NCLEX PN Saunders Assessment Practice 4 (Answered)

NCLEX PN Saunders Assessment Practice 4 (Answered) caring for a patient with flu like symptoms plenty of rest, increase intake of fluids, encourage client take antipyuretics to decrease fever. plan of action for the emergency department, in an event of internal fire. direct ambulating clients to walk to a safe location, remove all clients from danger before attempting to extinguish the fire, move bedridden clients away from the fire are by use of beds or stretchers. pregnant client receiving MAGNESIUM SULFATE for management of PREECLAMPSIA. client is experiencing toxicity from medication respirations of 10 bpm toxicity= cns depressant effects, respirations lower than 12 per minute, a LOSS of deep tendon reflexes, a sudden drop in fetal HR or maternal HR and BP. protienuria is noted 3+ in preeclampsia tb skin test administered to an individual with HIV. 72 hrs later your document should show POSITIVE results with area of induration at the test site measuring 7mm. normally area of induration greater than 15 mm is considered positive in low-risk. 5mm + in individuals with HIV infection is considered positive. An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent. Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply. Encourage frequent urination, Continue maternal and fetal assessments, Review breathing and relaxation techniques. Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor... client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse understands that this medication is used for which condition? An episode of diarrhea Rationale: Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy. It is not used for the conditions in options 1, 2, and 4. A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply Eat smaller and more frequent meals. Drink fluids between meals not with them. Rationale: Following gastric surgery, the client should eat smaller, more frequent meals to facilitate digestion. Fluids should be taken between meals not with them to avoid dumping syndrome. The nurse has reinforced instructions to a client who is scheduled for a cataract extraction. Which statement by the client indicates a need for further teaching? "No eating or drinking for at least 18 hours before the surgery." Rationale: The client scheduled for cataract surgery should be instructed that oral intake may be restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing per mouth (NPO) for 18 hours before surgery. A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which food in the diet? Ice cream Rationale: The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply. Place the child on a low-bacteria diet, Change dressings using sterile technique,Perform meticulous hand washing before caring for the child. Rationale: For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed with sterile technique. Not all visitors need to be restricted, but anyone who is ill should not be allowed in the child's room. Meticulous hand washing is required before caring for the child. In addition, gloves, a mask, and a gown are worn (per agency policy). Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item? blood pressure Rationale: Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. The nurse is monitoring a preterm labor client who is receiving magnesium sulfate intravenously. The nurse should monitor for which adverse effects of this medication? Select all that apply. Flushing, Depressed respirations, Extreme muscle weakness Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which is noted on data collection? Respirations of 10 breaths per minute Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs? Naloxone (Narcan) Rationale: Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which condition? Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? Seizures do not occur. Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should question administration of the medication if which condition is documented in the client's medical history? Peripheral vascular disease Rationale: Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further if the student makes which statement? "I will flush the eyes after instilling the ointment." Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after the instillation of the medication because the flush will wash away the administered medication. A 31-week preterm labor client dilated to 4 centimeters has been started on magnesium sulfate. Her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, which medication does the nurse anticipate will be prescribed? Betamethasone Rationale: Betamethasone, which is a glucocorticoid, is given to stimulate fetal lung maturation. It is used for clients in preterm labor between 28 and 32 weeks' gestation if the labor can be inhibited for 48 hours. The nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse should discontinue the oxytocin infusion and notify the registered nurse if which is noted on data collection of the client? Uterine hyperstimulation Rationale: Oxytocin stimulates uterine contractions, and it is one of the common pharmacological methods used to induce labor. An adverse effect associated with the administration of the medication is the hyperstimulation of uterine contractions. Therefore, oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse reinforces instructions to the mother and tells the mother to administer the iron with which best food item? Orange juice Rationale: Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 9 months Rationale: Isoniazid is given to prevent tuberculosis (TB) infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In