The nurse is preparing to administer the first dose of the p...

The nurse is preparing to administer the first dose of the prescribed IVPB antibiotic. Which 2 actions are most appropriate for the nurse to perform prior to initiating the infusion?

A. Administer a dose of PRN acetaminophen
B. Ask about the client's medication allergies
C. Ensure that prescribed blood cultures have been obtained
D. Ensure that the prescribed echocardiography has been obtained
E. Reschedule the antibiotic dose until the central venous catheter is in place

Correct Answer: B,C

Rationale: Antibiotic therapy is a critical component of treatment for clients with infective endocarditis (E). Before administering IV
antibiotics, the nurse should first obtain blood cultures to identify the infectious organism. Broad-spectrum antibiotics are
started initially. Targeted antibiotic therapy can be administered once the blood cultures identify the culprit organisms and their
antimicrobial susceptibilities. Before starting any medication, the nurse should ask about the client's medication allergies to
identify contraindications to therapy

The nurse is reinforcing discharge teaching to the client. Which of the following client statements indicate that the teaching has been effective? Select all that apply.

A. I am glad that I can continue to enjoy my morning cup of coffee.
B. "I can use aspirin to manage the pain in my knee.
C. I will drink alcohol with food to prevent more stomach ulcers
D. I will immediately report any dark stools to my health care provider.
E. "I will request a prescription for varenicline from my health care provider."

Correct Answer: D,E

Rationale: It is important that clients with peptic ulcer disease understand the signs and symptoms of a recurrence of gastrointestinal
bleeding (ie, melena, hematemesis). If these symptoms occur, the client should immediately notify the health care provider
to prevent life-threatening complications (eg, hemorrhagic shock) (Option 4).
To prevent new peptic ulcer formation or exacerbation, the nurse should instruct clients to limit activities that stimulate
production of gastric acid and impair ulcer healing (eg, smoking). Varenicline is a partial nicotine agonist that aids in smoking
cessation and may be useful for this client

Select 5 findings that require immediate follow-up.

A. left-sided headache
B. Bilateral lens opacity
C. 7.9-Ib (3.6-kg) weight loss within the past month.
D. blurred vision and redness in the left eye
E. severe pain in the left eye
F. red conjunctiva.
G. Left eye: pupil 4 mm and nonreactive to light

Correct Answer: A,D,E,F,G

Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light

Complete the following sentence by choosing from the lists of options. Based on the clinical findings, the client is most at risk for--------------------- as evidenced by the client's------------------------

A. vital signs
B. peritonitis and sepsis
C. fluid volume deficit and hypovolemic shock
D. abdominal pain
E. date of last menstrual period
F. intraabdominal hemorrhage and hypovolemic shock

Correct Answer: C,A

Rationale: The client's findings are most aligned with diabetic ketoacidosis (DKA). When there is a lack of insulin to transport glucose into cells, glucose
accumulates, creating an osmotic gradient that leads to diuresis (polyuria) and fluid loss. If the hyperglycemia persists, the process continues
and the fluid volume deficit decreases cardiac output and perfusion to vital organs (hypotension). The heart rate increases (tachycardia)
to compensate for the decrease in cardiac output. Without immediate treatment, compensatory mechanisms eventually fail, and the client is
at risk for developing life-threatening hypovolemic shock

The nurse has implemented the prescribed therapies and is now assisting the client to fill out the lunch menu. Which meal choice is best for this client?

A. Black beans and rice, sliced tomatoes, and a banana
B. Grilled chicken sandwich, corn on the cob, and applesauce
C. Hamburger patty on a whole wheat bun with avocado
D. Salmon, green peas, baked potato, and strawberries

Correct Answer: B

Rationale: This client is experiencing hyperkalemia and should reduce dietary intake of potassium. The preferred meal choice for this client would
include lean meat, such as chicken, that is grilled rather than cooked in oil, and side dishes consisting of fruits and vegetables low in
potassium, such as corn and applesauce (Option 2).
(Options 1, 3, and 4) Beans (a legume), salmon, tomatoes, bananas, potatoes, strawberries, whole wheat products, and avocados are all
high-potassium foods that the client should avoid at this time. Clients with cardiovascular disease should not consume red meat (eg,
hamburger patty) except in limited quantity because it is high in saturated fat.

The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.

A. Client ate 80% of the meals and took a shower today.
B. Client is seen joining group activities in the day room.
C. Client states, "I feel more energetic today than I have in many months."
D. Client is seen handing a personal watch and photo album to another client.
E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."

Correct Answer:

Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.