NCLEX Study Guide 2024 100% verified answers guaranteed pass, Exams of Health sciences

Download NCLEX Study Guide 2024 100% verified answers guaranteed pass and more Exams Health sciences in PDF only on Docsity!

NCLEX Study Guide 2024

100% verified answers

guaranteed pass

The charge nurse has received a change of shift report on the following laboring clients. The nurse should give priority for treatment to a A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. B. Client who is 39 weeks pregnant, G3P2, amniotomy performed, thin, green fluid. C. Client who is 38 weeks pregnant, G1P0, oxytocin infusing, no cervical dilation in 3 hours. D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated. A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. explained: for successful vaginal delivery, the fetus should be in a vertex position (I.e., parallel with maternal spine), flexed (I.e., chin to chest), and cephalic (I.e., head down) presentation Facial presentation occurs when the fetal head is fully extended, requiring immediate intervention (e.g., emergent cesarean section). delivering vaginally can cause trauma, spinal cord injuries, fetal distress, and demise.

The nurse is screening clients for those at increased risk for developing metabolic acidosis? At highest risk for developing metabolic acidosis is the client who A. Has nausea and vomiting B. Has sepsis and hypotension C. Is taking large doses of thiazide diuretics D. Has decreased oral intake and is dehydrated B. Has sepsis and hypotension The nurse is caring for a postoperative client who has voided 125 mL since the removal of the indwelling urinary catheter 6 hours ago. Which of the following actions should the nurse take? A. Perform a bladder scan B. Reassess urine output in 1 hour C. Administer 40 mg of furosemide D. Administer a 500 mL IV fluid bolus A. Perform a bladder scan Explanation: Client is experiencing decreased urinary output (<30mL/hr) and requires further assessment to determine the cause. The nurse observes a coworker who is inserting a nasogastric tube. Which of the following actions by the staff member would require the nurse to intervene? A. Uses slight pressure and rotates the tube during insertion

B. Advance the nasogastric tube while the client swallows water C. Flushes tube with normal saline after insertion to confirm patency D. Measures tube length from nose, to the earlobe, and then to the xiphoid process C. Flushes tube with normal saline after insertion to confirm patency Explanation: Nasogastric (NG) tube are flexible tubes placed in the nares down to the stomach. They provide enteral nutrition directly to the stomach or remove gastric contents, decompressing the stomach. NG tube insertion include:

1. Position the client in high-Fowler.
2. Determine the needed tube length
3. Lubricate and inset the tube, aiming towards the back of the throat and down towards the ear.
4. Instruct the client to put chin to chest and repeatedly swallow during insertion.
5. Stop insertion once the desired length is reached. Remove and start over if the tube meets resistance or the client experiences respiratory distress.
6. Secure with tape.
7. Confirm tube placement is in the stomach and not the lungs with an X-ray before utilizing. Without confirmation, aspiration could occur. After initial verification with an X- ray, tube placement is verified before each use by aspirating gastric contents or pH testing aspirated contents. Takeaway: Nasogastric tubes enter the nares and end in the stomach. Nasogastric tube placement must be confirmed with X-ray prior to use to avoid aspiration. The nurse has received information about assigned clients.

Which of the following clients has an increased risk for hypocalcemia? A. Client recovering from recent thyroidectomy B. Older adult client who has viral gastroenteritis infection C. Client who has breast cancer newly metastasized to the ribs D. Client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) A. Client recovering from recent thyroidectomy explanation: come back to finish The pediatric nurse assesses multiple clients. Which of the following clients should the nurse INVESTIGATE further for potential child abuse? A. 1 year old client who has bright red cheeks and a raised, bumpy rash bilaterally on the arms and legs B. A 5 month old client who has influenza and a 4 cm bluish-gray asymmetrical marking on the left buttocks C. A 10 year old client who has scratched shins and a clavicle fracture and reports falling while skateboarding D. A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed a hot iron D. A 7 month old client with palm burns whose caregiver says the client climbed up the sink and grabbed a hot iron The nurse is carting for a 8kg, 1 year old client who underwent a complete cardiac repair for tetralogy of pallor 8 hours ago.

Which of the following findings would REQUIRE IMMEDIATE follow-up? Select all that apply A. 1+ radial and femoral pulses B. Temperature of 100 F (37.7 C) C. Urine output of 5 mL in the last hour D. Pinkish-tan colored chest tube drainage E. Chest tube drainage of 19 mL in one hour F. Median sternotomy dressing has 2 mL of dried blood. A. 1+ radial and femoral pulses C. Urine output of 5 mL in the last hour explanation: TETRALOGY IS a combination of four congenital (present at birth) heart defects. The defects occur together and change the way blood flows through the heart and lungs. The nurse discusses developmental milestones with the caregivers pod several clients. Which finding REPORTED by a caregiver REQUIRES follow-up by the nurse? A. A 19 month old who often falls while running through the house B. A 22 month old who can say 4 words including "mom" and "more" C. An 18 month old who is able to build a tower containing 3 wooden blocks D. A 24-month who plays with a doll bedside a friend without asking the friend to play B. A 22 month old who can say 4 words including "mom" and "more"

The nurses is caring for an 8 - month old client diagnosed with pertussis. Which of the following INTERCEPTIONS should the nurse ANTICIPATE implementing? Select all that apply. A. Initiating droplet precautions B. Providing humidified oxygen C. Administering a bronchodilator D. Providing suctioning as needed E. Administering antiviral medications F. Encouraging frequent, small feedings A. Initiating droplet precautions B. Providing humidified oxygen D. Providing suctioning as needed F. Encouraging frequent, small feedings Ex: Pertussis (whooping cough) is a highly contagious bacterial upper respiratory infection that causes coughing spells filled by sharp inhalation that creates a The experienced pediatric intensive care registered nurse is preempting a newly licensed registered nurse who received repot on 4 clients. Which of the following ACTIONS taken by the new nurse REQUIRES the experienced nurse to intervene? A. Placing a client with varicella in a negative pressure isolation room. B. Performing oropharyngeal suctioning on a drooling client with croup. C. Placing an infant in prone position following myelomeningocele repair.

D, Drawing up insulin lisper before NPH insulin in the same syringe for a client with diabetes. B. Performing oropharyngeal suctioning on a drooling client with croup. ?????? The nurse receives report on four assigned pediatric clients. Which client should the nurse ASSESS first? A. A 2 year old client with a history of Kawasaki disease who just began vomiting and appears restless B. A 12 year old client with acute rheumatic fever who is making sporadic arm movements and grimacing C. A 3 month old client with coarctation of the aorta (COA) on a ventilator who is pale and has weak femoral pulses D. A 6 month old client with ventricular septal defect (VSD) who experiences labored breathing when placed supine. A. A 2 year old client with a history of Kawasaki disease who just began vomiting and appears restless Ex: Kawasaki disease (KD) is an acute, self resolving vasculitis affecting mostly small and medium-sized vessels, especially the coronary arteries. KD weakens vessel was and can cause coronary aneurysm (abnormal bulging of the vasculature) and myocarditis (inflammation of the myocardium) Coronary artery aneurysm increases the risk for coronary thrombosis and myocardial infarction (MI), making KD the most common cause of MI in children. Vomiting and restlessness can indicate MI in young children.

The nurse is caring for a client with suspected benign prostatic hyperplasia. Which of the following client statements SUPPORTS the diagnosis of benign prostatic hyperplasia? Select all that apply. A. "I am having frequent constipation" B "I recently noticed some blood in my urine." C. "I wake up several times at night to urinate." D. "I have had urinate more frequently lately." E. "When I try to urinate, I have difficulty getting started." F. "When I am urinating, it is more of a dribble than a stream." G. "I have noticed that my scrotum feels more swollen than normal." B "I recently noticed some blood in my urine." C. "I wake up several times at night to urinate." D. "I have had urinate more frequently lately." E. "When I try to urinate, I have difficulty getting started." F. "When I am urinating, it is more of a dribble than a stream." Ex: Benign prostatic hyperplasia (BPH) is enlargement of the prostate gland that results in storage/irritative and obstructive symptoms, together termed lower urinary tract symptoms (LUTS). Obstructive symptoms occurs as the urethra is compressed, which requires the bladder to contract more forcefully to excrete urine and can cause urinary retention. the earliest sign of BPH is diminished caliber and force of urine when voiding. other obstruction symptoms include delay or hesitancy when clients attempt to urinate, difficulty in maintaining the urine stream (I.e. intermittency), and dribbling after voiding. Store/irritative symptoms are caused by irritation, inflammation, or infection and include

urinary frequency, nocturne (3 or more voids during the night), urgency, dysuria, or hematuria Ket takeaway: Clinical manifestation of benign prostatic hyperplasia include: Nocturia Hematuria Urinary retention Urinary hesitancy Urinary frequency Diminished urine stream The nurse is assessing a newborn client born vaginally 22 hours Aho at 36 weeks gestation. Which of the following findings requires IMMEDIATE follow-up? A. Yellow tinge to the sclera B. Soft edema on occupant area of head C. Erytematous spots and white vesicles on the trunk D. Gas and spilts ip clear mucus three times in one hour A. Yellow tinge to the sclera Ex: Bilirubin is a byproduct of red blood cells (RBC) destruction that is processed it into bile and exerted in urine and stool. Factors tat increase RBC hemolysis (e.g birth trauma) or decrease bilirubin excretion (e.g immature liver) can cause hyperbilirubinemia

Take away: 'Yellow tinged skin or sclera indicate jaundice caused by hyperbilirubnemia The nurse is caring for four postpartum clients. Which of the following clients should the nurse see FIRST? A. Client who delivered 1 day ago experiencing scant reddish-brown purulent lochia B. Client who delivered 1 hour ago experiencing moderate vaginal bleeding and is receiving oxytocin IV C. Client who delivered 8 hours ago experiencing increased vaginal bleeding while breast-feeding D. Client who delivered 12 hours ago who is experienced a gush of vaginal blood while ambulating for the first time A. Client who delivered 1 day ago experiencing scant reddish-brown purulent lochia Ex: Postpartum vaginal discharge (ie. LOCHIA) occurs up two 6 weeks after delivery. The lochia starts as bright red and transitions to pink, brown, and then to white discharge. IMMEDIATELY following delivery, vaginal bleeding can be moderate but should be continually decrease. Lochia should smell like normal blood. PURULENT discharge indicates an infection that can led to serious complications, like sepsis, if left untreated. Therefore, the nurse should first nurse assess the client experiencing scant reddish-brown purulent lochia. Take away: Purulent lochia can indicate an infection and require probity assessment.

A nurse is assessing a client at 34 weeks gestation and auscultates a fetal heart rate of 90 bpm Bia doppler. Which of the following should the nurse do FIRST? A. Notify the healthcare provider B. Check the maternal heart rate C. Document the fetal heart rate D. Initiate a fetal non-stress test. B. Check the maternal heart rate A. Notify the healthcare provider C. Document the fetal heart rate D. Initiate a fetal non-stress test. DID not get to answer this one NOT SURE IF ITS RIGHT. The nurse is working with a new graduate nurse to perform a contraction stress test on a pregnant client Which action by the new graduate nurse requires INVENTION by the nurse? A. Discontinues the test if late decelerations of the fetal heart rate occur. B. Refuses to perform the test if the client report a history of uterine surgery C. Continues the stress test until all contractions are at least 90 seconds long D. Teaches the client how to use the breast pump to stimulate uterine contractuion C. Continues the stress test until all contractions are at least 90 seconds long Takeaway:

Nursing interventions for a CST include: Assess for contraindications, such as pervious uterine surgery Using a breast pump to stimulate uterine contractions. Discontinuing test for contrition _>90 seconds or for late decelerations. The charge nurse has received a change of shift report on the following laboring clients. The nurse should give PRIORITY for treatment to a A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. B. Client who is 39 weeks pregnant, G3P2, amniotic performed, thin, green fluid. C. Client who is 38 weeks pregnant, G1P0, oxytocin infusion, no cervical dilation in 3 hours. D. Client who is 28 weeks pregnant, G2P1, uterine contractions every 5 minutes, 4 centimeters dilated. A. Client who is 41 weeks pregnant, G2P1, pushing, facial presentation. Ex: Facial presentation: for a successful vaginal delivery, the fetus should be in vertex position (I.e parallel with maternal spine), flexed (I.e chin to chest), and cephalic (I.e, head down ), presentation. Takeaway: facial presentation indicates a fully extended fetal head, requiring an emergent cesarean delivery to prevent fetal harm. The nurse is caring for a client who had an endovascular repair of an abdominal aortic aneurysm 2 hours ago. The of the following would be a priority for the nurse to include in the plan of

care? A. Assess and document the client's hourly urine output. B. Measure the client's temperature and while blood cell count C. Measure the serum creatinine and blood urea nitrogen levels D. Palpate the pedal pulses and temperature of lower extremities D. Palpate the pedal pulses and temperature of lower extremities Ex: An abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta. If the AAA grows large enough, it could rupture, which is potentially fatal due to severe internal bleeding. One of the surgical treatments for AAA is an end-vascular repair, which involves stunting the aneurysm to prevent rupture. Following AAA repair, monitoring perfusion to the lower extremities is crucial sine the aorta supplies blood to the lower half of the body. Diminished or absent pedal pulses or cold or pale lower extremities indicate a clot or graft occlusion impairing blood flow Takeaway: Following endovascular repair of AAA, the nurse should prioritize munitioning lower extremities perfusion since the aorta supplies blood to the lower half of the body. The home care nurse cares for a 70 year old Male client who reports feeling hungry, weak, and "shaky" and is found to have a low blood glucose level. Which action by the nurse is APPROPRIATE at the time? A. Turn the client onto the his left side B. Give the client crackers with cheese C. Offer the client half a cup of orange juice D. Administer 1 mg of glucagon intramuscularly

C. Offer the client half a cup of orange juice Ex: The client is demonstrating signs of mild hypoglycemia Takeaway: The first intervention for a alert client experiencing mild hypoglycemia (blood glucose <70mg/dL [3.9 mol/L] is administering 15 grams of carbohydrate Fast-acting carbohydrates include fruit juice, glucose tablets or gel, and hard candies. The nurse in the emergency department is caring for a client with burn injuries to the torso and lower extremities who has 32% of their total body surface area (TBSA) burned, Which of the following actions should the nurse take FIRST? A. Inser an indwelling urinary catheter B. Administer warmed crystalloid fluids IV C. Cover the burn injuries with sterile dressing D. Obtain blood for an arterial blood gas (ABG) analysis B. Administer warmed crystalloid fluids IV Ex: Clients with large surface area burns (greater than 20-25%) are at high risk for hemodynamic instability. Priority intervention focus on airway maintaining adequate perfusion (e.g. IV insertion, warmed crystalloid fluids IV) Large burns increase capillary permeability, allowing large amounts of fluid to leak from capillaries into surrounding tissue. This fluid shift decreases intravascular pressure and causes hypovolemic shock.

Takeaway: Clients with large burn injuries require aggressive fluid volume resuscitation to maintain adequate perfusion prevent hypovolemic shock The nurse is caring for a client with a pneumothorax. The nurse notes the client is experiencing dyspnea. Which of the following ACTIONS should the nurse take FIRST? A. Prepare the client for intubation B. Administer supplemental oxygen C. Place the client in high Flower's position D. Prepare the client for chest tube insertion C. Place the client in high Flower's position Ex: A pneumothorax is a life-threatening respiratory emergency caused by air entering the pleural space, resulting in negative pressure, resulting in negative pressure and lung collapse. Prompt intervention is crucial to prevent dyspnea, severe respiratory distress, and decrease cardiac output caused by increased thoracic pressure. Takeaway: Management of pneumothorax administering oxygen chest tube insertion positioning the client in a Folwer's position The nurse is caring for a client who has thrombocytopenia Which of the following findings hold REQUIRE IMMEDIATE follow-up?

A. Petechiae on forearms B. Client reports hematuria C. Client reports bleeding gums D. Decreased levels of consciousness D. Decreased levels of consciousness ex: Thrombocytopenia is a platelet count below 150 x 10 (3) it is caused by low production from bone marrow suppression, destruction of platelets by autoimmune disorders Thrombocytopenia can cause bleeding, which manifest as ecchymoses, petechiae or bleeding from the nose and gums. As levels drop, bleeding may involve the kidneys, gastrointestinal tract, or brain. (HEMORRHAGING IS the major complications) Takeaway: The most serious complication of thrombocytopenia is intracranial bleeding, manifested by decreased levels of consciousness The nurse has been made aware of the following clients situations. The nurse should FIRST assess the client who? A. Has erythema and swelling to the left leg with purulent drainage at the site B. Has a history of migraines who report pain behind the right eye and nausea C. Woke up with decreased vision and repeats seeing "flashes of light" in their visual field D. Is 6 weeks pregnant, reporting mild stomach cramping, nausea, and an episode of vomiting C. Woke up with decreased vision and repeats seeing "flashes of light" in their visual field

Explanation: A sudden decreased in vision with visual field abnormalities (e.g., floaters, light flashes, or "a black curtain across the visual field") is a clinical manifestation of a retinal detachment, a medical emergency that causes permanent blindness if left untreated. If a retail detachment is confirmed, the nurse should prepare the client for surgery. The nurse should apply an eye patch to the attested eye to prevent further ocular stress and movement, which can worsen the detachment. Takeaway: A sudden loss of vision with visual field abnormalities (e.g., floaters, light flashes) is a manifestation of a retinal detachment, a medical emergency requiring immediate intervention to prevent permanent blindness. The nurse is caring for a client hospitalized with heart failure. Which meal item would be APPROPRIATE to include on this clients lunch tray? A. Broiled cod with roasted potatoes and carrots B. Deli turkey and cheddar sandwich with baked chips C. Chicken Caesar salad with croutons and ranch dressing D. Vegetable stir fry from a takeout restaurant seven with brown rice A. Broiled cod with roasted potatoes and carrots Explanation: Clients with heart failure are limited to 2 grams of sodium and 2 liters of fluid intake daily Broiled cod with roasted potatoes and carrots is a goos choice because it is low-sodium,

nutrient-dense meal that is low in saturated fat and high in protein Takeaway: Broiled cod with roasted potatoes and carrots is an appropriate meal choice for a client with heart failure, as it is low-sodium, nutrient-dense meal that is low in saturated fat and high in protein The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD). Which of the following FINDINGS would require IMMEDIATE follow- up? A. Lower extremity edema B. Paradoxical respirations C. Increased hemoglobin levels D. Pulse oximetry reading 88% B. Paradoxical respirations Explanation: Respiratory failure is a key complication of COPD characterized by hypoxia (low oxygen levels in the blood) or hypercapnia (elevated levels of carbon dioxide in the blood). Paradoxical respiration, also known as seesaw respirations, occur when the chest wall moves inward during inspiration rather than pushing outward. This is often a sign of impending respiratory failure from fatigued respiratory muscles, primarily the diaphragm. The nurse should IMMEDIATELY assess their client and anticipate providing mechanical ventilation.

Takeaway: Paradoxical respiration are the most immediately concerning sign of potential respiratory failure in a client with COPD and would require immediate follow-up The nurses has taught a client with newly diagnosed gastroesophageal reflux disease. Which of the following statements by the client DEMONSTRATES understanding of the teaching? A. :I can try following a ketogenic diet to lose weight." B. " I will suck on peppermint candy to masse the burning taste." C. " I can try eating two large meals daily since it is uncomfortable to eat." D. " I will take esomeparazole daily regardless of whether I have symptoms. D. " I will take esomeparazole daily regardless of whether I have symptoms. Explanation: Gastroesophageal reflex disease (GERD) is a chronic condition that occurs when stomach acid flows back into the esophagus, leading to discomfort and potential complication as acidic stomach contents come into contact with the lining of the esophagus. Nurses should teach clients that: Proton pump inhibitors (PPls) (e.g., esomeprazole, omeprazole) are prescribed to decreased the production of stomach acid. This medication needs to be taken daily to be effective. The effects of PPls build over time, so they should be taken consistently, even if symptoms are not present. Takeaway: PPls decreased the production of stomach acid and must be taken daily to treat GERD symptoms effectively

The nurse is planning care for a client who is at risk for increased intracranial pressure. Which of the following assessments should the nurse PRIORITIZE in the client's plan of care? A. Babinski reflex B. Presence of headache C. Pupil size and reactivity D. Level of consciousness D. Level of consciousness Explanation: Altered level of consciousness (LOC) is the most reliable, sensitive, and often the earliest indicator of (ICP) that appears before changes in pupil assessment, which are a late finding. Changes in LOC are most accurately assessed by using the Glasgow Coma Scale (GCS). Even subtle changes in GCS may indicate increased ICP, which can cause brain herniation and death if left untreated. Takeaway: assessing LOC is the most reliable, sensitive, and often earliest sign of increased ICP. The nurse is caring for a client with suspected chronic venous insufficiency. Which of the following findings would SUPPORT a diagnosis of chronic venous insufficiency? A. Absent pedal pulse B. Intermittent leg cramping with exercise C. Ulcers on the toes with well-defined edges D. Brown discoloration to the lower extremities

D. Brown discoloration to the lower extremities Explanation: CVI is a condition characterized by inadequate blood return from the lower extremities, resulting from elevated pressure in the veins that stretches the vessels and damages their valves over time. Manifestations of CVI include peripheral edema in the lower legs, which worsens with prolonged standing or sitting. CVI also causes skin changes, which include a thick, leathery appearance and brownish discoloration on the lower legs from hemosiderin deposits takeaway: CVI is caused by inadequate blood return from lower extremities. The nurse is preparing to administer medication to a client with pneumonia who had five liquid bowel movements so far today. Which action by the nurse is MOST appropriate? A. Request an order for loperamide B. Hold the client's schedules docusate C. Hold the client's scheduled antibiotics D. Changed the client's diet order to a "bland" diet/ B. Hold the client's schedules docusate Explanation: Antibiotics can cause diarrhea (e.g., C. diff) due to disruption of the normal intestinal bacterial flora. If a client develops diarrhea during hospitalization, the nurse should

HOLD or DISCONTINUE stool softeners or laxatives (e.g., decussate, polyethylene glycol). Administering docusate would worsen diarrhea and could contribute to fluid, electrolytes and acid-base imbalance Takeaway: Hold of discontinue any stool softeners or laxatives The nurse is caring for a client who received a kidney transplant 12 hours ago. Which of the following findings would require IMMEDIATE follow-up? A. A low serum sodium level B. Blood pressure 89/52 mmHg C. Urine output of 400 mL.hr for 2 hours D. Pink-tinged urine in the catheter drainage bag B. Blood pressure 89/52 mmHg NEED TO DOUBLE CHECK ANSWER D. Pink-tinged urine in the catheter drainage bag The nurse receives a prescription for IV push 2 mg diazepam and is unsure whether this is the appropriate dose for this medication. Which of the following is the BEST action for the nurse to take? A. Verify the medication dosage in the hospital's online medication reference. B. Ask the charge nurse whether no not this is a safe dose for this medication

C. Page the primary health care primary to clarify the intended correct dosage. D. Contact the hospital pharmacist to confirm the correct dosage was prescribed. D. Contact the hospital pharmacist to confirm the correct dosage was prescribed but I know how Dr are so I might do C. Page the primary health care primary to clarify the intended correct dosage. NEED TO CHECK ANSWER The nurse enters a client's room for the first time during the shift and realized that the IV fluids are infusing 100 mL/hr faster than prescribed rate. Which of the following actions should the nurse take FIRST? A. Adjust the infusion rate to the prescribed rate B. Assess the client's lungs sounds and vitals signs C. Complete an incident repot documenting the error D. Notify the primary health care provider about the error. A. Adjust the infusion rate to the prescribed rate Explanation: Medication errors are most common cause of clients har and occur due to a failure in the right of medication administration either by the prescribing healthcare provider, pharmacist, or administering nurse. When responding to a medication error, the nurse's highest priority is always clients safety. The nurse should FIRST prevent further harm to this clients by correcting the infusion rate. Takeaway:

When responding to any medication error, the nurse should always prioritize preventing further harm and assessing the client. Next, the nurse should contact the HCP to communicate assessment findings. Finally, the nurse should complete an incident report The nurse is caring for a client with hypertension who is taking lisinopril. Which of the following client findings is MOST concerning? A. Itchy lips and tongue B. Persistent dry cough C. Blood pressure of 142/92 mmHg D. Feeling lightheaded when standing quickly A. Itchy lips and tongue Explanation: Angiotensin-convetting enzyme (ACE) inhibitors (e.g., lisinopril, benazepril) lower blood pressure by inhibiting renin-angiotensin-aldosterone system (RAAS) function. Itch lips and tongue may be the first symptoms of angioedema, a severe side effect of ACE inhibitors that can process to airway obstruction and respiratory failure if not prompts treated. Angioedema occurs due to inhibition of the breakdown of bradykinin, a vasodilator. Increased levels of bradykinin can trigger an immune and inflammatory response, causing swelling go the face, lips, tongue, or throat. Takeaway: Angioedema is a life-threatening side effect of ACE inhibitors that may present initially as itchy lips and tongue

Dry cough and orthostatic hypotension are expected effect of ACE inhibitors The nurse is planning care for client with type 2 diabetes who is taking metformin. Which of the following would be a PRIORITY for the nurse to include in the plan of care? A. Monitoring the client's serum creatinine levels daily B. Checking the client's blood glucose four times daily C. Encouraging the client to eat whenever appetite is poor D. Hold metformin before the client has a CT scan with contrast D. Hold metformin before the client has a CT scan with contrast Explanation: Metformin is a biguanide oral anti diabetic medication that is first-line in the treatment of type 2 diabetes. Metformin does not lower blood glucose directly, but helps control blood sugar by decreasing glucose production in the liver and increasing tissue responsiveness to insulin (I.e., insulin sensitivity). Combining metformin with IV contrast material poses an increased risk for renal toxicity and life-threatening lactic acidosis; therefore, metformin should be help 1-2 days before a CT with contrast and for 48 hours afterwards. Takeaway: Metformin should be withheld 1-2 days before a CT scan with contrast medium and for 48 hours afterwards to ensure optimal renal function The nurse administers oral levothyroxine to a client with hypothyroidism.