1 | UWorld NCLEX-PN

The nurse is reinforcing education for a client recently diagnosed with an anaphylactic allergic reaction to latex. Which statement by the client indicates that the client correctly understands the condition? 1. "I do not need to worry about my allergy when I am outside of a health care environment " 2. "I should keep my epinephrine auto-injector pen with me at all times." 3. "I will be fine as long as I check labels to ensure that products do not contain latex." 4. "I will start eating healthier foods such as bananas and avocados."

CORRECT ANSWER: 2 Anaphylactic shock, the most severe form of an allergic reaction, is a medical emergency. Hives, itching, or a rash may or may not appear before rapid swelling of the face, mouth, and throat (ie, angioedema) makes breathing difficult or impossible within minutes. Clients with an anaphylactic allergic reaction should keep an epinephrine auto- injector pen with them at all times (Option 2 is correct). An intramuscular epinephrine injection into the thigh rapidly counteracts the life-threatening swelling, hypotension, and vasodilation that characterize anaphylaxis. Diphenhydramine is also given to treat the rash or itching (eg, hives, wheals, urticaria). (Option 1 is wrong) Latex products are extremely common. The nurse should reinforce education to clients that rubber products (eg, condoms, balloons, rubber bands) and other medical supplies (eg, gloves, urinary catheters) may contain latex. (Option 3 is wrong) Numerous products contain trace amounts of latex. This information may be omitted on labels and is therefore not reliable. (Option 4 is wrong) Bananas, avocados, strawberries, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to eat these foods cautiously due to potential cross-allergenicity. In addition. anaphvlaxis cannot be remediated by diet or exercise. The client must avoid latex and use emergency medications if exposed.

The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply. 1. Eating a high-protein snack at bedtime 2. Limiting alcohol intake 3. Losing weight 4. Taking a mild sedative at bedtime 5. Taking a nap during the day 6. Taking modafinil at bedtime

CORRECT ANSWER: 2, 3 Obstructive sleep apnea (OSA) is characterized by partial or complete airway obstruction during sleep that occurs from relaxation of the tongue and soft palate. The result is repeated episodes of apnea (≥10 seconds) and hypopnea (≤50% normal ventilation), which cause hypoxemia (decreased PaO2) and hypercapnia (increased PaCO2). Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression. Interventions for OSA include: • Using a continuous positive airway pressure (CPAP) device at night to keep the tongue from collapsing backward • Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax, leading to airway obstruction (Option 2 is correct.) • Weight loss and exercise may reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA (Option 3 is correct). • Avoiding sedating medications (eg, benzodiazepines, certain antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness (Option 1 is wrong) Eating before bedtime can interfere with sleep and contribute to excess weight. (Option 4 is wrong) Sedatives at bedtime can relax the muscles of the oral airway and lead to airway obstruction. (Option 5 is wrong) Napping during the day can make it more difficult to sleep through the night. (Option 6 is wrong) Stimulants such as modafinil may be prescribed for daytime sleepiness but should be avoided at bedtime as they can cause insomnia.

Which of the following instructions should be reinforced when caring for a 38-year-old female client with stress incontinence? Select all that apply. 1. Minimize caffeine and alcohol intake 2. Perform pelvic floor muscle exercises 3. Perform self straight catheterization 4. Urinate every 2 hours while awake 5. Use incontinence pads as needed

CORRECT ANSWER: 1, 2, 4, 5 Diagram of stress incontinence: https://imgur.com/c2KTfie Stress incontinence occurs during certain physical activities (eg, sneezing, laughing. coughing) and is usually caused by weak pelvic floor muscles (eg, from childbirth. aging, obesity). Clients can manage and/or reduce stress incontinence by: • Avoiding bladder irritants (eg, smoking, caffeine, alcohol), which can worsen incontinence (Option 1 is correct) • Performing pelvic floor muscle exercises (eg, Kegel exercises) to strengthen the urinary sphincter and structural supports of the bladder (Option 2 is correct) • Emptying the bladder every 2 hours while awake (ie, bladder training) to decrease the risk of incontinence episodes (Option 4 is correct) • Using incontinence pads or briefs as needed, but changing them often to prevent skin breakdown from moisture (Option 5 is correct) • Losing weight when appropriate to help decrease abdominal pressure on the bladder • Using pessaries to relieve minor pelvic organ prolapse if initial conservative measures (eg, bladder training) fail (Option 3 is wrong) Straight catheterization may be appropriate to help a client with urinary retention to void; however, a client with stress incontinence usually does not have a retention problem. Catheterization should be avoided, unless necessary, because it increases the risk for urinary tract infections.

The emergency department nurse has only one isolation room available. Which client should be assigned to the isolation room? 1. Child with chickenpox for the past 14 days whose lesions are crusted and dried 2. Child with impetigo who has been on antibiotics for 3 days 3. Child with leg rash secondary to poison ivy exposure 4. Child with suspected pertussis who has paroxysms of coughing

CORRECT ANSWER: 4 Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis (whooping cough) infection. Pertussis is a highly contagious disease that can be deadly if contracted in infancy before vaccination is started. This client should be placed on droplet precautions immediately to prevent the spread of the disease (Option 4 is correct). See this image for droplet precautions: https://imgur.com/aVGeKbH (Option 1 is wrong) Varicella (chickenpox) is no longer contagious once the lesions have crusted and dried, which can take as long as 3 weeks. Until lesions are crusted, a hospitalized client with varicella should be on airborne and contact isolation precautions. (Option 2 is wrong) Impetigo is a bacterial infection of the skin that causes crusty lesions with highly contagious drainage to the face, often spreading to other areas of the body. Impetigo is no longer contagious after 24 hours of antibiotics. (Option 3 is wrong) A client with a poison ivy rash is not contagious and does not require isolation. The rash develops only from contact with the urushiol oil from the plant itself. The pustules do not contain this oil; therefore, the rash cannot be spread via person-to- person contact.

A nurse is reinforcing education to an adolescent client on skin cancer prevention with special focus on melanoma. Which statements should the nurse include? Select all that apply. 1. "Apply a broad-spectrum sunscreen before and during outdoor sports." 2. "Apply sunscreen a few minutes before starting outdoor activities." 3. "Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier." 4. "Serious sunburns occur even on overcast days." 5. "Use tanning beds for 15 minutes or less for a base tan that is less likely to burn."

CORRECT ANSWER: 1, 3, 4 Skin cancers are most often caused by damage to the skin's DNA. This damage is typically due to exposure to ultraviolet (UV) radiation, primarily from the sun, but also from other sources (eg, tanning beds, sunlamps). The instructions to prevent sunburn and other sun-related damage include: -Avoid the sun, if possible, especially between 10 AM and 4 PM. UV rays are not blocked by cloud coverage and can be reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or even during outdoor winter activities (eg, skiing) (Option 4 is correct). - Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible. - Apply sunscreen: • Use a broad-spectrum sunscreen to block both UVA and UVB rays. • Choose a sunscreen with SPF ≥15 for daily use or SPF 230 for outdoor activities and sun-sensitive individuals. Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if possible (Option 1 is correct and Option 2 is wrong). • Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled "water resistant" or "very water resistant" (Option 3 is correct). • Avoid the use of tanning beds as they emit UV radiation (Option 5 is wrong).

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions? 1. "Ejaculation will make the infection worse." 2. "I enjoy iced tea, so I will drink more to stay hydrated." 3. "I should take ciprofloxacin until I feel better." 4. "I should take docusate to prevent straining."

CORRECT ANSWER: 4 Prostatitis is inflammation of the prostate gland that is usually caused by a bacterial infection. Symptoms include fever, rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management includes antimicrobial (eg, ciprofloxacin) and anti- inflammatory (eg, ibuprofen) medications. Alpha-adrenergic blockers (eg, tamsulosin, alfuzosin) help relax the bladder and prostate. Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis. Urethral catheterization is contraindicated due to the risk for additional pain and urethral inflammation. Clients with prostatitis should be instructed to: • Take stool softeners (eg, docusate) as prescribed to reduce straining during defecation; tension causes the pubic muscles to press against the prostate, causing pain (Option 4 is correct). • Take sitz baths, in which the hips and buttocks are immersed in warm water, to help relieve symptoms. (Option 1 is correct) Ejaculation during sexual intercourse or masturbation can reduce discomfort related to retained prostatic fluid. Clients should use a barrier prophylactic method (eg, condoms) when engaging in sexual activity with a partner to prevent transmission of the causative organism. (Option 2 is correct) Clients with prostatitis should ensure adequate hydration and avoid coffee, tea, and other caffeinated beverages due to their diuretic and stimulant properties, (Option 3 is correct) To ensure infection resolution, the client should be instructed to complete the full course of antibiotics (eg, ciprofloxacin) regardless of symptom improvement.

A client arrives at the clinic for a follow-up after an emergency department visit the night before. The client sustained an ulnar fracture, and a fiberglass cast was applied. Which of the following teachings related to cast care should the nurse reinforce? Select all that apply. 1. Contact the clinic if any hot areas or foul odors develop in the cast 2. Cover the cast with a plastic bag for bathing, and avoid getting the cast wet 3. Elevate the affected extremity above heart level for the first 48 hours 4. Expect some numbness and tingling of the fingers during the first week 5. Use only soft, padded objects to scratch the skin under the cast

CORRECT ANSWER: 1, 2, 3 Casts (eg, fiberglass, plaster) are applied to immobilize fractured extremities during healing. Instructions for cast care include: • Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1 is correct). • Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2 is correct). • Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3 is correct). • Regularly perform isometric and range of motion exercises to prevent muscle atrophy. (Option 4 is wrong) The client should also be instructed to contact the health care provider about symptoms of impaired circulation in the affected extremity, including numbness or tingling, pallor, coolness, loss of pulse distal to the cast, or pain that is unrelieved by ice, elevation, and pain medication. Swelling within the cast may result in compartment syndrome, a condition that involves limb-threatening tissue ischemia due to compression of blood vessels and nerves within the extremity's internal compartments. (Option 5 is wrong) The client should never insert objects inside the cast due to the risk of tissue injury and infection. Directing air inside the cast with a hair dryer on the cool setting may help relieve itching.

Which client in the emergency department should the nurse see first? 1. 2-year-old with fever and sore throat who is restless and drooling 2. 7-year-old with appendicitis who has right lower quadrant pain and vomiting 3. 9-year-old with immune thrombocytopenia who has generalized petechiae 4. 17-year-old with cystic fibrosis who is coughing up thick, blood-tinged sputum

CORRECT ANSWER: 1 Diagram of tripod position & epiglottitis: https://imgur.com/dhHMyC5 Acute epiglottitis is a supraglottic inflammatory process that occurs most commonly in children with Haemophilus influenza type b (Hib) infection. Inflammation of the epiglottis can cause airway obstruction and is a medical emergency. Common signs of impending airway obstruction include restlessness, stridor, and drooling due to dysphagia (Option 1 is correct). The nurse should prepare to assist with emergent endotracheal intubation. (Option 2 is wrong) If left untreated, the inflamed appendix may rupture, causing peritonitis, major abscess, or partial bowel obstruction. The client with acute appendicitis may require antibiotic administration and emergent surgical appendectomy. Although appendicitis is an emergent condition, a client with impending airway obstruction from epiglottitis must be seen immediately. (Option 3 is wrong) Immune thrombocytopenia (ITP) is an acquired disorder in which antibodies cause decreased platelet survival and production. Petechiae, pinpoint lesions on the skin from capillary hemorrhages, are a common sign of IP. Acute IP usually resolves spontaneously without complications, and management is primarily supportive (eg, platelet monitoring, corticosteroids, IV immunoglobulin). (Option 4 is wrong) Cystic fibrosis affects the secretory glands, resulting in thick sputum that may become blood-tinged from frequent coughing. A client with cystic fibrosis who has blood-tinged sputum should be evaluated, but care may be safely delayed until after caring for the client with impending airway obstruction.

The nurse is caring for a client with metastatic cancer. At 9 PM, the night-time health care provider (HCP) rounds on the client and is alarmed to find the client bradypneic, hypotensive, and somnolent. The HCP requests that the nurse give the client naloxone Which of the following is the best action by the nurse? Below are the progress notes: 1300 - Palliative care progress notes: Efforts to shrink tumors unsuccessful. Family conference held with client regarding poor prognosis and quality of life. Client desires to receive comfort measures only. Code status changed to "do not resuscitate." 2035 - Nurse's notes: Client groaning, drooling, dyspneic; respiratory rate 29 with wheezes and stridor on auscultation; pain 9/10. Provided oral care, positioned for comfort, and administered PRN morphine, will reassess in 30 minutes. 1. Approach the client's family to discuss whether to give naloxone in light of the client's wishes 2. Call the palliative HCP who prescribed the morphine sulfate to discuss the change in prescription 3. Describe the client's assessment data and plan of care, and do not give naloxone 4. Place the prescribed morphine on standby and obtain the naloxone prescription

CORRECT ANSWER: 3 Clients at the end of life should be relieved of pain and discomfort according to the ethical principles of beneficence (doing good) and nonmaleficence (doing no harm). As a client advocate, the nurse should actively ensure that unwanted or unwarranted treatment and client suffering are minimal. The client has requested a natural death without resuscitative efforts. Other health care providers (HCPs) may be unaware of the client's status or recent changes to the plan of care. Therefore, the nurse should inform the night-time HCP of the changes and should not give the naloxone even if cardiac and pulmonary functions are suppressed (Option 3 is correct). (Option 1 is wrong) The client and family already decided to withdraw treatment and pursue palliation; approaching the family about whether to intervene is inappropriate and may cause undue grief and guilt. (Option 2 is wrong) Before escalating the situation by calling the palliative HCP, the nurse should explain the client's status and wishes. If the night-time HCP insists that naloxone be given, the nurse should notify the charge nurse or supervisor. (Option 4 is wrong) Naloxone rapidly reverses the effects of opioid medications (eg, morphine). The resulting pain and discomfort for this client oppose nursing standards of care, violate the client's wishes, and are harmful to the client.

The clinic nurse is reinforcing instructions regarding the proper use of prescribed albuterol and beclomethasone metered-dose inhalers to a client with newly diagnosed asthma. Which of the following instructions should the nurse include? Select all that apply. 1. "Omit the beclomethasone if the albuterol is effective." 2. "Rinse your mouth well after using the beclomethasone inhaler." 3. "Use the albuterol inhaler immediately for acute asthma symptoms." 4. "Use the beclomethasone inhaler 5 minutes after the albuterol inhaler if you need both." 5. "Wash the beclomethasone inhaler under running water after each use.

CORRECT ANSWER: 2, 3, 4 Inhaled corticosteroids (ICSs) (eg, beclomethasone, budesonide, fluticasone propionate) are prescribed for long-term control of chronic airway inflammation. ICS use places the client at risk for an oral Candida infection (ie, thrush) due to local immunosuppression caused by retained steroids on the oropharyngeal mucosa. Clients should rinse the mouth and throat with water after each use to help prevent thrush (Option 2 is correct). Use of a spacer with the inhaler also decreases the risk. The mouthpiece of the metered-dose inhaler (MDI) should be wiped with a clean tissue/cloth after each use. Clients with asthma should be taught that during acute episodes (eg, wheezing, breathlessness, chest tightness), short-acting beta agonists (SABAs) (eg, albuterol, levalbuterol) are used as "rescue inhalants" (Option 3 is correct). If the client requires both medications, the SABA should be administered first to open the airways for maximum distribution of the ICS within the bronchial tree. The client should wait 5 minutes between SABA and the ICS use to allow for peak bronchodilation (Option 4 is correct). (Option 1 is wrong) ICSs are prescribed to prevent asthma exacerbations and should be taken on a regular schedule. (Option 5 is wrong) MDs should not be submerged in water to prevent damage to the canister. MDIs should be disassembled 1-2 times per week and the mouthpiece washed with warm, running water to avoid medication build up and blockages.

A pediatric client weighing 66 Ib is prescribed ibuprofen 5 mg/kg by mouth every 6 hr PRN for fever. It is available as an oral solution of 20 mg/mL. How many milliliters (mL) of ibuprofen should be given to the client per dose? Record your answer using one decimal place.

CORRECT ANSWER: 7.5 mL Go to this image for explanation: https://imgur.com/3sjc8xi

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which of the following actions should the nurse implement to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply. 1. Ask simple questions that require "yes" or "no" answers 2. If the client becomes frustrated, seek a different care provider to complete ADL 3. Remain calm and allow the client time to understand each instruction 4. Show the client pictures of ADL (eg, shower, toilet, toothbrush) or use gestures 5. Speak slowly but loudly while looking directly at the client

CORRECT ANSWER: 1, 3, 4 Receptive aphasia refers to impairment or loss of language comprehension (ie, speech, reading) that is caused by a neurological condition (eg, stroke, traumatic brain injury). The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When communicating with a client who has receptive aphasia, appropriate interventions include: • Ask short, simple, "yes" or "no" questions (Option 1 is correct). • Remain patient and calm, allowing the client time to understand each instruction (Option 3 is correct). • Use hand gestures or pictures (eg, communication board) to demonstrate activities (Option 4 is correct). (Option 2 is wrong) Clients with aphasia often become frustrated due to inability to communicate effectively. Frustration does not result from the nurse's care, so assigning the client to a different care provider is not an effective solution. (Option 5 is wrong) Eve contact is important in all communication but raising the voice will not help. Speaking loudly will not improve comprehension and may increase anxiety and confusion.

The nurse is reinforcing teaching on home care and symptom management for a client recently diagnosed with rheumatoid arthritis. What should the nurse encourage the client to do at home? Select all that apply. 1. Allow for periods of rest in the afternoon 2. Avoid using ice on painful joints 3. Perform range-of-motion exercises daily 4. Place a pillow under the knees before sleeping 5. Use moist heat packs to relax stiff joints as needed

CORRECT ANSWER: 1, 3, 5 Rheumatoid arthritis is an autoimmune disease characterized by chronic, systemic inflammation of the connective tissue in the synovial joints. Symptoms include swollen and painful joints; the pain and swelling typically start in the smaller joints and affect the client's ability to button clothing or perform other fine motor tasks. Chronic pain and stiffness eventually affect the joints of the arms and legs, making most activities of daily living difficult for the client. Clients are taught to use moist heat to relieve joint stiffness early in the morning (or as needed), perform range-of-motion exercises daily, and allow for periods of rest in the afternoon. Clients are also encouraged to use ice on painful joints (as needed) to relieve pain from joint motion throughout the day (Option 2 is wrong). A client should not sleep with a pillow under the knees as this can lead to joint contracture and loss of range of motion (Option 4 is wrong).

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the nurse? Select all that apply. 1. The UAP adds milk to mashed potatoes to make them thinner. 2. The UAP encourages the client to occasionally turn the head to the left. 3. The UAP helps the client sit in an upright position. 4. The UAP places food on the strong side of the client's mouth. 5. The UAP puts a straw in a fruit smoothie to prevent spilling.

CORRECT ANSWER: 1, 5 Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration. Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass.

An adult client was severely burned in a warehouse accident. The client has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg. Using the rule of nines, what percentage of the client's body surface area is burned. Record the answer using a whole number.

CORRECT ANSWER: 45% Google "rule of nines" and look for images to understand it. The rule of nines is used to estimate quickly the percentage of total body surface area (BSA) affected by partial- and full-thickness burns in an adult client. Superficial (first-degree) burns are not included in the calculation of affected BSA. For a client who has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg, TBSA is calculated as follows: TBSA = (back] + [anterior and posterior of right arm] + [anterior and posterior of right leg] TBSA = [181 + [4.5 + 4.5] + [9 + 9] TBSA= 18 + 9 + 18 = 45% Once the affected BSA has been estimated, the volume of necessary fluid resuscitation can be calculated (ie, Parkland formula 4 mL × kg of body weight x BSA]). TBSA also determines the required level of care. In general, clients require transfer to a burn center for specialty care for: - Full-thickness burns - Partial-thickness burns >10% TBSA - Electrical or chemical burns - Inhalation injuries

The nurse is caring for a client admitted 3 days ago with bacterial pneumonia who has become short of breath, restless, and difficult to rouse. Which additional finding indicates to the nurse that the client may be developing sepsis? 1. Capillary refill time of 5 seconds 2. Diminished breath sounds in the lung bases 3. Hyperactive bowel sounds 4. Urine output of 35 mL/hr

CORRECT ANSWER: 1 Sepsis is an exaggerated, life-threatening response by the body to a bloodstream infection that can result in hemodynamic instability, respiratory failure, and multiorgan dysfunction. Sepsis typically occurs when bacteria from a local or regional infection (eg, pneumonia, urinary tract infection) enters the bloodstream. Clients with sepsis often have manifestations of a systemic inflammatory response (eg, tachycardia, fever, elevated WBCs) and may exhibit signs of impaired organ function, such as: • Absent bowel sounds: lleus occurs in response to sepsis as blood is shunted away from the gastrointestinal tract to vital organ systems (eg, brain, lungs). • Capillary refill time >3 seconds (in adults): Prolonged capillary refill indicates inadequate perfusion of peripheral tissues (Option 1 is correct). • Increased blood glucose in the absence of diabetes: Gluconeogenesis occurs in response to the physiologic stress of infection. • Altered mentation: Changes in mental status (eg, difficulty rousing, agitation, confusion) occur from impaired cerebral perfusion and oxygenation. (Option 2 is wrong) Diminished breath sounds in the lung bases are expected in a client with pneumonia. (Option 3 is wrong) Hyperactive bowel sounds are associated with gastrointestinal distress, not sepsis. (Option 4 is wrong) Urine output of 35 mL/hr is within normal range (ie, ≥ 30 mL/hr or ≥ 0.5 mL/kg/hr). Oliguria is a possible sign of sepsis, however.

A client in the telemetry unit has end-stage heart failure. The rhythm shown in the exhibit is seen on the cardiac monitor. The nurse is unable to auscultate heart tones and the client is unresponsive. Which is the correct interpretation of this scenario? Go to the link below for additional information. Exhibit link: https://imgur.com/gqoRU5H 1. Systole 2. Complete heart block 3. Disconnected lead wire 4. Ventricular fibrillation

CORRECT ANSWER: 1 systole represents the total absence of ventricular electrical activity in the heart. No ventricular contraction occurs. The client in systole is pulseless, apneic, and unresponsive (Option 1 is correct). systole is usually a result of advanced cardiac disease, end-stage heart failure, or a severe disturbance in the electrical conduction system Treatment consists of CPR, administration of epinephrine and/or vasopressin, placement of an advanced airway, and treatment of any reversible causes. (Option 2 is wrong) In clients with complete heart block, electrical activity is present on the ECG; however, the atrial and ventricular rhythms are unrelated to each other. This is a medical emergency and requires pacing. (Option 3 is wrong) The lead connections should be checked in systole, but the nurse has already recognized the absence of heart tones and unresponsiveness in this client. (Option 4 is wrong) Ventricular fibrillation is characterized by chaotic electrical activity on the ECG. Lifesaving measures, including defibrillation, should be initiated unless the client has a do not attempt resuscitation directive.

A nurse is reinforcing teaching on oral medication administration to the parents of a 3-month-old. Which statement by the parents indicates the need for further teaching? 1. "I should add the medication to a bottle of formula before feeding." 2. "I should direct liquid medication to the back and inside of the cheek." 3. "I should hold my baby in a semi-reclining position during administration." 4. "I should use an oral syringe to measure the medication."

CORRECT ANSWER: 1 Administering liquid oral medications to infants requires specialized techniques to prevent aspiration and ensure correct dosing. Medications should never be mixed in a bottle of infant formula: if the child does not complete the feed. the full dose will not be administered (Option 1 is correct). The medication may also affect the taste of the formula, and the infant may refuse subsequent feeds. (Options 2 and 4 are wrong) Pediatric liquid medications should be administered by an oral syringe, which has small, accurate measurement increments and helps to prevent overmedicating. The liquid medication should be directed toward the back of the infant's cheek and dispensed slowly in small amounts, allowing the infant to swallow between squirts. If the medication is given into the back of the throat in large amounts or too quickly, the infant may aspirate. (Option 3 is wrong) Oral medication should be administered with the infant in a semi-reclining position, similar to the feeding position. This position promotes comfort and prevents aspiration.

A practical nurse is assisting a registered nurse in developing a care plan for a client who has undergone surgery for the creation of a permanent ileostomy. Which action by the client best indicates adjustment to the new ostomy? 1. Client is able to look at and touch the stoma 2. Client reads the materials provided on ostomy care 3. Client requests information about ostomy support groups 4. Client verbalizes methods to control gas and odor

CORRECT ANSWER: 1 Clients with new ostomies may experience grief or loss related to the alteration in body image and loss of bowel control. Clients must begin to accept the change in body image before becoming independent in self-care. Clients who are not coping with these changes may refuse to look at or participate in care of the stoma. The client's ability to look at and touch the stoma indicates acceptance of the change (Option 1 is correct). Interventions to facilitate coping include: • Supportive counseling and assistance in psychosocial adjustment •Teaching and facilitation of ostomy self-care • Provision of information about community resources (Option 2 is wrong) Reading educational materials is a passive activity and is not a strong indicator that the client is ready for self-care. (Option 3 is wrong) Community organizations can offer support and education. However, a client request for support group information does not indicate psychosocial adjustment to the new ostomy. (Option 4 is wrong) The client's ability to verbalize self-care methods indicates an understanding of teaching but does not demonstrate psychosocial adjustment to the new stoma.

The nurse is caring for a 75-year-old client with new urinary incontinence. Which clinical finding is most concerning and requires further investigation by the nurse? 1. Acute confusion 2. Elevated leukocyte count 3. Increased oral intake 4. Low-grade fever

CORRECT ANSWER: 1 Confusion is a common clinical manifestation of urinary tract infections (UTIs) in older adults. When a client develops new-onset confusion, the nurse should suspect infection or other possible causes (eg, dehydration, stroke, side effect of medications) and investigate further (Option 1 is correct). The nurse should notify the health care provider of these findings and obtain prescriptions for a urinalysis and/or urine cultures. (Option 2 is wrong) Although elevated leukocyte (ie, WBC) count is common to many infectious processes, this finding does not take precedence over acute confusion. Confusion is associated with potentially severe infectious and neurological problems that require immediate assessment and intervention. (Option 3 is wrong) Changes in appetite are influenced by natural processes of aging (eg, xerostomia [dry mouth], dysgeusia [impaired sense of taste]) and level of activity. Clients may increase their intake of heavily seasoned, salted, or sweetened foods. UTIs typically induce decreased interest in eating and oral intake due to persistent discomfort and malaise. (Option 4 is wrong) A low-grade fever may be indicative of an infectious process: because older adult clients often have a diminished immune response, even a low fever should be investigated. However, acute confusion may signal a more serious alteration in neurological status.

Which client in the family health clinic should the nurse see first? 1. Client taking dabigatran who reports heavy bleeding with the menstrual cycle 2. Client taking metronidazole who reports abdominal cramping and nausea 3. Client taking phenytoin who is due for a phenytoin serum level to be drawn 4. Client with diabetes taking prednisone who reports a 7 AM glucose of 260 mg/dL

CORRECT ANSWER: 1 Direct thrombin inhibitors (eg, dabigatran, bivalirudin) are anticoagulants often prescribed to prevent or treat thrombotic events in clients with atrial fibrillation, pulmonary embolism, and deep venous thrombosis. Clients taking direct thrombin inhibitors are at increased risk for bleeding. Signs of abnormal bleeding (eg, bruising, blood in stool or urine, epistaxis, heavy menstrual bleeding) require immediate assessment for hemorrhage and possible discontinuation of the medication (Option 1 is correct). (Option 2 is wrong) Gastrointestinal upset is a common adverse effect of many antibiotics including metronidazole. The nurse should instruct the client to take this medication with food to prevent abdominal discomfort, but this does not take priority over heavy bleeding. (Option 3 is wrong) Clients receiving phenytoin, an anticonvulsant, require routine monitoring of serum drug levels to ensure a therapeutic range (10-20 mcg/mL). However, routine monitoring of serum drug levels does not take priority over heavy bleeding. (Option 4 is wrong) Hyperglycemia is a common adverse effect of corticosteroids (eg, prednisone, methylprednisolone), which are used to decrease inflammation (eg, asthma, rheumatoid arthritis) or to provide hormone therapy (eg, adrenal insufficiency). The client may require dose adjustments for insulin or an antidiabetic medication, but this does not take priority over heavy bleeding.

The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1. Client who had an emergency appendectomy 48 hours ago and is reporting hearing ocean waves and seeing fish swimming through the walls 2. Client who had an exploratory laparoscopy 2 hours ago and has absent bowel sounds and is reporting nausea 3. Client with diabetes mellitus who has a foot ulcer and is reporting feeling "pins and needles" in the lower legs 4. Client with Parkinson disease who has tremors while resting and has developed black-colored urine after taking carbidopa/levodopa

CORRECT ANSWER: 1 Hallucinations represent a serious safety risk to the client and others; they may compel clients to engage in behaviors or activities that trigger self-injury or violence toward others (eg, command hallucinations). Hallucinations experienced by clients who do not have a psychiatric illness may indicate withdrawal from alcohol or narcotics, which can be life threatening without prompt intervention. Nurses should promptly assess clients with new or worsening hallucinations (Option 1 is correct). (Option 2 is wrong) Clients undergoing abdominal surgery (eg, exploratory laparoscopy) often have nausea and absent bowel sounds postoperatively for the first few hours due to side effects of aesthetics and decreased peristalsis after bowel manipulation. (Option 3 is wrong) Clients with diabetes mellitus may develop diabetic neuropathy as a complication of neurovascular damage from inadequate long-term blood glucose management. Feeling "pins and needles" is an uncomfortable but harmless symptom of diabetic neuropathy. (Option 4 is wrong) Resting tremors are an expected finding associated with Parkinson disease. Carbidopa/levodopa, a common medication used to manage symptoms of Parkinson disease, can cause a harmless darkening of urine color (eg, brown, black).

Several children at a local pediatric clinic are found to have hemoglobin levels of 10-11 g/dL. Which dietary modification would most likely help increase hemoglobin levels in these clients? 1. Ensuring adequate intake of meat, fish, and poultry 2. Increasing consumption of fruits and vegetables 3. Prioritizing intake of milk and other dairy products 4. Providing orange juice fortified with vitamin D at meals

CORRECT ANSWER: 1 Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from inadequate intake of foods high in iron. In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic) under a microscope. The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily absorbed by the body (Option 1 is correct). Plant-based foods (eg, dried fruits, nuts, legumes, green leafy vegetables, whole grains) are not as iron rich and contain a less bioavailable form of iron than animal-based foods. However, foods high in vitamin C (eg, tomatoes, potatoes, strawberries) may boost iron absorption when consumed with iron-rich foods. (Option 2 is wrong) Fruits and vegetables are not the best sources of dietary iron. (Option 3 is wrong) Milk and milk products are poor sources of dietary iron, and excessive calcium intake interferes with iron absorption. Overconsumption of milk, along with little or no consumption of other foods, is a leading cause of iron deficiency in young children. (Option 4 is wrong) Although sources of vitamin C (eg, orange juice) may enhance iron absorption, increased intake of iron-rich foods is priority in treatment of IDA. Vitamin D has no direct effect on anemia.

The nurse is caring for a hospitalized client with an acute exacerbation of heart failure. The client receives digoxin 0.5 mg PO once daily, furosemide 40 mg PO twice daily, and potassium chloride (KCl) 20 mEq PO twice daily. The client reports trouble swallowing the large KCI pill. The client's potassium level is 3.7 mEg/L. What action should the nurse take? 1. Consult with the pharmacist to see if other oral forms of KCI are available 2. Crush the pill and mix it with applesauce or pudding ( 3. Hold the KCI until the health care provider makes rounds 4. Instruct the client to tuck the chin to the chest when swallowing the pill

CORRECT ANSWER: 1 Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia. Oral KCl is available in extended-release tablets, capsules, dissolvable packets, effervescent tablets, and as an oral liquid. If a client has difficulty swallowing large pills, the nurse should consult the pharmacist to see if other forms of KCl are available and to determine if the medication is safe to crush (Option 1 is correct). If a more appropriate form (eg, liquid) is available, the nurse should discuss that change in route with the health care provider and obtain an updated prescription. (Option 2 is wrong) Some pills or capsules are sustained-release formulations, and crushing them may alter the release of the drug and cause an overdose of the medication. The nurse should consult the pharmacist before altering the form of the drug. (Option 3 is wrong) Use of a loop diuretic, such as furosemide, is a common cause of potassium depletion. Holding the KCl dose may cause the client's potassium level to fall below normal (<3.5 mEq/L), which can potentiate digoxin toxicity (eg, cardiac dysrhythmias, gastrointestinal upset). (Option 4 is wrong) Tucking the chin to the chest during swallowing is a technique used to prevent aspiration. This most likely will not help the client swallow the large pill.

The nurse cares for a client with end-stage liver disease who is not a candidate for a liver transplant. The client is considering participation in a research study investigating an experimental therapy. In discussing possible enrollment in the study with the client, which of the following statements by the nurse are appropriate? Select all that apply. 1. "Ask the research team about the risks, consequences, and benefits before signing consent." 2. "Before signing consent, make sure you understand the study's duration and your obligations." 3. "In your own words, can you tell me what you have been told about the study and what you will be required to do?" 4. "Remember that if you participate, you are not obligated to stay in the study. You may withdraw at any time." 5. "To maintain the integrity of the study, certain information may be withheld such as potential for harm or discomfort."

CORRECT ANSWER: 1, 2, 3, 4 Informed consent must be obtained from clients participating in a clinical trial. Prior to participation in a study, the researcher or a member of the research team must: • Inform the participant of the study's risks, consequences, and benefits (Option 1 is correct). • Explain the study's purpose, duration, and procedures and participant's obligations (eg, time commitment, evaluations) (Option 2 is correct). • Ask participants to explain the study in their own words, allowing the nurse to identify any need for clarification (Option 3 is correct). • Assure the participant that personal information will remain confidential. • Ensure that consent is obtained voluntarily and that the participant is fully capable of understanding the terms of the study prior to signing the consent form. • Disclose the participant's ability to withdraw from the study at any time (Option 4 is correct). (Option 5 is wrong) Before the participant signs the consent form, the research team must disclose any potential for harm or discomfort associated with the study.

The nurse is planning care for a client with a fractured femur who was placed in balanced suspension skeletal traction 2 hours ago. Which of the following interventions should the nurse include? Select all that apply. 1. Encourage intake of at least 2 L of fluid per day to prevent constipation 2. Ensure that the weights hang freely and do not touch the ground 3. Monitor skin integrity and signs of infection at the pin insertion sites 4. Perform frequent neurovascular checks on the affected extremity 5. Remove the weights briefly every 4 hours to prevent muscle spasms

CORRECT ANSWER: 1, 2, 3, 4 Skeletal traction involves surgically inserting screws, wires, and/or pins directly into a fractured bone and applying a pulling force (traction) via a pulley system and a rope. The pulley system allows free-hanging weights to suspend from the foot of the client's bed and pull on the skeletal pins to maintain alignment of the proximal and distal portions of the fractured bone. Appropriate nursing interventions for clients in skeletal traction include: • Encouraging increased fluid intake (22 L/day) to reduce the risk for constipation caused by immobility (Option 1 is correct) • Ensuring that the weights hang freely and are not resting on the ground or on medical equipment (Option 2 is correct) • Monitoring skin integrity and pin insertion sites for signs of infection (eg, erythema, drainage, swelling, malodor) (Option 3 is correct) • Performing frequent neurovascular checks, especially in the first 24 hours of traction therapy (Option 4 is correct) • Inspecting the rope for fraying and ensuring its correct position in the pulley track • Ensuring proper alignment of the client and the pulley system to facilitate union of the fractured bone (Option 5 is wrong) Skeletal traction not only provides proper alignment during bone healing, but also helps reduce muscle spasms that result from malalignment of the fracture. The weights should not be removed, even briefly, unless prescribed by the health care provider.

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. 1. Amphetamine use 2. Cigarette smoking 3. Cold exposure 4. Deep sleep 5. Sexual intercourse

CORRECT ANSWER: 1, 2, 3, 5 Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: • Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) • Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload • Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) • Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release • Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction • Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium (Option 4 is wrong) Deep sleep doesn't increase oxygen demand.

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply. 1. Family history of skin cancer 2. High number of moles 3. History of severe adolescent acne 4. Immunosuppressant medication use 5. Outdoor occupation

CORRECT ANSWER: 1, 2, 4, 5 Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: • Family or personal history of skin cancer (Option 1 is correct). • Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) • Aging • Atypical or high number of moles because some skin cancers develop from pre- existing moles (Option 2 is correct). • Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4 is correct). • Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5 is correct). Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their health care provider. Early detection and treatment significantly improve outcomes. (Option 3 is wrong) Acne is not a known risk factor for skin cancer.

The nurse is caring for a client with multiple renal calculi. Which of the following interventions should the nurse anticipate? Select all that apply. 1. Administer analgesics at regularly scheduled intervals 2. Encourage fluid intake of up to 3 L/day 3. Instruct client to stay on bed rest 4. Provide massage to the client's flank 5. Strain all urine for the presence of stones

CORRECT ANSWER: 1, 2, 5 The formation of renal calculi (ie, kidney stones) can be due to various factors (eg, family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi (Options 1 and 2 are correct). To retrieve stones that the client may pass, the nurse should strain all urine obtained (Option 5 is correct). The collected stones are analyzed to determine their composition (eg, calcium oxalate, calcium phosphate, struvite, uric acid, cystine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge. (Option 3 is correct) Immobilization is a contributing cause of renal calculi formation and should be avoided. Ambulation and frequent mobilization are encouraged as tolerated to help facilitate the passage of calculi. (Option 4 is correct) Massage therapy to the flank should not be performed to prevent further instigation of renal colic. Other interventions, such as monitored heat therapy, would be acceptable.

When reinforcing teaching for a client with polycythemia vera, which of the following instructions should the nurse include? Select all that apply. 1. Elevate the legs and feet when sitting 2. Increase dietary intake of foods rich in iron 3. Increase fluid intake during exercise and hot weather 4. Increase bath water temperature to reduce itching 5. Report swelling or tenderness in the legs

CORRECT ANSWER: 1, 3 ,5 Polycythemia vera (PV) is a chronic disorder of the bone marrow in which too many RBCs, WBCs, and platelets are produced. Clients with PV are at risk of developing blood clots (ie, thrombosis) due to increased blood viscosity. Clients should be instructed to: • Elevate the legs when sitting and wear support stockings to promote venous return (Option 1 is correct). • Increase fluid intake when fluid loss is anticipated (eg, perspiration) to prevent an additional increase in blood viscosity (Option 3 is correct). • Report signs of thrombosis (eg, swelling and tenderness of the legs) (Option 5 is correct). (Option 2 is wrong) The client should not increase intake of iron-containing foods and supplements, because this can cause further increases in hemoglobin production. Clients with PV need periodic phlebotomy to remove excess blood. (Option 4 is wrong) Itching is a common and frustrating symptom of PV. Reducing bath water temperature, using starch baths, and patting the skin dry (rather than rubbing vigorously) are beneficial in reducing itching.

The nurse plans to administer a client's oral medications via nasogastric tube. The nurse should question which of the following prescriptions scheduled to be given via this route? Select all that apply. 1. Enteric-coated ibuprofen 200-mg tablet 2. Extra-strength acetaminophen 500-mg tablet 3. Metoprolol extended-release 50-mg tablet 4. Sulfamethoxazole double-strength800-mg tablet 5. Tamsulosin 0.4-mg slow-release capsule

CORRECT ANSWER: 1, 3, 5 Enteric-coated medications have a barrier coating that dissolves at a slower rate, usually in the small intestine, to protect the lining of the stomach from irritants. Crushing enteric-coated medications (eg, ibuprofen, pantoprazole) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog feeding tubes, particularly small-bore nasogastric or enteral tubes (eg, jejunostomy tube, orogastric tube) (Option 1 is correct). Slow/extended/sustained-release medication formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications (eg, metoprolol, tamsulosin) alters this property and increases the risk of adverse effects from toxic blood levels due to more rapid medication absorption. The nurse should question the prescription and contact the health care provider for clarification. A new prescription for a suitable alternative (eg, elixir, immediate-release tablet) may be needed (Options 3 and 5 are correct). (Options 2 and 4 are wrong) Double- and extra-strength medications, such as acetaminophen and sulfamethoxazole, may be crushed and administered separately through an enteral tube as long as they are not enteric coated. The nurse should flush the tube with water before and after each administration.

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply. 1. "I don't have to use protection if my sexual partner is also HIV positive." 2. "I have to make sure my family knows not to borrow my razors." 3. "I need to avoid eating raw or undercooked meats and eggs." 4. "I started to use lambskin condoms during sex, as I have a latex allergy." 5. "I won't reuse or share any needs or syringes that I use to inject heroin."

CORRECT ANSWER: 1, 4 Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells resulting in progressive immune system impairment. When educating clients with HIV, the nurse should discuss health promotion and infection transmission prevention strategies, particularly safe sex practices. Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is important even with HIV-positive partners as HIV has multiple strains and confection results in HIV superinfection, which may hasten progression to AIDS (Option 1 is correct). Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of STIs due to the presence of small pores (Option 4 is correct). (Option 2 is wrong) Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV transmission risk and should be avoided. (Option 3 is wrong) Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid foodborne illnesses. (Option 5 is wrong) To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to avoid reusing or sharing needles or syringes.

A female client who is sexually active has had three urinary tract infections (UTIs) in 12 months. Which of the following instructions should the nurse reinforce about preventing UTI recurrence? Select all that apply. 1. Increase daily intake of fluids 2. Use a spermicidal contraceptive jelly 3. Use an over-the-counter douche after intercourse 4. Use fragrance-free perineal deodorant products 5. Void immediately after intercourse 6. Wear underwear made of cotton

CORRECT ANSWER: 1, 5, 6 Female clients should implement the following interventions to help prevent recurrent urinary tract infections (UTIs): • Take all antibiotics as prescribed; bacteria may still be present even if symptoms have improved. • Increase fluid intake; this dilutes the urine (minimizing bladder irritation), promotes frequent urination, and prevents urinary stasis (Option 1 is correct). • Wipe from front to back to prevent introducing bacteria from the vagina and anus into the urethra. • • • Void after sexual intercourse to flush out bacteria that may have entered the urethra (Option 5 is correct). • Avoid synthetic fabrics (eg, nylon, spandex), which seal in moisture and create an environment conducive to bacterial proliferation; cotton underwear is recommended instead (Option 6 is correct). • Take showers instead of baths, because bath products (eg, bubble bath, oils) and bacteria in bath water can irritate the urethra and increase the risk of infection. (Option 2 is wrong) Avoid spermicidal contraceptive jelly because it can suppress the production of protective vaginal flora, allowing proliferation of pathogenic bacteria, which may cause UTIs. In addition, diaphragms increase pressure on the urethra and bladder neck, which may inhibit complete bladder emptying; they should not be used until symptoms subside and the antibiotic course is completed. (Options 3 and 4 are wrong) Avoid douching and feminine perineal products (eg, deodorants, powders, sprays), because they can alter the vaginal pH and normal flora, increasing the risk for infection.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzyme (CK-MB) 4. Chest x-ray

CORRECT ANSWER: 2 B-type natriuretic peptide (BNP) is a peptide that causes natriuresis. BNPs are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL (>28.9 pmol/L) helps to distinguish cardiac from respiratory causes of dyspnea (Option 2 is correct). (Option 1 is wrong.) Arterial blood gases (ABGs) will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3 is wrong.) Cardiac enzymes (CK-MB) is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4 is wrong.) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate chronic obstructive pulmonary disease and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test.

The nurse is reviewing the charts of four clients in the outpatient pediatric clinic. Which client should the nurse see first? 1. 6-month-old who received the diphtheria-tetanus-acellular pertussis vaccine 18 hours ago and developed a fever of 102 F (38.9 C) and injection site redness 2. 11-month-old with inconsolable crying and drawing up of the legs toward the abdomen 3. 4-year-old who was diagnosed with right lung pneumonia 2 days ago and who has chest pain when breathing deeply 4. 15-year-old whose eyes are red and itchy and have a yellow discharge

CORRECT ANSWER: 2 Diagram of intussusception: https://imgur.com/41JfnQY Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate intussusception or another abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that contain mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt the blood supply, and cause intestinal tears (perforation). is an emergency, and the client should be seen immediately for further evaluation (Option 2 is correct). Care for more stable clients may be safely delayed until after caring for the client with potential intussusception. (Option 1 is wrong) Mild to moderate fever and local reactions are common after vaccinations. Severe allergic reactions (eg, anaphylaxis) and encephalopathy (eg, decreased level of consciousness, prolonged seizures) are the most serious reactions and require priority attention. (Option 3 is wrong) Pneumonia is often accompanied by chest and side pain that worsens with deep breathing due to rubbing of the nearby inflamed pleura (pleuritis). This client's symptoms are expected findings. (Option 4 is wrong) Red, itchy eyes with yellow discharge indicates bacterial conjunctivitis, or inflammation of the clear membrane (conjunctiva) that covers the eve. This client will need ophthalmic antibiotics and education on preventing the spread of infection to others.

An earthquake has caused a mass-casualty incident in the community. Stable clients must be released to make room for incoming clients affected by the incident. Which client should the nurse recognize as most appropriate for discharge? 1. Client with an acute head injury and a Glasgow Coma Scale score of 12 2. Client with an asthma exacerbation who has a peak flow at 85% of personal best 3. Client with deep vein thrombosis on IV heparin and platelet count of 40,000/mm³ 4. Client with liver cirrhosis and oozing esophageal varices who is receiving lactulose

CORRECT ANSWER: 2 In a disaster situation, the nurse should discharge stable clients to make space available for a high volume of incoming injured clients. A client with asthma who has a peak flow of at least 80% of personal best has good control of symptoms and airway compliance and is considered stable for discharge. Peak flow is the best measurement of airway compliance for asthma; a peak flow of <80% indicates uncontrolled symptoms requiring further acute treatment and monitoring (Option 2 is correct). (Option 1 is wrong) The Glasgow Coma Scale is used to assess level of consciousness in clients, with a score of 15 being normal. A client who sustained an acute head injury and has a Glasgow Coma Scale score of 12 has moderate neurologic impairment requiring further observation and care. (Option 3 is wrong) A client who is receiving IV anticoagulation and has thrombocytopenia (ie, platelets <150,000/mm³) may have heparin-induced thrombocytopenia and is at risk for paradoxical arterial thrombosis (eg, stroke) and, rarely, bleeding. This client requires further evaluation and care. (Option 4 is wrong) A client with oozing esophageal varices may experience gastrointestinal hemorrhage if the varices rupture and is at risk for increasing ammonia (from the digestion of protein in the blood). This client needs continued care (eg, lactulose administration) and intervention.

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform? 1. Add the secondary hernia to the consent form that the client signed before the procedure 2. Call the client's medical power of attorney so that the surgeon can obtain consent for the additional procedure 3. Document that an additional hernia was found and that it will require ]surgery at a later time 4. Witness an additional consent after the client is awake and both procedures are complete

CORRECT ANSWER: 2 Informed consent is required before any nonemergent procedure. The 3 principles of informed consent include: • The surgeon clearly explains the diagnosis, planned procedure with risks and benefits, expected outcome, alternate treatments, and prognosis without surgery. • The client indicates understanding of the information. • The client is competent and gives voluntary consent. The nurse is responsible for witnessing the client's signature and ensuring that the client is competent and understands information provided by the surgeon. Clients who are unconscious or under the influence of mind-altering drugs (eg, opioids) cannot provide consent. If the sedated client requires procedures not listed on the consent form, the client's next of kin, legal guardian, or power of attorney should be contacted so that the surgeon can explain the situation and obtain consent (Option 2 is correct). (Option 1 is wrong) Modifying a consent form after it has been signed is an illegal falsification of documentation. (Option 3 is wrong) Unless family members deny consent or cannot be reached, it is in the client's best interest to have the hernia repaired during this surgery rather than go through the physical and financial strain of a second surgery. (Option 4 is wrong) Procedures can be performed without prior consent only when lifesaving measures are necessary. Obtaining consent after a procedure is illegal and considered assault and battery.

The nursing unit has implemented a quality-improvement program to improve client pain management. Which is the best indicator of improved pain management? 1. Better client pain control as reported by a survey of the unit's nurses 2. Improved clients' self-reported pain scores on chart audits 3. Increase in number of PRN analgesics administered to clients 4. Increase in positive feedback on a client satisfaction survey

CORRECT ANSWER: 2 Measurements for quality improvement should be client-centered and objective (quantifiable), rather than subjective. An evidence-based data collection method (eg, numeric pain scale) should be used, if applicable (Option 2is correct). When evidence-based criteria are measured, survey results can be used as objective, retrospective measurements of a positive change. (Option 1 is wrong) Subjective, second-hand perceptions of client pain control reported by nurses may not reflect the actual adequacy of client pain relief. Objective, client- reported measurement tools should be used instead. (Option 3 is wrong) Increased analgesic administration could be attributed to many factors, including fluctuations in the number of clients on the unit or diversion of medication by staff (eg, theft). In addition, clients may obtain pain relief by nonpharmacologic means, and these measures are not reflected by measuring the number of analgesics administered. (Option 4 is wrong) Positive commentary on client satisfaction surveys is a subjective criterion. Overall client satisfaction is related to all aspects of care, including those unrelated to pain relief.

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? 1. A client with asthma who uses an albuterol nebulizer once a day 2. A client receiving intravenous broad-spectrum antibiotics daily 3. A teenage client with braces who drinks several sugary drinks daily 4. An elderly client with poor oral hygiene and inadequate nutrition

CORRECT ANSWER: 2 Oral candidiasis or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that may bleed when removed. Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise (Option 2 is correct). Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene. (Option 1 is wrong) Inhaled beta-2 agonists (eg, albuterol) do not increase the risk for fungal infections. However, individuals taking an inhaled corticosteroid (eg, budesonide, fluticasone) are at increased risk for oral candidiasis. To reduce this risk, the client should rinse the mouth after each inhaled dose and maintain good oral hygiene. (Options 3 and 4 are wrong) Proper oral hygiene and nutrition are important in prevention of oral candidiasis. However, the client with braces or poor hygiene and inadequate nutrition is at lower risk than one who is immunosuppressed or taking antibiotics.

The nurse reinforces discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching? 1. "I have to give myself shots in the belly because my spouse is afraid of needles!" 2. "I have to use a walker because I can't bear any weight on this knee yet." 3. "I will call my health care provider if I get short of breath or sore or swollen below my knee." 4. "The raised toilet seat makes it easier for me to get on and off the toilet by myself."

CORRECT ANSWER: 2 The average hospital length of stay following total knee arthroplasty is 3-5 days. After surgery, immediate initiation of physical therapy is a priority. An isometric quadriceps setting is initiated on the 1st postoperative day. The client should be fully weight bearing by discharge. Clients use an assistive device (eg, walker, crutches, cane, grab bar, hand rails) to help them sit, rise safely from a sitting to a standing position, and negotiate steps. A knee immobilizer is used to maintain extension during ambulation and at rest for about 4 weeks. (Option 1 is wrong) Venous thromboembolism (eg, deep vein thrombosis [DVT], pulmonary embolism [PE]) following knee arthroplasty is a major preventable complication. Anticoagulation with oral anticoagulants (rivaroxaban) or enoxaparin (Lovenox) injections is therefore prescribed for at least 2 weeks after surgery. Ankle exercises, anti-embolic stockings, and frequent mobilization are prescribed as well. (Option 3 is wrong) Clients are taught to recognize the warning signs and symptoms of DVT (eg, new swelling, tenderness, pain below the knee) or PE (eg, shortness of breath, pleuritic chest pain). (Option 4 is wrong) A raised toilet seat facilitates sitting on and rising from the toilet without over-bending the knee. Assistive devices, such as a long-handled shoehorn, shower chair, or grab bar, are also helpful for client safety at home.

The nurse is caring for the following clients. Which client is the priority to receive additional testing and treatment? 1. Client at 11 weeks gestation with productive cough but no abdominal pain 2. Client with Alzheimer disease and new-onset restlessness and confusion 3. Client with deformed forearm, normal pulses and sensation, and pain rated 8/10 4. Client with epilepsy who had a brief seizure last night but is now alert and oriented

CORRECT ANSWER: 2 Clients with dementia (eg, Alzheimer disease) are expected to be in an alert but disoriented state. Sudden onset of restlessness and confusion are signs of mental status changes that should be investigated further. These changes are considered priority because they are often the only signs of infection (eg, pneumonia, urinary tract infection) in an older adult with dementia (Option 2 is correct). Other considerations for a sudden change in mental status include hypoxia, hypoglycemia, or stroke. These findings should be immediately reported so the client can be quickly assessed and the cause of the altered mental status treated. (Option 1 is wrong) The client at 11 weeks gestation is stable and shows no signs of complications of pregnancy. Care for this client may be safely delayed until after caring for the client with new-onset restlessness and confusion. (Option 3 is wrong) The client with a deformed forearm may have a potential fracture and needs analgesics and x-rays. However, care for the client with a stable neurovascular status may be safely delayed until after the client with new-onset altered mental status. (Option 4 is wrong) The client with epilepsy who had a seizure may not be compliant with the prescribed medication regimen. The serum drug levels should be checked, but care for this stable client may be safely delayed.

The nurse in an outpatient clinic cares for a client with primary adrenal insufficiency (Addison disease) who has been taking hydrocortisone 20 mg/day for the last 8 years. Which client data is most important to report to the health care provider? 1. Development of moon face 2. Fever of 100 F (37.8 C) for 2 days 3. Heart rate increase from 75 to 84/min 4. Weight gain of 6 lb (2.7 kg) in 3 months

CORRECT ANSWER: 2 Corticosteroid therapy is the primary classification of medications used to treat Addison disease, an adrenocortical insufficiency. Signs and symptoms of infection should be reported to the health care provider immediately. Use of corticosteroids can cause immunosuppression. Infection can develop quickly and spread rapidly. Its anti-inflammatory effects may also mask signs of infection such as inflammation, redness, tenderness, heat, fever, and edema. In addition, physiological stress such as infection can trigger Addisonian crisis, a life-threatening complication of Addison disease (Option 2 is correct). (Options 1, 3, and 4 are wrong) Tachycardia, moon face, and weight gain are also adverse effects of long-term corticosteroid therapy; however, they are not as life-threatening as infection.

The nurse is caring for a pediatric client with osteomyelitis. When the nurse enters the room to administer antibiotics, the client's parent states, "We don't believe in antibiotics Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." 2. "Please tell me your understanding of your child's condition." 3. "What type of healing practices would you prefer for your child?" 4. "Without this medication, your child can get worse and could die."

CORRECT ANSWER: 2 IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be reviewing parental knowledge regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment (Option 2 is correct). (Option 1 is wrong) Asking about beliefs regarding medications in general may help in developing a teaching plan. However, it is more important to reinforce teaching to the parent about this child's specific and immediate need for antibiotics. (Option 3 is wrong) Preferred healing practices are an important aspect of spirituality; however, the priorities are to obtain parental consent for and initiate necessary treatment. Spiritual and cultural elements may be appropriate to include after physical needs (eg, IV antibiotics) are met. (Option 4 is wrong) Although true, this statement is inflammatory and would likely cause the situation to deteriorate, possibly leading to total refusal of care by the parent. It is most effective and important to respectfully review parental knowledge and reinforce teaching to obtain consent.

The nurse responds to a neighbor's calls for help and finds the neighbor's infant choking but still responsive. Which intervention is most appropriate at this time? 1. Call 911 and begin cardiopulmonary resuscitation 2. Perform 5 back slaps followed by 5 downward chest thrusts 3. Perform a finger sweep of the mouth to assess for foreign objects 4. Place the infant on the lap and perform abdominal thrusts

CORRECT ANSWER: 2 Picture of how to do Heimlich maneuver with infants: https://imgur.com/mgwnuwh To relieve choking in a responsive infant, the rescuer should: • Hold the infant face down on the forearm with the infant's head slightly lower than the body. The rescuer's forearm is supported on the thigh to avoid compressing the infant's soft throat tissue and fontanelles. • Forcefully perform 5 back slaps between the infant's shoulder blades with the heel of the hand. Using both forearms, turn the infant face up on the forearm with the head slightly lower than the body. Forcefully provide 5 chest thrusts in a downward motion over the lower half of the breastbone using 2-3 fingers (Option 2 is correct). • Repeat the cycle until the object is expelled or the infant becomes unresponsive (Option 1 is wrong) Cardiopulmonary resuscitation is not initiated until the infant becomes unresponsive. The priority intervention for a responsive infant is to attempt to dislodge the object obstructing the airway. (Option 3 is wrong) Finger sweeps are avoided unless the object is visualized and the rescuer is able to retrieve it easily with the fingers. Performing a blind finger sweep can push a foreign object further into the airway. (Option 4 is wrong) Abdominal thrusts are used in children age 21 and adults and are not recommended in infants (ie, age <1).

The nurse reinforces teaching to a client with hand osteoarthritis whose health care provider has recommended tropical capsaicin for pain relief. Which instruction about capsaicin should the nurse reinforce to the client? 1. Apply a heating pad or warm compress for 20 minutes after applying cream 2. Apply cream to hands and wait at least 30 minutes before washing them 3. Stop using the cream if a burning or stinging sensation occurs 4. Use only if oral pain medications have been ineffective

CORRECT ANSWER: 2 Topical capsaicin cream is an over-the-counter analgesic that effectively relieves minor pain (eg, osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30 minutes after massaging the cream into the hands before washing to ensure adequate absorption (Option 2 is correct). The client should avoid contact with mucous membranes (eg, nose, mouth, eyes) or skin that is not intact, because capsaicin is a component of hot peppers which can cause a burning sensation. When applying cream to other areas of the body (eg, knee), the client should wear gloves or wash hands immediately after application. (Option 1 is wrong) The application of heat with capsaicin is contraindicated because heat causes vasodilation, which increases medication absorption and can lead to a chemical burn. (Option 3 is wrong) Local irritation (burning, stinging, erythema) is common and usually subsides within the first week of regular use. If the client experiences persistent pain, redness, or blistering, the cream should be discontinued and the health care provider notified. (Option 4 is wrong) Topical capsaicin is often used concurrently with acetaminophen or NSAIDs (eg, naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (ie, 3 to 4 times daily) for long periods (eg, weeks to months) to achieve the desired effect.

The nurse prepares to administer an intermittent bolus enteral feeding to a client with a nasogastric tube. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Aspirate and discard 50 mL of gastric residual 2. Auscultate bowel sounds prior to feeding 3. Check the tube placement marking at the naris insertion site 4. Elevate the head of the bed to 45 degrees 5. Ensure that the formula is at room temperature.

CORRECT ANSWER: 2, 3 4, 5 Before administering intermittent enteral feedings, the nurse should: • Assess bowel function (eg, auscultate bowel sounds, measure gastric residual) to evaluate feeding tolerance (Option 2 is correct). • Check the tube placement marking at the naris insertion site. Displacement of the marking indicates that the tube may have been partially pulled out (Option 3 is correct). • Elevate the head of the bed to 30-45 degrees (and keep it elevated 30-60 minutes afterward) to minimize aspiration risk (Option 4 is correct). • Confirm tube placement (eg, radiology report, gastric aspirate pH) to ensure that the tip of the tube is correctly placed in the stomach or small intestine. • Flush tube with 30 mL of water (and again after feedings) to prevent clogging • Ensure enteral feeding formula is at room temperature to prevent abdominal cramping/discomfort (Option 5 is correct). (Option 1 is wrong) Aspirated gastric residual volume (GRV) should be returned to the stomach because repeatedly discarding it may cause hypokalemia and metabolic alkalosis. Facility policy may advise holding enteral feeding for high GRVs (eg, >500 mL) to minimize aspiration risk. However, a GRV of 50 mL is not excessive and should be returned. Some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk.

The palliative care nurse is caring for a terminally ill pediatric client who does not respond to verbal stimuli. The client's parent asks, "How can you tell if my child is in pain?" Which of the following findings would the nurse describe as signs of pain? Select all that apply. 1. Blank facial expression 2. Clenched jaw 3. Groaning 4. Knees bent up to chest 5. Lying still

CORRECT ANSWER: 2, 3, 4 Go to this image for FLACC scale: https://imgur.com/bd7v2Lc The FLACC scale (face, legs, activity, cry, and consolability) can be used to recognize pain in a pediatric client who is nonverbal or obtunded (nonresponsive). According to the FLACC scale, findings that indicate pain include: • Facial grimacing or frowning, clenched jaw, open mouth, or closed eyes (Option 2 is correct) • Restless or tense leg movements, kicking, or knees bent up toward chest (Option 4 is correct) • Restless activity, including squirming, arching, jerking, or fixed (stiff) position • Crying, moaning and groaning, whimpering, or screaming (Option 3 is correct) • Inconsolability and difficulty in comforting (eg, hugging, verbal reassurance) the client (Option 1 is wrong) A pediatric client who is comfortable will usually have a blank or neutral facial expression. Grimacing, frowning, and clenching of the jaw indicate pain, based on the FLACC scale. (Option 5 is wrong) A pediatric client who is comfortable will be relaxed and lie still. Restless movements, including squirming and jerking, indicate pain based on the FLACC scale.

The clinic nurse reinforces teaching to a client with systemic lupus erythematous. Which instructions will the nurse include? Select all that apply. 1. Avoid annual influenza vaccination 2. Avoid situations that cause physical and emotional stress 3. Avoid sun exposure and ultraviolet light when possible 4. Notify the health care provider if you have fever 5. Use antibiotic soap to cleanse skin rashes

CORRECT ANSWER: 2, 3, 4 Systemic lupus erythematosus (SLE) is an autoimmune disorder (the body's immune system erroneously attacks body tissues) that results in inflammation and damage to many body parts. Symptoms vary widely among affected individuals, but most experience painful/swollen joints, extreme fatigue, skin rashes, and kidney problems. The symptoms typically appear for periods of time (called flares) alternating with periods of remission. There is no cure for SLE, but it can be treated with immunosuppressants (eg, corticosteroids) or immunomodulators (eg, hydroxychloroquine). Pneumonia and annual influenza vaccinations are recommended for those with SLE as thev are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their health care provider (Options 1 is wrong. Option 4 is correct). Both physical and emotional stress can exacerbate SLE. Therefore, clients should follow a healthy lifestyle (eg, 7-8 hours of sleep, no smoking). Balanced exercise with alternating periods of rest is recommended (Option 2 is correct). Sunlight is known to worsen the rash of SLE and should be avoided when possible (especially between 10 AM-4 PM); protective clothing and sunscreen application are recommended during periods of sun exposure (Option 3 is correct). (Option 5 is wrong.) The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided. The rash is not due to bacterial infection.

The nurse is caring for a client who had a laparoscopic cholecystectomy 3 days ago. The client's WBC count has increased from 11,200/mm³ (11.2 x 10⁹/L) to 14,600/mm³ (14.6 x 10⁹/L) over the last 24 hours. The nurse understands that which of the following assessment findings indicate potential infection. Select all that apply. 1. Client rating left shoulder pain as 4 on a scale of 0-10 2. Greenish-grey drainage noted on surgical dressing 3. Productive cough with thick, green sputum 4. Stiff abdomen with rebound tenderness on palpation 5. Warm, reddened area around the incision site

CORRECT ANSWER: 2, 3, 4, 5 Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. See image: https://imgur.com/9jzaX1U Some potential postoperative infections include: • Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3 is correct). • Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5 are correct). • Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. • Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis mav lead to sepsis and death if untreated (Option 4 is correct). (Option 1 is wrong) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery.

The nurse is reinforcing education for a client with pubic lice. Which of the following statements should the nurse include in the education? Select all that apply. 1. "Pubic lice are only passed through sexual contact." 2. "Remove nits from pubic hair with a fine-toothed nit comb." 3. "Sexual partners should also receive treatment." 4. "Wash clothes and linens with hot water." 5. "Wash pubic hair with lice treatment shampoo."

CORRECT ANSWER: 2, 3, 4, 5 Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Pubic lice are most often passed via sexual contact and feed on human blood for nourishment. Clients with pubic lice have intense itching in the affected area. The nits (ie, lice eggs) are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair (eg, chest, axilla). Clients with pubic lice should be given the following instructions: • Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5 is correct) • After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2 is correct) • Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4 is correct) • Sexual partners should also receive pubic lice treatment (Option 3 is correct) (Option 1 is wrong) Pubic lice may be passed through close contact and sharing of linens. All household members are at risk for developing a pubic lice infestation and should be screened.

A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which of the following tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output 2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 4. Increasing the irrigation rate when the urine becomes more red than pink 5. Measuring the total volume of output in the drainage collection bag

CORRECT ANSWER: 2, 3, 5 Diagram of continuous bladder irrigation: https://imgur.com/gWqCAPH Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction of urine outflow by removing clotted blood from the bladder. A 3-wav catheter is used to continuouslv infuse solution into the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag. The licensed practical nurse (LPN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UAP): • Catheter care is a routine, noncomplex task that may safely be delegated to UAP (Option 2 is correct). • Any client reports of pain or bladder spasms to UAP should immediately be conveyed to the LPN because these symptoms may indicate obstruction (Option 3 is correct). • Measuring output is routine data measurement. UP should report the volume to the LPN, who will determine the adequacy of drainage (Option 5 is correct). (Option 1 is wrong) Clots or kinks may obstruct drainage and cause a smaller volume of outflow than inflow. The nurse should calculate this difference to determine the need to reestablish patency using manual irrigation. (Option 4 is wrong) The irrigation rate should be titrated to maintain light pink outflow drainage with few clots. UAP lack the knowledge and skills necessary to titrate inflow rate or monitor drainage quality.

The nurse is assisting with a presentation on protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply. 1. A family member informs the registered nurse that the client has not been taking the prescribed metformin at home 2. An oncology nurse reviews the electronic health record of a friend in the emergency department who was the victim of a recent mass shooting event 3. The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after lunch 4. The LPN tells the unlicensed assistive personnel (UAP), who is pregnant, not to enter the room of a client with toxoplasmosis 5. The UAP tells a client that the hospital roommate will return to the room after receiving hemodialysis

CORRECT ANSWER: 2, 3, 5 The nurse is ethically and legally obligated to protect clients' privacy and maintain confidentiality of their protected health information (PHI). Any client's PHI should only be shared with health care team members directly involved in that client's care. client's electronic health record should never be accessed by staff members who are not involved in that client's care (Option 2 is correct). Report sheets used by staff often include clients' PHI and must remain with staff at all times and be securely shredded at the end of each shift (Option 3 is correct). Without the client's permission, PHI (eg, diagnoses, treatments) cannot be shared with a hospital roommate (Option 5 is correct). (Option 1 is wrong) Health information from the client or client's family members can be provided to health care staff as long as it is not done in public areas. In fact, family members often provide valuable insight into the client's lifestyle and medication regimen at home. (Option 4 is wrong) Nurses are obligated to help protect staff and visitors by ensuring implementation of appropriate infection prevention precautions. Pregnant health care workers should not be exposed to clients with teratogenic infections (mnemonic TORCH: Toxoplasmosis, Other [varicella-zoster virus/parvovirus B191, Rubella, Cytomegalovirus, Herpes simplex virus).

The nurse is caring for a client whose unborn child has been diagnosed with anencephaly. Which of the following actions are appropriate to support the client in preparation for birth? Select all that apply. 1. Avoid bringing up the newborn's prognosis to prevent upsetting the client 2. Discuss the newborn's expected appearance with the client 3. Explain to the client that grieving cannot truly begin until one cries 4. Explore the client's preferences for social and spiritual support during labor 5. Remind the client of the ability to conceive again in the future

CORRECT ANSWER: 2, 4 Anencephaly (ie, the absence of a major portion of the brain and skull of a fetus) is incompatible with life. When caring for clients expecting the birth of a child with a poor prognosis, the nurse plays an important role in assisting to coordinate care and facilitating grief and psychological adjustment. Exploring the client's preferences for social (eg, family, friends) and spiritual (eg, chaplain, clergy) support helps the nurse accommodate the client's emotional and psychological needs and create a comforting setting (Option 4 is correct). To ease anxiety related to contact with the newborn, the nurse should offer to explain the newborn's expected appearance (ie, unique physical features) and potential bonding opportunities after birth (Option 2 is correct). (Option 1 is wrong) Avoiding discussion of the client's unique situation invalidates the client's experience and does not facilitate the grieving process. (Option 3 is wrong) The nurse should encourage parents to express grief in their own way and at their own pace, which may not include crying. (Option 5 is wrong) Reminding the client of the ability to have other children in the future invalidates the condition/prognosis of the current child.

For a client with an ankle sprain, which of the following interventions should the nurse encourage the client to perform during the first 24 hours after injury? 1. Apply a heating pad to the ankle to reduce inflammation 2. Elevate the leg on pillows, with the ankle above heart level 3. Perform range-of-motion exercises to prevent stiffness 4. Take ibuprofen as prescribed for relief of pain 5. Wrap the ankle with an elastic compression bandage

CORRECT ANSWER: 2, 4, 5 A sprain is a stretch and/or tear of a ligament from trauma to a joint. RICE (rest, ice, compression, elevation) is the standard treatment. NSAIDs (eg, ibuprofen) can also be taken to reduce pain (Option 4 is correct). Nonpharmacologic interventions during the acute phase (first 24-48 hours) include: • Rest: Activity and joint movement should be limited to prevent further injury. • Ice: Cold therapy (eg, ice pack) should be applied hourly but for no more than 10- 20 minutes. Cold induces vasoconstriction, which reduces pain, inflammation, and swelling. • Compression: Pressure/compression (eg, elastic wrap, splint) can help reduce swelling (Option 5 is correct). • Elevation: The extremity should be elevated above the level of the heart to help reduce swelling (Option 2 is correct). (Option 1 is wrong) Cold therapy should be used during the acute injury phase (first 24-48 hours). After this phase, moist heat (eg, warm water soak) can be applied for 20-30 minutes at a time to reduce pain and promote healing. (Option 3 is wrong) Rest and immobilization are indicated during the first 24-48 hours. After the acute phase, the client is encouraged to use and move the joint to improve circulation and reduce swelling, as long as the joint is protected with an immobilizer (eg, brace, splint).

The client is scheduled to have a cardiac catheterization. Which of the following findings would cause the nurse to question the safety of the test proceeding? Select all that apply. 1. Elevated serum C-reactive protein level 2. History of previous allergic reaction to IV contrast 3. Prolonged PR interval on ECG 4. Received metformin today for type 2 diabetes mellitus 5. Serum creatinine of 2.5 mg/dl (221 umol/L).

CORRECT ANSWER: 2, 4, 5 Cardiac catheterization involves injection of IV iodinated contrast to assess for obstructed coronary arteries. Potential complications of IV iodinated contrast include: • Allergic reaction: Clients with a previous allergic reaction to iodinated contrast may require premedication (eg, corticosteroids, antihistamines) to prevent reaction or an alternative contrast medium (Option 2 is correct). • Lactic acidosis: When administered to clients taking metformin, IV iodinated contrast can cause an accumulation of metformin in the bloodstream, which can result in lactic acidosis. Therefore, health care providers may discontinue metformin 24-48 hours before administration of contrast and restart the medication after 48 hours, when stable renal function is confirmed (Option 4 is correct). • Contrast-induced nephropathy: lodinated contrast can cause acute kidney injury in clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 mol/L1). Therefore, clients with renal impairment should not receive iodinated contrast unless absolutely necessary (Option 5 is correct.). (Option 1 is wrong.) C-reactive protein, produced during acute inflammation, may indicate elevated risk for coronary artery disease. However, it is not an indicator of an acute cardiac event and is not a safety concern for cardiac catherization. (Option 3 is wrong.) First-degree atrioventricular block may precede more serious conditions However, clients are usually asymptomatic and do not require treatment except for stopping the causative medication (eg, beta blocker, digoxin). This would not prevent the procedure from proceeding.

The licensed practical nurse (LPN) and registered nurse (RN) are caring for a client with systemic lupus erythematosus. Which of the following tasks delegated by the N should the LPN question? Select all that apply. 1. Administering oral immunosuppressant medications 2. Initiating a transfusion of packed RBCs 3. Monitoring client vital signs and pain level 4. Obtaining a sterile urine specimen for culture 5. Planning topics for client discharge teaching

CORRECT ANSWER: 2, 5 Go to this image for the scope of practice: https://imgur.com/BVRJsgE The licensed practical nurse (LPN) should recognize that the registered nurse (RN) cannot delegate initial assessment or teaching or tasks requiring clinical judgment. The RN is responsible for creating the plan of care and preparing discharge instructions. Although the LPN can assist in monitoring the client undergoing a blood transfusion, the RN must initiate transfusions and evaluate the client receiving blood products. The LPN cannot accept delegation of tasks involving discharge teaching or initiating blood product transfusion (Options 2 and 5 are correct). (Options 1, 3, and 4 are wrong) The scope of practice for the LPN includes administering most medications (except those given as a primary IV infusion or IV push), gathering clinical data about the client (eg, auscultating lung or bowel sounds, monitoring vital signs), and performing sterile procedures (eg, urinary catheterization, specimen collection).

The nurse receives laboratory reports on four clients. Which report is most concerning and should be reported to the health care provider? 1. Client admitted with pneumonia who has a PaCO2 of 32 mm Hg 2. Client receiving warfarin for atrial fibrillation who has an INR of 2.5 3. Client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL 4. Client with chronic obstructive pulmonary disease who has a PaO2 of 85 mm Hg

CORRECT ANSWER: 3 Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL is very low (normal adult male: 14-18; normal adult female: 12-16). This client should be assessed for active bleeding and for signs associated with severe anemia (eg, tachycardia, shortness of breath). The health care provider should be notified as soon as possible (Option 3 is correct). (Option 1 is wrong) Although a normal PaCO2 is 35-45 mm Hg, clients with pneumonia, as well as those with asthma, panic attacks, and pulmonary embolism, have tachypnea. Rapid breathing causes more carbon dioxide gas (CO2) to be exhaled, thereby reducing the amount of CO, in the blood (ie, PaCO2). (Option 2 is wrong) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation. To prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's IN is therapeutic. (Option 4 is wrong) A PaO2 280 mm Hg is a normal finding. In clients with chronic obstructive pulmonary disease (COPD), CO2 becomes trapped in the lungs due to blocked airways. The body adjusts to elevated CO, levels (which trigger increased respiratory rate in clients without COPD) and then uses the amount of oxygen in the blood (eg. PaO2) to regulate breathing.

The nurse cares for a client with an established ascending colostomy. Which client statement indicates a need for further teaching? 1. "I always try to drink 3 L of water each day." (13%) 2. "I avoid eating beans, broccoli, and cauliflower." 3. "I change the appliance and bag every other day." 4. "I empty the bag when it's about one-third full."

CORRECT ANSWER: 3 Colostomies may be performed on any part of the colon. Stool becomes more solid as it passes through the colon, so drainage characteristics vary with the location of the ostomy. Ascending colostomies produce semiliquid stool. Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal area, resulting in skin irritation due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is changed too frequently. The appliance should be changed every 5-10 days (Option 3 is correct). (Option 1 is wrong) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss, placing the client at risk for fluid and electrolyte imbalance. The client is encouraged to drink plenty of fluids to prevent dehydration. (Option 2 is wrong) A client with a colostomy has few dietary restrictions except to decrease intake of odorous and gas-forming foods (eg, beans, cauliflower, onions, broccoli). (Option 4 is wrong) The ostomy bag is emptied when one-third full because leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from skin.

A client is admitted to the emergency department after a fall with dizziness and light-headedness. Blood pressure is 88/62 mm Hg, and the cardiac monitor displays the rhythm in the image. The nurse recognizes it as which rhythm? Go to the image link below for more information. Image: https://imgur.com/qPQ6jW3 1. Complete heart block 2. 1st-degree heart block 3. Sinus bradycardia 4. Sinus rhythm

CORRECT ANSWER: 3 Go to this image for more help about this question: https://imgur.com/j4xFw2a Sinus bradycardia (SB) has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate of <60/min. SB is classified as symptomatic if, in addition to a heart rate <60/min, the client experiences such symptoms as dizziness, syncope, chest pain, and hypotension. The clinical significance of B depends on how the client tolerates it. The client with symptomatic SB is first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered. A permanent pacemaker may be needed. If SB is the result of a medication (eg, beta blocker, digoxin), the drug may need to be held, discontinued, or given in a reduced dosage. (Option 1 is wrong) Complete heart block, or 3rd-degree atrioventicular (AV) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm. (Option 2 is wrong) In 1st-degree AV block, every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. (Option 4 is wrong) Sinus rhythm has a rate of 60-100/min.

The nurse is administering 5 mg oxycodone PO q6h PRN for a client who has postoperative pain. Which intervention is appropriate? 1. Evaluate client's sedation level 2 hours after administration 2. Hold the dose of medication if the client is slightly drowsy 3. Tell the client to call for assistance before getting out of bed 4. Wait to administer until client practices breathing exercises

CORRECT ANSWER: 3 Opioid analgesics (eg, oxycodone, hydromorphone, morphine) are effective for controlling moderate to severe postoperative pain. Major adverse effects include sedation, respiratory depression, and hypotension. The client is at risk for falls from sedation or hypotension and should avoid getting out of bed unassisted (Option 3 is correct). The nurse should administer opioids for adequate pain control as needed and encourage participation in postoperative exercises to prevent complications (eg, atelectasis, deep venous thrombosis, pressure injuries). (Option 1 is wrong) The nurse should evaluate pain and sedation level during the opioid's peak effect, 30-90 minutes after administration of PO oxycodone. (Option 2 is wrong) The nurse should monitor the client's pain and sedation level before opioid administration and should hold the medication if the client is too drowsy to stay awake during conversation. Holding the medication is unnecessary if the client is only slightly drowsy. (Option 4 is wrong) Postoperatively, clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing, incentive spirometry). Therefore, clients should receive pain medication before breathing exercises because uncontrolled postoperative pain may cause clients to avoid deep breathing which can lead to atelectasis and pneumonia.

The practical nurse is assisting the registered nurse with completing a health history of a client with suspected rheumatic fever. Which question is most important to ask the client in order to establish a diagnosis? 1. "Do you typically take all of your antibiotics when they are prescribed?" 2. "Has anyone in your family had rheumatic fever?" 3. "Have you recently had a streptococcal throat infection?" 4. "What has your temperature been over the past several days?"

CORRECT ANSWER: 3 See this image: https://imgur.com/GdjqBA3 Rheumatic fever (RF) is an acute inflammatory disease of the heart that can occur as a complication 2-3 weeks after streptococcal pharyngitis. RF is caused by a delayed- onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity. RF affects the heart, skin, joints, and central nervous system. Evidence of a preceding streptococcal infection with the presence of either 2 maior criteria or 1 maior and 2 minor criteria indicate a high probability of RF. (Option 1 is wrong) Failing to complete a course of antibiotics is the cause of resistant infection strains and can result in recurring illness. It could contribute to the risk for RF but is not part of the criteria for diagnosing it. (Option 2 is wrong) Family history is not a risk factor for RF. (Option 4 is wrong) Fever is a symptom of many illnesses, not just RF.

The nurse is caring for a client who is 2 days postoperative craniotomy with bone flap removal. The nurse notes clear wound drainage saturating the dressing over the incision. Which action by the nurse is most appropriate at this time? 1. Cleanse the incision site with saline and apply a new, sterile dressing 2. Mark the edges of the drainage on the dressing and continue to monitor 3. Notify the health care provider of the color and amount of drainage 4. Turn the client onto the nonoperative side using the log-rolling technique

CORRECT ANSWER: 3 A craniotomy involves incision into the cranium and is indicated for elevated intracranial pressure or removal of tumors, blood, or abscesses. Postoperative clients are at risk for developing a cerebrospinal fluid (CSF) leak from an intraoperative dural injury, which increases the risk for meningitis. Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into the drain) or from the nose or ear suggests a possible CF leak requiring immediate notification of the health care provider (HCP) (Option 3 is correct). Interventions focus on decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain placement, and surgical intervention. (Option 1 is wrong) The incision should not be re-dressed until the HCP can evaluate the wound and drainage. (Option 2 is wrong) The nurse should mark the drainage edges at least once per shift for comparison. However, a saturated dressing may indicate a CSF leak. (Option 4 is wrong) Repositioning may be indicated but is not the most appropriate action at this time. Specific client positioning postoperative craniotomy is prescribed by the HCP. The head of the bed is usually elevated approximately 30 degrees to facilitate venous drainage and prevent increased intracranial pressure. If flat positioning is prescribed, the nurse should log-roll the client to alternate between the back and the nonoperative side.

The nurse cares for a 16-year-old client experiencing an asthma exacerbation. The client's parent is visibly upset and shouts that the client smells like cigarette smoke. What is the nurse's best action? 1. Allow the client and parent to finish the conversation privately 2. Ask the parent to leave the room until able to remain calm 3. Redirect the parent to encourage the client to perform deep breathing techniques 4. Reinforce education about the importance of smoking cessation

CORRECT ANSWER: 3 An asthma exacerbation occurs when a stimulus (eg, allergen [smoke], stress, illness) triggers acute inflammation and bronchoconstriction, causing shortness of breath and wheezing. Fear of not being able to breathe can cause severe anxiety, which may further exacerbate asthma symptoms (eg, hyperventilation). The nurse should reduce environmental stimuli and encourage coping mechanisms (eg, breathing exercises). If family members' actions are overstimulating an anxious client, the nurse should provide education about the importance of a calm environment and attempt to redirect the family member to assist in the client's care as able (eg, holding the client's hand, encouraging deep breathing techniques) (Option 3 is correct). (Option 1 is wrong) Allowing the parent's behavior to continue contributes to the stressful environment and the client's anxiety. (Option 2 is wrong) Asking the client's parent to leave without attempting to redirect first may only escalate the problem. An attempt to redirect and calm the parent and client would be the least invasive intervention to attempt first. (Option 4 is wrong) This client requires education about the importance of smoking cessation; however, the nurse should provide education in a calm environment once the client is stable.

The nurse receives report on four clients. Which client should the nurse see first? 1. Client who is confused and trying to pull out the indwelling urinary catheter 2. Client who is scheduled for hydrotherapy and has removed the dressing over an infected foot ulcer 3. Client whose dressing is saturated with bright red blood 2 hours after foot amputation surgery 4. Client with an arteriovenous graft who is experiencing new-onset pain and redness at the site

CORRECT ANSWER: 3 Following amputation, clients are at risk for hemorrhage. A small amount of bleeding at the amputation site is expected postoperatively, but a saturated dressing indicates excessive blood loss. The nurse should immediately apply a pressure dressing and notify the health care provider (Option 3 is correct). Care for other clients may be safely delayed until the client who is actively bleeding is stabilized. (Option 1 is wrong) A client who is confused and attempting to remove a line or drain is at risk for injury. Until mental status improves or invasive lines and tubes are discontinued, this client may require reorientation and one-to-one observation. (Option 2 is wrong) An infected foot ulcer should remain covered to protect healing tissue and contain drainage. Dressings are changed at regular intervals and removed intermittently for wound assessment or therapies (eg, debridement, hydrotherapy [whirlpool bath]). A dressing that falls off or is removed prior to hydrotherapy can be temporarily replaced with a sterile towel or gauze bandages, with a new dressing applied after therapy. (Option 4 is wrong) A client whose arteriovenous graft has signs of infection (eg, erythema, fever) is at risk for thrombosis, graft failure, or systemic infection. This client requires evaluation by the health care provider and possible surgical repair.

A client is seen following a motor vehicle collision. An IV infusion of 1 L of normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which finding alerts the nurse to the development of hypovolemic shock? 1. Jugular venous distension 2. Mean arterial pressure of 65 mm Hg 3. Urine output of 28 mL/hr 4. Warm, flushed skin

CORRECT ANSWER: 3 Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, bleeding, vomiting, diarrhea) or a relative (eg, third spacing) fluid loss. Reduced intravascular volume results in decreased venous return, stroke volume, and cardiac output; inadequate tissue perfusion; and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: • Change in mental status • Tachycardia with thready pulse • Cool, clammy skin • Oliguria • Tachypnea Decreased urine output (<30 mL/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function (Option 3 is correct). (Option 1 is wrong) Jugular venous distension occurs with increased central venous pressure and intravascular volume. (Option 2 is wrong) A mean arterial pressure of 70-105 mm Hg is considered normal, and >60 mm Hg is required for adequate tissue perfusion to vital organs (brain, coronary artery). (Option 4 is wrong) Warm, flushed skin can be an early sign of septic or neurogenic shock but is not associated with hypovolemic shock.

A nurse is assisting in the admission of a child with leukemia to the pediatric unit. Which client could share a room with this child? 1. A client recovering from a ruptured appendix 2 A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever

CORRECT ANSWER: 3 Leukemia, the most common form of childhood cancer, is characterized by unrestricted proliferation of abnormal white blood cells (lymphoblasts), resulting in depression of normal bone marrow activity (ie, myelosuppression). Neutropenia and immaturity of white blood cells places the client at risk for infection. If a client with leukemia must share a semiprivate room, the other client in the room should not have an infectious illness. It would be appropriate for a client with leukemia to share a room with a client with minimal change nephrotic syndrome, a noninfectious condition of the glomeruli that poses no risk to the client with leukemia (Option 3 is correct). (Option 1 is wrong) Appendicitis may be a result of an infectious process, and a ruptured appendix can lead to peritonitis and sepsis. A client recovering from a ruptured appendix poses a risk for infection to the client who has leukemia. (Option 2 is wrong) Clients with cystic fibrosis (CF) have pulmonary complications due to thickening of the mucus that traps bacteria. The tracheobronchial tree becomes colonized with bacteria, and recurrent respiratory infections are a lifelong problem. client with CF poses a risk for infection to the client who has leukemia. (Option 4 is wrong) Rheumatic fever occurs following pharyngitis caused by group A beta- hemolytic Streptococcus. A client with rheumatic fever poses a risk for infection to the child with leukemia.

The nurse is caring for 4 clients with type 1 diabetes mellitus. Which of these clients should the nurse see first? 1. 5-year-old whose capillary blood glucose is 72 mg/dL 2. 7-year-old who ate 100% of breakfast but is refusing to eat lunch 3. 9-year-old who is irritable and sweating after physical therapy 4. 11-year-old whose prescribed dose of insulin glargine is 30 minutes overdue

CORRECT ANSWER: 3 Symptoms of hypoglycemia: - Sweating & pallor - Irritability - Tremors & weakness - Tachycardia - Drowsiness - Hunger Hypoglycemia (blood glucose <70 mg/dL) presents an immediate danger to the client as life-threatening neurologic impairment (eg, lethargy, seizures, coma) can occur when the brain becomes glucose depleted. If a client with diabetes has symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger), the nurse should immediately assess the client, check capillary blood glucose, and provide a simple carbohydrate snack that can be digested rapidly (eg, juice, soft drink, candy). (Option 1 is wrong) A client with blood glucose of 72 mg/dL should be monitored for hypoglycemia: blood glucose should be reassessed within 30 minutes. However, a client displaying symptoms of hypoglycemia should be assessed first. (Option 2 is wrong) Skipping a meal could result in hypoglycemia. However, a client who ate earlier in the day and is not displaying symptoms of hypoglycemia is not the highest priority. (Option 4 is wrong) Insulin glargine (Lantus) is a long-acting (basal) insulin with a duration of 24 hours. It has no peak and is not used to correct acute hyperglycemic events. This medication should be given as soon as possible, but this client does not take priority over a client with symptomatic hypoglycemia.

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next? 1. Check for a carotid pulse for at least 10 seconds. 2. Provide rescue breaths at a rate of 10-12/min. 3. Resume chest compressions at a rate of 100/min. 4. Use the jaw-thrust maneuver to assess the airway.

CORRECT ANSWER: 3 The basic life support sequence is compressions, airway, and breathing (mnemonic - CAB). High-quality CPR is associated with improved client outcomes and begins with high-quality chest compressions (ie, 100-120/min, 2-2.4 in [5-6 cm] deep). Any unwitnessed collapse should be treated with 2 minutes of CPR, followed by activating the emergency response system and obtaining an automated external defibrillator. If no shock is advised, the nurse should resume high-quality chest compressions immediately (Option 3 is correct). (Option 1 is wrong.) Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall. (Option 2 is wrong.) Rescue breaths every 5-6 seconds (10-12 breaths/min) are given to clients who have a pulse but are not breathing normally. For clients with no pulse, the nurse should deliver cycles of 30 compressions followed by 2 rescue breaths. (Option 4 is wrong.) The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing. Assessing the airway is not indicated at this time.

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider? 1. Breast tenderness 2. Generalized weight gain 3. Leg swelling 4. Nausea and vomiting

CORRECT ANSWER: 3 Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider (HCP) immediately (Option 3 is correct). The client should also be taught smoking cessation and diabetes management, and to avoid long periods of immobilization to further decrease the risk of thrombus formation. (Option 1 is wrong) Breast tenderness and enlargement are common, expected side effects of estrogen therapy. (Option 2 is wrong) Generalized weight gain during estrogen therapy is caused by fluid retention and is generally mild. However, if weight gain with cardiovascular symptoms (eg, pedal edema) occurs, the HCP should be notified (Option 4 is wrong) Nausea and vomiting can occur with estrogen therapy and may be remedied with dosage adjustments or taking oral estrogen with food.

The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply. 1. Check the pins every 4 hours and turn the bolt clockwise to tighten loose pins 2. Maintain client on bed rest until the device is removed 3. Notify the registered nurse immediately of pin site drainage or increased pain 4. Perform neurovascular checks every 2-4 hours for 24 hours 5. Perform sterile pin care per institutional policy

CORRECT ANSWER: 3, 4, 5 An external fixator is a device composed of metal pins (screws) placed into the bone to stabilize it; these are positioned above and below the fracture through small incisions in the skin and muscle. After the pins are placed, they are attached to an adjustable external rod or frame outside the skin. Infection of the pin tract is a major complication associated with the device. The nurse should notify the supervisory registered nurse (RN) immediately of any systemic (eg, fever) or localized (eg, pin site drainage, pain, erythema, or swelling) signs of infection. Prompt antibiotic therapy is necessary as a localized pin tract infection can progress to osteomyelitis, an infection of bone (Option 3 is correct). Infection can also cause the pins to loosen, potentially leading to bone displacement. The nurse should perform meticulous sterile pin care per institutional policy, often with 1/2-strength hydrogen peroxide and normal saline or chlorhexidine solution (Option 5 is correct). Regular monitoring of neurovascular status (eg, distal pulses, color, capillary refill, sensory and motor function) is important after fixator placement as pin placement may compromise the integrity of nerves and vessels (Option 4 is correct). (Option 1 is wrong) Loosening of the pins can compromise bone alignment and healing. The nurse should assess the pins reqularly and notify the supervisory RN if they are loose but should not turn the bolts to tighten. (Option 2 is wrong) An external fixator device allows for early ambulation with the device in place, increases independence while maintaining bone immobilization, and prevents immobility hazards.

The nurse reinforces teaching about home care for the family members of a client admitted after a suicide attempt. Which of the following instructions are appropriate for the nurse to include? Select all that apply. 1. "Avoid discussion about suicide because it may increase the risk for additional attempts. 2. "If the client mentions self-harm, change the topic of conversation to a positive subject." 3. "Maintain a list of community resources and a suicide hotline for quick reference." 4. "Remove excess and unused medications, firearms, and knives from the home." 5. "Sudden positive outlook or calmness may indicate an impending suicide attempt.

CORRECT ANSWER: 3, 4, 5 Clients who have attempted suicide are at risk for further attempts. When providing education about care of a client with suicidal ideations, the nurse should encourage follow-up with the health care provider (HCP), enrollment in community-based counseling, and adherence to the prescription regimen (eg, antidepressant medications). The nurse should educate family members about measures to promote the client's safety, including: • Maintaining a list of phone numbers for community resources and suicide hotlines to which the client or family members can quickly refer in moments of acute suicidality (Option 3 is correct) • Creating a safe home environment by removing potentially dangerous items (eg, excess medications, firearms, knives) (Option 4 is correct) • Recognizing that a sudden positive outlook or calmness may be a sign that the client has developed a plan for suicide and feels hopeful about having resolution (Option 5 is correct) (Options 1 and 2 are wrong) The client's risk for acting on suicidal thoughts may be reduced, not increased, when provided the opportunity to express thoughts and related feelings. All communication about self-harm should be addressed directly with therapeutic communication.

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home. Which of the following instructions related to this medication should the nurse reinforce when demonstrating application of the patch? Select all that apply. 1. Apply a heating pad over the patch to aid drug absorption 2. Cut the patch in half before application if less medication is needed 3. Fold the used patch in half so that edges adhere and immediately discard 4. Place patch over source of pain for maximum effectiveness 5. Remove old patch when applying a new patch every 72 hours

CORRECT ANSWER: 3, 5 Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Used patches must be folded and discarded immediately, because some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) because accidental exposure is potentially fatal for children, pets, and caregivers (Option 3 is correct). Patches are replaced every 72 hours, and used patches must be removed before applying a new one (Option 5 is correct). (Option 1 is wrong) Heat (eg, heating pad) should not be placed over a patch because this accelerates absorption. (Option 2 is wrong) Cutting a transdermal patch damages the drug-delivery system, results in administration of an imprecise dose, and risks exposure to the person cutting the patch. (Option 4 is wrong) Transdermal patches should be applied to an area of flat, intact skin (eg, upper back, chest) to prevent accidental removal. The site should be clean, with little hair. Unlike transdermal patches, topical analgesic patches (eg, lidocaine, capsicum) deliver drug locally and are placed near the site of pain.

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply. 1. "I use a soft-bristle toothbrush and mild mouth rinse." 2. "I enjoy walking and wear nonskid footwear for safety." 3. "I use a safety razor and gentle shaving cream." 4. "Sometimes I get constipated, so I have been taking docusate." 5. "When I have a headache, I take over-the-counter ibuprofen."

CORRECT ANSWER: 3, 5 Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with IP have a platelet count <150,000/mm° (150 x 10%/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: • Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1 is wrong). • Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low-impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). • Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding. and hemorrhoids (Option 4 is wrong). (Option 3 is correct) Clients with IT should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5 is correct) Clients with IT should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management.

A nurse is caring for a client who was admitted following a suicide attempt. Which client statement is most concerning? 1. "I don't think that I will ever be okay again." 2. "I feel so angry because I failed at my attempt." 3. "I have been sleeping all the time lately." 4. "Very soon everything will be much better."

CORRECT ANSWER: 4 A client who has attempted suicide is at risk for repeated attempts and death by suicide. After beginning treatment (eg, antidepressant therapy), clients are at even higher risk because they begin to have more energy, allowing them to follow through with suicide plans. The nurse should assess the client's verbal and nonverbal cues and recognize that a sudden positive outlook is the most concerning sign that the client may have determined a plan for suicide and is at peace with it (Option 4 is correct). The nurse should directly ask the client about a suicide plan. (Options 1 and 2 are wrong) Hopelessness (belief that a situation is intolerable, inescapable, or unending) and anger are expected reactions to an unsuccessful suicide attempt. The nurse should encourage clients to share feelings to build rapport, support the client, and decrease feelings of isolation during an acute suicidal episode. (Option 3 is wrong) It is common for clients with depression and recent suicidal ideation to have either insomnia or excessive sleepiness. If sleep disturbances continue after the therapeutic effect of prescribed antidepressants should have occurred, the medication regimen may require adjustment.

A client with active herpes lesions has new prescriptions for oral acyclovir and topical lidocaine. What discharge teaching will the nurse reinforce to the client? 1. Adhesive bandaging should remain on the lesions to prevent virus shielding 2. Blood tests will be drawn to ensure that the virus is eradicated 3. Condoms should be used during intercourse until the lesions are healed 4. Gloves should be used to apply the medication to the lesions

CORRECT ANSWER: 4 Go to the image: https://imgur.com/GZM9I6e Acyclovir (Zovirax), famciclovir, and valacyclovir are commonly used to treat herpes infection as they shorten the duration and severity of active lesions. Genital herpes is a sexually transmitted infection caused by a herpes simplex virus and is highly contagious, especially when lesions are active. It remains dormant in the body even when active lesions are healed; however, it is still contagious, even when dormant. The infection can be spread to other people or other parts of the body via skin-to-skin contact; therefore, gloves should be used when applying topical antiviral or analgesic (eg, lidocaine) medications. There is no cure for genital herpes; treatment is aimed at relieving symptoms and preventing the spread of infection. (Option 1 is wrong) Herpetic lesions should be kept clean and dry. They can be cleansed with warm water and soap or other solutions. Bandages should not be applied to the lesions. (Option 2 is wrong) There is no cure for herpes infection, and recurrence of active lesions is common. Some clients may need long-term suppressive therapy. (Option 3 is wrong) During periods of active lesions, barrier contraception is not sufficient to prevent the spread of infection; therefore, abstinence from sexual intercourse is indicated. Condoms should be used during periods of dormancy due to viral shedding.

The charge nurse is making assignments for the shift. Which assignment should the practical nurse question? 1. Client who had surgery yesterday and needs a sterile dressing change and frequent oral analgesics 2. Client with an established tracheostomy and a prescription to titrate supplemental oxygen as needed 3. Client with an existing colostomy that requires irrigation and placement of a new pouch 4. Client with newly diagnosed diabetes requiring discharge teaching regarding insulin administration

CORRECT ANSWER: 4 Go to this image for the scope of practice: https://imgur.com/UT4a16f Assignments accepted by practical nurses (PNs) should be within the scope of practice outlined by their respective state boards of nursing. In general, the PN should provide safe, focused nursing care to clients with predictable needs. The PN may reinforce teaching that the registered nurse (RN) has initiated. The newly diagnosed diabetic client requires in-depth teaching regarding medication and blood glucose monitoring that has not been previously provided by the RN (Option 4 is wrong). (Options 1, 2, and 3 are wrong) The PN should be able to provide safe and effective care using fundamental nursing skills to stable clients with routine and predictable needs. Care of established colostomies or tracheostomies and sterile dressing changes require nursing discretion and skill (eg, sterile gloving, titration of continuous oxygen), but these clients are physiologically stable.

The client has metastatic cancer, and a living will on file indicates that the client does not want cardiopulmonary or pharmacologic resuscitation. The client is brought to the emergency department with respirations of 4/min and a heart rate of 20/min. What action does the nurse anticipate? 1. Administer manual breaths to the client with a bag-valve-mask apparatus 2. Ask the client if any changes have been made to the living will 3. Identify and call the client's durable power of attorney for health care 4. Provide the client with comfort measures and call the next of kin

CORRECT ANSWER: 4 The 2 most common forms of advance directives are living wills and durable powers of attorney for health care. When available, these take effect when the client cannot self-advocate or make decisions (eg, serious injury, terminal illness, dementia, end of life). A living will is a legal document representing the client's specific wishes regarding medical care (eg, life-saving measures); it is written in advance of the client's inability to make decisions. If a client has a living will, it should be honored (Option 4 is correct). (Option 1 is wrong) Manual ventilation is part of cardiopulmonary resuscitation. This would go against the client's desires; however, a nasal cannula can be applied for comfort. (Option 2 is wrong) If the client indicates a change of mind, it should be honored. However, a client with respirations of only 4/min and a heart rate of 20/min does not have adequate perfusion and oxygenation to the brain and is no longer able to make decisions. The client's wishes were indicated when the client was able to think clearly, and these wishes should be honored at this time. (Option 3 is wrong) A durable power of attorney makes medical decisions on behalf of the client, taking into consideration the situation and the client's known wishes. However, a durable power of attorney is not required if the client has a living will.

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the unlicensed assistive personnel prior to delegating interventions related to the client's activities of daily living? 1. "Be aware of the client's shoulder weakness and provide support as needed." 2. "Ensure that the client sits upright and tucks the chin when swallowing food." 3. "Explain all procedures in step-by-step detail before performing them. 4. "Make sure the items needed by the client are within reach."

CORRECT ANSWER: 4 The client has an impairment of cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls Therefore, when instructing the unlicensed assistive personnel (UP) about helping the client with activities of daily living, the nurse emphasizes the need to keep items at the bedside within the client's reach (Option 4 is correct). (Option 1 is wrong) Weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Impairment of CN VIII does not affect shoulder strength. (Option 2 is wrong) Dysphagia may occur with impairment of CN IX (glossopharyngeal) and CN X (vagus), not CN VIII. Instructing the client to tuck the chin while eating is a technique for those who have difficulty swallowing. (Option 3 is wrong) Impairment of visual acuity occurs with disorders affecting CN II (optic). Because impairment of CN VIII does not affect visual acuity, providing a detailed, step- by-step explanation of procedures may be helpful but is not the most appropriate instruction to give the UAP.

Which client should the nurse see first? 1. Client with atrial fibrillation with a new prescription for warfarin? 2. Client with chronic obstructive pulmonary disease with an oxygen saturation of 91% 3. Client with postoperative pain rated as 8 on a scale of 0-10 4. Client with third-degree heart block with a pulse of 42/min

CORRECT ANSWER: 4 Third-degree atrioventricular (AV) block, or complete heart block, occurs when electrical conduction from the atria to the ventricles is blocked, causing decreased cardiac output (eg, dizziness, syncope, mental status changes, heart failure, hypotension, bradycardia). The client with third-degree AV block is a high priority, because the client may decompensate to cardiogenic shock and even periods of asystole. Treatment includes administration of atropine and temporary pacing (eg, transcutaneous) until a permanent pacemaker can be placed (Option 4 is correct). (Option 1 is wrong) Atrial fibrillation puts clients at risk for development of atrial thrombi, which can embolize and cause a stroke. Administration of warfarin (a long-term anticoagulant) is important to prevent thrombus formation: however, symptomatic third- degree AV block is a higher priority. (Option 2 is wrong) Clients with chronic obstructive pulmonary disease often have pulse oximetry readings that are lower than normal (eg, 91%). The goal in this client population is to keep the oxygen saturation >90%. (Option 3 is wrong) The client experiencing severe postoperative pain should be assessed for surgical complications (eg, infection), and the pain should be treated (eg, hydrocodone). However, severe pain does not take priority over third-degree AV block. The nurse can see the client as soon as possible or ask another nurse for help.

The nurse is caring for a pregnant client with a positive urine drug screen. When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!" What is the best response by the nurse? 1. "If you leave without receiving treatment, you and your baby will be in danger." 2. "If you stay and continue to receive treatment, no one will call the police." 3. "You have the right to refuse treatment and can leave after you fill out a form. 4. "You should stay. You and I both have the same goal: to keep you and your baby safe."

CORRECT ANSWER: 4 Violence (eg, offensive language, physical aggression) may be precipitated by substance abuse, emotional stress, mental instability, or altered mentation from medical conditions. To de-escalate a violent situation and ensure the safety of the client and others, the nurse should: - Remove other clients from the area. - Keep a safe distance from the client with a clear path to safety. - Maintain a calm demeanor, keeping the hands visible. - Use clear, nonthreatening communication focusing on mutual goals (Option 4 is correct). (Option 1 is wrong) During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is no longer in crisis. (Option 2 is wrong) Bargaining with the client by providing false reassurance (eg, promising not to involve authorities) is nontherapeutic and may cause the client to lose trust in the nurse. (Option 3 is wrong) The client with impaired thinking from substance abuse is legally incompetent to leave the hospital against medical advice.

A pregnant client in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? 1. "If you experience Zika symptoms, notify your health care provider." 2. "Take precautions against mosquito bites throughout the trip." 3. "You are not far enough along for the Zika virus to affect your baby." 4. "You should consider postponing your trip until after you have the baby."

CORRECT ANSWER: 4 Zika virus is transmitted via mosquitoes, sexual contact, and infected bodily fluids Zika causes viral symptoms (eg, low-grade fever, arthralgias) and has been shown to cause microcephaly, developmental dysfunction, and encephalitis in babies born to Zika-infected women. Women who are attempting to conceive and those who are pregnant are encouraged to avoid travel to areas affected by Zika until after birth (Option 4 is correct). For clients currently living in a Zika-affected area, proper mosquito precautions (eg, insect repellant containing DEET) and safe sex practices (eg, barrier methods) should be utilized, and routine Zika testing may be provided. (Option 1 is wrong) Although this statement is true, it does not provide education on avoiding Zika infection. Waiting until symptoms are present does not address preventing fetal exposure and possible birth defects. (Option 2 is wrong) Current guidelines recommend that pregnant women avoid travel to Zika- affected areas completely. In addition, mosquitoes are not the only mode of transmission for the virus. (Option 3 is wrong) Zika virus can affect women in all stages of pregnancy.

A nurse is assisting in the postoperative care of a client who had a heart transplant. What intervention is most important to implement? 1. Apply sequential compression devices 2. Assist client in changing positions slowly 3. Encourage coughing and deep breathing 4. Use careful handwashing and aseptic technique

CORRECT ANSWER: 4 Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, tacrolimus) to prevent organ rejection, placing them at high risk for life-threatening infection. Postoperative infection control measures incorporate strict handwashing, aseptic technique for procedures, and possible reverse isolation (Option 4 is correct). (Option 1 is wrong) Sequential compression devices are used to prevent postoperative deep venous thrombosis (DVT). Although DVT prophylaxis is important for all clients postoperatively, it does not take priority over infection prevention for clients who are immunosuppressed. (Option 2 is wrong) The newly transplanted heart is enervated from the client's autonomic nervous system and is unable to appropriately respond to increased physical demands (eg, increased heart rate with activity). The client should be taught how to avoid orthostatic hypotension (eg, change positions slowly); however, this does not take priority over infection prevention. (Option 3 is wrong) Coughing, deep breathing, and incentive spirometry are interventions important for prevention of atelectasis and pneumonia. However, strict implementation of hand hygiene and aseptic technique is the most effective way to reduce the risk of all acquired infections in clients who are immunocompromised.

The nurse is reinforcing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which information is appropriate for the nurse to include? 1.. After symptoms resolve, levothyroxine may be discontinued 2. Levothyroxine should be taken in the evening with a prenatal vitamin 3. Medication dose will remain the same throughout pregnancy 4. Symptoms should begin improving within 4 weeks of starting levothyroxine

CORRECT ANSWER: 4 Hypothyroidism during pregnancy increases risk for other complications of pregnancy (eg, preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option 4 is correct). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option 1 is wrong) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option 2 is wrong) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option 3 is wrong) The client's dose of levothyroxine may need to be increased throughout pregnancy. TSH levels should be monitored closely during pregnancy, because these results may indicate the need for dosing changes of levothyroxine.

The nurse working in a long-term health care facility is caring for a client with a low-grade fever who reports diarrhea for 4 days. Which intervention is most appropriate? 1. Encourage rest and fluids and administer acetaminophen for the fever 2. Give 2 tablets of loperamide now and 1 tablet after each loose stool 3. Offer client bulk-forming foods such as whole-grain bread 4. Report the findings to the supervising registered nurse

CORRECT ANSWER: 4 Most episodes of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or that is accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication adverse effects, or laxative overuse. The HP will assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridioides [formerly Clostridium] difficile) (Option 4 is correct). (Option 1 is wrong) Rest, fluids, and acetaminophen are helpful and would be the primary choice in diarrhea that lasts ≤48 hours and has no other symptoms. (Option 2 is wrong) Loperamide is a synthetic opioid used as an antidiarrheal. It slows peristalsis and subsequently increases fluid absorption. It should not be used longer than 2 days or if fever is present because retention of bacteria or toxins inside the colon can make the process worse (eg, toxic megacolon). (Option 3 is wrong) Eating bulk-forming foods may be helpful with diarrhea; however, this option does not address the underlying problem causing the 4 days of diarrhea and fever. The client should be seen by the HCP.

The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention? 1. Abdominal breathing with 15-second pauses in a sleeping newborn 2. Apical pulse of 165/min in a newborn who is crying 3. Heart murmur in a newborn who is feeding appropriately 4. Respirations of 68/min with grunting in a newborn after cesarean birth

CORRECT ANSWER: 4 Newborns normally have respirations of 30-60/min. Sustained tachypnea, nasal flaring, retractions, and grunting are signs of newborn respiratory distress. Respiratory distress may be related to retained amniotic fluid in the lungs (more common following cesarean birth), meconium aspiration, or infection (Option 4 is correct). The newborn should be continuously monitored and may require respiratory support (eg, supplemental oxygen, noninvasive positive pressure ventilation) until the underlying cause is corrected and respiratory status stabilizes. (Option 1 is wrong) Characteristics of normal newborn respiratory patterns may include shallow, irregular, or abdominal respirations. Periodic pauses in respirations lasting <20 seconds often occur during the rapid eye movement (REM) cycle and decrease with age. (Option 2 is wrong) The apical heart rate should be counted for a full minute and is normally 100-160/min. Stimulated states (eg, crying, activity) may cause increased heart rate (ie, 2180/min), respirations, and blood pressure. The nurse should recheck vital signs when the newborn is calm. (Option 3 is wrong) A physiologic heart murmur is expected in the first 48 hours of life during the transition from fetal to neonatal circulation. Newborns with congenital heart disease have a pathologic heart murmur associated with other abnormal findings (eg, vital signs, cyanosis, poor feeding).

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1. Haemophilus influenza type b vaccine for a client allergic to penicillin 2. Hepatitis A vaccine for a client with a "cold" and temperature of 99 F (37.2 C) 3. Pneumococcal vaccine for a client with local swelling after last immunization 4. Varicella-zoster vaccine for a client recently diagnosed with leukemia

CORRECT ANSWER: 4 Vaccines should be administered at specific ages and intervals as passive placental immunity decreases and the child's immune system develops enough to produce antibodies in response to the vaccine. The nurse should always assess for allergies to vaccine components (eg, neomycin, gelatin, yeast) and screen for an allergy to latex (eg, lips swelling from contact with bananas, kiwis, or latex balloons). Most vaccines do not contain any latex; however, the nurse should use latex free equipment if an allergy is noted. Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella, rotavirus) due to the body's limited ability to prevent virus multiplication, which could result in a possible severe vaccine-induced illness (Option 4 is correct). Passive immunization, by transfusing immunoglobulins made from another person who has been vaccinated against an antigen, may be the only option for children with severe immunosuppression. Common misperceptions of contraindications to immunization: • Penicillin allergy. Allergies to nonvaccine components are not contraindications to immunization. No vaccines available in the United States contain penicillin (Option 1 is wrong). • Mild illness (with or without an elevated temperature) (Option 2 is wrong) • Mild site reactions (eg, swelling, erythema, soreness) (Option 3 is wrong) • Recent infection exposure • Current course of antibiotics

The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply. 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

CORRECT ANSWER: 4, 5, 6 Mycobacterium tuberculosis (TB) is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). Clinical manifestations of TB, regardless of location, include: • Low-grade fever • Night sweats • Anorexia and weight loss • Fatique Additional symptoms depend on the location of the infection. Pulmonary TB typically includes: • Cough • Purulent or blood-tinged sputum (hemoptysis) • Shortness of breath • Dyspnea Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1 is wrong) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2 is wrong) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3 is wrong) Back pain is a symptom of spinal TB.

The nurse is preparing to change a central venous catheter dressing using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used 1. Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing 2. Cleanse the site with CHG for at least 30 seconds using friction; allow to air-dry completely 3. Discard the clean gloves, perform hand hygiene, and apply sterile gloves 4. Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves 5. Remove old dressing and CHG-impregnated patch; inspect insertion site

CORRECT ORDER: 4, 5, 3, 2, 1 Central line dressing changes are sterile procedures and must be performed correctly to prevent infection. Steps should be performed in the following order: • Perform meticulous hand hygiene. • Don a surgical mask and apply a mask to the client (or ask the client to turn the head away from the dressing). Apply clean gloves (Option 4). • Remove the old dressing, including the chlorhexidine gluconate (CHG)-impregnated patch, making sure not to touch the insertion site (Option 5). • Inspect the site for drainage, erythema, heat, or inflammation. • Discard the clean gloves, perform hand hygiene, and apply sterile gloves (Option 3). • Cleanse the site with antimicrobial solution (eg, CHG), in a back-and-forth motion using friction, for at least 30 seconds; allow to air-dry completely (Option 2). • Apply the CHG-impregnated patch over the catheter insertion site and cover with the sterile transparent dressing (or use a CHG gel transparent dressing), making certain the edges of the dressing adhere well (Option 1). • Sign, date, and initial the dressing. • Document the procedure.

The nurse reviews the laboratory results for an adult male client admitted with septic shock. Which value requires the most immediate action? 1. BUN level of 44.4 mg/dL 2. Creatinine level of 1.1 mg/dL 3. Hematocrit of 48% 4. Potassium level of 5.9 mEq/L

CORRECT ANSWER: 4 Serum potassium (normal: 3.5-5 mEq/L) may increase in clients with progressive shock as a result of metabolic acidosis, which can cause a shift of potassium from the intracellular to the extracellular compartments. Because the most significant manifestation of hyperkalemia is a disturbance in cardiac conduction and the development of cardiac dysrhythmias, correction of the imbalance requires immediate action (Option 4 is correct). (Option 1 is wrong) Although a BUN level of 44.4 mg/dL (normal: 6-20 mg/dL) is elevated, it does not require immediate action. It can increase in clients in a shock state as the result of decreased perfusion to the kidneys (prerenal azotemia) or extrarenal factors such as dehydration, fever, or gastrointestinal bleed. (Options 2 and 3 are wrong) Normal creatinine level is 0.6-1.3 mg/dL and normal hematocrit level for an adult male is 39%-50%. Normal laboratory values require no intervention.

The nurse is caring for a client with a history of heroin use. Which clinical finding may indicate withdrawal? 1. Constipation 2. Constricted pupils 3. Drowsiness 4. Tachycardia

CORRECT ANSWER: 4 Go to this image for information about opioid withdrawal: https://imgur.com/Gn43cGG Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous svstem activity as the depressant effect of the opioid wanes (Option 4 is correct). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3 are wrong) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects.

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the health care provider? 1. Fasting blood glucose of 99 mg/dL 2. Serum creatinine of 2 mg/dL 3. Serum potassium of 3.9 mEq/L 4. Serum sodium of 140 mEq/L

CORRECT ANSWER: 2 Serum creatinine (normal: 0.6-1.2 mg/dL for males and 0.5-1.1 mg/dL for females). which provides an estimate of the glomerular filtration rate, is an indicator of kidney function. A level of 2 mg/dL may indicate diabetic nephropathy, a complication of diabetes mellitus associated with microvascular damage of blood vessels in the kidney (Option 2 is correct). Early treatment and tight control of blood glucose levels help prevent progressive renal injury in clients with diabetic nephropathy. (Option 1 is wrong) Normal serum fasting blood glucose is 74-106 mg/dL (Option 3 is wrong) Normal serum potassium is 3.5-5.0 mEq/L (Option 4 is wrong) Normal serum sodium is 136-145 mEq/L.

The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1. "I can stop taking these HIV drugs once my viral levels are undetectable." 2. "I need to get tested regularly for sexually transmitted infections because I'm sexually active." 3. "I should use latex condoms and barriers when having anal, vaginal, or oral sex." 4. "I won't stop injecting drugs, but I will use a needle exchange program."

CORRECT ANSWER: 1 Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1 is correct). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance. (Option 2 is wrong) Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Reqular testing (21 time annually) and treatment for STIs are recommended. (Option 3 is wrong) Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission. (Option 4 is wrong) IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange programs.

The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client to select food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sauteed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans

CORRECT ANSWER: 1 Chronic pancreatitis is an inflammatory disease that causes the tissue of the pancreas to become fibrotic, impairing pancreatic endocrine and exocrine functions. Chronic pancreatitis is most commonly caused by alcohol abuse, but may also result from biliary tract disease (eg, cholelithiasis), autoimmune processes, or cystic fibrosis. Lifestyle modification is a key component of treatment and includes cessation of alcohol and smoking as well as dietary modifications. Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats. Therefore, clients should follow a low-fat diet, with the degree of fat restriction based on the severity of disease. Due to lack of endogenous lipase, oral supplementation of pancreatic enzymes is often required before meals. To avoid exacerbating gastric discomfort, the client should avoid spicy and gas-forming foods. Low-fat food choices include lean meats (eg, fish, chicken), nonfat dairy products, vegetables/fruits prepared without added fat, and low-fat carbohydrates (eg, green peas) (Option 1 is correct). (Options 2, 3, and 4 are wrong.) Most dairy-containing foods (eg, macaroni and cheese, creamed soup), baked goods (eg, biscuits, cornbread, croissants), and some meats (eg, roast beef) are high in fat. Refried beans also contribute to gas formation and promote bloating. Salsas and spicy foods should be avoided.

The nurse caring for a client who had a femoral angioplasty finds the client's leg pale, cool, and pulseless. The nurse calls the health care provider at 2 AM, and the HCP begins to yell at the nurse, stating, "I'm sick and tired of you calling me in the middle of the night!" What is the best response by the nurse? 1. "I'm concerned that this client may lose a leg unless something is done immediately." 2. "I'm sorry to bother you. Is there someone else you'd like me to call?" 3. "It's my job to report critical findings, just like it's your job to come see my client right now." 4. "Yelling is unprofessional. I'll need to file a report with my supervisor once the client is stable."

CORRECT ANSWER: 1 The stress of bullying and workplace violence impairs clinical judgment and creates an unsafe environment for clients. In response to unprofessional conduct, the nurse should shift the focus of the conversation back to the client's needs, especially in situations that may result in client injury (Option 1 is correct). (Option 2 is wrong) Offering to call a different provider fails to address the urgency of the situation. The priority is for the nurse to advocate for the client's needs, as the client is experiencing a serious limb-threatening postsurgical complication. (Option 3 is wrong) Confrontational statements are more likely to provoke a fight rather than result in appropriate intervention for the client. (Option 4 is wrong) Incidents of bullying and workplace violence should be reported to a nursing supervisor, but the priority is to ensure that the client's needs are addressed.

The practical nurse is reviewing serum laboratory values for an 80-year-old client with an IV vancomycin prescription for treatment of methicillin-resistant Staphylococcus aureus infection. Which laboratory results should be reported to the registered nurse before the client receives the dose? Select all that apply. 1. Blood urea nitrogen is 60 mg/dL (21.4 mmol/L) 2. Creatinine is 2.1 mg/dL (185.6 umol/L) 3. Glucose is 140 mg/dL (7.7 mmol/L) 4. Hemoglobin is 15 g/dL (150 g/L) 5. Magnesium is 1.5 mEq/L (0.75 mmol/L) 6. White blood cell count is 14,000/mm³ (14 x 10⁹/L)

CORRECT ANSWER: 1, 2 Vancomycin is an antibiotic excreted by the kidneys that is used to treat serious gram- positive bacterial infections (eg, methicillin-resistant Staphylococcus aureus) and the diarrhea associated with Clostridium difficile infection. Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2- 3 times/week) in clients receiving vancomycin due to increased risk of nephrotoxicity, especially in those age >60, with impaired renal function, and who are receiving other nephrotoxic medications (eg, aminoglycoside antibiotics). The nurse should be familiar with the client's baseline levels of BUN and creatinine to monitor trends (mainly an increase in serum levels). The health care provider can decrease the drug dose and administration frequency or discontinue vancomycin if needed. Serum vancomycin trough level is monitored before the fourth dose (optimal levels: 15-20 mg/L [10.4- 13.8 umol/L]). The normal range for BUN is 6-20 mg/dL (2.1-7.1 mmol/L) and for creatinine is 0.6-1.3 mg/dL (53-115 umol/L). The nurse should notify the registered nurse (RN) that the client's BUN (60 mg/dL [21.4 mmol/L]) and creatinine (2.1 mg/dL [185.6 umol/L]) are both increased. (Option 3 is wrong) An elevated glucose level of 140 mg/dL (7.7 mmol/L) is expected in a client with an infection due to physiological stress and gluconeogenesis; this does not need to be reported to the RN. (Option 4 is wrong) A hemoglobin level of 15 g/dL (150 g/L) is normal (13.2-17.3 g/dL [132-173 g/L] in adult men; 11.7-15.5 g/dL [117-155 g/L] in adult women) and does not need to be reported to the RN (Option 5 is wrong) A magnesium level of 1.5 mEg/L (0.75 mmol/L) is normal (1.5-2.5 mEg/L [0.75-1.25 mmol/L]) and does not need to be reported to the RN. (Option 6 is wrong) A white blood cell count of 14,000/mm³ (14 x 109/L) is elevated and expected in a client with a serious infection; this does not need to be reported to the RN.

The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply. 1. Blood 2. Feces 3. Semen 4. Urine 5. Vaginal secretions

CORRECT ANSWER: 1, 3, 5 Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through unprotected sexual intercourse and intravenous illicit drug use (Options 1, 3, and 5 are correct). Infants born to infected mothers are also at risk for vertical transmission of hepatitis B Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B. (Option 2 is wrong) The transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and improper food handling. Therefore, this infection is seen primarily in developing countries. Hepatitis B is not transmitted through feces. (Option 4 is wrong) Urine is not known to be a mode of transmission for any form of hepatitis.

The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply. 1. Achieve and maintain a healthy weight 2. Avoid diet sodas 3. Avoid foods containing protein 4. Drink plenty of fluids 5. Restrict alcohol consumption

CORRECT ANSWER: 1, 4, 5 Gout is an inflammatory condition caused by ineffective metabolism of purines that results in an accumulation of uric acid in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Increasing fluid intake (2-3 L/day) reduces the risk of rate crystal deposits and prevents formation of kidney stones. Obese clients with medical risk factors (eg, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, lack of exercise) have increased risk for future gout attacks. Prevention should focus on lifestyle and dietary modifications. (Option 2 is wrong) An increased risk of gout is not seen with consumption of diet sodas. (Option 3 is wrong) Avoiding all foods containing protein is unpalatable and impractical.

The pediatric nurse plans a home visit for a 2-year-old who will soon be discharged with home health care. Which condition presents the most concern as a safety hazard in the child's home environment? 1. Family lives in a rural area 2. House is heated by a wood-burning stove 3. House was built in 1983 4. Parents are unemployed with limited financial resources

CORRECT ANSWER: 2 The safety of the home environment should be assessed prior to discharge of pediatric clients, especially those with illnesses requiring continuing health care services in the home. The nurse can prioritize safety risks according to Maslow's hierarchy of needs. An open wood-burning stove is a fire hazard that may cause physiologic damage from smoke inhalation or burns (Option 2 is correct). The nurse should investigate the family's access to other utilities and determine whether the stove is the home's only source of heat. (Option 1 is wrong) Rural environments are not an inherent risk to the safety of the child. However, follow-up may be required to ensure the client has access to resources (eg, grocery store, hospital). (Option 3 is wrong) Houses built before 1978 have a high probability of containing lead-based paint. Active renovations can significantly increase the amount of lead released into the home environment, causing lead poisoning (eg, neurologic and motor impairment). Living in a house built in 1983 is not associated with an increased risk of lead exposure. (Option 4 is wrong) Unemployment and limited financial resources can cause increased stress and require further evaluation but would not take priority over a physical safety hazard.

The nurse is reinforcing education about disease transmission. Which measure helps reduce contraction of West Nile virus? 1. Avoid raw, unpeeled fruits or vegetables 2. Limit contact with pets 3. Use insect repellant 4. Wash all bedding in hot water

CORRECT ANSWER: 3 West Nile virus is a mosquito-borne disease that may be asymptomatic or cause symptoms that range from mild (eg, fever, nausea, body aches) to severe (eg, encephalitis). The disease is most common during the summer months, especially during humid weather. Prevention focuses on avoiding mosquitoes and includes: • Using mosquito repellent (Option 3 is correct.) • Wearing light-colored long sleeves and long pants outdoors; mosquitoes are attracted to dark-colored cloth. • Avoiding outdoor activities at dawn and dusk when mosquitoes are most active. (Option 1 is wrong) Food and water precautions are indicated for infectious diseases contracted through contaminated water or food, such as hepatitis A or typhoid (enteric) fever. (Option 2 is wrong) Limiting contact with infected pets is classic advice for avoiding ringworm, a superficial fungal skin infection. West Nile virus is not known to infect pets or be transmitted by them. (Option 4 is wrong) Washing bedding in hot water is a classic instruction to help reduce allergies/asthma (eg, from dust mites) or scabies (a contagious skin infection caused by mites).

A nurse is called in from home to help care for an influx of clients being admitted after a bus accident. While assisting a coworker to prepare for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor in private about the concern 4. Telephone the appropriate regulatory agency and make a report

CORRECT ANSWER: 3 Nurses have an ethical and professional obligation to protect and promote client safety. One common, but often underrecognized, threat to client safety is receiving care from impaired medical professionals. Impairment may occur due to physical injuries, mental illness, and/or the use of impairing substances (eg, alcohol, narcotics, recreational drugs). Regardless of the cause, a nurse who suspects that a coworker may be impaired at work should immediately report the concern to a supervisor to prevent potential harm to clients (Option 3 is correct). (Option 1 is wrong) The nurse should report concerns regarding potentially impaired coworkers directly to a nursing supervisor. Involving additional staff is unwarranted and delays managerial action. (Option 2 is wrong) A potentially impaired coworker should be confronted by a nursing supervisor unless the nurse's behavior poses an imminent risk of harm to the client. (Option 4 is wrong) Reporting to the appropriate regulatory agency must be done if use of an impairing substance is confirmed. However, the nursing supervisor should be notified first so that immediate action can be taken to protect clients from harm.

The home health nurse is visiting a client who has been prescribed home oxygen. The nurse observes wall-to-wall stacks of old newspapers and magazines in every room, with narrow pathways that barely permit passage. What is the priority nursing action? 1. Call the mobile community mental health crisis unit. 2. Contact a service to remove the newspapers and magazines. 3. Reconcile the client's home medications. 4. Reinforce teaching about the safe use of oxygen equipment.

CORRECT ANSWER: 4 This client exhibits signs of hoarding disorder, an anxiety disorder characterized by persistent difficulty in discarding possessions, even those with no value (eg, bottles, newspapers). Clients with hoarding disorder may allow items to clutter and obstruct living areas, creating severe environmental and fire hazards. These clients are usually unconcerned by their behavior and rarely seek mental health services, although the behavior may distress family or friends. The nurse's primary goal is to ensure safety of the client using home oxygen. The nurse must reinforce the importance of keeping oxygen sources away from flame or sparks, not smoking while oxygen is in use, and safely storing empty oxygen bottles for avoiding serious accidents in an environment that is at hiah risk for hazardous events (eg, fire, entrapment) (Option 4 is correct). (Option 1 is wrong) Referral to mental health services is an appropriate intervention, but it is not the highest priority. (Option 2 is wrong) The nurse cannot independently attempt to remove items. If the nurse attempts to do so without consent. the client may experience severe anxiety, agitation. or hostility. (Option 3 is wrong) Reconciling the client's home medications is appropriate, but it is not the priority nursing action.

The nurse reinforces teaching on preventive measures against hepatitis A transmission to a group of clients who are homeless. Which measure would the nurse slate is the priority precaution to prevent transmission? 1. Do not share needles when injecting drugs 2. Practice safe sex by using condoms 3. Receive the hepatitis A vaccine 4. Wash hands after bowel movements and before eating

CORRECT ANSWER: 4 Transmission of hepatitis A occurs most commonly via the fecal-oral route and is due to poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce incidence of hepatitis A (Option 4 is correct). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, IV drug users, persons who travel to high prevalence areas, and those with clotting disorders or liver disease). (Options 1 and 2 are wrong) Hepatitis A virus is secreted in bile and generally transmitted via the fecal-oral route. However, the virus can also spread via unsafe sexual practices and needle sharing between IV drug users. Such behaviors should be discouraged and hand hygiene encouraged as the most important intervention for prevention. (Option 3 is wrong) Vaccination is important for preventing infection. However, hygienic measures (eg, hand washing, sanitation, cleanliness, avoiding sharing personal items) should be readily implemented by all clients regardless of means.

A client has developed diarrhea 24 hours after the initiation of continuous enteral tube feeding with a hypertonic formula. Which intervention is appropriate? 1. Collect a stool sample for culture and sensitivity 2. Dilute the formula with water 3. Discontinue the tube feeding 4. Slow the tube feeding rate of administration

CORRECT ANSWER: 4 Specific enteral tube feeding formulas are prescribed to meet a client's individual nutritional needs (eg, high-protein, low-carbohydrate). Hypertonic (hyperosmolar) formulas have a high concentration of carbohydrates and/or lipids, which can cause gastrointestinal upset (eg, diarrhea, abdominal cramps, nausea/vomiting), especially during the initiation of tube feeding. As in gastric dumping syndrome, fluid rapidly shifts into the intestines from surrounding compartments in an attempt to dilute the highly concentrated intestinal contents. Slowing down the tube feeding rate usually alleviates gastrointestinal upset by decreasing the volume of formula in the intestines (Option 4 is correct). When tube feeding is initiated, the rate is gradually increased to a prescribed goal rate to minimize the risk of gastrointestinal upset. The nurse should collaborate with the health care provider and/or dietitian to adjust the goal rate and formula as needed. (Option 1 is wrong) Sending a stool sample for culture and sensitivity would be appropriate if gastrointestinal infection is suspected as the cause of diarrhea. However, collecting a stool sample does not directly address the diarrhea. (Option 2 is wrong) Diluting tube feeding formula with water increases the risk of microbial contamination, which can lead to infection. A diluted formula supports microbial growth better than a full-strength formula. (Option 3 is wrong) The tube feeding should not be discontinued completely because this prevents the client from receiving necessary nutritional support. The tube feeding rate or formula should be adjusted if gastrointestinal upset occurs.

The nurse is providing postoperative care for a client who had an aortic valve replacement two days ago and has a chest tube. Which finding is most important to report to the supervising registered nurse? 1. Chest tube output of 175 mL in the past hour 2. International normalized ratio of 1.5 3. Temperature of 100.3 F (37.9 C) 4. Urine output of 90 mL over the past 3 hours

CORRECT ANSWER: 1 Diagram of chest drainage system: https://imgur.com/upfx4tA Chest tubes are used to drain air or fluid from the mediastinal or pleural space. Chest tube drainage >100 mL/hr may indicate hemorrhage from a disrupted suture site (Option 1 is correct). The client can quickly become hemodynamically unstable from large amounts of blood loss and may require blood transfusion or emergency surgery. (Option 2 is wrong) Clients who receive a mechanical valve replacement should receive anticoagulation (eg, warfarin) after surgery to prevent thrombus formation on the valve, which could embolize and cause stroke. The goal INR for a client with a mechanical valve is 2.5-3.5 and should be achieved within 5 to 7 days after starting warfarin. (Option 3 is wrong) Fevers are common and expected during the first few days following major surgery. The nurse should monitor the client for other signs of infection (eg, incisional redness, heat, swelling) because a low-grade fever (eg, 100.3 F [37.9 C]) is not a reliable indicator of postoperative infection. (Option 4 is wrong) The nurse should closely monitor the client's urine output (minimum ≥30 mL/hr). Low urine output can indicate a decrease in cardiac output due to complications of valve replacement (eg, bleeding, valve dysfunction, dysrhythmias).

The nurse participates in a health screening event for skin cancer. Which clinical finding would be most concerning? C 1. Client with a blue and black, irregularly shaped papule on the hand 2. Client with a pearly, pink papule with ulceration on the ear 3. Client with a pink patch with silvery scales on the neck 4. Client with a red, scaly patch with rough edges on the forehead

CORRECT ANSWER: 1 Diagram of skin cancer: https://imgur.com/0CFAlTt The three most common types of skin cancer include squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas are the most dangerous because they grow rapidly and are highly metastatic, resulting in a high mortality rate. When screening for skin cancer, the nurse should use the ABCDE method to identify lesions with melanoma-like characteristics. The ABCDE method includes assessing lesions for: • A - Asymmetry (eg, one half unlike the other) • B - Border irregularity (eg, notched or irregular edges) • C - Color changes and variation (eg, new blue or black pigmentation) (Option 1 is correct) • D - Diameter of 6 mm or larger (approximately the size of a pencil eraser) • E - Evolving (eg, changes in shape, size, and color) (Option 2 is wrong) Basal cell carcinomas are slow growing and have a pearly appearance; the usually do not metastasize. This client is a second priority. (Option 3 is wrong) Psoriasis is a common disorder characterized by silvery, scaly patches that can cause itching. (Option 4 is wrong) Actinic keratoses are precancerous lesions that are erythematous and have a hard texture and irregular borders.

A 2-year-old receives follow-up care at the clinic for atopic dermatitis (eczema). Which of the following instructions should the nurse reinforce with the parents regarding appropriate hygiene for this client? Select all that apply. 1. Apply emollient immediately after a bath 2. Dress child in wool pajamas 3. Give tepid baths with mild soap 4. Keep child's nails well trimmed 5. Thoroughly rub the skin dry after baths

CORRECT ANSWER: 1, 3, 4 Atopic dermatitis (AD), also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin. The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and resulting immune response to invading allergens. The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching leads to formation of new lesions and potential secondary infections. • Skin should be gently patted dry after bathing, followed by immediate application of an emollient to seal in moisture (Option 1 is correct). • Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry the skin and should be avoided (Option 3 is correct). • Nails should be trimmed short and kept filed to reduce scratches (Option 4 is correct). • Clothing should be soft (eg, cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long sleeves should be worn at night. • The client should avoid trigger factors, such as heat and low humidity. (Option 2 is wrong) Wool pajamas and other rough fabrics can cause itching and sweating. Soft cotton fabrics are a better choice. (Option 5 is wrong) Rubbing or vigorous drying can damage the skin and lead to exacerbations or infection. Skin should be patted dry gently.

The nurse cares for a 74-vear-old client with Clostridioides (formerly Clostridium) difficile colitis and a history of stroke with left-sided weakness. Which of the following nursing actions are appropriate to promote client safety? Select all that apply. 1. Apply color-coded, nonslip socks to the client's feet 2. Encourage the client to use a cane on the left side for support 3. Lower the bed and raise all bed rails before exiting the room 4. Place a bedside commode on the client's right side 5. Remind the client to call for assistance before toileting

CORRECT ANSWER: 1, 4, 5 Go here for fall risk precautions: https://imgur.com/ij65BNc The nurse should ensure that fall risk precautions (eg, nonslip socks, lowering the bed) are implemented for clients with multiple fall risk factors (eg, advanced age, neuromuscular weakness). Color-coded, nonslip socks help prevent a client from slipping and alert staff to a client's increased risk for falls (Option 1 is correct). Most falls are unobserved and occur in the client's room or bathroom. Evidence shows a correlation between falls and hurrying to the bathroom due to bowel/bladder urgency and/or frequency (eg, incontinence, Clostridioides [formerly Clostridium] difficile infection). For clients with unilateral weakness, assisting with toileting and placing a bedside commode on the client's unaffected, or "strong," side help prevent falls (Options 4 and 5 are correct). (Option 2 is wrong) A cane can provide support to a client with impaired mobility. However, the client with unilateral weakness should use the cane on the unaffected, or "strong." side (Option 3 is wrong) Lowering the bed is appropriate, but raising all bed rails is considered a restraint. Also, evidence shows that clients with impaired cognition (eg, dementia, delirium) can become entrapped in bed rails when trying to climb over them to exit the bed and are more likely to fall with all rails raised.

A client with severe vomiting and diarrhea was admitted with a blood pressure of 89/52 mm Hg and pulse of 120/min. A total of 2 L IV 0.9% sodium chloride was administered. Which of the following findings indicate that the client has been adequately rehydrated? Select all that apply. 1. Capillary refill is seconds 2. Skin remains tented when pinched 3. Systolic blood pressure drops when standing 4. Urine output is 360 mL in 4 hours 5. Urine specific gravity is 1.020

CORRECT ANSWER: 1, 4, 5 Signs of dehydration: https://imgur.com/z9TUziG After a client has received rehydration therapy (eg, IV fluid resuscitation), the nurse should monitor for signs of adequate hydration: • Stabilized vital signs (eg, absence of hypotension or tachycardia) • Capillary refill seconds, indicating normal peripheral perfusion, which is possible only if the client is adequately hydrated (Option 1 is correct) • Urine output >30 mL/hr and urine specific gravity of 1.003-1.030, indicating adequate renal perfusion (Options 4 and 5 are correct) (Option 2 is wrong) Decreased skin turgor (eg, skin remains tented for several seconds when pinched) indicates hypovolemia. As intravascular volume is depleted, fluids from the interstitial space are pulled into the vascular space. When healthy, adequately hydrated skin is pinched, it returns to normal almost immediately. (Option 3 is wrong) Orthostatic changes in vital signs are a sign of dehydration. When a client stands, the body normally vasoconstricts to preserve the blood pressure under the effects of gravity. If a client is dehydrated, the body has already maximally vasoconstricted; there is no compensatory mechanism left to adjust to the position change.

During the discharge process, the nurse observes a new parent placing a newborn into a car seat in the vehicle. Which action by the parent requires the nurse to intervene? 1. Anchors the car seat in the center of the vehicle's back seat 2. Dresses the newborn in a sleep sack before securing the harness 3. Keeps the car seat at a 45-degree angle 4. Uses a car seat that faces the rear of the vehicle

CORRECT ANSWER: 2 Motor vehicle restraints by age: https://imgur.com/NCRtHbY Vehicle safety for newborns and small children is important for reducing preventable injuries and deaths. Newborns and children age <2 years must be placed in a rear- facing car seat in the vehicle's back seat. The car seat's harness is secured snugly at or below the shoulders, at the hips, and between the legs; the connectors clip together at the center of the chest. The harness fits securely when the newborn is dressed in lightweight clothing. Tucking blankets between the newborn and the harness or dressing the newborn in bulky coats or a sleep sack reduces the car seat's effectiveness (Option 2 is correct). (Option 1 is wrong) The car seat should be placed in the back seat and in the center (away from the doors), if possible. This protects the child from airbag deployment as well as collisions to the vehicle's sides. (Option 3 is wrong) When the car seat tilts back at a 45-degree angle, there is less danger of the newborn's head and neck falling forward and obstructing the newborn's airway. (Option 4 is wrong) A rear-facing car seat protects the newborn's head and neck from whiplash in a collision.

The nurse receives report on four clients at change of shift. Which client should the nurse see first? 1. Client who smokes who has intermittent leg pain that is worse with walking and eases with rest 2. Client with diabetes who has burning and numbness in both lower legs and feet 3. Client with leg swelling and calf pain who was on a 15-hour flight 2 days ago 4. Client with pain, edema, and redness in the leg following a dog bite 1 hour ago

CORRECT ANSWER: 3 Diagram of deep vein thrombosis: https://imgur.com/8jouMag Life-threatening physiological problems (eg, airway, breathing, circulation) are the highest priority followed by less threatening problems (eg, pain, potential for infection). Unilateral edema and calf pain could be signs of a deep venous thrombosis (DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism) (Option 3 is correct). Prolonged immobilization (eg, airplane travel, bed rest) increases the risk for DVT. (Option 1 is wrong) A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of peripheral artery disease. This condition is not an immediate threat to survival. (Option 2 is wrong) The diabetic client with poor glucose control is at risk for developing neuropathy (burning, tingling, or loss of sensation) of a limb due to changes in the nerves. This is a chronic, progressive condition and is not an immediate threat to survival. (Option 4 is wrong) The client with a dog bite will need antibiotics and possibly a rabies vaccination, but there is no immediate threat to survival.

A client with schizophrenia spends time in the dayroom, sitting in a corner watching television. but does not initiate conversation or social interaction with other clients or staff. What is the most appropriate activity for the client? 1. Helping plan a unit picnic 2. Playing bingo with other clients 3. Playing board games with a staff member 4. Singing together in a group

CORRECT ANSWER: 3 Schizophrenia symptoms: https://imgur.com/9lZXHfy Schizophrenia is a psychiatric disorder in which clients have disturbed thought processes and impaired communication, affecting their ability to establish personal relationships and manage day-to-day interactions. For clients exhibiting negative symptoms (eg, social isolation, flat affect, apathy), the nurse can facilitate interpersonal functioning with one-on-one interaction in which the client can practice basic social skills in a nonthreatening way (eg, one-on-one board games). Once the client feels more comfortable, the nurse can encourage participation in activities requiring group interaction (Option 3 is correct). (Options 1, 2, and 4 are wrong) The client with schizophrenia who exhibits negative symptoms is not ready to plan or participate in group activities. However, group activities may become appropriate as the client begins to tolerate social interaction.

A client is scheduled for open repair of an abdominal aortic aneurysm. Which action is most important for the nurse to perform preoperatively? 1. Auscultate bowel sounds 2. Compare blood pressure in each arm 3. Observe amount of hair on the lower extremities 4. Palpate peripheral pulse strength

CORRECT ANSWER: 4 Diagram of open repair of abdominal aortic aneurysm: https://imgur.com/WMmrLeV Open repair of an abdominal aortic aneurysm (AAA) involves cross-clamping the aorta proximally and distally to the aneurysm and placing a graft. Establishing baseline data is essential for comparison with postoperative data. Preoperatively, the nurse should palpate the strength and quality of peripheral pulses; monitor urinary output and renal function testing; and evaluate neurologic status. The dorsalis pedis and posterior tibial pulse sites should be marked for easy location after surgery. This data collection is continued postoperatively to monitor for complications. Decreased or absent pulses; cool, pale, or mottled skin; or pain in the lower extremities postoperatively may indicate a limb-threatening event (eg, embolization, graft occlusion) that may require immediate surgical intervention (Option 4 is correct). (Option 1 is wrong) Although auscultation of bowel sounds is important, determining the strength and quality of peripheral pulses in the lower extremities is a priority. Abdominal auscultation is a higher priority postoperatively when monitoring for paralytic ileus. (Option 2 is wrong) Comparison of the blood pressure in each arm may be helpful in monitoring clients with upper aortic dissection or congenital aortic coarctation but not in clients with AAA. (Option 3 is wrong) The absence of hair growth on the lower extremities is more specific for peripheral artery disease but is not an important finding in a client with AAA.

The licensed practical nurse collects data on several older adult clients. Which finding is a priority to report to the supervising registered nurse? 1. Client taking metoprolol who has a pulse of 54/min and blood pressure of 154/82 mm Hg 2. Client with a PEG tube who has 345 mL of gastric residual volume aspirated before enteral feeding 3. Client with chronic obstructive pulmonary disease who has an SpO2 of 92% 4. Client with pneumonia who is receiving IV fluids and has a new S3 heart sound

CORRECT ANSWER: 4 Diagram of cardiac cycle & heart sounds: https://imgur.com/AceXgN8 An S3 sound occurs when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It may present as a normal finding in young adults. However, a new S3 in older adults is a significant finding because it may indicate the development of volume overload or heart failure. These conditions require prompt intervention because they may rapidly progress to life-threatening events (eg, respiratory compromise, cardiogenic shock). In this client, excessive IV fluids may be causing volume overload (Option 4 is correct). (Option 1 is wrong) Metoprolol is a beta-adrenergic blocker often used to treat heart failure and hypertension. Common side effects of beta blockers are bradycardia and hypotension. The health care provider should be notified if the client develops a heart rate of <50/min, hypotension, or cardiac symptoms (eg, dizziness, lightheadedness, nausea, chest pain) before or after administration. (Option 2 is wrong) Repeated high gastric residual volumes (eg, >250 mL) in clients receiving enteral feedings may indicate delayed stomach emptying and require adjustment to prevent nausea, vomiting, and abdominal distension. (Option 3 is wrong) Chronic obstructive pulmonary disease is a lung disorder that often causes dyspnea, hypoxia, and hypercarbia due to irreversible remodeling of the lower airways. The oxygen saturation goal for such clients is often 88%-92%.

A client with primary hypothyroidism who has been taking levothyroxine for 1 year has gained 10 lb (4.5 kg) in 6 months, despite having a poor appetite. The client states, "I feel sleepy all the time." Laboratory results today show high levels of thyroid-stimulating hormone (TSH). Which information should the nurse reinforce to the client? 1. "A new prescription will be issued for a decreased dose of levothyroxine." 2. "Discontinue levothyroxine immediately; we will reassess TSH levels in 3 months." 3. "Start taking levothyroxine with dietary fiber or calcium to increase its effectiveness." 4. "You will need to get a new prescription for an increased dose of levothyroxine.

CORRECT ANSWER: 4 Diagram of hypothalamic-pituitary-thyroid axis: https://imgur.com/1xHUlJw Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH. However, in primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine, a thyroid hormone replacement, is the most common treatment for hypothyroidism, a condition in which a thyroid hormone deficit slows the metabolic rate (eg, weight gain despite poor appetite, lethargy, fatigue). Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased (Option 4 is correct). (Options 1 and 2 are wrong) Decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the amount of circulating thyroid hormone decreases. (Option 3 is wrong) For best results, levothyroxine should be taken on a consistent morning schedule, before food ingestion. Foods containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can affect drug absorption.

The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. 1. Apply occlusive dressing after rewarming 2. Elevate affected extremities after rewarming 3. Massage the areas to increase circulation 4. Provide adequate analgesia 5. Provide continuous warm water soaks

CORRECT ANSWER: 2, 4, 5 Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis. and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: • Remove clothing and jewelry to prevent constriction. • Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3 is wrong). • Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5 is correct). • Avoid heavy blankets or clothing to prevent tissue sloughing. • Provide analgesia as the rewarming procedure is extremely painful (Option 4 is correct). • As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2 is correct). • Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1 is wrong). • Monitor for signs of compartment syndrome.

The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this. How should the nurse respond? 1. "You can cry and get it all out; I will stay with you." 2. "You have dealt with diabetes; you can conquer dialysis." 3. "You sound very discouraged and frightened." 4. "You still have a lot to live for; think about your family."

CORRECT ANSWER: 3 Therapeutic Communication Techniques: https://imgur.com/y8Dv0F6 Clients may feel overwhelmed when managing chronic illnesses. The nurse should assist them in processing difficult news or events through discussion of thoughts and feelings, which also fosters rapport. Reflecting, or referring the statement back to the client, is a therapeutic communication technique that promotes open dialogue and encourages the client to recognize feelings (Option 3 is correct). Acknowledging feelings is an important step in successfully navigating difficult circumstances. (Option 1 is wrong) Encouraging the client to cry if needed conveys concern but does not encourage further discussion of feelings. (Option 2 is wrong) Giving false reassurance is an example of a nontherapeutic communication technique that may seem supportive; however, it inappropriately offers hope for an outcome that the nurse cannot guarantee. False reassurance also invalidates and hinders discussion of the client's feelings. (Option 4 is wrong) Making cliché statements or automatic responses (eg, "you have a lot to live for") or shifting the focus to others' feelings (eg, "think about your family") invalidates the client's feelings and impedes open communication.

The nurse identifies which of the following risk factors as contributing to the development of peripheral artery disease? Select all that apply. 1. Cigarette smoking 2. Diabetes mellitus 3. Hyperlipidemia 4. Oral contraceptive use 5. Prolonged standing

CORRECT ANSWER: 1, 2, 3 Diagram of peripheral artery disease: https://imgur.com/fAV3IaG In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: • Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1 is correct) • Hypertension: Vessel damage from chronically elevated vascular resistance • Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2 is correct) • Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3 is correct) (Option 4 is wrong) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow (eg, venous stasis). (Option 5 is wrong) Unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, because standing facilitates blood flow by gravity to the lower extremities.

The nurse determines that a client with incontinence and limited mobility is at increased risk for skin breakdown and pressure injury. While caring for this client, which of the following nursing interventions are appropriate? Select all that apply. 1. Applying moisture barrier cream to the skin after performing perineal care 2. Providing foods that are high in protein and that contain adequate calories 3. Repositioning the client every 2 hours and using devices to maintain position 4. Restricting fluid intake to ≤ 2 L/day to reduce the number of incontinent episodes 5. Using foam padding on chairs to elevate the client's elbows and heels

CORRECT ANSWER: 1, 2, 3, 5 How to prevent pressure injuries: https://imgur.com/QrN8tad Pressure injuries are caused by long periods of external pressure that compresses dermal capillaries and the underlying soft tissue. Friction against the skin and shearing forces can also contribute to pressure injury. The nurse should assess every client's risk for pressure injury (using the Braden scale) on admission and at least once daily during hospitalization. To prevent pressure injury, the nurse should: • Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option 1 is correct). • Provide foods high in protein with adequate caloric intake to strengthen the skin as much as possible (Option 2 is correct). • Reposition clients every 2-4 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client in bed because shearing can occur (Option 3 is correct) • Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option 5 is correct). • Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin. (Option 4 is wrong) Adequate fluid intake is vital to ensure adequate hydration and circulation. Fluid restriction can make the skin drier and cause hemoconcentration, leading to poor circulation and an increased risk for pressure injury.

The nurse receives report on a postpartum client and newborn. Which of the following tasks can be assigned to unlicensed assistive personnel? Select all that apply. 1. Assisting the client with morning hygiene 2. Documenting the client's intake and output 3. Evaluating caregiver interactions with the newborn 4. Obtaining the newborn's axillary temperature 5. Reinforcing education on newborn bathing technique 6. Swaddling the newborn after diaper changes

CORRECT ANSWER: 1, 2, 4, 6 Scope of practice: https://imgur.com/msMiSIq Assisting clients with activities of daily living is within the scope of practice of unlicensed assistive personnel (UAP). Helping the postpartum client with morning hygiene, documenting intake and output, taking vital signs of stable clients, and swaddling the newborn may be assigned to UAP (Options 1, 2, 4, and 6 are correct). The licensed practical nurse (LPN) should follow the five rights of delegation when assigning care. (Option 3 is wrong) The LPN should collect data and monitor caregiver interaction with the newborn to identify impaired maternal-infant bonding. Evaluation requires skilled nursing judgment and cannot be assigned to the UAP. (Option 5 is wrong) The LPN is responsible for reinforcing client teaching and demonstrating home care. Once teaching and demonstration are complete, the UAP can assist the mother in bathing the newborn.

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse assists the health care provider with an amniotomy. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Check the client's temperature at least every 2 hours 2. Keep the client supine with the bed flat for 2 hours after the procedure 3. Monitor the fetal heart rate before and after the procedure 4. Note the color, odor, and consistency of the amniotic fluid 5. Perform perineal care and change absorbent pads as needed

CORRECT ANSWER: 1, 3, 4, 5 Diagram of amniotomy: https://imgur.com/hVnxaht Amniotomy refers to artificial rupture of membranes (AROM), which may be performed by the health care provider to augment or induce labor. After AROM, there is an increased risk for infection from organisms ascending into the uterus and risk for umbilical cord prolapse if the fetal head is not firmly applied to the cervix. When assisting with AROM, the nurse should: • Monitor for infection by checking the client's temperature at least every 2 hours after the procedure (Option 1 is correct). • Monitor the fetal heart rate before and after the procedure, as compression of a prolapsed cord can cause fetal bradycardia and distress (Option 3 is correct). • Document the quality and amount of amniotic fluid, which should be colorless and without a foul odor. Yellow-green fluid can indicate fetal passage of meconium in utero; a strong, foul odor may indicate infection (Option 4 is correct). • Provide frequent perineal care to increase comfort and prevent transmission of organisms into the uterus from contaminated amniotic fluid (Option 5 is correct). (Option 2 is wrong) After AROM, the client should be assisted to an upright position to encourage the fetal head to remain firmly applied to the cervix. Supine positioning decreases uteroplacental blood flow and fetal oxygenation.

The practical nurse is collaborating with the registered nurse to conduct a developmental assessment of a 4-year-old child. Which of the following tasks does the nurse anticipate that the child will perform successfully? Select all that apply. 1. Drawing a circle 2. Jumping rope with both feet 3. Sitting quietly for 30 minutes 4. Using a spoon and fork 5. Walking up and down stairs

CORRECT ANSWER: 1, 4, 5 Table of developmental milestones of preschoolers: https://imgur.com/uvho5uk Preschool-age children begin to master more gross motor activities while rapidly increasing their fine motor abilities. The preschooler age 4 should have the fine motor skills to manipulate small tools (eg, scissors, pencil) and therefore be able to draw simple shapes (eg, circle, square) and perform more self-care activities (eg, eating with a spoon and fork) (Options 1 and 4 are correct). The gross motor skills and balance of a child age 4 improve, allowing for more independent, complex movements (eg, walking up and down stairs) (Option 5 is correct). (Option 2 is wrong) A preschool-age child typically gains the ability to jump rope around age 5 A child age 4 would not yet be expected to jump rope successfully. (Option 3 is wrong) It is normal for preschool-age children to be unable to sit quietly for longer than 15 minutes at a time.

The clinic nurse gathers data from the parent of an adolescent client with suspected bulimia nervosa. Which of the following statements by the parent support this diagnosis? Select all that apply. 1. "I have noticed that my child has developed fine hair on the back." 2. "My child ate a large container of chocolate ice cream in one evening." 3. "My child frequently leaves the table during meals to go to the bathroom." 4. "My child is so underweight that I can clearly see the ribs and spine." 5. "The dentist informed me that my child's tooth enamel is wearing away.

CORRECT ANSWER: 2, 3, 5 Common characteristics of anorexia nervosa & bulimia nervosa: https://imgur.com/NQ5Nogs Bulimia nervosa (BN) is an eating disorder characterized by episodes of binge eating followed by actions to prevent weight gain (ie, compensatory behaviors). During episodes, clients consume an unusually large amount of food and cannot stop or control the eating. BN can be difficult to recognize because, unlike clients with anorexia nervosa (AN), those with BN typically maintain a normal weight. Common manifestations include: • Frequent binge-eating episodes (Option 2 is correct) • Compensatory behaviors (eg, leaving the table during meals for self-induced vomiting, laxative use) (Option 3 is correct) • Physical changes related to self-induced vomiting (eg, scars or calluses on the knuckles, enlarged parotid glands, erosion of tooth enamel, dental caries) (Options 5 is correct) • Body image concerns and low self-esteem (Option 1 is wrong) Lanugo is a common finding in newborns but can also result from starvation in clients who have AN. The nurse should evaluate clients with lanugo for AN or nutritional deficiencies. (Option 4 is wrong) Clients with AN typically have significantly low body weight, whereas clients with BN typically maintain a normal body weight.

The nurse is admitting a client with a seizure disorder and delegates preparation of the client's room to the student nurse. Which of the following actions by the student nurse indicate a correct understanding of seizure precautions? Select all that apply. 1. Ensures that suction equipment is present and operable 2. Ensures that supplemental oxygen and a bag valve mask are present 3. Places an oral airway at the head of the bed 4. Places padding on the side rails of the bed 5. Tapes a padded tongue blade at the head of the bed

CORRECT ANSWER: 1, 2, 4 Diagram of seizure precautions: https://imgur.com/OjugLl9 Clients experiencing seizures are at risk for injury and airway compromise. Seizure precautions should be instituted for all clients at risk for seizure, especially those with a medical history of seizure activity. To promote client safety, the nurse should ensure that the appropriate equipment is placed in the client's room and is readily available. Appropriate equipment includes: • Suction equipment for managing oral secretions and vomitus to help prevent aspiration (Option 1 is correct) • Supplemental oxygen, bag valve mask, and endotracheal intubation supplies because of the risk of airway occlusion, aspiration, apnea, and impaired respiratory effort (Option 2 is correct) • Padding for the side rails of the bed to prevent injury during clonic seizure activity (Option 4 is correct) (Options 3 and 5 are wrong) The nurse should never place anything in the mouth of a client experiencing a seizure. During tonic and/or clonic seizures, clients typically clench the jaw involuntarily. When this occurs, objects in the mouth (eg, oral airway, padded tongue blade) may break or dislodge, choking the client and/or damaging the teeth. Suctioning or endotracheal intubation, if needed, should be performed after the seizure ends.