Next generation NCLEX-PN ACTUAL EXAM

SEPTEMBER AND OCTOBER VERIFIED 100%

GURANTEED
chloride level

98-107

bicarbonate level

22-29

respiratory acidosis

low pH, high CO2

respiratory alkalosis

high pH, low CO2

metabolic acidosis

low pH, low HCO3

metabolic alkalosis

high pH, high HCO3

PaCO2 normal range

35-45

PaO2 normal range

80-100

interventions for respiratory alkalosis

voluntary holding of breath, or slowed breathing and the rebreathing of exhaled CO2 by methods such
as using paper bag or a rebreathing mask.

Kussmauls respirations
Respirations that are regular but abnormally deep and increased in rate

respiratory acidosis s/s

Drowsiness
Disorientation
Dizziness
Headache
Coma
↓BP
V-Fib
Hyperkalemia
Rapid/Irregular HR
Warm, flushed skin
Seizures
Hypoventilation
Hypoxia
Cyanosis

Respiratory Alkalosis S/S

lethargy
lightheadedness
confusion
tachycardia
dysrhythmias related to hypokalemia
nausea
vomiting
epigastric pain
numbness and tingling of the extremities
hyperventilation (tachypnea)

metabolic acidosis s/s

Drowsiness
Confusion
Headache
Coma
↓BP
Dysrhythmias (R/T Hyperkalemia)
Warm, flushed skin
Nausea/Vomiting/Diarrhea/Abdominal pain
Deep, rapid respirations

metabolic alkalosis s/s

Drowsiness
Diziness
Nervousness
Confusion
↑HR
dysrhythmias r/t hypokalemia
Anorexia/Nausea/Vomiting
Tremors
Hypertonic muscles
Muscle cramps/Tetany/Tingling in extremeties/Seizures
Hypoventilation

A client is admitted to the emergency department with a diagnosis of acute myocardial infarction (MI).
Which prescriptions should the nurse anticipate implementing? Select all that apply.

Aspirin,Oxygen ,Morphine,Nitroglycerin

As soon as a patient with an acute MI is brought to the emergency department, measures are taken to
relieve pain, decrease ischemia, and prevent further circulatory collapse and shock. The MONA
(morphine, oxygen, nitrates, aspirin) regimen is initiated.

A client has been on total parenteral nutrition for 8 weeks. The primary health care provider
prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued.
The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of
dragging it on for 3 days?" The nursing response should be to explain that the primary health care
provider is concerned about which phenomenon?

Rebound hypoglycemia

Clients receiving total parenteral nutrition are receiving high concentrations of glucose. To give the
pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before
discontinuing the parenteral nutrition, the body must adjust to the lowered glucose levels. If the total
parenteral nutrition were suddenly withdrawn, the client would probably have rebound hypoglycemia.

PTT time (heparin therapy/coagulation disorders)

25-35 seconds

PT time

11-12.5 seconds

INR

0.81-1.2 (2-3 for warfarin therapy, 3-4.5 for high dose warfarin)

male hematocrit
42-52%

female hematocrit

37-47%

BUN level

6-20

Theraputic PTT

between 1.5-2.5 times normal, value should not be less than 40 or greater than 87.5 seconds

segmented neutrophils (segs)

60-70%

patient on ibuprofen, the nurse realizes that consulting RN is necessary because the pt is also taking
what meds..

Warfarin, Glimepiride, Alodipine

NSAIDS should not be combined with anticoagulants (Warfarin), hypoglycemia can occur as an adverse
effect (Glimepiride), Toxicity can result if NSAIDS are combined with calcium channel blocker (Alodipine)

normal FASTING blood glucose

70-100

Calcium foods

cheese, collard greens, milk and soy milk, Rhubarb, sardines, tofu, yogurt

iron foods

breads and cereal, dark green veggies, dried fruits, egg yolk, legumes, liver, meats

magnesium foods

avocados, canned white tuna, cauliflower, cooked rolled oats, green & leafy veggies, milk, peanutbutter,
peas, pork, beef, chicken, potatoes, yogurt,

potassium foods

avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, pork, beef, veal, potatoes, raisins,
spinach, strawberries, tomateos
Zinc foods

eggs, green & leafy veggies, meats, protein rich foods

clear liquids

water, bouillon, clear broth, carbonated drinks, jello, hard candy, lemonade, ice pops, coffee/tea

full liquid diet

all clear liquids AND plain ice cream, sherbet, breakfast drinks, milk, pudding, custard, strained soups,
refined cooked cereal, fruit juice, strained veggie juice

pt having trouble with blood clotting, which food item should the client eat?

Green & leafy veggies

high in vitamin K, which acts as catalyst for facilitating blood clotting factors.

pt is a lacto-vegetarian, which food should be removed from tray?

Eggs

eat milk, cheese, dairy food but avoid meat, fish, poultry and eggs

Riboflavin food

milk, lean meats, fish, grains.

foods for wound healing

protein and vitamin C

chicken breast, milk, broccoli, and strawberries

Abruptio placentae

premature separation of the placenta from the uterine wall after the twentieth week of gestation and
before the fetus is delivered. The goal of management in abruptio placentae is to control the
hemorrhage and deliver the fetus as soon as possible.

Placenta previa

an improperly implanted placenta in the lower uterine segment near or over the internal cervical os.
Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is
made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A
diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are
monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring
(external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

Sengstaken-Blakemore tube

used for tx of esophageal varices, purpose is to hold pressure on bleeding varices, keep scissors at
bedside.Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or
asphyxiation. The tube should be cut and removed to prevent airway obstruction.

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air
embolism. Which action should the nurse take first?

Place the client on the left side with the head lowered.

Lying on the left side may prevent air from flowing into the pulmonary veins. Placing the head lower than
the body increases intrathoracic pressure, which decreases the amount of blood pulled into the vena
cava during inspiration.

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure.
The nurse should obtain which medication from the emergency cart to have ready for use as
prescribed?

Epinephrine

the symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other
common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness.
The nurse prepares to administer epinephrine and corticosteroid medications as prescribed.

air embolism s/s

chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air
embolism, auscultation over the right ventricle may reveal a churning "windmill" sound.

Signs of placental abruption

tender, rigid abdomen; pain; severe, dark red vaginal bleeding; maternal shock (hypotension); and fetal
distress.

The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous
infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?

Nalmefene

Nalmefene is a long-acting antagonist that is used to treat opioid overdose. Naloxone is also used to
treat opioid overdose.

Assessment findings with cardiac tamponade

tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure,
accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg).

Calcitonin

Lowers blood calcium levels

infiltrated IV s/s

Cool to touch, Swelling at the site, May not have a blood return

The nurse is caring for a client who had a small bowel resection the previous day and has continuous
gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse
anticipate to be prescribed for the client?

Lactated Ringer's solution

Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract
losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose
and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is
essential for calories when a client takes nothing by mouth (NPO).

When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths
per minute to an adult client?

10

Early signs of theophylline toxicity (asthma)

nausea, vomiting, tachycardia, headache, and irritability. Seizures indicate a toxicity level greater than 30
mcg/mL. A normal theophylline level is 10 to 20 mcg/mL.

During the emergent phase after a major burn injury, which abnormalities should the nurse expect to
note?

During the emergent phase of a burn injury, the client's hemoglobin and hematocrit will be elevated
because of fluid loss. Sodium will be decreased because of trapping in edema fluid and loss through
plasma leakage. Potassium will be increased because of disruption of the sodium-potassium pump,
tissue destruction, and red blood cell hemolysis, and albumin will be low because of loss through the
wound and increased capillary permeability.

Signs and symptoms of decreased cardiac output

hypotension, altered mental status, weak peripheral pulses, and decreased urinary output.

Romberg's sign
Falling to one side when standing with feet together and eyes closed, indicating abnormal cerebellar
function or inner ear dysfunction

conductive hearing loss

result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a
fluid buildup in the middle ear, can block the transmission of sound waves.

sensorineural hearing loss

result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the
sensory fibers that lead to the cerebral cortex.

Kohlberg's theory

-"Moral development progresses in relation to cognitive development."

-"A person's ability to make moral judgments develops over a period of time."

-"It provides a framework for understanding how individuals determine a moral code to guide his or her
behavior."

An older client has been prescribed digoxin. The nurse determines that which age-related change
would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection

The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

clinical signs of impending or approaching death

inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and
bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered
blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel
sounds in which abdominal quadrant first?

the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are
normally always present here.
The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for
the nurse to check in this client?

Oral mucosa

petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of
the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts
herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's
theory of cognitive development?

Animism

Animism means that all inanimate objects are given living meaning. Object permanence, the realization
that something out of sight still exists, occurs in the later stages of the sensorimotor stage of
development. Egocentric speech occurs when the child talks just for fun and cannot see another's point
of view. Global organization means that if any part of an object or situation changes, the whole thing has
changed. Egocentric speech and global organization occur during the preoperational stage.

The nurse instructs the unlicensed assistive personnel (UAP) assigned to care for an older adult client
to place an extra blanket in the client's room. The nurse provides this instruction because the older
adult is less able to regulate hot and cold body changes as a result of alterations in the activity of
which gland?

Sweat glands

Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation.
The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels
and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the
glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold
body changes. The parotid glands are responsible for the drainage of saliva, which plays an important
role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an
immunological role throughout life.

The nurse is collecting data from an older adult client. Which indicates a potential complication
associated with the skin of this client?

Crusting

The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss
of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a
potential complication.
The nurse is collecting medication information from a client, and the client states that she is taking
garlic as an herbal supplement. The nurse understands that the client is most likely treating which
condition?

Hyperlipidemia

Garlic is an herbal supplement that is used to treat hyperlipidemia and hypertension. An herbal
supplement that may be used to treat eczema is evening primrose. Insomnia has been treated with both
valerian root and chamomile. Migraines have been treated with feverfew.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How
should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision
can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a
person with normal vision can read at 60 feet.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using
the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision

The confrontational method of eye testing is used to examine visual fields or peripheral vision.
Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is
used to test pupillary response to light.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place
the blood pressure cuff to obtain an accurate measurement?

Two thirds the distance between the antecubital fossa and the shoulder

The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those
that are too large will cause inaccurate low values. The cuff should cover two thirds the distance
between the antecubital fossa and the shoulder.

The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for
newborns to prevent toxicity due to which causes? Select all that apply.

The liver is immature, The kidneys are less able to excrete medications

The increased medication sensitivity of neonates and infants is largely a result of the immature state of
five pharmacokinetic processes. These include medication absorption, renal medication excretion,
hepatic medication metabolism, protein binding of medication, and exclusion of medication from the
central nervous system by the blood-brain barrier.
Which observation indicates that the nurse is performing a whispered voice hearing assessment test
procedure correctly?

Asks the client to block one ear at a time

In a voice test, the nurse, while facing the client, stands 1 to 2 feet away and asks the client to block one
external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is
tested separately.

The nurse employed in a well-baby clinic is collecting data on the language and communication
developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects
to note which highest level of developmental milestones?

Babbling sounds

Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying
becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing
sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs
between 9 and 12 months.

A nursing student enrolled in a physical assessment course is asked to describe the probable signs of
pregnancy. The student displays correct understanding if the student lists which signs? Select all that
apply.

-Hegar's

-Chadwick's

-McDonald's

Hegar's sign is softening of the lower uterine segment. This allows the body of the uterus to flex against
the cervix, which is termed McDonald's sign. Chadwick's sign is a purple or blue discoloration of the
cervix, vagina, and vulva caused by increased vascular congestion.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an
instructor returned his work, noting it was substandard. Using Erikson's theory of personality
development, which developmental stage has this individual unsuccessfully mastered?

Autonomy vs. shame and doubt

Negative feelings of doubt and shame arise when individuals are made to feel self-conscious and shame.
The positive outcomes of mastering this developmental stage are self-control and willpower

In the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them
to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in
which Jean Piaget's first developmental stage?
Sensorimotor

Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The
preoperational stage is the second stage (2 to 7 years of age). The concrete operational stage is the third
stage (7 to 11 years of age). The formal operational stage is the fourth stage (11 years of age to
adulthood).

The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse
determines the child is in the phallic stage of Sigmund Freud's theory of personality development if
the parent makes which comment?

"Yesterday my son asked me why he looked different from his sister."

Freud's phallic stage of development includes the recognition of differences between the sexes.
Accomplishing toilet training occurs during the Freud's anal stage. Development of pubic hair is
characteristic of the genital stage. Freud's latency stage is characterized by same sex friendships and
making comments about the other sex.

The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child
makes which comment?

"I like drawing my mommy pictures with my finger paints."

A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus
guilt (late childhood, 3 to 6 years). A child in this stage enjoys exploring and making art. During Erikson's
stage of industry vs. inferiority, which occurs during school age (6 to 12 years), a child spends a great deal
of time in school and with friends. Hanging around at the mall describes behaviors that correspond with
the stage that occurs during adolescence, identity vs. role confusion. Episodes of negativism best
describes Erikson's stage of shame vs. doubt, which occurs during toddlerhood (early childhood, 18
months to 3 years).

Anthrax

caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the
skin, or inhalation. Antibiotics are administered.

drawing up Regular insulin and NPH use "RN"

draw regular insulin into the insulin syringe first, then draw the NPH insulin

Valerian

Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous
disorders such as anxiety and restlessness.

Findings associated with fluid volume excess

cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an
elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of
consciousness, and a decreased hematocrit level.

Causes of a fluid volume deficit

include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output,
insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with
cirrhosis, heart failure (HF), or decreased kidney function

s/s fluid volume deficit

increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor,
dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored
and odorous urine, an increased hematocrit level, and an altered level of consciousness.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse
expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur
secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

s/s hyponatremia

rapid/thready pulse, postural BP changes, weakness, abdominal cramping, poor skin turgor, muscle
twitching/ seizure, apprehension, confusion

Interventions for respiratory alkalosis

voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as
using a paper bag or a rebreathing mask as prescribed.

interventions for metabolic acidosis.

Dialysis and insulin administration

dialysis, sodium bicarbonate, treat underlying cause, treat hyperkalemia, IV FLUIDS ONLY, NO PO (due to
n/v)

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely,
understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The
nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis

most often occurs as a result of primary defects in the function of the lungs or changes in normal
respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by
chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with
COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of
breathing.

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all
that apply.

Client who has been vomiting for 2 days

Client receiving oral furosemide 40 mg daily

Metabolic alkalosis is caused by any condition that creates the acid–base imbalance through either an
increase in bases or a deficit of acids

Signs/symptoms of respiratory alkalosis

tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the
hands, and hypokalemia.

African American Health risks

Sickle cell anemia, HTN, heart disease, cancer, lactose intolerance, diabetes mellitus, obesity, insufficient
intake of vitamins and minerals

Asian American health risks

HTN, heart disease, cancer, lactose intolerance, Thalassemia

Hispanic and Latino health risks

HTN, heart disease, diabetes mellitus, obesity, lactose intolerance, parasites from unsanitary conditions

Native American health risks

alcohol abuse, obesity, heart disease, TB, arthritis, lactose intolerance, gallbladder disease.

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse
anticipates that the client will be treated with which vitamin or mineral?

Vitamin B12
Pernicious anemia is caused by a deficiency of the intrinsic factor, which results in the inability to absorb
vitamin B12 in the intestine. Treatment consists of weekly at first and then monthly injections of vitamin
B12.

Insulin glargine is prescribed for a client with diabetes mellitus. The nurse tells the client that which is
the best time to take the insulin?

Once daily at the same time each day

a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has
24-hour duration of action and is administered once a day at the same time each day.

The results are documented as a reactive nonstress test.

A negative test

A reactive nonstress test (normal/negative) indicates a healthy fetus. A nonreactive nonstress test is an
abnormal test and requires further follow-up. A suspicious test result also requires further follow-up. An
unsatisfactory test cannot be interpreted because of the poor quality of the fetal heart rate findings.

The nurse is caring for a client who is a victim of a major burn injury. Which are the names of
the primary phases of burn care assessment? Select all that apply.

resuscitative or emergency phase begins at the time of the injury and continues for about 48 hours.
With the onset of diuresis approximately 48 to 72 hours after the injury, the acute phase begins and
continues until wound closure occurs. The second phase can last for weeks to months. The goals of the
third phase (rehabilitative) are to minimize scarring and contractures, to restore the client's ability to
function in society, and to return to an established family role and vocation.

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse
anticipates that this client is at risk for which type of acid-base imbalance?

Metabolic acidosis

Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating
insulin, the blood glucose level rises while the cells of the body use all available glucose and then break
down glycogen and fat for fuel, which leads to the formation of ketones. The by-products of fat
metabolism are acidotic, leading to the complication called diabetic ketoacidosis.

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a
client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which
strategies to avoid foods high in potassium in the diet? Select all that apply.

-Use eggs as a source for protein.

-Avoid eating lunch meats and bolognas.

-Eat salads with cabbage and lettuce and avoid spinach.

A normal blood glucose level for newborn infants

40-60

The nurse is reinforcing medication discharge instructions for a client who has just begun taking
isocarboxazid for depression and knows that the client needs further teaching after stating that which
foods are safe to eat? Select all that apply.

Avocado,Bologna

The client who is taking isocarboxazid needs further teaching after stating that avocado and bologna are
safe to eat. Foods that are restricted for clients who take monoamine oxidase inhibitors (MAOIs) are
foods that contain tyramine and include avocados; figs; fermented, smoked, and organ meats; dried and
cured fish and most cheeses; foods with yeast; imported beers and Chianti wines; and some soups that
contain protein extract.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The
nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox

Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of
chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to
chickenpox.

pancytopenia

decrease in all blood cells types: red, white, and platelets

high risk for infection because of significantly low immunity. The client should not eat fresh fruits and
vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly.
The client should wear a mask when outside of the room to avoid potential infection spread from
persons in the hallways

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the
postoperative prescriptions, which should the nurse clarify?

Irrigating the NG tube

a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum.
Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however,
should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the
PHCP. In this situation, the nurse should clarify the prescription.

miotic agents used to treat glaucoma

Betaxolol
Pilocarpine
Pilocarpine hydrochloride

Baclofen

-antispasticity agentsskeletal muscle relaxants (centrally acting)

-Adverse: SEIZURES, do not give w/ seizure disorder

Cyclobenzaprine

skeletal muscle relaxants (centrally acting)

Food sources of riboflavin

milk, lean meats, fish, and grains

Urethritis in the male client

often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear
to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are
done for both and include culture and rapid assays.

The nursing instructor asks the nursing student about the physiology related to the cessation of
ovulation that occurs during pregnancy. Which response by the student indicates an understanding of
this physiological process?

Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are
high

The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female
adolescents regarding the menstrual cycle. The LPN tells the adolescents that the most likely day for
ovulation in a 30-day menstrual cycle is which day?

Day 16

The normal duration of the menstrual cycle is about 28 days. However, in a longer menstrual cycle,
ovulation typically occurs 14 days before day 1 of the next cycle. Thirty days minus 14 days would be day
16.

The maternity nursing instructor asks a nursing student to identify the hormones that are produced by
the ovaries. Which hormones identified by the student indicate an understanding of the hormones
produced by this endocrine gland

Estrogen, Progesterone
The ovarian cycle consists of three phases:

preovulatory, ovulatory, and luteal

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears
restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the
client's behavior, the nurse should suspect the client is how far dilated?

8 to 10 cm

During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As
contractions intensify, women often doubt their ability to cope with labor and fear

The nurse assists the nurse-midwife in examining the client. The midwife documents the following
data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes
ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can
increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright
can also increase the risk.

Thyroxine during pregnancy

Thyroxine increases during pregnancy to stimulate basal metabolic rate. It may also function to assist in
the neural development of the fetus.

The android pelvic shape

Convergent sidewalls, Narrow interspinous diameter, heart-shaped and narrow and is an unfavorable
shape for a vaginal birth.

what progesterone does for pregnancy

Progesterone maintains the uterine lining for implantation.

Oxytocin

produced by the posterior pituitary, stimulates the uterus to produce contractions during and after birth,
Oxytocin is used primarily for labor induction and augmentation

platypelloid pelvic shape

Shallow depth, Wide suprapubic arch, Compatible with vaginal delivery, Flattened anteroposteriorly, and
wide transversely
mittelschmerz

refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain
is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent
spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the
right or left side of the pelvis. It generally lasts a few hours to 2 days.

escharotomies

performed to alleviate the compartment syndrome that can occur when edema forms under
nondistendible eschar in a circumferential burn. Bleeding is considered a complication.

Presbycusis hearing loss

refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased
hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency
sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client.

s/s testicular cancer

testicular swelling without pain, heaviness in scrotum, back pain may indicate spreading.

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of
chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with
the chemotherapy?

Increased uric acid level

Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and
lymphomas, because the therapy results in massive cell destruction and the release of uric acid.

The client is taking phenytoin (Dilantin) for seizure control, and a blood sample for a serum drug level
is drawn. Which laboratory finding indicates a therapeutic serum drug result?

15 mcg/mL

The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which
laboratory test(s) would identify an adverse effect associated with the administration of this
medication?

liver function tests

Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver
damage

The normal serum ammonia level

10-80

ethambutol

-antibiotic to treat TB
-causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors
red and green

Nizatidine

histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine
H2-receptor blockers decrease the secretion of gastric acid

A client is taking lansoprazole for the chronic management of Zollinger-Ellison syndrome. If prescribed,
which medication would be appropriate for the client if needed for a headache?

Acetaminophen

Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking
medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal
antiinflammatory drugs (NSAIDs) such as naprosen and ibuprofen. Acetaminophen would likely be
prescribed for headache for this client because it would not be irritating to the stomach.

Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-

excreting diuretic.

They are weak diuretics that are used in combination with potassium-excreting diuretics. This
combination is useful when medication and dietary supplement of potassium is not appropriate.

furosemide adverse side effects

Tinnitus

Hypotension

Hypokalemia

Megestrol acetate

antineoplastic medication, appetite stimulant, used in caution with patients with thrombophlebitis

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of
chemotherapy. Which laboratory value should the nurse note as a result of the massive cell
destruction that occurred from the chemotherapy?

Increased uric acid level

Hyperuricemia is especially common following treatment for leukemias and lymphomas because
chemotherapy results in a massive cell kill, releasing uric acid into the blood. Although anemia,
decreased platelets, and decreased leukocytes also may be noted, an increased uric acid level is related
specifically to cell destruction. Massive cell destruction may result in high levels of potassium, not
hypokalemia.

Cyclophosphamide instruction

Increase fluid intake to 2000 to 3000 mL daily.

Hemorrhagic cystitis is a toxic effect that can occur with the use of cyclophosphamide. The client needs
to be instructed to drink copious amounts of fluid during the administration of this medication. Clients
also should monitor urine output for hematuria. The medication should be taken on an empty stomach,
unless gastrointestinal (GI) upset occurs. Hyperkalemia can result from the use of the medication;
therefore, the client should not be told to increase potassium intake.

Daunorubicin (anti tumor antibiotic for non-Hodgkins)

toxicity: cardiotoxicity, cardiomyopathy, ECG changes, pulmonary toxicity.

Levothyroxine

most common thyroid replacement

myexedema coma

progresses from hypothyroidism and shows decreases in mental status

s/s Hodgkins

- NIGHT SWEATS
- painless enlargement of lymph nodes
- anemia
- fatigue & weakness
-weight loss
- skin rashes
- itching

typical sign of ovarian cancer

abd distension/ fullness

leading cause of death from gynecological cancers and occurs in women older than 50 years. Less
common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in
bowel habits.

teaching plan for the client receiving an antineoplastic medication.

Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a
soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client
should notify the PHCP for a low grade temperature such as 99.5° F (39.7° C) and a sore throat.

s/s hypothyroidism

dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness;
muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes
and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter.

Exenatide

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 PHCP regarding this prescription.

-The medication is administered within 60 minutes before the morning and evening meal.

-The client is monitored for gastrointestinal (GI) side effects after administration of the medication.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client
is at risk for which vitamin deficiency?

B12

Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells.
When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability
to absorb vitamin B12. This leads to the development of pernicious anemia.

s/s dumping syndrome

vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down, cramping,
diarrhea,

acute pancreatitis meds

opiates for pain, anticholinergics, and antacid

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation
should indicate that a prolapse has occurred?

Protruding and swollen

in which bowel protrudes through the stoma, with an elongated and swollen appearance.

Misoprostol (GI)

prevention of gastric ulcers, take with meal, causes diarrhea & abdominal pain
Sucralfate (GI)

anti ulcer agent- creates protective barrier, take on empty stomach, causes constipation, may impede
absorption of warfarin, phenytoin, theophylline, digoxin, and some antibiotics. administer at least 2
hours apart from these meds.

H2 Antagonists (tidine)

Cimetidine, Ranitidine, Famotidine, Nizatidine

Cimetidine

suppress secretion of gastric acid, when taken with food slows absorption, wait 1 hour after antacids,
may cause mental confusion, agitation, disorientation, reduce dose for renal pts or if taking warfarin,
sodium, phenytoin, theophylline, or lidocaine

Ranitidine

suppress secretion of gastric acid, side effects uncommon, do not have to take with food

Famotidine & Nizatidine

suppress secretion of gastric acid, side effects uncommon , do not have to take with food

proton pump inhibitors (prazole)

Drugs: Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazole

MOA: Irreversibly inhibit H+/K+ ATPase in stomach parietal cells

Clinical Use: Peptic ulcer disease, gastritis, esophageal reflux, ZOLLINGER-ELLISON SYNDROME

Adverse Effects:

1. ↑ Risk of C. difficile infection

2. Pneumonia

3. ↓ Serum Mg2+ with long-term use

common side effects:

headache, diarrhea, abdominal pain, nausea

infliximab (Chron's disease)

Immunomodulator; reduces the degree of inflammation in the colon, thereby reducing the diarrhea
A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about
the possibility of infecting family members and others. Which information should reassure the client
that contaminating family members and others is not likely?

Family members or others who have been in close contact with a client diagnosed with tuberculosis are
placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious
after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of
therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

pulmonary edema interventions

notify RN, Administering oxygen, Inserting a Foley catheter, Administering furosemide , Administering
morphine sulfate intravenously

Pulmonary edema s/s

extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation
of the lungs reveals crackles.

Right-sided heart failure

systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure
buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and
abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen,
anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain

Left-sided heart failure

produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4
hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes
redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data,
the nurse should make which determination about the client's neurovascular status?

Normal, caused by increased blood flow through the leg

epididymitis

inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or
the bladder.
Tx:rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics.

client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual
combination of medications for the disease, including aluminum hydroxide as a phosphate-binding
agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this
data indicate?
Aluminum intoxication

Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many
phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration
of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated
with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be
prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

steal syndrome

Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client
exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the
fistula, which is caused by tissue ischemia

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which
disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis?

Diabetes mellitus

Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi,
chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling
or frequent urinary catheterization.

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has
documented that the client has a renal disorder. Which laboratory results would indicate a decrease in
renal function?

Elevated serum creatinine level, Decreased red blood cell (RBC) count, Elevated blood urea nitrogen
(BUN) level

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the
abdomen. Which would this indicate?

bleeding

If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the
abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or
microscopic hematuria should also indicate bleeding.

TUR syndrome (pt with BPH & a TURP)

caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may
show signs of cerebral edema and increased intracranial pressure, such as increased blood
pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and
vomiting.

presbycusis
hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in
the inner ear or auditory nerve.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor
associated with glaucoma?

Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the
development of glaucoma

Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing
action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure

Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic
effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension
and assessing the pulse for strength, weakness, irregular rate, and bradycardia

Cyclopentolate eye drops

To dilate the pupil of the operative eye

rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and
accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought
several bottles of medications prescribed by different specialists. During the admission assessment,
the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am
alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be
advised to notify the prescribing PHCP so that the medication can be discontinued and/or a substitute
that is less toxic to the ear can be taken instead.

Pilocarpine hydrochloride reversal med (glaucoma med)

Atropine sulfate

Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of
vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event
of systemic toxicity

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about
the purpose of the medication. The nurse should tell the client which purpose?
"The medication causes the pupil to constrict and will lower the pressure in the eye."

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs
would occur if ICP is rising?

Increasing temperature,

increase BP

decreasing pulse,

decreasing respirations,

Autonomic Dysreflexia S/S

The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is
characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden
severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a
life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

Kaposi's sarcoma

Form of skin cancer frequently seen in pts with compromised immune systems (AIDS, kidney transplant,
A client receiving antineoplastic medications

Pemphigus

autoimmune disease that causes blistering of the epidermis

systemic lupus erythematosus (SLE)

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs

Cushing's syndrome. Which statement by the student indicates an accurate understanding of this
disorder?

Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones.

Cardiac changes with hypokalemia

- Slight prolonged PR interval

- Peaked P wave
- ST depression
- Shallow/inverted T wave
- U wave

Mannitol
osmotic diuretic , It is used to reduce intracranial pressure in the client with head trauma.

toxicity reversal agent for heparin

Protamine sulfate

The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee
amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all
that apply.

peripheral neuropathy, limited joint mobility, bony deformity, peripheral vascular disease, and a history
of skin ulcers or previous amputation.

meperidine hydrochloride side effects (opioid)

respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding,

constipation, and urinary retention.

areflexia

absence of reflexes

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be
associated with spinal shock in this client? Select all that apply.

the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may
become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles
of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.

ACE inhibitors adverse effects

Fatigue
Dizziness
Headache
Mood changes
Impaired taste
Possible hyperkalemia
Dry, nonproductive cough, which reverses when therapy is stopped
Angioedema: rare but potentially fatal
Note: First-dose hypotensive effect may occur

The primary health care provider has written a prescription for ranitidine, for a client with
gastrointestinal reflux disease. The nurse is explaining how this medication works to treat this disease.
Which explanation should the nurse give?

The medication suppresses acid secretion by blocking H2 receptors.

The nurse has a prescription to give a client albuterol (two puffs) and beclomethasone
dipropionate (two puffs) by metered-dose inhaler. How much time should the nurse place between
administering the albuterol and then the beclomethasone dipropionate?

5 minutes

(bronchodilator first and gives time to open airway for glucocorticoid.)

DKA s/s

only in insulin dependent diabetics

BGL 400-900
dehydrated (4-6L lost)
No circulating insulin
+acidosis b/c body breaks down fat into ketones
Kussmaul (inc rate depth to blow off c02)

high phosphate foods

fish, chicken, eggs, milk products, vegetables, whole grains, and carbonated beverages

s/s child in sickle cell crisis

present with one or more swollen joints that are extremely painful (pain rated well above a 5 on a scale
of 1 to 10), fever, and low oxygen levels. The heart rate would be increased because of the pain and the
lack of normal red blood cells.

The nurse is assigned to assist in caring for a client admitted to the emergency department
with diabetic ketoacidosis (DKA). Which is the priority nursing action for this client who is in the acute
phase?

Administer intravenous (IV) regular insulin.

Vincristine (chemo)

chemotherapeutic medication that has the adverse effect of damaging the peripheral nerves. This
results in numbness in the extremities

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which
finding should the nurse note as being consistent with this diagnosis?

High serum glucose level and low serum bicarbonate level

In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and
urine. The arterial pH is low (less than 7.35.) The plasma bicarbonate is also low. The client would
exhibit polyuria and Kussmaul's respirations.
glucose tolerance test (OGTT)

client should have fasted for 10 to 12 hours. After a fasting blood sample is obtained, the client
consumes a 75-g or 100-g glucose load in 5 minutes. Blood is drawn every 30 minutes for 2 or 3 hours,
depending on the glucose load. During the test, the client may not eat, drink, or smoke.

agoraphobia

intense, excessive anxiety or fear about being in places or situations from which escape might be difficult
or embarrassing or in which help might not be available.

being on a bridge, riding in an elevator, being alone at home, and travelling in an airplane. Other
behaviors related to agoraphobia include being alone outside and travelling in a car or bus

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews
the laboratory results, knowing that which finding indicates this type of anemia?

RBCs that are microcytic and hypochromic

The results of a complete blood cell count in children with iron deficiency anemia will show low
hemoglobin levels and microcytic and hypochromic RBCs. The reticulocyte count is usually normal or
slightly elevated.

caloric test

checks CN 8 function, Water that is warmer or cooler than body temperature is infused into the ear.
A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus
(involuntary eye movements) within 20 to 30 seconds.

Tricuspid Atresia

there is no communication from the right atrium to the right ventricle.

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it
is important to monitor for additional complications at this time. Which assessment should be part of
the plan of care?

Any bleeding, such as in the gums, petechiae, and purpura

Bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia,

and should be reported.

Repaglinide

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

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

Diabetic ketoacidotic coma

fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing.

A client arrives at the emergency department following a burn injury that occurred in the basement at
home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the
client?

100% oxygen via a tight-fitting non-rebreather face mask

If inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather mask is
prescribed until carboxyhemoglobin levels fall below 15%

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations
during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

In the first trimester of pregnancy the pulse increases 10 to 15 beats per minute, the blood volume
increases 40% to 50%, the cardiac output increases 30% to 50%, and red blood cell mass
increases 17%. Blood pressure decreases in the first half of pregnancy, returning to baseline in the
second half. The white blood cell count increases in the second and third trimesters.

child with cystic fibrosis (CF)

chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands
(particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick,
causing obstruction of the small passageways of these organs. It is transmitted as an autosomal
recessive trait and can affect both males and females.

oral Griseofulvin

treatment for tinea capitis, give with milk

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.
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. Maternal and fetal assessments are
critical to determine the progress of labor and the safety of the mother and fetus. Breathing and
relaxation techniques are reviewed during the latent phase and encouraged during the active phase. The
client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid
intake. The client may take showers.

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse
should schedule the medication so that each dose is taken at which time?

To be effective in decreasing bowel motility, antispasmodic medications should be administered 30

minutes before mealtime

transfusion reaction

can include a backache among other signs such as chills, itching, or rash

Proven negligence

requires a duty, a breach of duty, the breach of duty must cause the injury, and damages or injury must
be experienced.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which
interventions in the plan of care for the client? Select all that apply.

Applying prescribed topical antibiotic, Administering prescribed corticosteroid, Applying Domeboro

solution to the affected skin

Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest,
groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium
permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe
the affected areas, reduce odor, and decrease the risk of infection. Treatments may include
corticosteroids, other immunosuppressants, and oral or topical antibiotics.

The nurse is preparing to administer an enema to an adult client. Which interventions should the
nurse plan to perform for this procedure? Select all that apply.

-Lubricate the enema tube and insert it approximately 4 inches

-Clamp the tubing if the client expresses discomfort during the procedure

-Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C)

-Left SIMS position

-hung about 12 to 18 inches above the client's anus

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain
proper positioning for the inflamed joints?

Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of
inflamed joints

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the
client's postoperative bleeding, the nurse should implement which interventions? Select all that apply.

-Observing perineal pad drainage

-Observing the abdominal dressing

-Rolling the client to one side to view bedding -monitoring output from the Jackson-Pratt drain

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions
to the mother regarding the administration of the iron. The nurse instructs the mother to administer
the iron in which way?

Between meals

iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the
absorption of iron by the body.

The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes
documentation that the client does not have a pleural friction rub that was auscultated the previous
day. How should this finding be interpreted?

Pleural fluid has accumulated in the inflamed area.

mydriatic medications

dilation of the pupil

Bell's palsy s/s

-Excessive tearing

-Inability to furrow brow

-A lag in closing the bottom eyelid

The five client basic principles of bioethics

justice, fidelity, autonomy, veracity, and beneficence

s/s epididymitis
**Inflammation of the tube at the back of the testicle that stores and carries sperm.

Fever, nausea and vomiting, and painful scrotal edema

s/s juvenile idiopathic arthritis (JIA)

intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are
warm to the touch, with limited range of motion. The child will complain of morning stiffness and may
protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue and lethargy,
anorexia, weight loss, and growth problems. A history of a late afternoon fever with temperature
spiking up to 105° F will also be part of the signs and symptoms.

risks associated with laryngeal cancer

Smoking cigarettes or cigars

Drinking alcohol, especially daily

Working in a dusty environment

Persistent exposure to chemicals in the air

Following a diet low in protein and vitamins

Hirschsprung's disease peds

-Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon-like stools
that are foul smelling

-Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to
thrive are also signs and symptoms.

Myringotomy

Myringotomy is a surgical procedure that allows fluid to drain from the middle ear. Bed rest is not
required, but activity may be restricted

s/s of cataracts

1. Painless, blurry vision

2. Dim surroundings
3. Reduced visual acuity
4. Glare sensitivity
5. Diplopia (Double vision)
6. floaters
7. increasing nearsightedness
8.complaints that colors are faded or appear yellowish or brownish
9. and difficulty with night vision

Myasthenia Gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness
of voluntary muscles

Myasthenia Gravis Treatment

- supportive, anticholinesterase drugs, corticosteroids

- no known cure

Graves disease

an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or

exophthalmos

Graves disease treatment

-Goal: inhibit production of thyroid hormones and block effect on the body
-Radioactive iodine therapy: destroys overactive thyroid cells over time
-Propylthiouracil, methimazole
-Betablockers
-Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The
nurse reviews the arterial blood gas reports for which results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a

client with no history of respiratory disease.

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk
for metabolic acidosis? Select all that apply.

Client with pancreatitis

Malnourished client

Client with diabetes mellitus

Client with status epilepticus

Client with severe prolonged diarrhea

Histoplasmosis

fungal infection that can occur in the client with AIDS. The infection begins as a respiratory
infection and can progress to disseminated infection.

Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an
enlargement of the client's lymph nodes, liver, and spleen as well.

phenylketonuria (PKU)

PKU results in central nervous system (CNS) damage.

Treatment includes dietary restriction of phenylalanine intake (not sodium). PKU is a genetic disorder
that results in CNS damage from toxic levels of phenylalanine in the blood

The nurse is caring for a client with Paget's disease. The nurse knows that when serum calcium levels
are lowered, what hormone secretion increases to release calcium to the blood?

Antidiuretic hormone (ADH)

ventricular dysrhythmias and lab results would show

hypokalemia

Beta Thalassemia

autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent.
The disease also has been reported in Asian and African populations

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is
in a cephalic presentation. Which findings while performing Leopold's maneuvers support the
identification of a cephalic presentation? Select all that apply.

-Small parts are located on the left side of the uterus.

-Small parts are located on the right side of the uterus.

-A soft, irregular non-ballottable shape is located just above the symphysis pubis.

Signs and symptoms of mastoiditis

mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood
cell (WBC) count.
early sign/symptom of lithium toxicity

(GI) disturbances, such as nausea, vomiting, and diarrhea

foods that are naturally high in iron

red meat, liver, other organ meats, blackstrap molasses, and oysters. Other good sources of iron are
kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and
apricots

potential complication of parathyroidectomy

Hypocalcemia because the parathyroid regulates calcium in blood

Trousseau's sign

can indicate Hypocalcemia. Place BP cuff on arm, inflate to pressure, greater than systolic BP, hold in
place for 3 min. Will induce spasm in hand and forearm if hypocalcemia present.

Chevostek's sign

tapping the face, observe for contraction on same side, Hypocalcemia is present with twitch on same
side of face

osteogenesis imperfecta

brittle bone disease, genetic disease resulting in impaired synthesis of collagen by osteoblasts

problem caused from Vegan diet only

Tingling in hands and feet

Megaloblastic anemia and neurological manifestations occur from Vitamin B12 deficiency