Immune, Allergy & Inflammation
A client taking an immunosuppressive corticosteroid should be especially alert for this type of complication.
ANSWER
Infection
Rationale: Corticosteroids are immunosuppressive and that fever, chills, sore throat, fatigue, or malaise should be reported.
In acute myeloid leukemia, low levels of these two blood-cell lines explain the major risks of infection and bleeding.
ANSWER
Neutrophils and platelets
Rationale: Neutropenia increases infection risk and thrombocytopenia increases bleeding risk.
A seizure caused by abnormal electrical activity confined to a limited area of the brain is called this.
ANSWER
Focal seizure
Rationale: Focal/partial seizures arise from a limited area of the brain.
A fracture in which bone breaks through the skin carries the greatest risk for this bone infection.
ANSWER
Osteomyelitis
Rationale: Open fractures as having the highest infection risk because the fracture breaks the protective skin barrier.
Breathlessness from pulmonary congestion is more characteristic of this side of heart failure.
ANSWER
Left-sided heart failure
Rationale: Left-sided heart failure is manifested with pulmonary congestion, crackles/wheezes, and breathlessness.
This eye-related monitoring schedule is emphasized for a client taking hydroxychloroquine.
ANSWER
An eye exam at start of therapy and every 6 months during therapy
Rationale: Hydroxychloroquine can cause pigmentary retinitis and vision loss, so periodic vision examinations are required.
Rapid destruction of malignant cells can dump intracellular contents into the bloodstream and produce this metabolic emergency.
ANSWER
Tumor lysis syndrome
Rationale: Tumor lysis is a metabolic emergency presenting with hyperkalemia, hyperuricemia, and hyperphosphatemia.
After lorazepam is given for status epilepticus, the next anticipated medication is this for ongoing seizure control (include route).
ANSWER
IV fosphenytoin
Rationale: IV fosphenytoin is recommended after a benzodiazepine to stabilize neuronal membranes and prevent further seizure activity.
Among common fracture sites, a closed fracture of this type of bone has a particularly high risk for fat embolism syndrome.
ANSWER
Long bone
Rationale: Closed long-bone fractures, especially of the femur, is high risk for fat embolism syndrome.
This potassium-sparing diuretic can cause hyperkalemia and hyponatremia.
ANSWER
Spironolactone
Rationale: Spironolactone retains potassium and can produce hyperkalemia and hyponatremia.
Second-generation antihistamines are distinguished from many first-generation agents by being less likely to cause this.
ANSWER
Drowsiness
Rationale: Reduced drowsiness as a key difference between generations.
This anemia requires replacement of vitamin B12 because intrinsic-factor deficiency prevents normal absorption.
ANSWER
Pernicious anemia
Rationale: B12 must be provided by injection because insufficient intrinsic factor prevents adequate GI absorption.
When supporting a grieving client who is angry or bargaining, the nurse should encourage this communication behavior.
ANSWER
Verbalization of feelings
Rationale: Encouraging expression and explaining that grief is individual and non-linear is essential to support a grieving client.
The defining structural problem in osteoarthritis is progressive loss of this joint tissue.
ANSWER
Cartilage
Rationale: Osteoarthritis by progressive erosion of cartilage within joints.
Tingling around the mouth or extremities can signal this electrolyte problem.
ANSWER
Hypocalcemia
Rationale: Clinical manifestations of hypocalcemia include tingling/numbness around the mouth or extremities.
Hypotension plus wheezing, stridor, and urticaria after a medication strongly points to this hypersensitivity category.
ANSWER
Type I hypersensitivity
Rationale: Type I reactions present with clinical manifestations that include hypotension, wheezing, stridor, GI/uterine spasm, and urticaria.
A macrocytic anemia pattern is associated with an elevated value for this RBC index.
ANSWER
MCV (mean corpuscular volume)
Rationale: Increased MCV is consistent with macrocytic anemia.
A connection to a higher power is an example of this dimension of comfort.
ANSWER
Psychospiritual comfort
Rationale: Connection to a higher power in the psychospiritual context can provide comfort.
For a client with a cast, this assessment is essential for detecting neurovascular compromise.
ANSWER
Neurovascular status
Rationale: Neurovascular assessment to monitor for complications such as compartment syndrome is essential when caring for clients with a fracture wearing a cast.
For an acute asthma exacerbation, this inhaled medication class is used for rapid symptom relief.
ANSWER
Short-acting beta-agonists (SABA)
Rationale: Inhaled short-acting beta-agonist is the rescue med for an acute exacerbation of asthma.
During an acute allergic reaction with breathing difficulty, this position best supports lung expansion.
ANSWER
High-Fowler's position
Rationale: High-Fowler's positioning allows optimal lung expansion and eases breathing.
A client with purulent drainage from an excoriated skin lesion would most likely need this diagnostic study to identify an infection.
ANSWER
Culture
Rationale: Cultures can be obtained from drainage/exudates to identify infection.
The broad statement, "Our facility needs to make more money next year" is missing these three major structural elements required to make it a SMART goal.
ANSWER
What are Specific, Measurable, and Time-bound?
Rationale: This goal lacks Specificity; it doesn't state "how the facility will make more money". This goal is missing Measurability; there is no metric attached to the goal (more money could mean $1.00 or $1,000.00). This goal is not time-bound; there needs to be a fixed target date.
Edema distal to a fracture site is a finding the nurse should report because it may indicate this syndrome.
ANSWER
Compartment syndrome
Rationale: Distal edema is a reportable manifestation of compartment syndrome.
After the acute phase of diverticulitis resolves, increasing this dietary component helps reduce recurrence risk.
ANSWER
Fiber
Rationale: A high-fiber diet after the acute phase promotes regular bowel movements and reduces colonic pressure.