NCLEX PN Saunders Assessment Practice 4 (Answered)

NCLEX PN Saunders Assessment Practice 4 (Answered) caring for a patient with flu like symptoms plenty of rest, increase intake of fluids, encourage client take antipyuretics to decrease fever. plan of action for the emergency department, in an event of internal fire. direct ambulating clients to walk to a safe location, remove all clients from danger before attempting to extinguish the fire, move bedridden clients away from the fire are by use of beds or stretchers. pregnant client receiving MAGNESIUM SULFATE for management of PREECLAMPSIA. client is experiencing toxicity from medication respirations of 10 bpm toxicity= cns depressant effects, respirations lower than 12 per minute, a LOSS of deep tendon reflexes, a sudden drop in fetal HR or maternal HR and BP. protienuria is noted 3+ in preeclampsia tb skin test administered to an individual with HIV. 72 hrs later your document should show POSITIVE results with area of induration at the test site measuring 7mm. normally area of induration greater than 15 mm is considered positive in low-risk. 5mm + in individuals with HIV infection is considered positive. An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent. Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply. Encourage frequent urination, Continue maternal and fetal assessments, Review breathing and relaxation techniques. Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor... client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition? An episode of diarrhea Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply Eat smaller and more frequent meals. Drink fluids between meals not with them. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals not with them to avoid dumping syndrome. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? "No eating or drinking for at least 18 hours before the surgery." Rationale: The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing per mouth (NPO) for 18 hours before surgery. A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet? Ice cream Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply. Place the child on a low-bacteria diet, Change dressings using sterile technique,Perform meticulous hand washing before caring for the child. Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy). Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item? blood pressure Rationale: Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. The nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse should monitor for which adverse effects of this medication? Select all that apply. Flushing, Depressed respirations, Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which is noted on data collection? Respirations of 10 breaths per minute Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs? Naloxone (Narcan) Rationale: Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which condition? Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should question administration of the medication if which condition is documented in the client's medical history? Peripheral vascular disease Rationale: Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student makes which statement? "I will flush the eyes after instilling the ointment." Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after the instillation of the medication because the flush will wash away the administered medication. A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, which medication does the nurse anticipate will be prescribed? Betamethasone Rationale: Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. The nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should discontinue the oxytocin infusion and notify the registered nurse if which is noted on data collection of the client? Uterine hyperstimulation Rationale: Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse reinforces instructions to the mother and tells the mother to administer the iron with which best food item? Orange juice Rationale: Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 9 months Rationale: Isoniazid is given to prevent tuberculosis (TB) infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended. infants and children, the recommended duration of isoniazid therapy is 9 months. children with human immunodeficiency virus infection, a minimum of 12 months 12 months Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client knowing that which would indicate the presence of systemic toxicity from this medication? Tinnitus Rationale: Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which time? At least 30 minutes before exposure to the sun Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating. Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which is the most appropriate nursing action? Informing the client that this is normal Rationale: Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates a systemic effect has occurred? Hyperventilation Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? Triglyceride level Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area? Axilla Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia) and lower from regions in which permeability is poor (back, palms, soles). The clinic nurse is collecting data on a client being admitted. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription the nurse should suspect that the client is being treated for which condition? Acne Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. The acid appears to work by suppressing the growth of Propionibacterium acnes and decreasing the proliferation of keratinocytes. Azelaic acid is a topical medication used to treat mild to moderate acne. The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments? "The medication will permanently stain my skin." Rationale: Silver sulfadiazine (Silvadene) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin. A client with severe acne is seen in the clinic, and the health care provider (HCP) prescribes isotretinoin (Amnesteem, Clavaris). The nurse reviews the client's medication record and should contact the HCP if the client is taking which medication? Vitamin A Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? Notify the registered nurse. Rationale: When antineoplastic medications are administered via IV, great care must be taken to prevent the medication from escaping into the tissues surrounding the injection site because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the registered nurse needs to be notified; he or she will then contact the health care provider. The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Pulmonary function studies Rationale: Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication? Uric acid level Rationale: Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply. Tinnitus, Ototoxicity, Nephrotoxicity, Hypomagnesemia Rationale: Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity. The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Consult with health care providers (HCPs) before receiving immunizations. Rationale: Because antineoplastic medications lower the immune response of the body, clients must be informed not to receive immunizations without a HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side effects. The client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which adverse effect is specific to this medication? Extremity numbness Rationale: An adverse effect specific to vincristine is peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history? Pancreatitis Rationale: Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between administration of the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. Tamoxifen (Soltamox) is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication? Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Rationale: Tamoxifen (Soltamox) is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen reduces DNA synthesis and estrogen response. The client with metastatic breast cancer is receiving tamoxifen (Soltamox). The nurse specifically monitors which laboratory value while the client is taking this medication? Calcium level Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain. The client with small cell lung cancer is being treated with etoposide (Toposar). The nurse assisting in caring for the client during its administration should understand that which side/adverse effect is specifically associated with this medication? Orthostatic hypotension Rationale: A side effect specific to etoposide (Toposar) is orthostatic hypotension. The client's blood pressure is monitored during the infusion. The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which reason? Treat hypocalcemic tetany. Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the health care provider is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching Withdraws the NPH insulin first Rationale: When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information? Refrigerate the insulin. Rationale: Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen because freezing affects the chemical composition of the insulin. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply. Diarrhea can occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. Candy or another simple sugar is carried and used to treat mild hypoglycemia episodes. Rationale: Repaglinide is a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen. The nurse is monitoring a client receiving levothyroxine sodium (Synthroid) for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. Insomnia, Weight loss, Mild heat intolerance Rationale: Insomnia, weight loss, and mild heat intolerance are side effects of levothyroxine sodium. Bradycardia and constipation are side effects are associated with hypothyroidism The health care provider (HCP) prescribes exenatide (Byetta) for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? The medication is withheld and the HCP is called to question the prescription for the client. Rationale: Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the HCP regarding this prescription. A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client