Pharmacology
The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply.
1. Back
2. Axilla
3. Eyelids
4. Soles of the feet
5. Palms of the hands
What is 1, 4, and 5
Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
What is 2
Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.
When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.
1. An irregularly shaped lesion
2. A small papule with a dry, rough scale
3. A firm, nodular lesion topped with crust
4. A pearly papule with a central crater and a waxy border
5. Location in the bald spot atop the head that is exposed to outdoor sunlight
What is 4 and 5
Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Exposure to ultraviolet sunlight is a major risk factor. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.
1. Allows for fetal movement
2. Surrounds, cushions, and protects the fetus
3. Maintains the body temperature of the fetus
4. Can be used to measure fetal kidney function
5. Prevents large particles such as bacteria from passing to the fetus
6. Provides an exchange of nutrients and waste products between the mother and the fetus
What is 1, 2, 3, and 4
The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.
1. Initiate confinement measures.
2. Acknowledge the client's behavior.
3. Assist the client to an area that is quiet.
4. Maintain a safe distance from the client.
5. Allow the client to take control of the situation.
What is 2, 3, and 4
During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
1. Vitamin K
2. Protamine sulfate
3. Aminocaproic acid
4. Potassium chloride
What is 2
The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.
The nurse is providing information to a client scheduled for a lumbar puncture. Which information should the nurse provide to the client?
1. The test will probably take about 2 hours.
2. Food and fluids will be restricted after the test.
3. A signed informed consent form will be required.
4. Maintaining bed rest after the test will not be necessary.
What is 3
Client preparation for a lumbar puncture includes obtaining an informed consent from the client because the procedure is invasive. The client is told that the test will take approximately 15 to 60 minutes. No dietary restrictions are required after the test, and the client should be encouraged to consume fluids. The nurse needs to inform the client about the need for bed rest after the test.
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?
1. Dyspnea
2. Headache
3. Weight gain
4. Hypothermia
What is 1
Histoplasmosis is an opportunistic 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. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.
The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
1. Monitor fetal heart rate continuously.
2. Monitor maternal vital signs frequently.
3. Perform a vaginal examination every shift.
4. Administer an antibiotic per PHCP prescription and per agency protocol.
What is 3
Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.
Which client is at greatest risk for committing suicide?
1. A client with metastatic cancer
2. A client with a newly diagnosed cardiac disorder
3. A client who just had an argument with her fiancé
4. A newly divorced client who states she has custody of the children
What is 1
The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.
The nurse is reviewing the record of a client who arrives at the primary health care clinic. The nurse notes that the client is taking letrozole. The nurse should suspect that the client has which disorder?
1. Hypothyroidism
2. Diabetes mellitus
3. Chronic kidney disease
4. Advanced breast cancer
What is 4
Letrozole is used in the palliative treatment for advanced breast cancer in the postmenopausal woman with disease progression after treatment with antiestrogen therapy. The conditions in options 1, 2, and 3 are not treated with this medication.
The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control?
1. The caregiver selects a previously opened gauze to cover the sternal wound.
2. The caregiver dons gloves before removal of the old dressing and then applies the new dressing.
3. The caregiver covers her mouth with her hand when she sneezes and then continues with the dressing change.
4. The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing.
What is 4
The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing the hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique.
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?
1. Restricting fluids
2. Placing a pillow under the knees
3. Encouraging active range-of-motion exercises
4. Applying a heating pad to the lower extremities
What is 3
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a primary health care provider's prescription.
A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action?
1. Instruct the client to avoid walking.
2. Assess for signs of venous thrombosis.
3. Instruct the client to elevate the legs throughout the day.
4. Tell the client that this is normal during pregnancy.
What is 2
If a woman complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The most appropriate nursing action is to check for the presence of additional signs of venous thrombosis. Ambulation is a necessary exercise, and the woman should be encouraged to ambulate during pregnancy. Although it is important to elevate the legs during pregnancy, elevating the legs consistently is not the most appropriate nursing action. It is not appropriate to tell the client that this is normal during pregnancy.
The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client?
1. Fear
2. Anxiety
3. Risk for aspiration
4. Distorted body image
What is 3
Priority is focused on physical problems. Aspiration is safeguarded against by keeping the client on nothing by mouth status for 6 to 8 hours before electroconvulsive therapy, removing dentures, and administering preprocedure medications as prescribed. Body image is not associated with this procedure. Although the remaining options could be appropriate problems, they are not the priority.
A nurse is administering a prescribed dose of dexamethasone to a client following cranial surgery. Which would the nurse implement to assess for a common side effect of this medication?
1. Monitor for hair loss.
2. Assess for decreased skin turgor.
3. Perform blood glucose monitoring.
4. Monitor laboratory test results for hyperkalemia.
What is 3
Side effects of dexamethasone include delayed wound healing, hyperglycemia, fluid overload, hirsutism, and hypokalemia. Hair loss, decreased skin turgor, and hyperkalemia are unrelated to the side effects of this medication.
A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first?
1. Suction the client through the endotracheal tube.
2. Instruct the client in the use of an incentive spirometer.
3. Turn the client from a 30-degree lateral position to a supine position.
4. Instruct the client to use a communication board to tell the nurse what is wrong.
What is 1
The client is choking on his secretions, which should be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing his airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.
The nurse is caring for a client with pancreatitis. Which finding should the nurse expect to note when reviewing the client's laboratory results?
1. Elevated level of pepsin
2. Decreased level of lactase
3. Elevated level of amylase
4. Decreased level of enterokinase
What is 3
The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.
Which newborn is most at risk for a brachial plexus injury?
1. A term infant with a history of a forceps-assisted delivery
2. A term infant delivered via primary cesarean section for malpresentation
3. A large for gestational age infant with a history of shoulder dystocia at delivery
4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes
What is 3
Brachial plexus injuries, a fractured clavicle, or a fractured humerus are all possible risks during a delivery of an infant with shoulder dystocia and must be considered during the immediate newborn assessment. Stretching or pulling away of the shoulder from the head may occur during a difficult delivery such as one involving shoulder dystocia. This positioning may cause damage to the upper plexus. Larger infants are more likely to be involved in a delivery in which inadequate space is a concern.
A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion?
1. Obtaining feedback from the client about the coping abilities of the caregiver
2. Gathering subjective and objective assessment from the caregiver and the client
3. Making a referral to the home care agency social worker to complete the assessment
4. Interviewing family members regarding their concerns for the health and well-being of the caregiver
What is 2
Caregiver strain can occur when a client is significantly dependent on someone else for personal and health care needs. To assess for caregiver strain, the nurse should gather subjective and objective data from the caregiver and the client. The nurse should not expect the client or family members to assess the coping abilities of the caregiver. Although a social worker may be helpful, the nurse needs to perform the assessment of the situation before making the referral.
Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?
1. Osteoarthritis
2. Hypothyroidism
3. Diabetes mellitus
4. Polycystic disease
What is 3
Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.
1. Oranges
2. Broccoli
3. Margarine
4. Cream cheese
5. Luncheon meats
6. Broiled haddock
What is 3, 4, and 5
Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Broiled haddock is also naturally lower in fat. Margarine, cream cheese, and luncheon meats are high-fat foods.
The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client?
1. Facial drooping
2. Periorbital edema
3. Ptosis of the eyelid
4. Twitching on the affected side of the face
What is 1
Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.
The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?
1. Ambulating
2. Breast-feeding
3. Taking sitz baths
4. Increasing activity after arriving home
What is 2
Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. Ambulating, taking sitz baths, and increasing activity do not affect afterpains.
A client is withdrawn, immobile and mute. Which appropriate action should the nurse take?
1. Encourage talking.
2. Leave the client alone.
3. Provide stimulation from other clients.
4. Occasionally ask open-ended questions.
What is 4
Clients who are withdrawn may also be immobile and mute. These clients require consistent, repeated approaches to establish interpersonal contact. The nurse facilitates communication with the client by sitting in silence and asking open-ended questions, with pauses to provide opportunities for the client to respond. This approach to communication with clients who are withdrawn requires much patience from the nurse. The remaining options are not appropriate nursing interventions.