Nclex RN UWORLD EXAM TEST BANK WITH ALL VERSIONS OF THE EXAM WITH ALLMODULES COVERED, Exams of Nursing

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150 QUESTIONS

The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair.

• ANSWER BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected. When administering furosemide, it is important to closely monitor
• ANSWER the client's vital signs, serum electrolytes (potassium), and kidney function tests (blood urea nitrogen, creatinine) prior to administration to prevent side effects such as hypokalemia, hypotension, and kidney injury. The steps for using an automated external defibrillator (AED) are as follows:
• ANSWER turn on the defibrillator, place the pads on the client's chest, continue chest compressions until the AED is ready to analyze the rhythm, charge the defibrillator, ensure staff members are all clear, deliver the shock, then resume compressions immediately. Fluid volume deficit
  • ANSWER is commonly caused by vomiting and diarrhea; treatment includes IV fluid resuscitation. Signs of adequate rehydration include capillary refill time <2 seconds, adequate urine output (>30 mL/hr), and normal urine specific gravity (1.005-1.030). Narrowed pulse

pressure occurs with hypovolemic shock, and orthostatic hypotension is indicative of ongoing fluid volume deficit. cardiogenic shock

• ANSWER Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload. Acute blood loss
• ANSWER (eg, gastrointestinal bleeding) is a medical emergency. The nurse should place the client in the supine position with the feet elevated to maintain blood perfusion to the brain and other vital organs. Stable angina
• ANSWER is predictable, intermittent chest pain that occurs when myocardial oxygen demand exceeds supply, most often caused by atherosclerosis. Pain is often precipitated by stress, emotional upset, tobacco use, strenuous activities (eg, exercise), and exposure to extreme temperatures. The nurse should recognize VF, a potentially lethal dysrhythmia. The ECG shows irregular waveforms of varying shapes and amplitudes. The client is unresponsive, pulseless, and apneic. Rapid treatment should include CPR, defibrillation, and drug therapy (eg, epinephrine, vasopressin, amiodarone).
• ANSWER Ventricular fibrillation (VF) in women, the elderly, and diabetics may have gastrointestinal distress as the main symptom; this needs to be evaluated with the institutional protocol for acute coronary syndrome. - ANSWER Myocardial infarctions

The client in VT must be assessed for the presence or absence of a pulse before further assessment or treatment is initiated. The unstable (hypotensive) client in VT with a pulse is treated with synchronized cardioversion.

• ANSWER Ventricular tacycardia In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).
• ANSWER Hypomagnesemia think Torsades de pontes Immediately following cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees. This prevents hip flexion, which could disrupt clot formation at the insertion site and cause bleeding.
• ANSWER Femoral cardiac catheterization is characterized by a total absence of ventricular electrical activity. The client is pulseless, apneic, and unresponsive. Treatment includes CPR, oxygenated ventilation, and advanced cardiovascular life-support measures (eg, epinephrine IV, advanced airway). Defibrillation is not effective for treatment of asystole or pulseless electrical activity.
• ANSWER Asystole measuring capillary refill and assessing skin color and temperature; these are usually within normal limits during the initial and compensatory stages of shock.
• ANSWER The adequacy of blood flow to peripheral tissues is determined by The nurse should teach the client with MVP ( Mitral Valve Prolapse)
• ANSWER to stay hydrated, avoid caffeine and alcohol, exercise regularly, reduce stress, and take beta blockers as prescribed for palpitations and chest pain. Nitrates are usually not effective for chest pain from MVP.

The client with symptomatic bradycardia should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.

• ANSWER Symptomatic bradycardia occurs when sinoatrial nodes fire at a rate of <60/min. Symptomatic sinus bradycardia is initially treated with atropine and transcutaneous pacing.
  • ANSWER Sinus bradycardia Immediately following cardiac catheterization,
  • ANSWER the client is maintained on bed rest with the affected extremity straightened. The head of the bed should remain ≤30 degrees, which prevents flexion at the hip which could disrupt the clot at the insertion site and initiate bleeding. is a genetically inherited bleeding disorder caused by a deficiency of clotting factor VIII. Laboratory findings consistent with hemophilia A include low factor VIII levels.
• ANSWER Hemophilia A is a life-threatening complication of Escherichia coli diarrhea that results in hemolytic anemia, thrombocytopenia, and acute kidney injury. HUS most commonly occurs due to ingestion of E coli from undercooked meat, especially ground beef.
  • ANSWER Hemolytic uremic syndrome (HUS) is the sudden onset of increased intraocular pressure due to impaired aqueous humor drainage through the angle of the anterior chamber. Miotic eye drops (eg, pilocarpine) act on the smooth muscle of the iris to constrict the pupils and increase the outflow of aqueous humor.
• ANSWER Angle-closure (acute) glaucoma refers to the complex physiological response that occurs when the body reacts to stress. During the alarm stage, the sympathetic nervous system is activated, leading to symptoms that include tachycardia, tachypnea, pupillary dilation, muscle tension, and mental alertness.

• ANSWER General adaptation syndrome Clinical manifestations of malabsorption
• ANSWER include gastrointestinal disturbances (eg, abdominal pain, bloating), low BMI, symptoms of anemia (eg, brittle nails, pallor), and steatorrhea (eg, pale stool color, oily stool). Symptoms of celiac disease
• ANSWER include diarrhea, pale-colored stools, iron deficiency anemia, nutrient malabsorption, and weight loss. Symptoms of irritable bowel syndrome include diarrhea and/or constipation. is typically determined with upper endoscopy and small bowel biopsy, which demonstrate a loss of small bowel intestinal villi and mucosal atrophy.
• ANSWER Diagnosis of celiac disease Indicated interventions for a client with celiac disease
• ANSWER disease include teaching the client about a gluten-free diet and instructing the client to avoid alcoholic beverages made with gluten (eg, beer, malted beverages). The nurse should reassure the client who is prescribed ferrous sulfate that
• ANSWER dark green stools are a harmless adverse effect of the medication. In addition, the nurse should instruct the client to take the medication on an empty stomach to enhance absorption and to take stool softeners to prevent constipation. Gluten-free foods include
• ANSWER dairy (eg, cheese, whole milk), fats and oils (eg, avocados, butter), grains (eg, brown rice), protein (eg, black beans, meats, poultry), and fruits and vegetables (eg, bananas, bell peppers, potatoes). Decreased gastrointestinal (GI) motility may occur

• ANSWER after abdominal surgery and lead to malnutrition, increased pain, and electrolyte and fluid imbalances. The nurse should monitor for signs of decreased GI motility, including excessive vomiting, abdominal distension, and absence of bowel sounds and/or flatus. Postoperative ileus is
• ANSWER associated absent/markedly decreased bowel sounds. In contract, mechanical small bowel obstruction is usually associated with hyperactive bowel sounds. Both conditions result in vomiting, abdominal distension, and abdominal pain. For a client with a suspected postoperative ileus,
• ANSWER x-rays of the abdomen and pelvis help rule out bowel obstruction through visualization of bowel gas pattern and dilation. Permitting oral intake (eg, clear liquid diet) as tolerated 24-48 hours postsurgery may help resolve the ileus by stimulating the return of peristalsis. In addition to routine postoperative care, nursing interventions for a client with postoperative ileus should
  • ANSWER focus on bowel stimulation to achieve the return of peristalsis. Anticipated interventions include frequent measurement of abdominal girth, use of nonopioid analgesics and nonpharmacological strategies for pain, frequent ambulation, and close monitoring of electrolytes (eg, hypokalemia). Excessive vomiting can
• ANSWER alter fluid volume, electrolytes, and acid-base balance. The nurse should prioritize the initiation of continuous IV fluids and potassium replacement for a client with severe vomiting and hypokalemia. When monitoring for resolution of postoperative ileus, the nurse should
• ANSWER evaluate for signs of return in peristalsis (eg, bowel sounds, flatus, bowel movement), corrected electrolyte imbalances, and improved pain and nausea. Client findings that are associated with cardiovascular conditions

• ANSWER (eg, abdominal pain that radiates to the back, excessive vomiting leading to electrolyte imbalance) or gastrointestinal bleeding (eg, alcohol use, pain after eating) should be prioritized for follow-up. Severe epigastric pain that occurs after eating can be associated with
• ANSWER acute cholecystitis, acute pancreatitis, or a bleeding gastric ulcer; in clients with acute pancreatitis, pain is relieved by leaning forward. Chronic alcohol use increases the risk for acute pancreatitis or a bleeding gastric ulcer. Acute pancreatitis should be suspected in clients with
• ANSWER a history of chronic alcohol use, severe epigastric pain after eating, vomiting, and an elevated serum lipase level. For a client experiencing acute pancreatitis, interventions that are indicated include - ANSWER maintaining NPO status, IV antiemetic and pain medications, client positioning for pain management, IV fluid therapy to prevent hypovolemia, and scheduled blood glucose checks. For a client with acute pancreatitis, aggressive fluid replacement with a - ANSWER lactated Ringer solution IV bolus will maintain adequate circulatory fluid volume, and prevent hypovolemic shock and complications related to electrolyte imbalance (ie, cardiac arrhythmias, neurological complications). Even after interventions for acute pancreatitis have been initiated, complications may occur in the acute care setting. Manifestations of respiratory distress - ANSWER (eg, coarse crackles, tachypnea), infection (eg, fever), and hyperglycemia all indicate compromised pancreatic tissue function and require immediate follow-up. Small bowel obstruction is - ANSWER an intestinal blockage that obstructs the flow of intestinal contents, resulting in abdominal distension, colicky abdominal pain, bilious vomiting, and inability to pass flatus or stool. Interventions include bowel rest (ie, NPO status) with gastrointestinal decompression, abdominal CT scan, and IV antiemetics and fluids.

Management of acute diverticulitis focuses on - ANSWER bowel rest (NPO status, NG suction, bed rest), and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided. Clients with alcohol use disorder often have - ANSWER low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures. Acute pancreatitis occurs due to - ANSWER the release of pancreatic enzymes (eg, lipase) in and around the pancreas, causing inflammation and autodigestion of pancreatic tissue. Causes include untreated cholelithiasis, alcohol use disorder, abdominal trauma, hypertriglyceridemia, and medical procedures that irritate the pancreas. Acute cholecystitis is - ANSWER inflammation of the gallbladder caused by gallstones or another mechanical biliary obstruction that blocks bile secretion and causes distension. Treatment includes supportive care (eg, NPO status, IV fluids, analgesia, antiemetics) and cholecystectomy (ie, surgical removal of the gallbladder). is a common postoperative complication caused by intraoperative sedation, immobility, and opioid analgesics. The nurse should first assess the client to promote informed client care. - ANSWER Constipation manifestations of hypovolemia (eg, hypotension, tachycardia, syncope), hematemesis (ie, vomiting blood), and dark/black stools. Frequent use of NSAIDs, tobacco, and alcohol is associated with an increased risk of GI bleeding. - ANSWER Signs concerning for an acute gastrointestinal (GI) bleed include Findings associated with upper gastrointestinal (GI) bleeding include - ANSWER melena (ie, dark, tarry stool), hematemesis (ie, vomiting blood), and risk factors for peptic ulcer formation (eg, NSAID use, Helicobacter pylori infection). Lower GI bleeding occurs in structures past the duodenum. Diverticulosis is a condition where diverticula (ie, hollow, outpouchings from the intestines) develop and weaken the intestinal wall which increases the risk for GI bleeding.

Peptic ulcer disease - ANSWER is characterized by erosion and ulceration of the protective layers (ie, mucosa) of the upper gastrointestinal (GI) tract, which allows digestive enzymes and stomach acid to break down underlying tissues, leading to potential perforation and upper GI bleeding. Anticipated prescriptions for clients with upper gastrointestinal (GI) bleeding include - ANSWER placing the client on NPO status to reduce the risk of continued bleeding and vomiting; administering IV fluids to restore circulating fluid volume and proton pump inhibitors to reduce gastric acid secretion; and collecting blood samples for type and crossmatch to prepare for blood transfusion. Anticoagulation (ie, heparin) is contraindicated for clients with active GI bleeding. An esophagogastroduodenoscopy (EGD) - ANSWER is the primary treatment for upper gastrointestinal (GI) bleeding. An EGD involves passing an endoscope down the esophagus to visualize the upper GI structures (eg, esophagus, stomach, duodenum), identify the source of the bleed, and perform interventions to stop bleeding (eg, hemostatic clipping). To prevent new peptic ulcer formation or disease exacerbation, clients should - ANSWER avoid activities (eg, smoking) and drugs (eg, caffeine, alcohol, NSAIDs) that stimulate production of stomach acid and impair ulcer healing. Clients should be instructed to report signs and symptoms of a recurrence of gastrointestinal bleeding (eg, melena) and request a prescription for a smoking cessation aid (eg, varenicline). Abdominal pain is a manifestation of - ANSWER several infectious or inflammatory conditions. Findings that require follow-up include epigastric and right upper quadrant pain, tenderness on palpation, alterations in vital signs (eg, fever, tachycardia), positive Murphy sign, and severe nausea and vomiting. Myocardial infarction and acute cholecystitis may cause - ANSWER epigastric abdominal pain that occurs after exertion or meals, radiates to the back or shoulder, and is associated with nausea and diaphoresis. In cholecystitis, inflammation also causes abdominal tenderness on deep inspiration (ie, positive Murphy sign).

Acute cholecystitis can be caused by - ANSWER gallstones or other mechanical biliary obstruction that blocks bile secretion and causes gallbladder distension. Retained bile may irritate and weaken the gallbladder wall, which can lead to gangrene and gallbladder perforation that can cause peritonitis. Treatment of acute cholecystitis includes - ANSWER administration of antibiotics, antiemetics, IV fluids, and electrolyte replacement and avoidance of oral intake to limit gallbladder stimulation. Surgical removal of the gallbladder (ie, cholecystectomy) is often required. If a client develops signs of peritonitis - ANSWER (eg, ridged abdomen, absent bowel sounds), the nurse should immediately prepare the client for emergency surgery and request a prescription for 0.9% sodium chloride IV bolus to correct hypotension. Following a cholecystectomy, the nurse should - ANSWER recognize that bilateral lower lobe crackles that do not clear with coughing and underuse of the incentive spirometer are concerning findings and may indicate atelectasis. Clinical manifestations of malabsorption include - ANSWER gastrointestinal disturbances (eg, abdominal pain, bloating), low BMI, symptoms of anemia (eg, brittle nails, pallor), and steatorrhea (eg, pale stool color, oily stool). Symptoms of celiac disease include - ANSWER diarrhea, pale-colored stools, iron deficiency anemia, nutrient malabsorption, and weight loss. Symptoms of irritable bowel syndrome include diarrhea and/or constipation. Diagnosis of celiac disease is - ANSWER typically determined with upper endoscopy and small bowel biopsy, which demonstrate a loss of small bowel intestinal villi and mucosal atrophy. Indicated interventions for a client with celiac disease include - ANSWER teaching the client about a gluten-free diet and instructing the client to avoid alcoholic beverages made with gluten (eg, beer, malted beverages).

The nurse should reassure the client who is prescribed ferrous sulfate that - ANSWER dark green stools are a harmless adverse effect of the medication. In addition, the nurse should instruct the client to take the medication on an empty stomach to enhance absorption and to take stool softeners to prevent constipation. is performed to remove impacted cerumen from the ear canal. To irrigate the ear, the external auditory canal should be straightened by pulling the pinna down and back for clients age ≤3 or up and back for clients age >3. - ANSWER Ear irrigation The nurse should assess the client for orthostatic hypotension by obtaining the client's blood pressure and heart rate in the supine, sitting, and standing positions. - ANSWER The nurse should notify the health care provider if any position change produces a decrease of systolic blood pressure ≥20 mm Hg. (eg, active listening, using open-ended questions) encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation between the nurse and client. - ANSWER Therapeutic conversation techniques hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated. - ANSWER Interventions to reduce falls in high-risk clients include Client falls can be prevented with - ANSWER exercise programs, good lighting, handrails, and hourly staff rounds. When a child accidentally ingests a poisonous substance, it is most important to - ANSWER assess the child's condition, including physical signs and symptoms, mental status, and behavior. Based on the condition of the child, the nurse can provide guidance and instructions to contact the appropriate agency (eg, emergency services, poison control center).

The nurse should first assess the client's condition before intervening. - ANSWER This is important as the ability to plan effective nursing care, set priorities, identify appropriate interventions, and make sound clinical decisions is based on the information obtained from the assessment. The least restrictive device or method to keep a client from - ANSWER interfering with medical treatment should always be tried first, before applying a physical restraint. Common physical restraint devices include - ANSWER belt and limb restraints; these require an order. Orthopedic immobilizers and protective devices used temporarily during routine procedures are not considered physical restraints. Medications that are standard treatments for specific conditions (eg, alcohol withdrawal, schizophrenia, mechanical ventilation) are not considered chemical restraints. - ANSWER The nurse should question a chemical restraint prescription that may not be medically necessary for a client's safety. Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure injuries. Massage over the bony prominences is not recommended for pressure injury prevention. - ANSWER Pressure injuries A low absolute neutrophil count increases a client's risk for - ANSWER infection. Gardening (soil) and contact with fresh flowers and plants should be avoided due to potential exposure to pathogens. The client's room should not have standing water. Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume - ANSWER capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill. Rapid response teams are formed as a means to get - ANSWER critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition.

Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output. Interventions for a client with low back pain include - ANSWER application of hot and cold compresses, administering NSAIDs and acetaminophen, remaining active as tolerated, and sleeping in a side-lying or supine position. Therapeutic communication techniques such as - ANSWER acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. - ANSWER The large magnet of an MRI can damage implantable devices or interfere with their function. The nurse should teach clients with insomnia good sleep hygiene such as using the bed for - ANSWER sleep only (no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day). Spiritual, cultural, and religious needs are an important part of the nursing assessment and plan of care. - ANSWER Clients have the right to verbalize and practice their beliefs; the nurse should facilitate spiritual practices within the plan of care. Visualization of NG tube placement by x-ray is the standard protocol to ensure proper placement prior to - ANSWER initiating enteral tube feedings. Verification by auscultating air is not an evidence-based method of placement verification. Initial management of heat exhaustion includes moving the client from the heat to a cooler area and providing a cool, electrolyte-containing sports drink or water. - ANSWER Early intervention in heat exhaustion can prevent the development of heat stroke, a potentially fatal condition leading to brain and additional organ damage.

Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. - ANSWER Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration. Principles of hearing aid care include: - ANSWER turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water. When performing oral care, clients should hold the toothbrush at a 45-degree angle to the gum line - ANSWER to promote penetration of the gum line and decrease the risk for bacteria entering compromised tissue. Interventions for reducing the risk of aspiration for clients with dysphagia include - ANSWER assisting the client to sit in an upright position and placing food on the stronger side of the mouth. A client with visual impairment should also be reminded to turn the head from side to side occasionally while eating to see everything on the plate. To calculate net fluid balance, the nurse should - ANSWER first convert the volume of 0.9% sodium chloride to milliliters, and then calculate intake and output totals. Finally, the nurse should subtract total output from total intake to calculate the net fluid balance. When caring for clients with overflow incontinence, - ANSWER the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed. The FLACC scale (Facial expression, Leg movement, Activity, Cry, Consolability) can be used to assess pain in nonverbal clients. - ANSWER Client behaviors or physical signs of pain include closed eyes and a clenched jaw, flexed positioning (eg, knees bent up), frequent shifting of positions, and moaning or whimpering.

Unstageable pressure injuries have - ANSWER slough and/or eschar in the base that prevents the nurse from fully visualizing the wound depth to determine the stage. Slough and eschar must be debrided before the wound can be staged. Urge incontinence (UI) - ANSWER is characterized by involuntary bladder muscle spasms that cause a strong, sudden urge to urinate followed by involuntary urine leakage. UI may be idiopathic or related to conditions that disrupt communication from the nervous system or impair urination, leading to increased bladder musculature over time. Enema administration can be uncomfortable for clients because - ANSWER instilling enema solution into the bowel may produce abdominal cramping and discomfort. If the client experiences discomfort during a cleansing enema, the instillation should be stopped temporarily (eg, 15-30 sec) and then resumed at a slower rate. Pain control is the priority assessment for clients with rheumatoid arthritis. - ANSWER Without adequate pain control, clients will have decreased ability to self-manage activities of daily living, maintain mobility and activity tolerance, and maintain self-esteem and a positive body image. Positional plagiocephaly, or flattening of the skull, can develop when infants spend a lot of time in the same position. - ANSWER Positioning techniques (eg, "tummy time," alternating the head position) can prevent or correct plagiocephaly. Infants should always be placed in the supine position to sleep. Postmortem care may be delayed or not performed if - ANSWER the family has certain cultural or religious beliefs or if the death is considered nonnatural, traumatic, or associated with criminal activity. Nurses should provide opportunities to support the families of clients and involve them in postmortem care as much as is desired and possible. Treatment with hypertonic enteral formulas can cause - ANSWER nausea, vomiting, and diarrhea. These symptoms can be alleviated by slowing the infusion rate and then gradually increasing the rate to the established goal.

Urge incontinence is characterized by involuntary bladder muscle spasms that cause a strong, sudden urge to urinate followed by involuntary urine leakage. - ANSWER Frequent nocturia is common and can cause significant sleep disruption. Clients with iron deficiency anemia should be taught to eat - ANSWER iron-rich foods such as meats, shellfish, eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal. Iron absorption can be enhanced by consuming iron-rich food with sources of vitamin C. The low-residue diet of a client with a new ileostomy helps prevent obstruction of the narrow lumen of the stoma. - ANSWER During the immediate postoperative period, the client should avoid foods that are high in fiber; stringy vegetables; and fruits and vegetables with pits, seeds, or edible peels. The nurse should ensure a client's foreskin is fully reduced before applying a condom catheter because prolonged retraction - ANSWER can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans penis. When a client with celiac disease does not experience symptom relief after starting a gluten- free diet, it is most important for the nurse to - ANSWER assess the underlying cause. The most common reason for persistent symptoms is that gluten has not been fully eliminated from the diet. For clients receiving peritoneal dialysis, strict intake and output monitoring is required, and dialysate is included when calculating net fluid balance. - ANSWER Net fluid balance is calculated by subtracting total output from total intake. Cystic fibrosis (CF) is a multisystem condition that causes the exocrine glands to be thicker and stickier than normal, damaging the gastrointestinal tract and impairing the absorption of nutrients. - ANSWER Clients with CF should consume a diet high in calories and protein to ensure adequate nutrients for growth and development.

To prevent falls when descending the stairs using a cane, - ANSWER the client should lead with the cane, follow with the affected leg, and then step down with the unaffected leg. Stress incontinence occurs during certain physical activities and is usually caused by weak pelvic floor muscles. - ANSWER Clients should limit caffeine and alcohol intake, void every 2 hours while awake, use incontinence pads as needed, and perform pelvic floor muscle exercises. is an opioid used for the treatment of opioid use disorder. Clients should notify the health care provider if experiencing symptoms of cardiac dysrhythmias (eg, dizziness, palpitations) because methadone can cause QT-interval prolongation and lethal cardiac dysrhythmias (eg, torsades de pointes). - ANSWER Methadone is a highly contagious infection. The infection can be prevented by receiving the varicella vaccine series starting at age 12-15 months. Manifestations often begin with low-grade fever, progressing to a pruritic, vesicular rash that begins on the face and spreads to the trunk and extremities. - ANSWER Chickenpox (varicella) work within the central nervous system to reduce pain perception. Abnormal respiratory findings (eg, shallow respirations, bradypnea) require follow-up prior to administering morphine because opioids can cause life-threatening respiratory depression. - ANSWER Opioids (eg, morphine, hydromorphone) The nurse is caring for a client with anorexia nervosa who began receiving total parenteral nutrition via a central venous access device 1 day ago. It would be a priority for the nurse to monitor the client for - ANSWER decreased serum phosphate and potassium levels A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication? - ANSWER "Tolerance develops quickly and persistent nausea is rare." are expected side effects when opioid pain medications are initiated. However, tolerance develops quickly and persistent nausea is rare. Nausea and vomiting are decreased when the

client lies still in a flat position. Anti-emetics may be needed initially. - ANSWER Nausea and vomiting NSAIDs can cause - ANSWER myocardial infarction, stroke, and hypertension and can exacerbate heart failure. NSAIDs also decrease the effectiveness of diuretics and antihypertensives. Clients with preexisting cardiovascular disease (eg, hypertension) should avoid ibuprofen or use it cautiously at a low dose and only for a short time. The half-life of naloxone (Narcan) is shorter than most narcotics. When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression. - ANSWER When naloxone is used to reverse the effects of narcotics, the nurse must monitor the client to ensure that the client does not fall again into excessive sedation and/or respiratory depression. is an expected long-term side effect of opioid use; clients will not develop tolerance to this side effect. It is important to teach aggressive preventive measures (eg, defecate when the urge is felt, drink 2-3 L of fluid/day, high-fiber diet, exercise) and simultaneous use of a stool softener and a stimulant. - ANSWER Constipation A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? - ANSWER Teach the client how to prevent constipation Nausea and vomiting are - ANSWER expected side effects when opioid pain medications are initiated. However, tolerance develops quickly and persistent nausea is rare. Nausea and vomiting are decreased when the client lies still in a flat position. Anti-emetics may be needed initially. chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect. - ANSWER Long-acting controlled-release opioid drugs for

The most serious adverse effect to morphine administration - ANSWER is respiratory depression. Sedation precedes respiratory depression; therefore, the nurse should monitor the client's level of consciousness and notify the health care provider if the client becomes sedated. Which instruction about capsaicin should the nurse provide the client? - ANSWER Apply cream to hands and wait at least 30 minutes before washing them. the affected area to ensure adequate absorption. A postoperative client is prescribed patient-controlled analgesia (PCA). The client tells the nurse, "I am pushing the button, but I'm still having a lot of pain." What is the priority nursing action? - ANSWER Perform a thorough pain assessment When providing care for a client prescribed patient-controlled analgesia (PCA), - ANSWER the nurse should assess pain on a regular and as-needed basis. The nurse should also reinforce previous teaching and evaluate the client's knowledge regarding proper PCA pump use. The nurse is reviewing new medication prescriptions for a client with pneumonia and chronic kidney disease. The nurse should clarify the prescription for - ANSWER ibuprofen NSAIDs (eg, ibuprofen, naproxen) - ANSWER are nephrotoxic and should be avoided in clients with chronic kidney disease. Factors that increase risk for opioid-related respiratory depression include - ANSWER advanced age, underlying pulmonary disease, recent surgery, concurrent use of other sedating medications, history of smoking, obesity, opiate-naive status, and snoring/sleep apnea. Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. - ANSWER When administering an opioid analgesic, the nurse should assist with ambulation, administer stool softeners to prevent constipation, and monitor the client's respiratory status.

All NSAIDs (eg, indomethacin, ibuprofen, naproxen) are associated with gastrointestinal toxicity, kidney injury, exacerbation of fluid overload/hypertension, and bleeding risk. - ANSWER They should be used at the lowest dose and for the shortest period possible. If a client is experiencing oversedation from opioids, the nurse should immediately administer - ANSWER naloxone, assess the client's respiratory rate, continue to stimulate the client, and notify the health care provider. The nurse should question initiation of apixaban therapy in the context of NSAID use. - ANSWER NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. Maintenance drug therapy after a pulmonary embolus typically includes - ANSWER administration of oral anticoagulants such as factor Xa inhibitors (eg, apixaban). NSAIDs (eg, indomethacin) increase the risk of bleeding when used concurrently with apixaban therapy. The nurse should question initiation of apixaban therapy in the context of NSAID use. opening between the ventricles, which results in shunting of oxygenated blood from the left to right ventricle and can lead to heart failure. Grunting during feeding in clients with a VSD is indicative of cardiac compromise and decreased oxygenation. - ANSWER Ventricular septal defect (VSD) can indicate fluid volume overload. The nurse should recognize clinical signs such as crackles in lungs, jugular venous distension, and peripheral edema as evidence of fluid volume overload. - ANSWER Elevated CVP occur during stressful or painful procedures and with hunger, crying, and feeding. Providing a calm environment, reducing hunger with small meals, keeping the infant warm, and preventing periods of excessive crying can help prevent hypercyanotic episodes. - ANSWER Hypercyanotic, or "tet," spells usually

A client with hypertension is prescribed lisinopril. The nurse instructs the client to notify the health care provider (HCP) immediately if which adverse effect occurs when taking this medication? - ANSWER Swelling of the lips and tongue have a low incidence of serious adverse effects except for angioedema, which causes rapid swelling of the lips, tongue, throat, face, and larynx and should be immediately reported to the health care provider. More common adverse effects of ACE inhibitors include dry cough, orthostatic hypotension, and hyperkalemia. - ANSWER ACE inhibitors (eg, captopril, enalapril, lisinopril) is a very potent antihypertensive medication. Abrupt discontinuation of the medication can result in serious rebound hypertension; therefore, clonidine should be tapered over 2-4 days for client safety. Common side effects of clonidine include dizziness, drowsiness, and dry mouth. - ANSWER Clonidine The nurse should teach the client that incisional pain from thoracotomy incisions between the ribs may be very painful after MIDCAB surgery. The nurse should encourage the client to take pain medication before the pain is too intense. The client should also be instructed to cough, breathe deeply while splinting the chest with a pillow, and use the incentive spirometer routinely to reduce the incidence of postop complications. - ANSWER Coronary artery bypass grafting The ECG of a client with a single-chamber atrial pacemaker should display - ANSWER a pacemaker spike before the P wave. On an electrocardiogram (ECG), - ANSWER the P wave represents atrial depolarization and the QRS complex represents ventricular depolarization. The ECG of a client with a single-chamber atrial pacemaker should display a pacemaker spike before the P wave. occurs when a blood clot becomes lodged in a vein. Clinical manifestations include unilateral edema, localized pain, tenderness to touch, warmth, and erythema. - ANSWER Deep venous thrombosis

is a life-threatening complication of pericarditis that develops when fluid accumulates within the layers of the pericardium. Clinical manifestations include tachycardia, muffled heart tones, jugular venous distension, and pulsus paradoxus. - ANSWER Explanation Cardiac tamponade Clients with pericardial effusion should be - ANSWER monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus indicate turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas. - ANSWER Murmurs Clients taking estrogen therapy are at an increased risk for - ANSWER hypercoagulability and thromboembolic complications. Signs or symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider immediately. The nurse needs to monitor groin puncture sites, peripheral pulses, urine output, and kidney function in the client who has had minimally invasive endovascular repair of an abdominal aneurysm. - ANSWER Endovascular abdominal aortic aneurysm repair i increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyle changes and medications. - ANSWER Peripheral artery disease on ECG is characterized by an irregular rhythm with fibrillatory waves instead of P waves. Treatment includes rate control and anticoagulation. - ANSWER Atrial fibrillation

is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias. - ANSWER Dopamine Clinical manifestations of hypovolemic shock - ANSWER are associated with inadequate perfusion and include urine output <0.5 mL/kg/hr, changes in mental status, hypotension, and tachycardia.