Archer 4

C Choice C is correct. The nurse should question the order written for radioactive iodine (I-131) in this 16-year-old female client, as this client is of childbearing potential. A woman of childbearing potential is defined as any woman or adolescent who has begun menstruation and can conceive. When given radioactive iodine (also referred to as RAI), RAI is taken up by the thyroid, causing the destruction of thyroid tissue. Radioactive iodine is highly effective and is the treatment of choice for Graves' disease in nearly all clients except pregnant clients, breastfeeding clients, or clients who hope to become pregnant within the next 12 months. Iodine, including radioactive isotopes, is readily transferred across the placenta, thus affecting the developing thyroid gland of a developing fetus. Therefore, in any female of childbearing potential, the American Thyroid Association recommends obtaining a beta-hCG within the 72 hours preceding the initiation of RAI therapy to rule out pregnancy. Choice A is incorrect. Atenolol is a beta-blocker used to treat hypertension or tachycardia. Based solely on the information contained within this question, this 16-year-old patient with Graves' disease could take atenolol. Choice B is incorrect. Propylthiouracil is one of the most commonly used anti-thyroid medications. Propylthiouracil works by impairing thyroid hormone synthesis and can be prescribed for clients below 18 years of age. Choice D is incorrect. Methimazole blocks thyroid hormone production from the thyroid gland and is FDA-approved for clients with Graves' disease. A woman of childbearing potential is defined as any woman or adolescent who has begun menstruation and can conceive (typically, 12 to 50 years of age, although deviations in the age ranges occur). Ionizing radiation sources include various radiology scans/tests and the administration of radioactive medications. The American College of Radiology (ACR) practice guideline for the performance of therapy with unsealed radiopharmaceutical sources states that pregnancy should be ruled out using one of the following four criteria: (1) A negative hCG test obtained within 72 hours before administration of the radiopharmaceutical, (2) Documented history of hysterectomy, (3) A postmenopausal state with absence of menstrual bleeding for two years, or (4) Premenarche in a child age of 10 years or younger.

A 16-year-old female client has been recently diagnosed with Graves' disease and subsequently admitted. Which of the following prescriptions, if ordered by the health care provider (HCP), should the nurse question? A. Atenolol B. Propylthiouracil C. Radioactive iodine (I-131) D. Methimazole

B Choice B is correct. Since this patient uses a wheelchair, a pressure ulcer is the most likely cause of sepsis. If it is uncared for, it can develop into an infection and spread into the bloodstream. Choice A is incorrect. This patient could be suffering from pneumonia, but a pressure ulcer is a more likely diagnosis. Choice C is incorrect. This patient could be suffering from a UTI, especially if he has to self-catheterize himself. However, the correct answer is pressure ulcers due to wheelchair use. Choice D is incorrect. It is unlikely that this patient is suffering from gonorrhea-related sepsis.

A 32-year-old man is admitted to the neurology floor after being admitted for sepsis. He has paraplegia and is bound to a wheelchair. What is the most probable cause of sepsis? A. Pneumonia B. Pressure ulcer C. Urinary tract infection D. Gonorrhea

A Choice A is correct. Placenta previa may occur as early as 20 gestational weeks. The manifestations of painless, bright red vaginal bleeding coincide with this condition. Commonly, the presentation of placenta previa is a finding on routine ultrasound examination at approximately 16 to 20 weeks. Choices B, C, and D are incorrect. A threatened abortion may only occur before 20 gestational weeks. Thus, this condition is excluded. Placental abruption is highly serious and manifests with painful vaginal bleeding that causes the uterus to be firm and tender. Uterine souffle is a soft, blowing sound. This sound may be auscultated over the uterus. This is the sound of blood circulating through the dilated uterine vessels, and it corresponds to the maternal pulse. Placenta previa is an implantation of the placenta in the lower uterus. As a result, the placenta is closer to the internal cervical os than to the presenting part (usually the head) of the fetus. The classic sign of placenta previa is the sudden onset of painless uterine bleeding in the last half of pregnancy. Many cases of placenta previa are diagnosed by ultrasound examination before any bleeding occurs.

A client at 32 gestational weeks reports the sudden onset of painless, bright red vaginal bleeding. The assessment showed a normal fetal heart rate and a non-tender uterus. The nurse understands that this client is at the highest risk of developing A. placenta previa. B. threatened abortion. C. placental abruption. D. uterine souffle.

A Choice A is correct. People with heart failure may improve their symptoms by reducing the amount of sodium in their diet. Sodium is a mineral found in many foods, especially salt. Overeating salt causes the body to keep or retain too much water, worsening the fluid buildup. Patients should be encouraged to follow a low-sodium diet to help manage symptoms of hypertension and to reduce edema. One of the most natural things a patient can do at home is to reduce the amount of sodium intake. They can also eat fresh vegetables rather than canned. If canned vegetables are the only option, the patient should rinse the plants with clean water and cook them with unsalted water. Choice B is incorrect. Canned vegetables should be avoided. Choices C and D are incorrect. Canned or processed meats are higher in sodium and should be avoided.

A client has been placed on a sodium-restricted diet following a myocardial infarction. Which of the following would be the most appropriate meals to suggest? A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange. B. Broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk. C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple. D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.

B Choice B is correct. The linea alba—the line that marks the longitudinal division of the midline of the abdomen—darkens to become the linea nigra due to hormone changes during pregnancy. This dark line of pigmentation may extend from the symphysis pubis to as high as the top of the fundus and becomes darker as pregnancy progresses. This hyperpigmentation typically disappears after childbirth. Choice A is incorrect. There is no need for further assessment or evaluation by a dermatologist, as this is a common occurrence of pregnancy. Choice C is incorrect. There is no connection between food intake and the appearance of the linea nigra. Choice D is incorrect. Hormonal changes during pregnancy cause temporary pigmentation darkening making the linea nigra more visually prominent in some women. This hyperpigmentation is not permanent and will typically disappear following childbirth Recognize that a linea nigra is a temporary hyperpigmentation that appears vertically down the abdomen due to hormone changes during pregnancy. Those with darker complexions tend to have a more pronounced linea nigra than those with fair complexions. In most individuals, the linea nigra darkens enough to be visible in the second trimester. Following delivery, fading is gradual, occurring over several weeks or months. The exact cause of linea nigra is unknown, but the hypothesis is that the melanocyte-stimulating hormone created by the placenta causes melanin to rise during pregnancy.

A client in her second trimester presents to the maternity clinic expressing concern that the dark, verticle line present on the midline of her abdomen may pose a danger to her baby. Which of the following would be the most appropriate action for the nurse to take in response to the client's concern? A. Refer the client to a dermatologist for assessment. B. Educate the client that this is a common occurrence in pregnancy called linea nigra, which usually disappears after childbirth. C. Ask the client what types of foods she has been ingesting. D. Educate the client that this is a common occurrence in pregnancy called linea nigra, which typically remains following childbirth.

A Choice A is correct. In Orthodox Judaism, all body parts removed during autopsy must be buried with the body because it is believed that the entire body must be returned to the earth. Choice B is incorrect. In Orthodox Judaism, organ donation may not be decided by family members. Choice C is incorrect. It is not allowed in Orthodox Judaism to donate organs since they believe that all of the client's organs must be buried with the dead. Choice D is incorrect. The rabbi can approve of organ transplantation, but not organ removal or organ donation.

A client that recently died of a car accident was sent to the coroner for autopsy. The client's family became concerned about the autopsy since they are of the Jewish religion. The nurse's approach to the family must be guided by the fact that: A. All body parts removed during autopsy must be buried along with the client. B. The client can donate his body parts with the consent of his next of kin. C. Judaism supports organ donation. D. An autopsy can only be allowed upon approval of a rabbi.

C Choice C is correct. This is an incorrect statement and therefore the correct answer to the question. Genetic counseling aims to let people understand that they have no control over inherited traits. Marriages and relationships can suffer because of this unless they are given adequate support. Choice A is incorrect. This is a correct statement. Genetic counseling results in making individuals feel well or free of guilt, knowing that the disorder they are worried about is not an inherited disorder. Choice B is incorrect. This is a correct statement. Genetic counseling results in individuals acquiring information about having a trait that is responsible for a child's condition. Some people may opt not to have children because of this, but it is essential knowledge for decision-making. Choice D is incorrect. This is a correct statement. Genetic counseling educates people regarding how a particular inherited trait is passed on to the next generation.

A couple in a fertility clinic tell the nurse that they are concerned about transmitting a particular disease to their children. The nurse refers them to genetic counseling. All of the following are the purposes of genetic counseling, except: A. Reassure people who are concerned about their children inheriting a particular disorder as well as provide concrete and accurate information. B. Allow people who are affected by inherited disorders to make informed choices about future reproduction. C. Educate the couple on how to prevent their child from acquiring inherited disorders. D. Educate the couple about inherited disorders and the process of inheritance.

C Choice C is correct. Cheyne-Stokes respirations are characterized by irregular respirations with periods of crescendo and decrescendo, with periods of apnea. It usually indicates brain dysfunction. Choice A is incorrect. Kussmaul respiration is characterized as deep, labored breathing associated with diabetic ketoacidosis. Choice B is incorrect. Ataxic breathing is similar to agonal breathing, characterized by completely irregular breathing with irregular periods of apnea. There is no pattern with this type of breathing, which is the case with Cheyne-Stokes respiration. Choice D is incorrect. Biot's breathing is similar to Cheyne-Stokes in that it is pattern-like. Biot's breathing can be characterized by short, shallow breaths followed by irregular periods of apnea.

A hospice nurse is taking care of a client with pancreatic cancer. The client's breathing becomes progressively deeper with periods of apnea. What is this breathing pattern called? A. Kussmaul B. Ataxic C. Cheyne-Stokes D. Biot's

B Choice B is correct. Adolescents need to establish their identity, which includes developing a mature sense of responsibility/independence. Providing the patient with his schoolwork will keep him connected to his peer group and give him a sense of accomplishment. Choice A is incorrect. Unlike infants and toddlers, adolescents are less likely to experience separation anxiety. Choice C is incorrect. Completing a puzzle is a task more appropriate for a school age child in Erikson's stage of industry vs. inferiority. In this stage, school age children seek to develop a sense of industry, compare themselves with their peers, and see how they measure up. The adolescent client in this question is in Erikson's stage of identity vs. role confusion. Helping the client complete his homework and promoting responsibility and independence is more appropriate for this developmental stage. Choice D is incorrect. Preschool and school-aged children may benefit from the social interaction that is offered in the activity room. Adolescents, however, are more likely to enjoy independent activities, especially after a surgical procedure.

A nurse is caring for a 13-year-old boy is scheduled to have a surgical repair of a spinal curvature. The adolescent will be hospitalized for approximately 2 weeks. While planning care, which nursing intervention will be most helpful during the hospital stay? A. Instruct parents to room-in with him. B. Encourage the patient to bring homework assignments to the hospital. C. Have the client complete a puzzle. D. Encourage the patient to go to the activity room daily.

D Choice D is correct. Nitroglycerin is used in the treatment of angina, pulmonary edema, and hypertensive emergencies. Nitroglycerin decreases both preload and afterload, which may result in hypotension. Thus the client's blood pressure needs to be monitored closely. Choices A, B, and C are incorrect. The effects of nitroglycerin do not impact these options. Nitroglycerin is a potent vasodilator (it decreases preload and afterload). It is indicated in angina. It is given in a variety of preparations, including sublingual, translingual, and topical. Dosing for sublingual nitroglycerin is one tablet under the tongue every five minutes (as long as the chest pain is persisting). The maximum tablet (or sprays) is three. The client should be instructed that emergency care should be sought if the pain is not relieved after the first dose. Nitroglycerin expires after six months, and the client should be instructed to keep their supply current. Nitrates are contraindicated if the client is taking medications such as vardenafil, tadalafil, or sildenafil. The client should take the nitroglycerin in a sitting or laying down position because sudden movement changes may cause orthostatic hypotension. Headache is an expected side effect of this medication and may be treated with acetaminophen. Nitroglycerin cannot be applied to a client for 24 hours as the client will develop a tolerance. Blood pressure should be monitored closely.

A nurse is caring for a client receiving nitroglycerin. It is essential to monitor the client's A. Temperature B. Respirations C. Urinary output D. Blood pressure

C Choice C is correct. The rupture of membranes causes the amniotic fluid to be expelled in large amounts. If the fetus has not engaged, the umbilical cord may prolapse along with the fluid; this poses a danger to both the fetus and the mother. The mother should then promptly arrive to the labor and delivery unit. Choice A is incorrect. The mucus plug may be passed several weeks before the onset of actual labor. Choice B is incorrect. The mother may experience bladder pressure and frequency when the fetus settles into the pelvis and this may occur a few weeks before labor. Choice D is incorrect. Prodromal signs of labor include nausea and vomiting but are not indicative of actual labor.

A woman in her 37th-week of gestation is wary about complications and labor signs. She asks the nurse, how would she know if it was time to go to the labor and delivery unit? The best response is: A. "When the mucus plug is out." B. "When you feel a heaviness in your bladder." C. "When you see a large gush of fluid coming out of your vagina." D. "When you feel nauseated and vomit altogether."

C Choice C is correct. This patient is showing signs in need of increased protein and caloric intake as evidenced by the elevated WBC count (normal WBC range: 4-11), open wound, low albumin level (normal prealbumin range: 15-36mg/dL), and BMI within the normal range, but very close to underweight (normal BMI range: 18.5-24.9). This patient needs increased protein and caloric intake to fight infection and promote wound healing. Choice A is incorrect. A low fiber/residue diet is indicated in GI conditions such as Crohn's disease, IBD, and diverticulitis. No assessment data is suggesting that the patient is experiencing any GI problems. Choice B is incorrect. No assessment data is suggesting that the patient is deficient in iron. TPN is indicated when a patient has an absorption problem or when oral intake is not possible. The patient should be started on an appropriate high-calorie, high protein diet first before any parenteral nutrition is considered. Choice D is incorrect. No assessment data is suggesting that the patient is experiencing any cardiac issues requiring a low sodium/heart-healthy diet.

An 86-year-old patient presents with an open wound of the right lower extremity, leucocyte count of 12000/ul, body mass index (BMI) 18.8, and a pre-albumin of 12 mg/dL. Which diet would be most appropriate for this patient? A. Low fiber, low residue B. Total parenteral nutrition (TPN) with iron supplementation C. High calorie, high protein D. Low sodium (heart healthy)

D Choice D is correct. It is the responsibility of the nurse to evaluate and check if the delegated tasks to the LPN have been performed. Choice A is incorrect. The LPN cannot assess a client. This is a task for the RN. Choice B is incorrect. The child has just undergone a cleft palate repair. There is a risk for the child to damage his incision site and aspirate if he/she is fed by untrained personnel. This task is for the RN. Choice C is incorrect. Demonstrating a procedure to the mother is similar to educating or teaching the client. The LPN is not allowed to perform teaching/education.

An RN is in charge of the unit with an LPN. Which situation indicates proper delegation of tasks by the RN? A. The RN delegates to the LPN to check the circulation of the child with a forearm cast. B. The LPN is tasked to feed a one-year old that just had a cleft palate repair. C. The LPN demonstrates urinary catheterization to the mother of a child with neurogenic bladder. D. The RN checks if the LPN completed all delegated tasks.

C Choice C is correct. Carbohydrates, proteins, and fats provide the energy that is necessary for cellular function. Choice A is incorrect. Iron, zinc, and calcium are three essential minerals. Choice B is incorrect. Folate, vitamin B12, and iron are necessary for oxygenation as well as optimal hemoglobin and hematocrit counts. Choice D is incorrect. Vitamins A, D, E, and K are fat-soluble.

Primary nutrients that are essential for optimal body function include: A. Iron, zinc, and calcium B. Folate, vitamin B12, and iron C. Carbohydrates, proteins, and fats D. Vitamins A, D, E, and K

C Choice C is correct. Mutual goal setting and decision-making with the client and others, such as family members and other members of the healthcare team, are essential to the working phase of the therapeutic nurse-client relationship process. This mutual goal setting and decision-making are critical to the success of care planning and optimal client outcomes. The phases of the nurse-client relationship in the correct sequential order are: The preinteraction phase The introductory phase The working phase The termination phase Choice A is incorrect. The termination phase of the therapeutic nurse-client relationship is characterized as the end of this relationship with the client, and, as such, the nursing skill that is essential to this phase in terms of meeting the client's needs is a summarization and not the collection of assessment data. After this relationship, the nurse will summarize the relationship, decisions that were made, and the outcomes that were or were not achieved. Choice B is incorrect. The summarization of outcomes is not done during the introduction/ interaction phase. Instead, the nursing skill that is necessary during this phase is the collection of assessment data, which is also the second phase of the nursing process. Choice D is incorrect. The nursing skills that are essential to the introductory phase of the therapeutic nurse-client relationship process are the ability to establishing participant expectations and to delineate the roles and responsibilities of both the nurse and the client as this relationship continues. Mutual goal setting and decision-making with the client and others, such as family members and other members of the healthcare team, are essential to another phase of this therapeutic nurse-client relationship process.

Select the phase of the therapeutic nurse-client relationship process that is most accurately paired with a nursing skill that is essential to its success in terms of meeting the client's needs. A. The termination phase: The collection of assessment data B. The introductory phase: The summarization of outcomes C. The working phase: Mutual goal setting with the client and others D. The introductory phase: Mutual goal setting with the client and others

B Choice B is correct. "I am sorry. Could you restate that thought so I can be clear about what you are saying?" is an example of seeking clarification, which is a therapeutic communication technique. Seeking clarification aims to ensure that the receiver of the message is precise and clear about the meaning of the sender's word. Choice A is incorrect. "I believe that you should not be thinking in this self-destructive and self-deprecating manner" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should allow the client to ventilate these feelings and then attempt to work with the client to resolve these feelings. Choice C is incorrect. "I am here to talk with you about your fears because you have refused to talk about these before" is not at all a therapeutic communication technique. It is highly judgmental and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should offer help and allow the client to vent their fears and concerns in an environment of openness, trust, caring, and compassion. Choice D is incorrect. "It is now time for you to start telling me about your substance abuse problem without further delay" is not at all a therapeutic communication technique. It is highly authoritative, judgmental, and not conducive to a therapeutic nurse-client relationship. Instead, the nurse should not probe the client but, instead, allow the client to ventilate about their substance abuse problem in an environment of openness, trust, caring, and compassion.

Select the therapeutic communication technique that is accurately paired with an example of it. A. Reflecting: "I really believe that you should not be thinking in this self-destructive and self-deprecating manner." B. Seeking clarification: "I am sorry. Could you restate that thought so I can be clear about what you are saying?" C. Offering of self: "I am here to talk with you about your fears because you have refused to talk about these before." D. Probing: "It is now time for you to start telling me about your substance abuse problem without further delay."

A Choice A is correct. This client requires a disease management referral because the client has been admitted multiple times to the hospital. Disease management is a coordinated set of interventions that aim to maximize the client's functionality while minimizing disease-related complications. The cost associated with hospitalizations and the risk of complications during hospitalizations make this client an ideal candidate for disease management services. Choices B, C, and D are incorrect. A client having a seizure while switching anti-epileptics is quite common. The reasoning is that when one therapeutic level declines, it takes time for the other to increase. An isolated seizure does not necessitate a disease management referral. The client with diabetes had an increase in their hemoglobin A1C. However, it is still below the desired goal of 7%. The nurse should trend the A1C and continue to advocate for more frequent blood glucose monitoring and adherence to prescribed medications. A client with schizophrenia being switched to a long-acting injectable is an excellent strategy to maximize adherence and minimize exacerbations (psychosis). These long-acting injectables are given in a single shot, and the client will return in a few weeks for another injection. ✓ Disease management effectively minimizes costly hospitalizations, maximizes resources, and promotes quality outcomes. ✓ Disease management utilizes evidence-based practices and may contain multiple disciplines (pharmacist, physical/occupational therapy, nursing). ✓ Conditions likely recommended for disease management include uncontrolled diabetes mellitus, asthma, chronic obstructive pulmonary disease, and obesity.

The charge nurse reviews medical records for clients ready for discharge from the nursing unit. Which client should be recommended for disease management services? A client with A. congestive heart failure (CHF), who has been admitted three times in the past two months. B. epilepsy who had one seizure after switching prescribed antiepileptics. C. diabetes mellitus, with an increase in hemoglobin A1C from 6.7% to 6.9%. D. schizophrenia being switched from daily dosing to long-acting injectable antipsychotic.

D Choice D is correct. FFP would be prescribed because this client is experiencing bleeding related to the prescribed warfarin. The client's INR is grossly elevated (therapeutic for VTE prophylaxis is 2-3), and FFP includes the Vitamin K-dependent clotting factors (factors II, VII, IX, X, proteins C, and S) that need to be replaced to stop the bleeding. Vitamin K may be prescribed, but the efficacy takes six to eight hours. FFP can treat the bleeding almost immediately. Choices A, B, and C are incorrect. PRBCs are indicated to treat anemia. Platelets would be prescribed to treat thrombocytopenia. Granulocytes are rarely prescribed, but if they are prescribed, they are indicated for severe aplastic anemia, neutropenia, and neonatal sepsis. ✓ FFP is indicated for deficiency of certain clotting factors. ✓ This blood product may also be used for warfarin toxicity along with Vitamin K. ✓ FFP may also provide some volume resuscitation; however, its primary purpose is to assist with clotting. ✓ FFP is administered to a client over 15-30 minutes.

The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? A. Packed red blood cells (PRBCs) B. Platelets C. Granulocytes D. Fresh frozen plasma (FFP)

A Choice A is correct. The client is experiencing intraabdominal bleeding with manifestations confirming shock. The client will need to have the blood volume replaced with emergent surgery. Type-specific PRBCs would be preferred; however, if the client is critical, O-negative blood may be transfused. Choices B, C, and D are incorrect. FFP would not be prescribed because this client is not experiencing blood loss related to warfarin or DIC. Platelets would be prescribed to treat thrombocytopenia. Granulocytes are rarely prescribed, but if they are prescribed, they are indicated for severe aplastic anemia, neutropenia, and neonatal sepsis. ✓ The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ✓ The universal blood donor type is O negative; the universal blood type for recipients is AB positive. ✓ A unit of PRBCs should be transfused over 2-4 hours using Y-type tubing. ✓ 20-gauge intravenous (IV) catheter should be used to administer a blood product. ✓ The nurse should verify the client's identification, blood product, and compatibility with a second nurse prior to transfusion.

The emergency department (ED) nurse cares for a client with severe intrabdominal bleeding. The client has tachycardia, hypotension, and a thready pulse. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product? A. Packed red blood cells (PRBCs) B. Platelets C. Granulocytes D. Fresh frozen plasma (FFP)

B Choice B is correct. The nurse should prepare for the delivery of the newborn because of a presenting fetal part. The nurse transporting the client to L&D would be highly inappropriate because the client could deliver the newborn during transport which is not safe. Finally, the nurse should prepare for the delivery of the newborn because the presenting part requires immediate application of fetal heart monitoring to determine the stability of the neonate. Choices A, C, and D are incorrect. Assessing the client's previous obstetric history would have very little probative value while a presenting fetal part is present. The nurse needs to act in this situation and not assess. Transporting the client to L&D would not be safe because a presenting fetal part signifies imminent delivery. Once delivery has occurred, and it is safe to do so, the client and the newborn should be transferred. The nurse should call for an L&D nurse in the ED, as that would be more appropriate. Tme the frequency and duration of contractions would be helpful but is not the priority because the delivery of the neonate is imminent, and the nurse needs to act to maintain the stability of the client and the neonate. Supplies necessary for the delivery of a newborn include - ✓ Sterile gloves ✓ OB towelettes ✓ Drape sheets ✓ Sterile gauze ✓ Bulb syringe ✓ Umbilical cord clamps ✓ Bag valve mask ✓ Neonatal warmer ✓ Intravenous access equipment

The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. The nurse should take which priority action? A. Assess the client's previous obstetric history B. Prepare for the delivery of the newborn C. Transport the client to the labor and delivery unit D. Time the frequency and duration of contractions

A Choice A is correct. Carbon monoxide poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the client to be immediately relocated away from the carbon monoxide. Moving the client outside is effective because of the fresh air. Once this has been completed, the nurse should notify the PHCP or call emergency medical services (EMS) for further treatment. Another priority treatment is providing the client with 100% high-flow oxygen regardless of their pulse oximetry, lung sounds, or arterial blood gas results. Choices B, C, and D are incorrect. Moving the client outdoors is an essential action. Once this action has been completed, the nurse should call EMS or the PHCP for guidance and treatment. The client's lung sounds have little clinical value in this acute emergency. The client's oxygen saturation would not provide the nurse with valuable information because the nurse needs to act immediately to cease exposure to this poison. The nurse understands that high-flow oxygen will be administered to the client regardless of their oxygen saturation; thus, this assessment has limited clinical value. Finally, pulse oximetry cannot screen for exposure to carbon monoxide.

The home health nurse is assessing a client with suspected carbon monoxide poisoning. The nurse should take which priority action? A. Move the client outdoors B. Notify the primary healthcare provider (PHCP) C. Auscultate the client's lung sounds D. Assess the client's pulse oximetry

D Choice D is correct. Dopamine is a vasopressor and is indicated in the treatment of shock. Dopamine is a vesicant, and a major adverse effect of dopamine is that it can extravasate and cause serious tissue damage. Hence, this medication is recommended to be infused through a central line to prevent this adverse complication. The nurse should immediately attend to this client and stop the infusion. If extravasation is suspected, the nurse should stop the infusion and aspirate any remaining IV fluid from the catheter. Choices A, B, and C are incorrect. The mechanically ventilated client has a protected airway, and the lack of spontaneous respirations explains why the client is receiving ventilation via assist control. Assist control provides full airway protection and delivers a preset number of breaths at a preset amount of tidal volume. The nurse does not need to follow up with the client as the ventilator provides appropriate treatment. A flail chest occurs from blunt force trauma and causes the client to have pain with inspiration. Another classic manifestation of a flail chest is paradoxical chest wall movement (inward movement of the thorax during inspiration, with outward movement during expiration). Gentle bubbling in the water seal chamber of their chest tube when coughing is normal and does not require follow-up. Continuous bubbling in the water seal chamber would require follow-up that suggests an air leak. When caring for a client receiving dopamine, the nurse should continuously assess the client's ✓ Heart rate and rhythm as certain doses of this medication may cause tachydysrhythmias. ✓ The client should have their peripheral vascular access device monitored closely as this medication is a vesicant. ✓ It is highly preferred that this medication be infused through a central line. ✓ Angina, decreased urinary output, and dysrhythmias should be reported immediately.

The intensive care nurse (ICU) cares for a group of assigned clients. The nurse should initially follow-up with the client who is A. mechanically ventilated and not taking spontaneous breaths while in the assist-control (AC) mode. B. being treated for a flail chest, reporting chest pain with inhalation. C. noted to have gentle bubbling in the water seal chamber of their chest tube when coughing. D. receiving intravenous (IV) dopamine via a peripheral vascular access device and reports pain at the site.

A Choice A is correct. Tourniquets should not be used in snake bites. The tourniquet impedes arterial blood flow and can be quite harmful to the extremity. The client should immobilize the affected extremity to decrease the absorption of the venom. Choices B, C, and D are incorrect. It would be appropriate to remove the jewelry and the wristwatch as the extremity may swell. Establishing intravenous (IV) access and collecting laboratory tests such as PTT, PT/INR, platelets, and CPK are necessary. Snake venom may cause life-threatening bleeding; thus, obtaining this laboratory work is critical. Obtaining type and crossmatch is necessary for the event blood products will be necessary. A common blood product used to treat coagulopathy caused by snake venom is fresh frozen plasma (FFP). ✓ Venomous snake bites can be fatal if emergency treatment is not promptly obtained. ✓ The client should immobilize the affected extremity, remove any jewelry, and seek emergent care. ✓ The local poison control will determine antivenom treatment. ✓ The nurse should obtain vital signs, initiate intravenous (IV) therapy, collect laboratory work, and monitor bleeding, neurovascular compromise, shock, and renal failure. ✓ The nurse should also contact poison control for guidance on the client's care.

The newly hired nurse is caring for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up? A. Applying a tourniquet proximal to the bite. B. Removing the client's wristwatch and jewelry. C. Establishing intravenous (IV) access. D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).

A Choice A is correct. Mashed bananas are an acceptable food choice for an infant with celiac disease. Bananas are 100% gluten-free. Bananas are safe for an infant if they are mashed. Choices B, C, and D are incorrect. Barley, rye, oats, and wheat contain gluten. These products contain gluten and should be excluded from the diet. Oats are not gluten-free; when processed and transported, they get contaminated by coming into contact with other gluten-containing products. ✓ Celiac disease may develop in infants as early as six months when solids are introduced. ✓ Often, for infants, a lag occurs between the introduction of gluten and the onset of symptoms. ✓ Manifestations of celiac disease include steatorrhea, malnutrition, abdominal distention, irritability, and iron deficiency. ✓ Consultation with a registered dietitian may help craft a diet that excludes or minimizes exposure to gluten. Foods such as fruits, vegetables, meat and poultry, fish and seafood, dairy, beans, legumes, and nuts are naturally gluten-free.

The nurse assists parents in picking out food for an 11-month-old child with celiac disease. Which food should the nurse recommend? A. Mashed bananas B. Oatmeal C. Wheat mini-pancakes D. Pieces of a bran muffin

C Choice C is correct. Trichomoniasis is a protozoan infection primarily spread through sexual contact. The treatment for this infection is metronidazole because of its antibiotic and antiprotozoal properties. This effective treatment may be prescribed in a single dose or over several days. Choices A, B, and D are incorrect. A 24-hour urine collection is not necessary to diagnose or verify the diagnosis of Trichomoniasis. This infection is primarily diagnosed by swabbing the vagina and viewing it under wet-mount microscopy. Contact precautions are not used for this infection because the primary mode of transmission is through sexual contact. This infection is not reported to public health services, unlike other sexually transmitted infections (syphilis, gonorrhea, chlamydia). ✓ Trichomonas vaginalis causes Trichomoniasis. ✓ Trichomonas vaginalis is a protozoan parasite primarily spread via sexual contact. ✓ This infection is only found in humans and may cause symptoms in females such as thin, malodorous vaginal discharge that is yellow/green. ✓ Other manifestations include pelvic pain and dyspareunia ✓ Males are commonly asymptomatic. However, they may have symptoms such as urethritis with purulent discharge. ✓ Treatment of this infection is a prescription of metronidazole which may be given in a single dose.

The nurse cares for a client newly diagnosed with Trichomonas vaginalis. The nurse plans to take which appropriate action? A. Start a 24-hour urine collection B. Initiate contact precautions C. Obtain a prescription for metronidazole D. Contact the local health department

D Choice D is correct. This is an appropriate and assertive response that not only that accomplishes the primary goal of keeping the client safe, but does so while avoiding infringing upon the HCP's rights. Additionally, by bringing in a third party (such as a pharmacist or unit manager), not only will the issue be clarified, but the situation will likely be diffused. Choice A is incorrect. In addition to being an aggressive and unprofessional form of communication, as a nurse, you would never intentionally administer a medication knowing it would harm the client. Here, the client's current bradycardia would be further reduced by administering the additional digoxin dose. Additionally, the client's hypokalemia increases the risk of digoxin toxicity. Therefore, a nurse would be correct in declining to administer this medication regardless of what the HCP has threatened. Choice B is incorrect. In addition to this being an unprofessional comment, nurses typically should listen to the health care provider (HCP). Choice C is incorrect. This comment is an aggressive and unprofessional form of communication. Although the health care provider (HCP) acted unprofessionally does not necessitate the nurse to do so as well.

The nurse caring for a client with cardiac arrhythmias is alerted to a new order from the health care provider (HCP) to administer an additional digoxin dose to the client. The nurse reassesses the client and the client's most recent lab values from that morning before relaying to the HCP that the client's heart rate is 40 BPM and serum potassium was 2.8 mmol/L. The HCP, however, insists and threatens, "Give the digoxin now, or I will have you fired!". The most appropriate response by the nurse would be: A. "Fine. I'll give the digoxin now, but this client will die." B. "I don't have to listen to you." C. "Don't you raise your voice at me again, or we'll see who gets fired." D. "I think we should discuss this with the pharmacist or the unit manager first."

D Choice D is correct. CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death. Choices A, C, and D are incorrect. A common misconception about CO poisoning is that it causes a decrease in SpO2. This is not accurate because pulse oximetry does not differentiate COHb from oxyhemoglobin. It is entirely plausible and likely that the client has a normal SpO2. CO poisoning would not cause hyperarousal. Instead, it would cause the client to experience dizziness and lethargy. As a compensatory mechanism from the falling cardiac output, tachycardia is commonly seen - not bradycardia.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding? A. Decreased pulse oximetry (SpO2) B. Hyperarousal C. Bradycardia D. Headache

Notify the rapid response team (RRT) Shout for the code cart/defibrillator Assess the client's carotid pulse and assess if the client is breathing Start chest compressions at 100 to 120/minute Provide rescue breaths When a nurse arrives at a scene where a client is unresponsive, the nurse should immediately summon help by activating the RRT. Once the team has been called, the nurse should request the code cart/defibrillator come to the bedside. Having the defibrillator readily available will ensure that emergency medications and any countershock can be delivered without delay. The nurse should then assess the client to see if they are breathing and check for a carotid pulse for no more than ten seconds. If a pulse is not palpable, the nurse should start chest compressions at 100 to 120 per minute. Once thirty compressions have been administered; the nurse should provide two rescue breaths. Once an AED arrives, the nurse should apply the AED (or defibrillator) and determine if the client has a shockable rhythm, such as ventricular tachycardia without a pulse or ventricular fibrillation. When performing CPR, the nurse needs to minimize interruptions and focus on providing effective compressions and ventilations ✓ A compression rate of 100-120/minute is desired ✓ An AED should be made available as urgently as possible ✓ Assessing for a pulse should not take more than ten seconds ✓ When obtaining a pulse for an infant, the nurse should assess the brachial artery. For a child and adult, the nurse will use the carotid artery ✓ Immediate family members should be allowed to be present during resuscitation as this has promoted better grieving

The nurse enters the room of a client who is unresponsive on the ground. The nurse should perform which actions? Place the actions the nurse should take in the appropriate order.

D Choice D is correct. Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. This is a major complication of appendicitis, and the nurse must immediately follow up with this client because a perforated appendix may quickly progress to peritonitis and then sepsis. Choices A, B, and C are incorrect. A stage III pressure ulcer that tests positive for Pseudomonas aeruginosa requires general follow-up because the nurse needs to initiate contact precautions and notify the primary healthcare provider (PHCP) about this result. Following the surgical creation of a stoma for an ileostomy or colostomy is expected to be edematous. The swelling likely will resolve within three to six weeks. The stoma being red is an optimal finding because that indicates effective perfusion. The client refusing breakfast with a blood glucose of 76 mg/dL requires general follow-up because the client's blood glucose is on the lower end of normal. However, this client is not hypoglycemic (< 70 mg/dL) and is not at risk for immediate harm. ✓ Appendicitis is an emergency that features pain in the right lower quadrant, nausea and vomiting, fever, leukocytosis, and anorexia. ✓ Appendicitis may be caused by obstruction, leading to inflammation and pressure. ✓ Nursing care for appendicitis includes - Maintaining nothing by mouth (NPO) status. Initiating an intravenous (IV) catheter. Administering prescribed antibiotics and IV fluids. Preparing the patient for surgery. The client should be monitored for perforation, which may manifest as abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees.

The nurse has become aware of the following client situations. The nurse should first follow up with the client who A. is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa. B. is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma. C. has type 2 diabetes mellitus and has a morning blood glucose level of 76 mg/dL, and refuses breakfast. D. is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip.

B Choice B is correct. A pulse deficit is a difference between the apical and peripheral pulses. This finding may signal that the client has a dysrhythmia, and the nurse should consider obtaining a 12-lead electrocardiogram and/or continuous telemetry monitoring. Choices A, C, and D are incorrect. A widened pulse pressure is the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP). For example, the client's blood pressure is 170/69 mm Hg. A pulse pressure greater than 40 mm Hg is considered widened. Pulsus paradoxus is an exaggerated decrease in systolic blood pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle (normal is 3 to 10 mm Hg); indicative of cardiac tamponade. A pulse deficit is not an expected finding and requires follow-up. ✓ A pulse deficit is the difference between the apical and peripheral pulses ✓ It is not expected that a pulse deficit should occur ✓ A pulse deficit may suggest that the client is experiencing a dysrhythmia such as atrial fibrillation

The nurse has collected a client's vital signs. The nurse notes that the client's apical pulse was 75 beats per minute, and the radial pulse was 69 beats per minute. The nurse should document this finding as A. a widened pulse pressure. B. a pulse deficit. C. pulsus paradoxus. D. an expected finding.

B Choice B is correct. Enterobiasis (pinworm) infection is characterized by intense nocturnal perianal itching. The child's nails should be short to avoid injury to the area, which may trigger cellulitis. Further, the short nails will decrease the likelihood of ova under the nail, which will cause reinfection and/or infecting others. Choices A, C, and D are correct. Showering is recommended over a tub bath because the water in the bath is contaminated with the parasite. The child should wash their hands more frequently, especially after using the bathroom. The ova survive under the nails, so reviewing hand hygiene with the child is essential. There is no need for the child to stay home during this infection, as appropriate hand hygiene will prevent the transmission of this parasite. ✓ Pinworm infestation is the most common helminthic infection in the United States. ✓ Enterobiasis infestation is seldom harmful, and reinfestation is common, as ova deposited in the environment can survive three weeks. ✓ Pinworm eggs may be ingested when people touch their mouth after they scratch their perianal area or handle contaminated clothes or other objects (e.g., bed linens). ✓ Treatment is available over the counter and may need to be repeated if the hygiene habits are not implemented. ✓ The oral treatment will need to be repeated in two weeks to ensure total eradication of the parasite. ✓ The nurse should recommend that the child adheres to strict hand hygiene, cut the nails short to prevent ova under the nails, and do daily showering. ✓ It is also recommended that linens are washed with warm water.

The nurse has instructed the parents of a child with an enterobiasis (pinworm) infection. Which statement by the parent would indicate a correct understanding of the teaching? A. "I will ensure my child takes a tub bath every night." B. "I will keep my child's fingernails short." C. "I will limit the number of times my child washes their hands with soap and water." D. "My child should stay home from school during the infection."

A, C Choices A and C are correct. A direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant's red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis (Choice C). Choice B is incorrect. The direct Coombs test does not measure antibodies in the maternal serum. Instead, the indirect Coombs test does this. Choice D is incorrect. The indirect Coombs test will check to see if the mother is at risk for Rh immunization.

When interpreting results from a direct Coombs test, you know that a positive result indicates which of the following? Select all that apply. A. Maternal antibodies are present on the infant's red blood cells. B. Antibodies are present in the maternal serum. C. The infant is at risk for erythroblastosis fetalis. D. The mother is at risk for Rh immunization.

B, E Choices B and E are correct. Frequent skin assessments should occur by the parents because the straps may dig into the skin, causing breakdown. This should be reported to the PHCP for a potential adjustment of the straps. Gentle massage of the skin under the straps to stimulate circulation is permitted. Choices A, C, D, and F are incorrect. These statements indicate ineffective teaching and require follow-up. The harness should not be removed during feedings or while the infant is napping. The harness should be applied as directed by the prescriber, but generally, it is worn 24 hours a day. The healthcare provider should remove, adjust, and apply the harness. Tight clothing is discouraged because this may cause the knees to come together, negating the therapeutic use of the harness. The legs of the infant should not be pulled during a diaper change because this may cause further injury to the hip. It is recommended that the diaper change be performed by lifting the baby from under the buttocks and slide the diaper under. The diaper should be under the harness - not over. The Pavlik harness is a treatment method for developmental dysplasia of the hip (DDH) ✓ Treatment before 2 months often achieves the highest rate of success ✓ Treatment involves the application of a harness, casting, or surgery ✓ For the newborn to 6 months, the Pavlik harness may be applied ✓ This harness is applied, adjusted, and removed by the PHCP - not the parents ✓ The goal of the harness is to prevent hip extension and adduction ✓ Skin care is important while a client is wearing the harness ✓ Skin should be checked frequently for any reddened areas or overt skin breakdown ✓ Lotions and powders should not be used because of the potential for fungal dermatitis ✓ The diaper should be placed under the straps ✓ The infant should be dressed in loose, stretchy clothing ✓ If the straps get soiled, gentle soap and water via a washcloth may be used ✓ Provide sponge baths to the infant while leaving the harness in place ✓ Frequent follow-up appointments are necessary because the infant is growing

The nurse has provided discharge instructions to the parents of an infant with a newly applied Pavlik harness. Which of the following statements by the parents would indicate effective teaching? Select all that apply. A. "I will remove the harness during feedings." B. "I will check for red areas under the straps and at the skin folds." C. "I will take off the harness while my baby is napping." D. "I will dress my baby in tight clothing." E. "I will gently massage the skin under the straps to stimulate circulation." F. "When I change my baby's diaper, I should pull their legs."

A, C, D Choices A, C, and D are correct. These statements require follow-up because they are not correct. The harness should not be removed during feedings. The harness should be applied as directed by the prescriber, but generally, it is worn 24 hours a day. The healthcare provider should remove, adjust, and apply the harness. Lotion and powders should not be placed under the straps because that may cause dermatitis. The diaper is placed under the straps to avoid soiling the harness. Choices B and E are incorrect. Frequent skin assessments should occur by the parents because the straps may dig into the skin, causing breakdown. This should be reported to the PHCP for a potential adjustment of the straps. Gentle massage of the skin under the straps to stimulate circulation is permitted. The Pavlik harness is a treatment method for developmental dysplasia of the hip (DDH) ✓ Treatment before 2 months often achieves the highest rate of success ✓ Treatment involves the application of a harness, casting, or surgery ✓ For the newborn to 6 months, the Pavlik harness may be applied ✓ This harness is applied, adjusted, and removed by the PHCP - not the parents ✓ The goal of the harness is to prevent hip extension and adduction ✓ Skin care is important while a client is wearing the harness ✓ Skin should be checked frequently for any reddened areas or overt skin breakdown ✓ Lotions and powders should not be used because of the potential for fungal dermatitis ✓ The diaper should be placed under the straps ✓ The infant should be dressed in loose, stretchy clothing ✓ If the straps get soiled, gentle soap and water via a washcloth may be used ✓ Provide sponge baths to the infant while leaving the harness in place ✓ Frequent follow-up appointments are necessary because the infant is growing

The nurse has provided discharge instructions to the parents of an infant with a newly applied Pavlik harness. Which of the following statements by the parents would indicate the need for additional teaching? Select all that apply. A. "I will remove the harness during feedings." B. "I will check for red areas under the straps and at the skin folds." C. "I will apply moisturizing lotion under the straps." D. "I will place the diaper over the straps." E. "I will gently massage the skin under the straps to stimulate circulation."

A, B Choices A and B are correct. Enterobiasis (pinworm) infections are a parasite that classically causes intense perianal itching that most commonly occurs at night. This constant itching causes the child to have sleep disturbances that may cause daytime irritability because of poor sleep. Choices C, D, and E are incorrect. An altered bowel pattern is not expected with this condition. Ribbon-like stools are a feature of Hirschsprung's Disease. Fever is not expected with this condition. ✓ Pinworm infestation is the most common helminthic infection in the United States. ✓ Enterobiasis infestation is seldom harmful, and reinfestation is common, as ova deposited in the environment can survive three weeks. ✓ Pinworm eggs may be ingested when people touch their mouth after they scratch their perianal area or after they handle contaminated clothes or other objects (e.g., bed linens). ✓ Treatment is available over the counter and may need to be repeated if the hygiene habits are not implemented. ✓ The oral treatment will need to be repeated in two weeks to ensure total eradication of the parasite. ✓ The nurse should recommend that the child adheres to strict hand hygiene, cut the nails short to prevent ova under the nails, and do daily showering. ✓ It is also recommended that linens are washed with warm water.

The nurse is assessing a child with enterobiasis (pinworm) infection. Which of the following would be an expected finding? Select all that apply. A. Intense perianal itching B. Poor sleep C. Constipation D. Ribbon-like stools E. Fever

D Choice D is correct. An ABG is vital to a client on a ventilator. The ABG allows the clinical team to determine the client's oxygenation status (PaO2) on modes such as continuous positive airway pressure (CPAP), often used before the mechanical ventilator is discontinued. If a client is not oxygenating well on CPAP, they are unlikely to be weaned from the mechanical ventilator. Choices A, B, and C are incorrect. These clinical parameters will be monitored while a client is receiving mechanical ventilation. A sputum culture is helpful if the client has any respiratory infection, as the specific pathogen can be identified, which will trigger the most appropriate treatment. However, a sputum culture will not provide information on whether a client is ready to be weaned. A chest x-ray helps determine the advanced airway placement and detect any acute or pulmonary disease. A CXR would not discern a client's oxygenation status like an ABG. Lung sounds are essential for any assessment but would not determine if the client is ready for weaning. For a client receiving mechanical ventilation, clinical indicators that they are ready for weaning include their ability to take spontaneous breaths, oxygenate themselves at a reasonable FiO2 level, a normalized pH, and hemodynamic stability. When caring for a client on a ventilator, you should be familiar with the following settings: Mode (Volume [SIMV, A/C] or Pressure [PSV]) Rate (Number of breaths per minute) Tidal volume (the amount of gas delivered to the client) Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath) PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis) Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

The nurse is assessing a client receiving mechanical ventilation. Which clinical data is most important to review before weaning the client off the ventilator? A. Chest x-ray B. Sputum culture C. Lung sounds D. Arterial blood gas (ABG)

B Choice B is correct. You would instruct the new UAP that the inner canthus of the eyes should be washed first, followed by the outer canthus of the eyes. Once the eyes have been cleansed in this manner, the UAP may then move on to the remainder of the face. Choice A is incorrect. As described in Choice B, the forehead is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the forehead region. Choice C is incorrect. As described in Choice B, the outer canthus is not the correct area to cleanse first; therefore, you would not provide positive feedback to a UAP who initiates a bed bath by cleansing the outer canthus prior to the inner canthus. Choice D is incorrect. Before performing this bed bath, the UAP correctly performed hand hygiene and donned clean gloves. Sterile gloves are not needed when performing a bed bath and instructing the UAP to don sterile gloves would be incorrect. To reduce the risk of infection, always perform hygiene measures while moving from cleanest to less clean or dirty areas. This often requires you to change gloves and perform hand hygiene during care activities. Begin with the inner canthus and move to the outer canthus. Bathing the eye from inner to outer canthus prevents secretions from entering the nasolacrimal duct. When washing a client's eyes, use plain warm water, as soap irritates the eyes. Use different sections of the washcloth or mitt for each eye to avoid transmission of any infection. Any rough patches may need to be soaked prior to removal. Gently, but thoroughly, dry the eyes as pressure can cause internal injury.

The nurse is assigned to supervise a new unlicensed assistive personnel (UAP) in completing personal hygiene tasks. Following the UAP gathering the needed supplies, performing hand hygiene, and donning clean gloves, you observe the UAP provide a bed bath to an elderly client on complete bed rest. The UAP begins by first washing the client's forehead. What should be the nurse's next action? A. Praise the new UAP because they have correctly washed the client's forehead first. B. Instruct the UAP that the inner canthus of the eyes should be washed first and use a new washcloth to do so. C. Instruct the new UAP that the outer canthus of the eyes should be washed first. D. Have the UAP stop and don sterile gloves for the bed bath

1420 mL

The nurse is calculating intake for a client. The client received one 100 mL intravenous antibiotic One eight-ounce cup of ice chips One eight-ounce cup of coffee One eight-ounce cup of ice cream Three eight-ounce cups of water The nurse should calculate the client's total intake as how many mL? Fill in the blank.

2340 mL

The nurse is calculating the 12-hour intake for a client The client received 0.45% saline at 85 mL/hr One eight-ounce cup of ice chips One eight-ounce cup of coffee One eight-ounce cup of ice cream Three eight-ounce cups of water One eight-ounce cup of pureed vegetables The nurse should calculate the client's total liquid intake as how many mL? Fill in the blank.

C Choice C is correct. Most eye injuries require a visual acuity exam which assesses a client's ability to read and identify distant objects. This is a standard assessment for any eye injury. Choices A, B, and D are incorrect. Rubbing the eye with a foreign body may cause an injury to the cornea. Hydrogen peroxide should not be used in the eye as it will cause serious injury. If the eye should be irrigated, sterile saline should be used. Placing a cold compress on the eye is an intervention for an eye contusion. ✓ For a foreign object in the eye, the client should not rub the eye because the object may cause damage to the cornea. ✓ A visual acuity examination should be obtained for any client with an ocular injury. ✓ To remove the object, have the client look upward, exposing the lower lid, wet a cotton-tipped applicator with sterile normal saline, gently twist the swab over the particle, and remove it. ✓ If the object has caused a corneal injury, prompt administration of ocular antibiotics will be necessary.

The nurse is caring for a child who reportedly got a wood chip in their right eye. The nurse should take which appropriate action? A. Rub the eye until the object dislodges B. Irrigate the affected eye with hydrogen peroxide C. Perform a visual acuity exam D. Place a cold compress on the affected eye

B Choice B is correct. A client experiencing an adrenal crisis (Addisonian crisis) tends to have significant hypovolemia and hyponatremia. Because of the deficiency of steroid hormones, distributive shock may follow. Restoring the circulatory volume is essential in the management of this crisis. Isotonic solutions such as 0.9% saline or D5NS ( dextrose 5% in water combined with 0.9% saline) must be used. Isotonic saline can address both hypovolemia and hyponatremia in the adrenal crisis. If there is concomitant hypoglycemia, the D5NS solution is preferred to increase the glucose, sodium, and circulatory volume. Choices A, C, and D are incorrect. Although lactated ringers (LR) is an isotonic solution, it is inappropriate in managing an adrenal crisis because the client is experiencing concomitant hyponatremia. LR will not correct the hyponatremia ( Choice A). D5W is hypotonic and would be detrimental if given by itself because it would increase the free water and lower the sodium further by dilution ( Choice C). D5LR has a limited benefit in an adrenal crisis because of its inability to raise sodium levels ( Choice D).

The nurse is caring for a client experiencing an adrenal crisis (Addisonian crisis). The nurse should be prepared to administer which intravenous fluid? A. Lactated Ringers (LR) B. 0.9% saline C. Dextrose 5% in water (D5W) D. Dextrose 5% in water and Lactated Ringers (D5LR)

B Choice B is correct. Peritonitis is an intra-abdominal severe infection that has a significant mortality rate. Peritonitis may originate from perforation (appendix, intestine, etc.), which causes a significant amount of fluid and bacteria to shift into the peritoneum. The priority treatment in peritonitis is administering prescribed antibiotics such as ciprofloxacin, metronidazole, or ceftriaxone. Choices A, C, and D are incorrect. Pantoprazole is a proton pump inhibitor used to treat esophageal reflux and peptic ulcer disease. Lactulose is indicated in the management of hepatic encephalopathy that reduces the amount of ammonia by having the client stool more often. Loperamide is an antidiarrheal effective in the treatment of diarrhea. None of these medications are directly used in the management of peritonitis. Clinical manifestations of peritonitis include ✓ Rigid, board-like abdomen ✓ Distended abdomen ✓ High fever ✓ Tachycardia ✓ Diffuse abdominal pain that continues to intensify ✓ Decreased bowel sounds and GI motility

The nurse is caring for a client who has just been diagnosed with peritonitis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Pantoprazole B. Ciprofloxacin C. Lactulose D. Loperamide

C Choice C is correct. Depression and anxiety can still be effectively treated while a client is pregnant. SSRIs (citalopram, sertraline, fluoxetine) can be effectively continued while a client is pregnant to cause mood stabilization and prevent depressive episodes. The only SSRI likely to be switched is paroxetine because of its slight risk for teratogenicity. Thus, the client may have to be switched to a safer agent like sertraline if they take paroxetine. Even electroconvulsive therapy (ECT) is safe for a pregnant client. Choices A, B, and D are incorrect. These statements are false. Not treating antenatal depression and anxiety disorders may put the client at risk for destabilizing their mood, which at worse, could lead to self-harm. Thus, depression may be effectively managed with the vast majority of SSRIs. Pregnancy does not specifically put depression into remission. Depression may actually worsen with pregnancy because of the fluctuating hormone levels. SSRI usage does not trigger an automatic cesarean section at delivery. ✓ SSRIs are generally safe to continue during pregnancy, except for paroxetine. ✓ A client with unipolar depression and anxiety disorders should continue treatment as prescribed. ✓ If a client has ADHD, amphetamines are preferred over methylphenidate for their safety profile.

The nurse is caring for a client who is six weeks pregnant and inquires about her prescribed antidepressant. Which statement, if made by the client, would indicate effective understanding? A. "I will need to stop my antidepressant until after I have delivered." B. "I will not need an antidepressant while pregnant because pregnancy causes depression remission." C. "I may have to switch to a new antidepressant while I am pregnant." D. "If I continue my antidepressant medication, I must undergo a cesarean section at delivery."

A Choice A is correct. Electrical burns are serious and require the client to undergo cardiac monitoring because of the risk of dysrhythmias. The nurse's priority action is to obtain telemetry monitoring or perform a 12-lead electrocardiogram. Choices B, C, and D are incorrect. These types of burns cause an 'iceberg' effect where the client's external injuries appear minor, but the internal injuries may be catastrophic. Electrical burns may trigger immediate ventricular fibrillation or asystole. Thus, it is important to monitor the client's cardiovascular status immediately following this type of injury. Electrical burns may be caused by lightning or weapons such as tasers. Additionally, exposure to live power wires may cause this type of injury. The longer the electricity is in contact with the body, the greater the damage. Thus, it is a priority to terminate the electrical source (if possible) and then render care. The care that should be provided includes an immediate assessment of the client's cardiovascular status because of the chance of fatal dysrhythmias. Accidental electrical injuries may be avoided by refraining from inserting objects into an electrical plug. Electrical devices should not be used near a body of water. Finally, any frayed electrical cords should be replaced.

The nurse is caring for a client who sustained an electrical burn. The priority action the nurse should take is to perform A. Electrocardiogram (ECG) B. Arterial blood gas (ABG) C. Wound care D. Initiate supplemental oxygen

D Choice D is correct. CO poisoning requires aggressive oxygenation at a FiO2 of 100%. A nonrebreather is the only delivery device to provide this high oxygen level beyond mechanical ventilation. Choices A, B, and C are incorrect. CO poisoning requiring 100% oxygenation would exclude these devices. A nasal cannula can deliver 1-6 L/min for oxygen concentration (FiO2) of 24% (at 1 L/min) to 44% (at 6 L/min). Venturi mask can deliver 4-10 L/min oxygen flow for FiO2 of 24%-55%. A simple face mask can deliver 5-8 L/min oxygen flow for FiO2 of 40%-60%. ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

The nurse is caring for a client with carbon monoxide (CO) poisoning. The nurse anticipates administering oxygen via A. nasal cannula. B. venturi mask. C. simple mask. D. nonrebreather mask.

A Choice A is correct. Hyponatremia is a classic clinical feature associated with the syndrome of inappropriate antidiuretic hormone (SIADH). The hyponatremia may become severe and cause the client to have an altered mental status (AMS). This AMS is concerning because this signals that the serum sodium is quite low and warrants immediate intervention. Choices B, C, and D are incorrect. Expected findings associated with SIADH include increased urine-specific gravity (concentrated urine), oliguria (reduced urinary output), and inappropriately increased thirst. These are expected findings, so they would not require immediate follow-up. It is important to note that increased thirst can be seen both in diabetes insipidus as well as SIADH. Plasma osmolality is the primary factor that regulates antidiuretic hormone (ADH) and thirst. Most of the osmolality is determined by the sodium content. If the osmolality increases, it stimulates ADH release and increases thirst. If osmolality decreases, it suppresses ADH and thirst. The normal function of ADH is to retain water. However, there is inappropriate ADH secretion in SIADH, and this general feedback between plasma osmolality, ADH, and thirst regulation is lost. Despite low sodium and low osmolality, there is inappropriately high ADH and inappropriately increased thirst. Inappropriately increased thirst in SIADH is felt to be because of the downward resetting of the osmotic threshold in the thirst center.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up? A. Disorientation B. High urine specific gravity C. Oliguria D. Increased thirst

A, B, D Choices A, B, and D are correct. A: Patients with dementia often experience increased confusion during evenings (sundowning effect) and may not be able to effectively communicate their needs. Cognitively impaired patients who frequently try to get out of bed at night may be attempting to get to the bathroom. This nurse and other members of the patient's care team should implement a toileting schedule for this patient to reduce unsafe attempts and prevent incontinence. B: Placing this patient near the nurses' station would be appropriate since it would allow for faster assistance/alarm response and more frequent assessments. D: Electronic bed and chair alarms would be an appropriate, non-restraint intervention for this patient that would help to reduce the risk of falls by signaling to staff that the patient may be attempting to get out of bed. Choice C is incorrect. Full-length bedrails are a form of physical restraint when used to prevent the patient from getting out of bed. Confused patients may not recognize the bedrail as a reminder to stay in bed, and studies have shown that routine use of these barriers can increase the risk of falls and injury.

The nurse is caring for a patient with dementia who exhibits increased confusion during the evenings and frequently attempts to get out of bed. Which interventions would be appropriate for the nurse to implement before resorting to physical restraints? Select all that apply. A. Initiate toileting schedule B. Place patient near the nurses' station C. Keep one bedrail fully up and the other side half up D. Implement electronic bed alarm

D Choice D is correct. This is the most appropriate response by the nurse. She correctly explains to the client that the sharp tortilla chips would be really hard on the surgical site after a tonsillectomy. Allowing clients to eat foods like chips or popcorn after surgery in the back of the throat would put them at risk for damage to the incision and subsequent hemorrhage. Offering the client something soft, such as jello or soup, is what is most appropriate. Choice A is incorrect. This is not an appropriate response. The client should not be eating anything hard or sharp like chips after a tonsillectomy. That food could damage the surgical area at the back of the throat and cause postoperative complications such as hemorrhage and sore throat. Choice B is incorrect. This is not an appropriate response. It is fine for the client to eat, but they will need to start with a soft diet in order to protect the surgical site. It is not necessary to keep the client NPO after their surgery has finished and the gag reflex has returned. Choice C is incorrect. This is not an appropriate response. Although the nurse correctly identified that chips are not a good choice after surgery, she gave the client incorrect information about the reason. Clients after a tonsillectomy need a soft diet, not a diet that is high in protein.

The nurse is caring for a teenager who is recovering from a tonsillectomy. The nurse walks into the room and sees the client eating chips and salsa from a Mexican restaurant. Which response by the nurse is most appropriate? A. "I love that restaurant! Their chips are so good." B. "You cannot eat anything yet, I am sorry." C. "Chips are not a good choice right now because you need a high protein diet after your surgery." D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now."

C Choice C is correct. A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress. Choices A, B, and D are incorrect. An NGT is not necessary following this procedure. Following a CL repair, some infants can return to breastfeeding or bottle feeding, where some may have to be fed via a syringe. A bottle of sterile water is necessary if a client has a chest tube and it becomes disconnected from the drainage system. A chest tube is not used in this surgery. A tracheostomy is necessary at the bedside for a client immediately after a thyroidectomy, which may be used if the client gets airway edema. ✓ Following a cleft lip repair, some surgeons allow the infant to return to breastfeeding or bottle-feeding, whereas others require syringe-feeding once the child is awake and alert. ✓ The nurse should provide pain management which may include acetaminophen. ✓ The nurse should ensure that no rigid objects are inserted into the mouth that may disrupt the suture line. ✓ After the infant is fed, the suture line may be cleaned with water, and a thin layer of antibiotic ointment may be applied. ✓ Finally, the infant should not be positioned prone and positioned to prevent airway obstruction. ✓ The ideal position is the infant positioned on their back, slightly upright.

The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure? A. Nasogastric tube (NGT) B. Bottle of sterile water C. Suction equipment D. Tracheostomy

B Choice B is correct. The nurse should emphasize the manifestations associated with an asthma attack. Although deaths from asthma attacks have considerably declined, the nurse needs to convey that symptoms such as chest tightness, increased respirations, accessory muscle use, and audible wheezing are to be immediately addressed by administering prescribed albuterol via an inhaler. Choices A, C, and D are incorrect. These are pertinent topics to discuss with the child and his parents. However, unlike an unrecognized asthma attack, they do not present any danger to the child. Teaching for asthma can be lengthy and best completed using written and verbal instructions. Use of a Peak Expiratory Flow Meter 1. Before each use, ensure the sliding marker or arrow on the peak expiratory flow meter is at the bottom of the numbered scale. 2. Stand up straight. 3. Remove gum or food from your mouth. 4. Close your lips tightly around the mouthpiece. Be certain to keep your tongue away from the mouthpiece. 5. Blow out as hard and as quickly as you can, a "fast, hard puff." 6. Note the number by the marker on the numbered scale. 7. Repeat the entire routine three times, but wait at least 30 seconds between each. 8. Record the highest of the three readings, not the average. 9. Measure your peak expiratory flow rate (PEFR) close to the same time and the same way each day (e.g., morning and evening, before and 15 minutes after taking medication). 10. Keep a record of your PEFRs.

The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is A. how to use a peak flow meter. B. signs and symptoms of an asthma attack. C. the need to stay current with immunizations. D. community resources available for asthma management

C Choice C is correct. For a client with congestive heart failure prescribed bumetanide, a loop diuretic, the client should verbalize the importance of weighing themselves daily. Their daily weight should be obtained in the morning after the first void. Choices A, B, and D are incorrect. Increasing the intake of protein while taking a loop diuretic is not necessary. It is potassium that should be increased because bumetanide is a potassium-wasting diuretic. Recording the client's urinary output is not necessary, nor is it an accurate way to determine the client's fluid status. Intake and output are crude ways of determining a client's fluid level. Blood pressure should be monitored while a client takes this medication - but not daily. Additionally, this medication does not impact the pulse and thus is irrelevant. Loop diuretics act primarily along the thick ascending limb of the loop of Henle, blocking chloride and, secondarily, sodium resorption. Loop diuretics are also thought to activate renal prostaglandins, which dilate the blood vessels of the kidneys, the lungs, and the rest of the body (i.e., reduction in renal, pulmonary, and systemic vascular resistance). The hemodynamic effects of loop diuretics are a reduction in both the preload and central venous pressures (which are the filling pressures of the ventricles). These actions make them useful in treating the edema associated with heart failure, hepatic cirrhosis, and renal disease. Examples of loop diuretics include - bumetanide, ethacrynic acid, furosemide, and torsemide.

The nurse is counseling a client with congestive heart failure (CHF) about newly prescribed bumetanide. The nurse determines that the teaching has been effective when the client plans to A. increase their daily intake of protein. B. record their daily urinary output. C. weigh themselves daily. D. take their blood pressure and pulse daily.

A Choice A is correct. Primary prevention is often referred to as the true level of prevention because it occurs before disease or illness. Demonstrating the appropriate use of a car seat is primary prevention because it happens before an automobile crash, a leading cause of death for those younger than 19. Choices B, C, and D are incorrect. Demonstrating the use of the car seat before an automobile crash is a primary level of prevention. Please see the additional information section for examples of the other levels of prevention.

The nurse is demonstrating the appropriate use of a car seat to a client. The nurse is demonstrating which level of prevention? A. Primary B. Secondary C. Tertiary D. Quaternary

D Choice D is correct. The nurse is in the planning phase, and the crux of this phase is to identify the purpose of the group, its objectives, individuals who may attend, and weekly topics. Choices A, B, and C are incorrect. The working phase is when the group performs the work, such as communicating with others, doing therapeutic exercises, and strengthening their rapport. The orientation phase is when the nurse ensures that group members feel welcome and understand the group's purpose. Termination is when the nurse recaps the group's successes and future goals. ✓ Therapeutic groups have four phases: planning, orientation, working, and termination. ✓ The planning phase deals with the nurse planning the name of the group, its objectives, types of individuals, setting, and schedule. The nurse should plan a group that involves members that are ready to join. Thus, individuals with psychosis or mania would be inappropriate for therapeutic groups. ✓ The orientation phase deals with the nurse introducing the group, the structure, its purpose, and when the group is to be terminated. The nurse should encourage rapport-building during this phase. ✓ The working phase is when the nurse facilitates problem-solving. The problem-solving should be focused and align with the group's purpose. The nurse should ensure that all members have equality regarding a group's discussion. ✓ The termination phase is when the nurse summarizes the accomplishments and future goals. Some individuals may have difficulty during this phase. To ensure a smooth termination phase, the nurse should inform group participants of when the group will terminate (after three sessions, etc.) during the orientation phase. Participants may exhibit a sense of hostility during this phase if they are not ready to let go.

The nurse is developing group therapy sessions on substance use disorders. The nurse develops weekly topics and plans to host the sessions in a community center. The nurse is in which phase of therapeutic group development? A. Working B. Orientation C. Termination D. Planning

B Choice B is correct. Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence. Choices A, C, and D are incorrect. Diabetes insipidus would not increase the risk of wound disruption, whereas diabetes mellitus would increase the risk of poor wound healing, especially if the diabetes is uncontrolled. Hemophilia is a genetic blood clotting disorder and does not directly cause poor wound healing. Inflammatory bowel disorder is a broad term for Crohn's or Ulcerative Colitis. These conditions do not directly lead to poor wound healing like Cushing's syndrome.

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication? A. Diabetes insipidus B. Cushing's syndrome C. Hemophilia D. Inflammatory bowel disease

D Choice D is correct. This is an appropriate action because it addresses the problem and allows the group to engage in problem-solving, which is the crux of group therapy. The nurse should solicit feedback from other group members on how they feel the group is going or share observations. This tactic, while challenging, promotes problem-solving and reflection, both of which are essential in therapy. Choices A, B, and C are incorrect. Asking the client to leave the session is inappropriate and would ultimately delay the client's ability to meet their therapeutic goals. The client needs to recognize that they are monopolizing the group and that leaving would not have any benefit. The nurse should not stop the session because that would further magnify the disruption, and stopping the session would cause unnecessary delay for the other group members. The nurse needs to address the behavior, so the rest of the group can be productive. Thus, the nurse needs to address the behavior diplomatically. ✓ Therapeutic groups have four phases: planning, orientation, working, and termination. ✓ The planning phase deals with the nurse planning the name of the group, its objectives, types of individuals, setting, and schedule. The nurse should plan a group that involves members that are ready to join. Thus, individuals with psychosis or mania would be inappropriate for therapeutic groups. ✓ The orientation phase deals with the nurse introducing the group, the structure, its purpose, and when the group is to be terminated. The nurse should encourage rapport-building during this phase. ✓ The working phase is when the nurse facilitates problem-solving. The problem-solving should be focused and align with the group's purpose. The nurse should ensure that all members have equality regarding a group's discussion. ✓ The termination phase is when the nurse summarizes the accomplishments and future goals. Some individuals may have difficulty during this phase. To ensure a smooth termination phase, the nurse should inform group participants of when the group will terminate (after three sessions, etc.) during the orientation phase. Participants may exhibit a sense of hostility during this phase if they are not ready to let go.

The nurse is leading a group therapy session on substance use disorders. The nurse observes that a client is monopolizing the session. The nurse should take which appropriate action? A. Ask the client to leave the therapy session B. Stop the session to review the rules with the group C. Allow the client to express themselves uninterrupted D. Ask the group if they would like to share their observations about other members

C Choice C is correct. The premise of social justice is expanding access to affordable healthcare for all individuals. The nurse recommending health services for underserved areas is a way to improve health inequalities in the community. Another example would be the nurse endorsing expanding health services and eligibility for Medicaid. Choice A is incorrect. Establishing interdisciplinary collaboration between nursing and nutritional services does not focus on the community, as the focus is on two professional departments and no clear beneficiary. Providing more confidential waste containers at local drug stores relates to promoting confidentiality as this does not expand the offering of medical services. Offering inpatient clients the ability to select their meal times aligns with the nurse promoting autonomy. ✓ The primary focus of healthcare justice is the fair and equitable treatment of individuals. ✓ The goal is to expand access so all individuals may enjoy healthcare regardless of their culture, gender, age, or income status. ✓ The nurse promoting programs and services that targes underserved areas are a prime example of promoting this type of justice.

The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal? A. Establishing interdisciplinary collaboration between nursing and nutritional services B. Providing more confidential waste containers at local drug stores C. Offering free telehealth offerings in underserved areas of the community D. Offering inpatient clients the ability to select their meal times

Ask the client to void Position the client supine with the knees bent and the arms at their side Place pillows beneath the client's knees Inspect the abdomen Auscultate all four quadrants of the abdomen Palpate the abdomen

The nurse is performing a focused physical assessment. Place the steps in correct order to perform a gastrointestinal assessment. Place the steps in the appropriate order.

B Choice B is correct. Admission status is essential information provided in the hand-off report because involuntary admission requires the client to stay in the healthcare facility. This status is typically required when a client may pose a threat to themselves or others. This type of involuntary admission status also may raise the risk of the patient eloping. This should be communicated because if a client is involuntarily admitted, they may not have a rational thought process which may raise the risk of self-injury if they do successfully elope. Choices A, C, and D are incorrect. The current medication list is generally not communicated during the hand-off report. Hand-off reports should include new prescriptions or prescriptions pertinent to the client's care. The oncoming nurse may easily obtain this list by accessing the medication administration record. Food and mealtime preferences are important to delivering client-centered care but do not prioritize the client's admission status. Finally, the presence of family at the bedside may be irrelevant unless pertinent family dynamics impact care. When a client is admitted involuntarily, the nurse should still respect the client's autonomy for treatment decisions (this includes the right to refuse medication). The exception to this rule is if the client is experiencing a behavioral crisis and requires emergent medications for stabilization. This requires the prescriber to note their reasoning. Additionally, a client's right to refuse medications may be overridden by a court order (for example, a court order stating that the client must take risperidone for stabilization).

The nurse is performing a verbal hand-off report for a client. Which essential information should the nurse include in the report? A. Current medication list B. Involuntary admission status C. Food and mealtime preferences D. The presence of family at the bedside

D Choice D is correct. Justice is an ethical principle that is centered around equality. By having clients seen in this manner, the nurse is not providing special treatment or preference to a particular individual(s) based on factors such as the ability to pay or ethnicity. Choices A, B, and C are incorrect. Nonmaleficence stems from pertains to doing no harm. The nurse should always engage in client care directed at positive outcomes versus any acts that may cause harm, such as giving medication without verifying a client's identity first. Veracity is the principle directed at the nurse being honest in all situations. Veracity promotes a positive relationship by making the nurse authentic and not deceptive. Paternalism references a healthcare worker making decisions for the client based on their best interest. A paternalistic action would be a physician overriding a client's do not resuscitate status during a code. ✓ Justice emphasizes that the nurse treats all clients equally. ✓ The nurse should be aware of any bias they may have towards an individual(s). ✓ A bias may be mitigated through self-reflection and consulting with a trusted colleague or an ethics advisor.

The nurse is planning a staff development conference about changing the process clients are seen at a clinic to a first come, first served basis. This proposed change will model which ethical principle? A. Nonmaleficence B. Veracity C. Paternalism D. Justice

B Choice B is correct. The primary way HCV is transmitted is through blood exposure which a needle stick may trigger. The nurse should discuss safety regarding the disposal of needles, such as the importance of not recapping needles. Choices A, C, and D are incorrect. HCV does not currently have a vaccine. A vaccine is available for hepatitis A and B, but it is not available for HCV. However, a robust cure for HCV does exist. HCV is not spread through urine or feces. The primary mode of transmission is through the exposure of the infected individual's blood. Individuals with HCV are not isolated and receive standard precautions. ✓ Hepatitis C symptoms have an insidious onset. During the illness, the client may be asymptomatic. ✓ Hepatitis C has an incubation period between 2 weeks and six months. ✓ The virus is spread through infected blood. Thus, hepatitis C may be transmitted via needlesticks, unregulated tattooing, perinatal, and contact with infected blood. ✓ While sexual transmission is possible, the risk is relatively low with sexual contact. ✓ No vaccination exists for hepatitis C; however, robust cures are available for specific genotypes.

The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic? A. How to obtain the HCV vaccine B. How to dispose of sharps safely C. How to dispose of urine and feces for those with HCV D. Isolation precautions for individuals with HCV

A, D Choices A and D are correct. Severe impairments in functioning characterize borderline personality disorder. Its major features are marked instability, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Splitting is a hallmark manifestation of this disorder in which an inability to view both positive and negative aspects of others as part of a whole, results in viewing someone as either a wonderful person or a horrible person. Projection is also a cardinal defense mechanism for this disorder in which an individual unconsciously rejects emotionally unacceptable features and attributes them to others. Choices B, C, and E are incorrect. Sublimation and altruism are generally constructive defense mechanisms and are not employed by clients with BPD. Conversion is characterized by the unconscious transformation of anxiety into a physical symptom with no organic cause. A borderline personality disorder is about five times more common in first-degree biological relatives with the same disorder compared with the general population. This disorder is highly associated with genetic factors such as hypersensitivity, impulsivity, and emotional dysregulation. A key intervention for a client with BPD is to assess for suicidality. Parasuicide is common with this personality disorder; however, it is essential to keep this client safe. Defense mechanisms commonly seen in this personality disorder include splitting, projective identification, and denial.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply. A. Splitting B. Sublimation C. Altruism D. Projection E. Conversion

D Choice D is correct. This needle size and gauge are appropriate for a neonate. When administering IM medications to a neonate or young child, the vastus lateralis is the preferred site. For the volume to be administered in an IM, it is recommended to be 0.5 mL or less for infants; up to 2 mL for children. Choices A, B, and C are incorrect. These needle sizes are not recommended for infants as they can cause excessive pain and trauma to the muscle. ✓ A key advantage of using the vastus lateralis is that an intramuscular (IM) injection may be given if the client is supine, side-lying, or sitting. ✓ Aspiration for routine injections into deltoid or vastus lateralis is not indicated because there are no large blood vessels in these locations. ✓ To locate the vastus lateralis, the nurse should palpate to find greater trochanter and knee joints; divide vertical distance between these two landmarks into thirds; inject into middle third.

The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication? A. 19 gauge, 1 1/2" (3.8 cm) needle B. 18 gauge, 1" (2.5 cm) needle C. 20 gauge, 1" (2.5 cm) needle D. 25 gauge, 5/8" (1.6 cm) needle

C Choice C is correct. Individuals with difficulty obtaining and sustaining housing have high rates of treatment non-adherence. Lack of adequate housing poses a serious threat to treatment adherence because of the lack of privacy, storage of medications, and a sense of detachment from the community. This client should be referred for outpatient services because they are homeless and have a substance use disorder. Both are issues that may be mitigated with community services. Choices A, B, and D are incorrect. Cancer support groups are essential for a client coping with the illness. This would be an appropriate referral, but not the greatest need of a referral considering the client lives with family, which can be viewed as a support system. A client recovering from a stroke requires many interdisciplinary resources and would not need a referral for community services because they are going to inpatient rehab. A client leaving AMA would not require a referral; the serious cellulitis diagnosis is acute and will resolve with antibiotics. An RN may initiate referrals. The nurse should identify clients with the most significant need for community services. Examples of clients needing community services include: Homelessness Complex conditions (HIV, cancer) Insufficient support systems Financial instability

The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services? A. A client newly diagnosed with skin cancer that lives with family. B. A client recovering from a stroke and is discharged to inpatient rehab. C. A client who is homeless and has a substance use disorder. D. A client leaving against medical advice for the treatment of cellulitis.

A Choice A is correct. This statement indicates effective teaching by the nurse. Following cataract surgery, the client should not get any water in the affected eye for three to seven days. This measure will reduce the potential for infection. Choices B, C, and D are incorrect. Following cataract surgery, the client may resume light chores, but activities that may increase the intraocular pressure (normal is 10-21 mm Hg), such as vacuuming, should be avoided for several weeks because of the forward flexion involved and the rapid, jerky movements. Other activities that may raise the intraocular pressure that should be suspended include lifting objects heavier than 10 pounds, straining, vomiting, sexual intercourse, and keeping the head in a dependent position. Creamy, white drainage is normal that may cause crusting (especially in the morning); however, yellow or green drainage is suggestive of infection. Aspirin should not be taken because of its impact on blood clotting. Cool compresses and acetaminophen are generally permitted. ✓ Following cataract surgery, the nurse should educate the client about the prescribed eye drops they will need. It is helpful to write this information out so it may be later referenced. ✓ The nurse should emphasize the need for appropriate follow-up. ✓ Most clients experience a dramatic improvement in their vision following this procedure. However, the maximum benefit may be delayed for up to several weeks. ✓ The nurse should instruct the client to avoid activities that can raise the IOP, such as sexual intercourse, tight shirt collars, and straining during a bowel movement.

The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching? A. "I should avoid getting water in the eye for 3 to 7 days after surgery." B. "It is okay for me to resume normal chores such as vacuuming." C. "It is okay for me to have green or yellow, thick drainage from the eye." D. "I may take aspirin for any pain I may experience."

B Choice B is correct. Diabetes mellitus is known to cause delayed wound healing because of damage to the body's blood vessels. Wound dehiscence occurs when the wound's edges break open at the site. Choice A is incorrect. The development of a URI is not directly a concern in a diabetic patient who has recently received surgery. Choice C is incorrect. Swelling in the residual limb is expected in the first period after surgery. This phenomenon is unrelated to diabetes mellitus. Choice D is incorrect. Redness is expected at the surgical site and is unrelated to diabetes mellitus.

The nurse is providing instructions to the family members of a diabetic patient who has just received a right-side below the knee amputation (BKA). The nurse should inform the family to watch the patient closely for which of the following concerning issues? A. The development of an upper respiratory infection B. Wound dehiscence C. Swelling of the left leg D. Redness at the surgical site

B, E Choices B and E are correct. These statements are false and require follow-up. Digoxin is not a diuretic, and the client does not explicitly need to check the weight daily. Further, visual changes are concerning because they are signs of digitalis toxicity (although the initial sign of digoxin toxicity is anorexia and nausea). However, the client with visual changes should not call their eye doctor. The client should notify the medication prescriber. Choices A, C, and D are incorrect. These statements are true and do not require follow-up. Digoxin has a negative chronotropic effect (which reduces the client's heart rate), and the client should take their pulse before administration (choice A). The minimum pulse before receiving digoxin is 60/minute for an adult. A significant precipitator of digitalis toxicity is hypokalemia. The client should be taught that increasing the amount of potassium in their diet would be effective because it would help prevent hypokalemia (choice C). A disadvantage of digoxin therapy is that it has a narrow therapeutic window. High levels may be life-threatening due to digoxin toxicity. This requires a client to have therapeutic drug monitoring (the optimal therapeutic level is 0.5-2.0 ng/mL, choice D). ✓ Digoxin is a cardiac glycoside utilized in the treatment of atrial fibrillation and heart failure. While this medication has fallen out of favor because of its numerous interactions, this medication is still available. ✓ The apical pulse must be obtained prior to administering this medication. The apical pulse must be at least 60/minute for adults; 70/minute for children; and 90/minute for infants. ✓ The therapeutic level for digoxin is 0.5-2 ng/mL

The nurse is reviewing discharge teaching with a client who was newly prescribed digoxin. Which statement, if made by the client, would require follow-up? Select all that apply. A. "I should take my pulse before taking each dose." B. "This medication will require me to take my weight daily." C. "This medication will require me to have periodic blood work." D. "I will ensure I get plenty of potassium in my diet." E. "If I notice visual changes, I will call my eye doctor."

A, B, C, D, F Choices A, B, C, D, and F are correct. The crux of the vegan diet is that it excludes foods that come from animals, including dairy products and eggs. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Choice E is incorrect. The vegan diet excludes anything from an animal, including seafood, cheese, eggs, and cream. ✓ The vegan diet focuses on no meat or animal fats. ✓ The diet is generally high in fiber. ✓ Foods such as nuts, legumes, tofu, grapefruit, melon, and soy are permitted. ✓ Vegan diet is generally safe during pregnancy but requires appropriate meal planning. ✓ The primary difference between a vegan and a vegetarian diet is that a vegetarian diet includes eggs and dairy.

The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. A. Legumes B. Tofu C. Almonds D. Prunes E. Baked fish F. Grapefruit

A, B, D Choices A, B, and D are correct. The crux of a vegetarian diet is that it excludes foods such as meat, fish, and poultry. Foods such as vegetables, nuts, legumes, plant-based oils, and seeds are encouraged. Dairy products are generally permitted on a vegetarian diet. However, subvariants of this diet exist. Choices C, E, and F are incorrect. The vegetarian diet excludes meat, poultry, and seafood. ✓ The vegetarian diet focuses on no meat, poultry, or seafood. ✓ Foods such as dairy, legumes, tofu, grapefruit, melon, and soy are permitted. ✓ Vegan and vegetarian diets are generally safe during pregnancy but require appropriate meal planning. ✓ The primary difference between a vegan and a vegetarian diet is that a vegetarian diet includes eggs and dairy.

The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply. A. Legumes B. Almond butter C. Grilled chicken D. Apricots E. Baked fish F. Seafood salad

A, B, F Choices A, B, and F are correct. These vaccines are contraindicated during pregnancy. If the client is scheduled to receive any of these vaccines, the nurse should inquire about the client's pregnancy status prior to vaccine administration. Choices C, D, and E are incorrect. Hepatitis A and B are safe to administer during pregnancy. Influenza vaccination is permitted during pregnancy but cannot be the live influenza vaccine (LAIV). The inactivated influenza vaccine is safe and approved for individuals who are pregnant. Tdap (Tetanus, Diphtheria, Pertussis) is permitted during pregnancy. Vaccines either not recommended or contraindicated during pregnancy include: ✓ MMR ✓ Varicella ✓ Zoster ✓ HPV ✓ Polio

The nurse is teaching a continuing education course regarding vaccines and pregnancy. It would be appropriate for the nurse to state which vaccines are not recommended to be administered during pregnancy? Select all that apply. A. Measles, mumps, and rubella (MMR) B. Varicella C. Hepatitis A D. Inactivated Influenza E. Tdap (Tetanus, Diphtheria, Pertussis) F. Human papillomavirus (HPV)

B Choice B is correct. Compression stockings/hose are effective because the external pressure promotes venous return. Compression hose combined with frequent position changes, daily walks, frequent position changes, and keeping the legs elevated to facilitate venous return is recommended. Choices A, C, and D are incorrect. These measures are not recommended when a client is managing varicose veins. Keeping the legs dependent is recommended for arterial insufficiency, where legs elevated is recommended to promote venous return. Standing in positions for a long period of time is not recommended. The nurse should advise the client to change positions frequently and engage in daily walks. Finally, aspirin may help with the pain associated with vaircose veins, but they do not prevent the formation of varicose veins. Varicose veins can be managed by recommending that the client ✓ Wear compression hose/stockings ✓ Keep the legs elevated to promote venous return ✓ Engage in frequent position changes of the legs ✓ Daily walks are recommended; high impact exercise may contribute to the development of varicose veins

The nurse is teaching a group of clients about varicose veins and home care management. Which of the following should the nurse include in the teaching session? A. When you are sitting, keep your legs lower than your heart B. Wear compression stockings during the day C. Participate in activities that have you stand for long periods D. Take a low-dose aspirin to prevent the development of new varicose veins

B Choice B is correct. The client should be instructed to increase their fluid and fiber intake to prevent constipation because constipation may cause a client to experience significant pain. If the client is still experiencing constipation as they recover from an episiotomy, the primary healthcare provider (PHCP) may prescribe a stool softener. Choices A, C, and D are incorrect. Pain and urgency with urination are concerning symptoms of cystitis. The client should report this to the PHCP. Stinging with urination may occur but should not be painful or have an increased urgency. The client should be instructed to clean the area with a peri bottle and pat it dry. For the first 12 hours following an episiotomy, the nurse should advise the client to apply a cold compress for the first 12 hours, followed by a warm compress afterward. The client should not use a continuous motion when wiping, nor should they use a washcloth which may cause trauma to the area. Patting dry with toilet paper or using a sitz bath or peri bottle could be helpful. ✓ An episiotomy is an incision into the perineum right before birth ✓ Indications for an episiotomy include resolution of shoulder dystocia, breech delivery, macrosomic fetus, and birth assisted with a vacuum or forceps. ✓ Infection is the main risk following an episiotomy. ✓ Fever should be reported along with foul-smelling drainage. ✓ Cold applications are applied for at least the first 12 hours, followed by warm perineal applications after 12 hours. ✓ The client should increase their fluids and fiber to prevent constipation which may aggravate their pain. ✓ It is also recommended that the client pat dries with toilet paper and irrigate the peri area with warm water.

The nurse is teaching a postpartum client about caring for her episiotomy. Which of the following statement by the client would indicate a correct understanding of the teaching? A. "I can expect to have pain and urgency with urination." B. "I should increase my fluid and fiber intake." C. "I will clean the area with hot, soapy water." D. "I should wipe in a continuous motion using a washcloth."

B Choice B is correct. The client should be instructed to increase their fluid and fiber intake to prevent constipation because constipation may cause a client to experience significant pain. If the client is still experiencing constipation as they recover from an episiotomy, the primary healthcare provider (PHCP) may prescribe a stool softener. Choices A, C, and D are incorrect. Pain and urgency with urination are concerning symptoms of cystitis. The client should report this to the PHCP. Stinging with urination may occur but should not be painful or have an increased urgency. The client should be instructed to clean the area with a peri bottle and pat it dry. For the first 12 hours following an episiotomy, the nurse should advise the client to apply a cold compress for the first 12 hours, followed by a warm compress afterward. The client should not use a continuous motion when wiping, nor should they use a washcloth which may cause trauma to the area. Patting dry with toilet paper or using a sitz bath or peri bottle could be helpful. ✓ An episiotomy is an incision into the perineum right before birth ✓ Indications for an episiotomy include resolution of shoulder dystocia, breech delivery, macrosomic fetus, and birth assisted with a vacuum or forceps. ✓ Infection is the main risk following an episiotomy. ✓ Fever should be reported along with foul-smelling drainage. ✓ Cold applications are applied for at least the first 12 hours, followed by warm perineal applications after 12 hours. ✓ The client should increase their fluids and fiber to prevent constipation which may aggravate their pain. ✓ It is also recommended that the client pat dries with toilet paper and irrigate the peri area with warm water.

The nurse is teaching a postpartum client about caring for her episiotomy. Which of the following statement by the client would indicate a correct understanding of the teaching? A. "I can expect to have pain and urgency with urination." B. "I should increase my fluid and fiber intake." C. "I will clean the area with hot, soapy water." D. "I should wipe in a continuous motion using a washcloth."

D Choice D is correct. Saying, "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?" is an example of a therapeutic communication technique known as "focusing". During conversations, patients may mention certain issues that are important to them. When this happens, nurses can focus on the client's self-perceived priorities, prompting them to discuss issues further. Choice A is incorrect. Saying, "You're afraid your baby will be born after your due date, is that correct?" is known as seeking clarification. Choice B is incorrect. Saying, "I've noticed a lot of bruising on your arms," is making an observation. Choice C is incorrect. Saying, "What would you like to talk about during our appointment today?" is known as using a broad opening.

The nurse is using the therapeutic communication technique while caring for her prenatal client. Which phrase, when used by the nurse, is an example of "focusing"? A. "You're afraid your baby will be born after your due date. Is that correct?" B. "I've noticed a lot of bruising on your arms." C. "What would you like to talk about during our appointment today?" D. "Earlier you mentioned feeling scared at home. I'd like to talk about that a bit more. What is causing you to feel scared at home?"

A Choice A is correct. Since this is a closed chest injury, the most common sign of pneumothorax (PTX) will be diminished breath sounds. Choice B is incorrect. A barrel chest occurs over time and indicates chronic obstructive pulmonary disease (COPD). Choice C is incorrect. With most cases of pneumothorax, the patient will become tachypneic rather than have a lower than usual respiratory rate. Choice D is incorrect. A sucking noise is noted in an open chest injury. NCSBN client need Topic: Physiological Integrity, Reduction of Risk Potential

The nurse is working with a client who suffered a blunt injury to the chest wall. Which of the following assessment findings would indicate the presence of a pneumothorax? A. Diminished breath sounds B. A barrel chest C. Lower than normal respiratory rate D. A sucking noise at the site of the injury

A Choice A is correct. When a client is ambulating upstairs using a cane, the client will face the stairs and place the cane on the side opposite the handrail. Then, the client will advance the unaffected (stronger) leg up to the next step, then the cane and the affected (weaker) leg simultaneously. This reflects adequate understanding. Remember that the weaker side and the cane share the load and should always move together. Choices B, C, and D are incorrect. These statements require follow-up because they do not follow the correct (and safe) sequence for ambulating with a cane while ascending stairs. Improper usage of a cane may result in falls. Walking on a level surface: When walking on a level surface, the client should hold the cane on the same side as the stronger leg. ✓ This helps the client shift the weight to the stronger side as they move. Therefore, the client should move the weaker or injured leg simultaneously while moving the cane. ✓ Always remember that the cane and the injured/ weaker side act as partners - they always move together. By doing this, the cane can share the load with the injured leg. ✓ The client should step with the weak leg as they pick up the cane and press down with the cane again when they step down with their weak leg. B. Using the stairs: " Up with the good, and down with the bad" is a good statement while educating the client regarding cane usage to navigate the stairs. ✓ Up with the good: If the client must ascend stairs, the nurse should instruct the client first to hold the cane on their stronger side. ✓ Then the client should advance the unaffected (good) leg onto the step and, following that, move the affected (weaker) leg and the cane simultaneously onto the step. ✓ The cane and the weaker side should always move together. ✓ Down with the bad: If the client must descend stairs, the nurse should instruct the client to hold the cane on their stronger side. The client should simultaneously place the cane and the affected (weaker) leg down on the next step, followed by the unaffected (stronger) leg.

The nurse observes a client go up the stairs with a cane. It would indicate effective teaching if the client grabs the handrail and A. places the stronger leg up a step, then simultaneously moves up the weaker leg and cane. B. holds the cane in one hand and hops up each stair using the stronger leg. C. places the cane up a step, then simultaneously moves up the stronger and weaker legs. D. places the weaker leg up a step, then simultaneously moves up the stronger leg and cane.

D Choice D is correct. Observing a client at the start of the blood transfusion is to quickly assess a potentially fatal hemolytic / ABO incompatibility reaction - not a febrile reaction. A hemolytic reaction would manifest as lower back or chest pain, apprehension, and dyspnea. A febrile reaction would not manifest as quickly as a hemolytic reaction. Therefore, this action requires follow-up. Choices A, B, and C are incorrect. These actions are appropriate and do not require follow-up by the nurse. It is appropriate for the newly-hired nurse to thoroughly verify the physician's order, the compatibility of the blood product, consent for the transfusion, and the universal identifiers of the client's name and date of birth. A second nurse must verify the blood product with the nurse to ensure client safety. It is appropriate for a UAP to obtain pre-transfusion vital signs because the transfusion has not started. Thus, this task may be delegated. The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ➢ A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product. ➢ Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom. ➢ If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis. ➢ Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.

The nurse observes a newly hired nurse caring for a client prescribed a unit of packed red blood cells. It would require immediate intervention if the nurse observes the newly hired nurse A. spikes the unit of blood with Y-type blood tubing. B. verifies the client's name, date of birth, blood compatibility, and expiration date with another nurse. C. instructs the unlicensed assistive personnel (UAP) to obtain pre-transfusion vital signs D. remains with the client for the first 15-30 minutes to observe for a febrile reaction.

D Choice D is correct. Observing a client at the start of the blood transfusion is to quickly assess a potentially fatal hemolytic / ABO incompatibility reaction - not a febrile reaction. A hemolytic reaction would manifest as lower back or chest pain, apprehension, and dyspnea. A febrile reaction would not manifest as quickly as a hemolytic reaction. Therefore, this action requires follow-up. Choices A, B, and C are incorrect. These actions are appropriate and do not require follow-up by the nurse. It is appropriate for the newly-hired nurse to thoroughly verify the physician's order, the compatibility of the blood product, consent for the transfusion, and the universal identifiers of the client's name and date of birth. A second nurse must verify the blood product with the nurse to ensure client safety. It is appropriate for a UAP to obtain baseline vital signs because the transfusion has not started. Thus, this task may be delegated. The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ➢ A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product. ➢ Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom. ➢ If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis. ➢ Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.

The nurse observes a newly hired nurse caring for a client prescribed a unit of packed red blood cells. It would require immediate intervention if the nurse observes the newly hired nurse A. verifies the physician's order for a blood transfusion and ensures that it is complete. B. verifies the client's name, date of birth, blood compatibility, and expiration date with another nurse. C. instructs the unlicensed assistive personnel (UAP) to obtain baseline vital signs. D. remain with the client for the first 15-30 minutes to observe for a febrile reaction.

B Choice B is correct. Asterixis is a hand flapping tremor that may be elicited by having the client close their eyes, extend their arms, dorsiflex their wrist, and spread their fingers. End-stage renal disease causes azotemia and may trigger this unilateral or bilateral tremor in end-stage renal disease. While this tremor is poorly understood, it is likely the accumulation of nitrogenous waste that contributes to the development of this action. This tremor has also been associated with moderate to severe hepatic encephalopathy. Choices A, C, and D are incorrect. Neuroleptic Malignant Syndrome is an insidious autonomic reaction that adversely causes muscle rigidity, tachycardia, and pyrexia. NMS is commonly triggered by antipsychotics and causes hyporeflexia; thus, it would not cause asterixis. HIV is an infectious disease that does not produce asterixis. Rheumatic fever is a condition characterized by arthritis, carditis, and chorea. While an individual with rheumatic fever may have motor disturbances, the Sydenham chorea produces a dance-like motion overtly seen during gross motor movements. These brief shock-like movements may be associated with conditions such as hepatic encephalopathy, end-stage renal disease, and drug intoxication with phenytoin. Most asterixis is bilateral but unilateral asterixis may develop because of pathology in the brain.

The nurse performs a physical assessment on a client and observes the following finding while the client has their arms extended. The nurse understands that asterix is consistent with which of the following A. Rheumatic fever B. End-stage renal disease C. Neuroleptic Malignant Syndrome (NMS) D. Human Immunodeficiency Virus (HIV)

A Choice A is correct. ➢ The client's total number of pregnancies (including the current one) is three. This is documented under gravida (G). She is currently pregnant, had one ectopic pregnancy, and was pregnant with twins. ➢ The client has had one-term birth: the twins were born at 39 gestational weeks. This is documented under the term (T). Term is any birth after 37 gestational weeks. ➢ The client has not had any preterm (P) births (any birth between 20 and 37 gestational weeks). ➢ The client has had one ectopic pregnancy, which is documented as an abortion (A). ➢ The client has two living (L) children, the twins, who were born at 39 gestational weeks.

The nurse performs an obstetrics history on a client seeking antenatal care for a confirmed pregnancy. The client reports having six-year-old twins born at 39 gestational weeks. She had an ectopic pregnancy at four gestational weeks that occurred sixteen weeks ago. When completing the client's documentation, the nurse should record the GTPAL as A. G = 3, T = 1, P = 0, A = 1, L = 2 B. G = 3, T = 2, P = 0, A = 1, L = 2 C. G = 4, T = 2, P = 0, A = 1, L = 2 D. G = 3, T = 2, P = 0, A = 1, L = 1

A, B Choices A and B are correct. The parents of children with congenital heart defects need to be aware of the "early" signs of heart failure, so they can report them to the healthcare provider before it is too late. Diaphoresis (Choice A), or excessive sweating is a common early sign of heart failure. Parents should be taught to look out for excessive sweating, especially at rest. Sudden weight gain (Choice B) is due to fluid retention and edema. This indicates decreased cardiac output, increased venous congestion, and is an early sign of heart failure. Choice C is incorrect. An infant or child having "no wet diapers" would mean he/she is severely oliguric. Oliguria is due to decreased kidney perfusion that occurs during untreated heart failure. This degree of damage to the kidneys takes time and is a late sign of heart failure, not an early warning. Choice D is incorrect. Hypoxia is also a late sign of heart failure, not an early warning. Hypoxia is typically secondary to pulmonary edema that develops during untreated heart failure.

When educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following are considered early signs of heart failure? Select all that apply. A. Diaphoresis B. Sudden weight gain C. No wet diapers D. Hypoxia

B Choice B is correct. During any mechanical lift transfer, the nurse should instruct the client to fold their arms over the chest, preventing injuries to the client's arms during the transfer. Choices A, C, and D are incorrect. The side rails of the stretcher should be lowered during the actual transfer because the side rails being raised may impede the client from transferring the stretcher to the wheelchair. If the side rails were raised, this would cause the nurse to raise the client even higher using the lift, which could cause injury if the client were to fall. Gloves and a gown are unnecessary for this procedure and would waste facility resources. Standard precautions are sufficient for this task. The wheels of the stretcher and wheelchair should be locked to prevent the client from slipping from either. ✓ A mechanical lift should only be used by staff who have been appropriately trained. ✓ A mechanical lift may be hydraulic or be affixed to the ceiling. ✓ The nurse (or UAP) should always check the weight restrictions for the lift before its use. ✓ When applying a mechanical lift to a client, the lift will be applied with the client lying supine in bed. ✓ A second staff member must assist the hydraulic lift to lower the client into the chair (or back to bed).

The nurse plans to use a mechanical lift to transfer a client from a stretcher to a wheelchair. Which appropriate action should the nurse take? A. Keep the stretcher's side rails raised during the transfer B. Instruct the client to fold their arms over their chest C. Apply gloves and gown for this procedure D. Unlock the wheels on the stretcher and wheelchair

B Choice B is correct. A unit of PRBCs will add fluid volume, and if the client has pulmonary edema, the unit of blood should be questioned with the PHCP until the edema has resolved. Giving a unit of PRBCs may worsen pulmonary edema. Clients at risk for transfusion-associated circulatory overload (TACO) will need to receive their unit of PRBCs slower and may require diuretics after the blood has been administered. Choices A, C, and D are incorrect. A febrile illness is not a contraindication for a blood transfusion. It may make recognizing a febrile reaction more difficult. Still, it can be done by using the client's baseline temperature and looking for other clinical features such as chills, tachycardia, and tachypnea. Mechanical ventilation is not a contraindication to a client receiving blood products. The nurse must recognize other reaction manifestations, such as pallor, fever, tachycardia, and hypotension. A client with a chest tube for a hemothorax is not a contraindication for administering a blood product. If the hemothorax causes that much bleeding, a transfusion is much more likely to prevent shock. ✓ The nurse should remain with the client during a transfusion's first fifteen to thirty minutes to observe for a hemolytic or allergic reaction. ✓ The universal blood donor type is O negative; the universal blood type for recipients is AB positive. ✓ A unit of PRBCs should be transfused over 2-4 hours using Y-type tubing. ✓ 20-gauge intravenous (IV) catheter should be used to administer a blood product. ✓ The nurse should verify the client's identification, blood product, and compatibility with a second nurse prior to transfusion.

The nurse reviews prescriptions for packed red blood cell (PRBC) transfusions. Which PRBC transfusion should the nurse question with the primary healthcare provider (PHCP)? A client A. with a febrile illness. B. with pulmonary edema. C. receiving mechanical ventilation. D. with a chest tube for a hemothorax.

A, D Choices A and D are correct. These actions by the UAP are incorrect and require follow-up. The HOB should be between 30-45 degrees to facilitate effective oral hygiene and prevent aspiration. A towel is placed across the client's chest to prevent soiling of their clothes. This towel should be placed in a linen bag following its use. Items that should be deposited in a biohazard bag will be saturated with blood or blood products. This bag prevents the safe transport of products that may contaminate other areas in the facility. Gross bleeding is not expected during basic oral hygiene. Choices B, C, and E are correct. These actions are correct by the UAP. The UAP should perform hand hygiene before and after this procedure. Clean gloves should be worn because of exposure to body fluids. The correct brush technique is holding the toothbrush bristles at a 45-degree angle to the gum line. Applying moisturizing lubricant after the client has brushed and rinsed is appropriate. 1. Explain procedure to client, discussing client's preferences; assess client's ability to grasp and manipulate toothbrush and willingness to help with oral care. 2. Place paper towels on over-bed table and arrange other equipment within easy reach. 3. Provide privacy by closing room doors and drawing room divider curtain. Raise bed to comfortable working position. 4. Raise head of bed (if allowed) and lower near side rail. Move client or help them move closer to side. Place client in side-lying position if needed (if aspiration risk). Place towel over client's chest. 5. Apply clean gloves. Apply enough toothpaste to brush to cover length of bristles. Hold brush over emesis basin. Pour small amount of water over toothpaste. 6. Client may help with brushing. Hold toothbrush bristles at 45-degree angle to gum line. Be sure that tips of bristles rest against and penetrate under gum line. Brush inner and outer surfaces of upper and lower teeth by brushing from gum to crown of each tooth. Clean biting surfaces of teeth by holding top of bristles parallel with teeth and brushing gently back and forth. Brush sides of teeth by moving bristles back and forth. 7. Have client hold brush at 45-degree angle and lightly brush over surface and sides of tongue. Avoid initiating gag reflex. 8. Allow client to rinse mouth thoroughly by taking several sips of cool water, swishing water across all tooth surfaces, and spitting into emesis basin. Use this time to observe client's brushing technique and teach the importance of regular hygiene. 9. Have client rinse mouth with antiseptic rinse for 30 seconds. Then have client spit rinse. 10. Allow client to rinse mouth thoroughly with cool water and spit into emesis basin. Help wipe the client's mouth. 11. Inspect oral cavity to determine effectiveness of oral hygiene and rinsing. Ask client whether mouth feels clean or if there are any sore or tender areas. Remove towel and place in linen bag. 12. Remove and dispose of gloves and perform hand hygiene. Return client to a comfortable position. Raise side rails (as appropriate), and lower bed to lowest position. Place nurse call system within client reach.

The nurse supervises unlicensed assistive personnel (UAP) assist a client who is bed-bound with oral hygiene. Which action by the UAP requires follow-up? Select all that apply. A. Raises the head of the bed (HOB) to 15 degrees B. Holds the toothbrush bristles at a 45-degree angle to the gum line C. Performs hand hygiene and applies clean gloves D. Removes the towel and places it in a biohazard bag E. Applies moisturizing lubricant to the lips after brushing and rinsing

A Choice A is correct. This finding requires follow-up because flank pain when a client has a nephrostomy tube would suggest pyelonephritis, a serious infection. Common findings associated with pyelonephritis include cloudy urine, nausea, fever, and malaise. This infection must be treated promptly because it can lead to urosepsis. Choices B, C, and D are incorrect. All of these findings are expected and do not require immediate follow-up. Abdominal cramping associated with PD can be treated by having the client slow the fluid infusion and ensuring that it is warmed. Facial edema is a classic finding associated with nephrotic syndrome. Other findings with nephrotic syndrome include massive proteinuria and reduced serum albumin levels. Almost all antibiotics may cause a client to develop a benign rash. ✓ Nursing care for pyelonephritis is like that of cystitis, which includes the administration of prescribed antibiotics, educating the client to stay hydrated, and measures to prevent a recurrence. ✓ A nephrostomy tube increases the client's risk for pyelonephritis because the catheter is directly threaded into the renal pelvis. ✓ A complication of pyelonephritis is sepsis. Thus, signs of sepsis, such as tachycardia and hypotension, should be reported to the primary healthcare provider.

The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting A. bilateral flank pain who has two nephrostomy tubes. B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD). C. facial edema while being treated for nephrotic syndrome. D. a localized rash following the administration of ciprofloxacin for cystitis.

B Choice B is correct. Carbon monoxide (CO) poisoning is a serious emergency that is often fatal if not promptly treated. This medical emergency requires the priority treatment of 100% high-flow oxygen. CO has a strong affinity for hemoglobin 200x more than oxygen. Providing the client with high-flow oxygen is an essential treatment because, if untreated, death may occur. Choices A, C, and D are incorrect. Pulse oximetry cannot screen for exposure to carbon monoxide. However, continuous monitoring is a standard of care whenever oxygen is administered. A peripheral vascular access device is often inserted to obtain a metabolic panel to screen for electrolyte disturbances. If the CO level rises high enough, the client is at risk for fatal dysrhythmias and ST-segment depression. An ECG should be obtained, but it does not prioritize administering the client high-flow oxygen. ✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen ✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting ✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes ✓ This poisoning is tasteless, odorless, and colorless ✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition? A. Initiate continuous pulse oximetry monitoring B. Administer high-flow oxygen C. Insert a peripheral vascular access device D. Obtain a 12-lead electrocardiogram (ECG)

A Choice A is correct. A subtotal thyroidectomy requires the nurse to monitor the client for complications such as laryngeal edema. This may be manifested as a hoarse voice, difficulty swallowing, and stridor. The primary healthcare provider (PHCP) may prescribe post-operative steroids to prevent this complication. The nurse needs to follow up with this client to assess the client's airway patency. Choices B, C, and D are incorrect. Pain following a dressing change is quite common and requires general follow-up. The nurse can mitigate this pain by medicating the client with prescribed analgesics before the dressing change. A key intervention for a client with pneumonia is to mobilize and use the incentive spirometer (IS). The IS is commonly prescribed hourly while the client is awake. This requires general follow-up but is not the priority. Finally, the client's consent will need to be evaluated for completion. However, the surgical procedure is in eight hours, and the nurse has ample time to address this task. Common complications following thyroidectomy surgery are as follows: ✓ Hypocalcemia: accidental injury or removal of the parathyroid gland can reduce the circulating blood calcium levels. Acute hypocalcemia may present with the Chvostek Sign (tapping on the cheek causes facial twitching), Trousseau's Sign (applying pressure on the arm causes carpopedal spasms), muscle cramps, paresthesia, peri-oral numbness, tetany, seizures, and cardiac arrhythmias. If untreated, it can be life-threatening. To prevent this complication, every thyroidectomy patient is started on 3 grams of elemental calcium per day as soon as they can begin an oral diet. ✓ Recurrent laryngeal nerve (RLN) injury: hoarseness of voice from RLN injury is common due to the damage of RLN intra-operatively. ✓ Following a thyroidectomy, the nurse should have readily available airway equipment and calcium gluconate.

The nurse working on a medical-surgical unit is caring for assigned clients. The nurse should plan to initially assess the client who A. had a subtotal thyroidectomy 12 hours ago and reports difficulty swallowing. B. reports increased pain following a sterile dressing change for a stage IV pressure ulcer. C. has bilateral lower lobe pneumonia and has not used the incentive spirometer in six hours. D. is scheduled for an adrenalectomy in eight hours and has not signed the informed consent.

264 MG

The primary healthcare provider (PHCP) prescribes 20 mg/kg of acetaminophen for a child weighing 29 lbs. How many milligrams should the nurse administer to the child? Fill in the blank. Round your answer to the nearest whole number.

D Choice D is correct. Citalopram is an antidepressant. This selective serotonin reuptake inhibitor (SSRI) is prescribed for depressive and anxiety disorders. If a client has depression, one of the associated manifestations is decreased self-esteem/self-worth. This may cause clients to reduce their ability to engage with others and become socially withdrawn. Choices A, B, and C are incorrect. Citalopram does not impact muscle coordination, whereas medications like levodopa-carbidopa indicated for Parkinson's disease may be beneficial. Other medications that may improve muscle coordination are muscle relaxants like baclofen. A circumstantial speech pattern would not be a therapeutic finding and would be found in certain mood disorders, such as bipolar, when the client is either hypomanic or manic. This also may be a feature if a client is experiencing psychosis. A circumstantial speech pattern is where the client fails to get to the primary point of the conversation in a timely manner. A longer attention span would be accomplished through medications such as amphetamine or methylphenidate. These medications treat ADHD. Citalopram is not used in the management of ADHD or bipolar disorder. ✓ The SSRI medication class includes citalopram, escitalopram, fluvoxamine, fluoxetine, sertraline, and paroxetine. ✓ These medications treat generalized anxiety disorder and major depressive disorder. ✓ It takes approximately four to six weeks for these medications to establish efficacy. ✓ The nurse should monitor the client for suicidal behavior or an abrupt mood shift which may indicate the development of mania.

This nurse is caring for a client who is receiving prescribed citalopram. Which of the following findings would indicate a therapeutic response? A. Improved muscle coordination B. Circumstantial speech pattern C. Longer attention span D. Increased self-esteem

B Choice B is correct. Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. Choices A, C, and D are incorrect. Sitagliptin is not indicated for hyperlipidemia, hypothyroidism, or hypertension. ✓ Medications used to treat hyperlipidemia would be statin medications. ✓ Medications used to treat hypothyroidism would be levothyroxine. ✓ Medications used to treat hypertension would be lisinopril, diltiazem, propranolol, or candesartan. Sitagliptin is a treatment that may be prescribed for type II diabetes mellitus ✓ Persistent abdominal pain should be reported because pancreatitis is the major adverse effect of this medication. ✓ Other medications in this class include linagliptin, saxagliptin, and alogliptin.

This nurse is caring for a client who is receiving prescribed sitagliptin. The nurse understands that this medication is intended to treat which condition? A. Hyperlipidemia B. Diabetes mellitus C. Hypothyroidism D. Hypertension

B Choice B is correct. Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. The most common adverse effect associated with this medication is pancreatitis. Pancreatitis is manifested by abdominal pain, nausea, and persistent vomiting. Choices A, C, and D are incorrect. Sitagliptin may cause headaches, nasal stuffiness, and an occasional dry cough. Respiratory congestion is common with this medication, but it is not as severe as a client with pancreatitis, which could die without treatment. Pancreatitis causes significant dehydration, which, if untreated, may lead to hypovolemic shock. Sitagliptin is a treatment that may be prescribed for type II diabetes mellitus ✓ Persistent abdominal pain should be reported because pancreatitis is the major adverse effect of this medication. ✓ Other medications in this class include linagliptin, saxagliptin, and alogliptin.

This nurse is caring for a client who is receiving prescribed sitagliptin. Which assessment findings indicate the client is experiencing a severe adverse effect? A. Nasal stuffiness B. Abdominal pain C. Headache D. Occasional dry cough

B Choice B is correct. Tolvaptan is a vasopressin antagonist and is indicated in treating the syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the client retains water which causes fluid retention without edema. Classic manifestations of SIADH include polydipsia, hemodilution, and oliguria. This medication promotes free water excretion, normalizing sodium levels and increasing urine output. This urine-specific gravity is normal (1.005 - 1.025) and indicates that the medication is having its therapeutic effect because a client with SIADH would have a high USG from the limited water spilled into the urine. Choices A, C, and D are incorrect. Tolvaptan has no direct impact on cholesterol or glucose. A BUN of 5 mg/dL would be expected with SIADH as the excessive water causes a decrease in this value. The normal level for BUN is 10-20 mg/dL. ✓ SIADH may be caused by pulmonary tuberculosis and certain lung malignancies. ✓ Clinical features of SIADH include hyponatremia because of excessive water. Other features include increased urine-specific gravity, oliguria, and hemodilution. ✓ Treatment includes prescribed fluid restrictions and tolvaptan. ✓ Tolvaptan causes the excretion of free water, which raises sodium levels. ✓ The client's sodium needs to be monitored carefully while administering this medication because it may cause hypernatremia. ✓ This medication is very hepatotoxic, and the liver function tests should be monitored closely.

This nurse is caring for a client who is receiving prescribed tolvaptan. Which of the following findings would indicate a therapeutic response? A. Fasting blood glucose 100 mg/dL B. Urine specific gravity 1.010 C. Total cholesterol 176 mg/dL D. BUN 5 mg/dL

D Choice D is correct. When assessing pulses, the strength, volume, and fullness of the peripheral pulses are categorized and documented as follows: 0: Absent pulses 1: Weak pulse 2: Normal pulse 3: Increased volume 4: Abounding pulse Choices A and B are incorrect. Grades and grading are not used to document pulses. Choice C is incorrect. The pulse is weak and thready, not regular.

What is the correct documentation of the patient's peripheral pulse when the finding is that the posterior tibial pulse is weak and thready? A. Grade C posterior tibial pulse B. Posterior tibial pulse is Grade B C. The client's posterior tibial is 2 D. Posterior tibial pulse is 1

B, F Choices B and F are correct. The trachea and bronchi belong to the lower respiratory tract, not the upper. The respiratory tract is divided into two sections: the upper respiratory tract and the lower respiratory tract. The upper respiratory tract and the mouth function as the entry point of air and food into the body. The nose, mouth, and throat serve as a common channel for air to reach the lungs and food to enter the esophagus and stomach. The upper respiratory tract warms, filters, humidifies, and transports air into the lower respiratory tract. The upper respiratory tract includes the nostrils, nasal cavities, pharynx, epiglottis, and larynx. Pharynx is often referred to as Throat. Larynx ( voice box) is the portion of the airway between the pharynx and the trachea. Larynx is the transition point between upper and lower respiratory tracts. The larynx contains two important parts: the epiglottis and the vocal cords. The lower respiratory tract includes the trachea, bronchi, bronchioles, and lungs. Choices A, C, D, and E are incorrect. All of these answer choices constitute parts of the upper respiratory tract. Adenoids (Choice A) are lymphatic glands located behind the nasal cavity, usually at the nasopharynx (a part of the upper respiratory tract). Adenoids and the tonsils belong to the lymphatic system. They help fight infections. Sinuses (Choice C), throat/pharynx (Choice D), and epiglottis (Choice E) are parts of the upper respiratory tract as well. Knowing the parts of the respiratory system helps the nurse to identify the source/site of the symptoms. Certain serious conditions like epiglottitis in children should be identified right away. The epiglottis is a component of the larynx. It is a small, movable leaf-like structure just above the larynx that serves as a lid, preventing food and drink from entering the airway. If the epiglottis becomes swollen (epiglottitis), it may obstruct the airway. Epiglottitis refers to infection/inflammation of the epiglottis, which may cause stridor, and is characterized by the "four D's" - dysphagia (difficulty swallowing), dysphonia (muffled voice), drooling, and distress. Stridor is a high-pitched sound during breathing. An inspiratory stridor (stridor during breathing in) suggests airway obstruction above the glottis, such as in the case of acute epiglottitis.

Which of the following are not part of the upper respiratory tract? Select all that apply. A. Adenoids B. Trachea C. Sinuses D. Pharynx E. Epiglottis F. Bronchus

B Choice B is correct. A 25-year-old female client who is taking ibuprofen is the client who is at the highest risk for lithium toxicity. Lithium is excreted through the kidneys, and any medication that can decrease glomerular filtration rate can therefore cause increased retention of lithium, increasing the serum levels of the drug and potentially causing toxicity. The most common medications which can do this are ACE inhibitors, angiotensin II receptor antagonists (sartans), diuretics, and non-steroidal anti-inflammatory drugs (NSAIDs). Ibuprofen is an NSAID that can decrease the glomerular filtration rate causing retention of lithium and increased serum levels of the medication. It should therefore not be prescribed with lithium due to the increased risk for toxicity. Choice A is incorrect. The 35-year-old male client who is taking theophylline is not the client who is at the greatest risk for lithium toxicity. Theophylline increases the excretion of lithium through the proximal consulted tubule of the nephron. When theophylline and lithium are taken together, theophylline, therefore, increases the amount of lithium output in the urine. This can then lead to a decrease in the amount of lithium in the blood, causing low lithium levels. Choice C is incorrect. The 45-year-old male client who is taking methazolamide is not the client that is at the highest risk for lithium toxicity. Methazolamide is a carbonic anhydrase inhibitor. these medications are used to treat glaucoma, altitude sickness, congestive heart failure, and epilepsy. They work by promoting diuresis in the proximal tubule of the kidney. Because they promote diuresis in the proximal tubule of the kidney, they cause the excretion of lithium. As lithium is excreted in the urine, the amount remaining in the blood is decreased and serum lithium levels are lower. Carbonic anhydrase inhibitors include acetazolamide, methazolamide, dorzolamide, brinzolamide, diclofenamide, ethoxzolamide, and zonisamide. Choice D is incorrect. The 55-year-old female client who is taking mannitol is not the client that is at the highest risk for lithium toxicity. Mannitol is an osmotic diuretic. Osmotic diuretics primarily inhibit water reabsorption. They do so in the proximal convoluted tubule, as well as in the descending loop of Henle and the collecting duct. All of these regions of the kidney are highly permeable to water, which is what makes osmotic diuretics so useful for inhibiting water reabsorption. When water reabsorption is inhibited, urine output is increased. With this increase in urine output, lithium is also excreted. Just as with answer choice C, mannitol will also cause serum lithium levels to be lower due to the increased excretion of lithium in the urine. Osmotic diuretics include drugs such as Mannitol, Glycerin, Isosorbide, and Urea. Lithium is excreted almost entirely by the kidneys. Lithium is freely filtered by the glomerulus since it is not bound to serum proteins. In the proximal tubule, lithium is handled similarly to sodium. Thus, factors that decrease GFR or increase proximal tubule reabsorption, such as volume depletion, will increase serum lithium levels. Conversely, factors that decrease proximal tubule sodium reabsorption, such as carbonic anhydrase inhibitors, aminophylline, or osmotic diuretics, will increase lithium excretion and decrease serum lithium levels. Lithium has a narrow therapeutic index, with therapeutic levels between 0.6 and 1.2 mEq/L. Because toxicity can occur at levels >1.5 mEq/L, lithium levels must be carefully monitored and lithium dosage adjusted as necessary. This is especially true following changes in other medications that alter renal function, such as angiotensin-converting enzyme (ACE) inhibitors or nonsteroidal anti-inflammatory drugs (NSAID).

Which of the following clients is at greatest risk for toxicity to lithium? A. A 35-year-old male client who is taking theophylline [26%] B. A 25-year-old female client who is taking ibuprofen [22%] C. A 45-year-old male client who is taking methazolamide [23%] D. A 55-year-old female client who is taking mannitol

C, D Choices C and D are correct. The nurse would expect to administer colace (Docusate) after the patient has a repair of an anorectal malformation. Colace is a stool softener that will help to pull water into the intestines and soften the stool. This will make bowel movements easier for the patient after surgery (Choice C). Initiation of a high fiber diet after surgery for an anorectal malformation is an expected intervention. A high fiber diet will assist the patient in passing stool more quickly, which is vital after repairing anorectal malformation (Choice D). Choice A is incorrect. Administration of imodium after repair of an anorectal malformation is not appropriate. This is an anti-diarrheal that would be administered to the patient experiencing diarrhea. This is not expected with an anorectal malformation repair. Choice B is incorrect. Initiation of a high-calorie diet is not necessary after repair of an anorectal malformation. Instead, a high fiber diet should be initiated. A high fiber diet will assist the patient in passing stool more easily, which is essential after repair of an anorectal malformation.

Which of the following interventions does the nurse anticipate when caring for a patient after repair of an anorectal malformation? Select all that apply. A. Imodium administration B. Initiation of a high-calorie diet C. Colace administration D. Initiation of a high-fiber diet

B Choice B is correct. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm more room and facilitating lung expansion. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations. Because of this "shallow" breathing, ventilation is affected, and Co2 accumulates. Dyspneic clients can often breathe better in an upright position. When standing or sitting, gravity pulls the abdominal organs down and away from the diaphragm, creating more space in the thoracic cavity. This allows the lungs more room for expansion and allows the client to take more air with each breath ( better ventilation). Choices A, C, and D. None of these answer choices are appropriate as the first nursing action for a patient experiencing dyspnea. Recumbent positions ( Choices A and C) limit expiratory flow and cause a decrease in elastic recoil of the lung. Therefore, such positions do not improve ventilation. The nurse should check the client's blood pressure ( Choice D), but the priority action should be to position the client to reduce breathlessness and the effort of breathing.

Which of the following is the first nursing action for a patient experiencing dyspnea? A. Remove pillows from under the patient's head B. Elevate the head of the bed C. Elevate the foot of the bed D. Take the patient's blood pressure

A Choice A is correct. The patient in this option is confined to bed and has visits/interactions with others that may be limited leading to sensory deprivation. The reticular activating system (RAS) is a network of neurons located in the brain stem that projects anteriorly to the hypothalamus to mediate behavior. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain. As a result, the person may hallucinate simply to maintain an optimal level of arousal. Factors that place patients at a higher risk for sensory deprivation may include: An environment that has decreased stimuli Impaired ability to receive environmental stimuli (impaired vision or hearing) Inability to process environmental stimuli (patients with spinal cord injuries, brain damage, or confused/disoriented patients) Choices B, C, and D are incorrect. All of these answer choices reflect patients who are in environments in which environmental stimuli are adequate to prevent sensory deprivation.

Which of the following patients is at greatest risk for sensory deprivation? A. An older man who is confined to bed at home following a stroke. B. An adolescent in an oncology unit who is working on homework supplied by her friends. C. A woman in active labor. D. A toddler in a playroom awaiting same-day surgery.

B Choice B is correct. While the Patient Self-Determination Act requires health care facilities to provide information about the patient's right to refuse or accept treatment, the patient has the right to withdraw that information. Should the patient decline verbal and written information about advanced directives, the nurse should document that information was offered, and document the patient's refusal, quoting the patient's statements. Choices A and C are incorrect - The patient has the right to autonomy and self-determination, including refusing information regarding advanced directives. He is not required to have advanced instruction in place while in the hospital. Choice D is incorrect - The patient's refusal to accept information about advanced directives is not an indication of the patient's level of competence.

While admitting a patient, the nurse begins to review information regarding advanced directives. Still, the patient becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action? A. Leave the handout on the patient's bedside table instructing him that he must review the content. B. Document the patient's refusal, using the patient's own words, in quotes. C. Explain to the patient that he must make decisions about accepting or refusing treatment while in the hospital. D. Request an assessment of the patient's competency related to making decisions about advanced directives.

C Choice C is correct. A health care proxy is an individual named in a written legal document designated to make medical decisions for the client when the client is no longer able to make decisions for themself. Choice A is incorrect. Although a client may designate their spouse or significant other as their health care proxy, an official health care proxy requires the completion of legal paperwork and a copy of the documents to be provided to the hospital or healthcare provider. Without doing so, the significant other or spouse cannot be the legally designated health care proxy. Choice B is incorrect. Health care proxies make decisions about healthcare. In general, if the health care proxy follows the client's pre-discussed wishes, there are no financial implications for the health care proxy. Choice D is incorrect. A health care proxy designation and a designation to receive confidential information protected under HIPAA are two distinct designations. Recognize that a health care proxy is an agent named in a legal document designated to make medical decisions for the individual signing the document when they can no longer make decisions for themselves. How is a health care proxy different than a power of attorney (POA)? A power of attorney (POA) primarily authorizes the person you designate to make financial decisions for you. It cannot be used to make health care decisions. You must complete a health care proxy to enable someone else to make healthcare decisions for you when you can no longer do so.

You are caring for a client who states they have a health care proxy. Which of the following most accurately describes a health care proxy? A. The client's legal designation to their spouse or significant other allowing them to have a voice in health care treatment options as the client ages B. An individual designated by the client to assist in medical decision-making who also becomes responsible for a minimum of one-half of all medical bills accrued by the client C. An individual the client legally designates to make medical decisions when the client is no longer capable of doing so D. A specific designation specifying who can receive and discuss the client's privileged healthcare information

D Choice D is correct. Post-traumatic stress disorder (PTSD) is characterized by ongoing and unyielding nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Post-traumatic stress disorder occurs primarily among those who have witnessed and/or been exposed to a severe traumatic event (i.e., warfare, rape, witnessing a murder, etc.) likely to invoke feelings of fear, helplessness, or horror in the individual who witnesses the event. Choice A is incorrect. A panic disorder occurs when the client experiences repeated panic attacks, typically accompanied by fears about future attacks or changes in behavior to avoid situations that might predispose the client to additional attacks. Choice B is incorrect. A phobia is a fear of and/or anxiety regarding a particular situation or object to a degree that is out of proportion to the actual danger or risk. Contact with the situation or object is usually avoided when possible, but if exposure occurs, anxiety quickly develops. Choice C is incorrect. The term "anxiety disorders" is a broad umbrella term encompassing numerous anxiety-related psychiatric disorders, including, but not limited to, agoraphobia, generalized anxiety disorder, acute stress disorder, social phobia, post-traumatic stress disorder, etc. Anxiety disorders are characterized by varying degrees of generalized anxiety ranging from mild to severe. Treatments vary based on the client's specific anxiety disorder(s), but typically involve a combination of psychotherapy specific for the disorder and medication therapy treatment (most commonly benzodiazepines and/or selective serotonin reuptake inhibitors (SSRIs)). Clients with an anxiety disorder are more likely than other individuals to experience depression. Although post-traumatic stress disorder is included under the umbrella term of anxiety disorders, this is not the best answer to this question. Symptoms of post-traumatic stress disorder can be subdivided into categories: intrusions, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity. Diagnosis is based on history. Treatment often consists of exposure therapy and/or drug therapy (most commonly, selective serotonin reuptake inhibitors (SSRIs)). Many post-traumatic stress disorder clients also experience survivor's guilt.

Your client is affected by nightmares, flashbacks to a previous event, and intrusive, threatening thoughts. Which disorder is this client most likely experiencing? A. Panic disorder B. A phobia C. Anxiety disorder(s) D. Post-traumatic stress disorder