days. Laboratory Results Day 1 | 1100: Urinalysis Color: Amber (Amber yellow) Appearance: Cloudy (Clear) Specific gravity: 1.04 (1.005 to 1.03) pH: 9 (4.6 to 8) Glucose: None (None) Ketones: None (None) Bilirubin: None (None) Blood: Trace (None) Nitrite: Positive (negative) Leukocyte esterase: Positive (Negative) RBC: 18 (less than 2) WBC: 30 (0 to 4) Urine culture: pending The nurse should determine that the priority hypothesis is that the client is at the highest risk for developing pyelonephritis as evidenced by the client's urinalysis results. The urinalysis indicates dark cloudy urine, increased specific gravity, increased pH, increased red and white blood cells, positive nitrites, positive leukocytes, and trace amounts of blood, which indicate a urinary tract infection (UTI). If left untreated, a UTI can lead to pyelonephritis. Nurses' Notes Day 1 | 0900: Client is 65-year-old who reports pain and burning on urination. Client states, "I am having trouble making it to the bathroom on time and I'm up throughout the night needing to urinate." Client alert and oriented x 3. Bilateral breath sounds clear. Respirations even and unlabored. S 3 auscultated. Lower extremity edema +1. Radial and pedal pulses +2. Bowel sounds normoactive. Client reports no nausea or vomiting. Client has a history of type 2 diabetes mellitus, hypertension, and COPD. Vital Signs 0900: Temperature 37.2° C (99° F) Heart rate 88/min Blood pressure 142/88 mm Hg Respiratory rate 20/min Oxygen saturation 92% on room air The nurse is planning to teach the client how to prevent further UTIs from occurring. Which of the following instructions should the nurse plan to include? Drink orange juice daily. The nurse should instruct the client to avoid citrus juices, which can irritate the urinary tract. The nurse can recommend the client drink at least one glass of cranberry juice daily to decrease the ability of bacteria to adhere to the lining of the urinary tract. Gently cleanse the perineum before intercourse. When generating solutions, the nurse should educate the client on how to prevent future UTIs by cleansing the perineum prior to intercourse. During intercourse, bacteria from the skin can enter the urinary tract, causing infection. Void every 4 to 6 hr during the day. The nurse should instruct the client to void every 2 to 3 hr, rather than every 4 to 6 hr, during the day. Frequent voiding prevents overdistension of the bladder and helps to flush bacteria from the urinary tract. Drink approximately 4 L of fluids daily. The nurse should instruct the client to drink as much as 2 to 3 L, rather than 4 L, of fluids daily, unless contraindicated by other health conditions. Increased fluids promote renal blood flow and help to flush bacteria from the urinary tract. The client returns to the provider’s office 3 days later. 3 days later | 0900: Client returns to office due to orange-colored urine and diarrhea. Client reports drinking a minimum of 3 L of fluids daily as instructed and states, "I'm still going to the bathroom a lot, and I noticed that I am bruising more easily." 3 days later | 0900: Temperature 37.7° C (100.9° F) Heart rate 87/min Blood pressure 144/90 mm Hg Respiratory rate 22/min Oxygen saturation 93% on room air Which of the following assessment findings should the nurse report to the provider as unexpected? Assessment Finding Expected Unexpected Temperature Skin Bowel elimination Blood pressure Voiding pattern Urine color Oxygen saturation When taking action, the nurse should identify that the client's urine color, voiding pattern, oxygen saturation, and blood pressure are expected findings and do not need to be reported to the provider. The client's report of orange urine is an expected finding due to the prescribed medication phenazopyridine, which can cause reddish-orange discoloration of urine. The client's voiding pattern is an expected finding due to increased fluid intake of 3 L daily. The client's oxygen saturation is an expected finding due to the client's history of COPD. The client's blood pressure is an expected finding due to the client's history of hypertension. The nurse should identify that the client's temperature, skin, and bowel elimination are unexpected findings and should be reported to the provider. The client's temperature is above the expected reference range, which can be an indication of Clostridium difficile. The client's diarrhea can also be an indication of C. difficile. The client's unexpected bruising can be an indication of Stevens-Johnson syndrome. C. difficile and Stevens-Johnson syndrome are potential side effects of trimethoprim/sulfamethoxazole. 3 days later | 1100: Urinalysis Color: Orange (Amber yellow) Appearance: Clear (Clear) Specific gravity: 1.005 (1.005 to 1.03) pH: 4.6 (4.6 to 8) Glucose: Trace (None) Ketones: None (None) Bilirubin: None (None) Blood: None (None) Nitrite: Negative (negative) Leukocyte esterase: Negative (Negative) RBC: 0 (less than 2) WBC: 0 (0 to 4) Findings that indicate the client’s urinary tract infection is improving. Specific gravity pH WBC Glucose Urine color Heart rate Respiratory rate Fluid intake When evaluating outcomes, the nurse should identify that the client's urinary tract infection (UTI) is improving as evidenced by the client's urine specific gravity, pH, and WBC results. These findings are within the expected reference ranges and indicate that the medication has been effective in treating the UTI. A nurse is assessing a client who has antisocial personality disorder. Which of the following manifestations should the nurse expect? Lack of remorse A client who has antisocial personality disorder is more likely to show a lack of remorse. Sensitivity to rejection A client who has narcissistic personality disorder is more likely to show sensitivity to rejection. Extreme mood swings A client who has bipolar disorder is more likely to exhibit extreme mood swings. Self-mutilating behavior A client who has a borderline personality disorder is more likely to exhibit self-mutilating behaviors. A nurse is providing discharge instructions to a client who has a new prescription for warfarin. Which of the following client statements should the nurse identify as an indication that the client understands the teaching? "I should report a change in the color of my stools." The nurse should inform the client that red, black, or tarry stools can indicate bleeding, an adverse effect of warfarin, and the client should report these findings to the provider. "I can take acetaminophen to treat a headache." The nurse should inform the client that taking acetaminophen can increase the risk for bleeding. "I will take a calcium supplement while taking this medication." The nurse should inform the client that calcium supplements are not i