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NCLEXRN2023
| Question | Answer |
|---|---|
| A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause | Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. |
| A client who had a cholecystectomy has a T-tube for drainage. The nurse measures the amount of bile drainage from the T tube at the end of each shift. How should the nurse record the drainage? | T-tube bile drainage is recorded separately on the output record. Adding the t-tube drainage to the urine output or wound drainage makes it difficult to accurately determine the amounts of bile, urine, or drainage. |
| Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis? | A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. |
| When assessing a client’s inguinal hernia, the nurse should place the client in which position? | For the best assessment of an inguinal hernia, the client should be in a standing position to allow the examiner to palpate for the inguinal ring. |
| A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. Which nursing diagnosis should receive top priority? | In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. fluid volume excess is present, the diagnosis ineffective breathing pattern takes precedence |
| One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has: | An appropriate expected outcome is for the client to achieve optimal nutritional status through the use of oral feedings or total parenteral nutrition (TPN) |
| A client who had a splenectomy yesterday has a nasogastric (NG) tube. What should the nurse assess to determine the effectiveness of the NG tube? | A splenectomy may involve manipulation of the upper abdominal organs, such as diaphragm, stomach, liver, spleen, and small intestines. An NG tube is placed to decrease abdominal distention in the immediate postoperative phase. |
| A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note | Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. |
| A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will | For a colonoscopy, the nurse initially should position the client on the left side with knees bent to permit proper visualization of the large intestine. |
| A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's best response? | The nurse should explain that the incidence of breast cancer increases with age and current guidelines recommend women have a mammogram every 2 years until age 74. |
| The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next? | The normal calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.63 mmol/L). Hypercalcemia is commonly seen with malignant disease and metastases |
| A nurse is teaching a community class about how to decrease the risk of cancer. What is the best food for the nurse to recommend? | A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. |
| A client receiving chemotherapy for cancer has an elevated serum creatinine level. What should the nurse do next? | Nephrotoxicity caused by chemotherapy is assessed by monitoring serum creatinine. Creatinine is the most sensitive indicator of proper kidney function. In this case the client is experiencing decreased kidney function, most likely due to the chemotherapy. |
| The client with colon cancer has an abdominal-perineal resection with a colostomy. To promote hygiene following surgery, what should the nurse do? | Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. |
| During handing-off communication, the nurse in the cardiac step-down unit learns that a client with a history of anterior wall myocardial infarction has had high normal pulmonary artery wedge pressures. For what should the nurse assess? | High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop and cause pulmonary crackles. In left-sided heart failure, hypotension may result. |
| A client in the emergency vomiting and diarrhea for the previous 24 hours. blood pressure is 90/60 mm Hg, respiration 20 breaths minute, heart rate 92 beats per minute, temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first? | Then the nurse should treat the fluid volume deficit, then the temperature. This client has hypotension, and the nurse would raise the legs, not the head, of the bed first to improve perfusion to the brain, as it is the least restrictive intervention. |
| The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which finding requires further evaluation? | An ankle-brachial index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication |
| Which assessment finding supports the administration of protamine sulfate? | Protamine sulfate is the antidote specific to heparin.aPTT heparinized clients is 2–2.5 times normal. INR relates to therapy with warfarin, not heparin. An INR value of 8 is abnormally high and administration of vitamin K, the antidote for warfarin. |
| Which position is best for a client with heart failure who has orthopnea? | Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. |
| A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should | RT upper abdomen (the area over the liver) compressed 30 to 40 seconds, observes internal jugular vein. internal jugular veinbecomesdistended,positivehepatojugularreflux.Hepatojugular reflux, a sign of right-sided heart failure, assessed bed 45-degr |
| The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? | The nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? |
| A client receiving digoxin has a serum magnesium level of 0.9 mg/dL (0.57 mmol/L). What is the nurse’s best action? | The decreased magnesium level can potentiate digoxin toxicity, healthcare provider notified. The digoxin not be administered until the nurse receives clarification from the healthcare provider. Calcium gluconate is administered for hypermagnesemia. |
| What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine? | When given to treat acute MI, morphine eliminates pain, reduces preload and afterload, reduces vascular resistance, reduces cardiac workload, and reduces the oxygen demand of the heart. |
| To relieve chest pain associated with pericarditis, which position should the nurse encourage the client to assume? | The nurse should encourage the client to lean forward, because this position causes the heart to pull away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. |
| A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal? | The client's symptoms heart failure. BNP is a neurohormone that's released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/ml associated with mild heart failure. |
| While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. What is the nurse’s next action? | The nurse measures the apical-radial pulse for a deficit; apical rate minus radial rate. A deficit is present during atrial fibrillation, and premature ventricular contractions because some heart beats do not perfuse to distal areas. |
| The client is to go to an anticoagulant monitoring laboratory every 3 weeks. The last visit to the laboratory was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse should instruct the client to do? | These symptoms suggest that the client is receiving too much warfarin; the client should return to the laboratory and have a blood sample drawn to determine the prothrombin levels and have the dosage of warfarin adjusted. |
| The nurse teaches the client with a demand pacemaker that the device functions by providing stimuli to the heart muscle: | A demand pacemaker functions only when the heart rate falls below a certain level. A fixed-rate pacemaker stimulates heart contractions at a constant rate independent of the client’s heart rate. |
| A term primigravida in a car accident 3 hours ago. having labor contractions every 4 minutes, and her cervical exam is dilated 3 cm, 100% effaced, and station −1. states her pain is constant severe, 10/10. What is the nurse’s the priority action? | The woman is at risk for placental abruption due to her recent car accident. Symptoms of a placental abruption include unrelenting pain and a rigid boardlike abdomen. She may or may not have vaginal bleeding. |
| A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? | Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. |
| A client currently on bed rest for a threatened abortion begins to experience bearing-down sensations and suddenly expels tissue. What is a priority action for the nurse? | This will assist in determining the client’s status based on vital signs and blood loss. An assessment is needed prior to transfer to the birthing room. There is no need for sedation at this time. |
| A client has her first prenatal visit at 15 weeks' gestation. The client weighs 144 lb (65.5kg) and states this is a 4-pound weight gain. Which assessment finding requires further investigation? | Fundal height (in centimeters) should roughly equal the number of weeks' gestation. This client should have a fundal height of 15 to 16 cm. A height of 18 cm could be indicative of many things, including multiples or polyhydramnios |
| A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid–base balance? | The kidney performs two major functions to assist in acid–base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. |
| When assessing a client who is receiving tricyclic antidepressant therapy, the nurse should be alert for which finding that could suggest the client is experiencing anticholinergic effects? | Anticholinergic effects, which result from blockage of the parasympathetic nervous system, include urine retention, blurred vision, dry mouth, and constipation. |
| During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which intervention would be most appropriate to institute? | A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore, extraneous noise should be minimized and bright lights avoided as much as possible. |
| he nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? | nonstress test, an electronic fetal monitor provides a tracing of (FHR). FHR accelerates , indicating fetus has an intact autonomic nervous system not affected by uterine hypoxia. A reactive (normal) nonstress test with two accelerations going up 15 be |
| An adolescent primigravid client at 26 weeks' gestation has gained 25 lb (11.34 kg) since becoming pregnant. Which of the following is the recommended amount of weight gain during the third trimester? | Clients should be advised to gain a total of 25 to 35 lb (11.34 to 15.88 kg) if they are of average weight when becoming pregnant. The recommended pattern is 1 lb (0.45 kg) per month in the first trimester, then 1 lb (0.45 kg) per week in the second and |
| The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client’s condition? | A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed p |
| When an infant with pyloric stenosis is admitted to the hospital, which aspect of the plan of care should the nurse implement first? | Unless the infant is in hypovolemic shock, obtaining a baseline weight is an important first action because the weight is used to calculate the child’s fluid and electrolyte needs. |
| A client at 39 weeks' gestation comes to the labor and delivery suite. The client states the membranes ruptured 12 hours ago. What priority assessment will the nurse perform? | When membranes rupture, the priority focus should be on assessing the FHR first to identify a deceleration, which might indicate cord compression secondary to cord prolapse. |
| A client with schizophrenia hears a voice saying the client is evil and must die. The nurse understands that this client is experiencing: | A hallucination is a sensory perception, such as hearing voices and seeing objects, that only the client experiences. A delusion is a false belief. Flight of ideas refers to a speech pattern in which a client skips from one unrelated subject to another. I |
| A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound? | A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the peric |
| Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? | Administering pain medication would have the highest priority during the first hour after the client’s admission. |
| Which client has the highest risk of ovarian cancer? | he incidence of ovarian cancer increases in women who have never been pregnant, are older than age 40, are infertile, or have menstrual irregularities. Other risk factors include a family history of breast, bowel, or endometrial cancer. The risk of ovaria |
| A client with a diagnosis of schizophrenia is experiencing paranoia and tells the nurse about hearing a voice saying, "Don't take those poisoned pills from that nurse!" Which objective assessment regarding this statement will the nurse report to the healt | Hallucinations are sensory experiences of perception without corresponding stimuli in the environment. This client objectively reports to the nurse the fearfulness and experience of this hallucination—a perceptual disturbance. This differs from the though |
| After a nasogastric (NG) tube has been inserted, which finding helps the nurse determine that the tube is in the proper place? | Measuring the pH of the aspirated gastric fluid is the most accurate determination of the placement of the NG tube. A pH lower than 4 indicates that the tube is in the stomach. Whether or not the client is gagging or coughing is not an accurate way to det |
| What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right modified radical mastectomy? | Treatment for cellulitis includes oral or intravenous antibiotics for 1 to 2 weeks, elevation of the affected extremity, and application of warm, moist packs to the site. Arm exercises help to reduce swelling, but do not treat the infection. |
| Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy? | Warfarin sodium interferes with clotting. The nurse should monitor the PT and evaluate for the therapeutic effects of coumadin. A therapeutic PT is between 1.5 and 2.5 times the control value; the PT should be established by the health care provider (HCP) |
| A mother tells a nurse that her child has been exposed to roseola. After the nurse teaches the mother about the illness, which finding, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? | Children with roseola have a high fever for 3 days, which drops suddenly. Then a nonpruritic rash appears, typically lasting for 1 to 2 days. High fever followed by a rash is a characteristic sign. Associated symptoms include cold symptoms, cough, and lym |
| The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? | primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce w |
| The nurse is working on a psychiatric unit with new admissions with suicidal ideation. What characteristic is being described by a client who states, "I want to live, but maybe the answer is to die"? | One of the characteristics most commonly shared by suicidal persons is ambivalence, an internal struggle between self-preserving and self-destructive forces. These doubts are expressed when a person threatens or attempts suicide and then tries to get help |
| Parents of a neonate who is 32 weeks of age ask the nurse, “Why does he have a feeding tube in his nose?” What is the nurse’s best response? | At 32 weeks’ gestation, a neonate has limited ability to coordinate sucking, swallowing, and breathing. The sucking reflex is present at 32 weeks’ gestation, but the neonate cannot coordinate the reflex with swallowing and breathing. The stomach has the c |
| A client has an International normalized ratio (INR) of 1.6, creatine kinase-MB (CK-MB) of 90 μ/L, troponin 2.1 ng/L, and myoglobin 90 μg/L. Which result requires the nurse to take action? | Troponins I and T are cardiac enzymes that are only released when the cardiac muscle is damaged. Elevation of these values above the respective reference ranges of 0–0.1 ng/L or 0–0.2 ng/L indicates a myocardial infarction. Myoglobin is released when musc |
| A client's membranes broke Her medical history includes testing positive for human immunodeficiency virus (HIV). The client inquires about having the fetal scalp electrode placed because she's worried about her baby. Which response by a nurse is best? | The nurse should explain to the client that fetal scalp electrode application increases the risk of maternal-fetal HIV transmission. Therefore, its use is contraindicated in clients that test HIV positive. Explaining what the fetal scalp electrode is, how |
| A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the | The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the inserti |
| A nurse is discussing principles in healthcare ethics with the nursing students. Which would be an appropriate example of nonmaleficence? | Protecting clients from a chemically impaired practitioner is an appropriate example of nonmaleficence, which means to avoid doing harm, to remove from harm, and to prevent harm. Performing dressing changes to promote wound healing, providing emotional su |
| When assessing a client with diabetes for diabetic nephropathy, the nurse should determine if the client has: | Asymptomatic proteinuria is an initial sign of diabetic nephropathy. Microscopic proteinuria should be monitored yearly in all clients with diabetes for over 5 years. Polyuria and increasing glycosuria are symptoms of poorly managed diabetes. Ketonu |
| When assessing a client with pheochromocytoma, a tumor of the adrenal medulla that secretes excessive catecholamine, the nurse is most likely to detect | Pheochromocytoma causes hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss. It isn't associated with hypotension, hypoglycemia, or bradycardia. |
| The nurse is assessing a client with an A-V fistula. Which finding should the nurse report to the healthcare provider? | The nurse’s priority is to ensure adequate circulation to the arm with the fistula. Discoloration may indicate poor circulation at the fistula site. A bruit (murmur) and vibration (thrill) should be assessed. Wearing long sleeves would be appropriate as l |
| The nurse is assigned to care for the following clients. Which client should the nurse see first? | A heart rate of 48 beats per minute may have significant implications for cardiac output and hemodynamic stability. Clients with Graves disease usually have a rapid heart rate, but 94 beats per minute is a normal finding. The diabetic client may need slid |
| A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer | This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or |
| Which goal is the priority for a client in Addisonian crisis? | Addison’s disease is caused by a deficiency of adrenal corticosteroids and can result in severe hypotension and shock because of uncontrolled loss of sodium in the urine and impaired mineralocorticoid function. This results in loss of extracellular fluid |
| A client with type I diabetes mellitus is scheduled to have surgery. The client has been nothing-by-mouth (NPO) since midnight. In the morning, the nurse notices the client’s daily insulin has not been prescribed. Which action should the nurse do first? | The nurse should first obtain the blood glucose level and then contact the health care provider to clarify whether the client’s usual insulin dose should be given before surgery; having the blood glucose level is objective information that the health care |
| The health care provider (HCP) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin. What should the nurse teach the client about this insulin? | Insulin detemir is used only if the solution appears clear and colorless with no visible particles. Insulin detemir is not diluted or mixed with any other insulin preparations. As with any insulin therapy, lipodystrophy may occur at the injection site and |
| A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has | Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. |
| Clients with peptic ulcer disease is characterized by severe abdominal pain that presents several hours after a large meal. | complain of a dull, gnawing epigastric pain that's relieved by eating. |
| Appendicitis | ischaracterized by a periumbilical pain that moves to the right lower quadr ant and rebound tenderness. |
| Cholelithiasis | is characterized by severe abdominal pain that presents several hours after a large meal. |
| Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? | must be handled with strict aseptic technique (due to the high glucose content, it is a perfect medium for bacterial growth). Also, because of the high tonicity, TPN must be administered through a central venous access, not a peripheral IV line. There is |
| When caring for a client with ulcerative colitis the nurse should: | Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential. Sitz baths are comforting and cleansing.It is not appropriate to administer stool softeners to a client with diarrhea. |
| A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? | Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, wh |
| A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score? | The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points. |
| A client had a thrombotic cerebrovascular accident and now has flaccid hemiplegia of the right side. When can the health care team begin rehabilitation for this hospitalized client? | Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time the client is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities. This goal is achieved through such techniques as po |
| The nurse is teaching a young female about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client makes which statement? | An alternative or additional method of birth control must be used because oxcarbazepine reduces the effectiveness of oral contraceptives. Higher doses of oral contraceptives will not help in achieving this purpose, but the client needs an additional or al |
| A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? | Systemic absorption of atropine can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instil |
| A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first? | Initially, the extracellular fluid volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greate |
| After the nurse teaches the parent of an infant with pyloric stenosis about the condition, which cause, if stated by the parent, indicates effective teaching | Pyloric stenosis involves hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration. Telescoping of the bowel is called intussusception. Overfeeding, feeding to |
| A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of what would be significant to this client's diagnosis? | The client's symptoms are suggestive of ulcerative colitis, and a family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, is a risk factor. A family history of peptic ulcers, celiac disease, or appendicitis |
| A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to | A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and |
| A client with Raynaud’s phenomenon is prescribed diltiazem. The nurse should assess the client for which intended outcome of this drug? | Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with Raynaud’s phenomenon when other therapies are ineffective. Diltiazem relaxes smooth muscles and improves peripheral perfusion, thereby reducing finger numbness. Dilt |
| A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern? | When there is a history of atherosclerosis affecting the heart and resulting in intermittent claudication, there is arterial insufficiency. This results in inadequate provision of oxygenated blood to the muscles when there is an increase in muscle demand. |
| A nurse knows that the major clinical use of dobutamine is to | Dobutamine, a catecholamine agent, increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Ph |
| mechanic receives emergency care for corneal injury. The physician orders dexamethasone, two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate, 0.5% ointment to be placed in the c | Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This action reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone and other anti-inflam |
| A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention? | The student nurse shouldn't keep the client in one position. The student nurse should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be cl |
| A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates | Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction |
| The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which symptom? | The client with sensorineural hearing loss has difficulty hearing high-pitched sounds. Aging and ototoxicity are two causes of sensorineural hearing loss. The client’s ability to speak is not affected. The client who cannot assign meaning to sound has cen |
| What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock? | Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate. Hypothermia-hyperthermia machines ar |
| A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine, 0.5 mg P.O. daily, and asks when the client takes the drug each day. Which response indicates that the client underst | To minimize the risk of adverse drug reactions, the client should take benztropine as a single dose at bedtime. Taking it on arising in the morning or taking it with or after a meal wouldn't minimize adverse effects. |
| The nurse is evaluating the therapeutic goal of a client with history of cardiac dysrhythmias and newly completed radiofrequency catheter ablation. Which client-centered goal is most appropriate? | The therapeutic goal of radiofrequency catheter ablation is to destroy errant tissue in hopes of allowing impulse conduction to travel over appropriate pathways. The goal does not include dilation of blood vessels or reperfusion of heart tissue. There is |
| Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next? | Normal therapeutic serum phenytoin level ranges from 10 to 20 mcg/ml. No nursing action is needed at this time. |
| During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates | Swallowing motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII no motor.cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. cranial nerve V chewing. Cranial nerve VI lateral eye movement. |
| A client develops atrial fibrillation following an acute myocardial infarction. The physician orders digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to | I.M. administration of digoxin isn't recommended causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels, digoxin doesn't increase the serum creatinine level. When digoxin is administered, serum d |
| A client’s electrocardiogram (EKG) tracing shows normal sinus rhythm followed by three premature ventricular contractions (PVCs) and a return to normal sinus rhythm. What is the priority action of the nurse? | Nonsustained ventricular tachycardia is several consecutive PVCs followed by the return to normal sinus rhythm. PVCs may reduce the CO and lead to angina and heart failure depending on frequency. Because PVCs in CAD or acute MI indicate ventricular irrita |
| A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by | To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes |
| he nurse should adjust a client's heparin dose according to a prescribed anticoagulation order based on maintaining which laboratory value at what therapeutic level for anticoagulant therapy? | The nurse should adjust the heparin dose to maintain the client's partial thromboplastin time between 1.5 and 2.5 times the normal control. The prothrombin time and International Normalized Ratio are used to maintain therapeutic levels of warfarin, oral a |
| When a client is receiving a cephalosporin, the nurse should monitor the client for which finding? | Drug-induced hemolytic anemia is acquired, antibody-mediated, red blood cell destruction precipitated by medications, such as cephalosporins, sulfa drugs, rifampin, methyldopa, procainamide, quinidine, and thiazides. Purpura is a condition with various ma |
| After instructing a 20-year-old nulligravid client about the adverse effects of oral contraceptives, the nurse determines that further instruction is needed when the client states which factor as an adverse effect? | The nurse determines that the client needs further instruction when the client says that one of the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that ovarian and endometrial cancers are reduced in women using oral cont |
| Which factor best indicates that a client is complying with digoxin therapy? | A client who complies with drug therapy is less likely to have a recurrence of cardiac failure. Client knowledge of how to check a radial pulse and actions to take if it is not within normal limits can prevent a toxic digoxin reaction. The other choices d |
| The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site has which appearance? | A properly administered intradermal injection shows evidence of a bleb at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection |
| Anticholinergic drug | Atropine |
| Atropine/eye=mydriasis | dialation of the pupil |
| Atropine/eye-cycloplegia | inability to focus visually/unresponsive to light |
| Atropine/eye-uses | before eye surgery inflammatory conditions of the eye |
| Other drugs like Atronpine | cyclopenolate,tropicamide |
| Atropine/GI | reduction of GI motility from stomach to colon prolong gastric emptying;lengthened intestinal time |
| Atropine heart | tachycardia |
| Salivary.Sweat,lacrimal glands/Atropine | dry mouth,dry skin,increased temp |
| Scopolamine | motion sickness,POST operative n/v |
| Ipratropium | use up to 4Xs a day |
| Tiotropium | once a day |
| over active bladder meds | TOLTERODINE DARIFENACIN SOLIFENACIN OXYBUTYNIN TROSPIN FESOTERODINE |
| meds for Parkinson like disorders | BENZTROPINE TRIHEXYPHENIDYL |
| Adverse effects/Anticholinergics ABCDs | agitation, blurred vision, constipation& confusion, dry mouth ,stasis of urine & sweating |
| Tricyclic Antidepressants | AMITRITYPLINE AMOXAPINE DESIPRAMINE DOXEPIN IMIPRAMINE |
| SSRIs | escitalopram,sertraline |
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hobart3809