ATI comprehensive practice B, ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C

ATI comprehensive practice B, ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. ...

ATI comprehensive practice B, ATI Comprehensive Final Quiz, RN Comprehensive Predictor 2019 A, RN Comprehensive Predictor 2019 Form B and C A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? - Answer- hemoglobin 14.9 g/dL a nurse working in an emergency department is triaging four clients. which of the following clients should the nurse recommend for treatment first? -Answer- a middle adult client who has unstable vital signs a nurse is caring for a client who has fluid volume overload. which of the following tasks should the nurse delegate to an assistive personnel? -Answer- measure the client's daily weight a nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. what is the amount in grams the nurse should administer? -Answer- 18 g a nurse is conducting a physical examination for an adolescent and is assessing the rang of motion of the legs, which of the following images indicates the adolescent is abducting the hip joint? -Answer- Moving the leg away from the midline of the body (off to the side, not to the front) a nurse is caring for a client who has hyperthyroidism. which of the following findings should the nurse expect? -Answer- tremors tachycardia, diaphoresis, weight loss, insomnia, exopthalmia hypothyroidism has dry corase hair, bradycardia, and periorbital edema a nurse is assessing a school age child who has bacterial meningitis. which of the following findings should the nurse expect? -Answer- nuchal rigidity also weight loss a nurse is assessing a newborn's heart rate. which of the following actions should the nurse take? -Answer- auscultate the apical pulse at least 1 min a nurse is preparing to assist with a thoracentesis for a client who has pleurisy. the nurse should plan to perform which of the following actions? -Answer- instruct the client to avoid coughing during the procedurea nurse is the emergency department is assessing a preschooler who has a facial laceration. the nurse should identify which of the following findings as a potential indication of child sexual abuse? -Answer- the child exhibits discomfort while walking a nurse is preparing to teach about dietary management to a client who has crohn's disease and an enteroenteric fistula. which of the following nutrients should the nurse instruct the client to decrease in their diet? -Answer- fiber - reduce diarrhea and inflammation a nurse is caring for a client who has a prescription for a continuous passive motion CPM machine following a total knee arthroplasty. which of the following actions should the nurse take? -Answer- Turn off the CPM machine during mealtime promote client comfort and dietary intake a nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? -Answer- radial vein of the inner arm a nurse is developing a client education program about osteoporosis for older adult clients. the nurse should include which of the following variables as a risk factor for osteoporosis? -Answer- sedentary lifestyle also, small framed body with a thin build, estrogen deficiency a nurse in an emergency department is caring for a child who has a fever and fluid filled vesicles on the trunk and extremities. which of the following interventions should the nurse identify as the priority? -Answer- initiate transmission based precautions a nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. which of the following actions should the nurse take first? -Answer- change the position of the client a home health care nurse is developing a teaching plan for a client who has a new ileostomy. which of the following instructions should the nurse include? -Answer- empty the appliance when it is one third to one half full a nurse is reviewing the laboratory report of a client who has end stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? -Answer- sodium 148 mEq/L a nurse is caring for four clients. which of the following tasks should the nurse delegate to an assistive personnel? -Answer- Arrange the lunch tray for a client who has a hip fracturea nurse is preparing a client for a paracentesis. which of the following actions should the nurse take? -Answer- instruct the client to void a nurse has received change of shift report on four assigned clients. for which of the following clients should the nurse intervene to prevent a potential food and medication interaction? -Answer- a client who is receiving an MAOI and is requesting a cheeseburger for dinner a nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. which of the following actions should the nurse plan to take? -Answer- allow for frequent rest periods throughout the day a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. the client reports bladder spasms, and the nurse observes a decreased urinary output. which of the following actions should the nurse take? -Answer- irrigate the catheter with 0.9% sodium chloride irrigation a nurse is assessing a client who has COPD. which of the following findings should the nurse expect? -Answer- pH 7.31 a nurse in a community center is providing an educational session to a group of client about ovarian cancer. which of the following manifestations of ovarian cancer should the nurse include in the teaching? -Answer- abdominal bloating increase in abdominal girth, pelvic or abdominal pain, early satiety, urinary frequency of urgency a nurse is caring for a client who has active tuberculosis TB. which of the following actions should the nurse plan to take to prevent the transmission of the disease? - Answer- Have the client wear a surgical mask while being transported outside the room a nurse is caring for a group of clients. which of the following clients should the nurse attend to first? -Answer- an older adult client who is anxious and attempting to pull out an IV line an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed. for which of the following situations should the nurse intervene? - Answer- The LPN and the AP grasp the client under his arms to lift him up in bed a nurse is preparing to administer insulin to a client via a pen device. which of the following actions should the nurse take? -Answer- hold the insulin pen device perpendicular to the client's skin to inject the medication a nurse is caring for a client who has immunosuppression and a continuous IV infusion. which of the following actions should the nurse take? -Answer- monitor the client's mouth every 8 hoursa nurse is providing teaching about advance directives to a middle adult client. which of the following client responses indicates an understanding of the teaching? -Answer- "I can designate my partner as my health care surrogate" a nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. which of the following medications should the nurse expect to administer? -Answer- oxytocin a nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? -Answer- seeks input from the other nurses a nurse is assigning task roles for a group of clients in a community mental health clinic. which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? -Answer- noting the progress of the group toward assigned goals a nurse is creating a plan of care for a newly admitted child. which of the following actions should the nurse include in the plan? -Answer- Administer high dose antibiotic therapy cystic fibrosis kid with lung infection a nurse is caring for a newborn immediately after delivery. which of the following interventions should the nurse implement to prevent heat loss by conduction? -Answeruse a protective cover on the scale when weighing the infant a nurse is caring for a client who has abdominal surgery 24 hr ago. which of the following actions is the nurse's priority? -Answer- assist with deep breathing and coughing a nurse in an outpatient mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? -Answer- a client who channels their energy into a new hobby following the loss of their job a nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. which of the following actions should the nurse take? - Answer- aspirate contents from the tube and verify the pH level an antepartum nurse is caring for four clients. for which of the following clients should the nurse initiate seizure precautions? -Answer- a client who is at 33 weeks of gestation and has severe gestational hypertensiona nurse is providing discharge teaching to a client who is to receive home oxygen therapy. which of the following instructions should the nurse include in the teaching? - Answer- wear clothing made with cotton fabrics while oxygen is in use use water soluble lubricant not petroleum based lubricant a nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place a new prescription for crutches. The client is non weight bearing for 6 weeks. which of the following instructions should the nurse include in the teaching? -Answer- use a three point gait a nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. which of the following information should the nurse include in the change of shift report? -AnswerThe time of the client's last dose of pain medication a nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal VP shunt. Which of the following findings should the nurse report to the provider? -Answer- irritability when being held - increased intracranial pressure a nurse is caring for a client who has a prescription for chlorpromazine. which of the following findings should the nurse identify as an indication that the medication is effective? -Answer- decreased hallucinations a nurse is providing teaching about lithium to a client who has bipolar disorder. which of the following statements should the nurse include in the teaching? -Answer- "Notify your provider if you experience increased thirst" a nurse is caring for a client who has a fecal impaction. which of the following actions should the nurse take when digitally evacuating the stool? -Answer- insert a lubricated gloved finger and advance along the rectal wall a nurse is planning to delegate client care tasks to an assistive personnel AP. which of the following tasks should the nurse plan to delegate to the AP? -Answer- perform gastrostomy feedings through a client's established gastrostomy tube a nurse manager is preparing an educational session for nursing staff about how to provide cost effective care. which of the following methods should the nurse include in the teaching? -Answer- delegate non nursing tasks to ancillary staff a nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. which of the following observations should the nurse identify as an indication for potential violence? -AnswerThe client is pacing around the chair in which their partner is sittinga nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy. The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." which of the following responses should the nurse make? - Answer- "You have the right to change your mind about this procedure at any time" A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? -Answer- Agency for healthcare research and quality a nurse is assessing a newborn following a vaginal delivery. which of the following findings should the nurse report to the provider? -Answer- Nasal flaring A charge nurse is speaking with the partner of a client. the partner states that the client is not receiving adequate care. which of the following actions should the charge nurse take first to resolve the situation? -Answer- ask the partner to list specific concerns a nurse is providing information to a client immediately before his scheduled Romberg test. which of the following statements should the nurse make? -Answer- "I will be checking you once with your eyes open and once with them closed" A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. which of the following statements by the client indicates an understanding of the teaching? -Answer- "I will wear a supportive bra overnight" a nurse is caring for a client who is taking valproic acid for seizure control. for which of the following adverse effects should the nurse monitor and report? -Answer- jaundice a nurse is providing discharge instructions about newborn care to a client who is postpartum. which of the following statements indicates to the nurse that the client understands the teaching? select all -Answer- "I will cover my baby's body when I wash her hair" "I will use the bulb syringe first in her mouth then in her nose" A nurse on a mental health unit is conducting a mental status examination MSE on a newly admitted client. which of the following components of the MSE is the priority for the nurse to assess? -Answer- ideas of self-harm a nurse is preparing to administer lactated ringers 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? Round to nearest whole number -Answer- 13 a nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. the nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? -Answer- irritabilitya nurse is providing teaching to a client who is scheduled for electroconvulsive therapy ECT. The nurse should inform the client that which of the following findings is an adverse effect of ECT? -Answer- short term memory loss a charge nurse notices that one of the nurses on the shift frequently violates unit polices by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? -Answer- "I would like to talk to you about the unit polices regarding break time" A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. which of the following findings should the nurse expect? -Answer- urine specific gravity 1.052 a nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. which of the following laboratory values indicates that the client needs additional nutrients added to the feedings? -Answer- albumin 2.8g/dL should be 3.5 to 5.0 A nurse is conducting group therapy with clients who have breast cancer. the nurse should recognize which of the following statements by a client as an example of altruism? -Answer- "I told my doctor that I would like to start a support group for other women who are sick in my community" - reaching out and helping others a nurse is providing dietary teaching to a client who has a new prescription for phenelzine. which of the following food recommendations should the nurse make? select all -Answer- broccoli yogurt cream cheese a nurse is assessing a client for compartment syndrome. which of the following findings should the nurse expect? -Answer- edema a nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? -Answer- ensure that the client understands the medication regimen a nurse at an urgent care clinic assessing a client who reports impaired vision in one eye. which of the following reports by the client should indicate to the nurse that the client has a detached retina? -Answer- floating dark spots a nurse on a medical surgical unit is assessing a client who has had a stroke. for which of the following findings should the nurse initiate a referral for occupational therapy? - Answer- difficulty performing ADL'sa nurse is assessing a client following a colonoscopy. which of the following findings should indicate to the nurse that the client is hemorrhaging? -Answer- rapid decrease in blood pressure a nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end stage kidney disease. the donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day" which of the following responses should the nurse make? -Answer- "You're afraid that your other kidney will fail at some point after the organ donation" a nurse is assessing a client who has pulmonary edema. which of the following findings should the nurse expect? -Answer- pink frothy sputum A nurse administers an incorrect dose of medication to a client. the nurse recognizes the error immediately and completes an incident report. which of the following facts related to the incident should the nurse document in the client's medical record? - Answer- time the medication was given a nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. the client suddenly becomes restless and reports feeling lightheaded. which of the following actions should the nurse take? -Answer- check the client's oxygen saturation level a nurse in an emergency department is assessing a school age child who was brought in by their parents and has scald burns to both hands and wrists. the nurse suspects physical abuse. which of the following actions should the nurse take? -Answer- contact child protective services a nurse is caring for a 2 month old infant who has Hirschsprung disease HD. Which of the following areas should the nurse assess for manifestations of HD? -Answer- C, the abdomen for distention and visible peristalsis a nurse is admitting a client to the psychiatric unit after attempting suicide. the client states "My family does not care whether I live or die", which of the following responses should the nurse make? -Answer- "how does this make you feel" a nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. which of the following instructions should the nurse include in the teaching? select all -Answer- "shake the medication bottle well before each dose is given" "store the medication in the refrigerator" "report diarrhea to the provider immediately" a nurse on a medical surgical unit is caring for a client who has a new diagnosis of terminal cancer. the client tells the nurse that they would like to go home to be withfamily and loved ones. which of the following actions should the nurse take? -Answermake a referral for social services a nurse is assessing a client who has a chest tube. which of the following findings should the nurse expect? -Answer- occlusive dressing drainage should be less than 70 ml/hr continuous bubbling in the water seal chamber indicates an air leak a nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. the clients family tells the nurse they are concerned about the level of care the client will receive. which of the following actions should the nurse take? -Answer- facilitate an interdisciplinary conference at the new facility for the family a nurse is assessing a client who has major depressive disorder and is taking amitriptyline. which of the following findings should the nurse identify as an adverse effect of the medication? -Answer- blurred vision a charge nurse is providing an educational session about infection control for a group of staff nurses. which of the following statements by one of the staff nurses indicates an understandings of isolation precautions? -Answer- "A client who requires airborne precautions should be placed in a negative pressure airflow room" a nurse is preparing to administer a blood transfusion to a client. which of the following procedures should the nurse follow to ensure proper client identification? -Answerverify the client and blood product information with another licensed nurse a nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. the client shows the nurse multiple superficial self inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders. -Answer- borderline - emotionally unstable, troubled interpersonal relationships, often engage ion harmful behaviors a nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. which of the following prescriptions should the nurse clarify with the provider? -Answer- apply a cold pack to the clients ankle for 30 min every hour - type 1 diabetes is a contraindication for cold therapy a nurse is teaching about adverse effects with a client who is starting to take captopril. which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? -Answer- cough - due to build up of bradykinin in the lungsa nurse is reviewing the ABG values of a client. The client has a pH of 7.2, psco2 of 60 mm Hg, nd HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid base imbalances? -Answer- respiratory acidosis a nurse in a providers office is assessing an adolescent who has been taking ibuprofen for 6 months to treatjuvenile idiopathic arthritis. which of the following questions should the nurse ask to assess for adverse effect of this medication? -Answer- "Have you had any stomach pain or bloody stools? a nurse on a pediatric unit has received change of shift report for four children. which of the following children should the nurse assess first? -Answer- a 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain a nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. which of the following actions should the nurse take? - Answer- implement fall precautions for the client - orthostatic hypotension and dizziness a nurse is assessing a client who has decreased visual acuity due to cataracts. the nurse should identify that which of the following physiological changes is the cause for the client's visual loss? -Answer- increased opacity of the lens a nurse is caring for a client following a vacuum assisted birth. the nurse should monitor the client for which of the following complications related to vacuum assisted birth? - Answer- cervical laceration a nurse is updating the plan of care for a client who is 48 hr post operative following a laryngectomy and is unable to speak. which of the following actions should the nurse plan to take first? -Answer- determine the clients reading skills a nurse is caring for a school age child who has dehydration and is receiving an oral rehydration solution. which of the following laboratory results indicates that the treatment regimen is effective -Answer- serum sodium 138 mEq/L a school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. upon arrival at the playground, which of the following actions should the nurse take first? -Answer- survey the scene for potential hazards to staff and children a nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. the nurse is unable to locate members of the clients family to obtain consent. which of the following actions should the nurse take? - Answer- proceed with provision of medical care a nurse is caring for a school age child who is taking valproic acid. the nurse should expect the provider to order which of the following diagnostic tests? -Answer- serum liver enzyme levelsa nurse manager is preparing to teach a group of newly licensed nurses about effective time management. which of the following steps of the time management process should the nurse manager include as the priority? -Answer- making a list of activities to complete a nurse is caring for a client who has pulmonary embolism. the client is receiving heparin via continuous IVinfusion at 1,200 units/hr and warfarin 5 mg PO daily. the morning laboratory values for the client are aPTT 98 seconds and INR 1.8. which of the following actions should the nurse take? -Answer- withhold the heparin infusion a nurse is providing teaching to a school age child who has asthma about using albuterol metered dose inhaler. which of the following instructions should the nurse include? -Answer- take the medication 15 min before playing sports a home health nurse is evaluating a school age child who has cystic fibrosis. the nurse should initiate a request for high frequency chest compression vest in response to which of the following parent statements? -Answer- "my child has only a small amount of mucus after percussion therapy" a nurse is planning care for a client who is receiving chemotherapy and has neutropenia. which of the following interventions should the nurse include in the plan? - Answer- avoid including raw fruits in the clients diet a nurse is caring for a client who is in the fourth stage of labor and is reviewing oxytocin via continuous IV infusion. which of the following assessments is the nurse's priority? - Answer- amount of vaginal bleeding a nurse is caring for a client who is in the resuscitation phase of burn injury. which of the following findings should the nurse expect? -Answer- hyponatremia hyperkalemia a nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. which of the following information should the nurse include in the teaching? -Answer- "I will need to measure your weight daily" a nurse is assessing a client who has bipolar disorder. which of the following alterations in speech is the client using? -Answer- flight of ideas - changing topics suddenly a home health nurse is caring for a group of older adult clients. the nurse should initiate a referral to the program of all inclusive care for the elderly PACE for which of the following clients? -Answer- a client whose caregiver requests adult day care services PACE provides adult day care services along with in home assessments and supportive servicesa nurse at a mental health clinic is caring for four clients. the nurse should recognize that which of the following clients is using dissociation as a defense mechanism? - Answer- a client who was abused as a child describes the abuse as if it happened to someone else a nurse is caring for a client who has active pulmonary tuberculosis. which of the following actions should the nurse take? -Answer- assign the client to a private room with negative air pressure a nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3 hour oral glucose tolerance test. which of the following instructions should the nurse include in the teaching? -Answer- you will need to fast the night before the test a blood sample is collected every hour a nurse is providing education to the parent of a school age child who has asthma. which of the following statements by the parent indicates an understanding of the teaching? -Answer- "I will make sure my child receives a yearly influenza vaccination" a nurse is caring for a client who is receiving a continuous heparin infusion. which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? -Answer- aPTT - for those on heparin it should be 60-80 seconds a nurse is assessing a client who is taking propranolol. which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol? -Answer- wheezing a client is receiving IV fluids at 150 mL/hr. which of the following findings indicates that the client is experiencing fluid overload? -Answer- dyspnea a nurse is assessing a client whose partner recently died. the client states, "I don't know what to do without my partner. life is just not worth living" which of the following responses should the nurse make? -Answer- "You seem to be having a difficult time right now" a nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. which of the following clients should the nurse recommend for discharge? -Answer- a client who has cellulitis and is receiving oral antibiotics every 8 hours a nurse is performing an admission assessment on a client who had a recent positive pregnancy test. the first day of her last menstrual period LMP was May 8. according to Nagele's rules, which of the following dates should the nurse document as the clientsestimated date of birth EDB? -Answer- February 15th (add 7 days to LMP and then subtract 3 months) a nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. which of the following instructions should the nurse include? - Answer- use a reward system to modify the childs behavior a nurse in a providers office is caring for an 18 month old toddler who has a blood lead level of 3 mcg/dL. which of the following actions should the nurse take? -Answerrecommend rescreening in 1 year - it is within the expected reference range a nurse is caring for a client who has cancer and is deciding between two treatment plans. the client asks the nurse for assistance in making the decision. which of the following responses should the nurse make? -Answer- "Tell me more about your understanding of the options" a nurse is caring for a client who has a new prescription for clonidine. the nurse should inform the client that which of the following findings is an adverse effect of this medication? -Answer- dry mouth a nurse is creating a plan of care for a client who has left sided weakness following a stroke. which of the following interventions should the nurse include in the plan? - Answer- support the client's left arm on a pillow while sitting a nurse is caring for a client who has acute blood loss following a trauma. the client refuses a blood transfusion that might potentially save their life. which of the following actions should the nurse take first? -Answer- explore the client's reasons for refusing treatment a nurse is performing an abdominal assessment on a client. identify the sequence of actions the nurse should take. (in order) -Answer- Inspection auscultation percussion palpation a nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome SIDS. Which of the following guardian statements indicates an understanding of the teaching -Answer- "I will not allow anyone to smoke near my baby" a nurse is preparing a sterile field to perform a sterile dressing change. which of the following interventions should the nurse use to maintain surgical aseptic technique? - Answer- maintain sterile objects within the line of visiona nurse is caring for a client who has a magnesium level of 2.7 mEq/L. which of the following interventions should the nurse plan to take? -Answer- initiate continuous cardiac monitoring - mag level is high a nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. which of the following findings indicates the client's use of ginger tea is effective? - Answer- the client reports a decrease in episodes of nausea a nurse is caring for a client who has deep vein thrombosis. which of the following actions should the nurse take? -Answer- instruct the client to elevate the affected extremity when sitting a nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. after the nurse opens the packet containing the new pouch, the client declines to accept it. which of the following actions should the nurse take? -Answer- ask another nurse to witness the disposal of the new patch a nurse is assessing an older adult client who has pneumonia. which of the following findings should the nurse expect? -Answer- acute confusion - along with fatigue, lethargy, and anorexia a nurse is providing teaching about the basal body temperature method of birth control. which of the following information should the nurse include in the teaching? -Answer- "your body temperature might decrease slightly just prior to ovulation" - decrease in body temperature of 1 degree commonly occurs immediately prior to ovulation a nurse manager in a long term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. which of the following actions should the nurse manager take first? -Answer- form a committee of staff members to investigate current staffing issues a nurse is preparing to administer an IM injection to a client who is obese. which of the following actions should the nurse plan to take? -Answer- use the ventrolateral site - it has a thick area of muscle and contains no large nerves or blood vessels a hospice nurse is consulting with a client and her family about receiving home services. which of the following statements should the nurse identify as an indication that the family understands home hospice care? -Answer- "We can expect the hospice nurse to provide support for us after our mother's death" a nurse is assessing a client after administering epinephrine for an anaphylactic reaction. which of the following findings should the nurse identify as an adverse effect of this medication? -Answer- report of chest paina nurse is caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. the nurse should monitor the client for which of the following adverse effects of PEEP? -Answer- tension pneumothorax a nurse manager is reviewing client's rights with the nurses on the unit. the nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? -Answer- autonomy a nurse preceptor is evaluating the performance of a newly licensed nurse. which of the following actions by the newly licensed nurse requires intervention by the preceptor? - Answer- starts a task then determines what supplies are needed a nurse manager is preparing an educational session about advocacy to a group of nurses. the nurse manager should indicate which of the following information in the teaching? -Answer- advocacy is a leadership role that helps others to self actualize a nurse is admitting a client who has pneumonia. the nurse should initiate which of the following isolation precautions for the client? -Answer- droplet a nurse has just received change of shift report on four clients. which of the following clients should the nurse assess first? -Answer- a client who is postoperative with abdominal distention and no bowel sounds during a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. which of the following actions should the day shift nurse take? -Answer- move the client to a room near the nurses station a nurse is reviewing the laboratory results of a toddler who has hemophilia A. which of the following aPTT values should the nurse expect? -Answer- 45 seconds a nurse is planning care for a client who has rheumatoid arthritis. which of the following interventions should the nurse include in the plan? -Answer- increase the client's dietary iron intake - promotes tissue repair a nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. which of the following manifestations should the nurse expect? - Answer- strict adherence to routines a nurse is caring for a client who had a stroke 6 hr ago. which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure? ICP -Answer- place the client in a quiet environment What is a nurses priority action when a patient is experiencing anaphylactic shock while receiving IV medications? -Answer- Priority action: stop the medication infusionThe nurse can also: Administer epinephrine; infuse .9% sodium chloride, and elevate the lower extremities to help maintain adequate blood pressure A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first? -Answer- Accompany the client back to his room. What medication is contra indicated while taking St. John's wort? And why? -AnswerSertraline Taking concurrently puts the patient at risk for serotonin syndrome Both of these are used for Tx of depression Persistent otitis media -Answer- An infection of the middle ear Passive smoking promote adherence of respiratory pathogen's to the lining of the middle ear space which prolongs inflammation and impedes drainage from the ear Exposure to cold weather does not cause otitis media Acarbose (Precose) adverse effects -Answer- Sleepiness, headaches, anemia; the most common adverse effects are gastrointestinal - diarrhea, abdominal distention, cramping, flatulence presbyopia -Answer- impaired vision as a result of aging Can affect one's ability to read the newspaper, the lens is unable to change shape to focus on close up objects Myelomeningocele -Answer- Most severe form of spina bifida in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac and protrude through the spine Neural tube defect pts are at Rx for latex allergy Most common complication of this disorder is UTI Prevention of the development of amblyopia -Answer- A disorder of the eye and which unilateral central blindness occurs as a result of another problem, such as strabismus Parents should patch the unaffected I Strabismus -Answer- Cross eyedWithout treatment by 6 years of age this can lead to central blindness (amblyopia) Ethambutol (Myambutol) -Answer- Med for TB, report vision changes immediately Adverse effects: loss of red/green color discrimination due to optic neuritis; d/c if this occurs Isoniazid (INH) -Answer- Antitubercular Adverse effects: hepatotoxicity, peripheral neuropathy, yellowing of the sclera is an indication of jaundice that accompanies liver failure Rifampin (Rifadin) -Answer- Anti TB and Antibiotic Adverse effects: changes in color of bodily secretions to red-orange What is a patient at risk for when they're platelet count is below the reference range? - Answer- Indicates thrombocytopenia, which puts the patient at increased risk for bleeding What should a nurse anticipate with bladder distention in the fourth stage of labor? - Answer- Bladder will fluctuate with palpation Bladder is dull to percussion Uterus will be displaced to the right, is boggy, well above the umbilicus cystitis -Answer- inflammation of the bladder lining, Commonly occurs with UTI Prevention methods: Stay well hydrated, urinate before and after sex, wipe front to back, avoid tub baths Intrauterine device (IUD) -Answer- Small, T-shaped device inserted by a physician inside the uterus to prevent pregnancy Increased risk for a topic pregnancy Does not protect from STI's or HIV Manifestations of retinal detachment -Answer- sudden onset of decreased peripheral or central vision, dark floaters, flashes of light. curtain vision over part of visual field Manifestations of cataract -Answer- Decreased color perception, blurry vision,clouding of the lens of the eyeWithout treatment leads to blindness Manifestations of Angle-closure glaucoma -Answer- Rapid onset of e severe pain around the eyes and face, reduced vision, colored halos, headaches, sudden onset of elevated IOP Manifestations of macular degeneration -Answer- Gradual, mild to moderate reduction of central vision Nursing actions for a patient in Balanced skeletal traction -Answer- Patient who is in mobile is at risk for constipation, nurse should encourage a high fiber diet and increased fluid intake Active range of motion of the affected limb is not feasible due to limited mobility with the traction apparatus The nurse should not remove the weights after they're in place Nurse should inspect the pin site at least every 8 to 12 hours due to risk of infection Priority assessment for infant experiencing dehydration -Answer- Measure the patient's weight daily; critical for infants and children because fluid accounts for a greater portion of their body weight What is included in an infant Hydration assessment what does it determine? -AnswerChecking for absence of tears, palpating the fontanelles excess skin turgor Assessing these factors determines degree or severity of an infants dehydration Priority action for a patient who had a seizure and is unconscious -Answer- Priority action: CHECK AIRWAY PATENCY (airway always first) A nurse can then assess the patient for injuries perform a neurological exam and measure the patient's vital signs once an airway is established Vaginal yeast infections during pregnancy -Answer- Hormonal changes of pregnancy change the acidity of the vagina, making used infections more common Clozapine (Clozaril) -Answer- Atypical Antipsychotic Tx of schizophrenia Adverse effects: urinary retention, orthostatic hypotension, agranulocytosis Fever is an early indication of possible depletion of WBCs or agranulocytosis; WBC count should be checkedtympanostomy tube placement -Answer- placement of a tube in the tympanic membrane to relieve symptoms caused by fluid buildup Most children do not need tubes from more than one year; usually fall out on their own between 6 to 12 months after insertion Should wear air plugs to prevent contaminated or soapy water from entering the ears Hearing impairment common with otitis media and can continue after tubes are in place Thrombocytopenia precautions -Answer- Thrombocytopenia is a low platelet count, common after bone marrow transplant's Patients are at increased risk for bleeding Prevention: avoid hard foods No fresh flowers because patient is in protective isolation Use of an electric shaver Do not blow nose or insert objects into nares Lactose free calcium sources -Answer- One cup of collard greens provides about the same amount of calcium equivalent to 8 ounces of milk Ventriculoperitoneal shunt placement discharge teaching -Answer- Patient at increased risk for infection especially 1 to 2 months after placement; parents should report fever, vomiting, seizure activity, decreases in responsiveness which all are indications of infection A minimal amount of fluid is redirected from the ventricles to the abdomen by the shunt and is absorbed readily into the peritoneum Older children should wear a helmet during physical activity to decrease risk for injury, Helmet is not necessary for infants Chronic use of oral glucocorticoids high doses by children can result in what? -AnswerSlowed linear growth Children should be prescribed inhaler glucocorticoids in order to deliver the antiinflammatory agent directly to the local target area resulting in a decrease risk of adrenal suppression (which leads to slowed linear growth)Abdominal aortic aneurysm (AAA) -Answer- aorta that becomes abnormally large, ballooning outward *triple A= triple the size* Indications of a rupturing AAA: Sudden and increasing lower abdominal and back pain (indication that the aneurysm is extending down word and pressing on the lumbar sacral nerve roots) Indications of Shock including decreased BP and increased pulse Right sided heart failure -Answer- *RIGHT= EVERYTHING ELSE BUT LUNGS Fluid backs up into heart Manifestations: S3 gallop, peripheral edema, jugular vein distention Left sided heart failure -Answer- *LEFT =LUNGS Fluid backs up into lungs Manifestations: crackles in lungs, dyspnea, pulmonary edema (d/t blood cannot get out of pulmonary circulation) Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys Varenicline (Chantix) -Answer- Smoking cessation Adverse effects: changes in mood, n/v, altered sense of taste, skin rash Rx factors: ↑risk depression/suicide; priority nursing action is to monitor for any mood changes Colorectal cancer primary, secondary, tertiary prevention methods -Answer- Primary prevention: Smoking secession, there is an association between ling-term smoking in colorectal cancer Dietary teaching on the benefits of a diet high in cruciferous vegetables, which helps prevent the development of the disease Secondary prevention: Screening exams starting at age 50 promotes early detection of the disease Tertiary prevention: information about ostomy appliances and care, an action to minimize the effects of long-term disease or disabilityPatient education for EEG therapy -Answer- EEG electrodes only monitor brain activity, they do not stimulate Patient should not drink any beverages that contain caffeine the day of the test, patient should not fast because hypoglycemia can affect diagnostic results Patient should shampoo their hair before the procedure and refrain from putting any styling products on it afterwards to promote adherence of the electrodes to the scalp Short term memory loss does not occur after an EEG (common after electroconclusive therapy) Doxycycline (Vibramycin, Doryx) -Answer- Tetracycline antibiotic Adverse effects: photosensitivity, diarrhea, interference with color vision Avoid direct exposure to sunlight or UV light, wearing protective clothing outdoors and using sunscreen Precipitous labor -Answer- Labor that lasts 3 hours or less from onset of contractions to time of delivery occurs between 20 and 37 wks gestation, uterine contractions and cervical changes Priority nursing action: Regardless of the cause of rapid delivery, uterine atony can result, causing PP hemorrhage; nurse should palpate the fundus and massage as needed to monitor and reduce risk of hemorrhage What oxygen-delivery method should a nurse plan to use for a patient with history of COPD? -Answer- Nasal cannula- delivers precise concentrations of 02 which is required in a COPD patient Simple face masks and nonrebreather mask can reduce the respiratory drive in a patient with COPD; do not use Patient education on how to use an albuterol metered dose inhaler -Answer- 1. Remove the cap 2. Shake the canister 3. Hold the mouthpiece 2 to 4 cm or 1 to 2 inches from the mouth 4. Tilt your head back slightly and open your mouth wide 5. Depress the medication canister I'll taking a slow deep breath to facilitate delivery of the medication through the airway 6. Hold your breath for 10 seconds, then resume usual breathing pattern What protective equipment is necessary when entering a patient's room who has MRSA infection? -Answer- Contact precautions- gown, gloves, mask/goggles (if secretionsfrom the infected individual could spray into the personnels face), use of hand sanitizer when entering and exiting patient room When in direct contact with the patient a personnel must wear a gown When not in direct contact with the patient but still in contact with the patients environment, personnel should don gloves and use hand sanitizer when entering and exiting pancreatitis -Answer- Lab results: Elevated amylase within 12 to 24 hours and remains elevated for 2 to 3 days Hypomagnesia Hypocalcemia Increased WBC count, indication of inflammation Nursing interventions: first pain relief, second cough and deep breathe Discharge teaching on performance of intermittent urinary self catheterization at home - Answer- Might initially require self-catheterization every 2 to 3 hours, with the frequency eventually going to every 4 to 6 hours; longer interval between catheterization can result in bladder distention and increased risk of UTI Should empty bladder completely with each catheterization, to decrease risk of UTI No need for sterile technique; Home use of clean technique shows no greater risk for infection due to acclamation to the bacterial environment of the home Drink at least 2 to 2.5 L of fluid daily Hypovolemic shock lab values and S&S -Answer- Decreased BUN (<10) Elevated hematocrit (>47% in F; >52% in M) Increased urine specific gravity (>1.030) Other indications of hypervolemia: weak pulse, tachycardia, orthostatic hypotension, tackypnea, decreased urinary output, slow capillary refill Phenelzine (Nardil) -Answer- MAOIs Restrict foods containing tyramine: processed meats,lunch meats, aged cheeses, sourdough, alcoholic beverages, overripe fruits, fava beans or fermented soybeans Possible food options: chicken salad, whole wheat enriched bread or crackers, cereals, fish or poultry, sweet potato or white potato, fresh or frozen fruits and vegetables, eggsNursing actions prior to initiating feeding via gastrostomy tube for a patient who had a stroke -Answer- Priority action: Elevate the head of the bed because of increased risk of aspiration Formula should be at room temperature Nurse should flush the tube with water before initiating to ensure patency of the tube Verify the gastric pH is within proper range for placement in the stomach (1.5-3.5) Zidovudine (Retrovir) -Answer- Antiretroviral, AIDS Early Adverse effects: Gi upset, fatigue headache, fever, rash. Late adverse effects: anemia, neutropenia, neuropathy, myopathy Other adverse effects: decreased appetite, anxiety, decreased hemoglobin* (anemia and neutropenia can occur d/t bone marrow suppression) Priority nursing action: monitor hemoglobin levels Tolvaptan (Samsca) -Answer- Tx SIADH Promotes excretion of water which helps correct the flute in balance and patient to have SIADH Vasopressin (ADH) -Answer- Exogenous form of antidiuretic hormone secreted by the pituitary gland Stimulates water reabsorption in the kidneys Tx Diabetes Insipidus Contraindicated: pts w/ SIADH because it worsens manifestations Desmopressin acetate (DDAVP) -Answer- Synthetic form of antidiuretic hormone Medicine used to treat hyposecretion of ADH Contraindicated: patients with SIADH because it worsens manifestations Chlorpropamide (Diabinese) -Answer- (Used less often today) Antidiabetic agents that also has antidiuretic affects Tx of Diabetes InipidusContraindicated: patient with SIADH because it worsens manifestations Adverse effects: Gastrointestinal, Cutaneous reactions, Hypoglycemia, Dermatitis, eczema Skin lesions that indicate Malignant melanoma -Answer- Irregularly shaped lesions w/ hues of blue, white and red tones Commonly start an exposed skin areas like the back, scale, face, neck and metastasizes readily to other areas Pharmacological treatment of chronic phantom limb pain -Answer- Amitriptyline: tricyclic antidepressant Gabapentin: anti-epileptic Propranolol and other beta blockers: can reduce the persistent doll, burning sensations of chronic phantom limo pain Preoperative teaching for a patient who is to undergo LASIK eye surgery -Answer- Type of we Factive laser eye surgery to correct myopia, hyperopia, astigmatism, which are most common causes of nearsightedness Overcorrection or under correction can occur so some patients will need prescription eyeglasses after the surgery Patient might receive sedation prior to the procedure and may have blurry vision, tearing, and hyper sensitivity to light postoperatively; should not drive afterwards Should not wear soft contact lenses for 2 to 3 weeks or hard contact lenses for four weeks prior to surgery because it limits oxygenation to the cornea which can slow postop healing Some patients will have clear vision an hour after surgery but it can take up to four weeks for complete healing in optimal vision to occur Nursing interventions for a patient receiving a transfusion of packed RBCs that is exhibiting manifestations of a hypervolemic reaction -Answer- Hypervolemic rxn due to circulatory overload If the blood transfusion is to rapid for the patient size/status this will occur Priority nursing action: use a transfusion pump to regulate and maintain the transfusion at a slower rateAdministration of insulin glargine (Lantus ) and NPH insulin -Answer- Do not mix insulin glargine with any other insulin- use separate syringes for administering both types of insulin Lantus (insulin glargine) -Answer- Long-acting T1DM, T2DM Can administer at anytime of the day, administered only once in a 24 hour period Clear solution Pharmacological treatment of residual limb pain -Answer- Meperidine (Demerol) Opioid More effective for residual limb pain rather than phantom limb pain NPH (Humulin N) -Answer- Intermediate-acting insulin. Tx DM2 Onset: 1-2 hours. Peak: 4-12 hours. Duration: 18-24 hours. Cloudy solution Roll the valve between the palms, do not shake before administration When administering the patient should rotate injection sites in the same anatomical area to prevent lipodystrophy Developmental skills established by 18 months old -Answer- Acquired at 8 months: sitting unsupported, stranger anxiety Acquired at 9 months: drinking well from a cup Acquired at 12 mo: Presence of six teeth, ability to say two words or speak in 2-word phrases Acquired at 18 mo: closure of anterior fontanel Treatment for systemic manifestations of SLE (systemic lupus erythematosus) -AnswerCorticosteroids, such as prednisone, treatment of choice for SLE because of rapid antiinflammatory actionExpected lab values for a patient w/ SLE (lupus) -Answer- Pancytopenia (decreased platelets, RBCs, HCT) increased ESR systemic lupus erythematosus (SLE) -Answer- Autoimmune disorder a more severe form of lupus involving the skin, joints, and often vital organs- such as heart, lungs, kidneys Inflammation of these organs Indications of thyrotoxicosis -Answer- Occurs if too much levothyroxine is taken Manifestations: chest pain, tachycardia, insomnia, tremors, hyperthermia, heat intolerance, diaphoresis Notify provider is these occur Levothyroxine (Synthroid) -Answer- Tx for Hypothyroidism Manifestations of hypothyroidism such as constipation should subside during therapy Pts taking this often lose weight and revert to an average basal metabolic rate Symptoms of fatigue can persist until the patient reaches therapeutic levels Patient education for the first 48 hrs following placement of a fiberglass cast on a lower extremity -Answer- Do not insert any objects between the cast and skin, scratches/abrasions can lead to infection Reston avoid strenuous activities but use the muscles of the leg and joints above and below the cast Keep the affected limb above the level of the heart to prevent edema and pain and promote venous return Keep cast dry Nonpharmacological approaches to relieve osteoarthritis pain -Answer- Warm packs or compresses well balanced diet to maintain healthy weight Rest joints in functional position, do not place pillows under knees to avoid flexion contracturessleep for 8 to 10 hours per night and rest for 1 to 2 hours when awake Bleomycin (Blenoxane) -Answer- Antibiotic Antineoplastic Adverse effects/ Rx factors: thrombocytopenia, decreased kidney function which leads to peripheralperipheral edema and weight gain Complications: severe lung injury, including pneumonitis and pulmonary fibrosis --> Priority nursing assessment: pulmonary function *REMEMBER: mycin drugs = mon pulmonary function Prednisone (Deltasone) -Answer- Glucocorticoid, corticosteroid, anti-inflammatory Tx of arthritis; high doses required At Rx for delayed wound healing Nifedipine (Procardia) -Answer- Ca channel blocker Tocolytic that is given to stop preterm labor Adverse effects: dermatitis, urticaria hemothroax -Answer- blood in the pleural cavity (chest) Treatment: chest tube insertion to drain blood accumulated in chest cavity Rubeola (measles) -Answer- Airborne infection, opportunistic infection Manifestations: Koplik spots/oral lesions that are small, irregular spots w/ blue/white center appearing on bucks mucosa opposite to molars (prodromal stage of measles) Candidiasis (thrush) -Answer- Opportunistic fungus that develops and oral cavity of patients who have amateur/compromised immune system's Manifestations: cheesy white plaque that looks like milk curds on the bugle mucosa and tongue Often initial opportunistic infection and HIV-positive child who is developing AIDS Transient ischemic attack (TIA) -Answer- Temporary disturbance of the blood supply to the brain causes TIAs, which are brief alterations in neurological functionMost common causes: atherosclerotic plaque in the carotid arteries and hypertension Monitor: BP regularly to promote hypertension management and reduce risk of another TIA or cerebrovascular accident D/C teaching: Limit Na intake to help control HTN and prevent future TIAs Increase K intake to manage HTN Increase fiber intake Limit alcohol intake to no > 2 serving for men and 1 serving for women per day What does it mean when the low-pressure alarm on a mechanical ventilator sounds? - Answer- There is either a leak or the tubing has come apart or detached from the patient What equipment should be available at the bedside of a patient following a subtotal thyroidectomy? -Answer- Tracheostomy Tray Laryngeal edema common post-thyroidectomy can lead to respiratory distress and airway obstruction which makes emergency intubatuon difficult and increases risk for hemorrhaging because it increases tension in incision during insertion Metropolol d/c teaching -Answer- Do not stop taking abruptly because it increases patient risk for angina, HTN, MI; reduce the dosage gradually over 1 to 2 weeks Count your radio pulse daily Change positions slowly d/t Rx of orthostatic hypotension Expected findings of celiac disease -Answer- Foul, fatty, frothy stools known as steatorrhea Indications of an acute intravascular hemolytic reaction for a patient who is receiving a transfusion of packed RBCs -Answer- This type of transfusion reaction causes acute kidney injury (leading to oliguria and hemoglobinuria) Manifestations: oliguria and hemoglobinuria, tachypnea, fever, hypotension Indications that can make a hearing aid whistle include- -Answer- Poor seal with the earmold, air infection, excessive wax in the canal, and proper fit, malfunction hyperthyroidism -Answer- excessive activity of the thyroid gland Manifestations: inability to sleep, creased attention span, mild to severe hyperactivity, low-grade fever, diaphoresis, restlessness, increased systolic BP, tachycardia, dysrhythmias, increased protein, lipid, carbohydrate metabolism rateRecommendations for managing this disorder: Frequent rest. periods in a quiet environment Cool environment to decrease discomfort of heat intolerance Increase caloric intake with meals to prevent muscle weakness and wasting from increased metabolism rate Pneumothorax -Answer- Air in the pleural cavity (chest cavity) Rx after blunt chest trauma Tx: chest tube insertion Addison's disease -Answer- occurs when the adrenal glands do not produce enough of the hormones cortisol (glucocorticoids) or aldosterone Manifestations: severe fluid and electrolyte imbalances -> Hyponatremia, hyperkalemia Tx: (to Prevent addisonian crisis) nurse should do rapid infusion of IV fluids such as .9 percent sodium chloride and IV administration of high-dose corticosteroid such as hydrocortisone to correct deficiency Treatment for hypoparathyroidism -Answer- IV Ca+ or phosphate binding drugs An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors?A. The infant's mother is likely HIV positive.B. The infant's ELISA test result is probably a false positive for HIV.C. Antiretroviral medications are inappropriate for infants and children who have HIV.D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations -Answer- A. The infant's mother is likely HIV positive DKA therapy -Answer- Initial goal is a blood glucose level below 240 Patient should receive regular insulin via continuous IV infusion and have blood glucose monitored hourly Mantoux skin test -Answer- Negative result = reddened, flat area with no induration Positive result = injection cite is raised and feels hard to the touch (induration), with redness; determines exposure to TB not Dx of active TB A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)? -Answer- headachecaused by the rapid removal of urea during hemodialysis; CNS disorder Rx factors: elevated BUN above 175 Manifestations: headache, nausea, vomiting, decreased LOC, seizures, restlessness; when severe, patient progress to confusion, seizures, coma, death A nurse is assessing a child who has acute lymphocytic leukemia and is receiving vincristine sulfate. Which of the following findings is the nurse's priority? -Answerparethesia Tx of acute lymphocytic leukemia Greatest Rx factor for the pt: neurotoxicity (adverse effect) Early findings of neurotoxicity: parethesia (numbing of peripheral extremities) which can progress to I don't gnomic and CNS dysfunction if not treated alopecia -Answer- hair loss Rx for body image alteration chronic kidney disease -Answer- kidney damage or a decrease in the glomerular filtration rate lasting for 3 or more months Restrict protein intake to preserve kidney function May require calcium, vitamin D, iron supplements Cochlear implants -Answer- Work by directly