The client has drain and indwelling urinary catheter

A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment. The nurse should assess the client to monitor for which of the following adverse effects?

Thinning of the skin

MY ANSWER

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Question: 89 of 90
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Dependent edema

The nurse should identify that dependent edema is a manifestation of right-sided heart failure due to right ventricular failure and fluid retention from pressure building up in the venous system.

Frothy sputum

MY ANSWER

PAUSE FLAG
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm

Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?

This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar hyperventilation and resultant respiratory alkalosis.

Respiratory acidosis
This pH is alkaline (increased) and the PCO2 is decreased. A decreased pH and an increased PCO2 indicate respiratory acidosis.

PAUSE FLAG
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect?

Osteoporosis

MY ANSWER

A client who has hyperthyroidism can develop heat intolerance, along with an increase in sweating.

A pearly, waxy nodule

A firm, nodular, crusty, or ulcerated lesion

A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with an

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Question: 85 of 90
CORRECT

to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C is incorrect. The nurse should palpate the jaw and mastoid muscle of a client who has temporomandibular joint dysfunction. This can be caused by misaligned teeth, arthritis, or grinding of the teeth. With palpation, the nurse might feel a click, pop, or grating sensation when the client opens or closes the jaw.

High lipase

Low hemoglobin

A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level because of the difference in ratio between intravascular fluid and blood cells.

INCORRECT

The nurse should instruct the family member to remove clutter from rooms and hallways so the client is able to walk without the risk of falling or tripping over objects. Later in the disease, the client can experience seizures, so cluttered areas could be a risk to the client.

Place a monthly calendar in the client's room.

Review the daily schedule with the client every morning.

The nurse should instruct the family member to use short, simple sentences when explaining an activity to the client. The explanation should be done immediately before the activity to aid the client's memory and ability to follow directions.

Refractory hypoxemia

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Question: 81 of 90
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Coughing

Status asthmaticus causes labored breathing and wheezing. Coughing indicates that the client is exchanging air and is a manifestation of pneumonia, not status asthmaticus.

A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.

Presence of coarse crackles

PAUSE FLAG
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider?

Hirsutism, an increased growth of hair in unexpected places on the client's body, is nonurgent because it is an expected finding for a client who is taking phenytoin.

Constipation

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Question: 79 of 90
INCORRECT

Oral temperature of 37.2° C (99° F)

The nurse should expect a slight elevation of the client's temperature postoperatively. However, an increased temperature elevation or a spike can indicate an infection.

Decreased bowel sounds in all quadrants of the abdomen

MY ANSWER

PAUSE FLAG
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?

Increased abdominal girth MY ANSWER

Increased abdominal girth is an expected finding with right-sided heart failure due to systemic congestion and an enlarged liver and spleen. Systemic congestion can lead to fluid retention and increased pressure in the venous system, which can manifest with edema in the lower
extremities.

PAUSE FLAG
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

This response indicates role overload because the client is feeling overwhelmed with having to care for their aging parents.

"At times, I get so frustrated with how to care for my parents."

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Question: 76 of 90
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The client's blood pressure is elevated.

The client can have an adverse effect called red man syndrome, which causes hypotension and tachycardia, due to infusing the vancomycin too rapidly. The nurse should infuse the medication over at least 60 min.

Blurred vision is not a manifestation of an infusion reaction to vancomycin. Vancomycin can have sensory implications, however. Although rare, it can cause ototoxicity, which is generally reversible.

The client is experiencing polyuria.

PAUSE FLAG
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?

Potassium 3.5 mEq/L
A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L and does not indicate nephrotoxicity. However, the nurse should report a dramatic change in potassium level to the provider.

FLAG

A nurse is caring for a client who has dumping syndrome following a gastric resection. The

Anorexia can result from dumping syndrome because the client can easily become reluctant to

eat to avoid the unpleasant manifestations of this syndrome, resulting in weight loss.

absorption of iron in the duodenum, causing iron-deficiency anemia.

Hypercalcemia

rapid gastric emptying.

A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?

A pH level of 7.32 indicates the client is in an acidotic state. Acidosis occurs with bronchoconstriction and indicates the medication has not been effective.

The client's forced expiratory volume is decreased after treatment with medication.

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Question: 72 of 90
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"If I can keep my hemoglobin A1C less than 6.5%, I will be cured of diabetes."

Tight control of blood glucose levels can minimize complications associated with diabetes mellitus such as cardiovascular disease, nephropathy, neuropathy, and retinopathy. The nurse should instruct the client that type 1 diabetes mellitus is a chronic condition that causes the body to fail to manufacture insulin and cannot currently be cured.

Microvascular changes to the vessels in the eyes occurs with elevated blood glucose levels, which can lead to retinopathy. To monitor for changes to the eyes, the client should have eye examinations every year.

"I should soak my feet daily in warm, soapy water."

PAUSE FLAG

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply.)

Echinacea is incorrect. Echinacea is a supplement that a client might take to improve the immune system and has no known interaction with warfarin.

Aspirin is correct. Aspirin is an antiplatelet medication. It can increase the risk of bleeding when taken with warfarin.

PAUSE FLAG