Nursing Care Plan

Dear Nurses: DEAR NURSES WELCOME TO 2018

2018-03-10T04:23:00.001-08:00

<a href="http://www.cncplansonline.com/2012/02/nursing-care-bed-sore-pressure-sores.html">Nursing</a>

Nclex Review Questions Answer and Rational Practice

2018-02-26T03:54:00.000-08:00

Nclex Review Questions Answer and Rational Practice Q.1 A 10-month-old child with recurrent otitis media is brought to the clinic for evaluation. To help determine the cause of the child's condition, the nurse should ask the parents:
a)"Does water ever get into the baby's ears during shampooing?"
b)"Do you give the baby a bottle to take to bed?"
c)"Have you noticed a lot of wax in the baby's ears?"
d)"Can the baby combine two words when speaking?"

Q.2 A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask:
a)"Do you have the pain all the time?"
b)"Can you describe the pain?"
c)"Where does it hurt the most?"
d)"Is the pain stabbing like a knife?"

Q.3 A 56-year-old client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which of the following symptoms indicates a toxic response to the chemotherapy?
a)Decrease in appetite.
b)Drowsiness.
c)Spasms of the diaphragm.
d)Cough and shortness of breath.

Q.4 After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
a)Peritonitis.
b)Thrombophlebitis.
c)Ascites.
d)Inguinal hernia.

Q.5 A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?
a)The client sees his physician for a check-up yearly.
b)The client has never traveled outside of the country.
c)The client had a liver transplant 2 years ago.
d)The client works in a health care insurance office.

Q.6 When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?
a)Shock
b)Encephalitis
c)Increased intracranial pressure (ICP)
d)Status epilepticus

Q.7 A client with inflammatory bowel disease is receiving total parenteral nutrition (TPN). The basic component of the client's TPN solution is most likely to be:
a)An isotonic dextrose solution.
b)A hypertonic dextrose solution.
c)A hypotonic dextrose solution.
d)A colloidal dextrose solution

Q.8 While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?

a)Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. b)Ask the client to assume a side-lying position with the knees flexed.
c)Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
d)Place the client on a bedpan in case the uterine palpation stimulates the client to void.

Nclex RN Practice Question 2018 Nclex Test Practice Question

2018-01-02T23:18:00.000-08:00

Nclex RN Practice Question 2018 Nclex Test Practice Question

Q.1 A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?

a) Use a cool air vaporizer with plain water.
b) Use saline nose drops and then a bulb syringe.
c) Blow into the child's mouth to clear the infant's nose.
d) Administer a nonprescription vasoconstrictive nose spray.

Q.2 A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report?

a)Incident report.
b)Nurse's shift report.
c)Transfer report.
d)Telemedicine report.

Q.3 To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:

a) Avoid excessive sun exposure.
b) Follow a low-cholesterol diet.
c) Obtain extra rest.
d) Supplement the diet with pyridoxine (vitamin B6).

Q.4 A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:

a) monitoring of arterial oxygen saturation (SaO2).
b) arterial blood gas (ABG) studies.
c) chest auscultation.
d) a chest X-ray.

Q.5 When caring for a client after a closed renal biopsy, the nurse should?

a) Maintain the client on strict bed rest in a supine position for 6 hours.
b) Insert an indwelling catheter to monitor urine output.
c) Apply a sandbag to the biopsy site to prevent bleeding.
d) Administer I.V. opioid medications to promote comfort.

Q.6 The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:

a) Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
b) Check respirations in 30 minutes because the effects of morphine will have worn off by then.
c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
d) Monitor respirations each time the client receives morphine sulfate 10 mg I.M

Q.7 The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
a) Contact the client's audiologist.
b) Cleanse the hearing aid ear mold in normal saline.
c) Irrigate the ear canal.
d) Check the hearing aid's placement.

Q.8 A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?
a) Hypoactive bowel sounds
b) Severe lower back pain
c) Sensory deficits in one arm
d) Weakness and atrophy of the arm muscles

Q.9 The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
a) Perform the procedure safely and correctly.
b) Critique the nurse's performance of the procedure.
c) Explain all steps of the procedure correctly.
d) Correctly answer a posttest about the procedure

Q.10 A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates:

a) Absence of nausea and vomiting.
b) Passage of mucus from the rectum.
c) Passage of flatus and feces from the colostomy.
d) Absence of stomach drainage for 24 hours

Nclex RN Examination Practice Answer and Rational Part 5

2017-12-25T03:07:00.001-08:00

Nclex RN Examination Practice Answer and Rational Part 5
Answer Q.1
c) Kernig's sign. Reason: Signs and symptoms of meningitis include Kernig's sign, stiff neck, headache, and fever. To test for Kernig's sign, the client is in the supine position with knees flexed; a leg is then flexed at the hip so that the thigh is brought to a position perpendicular to the trunk. An attempt is then made to extend the knee. If meningeal irritation is present, the knee can't be extended and attempts to extend the knee result in pain. Cullen's sign is the bluish discoloration of the periumbilical skin caused by intraperitoneal hemorrhage. Koplik's spots are reddened areas with grayish blue centers that are found on the buccal mucosa of a client with measles. Chvostek's sign is elicited by tapping the client's face lightly over the facial nerve, just below the temple. A calcium deficit is suggested if the facial muscles twitch.

Answer Q.2
b) Observe the child for restlessness. Reason: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. Numeric pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.

Answer Q.3
b) Talk quietly to the infant while he is awake. Reason: Infants are sensitive to stress in their caretakers. The best way to handle an anxious infant is to talk quietly to him, thereby soothing the infant. Limiting holding of the infant to feeding periods interferes with meeting the infant's needs for close contact, possibly compromising his ability to develop trust. Playing music in the room for most of the day and night will make it difficult for the infant to differentiate days from nights. Having a friend take the infant for several days will not necessarily take care of the problem because when the infant returns to the mother the same behaviors will recur unless the mother makes some changes.

Answer Q.4
a) Nursing informatics. Reason: Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. A specific application of nursing informatics is the use of PDAs in the clinical setting. The devices are less likely to be used to perform documentation or to constitute client records. Telemedicine involves the remote provision of care.

Answer Q.5
d) 90 degrees. Reason: When giving an I.M. injection, the nurse inserts the needle into the muscle at a 90-degree angle, using a quick, dartlike motion. A 15-degree angle is appropriate when administering an intradermal injection. A 30-degree angle isn't used for any type of injection. The nurse may use a 45- or 90-degree angle when giving a subcutaneous injection.

Answer Q.6
b) Breastfeeding Reason: Breastfed infants should eat within the first hour of life and approximately every 2 to 3 hours. Successful breastfeeding will likely require sustained support, encouragement, and instruction from the nurse. Information on SIDS, infant bathing, and sleep-wake cycles are also important topics for the new parent, but they can be covered at any time prior to discharge.

Answer Q.7
c) "I should become involved in a weight loss program." Reason: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

Answer Q.8
a) Contact the surgeon to rewrite the order. Reason: The nurse should not administer drugs without a complete order. In this case the order does not contain information about dosage and uses abbreviations that can cause confusion.

Answer Q.9
b) administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. Reason: NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

Answer Q.10
c) Promote regular flossing of teeth. Reason: Mucositis is an inflammation of the oral mucosa caused by radiation therapy. It is important that the client with mucositis receive meticulous mouth care, including flossing, to prevent the development of an infection. Mouth care should be provided before and after each meal, at bedtime, and more frequently as needed. Extremes of temperature should be avoided in food and drink. Half-strength hydrogen peroxide is too harsh to use on irritated tissues.

Nclex RN Examination Practice Question 5

2017-12-12T18:58:00.000-08:00

Nclex RN Examination Practice Question 5

Q.1 An 8-year-old child is suspected of having meningitis. Signs of meningitis include:
a)Cullen's sign.
b)Koplik's spots.
c)Kernig's sign.
d)Chvostek's sign.

Q.2 When assessing for pain in a toddler, which of the following methods should be the most appropriate?
a) Ask the child about the pain.
b) Observe the child for restlessness.
c) Use a numeric pain scale.
d) Assess for changes in vital signs.

Q.3 A parent confides to the nurse that their 8-month-old infant is anxious. Which of the following suggestions by the nurse is most appropriate to help the mother lessen her anxiety about her infant?
a) Limit holding the infant to feeding times.
b)Talk quietly to the infant while he is awake.
c)Play music in his room for most of the day and night.
d)Have a close friend keep the infant for a few days

Q.4 A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of:
a) Nursing informatics.
b) Electronic medical records.
c) Telemedicine.
d) Computerized documentation.

Q.5 When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of:
a) 15 degrees.
b) 30 degrees.
c) 45 degrees.
d) 90 degrees

Q.6 A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on:
a) Sudden infant death syndrome (SIDS)
b) Breastfeeding
c) Infant bathing
d) Infant sleep-wake cycles

Q.7 A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
a)"I need to keep my inhaler at the bedside."
b)"I should eat a high-protein diet."
c)"I should become involved in a weight loss program."
d)"I should sleep on my side all night long."

Q.8 Before cataract surgery, the nurse is to instill several types of eye drops. The surgeon writes orders for 5 gtts of antibiotic in OD, and 3 drops of topical steroid drops in OD. The nurse should:
a) Contact the surgeon to rewrite the order.
b) Administer the antibiotic in the left eye and the steroid in the right eye.
c) Administer both types of drops in the right eye.
d) Contact the pharmacist for clarification of the order.

Q.9 A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include:
a) administration of opioids for pain control.
b) administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.
c) administration of monthly intra-articular injections of corticosteroids.
d) vigorous physical therapy for the joints.

Q. 10 A client who is undergoing radiation therapy develops mucositis. Which of the following interventions should be included in the client's plan of care?
a) Increase mouth care to twice per shift.
b) Provide the client with hot tea to drink.
c) Promote regular flossing of teeth.
d) Use half-strength hydrogen peroxide on mouth ulcers.

Answer and Rational

NCLEX RN Endocrine and Metabolic Disorders Answer and Rational

2017-12-06T00:24:00.001-08:00

Answer 1. c) "Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." Reason: The nurse should make the client aware that diabetes affects sensation in the feet and that
he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information.

Answer 2. d) Crying whenever diabetes is mentioned Reason: A client who cries whenever diabetes is mentioned is demonstrating ineffective coping. A recent weight gain and failure to monitor blood glucose levels would support a nursing diagnosis of Noncompliance: Failure to adhere to therapeutic regimen. Skipping insulin doses during illness would support a nursing diagnosis of Deficient knowledge related to treatment of diabetes mellitus.

Answer 3. a) "We're very concerned about your foot and we want to provide the best possible care for you." Reason: The client's response indicates that he's in denial and needs further insight and education about his condition. Letting the client know that the nurse has his best interests in mind helps him accept the wound-care nurse. Although telling the client that his condition is serious and that the wound care nurse will see him that day are true statements, they're much too direct and may increase client resistance. Telling the client he could lose his foot is inappropriate and isn't therapeutic communication.

Answer 4. d) Demonstrating correct technique Reason: The best way to validate blood glucose meter use is to allow the nursing assistant to demonstrate correct technique. Verbalizing understanding doesn't demonstrate that the nursing assistant knows proper technique. Documenting a normal blood glucose level and having previous certification don't demonstrate blood glucose meter use.

Answer 5. a) Administer half of the client's typical morning insulin dose as ordered. Reason: If the nurse administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered. Oral antidiabetic agents aren't effective for type 1 diabetes. I.V. insulin infusions aren't necessary to manage blood glucose levels in clients undergoing routine surgery.

Answer 6. a) Perform the procedure safely and correctly. Reason: The nurse should judge that learning has occurred from evidence of a change in the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates acquisition of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill.

Answer 7 c) "Diabetes can affect sensation in your feet and you can hurt yourself without realizing it." Reason: The nurse should make the client aware that diabetes affects sensation in the feet and that he might hurt his foot but not feel the wound. Although it's important that the client's shoes fit properly, this isn't the only reason the client's feet need to be checked. Telling the client that diabetes mellitus increases the risk of infection or stating that the circulation in the client's feet indicates the severity of his diabetes doesn't provide the client with complete information.

Answer 8 b) 15 g of carbohydrates. Reason: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

NCLEX RN Endocrine and Metabolic Disorders Practice Question

2017-12-06T00:11:00.000-08:00

NCLEX RN Endocrine and Metabolic Disorders Question

Q.1 When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:
a)"The physician wants to be sure your shoes fit properly so you won't develop pressure sores."
b)"The circulation in your feet can help us determine how severe your diabetes is."
c)"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it."
d)"It's easier to get foot infections if you have diabetes."

Q.2 A client is diagnosed with diabetes mellitus. Which assessment finding best supports a nursing diagnosis of Ineffective coping related to diabetes mellitus?
a)Recent weight gain of 20 lb (9.1 kg)
b)Failure to monitor blood glucose levels
c)Skipping insulin doses during illness
d)Crying whenever diabetes is mentioned

Q.3 A nurse is caring for a client with poorly managed diabetes mellitus who has a serious foot ulcer. When she informs him that the physician has ordered a wound care nurse to examine his foot, the client asks why he should see anyone other than this nurse. He states, "It's no big deal. I'll keep it covered and put antibiotic ointment on it." What is the nurse's best response?
a)"We're very concerned about your foot and we want to provide the best possible care for you."
b)"This is a big deal and you need to recognize how serious it is."
c)"This is the physician's recommendation. The wound care nurse will see you today."
d)"You could lose your foot if you don't see the wound care nurse."

Q.4 Which finding best indicates that a nursing assistant has an understanding of blood glucose meter use?
a)Verbalizing an understanding of blood glucose meter use
b)Documenting a normal blood glucose level
c)Providing documentation of previous certification
d)Demonstrating correct technique

Q.5 A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?
a)Administer half of the client's typical morning insulin dose as ordered.
b)Administer an oral anti diabetic agent as ordered.
c)Administer an I.V. insulin infusion as ordered.
d)Administer the client's normal daily dose of insulin as ordered.

Q.6.The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
a)Perform the procedure safely and correctly.
b)Critique the nurse's performance of the procedure.
c)Explain all steps of the procedure correctly.
d)Correctly answer a post test about the procedure.

Q.7 When referred to a podiatrist, a client newly diagnosed with diabetes mellitus asks, "Why do you need to check my feet when I'm having a problem with my blood sugar?" The nurse's most helpful response to this statement is:
a)"The physician wants to be sure your shoes fit properly so you won't develop pressure sores."
b)"The circulation in your feet can help us determine how severe your diabetes is."
c)"Diabetes can affect sensation in your feet and you can hurt yourself without realizing it."
d)"It's easier to get foot infections if you have diabetes."

Q.8 A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:
a)10 g of carbohydrates.
b)15 g of carbohydrates.
c)20 g of carbohydrates.
d)25 g of carbohydrates.

Answer and Rational

Nclex Answer Practice Question and Rational 4

2017-11-24T04:17:00.000-08:00

Nclex Answer Practice Question and Rational 4

1.Answer

c) may induce bronchospasm.
Rational: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex.

2.Answer

d) Social isolation. Reason: Social isolation is a concern for an older adult who has diminished hearing and vision. Feeling disoriented may be related to cognitive problems rather than diminished hearing and vision. Diminished hearing and vision is related to the aging process and does not result in impairment of the older adult's thought processes. The client with impaired hearing and vision is unlikely to experience sensory overload.

3.Answer

c) Pin moves slightly at insertion site. Reason: Skeletal pins should not be loose and able to move. Any pin loosening should be reported immediately. Slight serous drainage is normal and may crust around the insertion site or be present on the dressing. The pin insertion site should be cleaned with aseptic technique according to facility policy. Pin insertion sites are typically not painful; pain may be indicative of an infection and should be reported.

4.Answer

a) Moderate to severe anxiety. Reason: Anxiety, especially at higher levels, interferes with learning and memory retention. After the client's anxiety lessens, it will be easier for him to learn the steps of the blood glucose monitoring. Because the client's illness is a chronic, lifelong illness that severely changes his lifestyle, it is unlikely that he is uninterested in the illness or how to treat it. It is also unlikely that dementia would be the cause of the client's frustration and lack of memory. The client's response indicates anxiety. Client responses that would indicate lessening anxiety would be questions to the nurse or requests to repeat part of the instruction.

5.Answer

c) Discontinue the transfusion. Reason: Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction and the nurse's first action should be to discontinue the transfusion as soon as possible and then notify the physician. Antipyretics and antihistamines may be ordered. The nurse would not administer acetaminophen without an order from the physician. The client's blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate.

6.Answer

c) pressurelike pain. Reason: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.

7.Answer

a) Autonomy Reason: Autonomy refers to an individual's right to make his own decisions. Fidelity is equated with faithfulness. Nonmaleficence is the duty to "do no harm." Veracity refers to telling the truth.

8.Answer

b) Support systems and coping strategies. Reason: The client's resources for coping with the emotional and practical needs of herself and her family need to be assessed because usual coping strategies and support systems are often inadequate in especially stressful situations. The nurse may be concerned with the client's use of denial, decision-making abilities, and ability to pay for transportation; however, the client's support systems will be of more importance in this situation.

9.Answer

c) Confusion and restlessness Reason: Confusion and restlessness are signs of lidocaine toxicity. Nausea and vomiting may occur with oral administration of mexiletine (Mexitil) or tocainide (Tonocard) — other class IB drugs. Pupillary changes and hypertension aren't signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.

10.Answer

a) Bradycardia. Reason: As a result of vigorous suctioning the nurse must watch for bradycardia due to potential vagus nerve stimulation. Rapid eye movement is not associated with vagus nerve stimulation. Vagal stimulation will not cause seizures or tachycardia.

11.Answer

b) Retained placental fragments. Reason: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever the placenta is manually removed after delivery, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urine retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.

12.Answer

a) An abrupt lengthening of the cord Reason: An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus isn't an indication for detachment of the placenta.

13.Answer

c) Calcium gluconate. Reason: The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.

14.Answer

b) Seizures. Reason: Generalized seizures may occur on the second or third day of withdrawal from barbiturates. Without treatment, the seizures may be fatal. Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen. Orthostatic hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen. Hyperthermia, rather than hypothermia, occurs during withdrawal.

15.Answer

a) Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol). Reason: The client's anxiety as reflected in rapid pacing and clang associations is rising as a result of his paranoid delusions. Administering the Ativan and Haldol will help the anxiety and delusions. He is not threatening others at this point, so seclusion, restraints, and asking clients to leave the area is not necessary.

16.Answer

d) Assessing the incision site. Reason: The registered nurse is responsible for monitoring the surgical site for condition of the dressing, status of the incision, and signs and symptoms of complications. Unlicensed assistive personnel who have been trained to report abnormalities to the registered nurse supervising the care may take vital signs, record intake and output, and give perineal care.

17.Answer

c) 20 minutes. Reason: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.

18.Answer

c) Restlessness and shortness of breath. Reason: Restlessness indicates cerebral hypoxia due to decreased circulating volume. Shortness of breath occurs because blood collecting in the pleural space faster than suction can remove it prevents the lung from reexpanding. Increased blood pressure and decreased pulse and respiratory rates are classic late signs of increased intracranial pressure. Decreasing blood pressure and increasing pulse and respiratory rates occur with hypovolemic shock. Sanguineous drainage that changes to serosanguineous drainage at a rate less than 100 ml/hour is normal in the early postoperative period. Urine output of 180 ml over the past 3 hours indicates normal kidney perfusion.

19.Answer
b) 15 g of carbohydrates. Reason: The nurse should instruct the client to administer 1 unit of insulin for every 15 g of carbohydrates.

20.Answer

a) Nausea. Reason: Prochlorperazine is administered postoperatively to control nausea and vomiting. Prochlorperazine is also used in psychotherapy because of its effects on mood and behavior. It is not used to treat dizziness, abdominal spasms, or abdominal distention.

Nclex RN Answer and Rational Mood, Adjustment, and Dementia Disorders

2017-11-22T18:52:00.001-08:00

Nclex RN Answer and Rational Mood, Adjustment, and Dementia Disorders

Answer 1,
d) Reality-orientation. Reason: Because the client has confusion, short-term memory loss, and a short attention span, a reality-orientation group is recommended to help the client maintain an optimal level of functioning, decrease isolation, and increase self-esteem. Focus is on the "here and now" and provides reality testing, structure, and social support. A client with a cognitive disorder is unlikely to benefit from an insight-oriented group, where the focus is on role relationships. Short-term memory loss and confusion interfere with the ability to learn about medication management. Short-term memory loss and confusion interfere with the ability to describe and solve problems.

Answer 2
c) nortriptyline (Pamelor). Reason: Nortriptyline, a tricyclic antidepressant, is used in first-time drug therapy because it causes few anticholinergic and sedative adverse effects. Phenelzine isn't ordered initially because it may cause many adverse effects and necessitates dietary restrictions. Thiothixene and trifluoperazine are antipsychotic agents and, therefore, inappropriate for clients with uncomplicated depression.

Answer 3

c) Widening QT interval Reason: Amitriptyline therapy may cause a conduction delay, demonstrated by a widening QT interval on the ECG. U waves, a depressed ST segment, and a prolonged PR interval aren't typically induced by amitriptyline therapy.

Answer 4

c) "It's important for him to take his medication so that the depression will not return or get worse." Reason: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive.

Answer 5

a) from any segment of the population. Reason: Victims of childhood sexual abuse come from all segments of the population and from all socioeconomic backgrounds. Most victims know their abuser. Children rarely willingly engage in sexual acts with adults because they don't have full decision-making capacities.

Answer 6

b) Question the primary health
care provider about the Tylenol prescription. Reason: The nurse should question the Tylenol order because the client overdosed on Tylenol, and that analgesic would be contraindicated as putting further stress on the liver. There is no need to hold the PM Milk of Magnesia or Maalox. There is no indication that the client is agitated or needs medication for agitation. There is little likelihood that the client needs an IV after being transferred out of an intensive care unit, as the client will be able to take oral fluids.

Answer 7

a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." Reason: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks of therapy before the full therapeutic effects are experienced. Because the client has been taking the drug for only 3 days, it is too soon to determine if the current dosage of imipramine is effective. It is also too soon to consider taking another antidepressant.

Answer 8

b) Hypertensive crisis Reason: The most serious adverse reaction associated with high doses of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high doses. Muscle spasticity (not flaccidity) is associated with MAO inhibitor therapy. Hypoglycemia isn't an adverse reaction of MAO inhibitors.

Answer 9

c) situational crisis. Reason: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.

Answer 10

a) flight of ideas and inflated self-esteem. Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.

Nclex RN Question Mood, Adjustment, and Dementia Disorders

Nclex RN Question Answer and Rational About Mood, Adjustment, and Dementia Disorders

2017-11-21T19:33:00.002-08:00

Nclex RN Question Answer
and Rational About Mood, Adjustment, and Dementia Disorders

Q.1 A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which of the following therapy groups would be best suited for this client?

a)Insight-oriented.
b)Medication management.
c)Problem solving.
d)Reality-orientation.

Q.2 A client with major depression sleeps 18 to 20 hours per day, shows no interest in activities he previously enjoyed and reports a 17-lb (7.7-kg) weight loss over the past month. Because this is the
client's first hospitalization, the physician is most likely to order:

a)phenelzine (Nardil).
b)thiothixene (Navane).
c)nortriptyline (Pamelor).
d)trifluoperazine (Stelazine).

Q.3 A nurse is evaluating a client's electrocardiogram (ECG). Which ECG change can result from amitriptyline (Elavil) therapy?

a)Presence of U waves
b)Depressed ST segment
c)Widening QT interval
d)Prolonged PR interval

Q.4 The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about
disease process and medications has been effective?

a)"His depression is almost cured."
b)"He's intelligent and won't need to depend on a pill much longer."
c)"It's important for him to take his medication so that the depression will not return or get worse."
d)"It's important to watch for physical dependency on Zoloft."

Q.5 A nurse is facilitating mandated group therapy for clients who have sexually abused children. Children who are victims of sexual abuse are typically:

a)from any segment of the population.
b)of low socioeconomic background.
c)strangers to the abuser.
d)willing to engage in sexual acts with adults.

Q.6 A client who took an overdose of Tylenol in a suicide attempt is transferred overnight to the psychiatric inpatient unit from the intensive care unit. The night shift nurse called the primary health
care provider on call to obtain initial prescriptions. The primary health care provider prescribes the typical routine medications for clients on this unit: Milk of Magnesia, Maalox and Tylenol as needed.
Prior to implementing the prescriptions, the nurse should?

a)Ask the primary health care provider about holding all the client's PM prescriptions.
b)Question the primary health care provider about the Tylenol prescription.
c)Request a prescription for a medication to relieve agitation.
d)Suggest the primary health care provider write a prescription for intravenous fluids.

Q.7 The wife of a 67-year-old client who has been taking imipramine (Tofranil) for 3 days asks the nurse why her husband isn't better. The nurse should tell the wife:

a)"It takes 2 to 4 weeks before the full therapeutic effects are experienced."
b)"Your husband may need an increase in dosage."
c)"A different antidepressant may be necessary."
d)"It can take 6 weeks to see if the medication will help your husband."

Q.8 A nurse is monitoring a client receiving tranylcypromine sulfate (Parnate). Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor?

a)Hypotensive episodes
b)Hypertensive crisis
c)Muscle flaccidity
d)Hypoglycemia

Q.9 A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of:

a)alcoholism.
b)a manic episode.
c)situational crisis.
d)depression.

Q.10 Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

a)flight of ideas and inflated self-esteem.
b)increased sleep and greater distractibility.
c)decreased self-esteem and increased physical restlessness.
d)obsession with following rules and maintaining order.

Nclex RN Answer and Rational About Mood, Adjustment, and Dementia Disorders

Nclex Question Answer for Cardiovascular Heart

2017-11-03T23:12:00.002-07:00

Nclex Question Answer for Cardiovascular

Q1.In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:

a)The client will remain in the ICU for 5 days.
b)The client will sleep most of the time while in the ICU.
c)Noise and activity within the ICU are minimal.
d)The client will receive medication to relieve pain

Q.2 When assessing a client for early septic shock, the nurse should assess the client for which of the following?

a)Cool, clammy skin.
B)Warm, flushed skin.
c Increased blood pressure.
d)Hemorrhage

Q.3 Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?

a)"Take an extra dose of digoxin if you miss one dose."
b)"Call the physician if your heart rate is above 90 beats/minute."
c)"Call the physician if your pulse drops below 80 beats/minute."
d)"Take digoxin with meals."

Q.4 A client with a past medical history of ventricular septal defect repaired in infancy is seen at the prenatal clinic. She is complaining of dyspnea with exertion and being very tired. Her vital signs are 98, 80, 20, BP 116/72. She has + 2 pedal edema and clear breath sounds. As the nurse plans this client's care, which of the following is her cardiac classification according to the New York Heart Association Cardiac Disease classification?

a)Class I.
b)Class II.
c)Class III.
d)Class IV.

Q.5 A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound?

a)Opening snap
b)Graham Steell's murmur
c)Ejection click
d)Pericardial friction rub

Q.6 A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?

a)Nausea and vomiting
b)Pupillary changes
c)Confusion and restlessness
d)Hypertension

Q.7 A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth daily, and furosemide (Lasix), 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity may also cause:

a)visual disturbances.
b)taste and smell alterations.
c)dry mouth and urine retention.
d)nocturia and sleep disturbances

Nclex Questions Answer with rationale 2017

2017-10-23T00:36:00.000-07:00

Nclex Questions Answer with rationale 2017

Q.1 A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:

a)nausea and vomiting.
b)dyspnea and cyanosis.
c)fatigue and weakness.
d)thrush and circumoral pallor.

Q.2 A physician has ordered penicillin G potassium (Pfizerpen), I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When
considering best practice, what should the nurse's priority intervention be?

a)Holding the penicillin G potassium and charting that it was held because the client is allergic
b)Administering the penicillin G potassium and staying alert for any reaction
c)Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin
d)Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction

Q.3 An Arab client with pneumonia has been admitted to the health care facility. What should the nurse avoid while conducting the interview of the client?

a)Giving a light handshake.
b)Maintaining eye contact.
c)Asking about the client's symptoms.
d)Asking about the client's medical history

Q.4 The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?

a)Minimal leaking.
b)No swelling.
c)Tissue pallor.
d)Evidence of a bleb or wheal.

Q.5 The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal?

a)Soft.
b)Egg-shaped.
c)Spongy.
d)Lumpy

Q.6 During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations,
and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first?

a)Ask another nurse to verify the findings.
b)Notify the primary care provider of the findings.
c)Raise the head of the bed.
d)Administer an antipyretic.

Q.7 A nurse should expect a 3-year-old child to be able to perform which action?

a)Ride a tricycle
b)Tie his shoelaces
c)Roller-skate
d)Jump rope

Q.8 Which of the following measures should the nurse include in the care plan for a child who is receiving high-dose methotrexate (amethopterin) therapy?

a)Keeping the child in a fasting state.
b)Obtaining a white blood cell (WBC) count.
c)Preparing for radiography of the spinal canal.
d)Collecting a specimen for urinalysis

Q.9 A client in an acute care setting tells the nurse, "I don't think I can face going home tomorrow." The nurse replies, "Do you want to talk more about it?" The nurse is using which technique?

a)Presenting reality
b)Making observations
c)Restating
d)Exploring

Q.10 On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for:

a)endometritis.
b)postpartum hemorrhage.
c)subinvolution.
d)afterpains

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NCLEX Practice Question Answer With Rational 4

2017-10-11T22:07:00.000-07:00

NCLEX Practice Question Answer With Rational 4

Q1.A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:
a)is a respiratory depressant.

b)is a respiratory stimulant.
c)may induce bronchospasm.
d)inhibits the cough reflex.

Q2.A potential concern when caring for an older adult who has diminished hearing and vision is the client's:
a)Feelings of disorientation.
b)Cognitive impairment.
c)Sensory overload.
d)Social isolation.

Q3.The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?
a)Presence of crusts around the pin insertion site.
b)Serous drainage on the dressing.
c)Pin moves slightly at insertion site.
d)Client does not feel pain at insertion site.

Q4.A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about blood glucose testing. After the session, the client states, "I can't be expected to remember all this stuff." The nurse should recognize this response as most likely related to which of the following?
a)Moderate to severe anxiety.
b)Disinterest in the illness.
c)Early-onset dementia.
d)Normal reaction to learning a new skill.

Q5.A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
a)Administer acetaminophen.
b)Take the client's blood pressure.
c)Discontinue the transfusion.
d)Check the infusion rate of the blood

Q6.Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is:
a)erythema.
b)leukocytosis.
c)pressurelike pain.
d)swelling

Q7.A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?
a)Autonomy
b)Fidelity
c)Nonmaleficence
d)Veracity

Q8.A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with:
a)Denial as a primary coping mechanism.
b)Support systems and coping strategies.
c)Decision-making abilities.
d)Transportation and money for the boys

Q9.A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity?
a)Nausea and vomiting
b)Pupillary changes
c)Confusion and restlessness
d)Hypertension

Q10. A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?
a)Bradycardia.
b)Rapid eye movement.
c)Seizures.
d)Tachycardia

Q.11 A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following?
a)Perineal lacerations.
b)Retained placental fragments.
c)Cervical lacerations.
d)Urine retention

Q12. Which finding indicates placental detachment?
a)An abrupt lengthening of the cord
b)A decrease in the number of contractions
c)Relaxation of the uterus
d)Decreased vaginal bleeding

Q13. The primary health care provider orders intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside?
a)Diazepam (Valium).
b)Hydralazine (Apresoline).
c)Calcium gluconate.
d)Phenytoin (Dilantin).

Q14.After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
a)Psychosis.
b)Seizures.
c)Hypotension.
d)Hypothermia.

Q15.A newly admitted client diagnosed with paranoid schizophrenia is pacing rapidly and wringing his hands. He states that another client is out to get him. Then he says, "Protect me, select me, reject me." The nurse should next:
a)Administer his oral PRN lorazepam (Ativan) and haloperidol (Haldol).
b)Place the client in temporary seclusion before he has a chance to hurt others.
c)Call the primary health care provider for a prescription for restraints.
d)Ask the other clients to leave the immediate area.

Q16. The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which of the following can NOT be delegated to the UAP?
a)Taking vital signs.
b)Recording intake and output.
c)Giving perineal care.
d)Assessing the incision site

Q17.A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
a)5 minutes.
b)10 minutes.
c)20 minutes.
d)30 minutes.

18.Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?
a)Increased blood pressure and decreased pulse and respiratory rates.
b)Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours.
c)Restlessness and shortness of breath.
d)Urine output of 180 ml during the past 3 hours.

Q19.A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every:
a)10 g of carbohydrates.
b)15 g of carbohydrates.
c)20 g of carbohydrates.
d)25 g of carbohydrates

Q20.Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?
a)Nausea.
b)Dizziness.
c)Abdominal spasms.
d)Abdominal distention

NCLEX For Answer Link
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How To Change Tracheostomy Tube Nursing Skills and Procedure

2017-09-29T10:40:00.003-07:00

Tracheostomy tubes need to be changed monthly to decrease the chance of infection. You should always have a back up trach tube. One of the same size and one a size smaller.
Do Not change the trach tube unless youhave gone through proper training.
It is very important to use sterile technique during the trach change procedure.

Equipment Needed:• Sterile tracheostomy tube • Sterile gloves • Sterile water soluble lubricant • Sterile towel • Suction equipment • 10 cc syringe • Ambu bag • Sterile 4x4 gauze • Trach tube holder • Trach dressing • Hydrogen Peroxide

Procedure:

1. Wash your hands
2. Open the sterile towel for the sterile field
3. Open the sterile supplies and place them on the sterile field
4. Put the sterile glove on your dominant hand
5. Make sure the new trach tubes cuff is fully deflated. Be sure to not contaminate the tube by touching anything with it.
6. Remove the inner cannula and replace it with the obturator
7. Check the cuff by inserting 10 cc of air in the cuff and check holes.
8. Lubricate the tip of the tube with a water soluble lubricant. Do not use a petroleum based product.
9. Suction the patient if needed

10.If the patient has a cuff, deflate the cuff by pulling out all of the air out of the cuff.
11.Remove the trach dressing and the trach tube holder
12.Clean the skin as needed with a sterile 4x4 and sterile water
13.Disconnect the patient from the ventilator. You may need for someone to ventilate the patient with the ambu bag while you change out the trach
14.Remove the trach tube using a forward, downward motion.
15.With your sterile hand, gently insert the new trach tube within 30 minutes with the obturator in place. 16.Immediately remove the obturator
17.Insert the inner cannula into the trach tube
18.Inflate the cuff using minimal leak technique or using a Cuff manometer.
19. Check to see if adequate air exchange is taking place by placing your hand over the opening of the cannula. If no air exchange, the tube is not in the trachea and should be removed immediately and the patient manually ventilated with a mask
20.Once the tube is in place, stabilize the tube with one hand until secured in place with a tube holder.
21.After the tube is secure, reconnect the patient to the ventilator
22.Apply trach dressing
23.Dispose of all supplies
24.Wash your hands

Early Warning Signs It is very important for you to know the signs and symptoms of infection or other problems.
Signs of Infection: • Changes in sputum color, volume, odor and consistency Causes of infection include not washing hands properly, using • Dirty equipment • Improper suctioning • Improper trach changes • Improper stoma care

Breathing Symptoms: • Increased shortness of breath • Wheezing • Increased coughing • Increased respiratory rate • Increased accessory muscle use

Sputum Changes: • Color change (yellow, green, tan or brown) • Increase in quantity • Change in consistency • Bloody

Stoma Symptoms:• Pulsating tracheostomy tube • Bleeding from the stoma • Discharge or odor from the stoma • Swelling or redness

Other Symptoms:• Fever • Loss of appetite • Rapid weight gain • Swelling of hands and feet • Headaches • Sleepiness • Visual disturbances • Dizziness • Cyanosis • Confusion or anxiety

If you are having any physical problems contact your physician

Respiratory NCLEX RN Test Questions and Answers

2016-10-19T10:42:00.000-07:00

Respiratory NCLEX RN Test Questions and Answers
Q.1 A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to:
a)Call for emergency assistance.
b)Attempt reinsertion of tracheostomy tube.
c)Position the client in semi-Fowler's position with the neck hyperextended.
d)Insert the obturator into the stoma to reestablish the airway.

Q.2 A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
a)Position changes every 4 hours.
b)Nasotracheal suctioning to clear secretions.
c)Frequent linen changes.
d)Frequent offering of a bedpan

Q.3 The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:
a)Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
b)Check respirations in 30 minutes because the effects of morphine will have worn off by then.
c)Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
d)Monitor respirations each time the client receives morphine sulfate 10 mg I.M.

Q.4 A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
a)"I need to keep my inhaler at the bedside."
b)"I should eat a high-protein diet."
c)"I should become involved in a weight loss program."
d)"I should sleep on my side all night long."

Q.5 A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
a)Nausea or vomiting
b)Abdominal pain or diarrhea
c)Hallucinations or tinnitus
d)Light-headedness or paresthesia

Q.6 A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:
a)is a respiratory depressant.
b)is a respiratory stimulant.
c)may induce bronchospasm.
d)inhibits the cough reflex.

Q.7 Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?
a)Increased blood pressure and decreased pulse and respiratory rates.
b)Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours.
c)Restlessness and shortness of breath.
d)Urine output of 180 ml during the past 3 hours.

Answer and Rational

Nursing Care-Intervention Client/Patient with Postpartum Hemorrhage

2016-06-15T22:45:00.000-07:00

Postpartum hemorrhage is excessive blood loss in a woman after childbirth. It is called primary when it is within the first 24 hours after childbirth. Secondary (or delayed) postpartum hemorrhage occurs between 24 hours to six weeks after childbirth. Some blood loss is normal.

NURSING DIAGNOSIS: Risk for deficient fluid volume related to uterine atony and hemorrhage
Expected Outcome: Fundus is firm, lochia is moder-ate, and there is no evidence of hemorrhage.

Nursing Care/Intervention Postpartum hemorrhage

Monitor and palpate fundus for location and tone to deter-mine status of uterus and dictate further interventions be-cause atonic uterus is most common cause of postpartum hemorrhage.

Monitor intake and output, assess for bladder fullness, and encourage voiding because a full bladder interferes with in-volution of the uterus.
Monitor lochia (color, amount, consistency), and count and weigh sanitary pads if lochia is heavy to evaluate amount of bleeding.
Monitor vital signs (increased pulse and respirations, de-creased blood pressure) and skin temperature and color to detect signs of hemorrhage or shock.
Monitor postpartum hematology studies to assess effects of blood loss. If fundus is boggy, apply gentle massage and assess tone re-sponse to promote uterine contractions and increase uterine tone. (Do not overstimulate because doing so can cause fun-dal relaxation.) Express uterine clots to promote uterine contraction.
Administer fluids, blood, blood products, or plasma expanders as ordered to replace lost fluid and lost blood volume.

Explain to the woman the process of involution and teach her to assess and massage the fundus and to report any per-sistent bogginess to involve her in self-care and increase sense of self-controt. Administer oxytocic agents per physician or nurse-midwife order and evaluate effectiveness to promote continuing uterine contraction.

Nursing Care Plan and Managment ARDS (Acute Respiratory Distress Syndrome)

2016-06-12T00:25:00.002-07:00

ARDS, or acute respiratory distress syndrome, is a lung condition that leads to low oxygen levels in the blood. ARDS can be life threatening because your body's organs need oxygen-rich blood to work well.

Nursing Diagnosis about ARDS(Acute Respiratory Distress Syndrome)
• Ineffective breathing pattern related to anxiety
• Impaired gas exchange related to effects of near-drowning
• Anxiety related to hypoxemia
• Risk for decreased cardiac output related to mechanical ventilation
• Risk for injury related to endotracheal intubation

Nursing care ARDS(Acute Respiratory Distress Syndrome)

Monitor vital signs every 1 to 2 hours.
Monitor the patient’s level of consciousness, noting confussion or mental sluggishness.
Monitor oxygen saturation and ETCO2 levels every 30 to 60 minutes initially after instituting mechanical ventilation; report doctor
Obtain ABGs as ordered or indicated; monitor and report results
Suction via endotracheal tube as needed to maintain clear Airways
Gives sedatives as ordered to reduce restlessness.
Maintain joint mobility by performing passive range-of-motion exercises.
Monitor urine output hourly; report output of less than 30 mL hour
Assess skin color, capillary refill, and the presence of edema every four hours
Assess lung sounds and chest excursion every 1 to 2 hours.

Nasogastric Tube Insertion Procedure Nursing Skills

2016-04-22T08:15:00.000-07:00

A Nasogastric Tube is a narrow bore Nasogastric Tube passed into the stomach via the nose. It is used for short- or medium-term nutritional support, and also for aspiration of stomach contents - eg, for decompression of intestinal obstruction.

Gather necessary equipment

Nasogastric tube
Gloves
Cup of water
Lubricating jelly
Tape
Safety pin
pH paper
Rubber band
Stethoscope
Irrigation tip syringe
Bath towels or blue pad
Emesis basin
Flash light.

Procedure:

Check physician’s order.
Provide for privacy
Explain the procedure to the client’s
Position patient in high Fowler’s position with pillow behind head and shoulders.
Stand at the right side of patient if right handed and the left side of patient if left
handed.
Place bath towels or blue pad over chest and give tissues to patient.
Prepare split tape.
Mark length of tube to be inserted with tape. Measure distance to insert tube
measuring from the tip of the nose, to the earlobe, to the xiphoid process.
Curve tip of tube tightly around index finder and release.

Lubricate end of tube generously with water soluble lubricating jelly.
Instruct patient to extend neck back against pillow and begin to insert tube into
naris with curved end pointing downward.
Continue to pass tube along floor of nasal passage; aiming down toward ear.
When resistance is felt apply gentle downward pressure to advance the tube (do not
force past resistance).
Note: If resistance continues, withdraw tube, allow patient to rest, relubricate tube
and insert into other naris.
Continue insertion of tube until just past nasopharynx by gently rotating tube
toward opposite naris
a. Stop tube advancement, allow patient to rest
b. Explain that the next step requires swallowing.
With tube just above oropharynx, instruct patient to flex head forward and dry
swallow or suck air in through a straw; advance with each swallow; if patient has
trouble swallowing and is allowed fluids, offer a glass of water; advance tube with
each swallow of water until tape marking is at the nose.
Attach irrigation tip syringe, inject 30 ml of air and auscultate woosh over
epigastric area, then aspirate gently back to obtain gastric contents.
Measure pH of gastric contents with color coded pH paper.
If tube is not in stomach, advance another 2.5-5 cm and repeat step 18 and 19.
Secure tube to nose with tape; avoid pressure on nares.
Fasten end of tube to gown by looping rubber band around tube in a slip knot , or
by applying tape, and pin to gown.
Remove irrigation tip syringe and attach tube to suction as ordered.
Unless otherwise ordered by physician, head of bed should remain elevated to 30
degrees.

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Hyperbilirubinemia or Neonatal Jaundice Nursing Diagnosis and Intervetions

2015-04-03T10:06:00.000-07:00

Neonatal Hyperbilirubinemia or Neonatal Jaundice in newborn is one of the most common problems encountered in term newborns. Although up to 60 percent of the term new borns have clinical jaundice in the first week of life. Hyperbilirubinemia is a conditionin which there is too much bilirubin in blood. When red blood cells breakdown, a substance called bilirubin is formed. Babies are not easily able to get rid of the bilirubinand it can build up in the blood and other tissues and fluids of the baby’s body. This is called Hyperbilirubinemia. Because of bilirubin has a pigment or coloring, it causes a yellowing of the baby’s skin and tissues. This is called jaundice. Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or at any time afterward. Generalsigns and symptoms are yellow eyes, skin, tiredness, fatigue, light colored stools, anddark urine.

Nursing Diagnosis
1.Risk for Injury related to abnormal blood profile as evidenced by increase bilirubin level of 1.59mg/dl.

Nursing Interventions

Remove clothing and exposed to photo therapy.Rational:Aids in diagnosing underlying cause in connection with the appearance of jaundice.
Covered eyes and genitalia.Rational:To prevent eyes from direct exposure to light and prevent sterility of the baby.
Re positioned the baby every 2 hours.Rational:To prevent burns.
Kept warm and dry.Rational:To prevent further complications.
Vital signs taken and recorded every 1 hour.Rational:To obtain the baseline data.
Instructed on Strict Aspiration Precaution(SAP) and advised the mother to burp the baby every after feeding.Rational:To prevent aspiration pneumonia and to prevent colic.
Monitored input andoutput; IVF regulatedat 14 uggts/ min.Rational:To prevent dehydration and replace fluid and electrolyte lost .
Provided quiet and warm environment .Rational:To promote comfortand prevent irritability.
Instructed the mother to use stimulation technique such as touching.Rational:To promote sense of warmth,
Security and attachment.Health teachings given to the mother such as personal hygiene,importance of breastfeeding, and newborn screening.Rational:To detect early the possible diseases of the patient.

Nursing Diagnosis
2.Risk for fluid imbalance related to prolonged exposure to photo therapy as evidenced by dry skin

Nursing Interventions

Monitored input andoutput; IVF regulatedat 14 uggts/ min.Rational:attended To prevent dehydration andreplace fluid and electrolyte lost
Vital signs taken and recorded.Rational:To obtain the baselinedata
Bedside care done including stretching of linens and organizing bedsides.Rational:To promote comfort and good hygiene
Instructed Strict Aspiration Precaution(SAP) Rational:To prevent aspiration pneumonia
Kept back dry Rational:To prevent further complications.
Health teachings given to the mother such asthe importance of breastfeeding, handwashing, and proper hygiene Rational:To promote healthy lifestyleursing
Needs attended

Nursing Diagosis:
Risk for skin breakdown related to prolonged use of photo therapy.

Nursing Interventions

Maintained and monitored baby’s eye patches while under phototherapy.Rational:To protect retina from damage due to high intensity of light.
Removed baby under phototherapy and removed eye patches during feeding.Rational:To provide visual stimulation and facilitates attachment behaviors.
Inspected eyes everyafter phototherapy for conjunctivitis, drainage and corneal abrasions due to irritation from eye patches .Rational:To reduce complications and monitor the effectiveness of the management.
Provided minimal coverage of the body except for genitals.Rational:To provide maximal exposure and shielded the sensitive parts such as the eyes and genitals.
Repositioned the babyevery 2 hours.Rational:To promote equal distribution of phototherapy exposure

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Tips Home Remedies for Nausea and Vomiting Effective and useful

2014-12-03T05:23:00.000-08:00

20 Home Remedies for Nausea and Vomiting:

Sometimes you can predict it, and sometimes you can't. Whether or not you see it coming, nausea and vomiting is never pleasant. Here are some effective home remedies for preventing regurgitation:
Stick to clear liquids. If your stomach is upset, it probably doesn't need the additional burden of digesting food. Stick to fluids until you feel a little better and have stopped vomiting. Clear, room-temperature liquids, such as water or diluted non citrus fruit juices, are easier to digest, and they are also necessary to prevent the dehydration that may result from vomiting or diarrhea.
Let it run its course. The best cure for the 24-hour "stomach flu" (it isn't truly "the flu" -- or influenza -- which is an upper respiratory infection caused by specific microorganisms) is bed rest mixed with a tincture of time, doctors agree. The more rest you get, the more energy your body will have to devote to fighting the invader.
Hit the bed. Rest is often the best cure for whatever's causing your nausea or vomiting.
Don't drink alcohol. As anyone who has suffered a hangover knows, alcohol can be very irritating to the stomach. If you already have an upset stomach, now is certainly not the time to imbibe. (And if your current stomach upset is the result of drinking alcohol, forget the old saw about having "a hair of the dog that bit you"; more alcohol will only make you sicker.) The same goes for fatty foods, highly seasoned foods, beverages containing caffeine, and cigarettes.
Let it flow. The worst thing you can do for vomiting is to fight it, because vomiting is your body's way of getting rid of something that is causing harm in your stomach. Trying to hold back the urge can actually cause tears in your esophagus.
Think pink. OTC stomach medications that contain bismuth, such as Pepto Bismol, claim to coat the stomach and may help relieve some of the discomfort you feel. Avoid Alka-Seltzer and other aspirin-containing products, however, because aspirin can irritate the stomach.
Try a cold compress. A cold compress on your head can be very comforting when you are vomiting. It won't stop you from spewing, but it may help you feel a little better.
Maintain your electrolyte balance. Along with replacing the fluids you lose through vomiting, it is also important to maintain the balance of sodium and potassium (the electrolytes) in your system. If you are unable to keep down food for more than a day or so, have a sports drink, such as Gatorade, which is easy on the stomach and designed to replace electrolytes. Try diluting it with water if drinking it straight bothers your stomach.

Potassium chloride(kcl) and Nursing Interventions

2014-10-29T20:11:00.002-07:00

This medication is a mineral supplement used to treat or prevent low amounts of potassium in the blood. A normal level of potassium in the blood is important.

Actions:
Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses, contraction of cardiac, skeletal, and smooth muscles, maintenance of normal kidney function, and for enzyme activity. Plays a prominent role in both formation and correction of imbalances in acid–base metabolism.

Nursing Interventions:

Administer liquid form to any patient with delayed GI emptying.
Administer oral drug after meals or with food and a full glass of water to decrease GI upset.
Caution patient not to chew or crush tablets; have patient swallow tablet whole.
Monitor I&O ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician.
Lab test: Frequent serum electrolytes are warranted.
Mix or dissolve oral liquids, soluble powders, and effervescent tablets completely in 3–8 oz of cold water, juice, or other suitable beverage, and have patient drink it slowly.
Arrange for serial serum potassium levels before and during therapy.
Arrange for further dilution or dose reduction if GI effects are severe.
Agitate prepared IV solution to prevent "layering" of potassium; do not add potassium to an IV bottle in the hanging position.
Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia.
Monitor IV injection sites regularly for necrosis, tissue sloughing, phlebitis.
Monitor cardiac rhythm carefully during IV administration.
Caution patient that expended wax matrix capsules will be found in the stool.
Caution patient not to use salt substitutes.

The Child with Bacterial Meningitis Nursing Interventions

2014-08-08T07:59:00.002-07:00

The Child with Bacterial Meningitis nursing interventions

Nursing diagnosis:1. Inability to Sustain Spontaneous Ventilation related to level of consciousness

Place the child on a cardiorespiratory monitor with a 20-second alarm.Rational:¦ The alarm on the monitor alerts staff that the child is having bradycardia or an apneic spell.
Have resuscitation equipment,including oxygen, resuscitation bag with mask, and suction apparatus at bedside.Rational:¦ Equipment should be at bedside in case of respiratory arrest. Bag-valve mask ventilation is recommended as the child’s respiratory secretions contain bacteria.
Stimulate child if apneic; if no response, begin manual ventilations and call for emergency
resuscitation.Rational:¦ Stimulation may encourage spontaneous respirations; if not, ventilation is necessary. Calling for emergency resuscitation ensures help in managing the child in a timely manner.
Monitor heart rate and perform compressions if necessary.Rational:¦ The apneic child may have bradycardia resulting from cardiac hypoxia.

2. Risk for Injury related to infection of cerebrospinal fluid and potential sequelae

Administer prescribed antibiotics and corticosteroids as scheduled.Rational:¦ Administration of antibiotics helps eradicate the pathogen and prevent cerebral edema.Adminstration of corticosteroids neurologic sequelae.diminishes inflammatory response and reduces the chance of Note return of fever, nuchal rigidity,or irritability. Monitor vital signs,assess for signs of increased intracranial pressure, measure head circumference once or twice daily,note changes in responsiveness. Notify the physician immediately if any signs are detected.Rational:¦ Watching for common sequelae such as subdural effusions or septic arthritis ensures prompt treatment.
Monitor for syndrome of inappropriate antidiuretic hormone secretion (SIADH) and watch for signs of increased intracranial pressure (ICP).Rational:¦ SIADH can be either avoided or quickly managed if early recognition is achieved.
Perform strict intake and output measurements. Determine urine specific gravity. Check electrolytes and osmolality of both serum and urine. Weigh the child daily. Restrict fluids and give sodium chloride as ordered.Rational:¦ Low urine output with a high specific gravity is a sign of fluidretention and SIADH. The child is maintained with lower fluids and provided sodium supplements to reduce the possibility for cerebral edema.

Nursing Diagnosis(Sepsis): Infection related to microorganism invasion into the body

2014-07-06T11:28:00.000-07:00

Nursing Diagnosis(Sepsis): Infection related to microorganism invasion into the body.
Nursing Intervention:
1,Wash hands before and after each patient care activity.
Rational:
To decrease risk of nosocomial infection or transmission of infection.
2,Use strict aseptic technique when handling invasive lines and equipment.
Rational:
To decrease risk of nosocomial infection.
3,Initiate broad spectrum antibiotics early and change to narrow spectrum when culture results are known.
Rational:
Broad spectrum antibiotics are intended to work against a wide array of organisms, however, it is most prudent to utilize a narrow spectrum antibiotic for treatment once the specific organism has been identified.
4,Obtain blood, sputum, urine and wound cultures upon initial suspicion of onset of sepsis.
Rational:
To locate and identify the source of infection.

Necessary Precautions to be taken before a Blood Transfusion

2014-04-25T05:55:00.002-07:00

Verify that an order for the transfusion exists.
Conduct a thorough physical assessment of the patient (including vital signs) to help identify later changes.
Document your findings. Confirm that the patient has given informed consent.
Teach the patient about the procedures associated risks and benefits, what to expect during the transfusion, signs and symptoms of a reaction, and when and how to call for assistance.
Check for an appropriate and patent vascular access.
Make sure necessary equipment is at hand for administering the blood product and managing a reaction, such as an additional free I.V. line for normal saline solution, oxygen, suction, and a hypersensitivity kit.
Be sure you're familiar with the specific product to be transfused, the appropriate administration rate, and required patient monitoring. Be aware that the type of blood product and patients condition usually dictate the infusion rate. For example, blood must be infused faster in a trauma victim who's rapidly losing blood than in a 75-year-old patient with heart failure, who may not be able to tolerate rapid infusion.
Know what personnel will be available in the event of a reaction, and how to contact them. Resources should include the on-call physician and a blood bank representative.
Before hanging the blood product, thoroughly double-check the patients identification and verify the actual product. Check the unit to be transfused against patient identifiers, per facility policy.
Infuse the blood product with normal saline solution only, using filtered tubing.

Refrence

Silvergleid A. Immunologic blood transfusion reactions. UpToDate. October 17, 2008. www.uptodate.com/patients/content/topic.do?topicKey=~EE8E1UGcUSyKQT. Accessed December 22, 2008.

Fragile Veins IV Catheter Insertion and Nursing Actions

2014-03-20T06:20:00.001-07:00

Fragile Veins IV Catheter Insertion and Nursing Actions
1. Avoid using tourniquet as much as possible. If possible, never use a tourniquet to facilitate IV insertion in a patient with very fragile veins. Older adults, for example, have dilated veins most of the time so using torniquet is obviously out of the picture. However, when using tourniquet is necessary, try to choose those that are made with light materials, apply it lightly, and remove as soon as you see a back flow of blood in the cannula. Improper use of tourniquet for this particular type of patient may lead to venous "blow", hematoma formation, and skin damage.

2. Use the smallest catheter available. The size or gauge of catheter to be used will largely depend on the specific therapy the patient is going to receive. However, since the patient has fragile veins, health practitioners must choose the smallest size possible to avoid possible damage. As a standard, patient with fragile veins must only get gauge 22 or gauge 24 for the IV therapy. According to Infusion Nurses Society (INS), "When the catheter is too large for the vessel lumen, irritation from the catheter is very likely to cause mechanical phlebitis and possibly thrombus formation."

3. Use "bevel-up", "low angle" and "slowly but surely" types of approach. Before proceeding to the actual IV insertion, determine first the proper needle-skin angle to be utilized and provide good skin traction to stabilize the vein. Then, using the bevel-up approach, slowly insert the needle on the top of the vein, making at least 10-20 angle (or almost flat) with the skin especially if the veins are dilated and can easily be seen through the skin surface. You have to take your time to avoid causing additional harm and damage to the patient's veins.

4. Choose paper-type tape in securing the catheter. A dry and skin can get unnecessary damage when plastic or silk skin adhesives are used to secure the IV catheter. To avoid this, paper-type tapes are usually preferred to maintain IV insertion for patients with sensitive skin types and unstable veins. Upon termination, use of adhesive solution will greatly ease the process of adhesive removal without bringing additional damage to the skin.

5. Provide the patient useful health education to improve his condition. As a patient advocate and educator, it is the nurse's responsibility to provide patients valuable information that will definitely help to improve their condition in the long run. Use of moisturizers, avoiding excessive sun exposure, eating a balanced diet rich in protein, and adequate fluid intake are just some of the helpful information a nurse can impart to her patients. IV insertion for patients with fragile veins seem to be a very daunting task but with greater practice and exposure with these types of challenges, a nurse can surely get the fulfillment from a job well done. It is our responsibility of nurses to improve our craft for the betterment of the profession and the health condition of the society as a whole. It takes time but no one said it's impossible to achieve.
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