HESI RN Practice

A client is scheduled to receive oral digoxin. The nurse notes the client has a serum digoxin level of 2.8ng/ml (therapeutic range 0.5-2.0ng/ml). Which actions should the nurse take? (Select all that apply.) A. Notify the provider of the lab result. B. Hold the prescribed dose of digoxin. C. Check an apical pulse. D. Repeat the serum digoxin level in 2 hours. E. Call the pharmacy to discontinue the digoxin.

ANS: A, B, C Digoxin is a cardiac glycoside that has antiarrhythmic and inotropic effects. This medication slows conduction through the SA and AV nodes, therefore slowing the heart rate and also increasing the force of the cardiac contraction which improves cardiac output. These are desirable effects in the treatment of atrial fibrillation as well as heart failure. However, digoxin is a high-risk medication with a narrow therapeutic range. Serum levels are typically drawn 6-8 hours after dose administration. The nurse must monitor closely for digitalis toxicity which includes abdominal pain, nausea, vomiting, visual disturbances, bradycardia and other arrythmias. If the client's serum digoxin level is elevated but they are asymptomatic, withholding the next dose may be the only action that is needed. If the client is symptomatic, serum potassium should be monitored as hyperkalemia often occurs concurrently. Digoxin immune Fab is a medication that binds to serum digoxin and helps to excrete it via the kidneys and can be used in symptomatic toxicity. Option A, notify the provider of the lab result, is correct because the nurse will need to notify the provider to obtain an official order to withhold the medication as well as make a plan for managing digoxin administration in the future. Option B, hold the prescribed dose of digoxin, is correct as the nurse should withhold the medication as the serum level is outside of the therapeutic range. Administration of the medication could lead to severe bradycardia or life-threatening arrythmias. The nurse should also obtain an order to hold the medication. Option C, check an apical pulse, is correct as the nurse should assess the client for bradycardia or any abnormal heart rhythm in the presence of an elevated serum digoxin level. The nurse should listen to the apical pulse for one full minute and note any changes in rate, rhythm or quality. Option D, repeat the serum digoxin level in 2 hours, is incorrect because it would not be appropriate to recheck the level this soon after the initial lab draw. Typically, if a digoxin level is found to be elevated, the client should be assessed for adverse effects, the next dose should be held and the provider should be notified to modify the dose if needed. In the client without adverse effects, the serum digoxin level should be rechecked within 24-72 hours to capture the decline of the serum level. If adverse effects were noted, an antidote for digoxin, Digibind (digoxin immune FAB) can be administered and will bind with serum digoxin in order to render it inactive. Even in this case, it is not recommended to recheck serum digoxin this soon after the administration of Digibind because the value measures both free and bound digoxin and would not be clinically useful. Option E , call the pharmacy to discontinue the digoxin, is incorrect as discontinuing a medication is a task that the health care provider must manage. The nurse can discuss discontinuing the medication with the provider but there is no need to call the pharmacy in order to withhold a medication dose.

The nurse is caring for a client in protective isolation while receiving chemotherapy for acute myeloid leukemia. When reviewing the client's most recent laboratory results, which action should the nurse take? A. Hold daily dose of subcutaneous heparin. B. Discuss the removal of protective isolation with healthcare provider. C. Obtain orders for blood, sputum, and urine cultures. D. Obtain order for platelet transfusion.

ANS: B The term "protective isolation" describes a range of practices used to protect severely immunocompromised clients from infection. Protective isolation includes 1) Physical separation from other clients, typically in a standard single room; 2) Barrier measures to prevent the exogenous acquisition of micro-organisms, with staff and visitors to wear sterile gowns, masks, gloves; 3) Restrictions placed on movement, visitors, and diet (no fresh fruits, raw vegetables, flowers); 4) Antimicrobial prophylaxis and 5) supportive care to maintain the integrity of skin and mucous membranes, including skin, oral and dental care. The need for protective isolation is usually evaluated based on the presence of neutropenia, as neutrophils are the main effector cells in the initiation of an immune response. An absolute neutrophil count < 1,500/mm3 is consistent with neutropenia, and levels < 500/mm3 are an absolute indication for protective isolation. Clients with hematologic cancers such as AML and those receiving chemotherapy commonly develop neutropenia. Choice B, "discuss the removal of protective isolation with healthcare provider" is an appropriate action based on the client's most recent laboratory results, as the client's absolute neutrophil count has returned to normal limits. Choice A is incorrect because clients with cancer are at increased risk for thrombosis and should receive DVT prophylaxis. Holding the client's heparin is appropriate only for platelet levels < 50,000/mm3. Choice C is incorrect because the client's severely elevated WBC count is likely in the setting of acute leukemia rather than due to an acute infection. It is important to realize that these white blood cells are defective and do not aid in infection prevention. They do increase the viscosity of the blood, thereby increasing the risk of thrombosis. Blood, urine, and sputum cultures are indicated if the client develops symptoms of infection, such as low-grade fever, cough, or urinary symptoms. Choice D is incorrect because even though the client's platelet level is decreased (normal > 250,000/mm3), platelet transfusions are not typically done in clients with leukemia unless 1. An invasive procedure is needed (e.g., for surgery platelets >50,000 are required), 2. The client is actively and uncontrollably bleeding or 3) if platelet levels decrease < 10,000 (institution dependent).

A client has been taking oatmeal baths every day for the last 2 weeks as prescribed. Which information should the nurse obtain to determine the effectiveness of this intervention? A. Improvement of acne B. Reduction of lymphedema C. Improvement in skin hydration and turgor D. Reduction in itching and pruritis

ANS: D Oatmeal baths are prescribed for clients with eczema and psoriasis to reduce skin itching and pruritus. Oatmeal contains components called avenanthramides that have anti-inflammatory and antihistaminic activity and thereby decrease disease activity. A reduction in itching and pruritus indicates that treatment is effective. Choice A is incorrect because oatmeal does not improve acne. Topical antibiotics, benzoyl peroxide, and retinoids are appropriate interventions for clients with acne. Choice B is incorrect because oatmeal does not improve lymphedema. Compression garments and leg elevations are appropriate interventions for lymphedema. Choice C is incorrect as oatmeal will not directly hydrate the skin or improve skin turgor. Hydrating creams and oral fluids are measures to improve skin hydration and turgor.

An 8 year old client is prescribed 300,000 units of penicillin G potassium per kg of body weight intramuscularly in 4 divided doses every 24 hours. The child weighs 55 lbs. Calculate the units of penicillin the nurse should administer every 6 hours. Enter numeric value only.

ANS: 1,875,000 units The child weighs 55 lbs. divide this number by 2.2. The child weighs 25kg. Multiply 25 times 300,000. the child needs to receive 7,500,000 units of penicillin over 24 hours in 4 divided doses. Divide 7,500,000 by 4. The child is to receive 1,875,000 units of penicillin G potassium every 6 hrs.

A client is prescribed to receive 3 liters of total parent earl nutrition and 1/2 liter of intralipids over every 24 hours. How many milliliter of fluid will the client receive every hour? (Enter numeric value only. If rounding is required, round to the nearest whole number)

ANS: 146 The client is to receive 3500 ml of fluid over 24 hours. Divide 24 into 3500. The client will receive 146 ml of fluid everyhour

A child is diagnosed with nephrotic syndrome. Which information should the nurse include in the discharge teaching plan? (Select all that apply.) A. Administer desmopressin acetate tablet each night before bed B. Weigh the child each morning upon waking. C. Ensure the child plays outside when the weather is appropriate. D. Wash hands often and avoiding friends and family who are ill. E. Test the urine for ketones daily

ANS: B, C, D Nephrotic syndrome is a kidney disorder is which large amounts of protein are lost via the urine. This proteinuria causes hypoalbuminemia and the resulting fluid shifts lead to large amounts of edema. The condition is thought to be caused by an immune response because it is often responsive to immunosuppressive treatment, but it can also develop following a systemic disease such as hepatitis, lupus, heavy metal poisoning, or cancer. The condition will be managed at home so it is essential that the nurse provides teaching for the parents or caregivers to allow them to feel comfortable and confident in providing care. Option B, weight the child each morning upon waking, is correct because children with nephrotic syndrome are at risk for developing fluid imbalances. Because they are losing large volumes of protein via the urine, they often develop edema, especially of the face, hands, and dependent areas. This can leave them with decreased intravascular volume. Noticing any change in weight early allows the parents to seek medical attention early and avoid complications related to fluid volume. Option C, ensure the child plays outside when the weather is appropriate, is correct because this will help prevent skin complications as well as allow the child to meet many developmental milestones. Due the excessive edema that can occur with nephrotic syndrome, skin breakdown around edematous areas is common. Children should be encouraged to play, especially large motor activities, to promote circulation. The skin should also be kept clean and edematous areas should be elevated when resting. In addition, being outside or playing with other children is essential for the physical and emotional development of a child with a chronic condition. Option D, wash hands often and avoid family and friends who are ill, is correct as children with nephrotic syndrome are more susceptible to complications related to communicable diseases because they are taking immunosuppressive medications in addition to losing valuable antibodies through the urine. Visitors should be asked to wash their hands and be free from sore throat, upper respiratory infections or fever. A child who is taking immunosuppressive medications is unable to mount a defense to common childhood colds and viruses and extra precautions should be taken to avoid infection. Option A, administer desmopressin acetate tablet each night before bed, is incorrect as this medication is used in the treatment of nocturnal enuresis or bed-wetting. Desmopressin is the synthetic version of the body's naturally occurring hormone ADH, or anti-diuretic hormone. It helps the body to retain water, therefore decreasing urine output and bladder filling at night. This medication is not appropriate for the child with nephrotic syndrome as they are already susceptible to fluid volume excess. Option E, test the urine for ketones daily, is incorrect because ketones appear in the urine due to impaired carbohydrate metabolism that is often seen in diabetes. In a child with nephrotic syndrome, the parents will test the urine for protein daily. As nephrotic syndrome worsens, increased protein is lost via the urine and the parents should seek medical attention if this change is noted. This urine sample should be collected in the morning because it will be the most concentrated.

The nurse is evaluating laboratory results of a client with thyroid dysfunction. Based on the provided information, the nurse would expect to see what findings when assessing the client? (Select all that apply) A. Drowsiness B. Decreased body temperature C. Increased heart rate D. Hyperventilation E. Hypertension

ANS: A, B The laboratory results indicate that the client is experience in severe hypothyroidism (high TSH, very low T3, T4) as well as respiratory acidosis, which is a manifestation of hypothyroidism due to hypoventilation. Other symptoms associated with severe hypothyroidism include mental status changes such as drowsiness (Choice A) and decreased body temperature (choice B). Choices C, D, and E are incorrect because these symptoms are seen in clients with hyperthyroidism. The client is likely to have bradycardia and hypotension, as well as hypoventilation (of which respiratory acidosis is a manifestation)

A client with a mental health disorder who is taking several sed ating medications uses the call light for assistance with walking to the bathroom. After waiting for several minutes, the client begins to get out of bed by herself. A staff nurse walking past the room stops the client, issues a warning, and then applies a vest and wrist restraints. When notified of the situation, how should the nurse manager respond? A. Contact healthcare provider to obtain order for restraints В. Reprimand staff nurse for violating the client's rights. С. Review fall precautions with nursing staff. D. Instruct staff to active a bed alarm and file a "near miss" incident report

ANS: B Clients taking sedating medications are at increased fall risk. Nursing care should focus on providing a safe and injury free environment. Education should be provided to ensure that the client is aware of their limitations and follows safety protocols. In the situation described in the question, the client followed the correct process by signaling the nurse with the call light for assistance with ambulating to the bathroom. When no assistance was provided in a timely manner, the client got up and attempted to walk to the bathroom by themselves. This behavior does not constitute the need for a vest or wrist restraints, but demonstrates inadequate care on the part of the nursing staff, both in providing timely care to the client and by applying restraints without a medical indication. The nurse manager should reprimand the staff nurse for violating this client's rights and review that restraints can only be applied if the client is a risk for self or others and less invasive measures fail to resolve the situation. Choice A is incorrect because there is no medical indication for restraints and the client's restraints should be lifted as soon as possible. Proper nursing care and falll prevention that do not violate the client's rights should be implemented. Note that a physician's order is required before the implementation of any type of restraint. Choice C is an appropriate action but fails to address the more important issue of the violation of the client's rights. Choice D is incorrect because a bed alarm is considered a form of restraint and requires a physician's order. Rather than using a bed alarm to restrict the client's movement, the nursing team should come up with ways to address client needs in a more timely manner. Filing a "near-miss" report is an appropriate action as the client could have sustained a fall. A Near Miss is an unplanned event that did not result in injury, illness, or damage - but had the potential to do so. The reason for filing a near miss incident report is to determine the cause or causes of the incident; to identify any risks, hazards, systems or procedures that contributed to the incident; and to recommend corrective action to prevent similar incidents.

Which instruction should the nurse include in the discharge plan for a client who had an arteriovenous fistula placed in the left forearm for future hemodialysis? (Select all that apply.) A. Wear a sling for one week to protect the left arm. B. Remind all healthcare workers to use the left arm only for blood draws. C. Evaluate the color and temperature of the left arm three times daily. D.Palpate for a pulse proximal to the fistula site. E. Palpate for a thrill at the access site.

ANS: A, C, E Hemodialysis is the treatment for end-stage renal disease. Dialysis uses diffusion to remove fluid and solutes from the blood when the kidneys are no longer able to complete this function. A few weeks prior to initiating dialysis, clients undergo a surgical procedure to place an arteriovenous (AV) fistula, which is an artificial connection between a vein and an artery. The increased arterial blood flow causes the vein to grow in diameter, making it an accessible point for the large dialysis needle. Without this large vein, regular hemodialysis would not be possible. The client should be instructed on how to care for the AV fistula as it requires frequent assessment to prevent loss of access and infection. Option A, wear a sling for one week to protect the left arm, is correct as the client should not use the left arm in order to allow the fistula to heal and prevent dehiscence. Option C, evaluate the color and temperature of the left arm three time daily, is correct as the client should be taught to evaluate the neurovascular status of the site at home. This would also include assessment for numbness and tingling as well as the ability to wiggle the fingers. Additionally, the client should be instructed to monitor for signs of infection (redness or drainage at the fistula site, fevers). Option E, palpate for a thrill at the access site, is correct as this assessment indicates that the AV fistula is functioning correctly. A thrill is a rumbling sensation that is palpated over the site and should decrease as you move proximal to the site. It is caused by the turbulent blood flow between the artery and vein and is an expected finding. If a thrill is not palpated or becomes weak, the client should notify the provider immediately. Option B, remind all healthcare workers to use the left arm only for blood draws, is incorrect because the client should be taught to have healthcare workers avoid using the arm with the fistula for blood draws. The site should only be accessed by healthcare workers specially trained in using a fistula and be avoided for routine lab work. Option D, palpate for a pulse proximal to the fistula site, is incorrect as the client should be taught to palpate for a pulse distal to the fistula site. This indicates that arterial blood flow is reaching the tissues past the fistula site and that the hand is being adequately perfused

The nurse has administered 2 tablets of acetaminophen/oxycodone (325/5mg) to a client recovering from a knee replacement. To indicate the medication's effectiveness, which statement should the nurse document? A. Client reports that they slept well during the night. B. Client had a bowel movement. C. Client completed physical therapy session. D. Client has a RASS score of -3.

ANS: C A knee replacement, or arthroplasty, is a surgical intervention that replaces the bony surfaces of the knee with a synthetic joint and is used to decrease pain and disability in the client with osteoarthritis. Pain management is especially important following this procedure. The combination medication of acetaminophen and oxycodone, often referred to as Percocet, is an opioid combination medication and requires careful assessment and monitoring by the nurse. When documenting the effectiveness of this medication, the nurse should look for relief of pain as well as the ability to complete activities of daily living and therapy sessions. Option C, client completed physical therapy session, is correct as this demonstrates that the client's pain was tolerable and they were able to complete their required physical therapy. Option A, client reports they slept well during the night, is incorrect as this outcome is beneficial to the client, but is not the desired result after the administration of acetaminophen/oxycodone. The nurse should be assessing for pain relief and completion of tasks of daily living such as ambulating to the bathroom. Option B, the client had a bowel movement, is incorrect as this outcome is not related to the effectiveness of pain medication. Opioids can cause constipation and the nurse should monitor bowel function and implement preventative measures, such as increased fluid and fiber intake, but a bowel movement is not the desired effect of opioid administration. Option D, client has a RASS score of -3, is incorrect as this is an undesirable effect of opioid administration. The Richmond agitation sedation score (RASS) is a nursing assessment that has been proven to be both reliable and valid across care setting and caregivers in measuring sedation. Opioids can cause drowsiness, sedation, confusion and respiratory depression and the nurse should complete a sedation score on administration to obtain a baseline and within one hour to determine if there has been any change in the client's status. A RASS score of -3 indicates that the clients displays movement in response to stimuli but does not open their eyes. This is considered to be moderate sedation and is not appropriate for a client receiving oral pain medication. Steps should be taken to reverse the effects of the opioids if this was the nurse's assessment. A RASS score of -2 to 0 is appropriate for client's receiving oral opioids.

The nurse is triaging clients at the scene of a multiple motor vehicle collision. In which order should the nurse implement these actions? (Arrange with the first on top and the last on the bottom.) 1. Open the airway of a client with crushing chest injury and no respirations 2. Ask client with facial lacerations, independent ambulation, and normal verbal responses to get behind the guardrail 3. Control bleeding in a client with fractured lower extremity and hematoma formation in the left groin who is losing consciousness 4. Assess pulse in a client with a fractured forearm and possible fractured lower leg who is oriented and conscious

ANS: 2, 1, 3, 4 During a disaster with mass casualties, the nurse should triage according to the Green, Red, Yellow, and Black color coding system. START (Simple Triage and Rapid Treatment) is a commonly used triage system. Following the algorithm, the nurse should first remove all walking wounded from the scene (Choice B). Next, the nurse should open the airway of the client with absent respirations (Choice A). If positioning of the airway does not result in normal respirations, the nurse should triage the client with a black label (diseased) and no further care should be given. If positioning of the airway results in respirations, the client will receive a red label (immediate care needed). Next, the nurse should control the bleeding of client C, who will be triaged as red (immediate care needed) due to altered consciousness and likely circulatory collapse. Last, the nurse should address client D. This client will have received a yellow tag (delayed care). This client is relatively stable but does require care within the next few hours.

The nurse is admitting an adolescent client with diabetic ketoacidosis (DKA). The client is drowsy, with blood pressure of 90/60 mmHg and a bedside blood glucose reading of 922mg/dL. In what sequence should the nurse complete the orders? 1. Administer IV bolus of regular insulin 2. Arrange meeting with nutritionist. 3. Initiate 1L 0.9% normal saline bolus. 4. Apply telemetry and draw lab work. 5. Administer subcutaneous insulin. 6. Set up regular insulin infusion.

ANS: 4, 3, 1, 6, 5, 2 Diabetic ketoacidosis (DKA) is a life-threatening complication of type I diabetes. Typically precipitated by infection or illness, insulin levels are insufficient to meet the body's metabolic needs, leading to severe hyperglycemia. The body then begins to metabolize amino-acids and fats instead of glucose for its energy needs. This causes metabolic acidosis and the development of ketones. For a client in DKA, fluid replacement, insulin administration, and electrolyte management are the primary interventions. In this scenario, the nurse should use the nursing process to determine which action is the priority. DKA develops rapidly (over hours as opposed to days) and the nurse should utilize rapid, focused assessment. The first action the nurse should take is to apply telemetry and draw lab work. Telemetry should be applied as arrythmias are common related to electrolyte imbalances. Imbalances related to sodium and potassium are the most common and the nurse should also obtain blood to monitor renal function and arterial blood gases. Next, using the ABC (airway, breathing, circulation) framework the nurse should begin by addressing the circulatory concern of low blood pressure and initiate the fluid bolus. The next step the nurse should take is to manage the high blood sugar. First, the nurse would administer a bolus of regular insulin IV followed by setting up an infusion. Once the client is alert, has active bowel sounds, and is tolerating food, the insulin regimen should be switched to subcutaneous insulin. The client should also receive teaching about managing blood sugars at home and utilizing insulin appropriately. At the end of the hospital admission, when the client is stabilized, would be the appropriate time to arrange for a nutritionist consultation.

A recently deceased client needs post-mortem care. In which order should the nurse provide this care (Arrange from first on top to last on bottom) 1. Remove in dwelling devices 2. Invite family members to view the deceased 3. Collect specimens as requested 4. Verify if autopsy and/or tissue and organ donation requests have been made 5. Bathe and dress the body of the deceased 6. Replace dentures, close the eyes, and remove jewelry 7. Place body within the shroud 8. Attach identification to toe and wrist 9. Place the body in a suite position with the head of the bed elevated

ANS: 4,9,3,1,6,5,2,8,7. Post mortem care is provided by the nurse after the client has been declared death. The first action is to verify if autopsy and/or tissue and organ donation requests have been made (4), as this will require special preparation of the body. Prior to proceeding with other activities, the client should be placed in a supine position with the head of the bed elevated to decrease livor mortis (9). Next, the nurse should collect specimens as requested (3) and afterwards remove all indwelling devices (1) to make it easier to bathe and dress the body and create a normal appearance for the family when viewing the body. The next step is to replace the dentures to give the face a more natural appearance, close the client's eyes by gently pulling the eyelids closed, and removing all jewelry (6), followed by bathing and dressing the body (5). After the client has been dressed in a clean gown and covered with a clean sheet, the nurse should invite the family to view the deceased (2). Jewelry and personal belongings should be given to the family at this time. After the family has left, the nurse should attach proper identification the client's toe and wrist (8) and place the body in a shroud (7) for transportation to the morgue.

The nurse is planning a diet for a client with chronic renal disease. Which snack is an appropriate choice? A. Cucumbers with hummus. B. Peanut butter and banana sandwich. C. Whole milk yogurt with nuts and dried fruit. D. Cubed cheese and pear slices.

ANS: A Chronic kidney disease (CKD) refers to a decline in renal function and can vary in severity from mild to severe. Complications of CKD include the accumulation of waste products, anemia, hypertension, metabolic acidosis, fluid volume excess, and electrolyte imbalances including hypocalcemia, hyperphosphatemia and hyperkalemia. In order to manage these complications, CKD clients must often follow a restricted diet. This is typically a high carbohydrate diet with restrictions related to fluid, protein, and potassium. Option A, cucumbers with hummus, is correct because this snack follows the appropriate restrictions for a client with CKD. Cucumbers are low in potassium and hummus is low in protein. Option B, peanut butter and banana sandwich, is incorrect because nuts, including nut butters such as peanut butter and almond butter, are high in protein. Most fruits, including bananas, oranges, kiwi and apricots, are high in potassium and should be avoided in the diet of a client with CKD. Option C, whole milk yogurt with nuts and dried fruit, is incorrect because this option is high in protein as well as potassium. Dairy products such as milk, yogurt, and cheese are typically high in protein. Nuts are also high in protein while dried fruit contains too much potassium for a client with CKD. Option D, cubed cheese and pear slices, is incorrect because this option is high in protein, sodium, and potassium. Cheese is a high-protein snack that also contains sodium. Pears, like most fruits, are high in potassium. The diet for a client with CKD should include low-protein, low-sodium, low-potassium foods.

An elderly client who is admitted with severe dehydration secondary to gastroenteritis has limited mobility, poor appetite, and poor skin turgor. Which intervention is most important for the nurse to include in the client's plan of care? A. Reposition client every 2 hours. B. Assess baseline abilities for activities of daily living. C. Provide calorie dense snacks at bedside. D. Have client work with physical therapy.

ANS: A Dehydration, limited mobility, poor appetite, and poor skin turgor predispose this client to the development of pressure ulcers. The priority nursing action is to reposition the client every 2 hours to prevent skin breakdown. Choice C is incorrect because a client with gastroenteritis may not be able to tolerate calorie-dense snacks. The nurse should first assess if the client can tolerate clear liquids and slowly advance the diet as tolerated. Choices B and D are appropriate actions after the client's clinical status improves. Assessment of the client's baseline abilities for activities of daily living will help the nurse evaluate the client's needs upon discharge (Choice B). Physical therapy can be offered after the client regains strength to improve mobility and strength and to reduce fall risk.

A client is diagnosed with Raynaud's disease. Which instruction should the nurse provide to prevent complications from this condition? A. Complete a set of vigorous punching exercises during a painful episode. B. Eat a high-protein diet and monitor for headaches. C. Apply compression stockings in the morning and remove in the evening. D. Avoid prolonged standing or sitting with legs crossed.

ANS: A Raynaud's disease is a vasospastic disease of the small arteries. It most often affects the circulation of the hands and fingers but can sometimes involve the toes. Symptoms include coldness, pallor, and pain as blood flow is restricted. Long term complications include brittle nails, atrophy of the surrounding tissues, and occasionally skin ulcerations. The symptoms typically start in response to cold temperatures or emotions such as stress. Clients should be instructed to avoid contact with cold materials and cold environments in addition to using warm mittens or socks if exposure must occur. They should also be counseled on tobacco cessation due to nicotine's vasoconstrictive properties. Option A, complete a set of vigorous punching exercises during an episode, is correct as this action increases hydrostatic pressure, improves circulation and warms the body through exercise. This is an effective non-pharmacological technique for managing the symptoms of Raynaud's disease. Option B, eat a high-protein diet and monitor for headaches, is incorrect as these interventions do not improve circulation or prevent the vasoconstriction that occurs with Raynaud's disease. These actions can be helpful in the management of pregnancy-induced hypertension. Adequate protein intake is important to prevent the development of edema and headaches can be a sign of either the development of eclampsia or HELLP syndrome. Option C, apply compression stockings in the morning and remove in the evening, is incorrect as this intervention does not improve poor arterial blood flow that is associated with Raynaud's syndrome. Instead, compression stockings improve venous circulation and promote the return of blood in the lower extremities to central circulation. Compression stockings are useful in improving edema and preventing the development of deep vein thrombosis due to venous stasis. Option D, avoid prolonged standing or sitting with legs crossed, is incorrect as this intervention is not related to the arterial circulation of the hands that is affected by Raynaud's disease.

An elderly client with poor life expectancy states that he wants to start hemodialysis treatment for end-stage renal disease (ESRD). The client's family is upset and asks the nurse to discourage the client from pursuing further treatment as the benefits are unlikely to outweigh the risks. Which action should the nurse take? A. Contact healthcare provider to complete a client competence assessment. B. Identify the client's Power of Attorney (POA). C. Explain to the client that his expectations regarding hemodialysis may be unrealistic. D. Refer this situation to the hospital ethics committee.

ANS: A When a conflict arises between a client's wishes and the wishes of the family, the healthcare team should determine if the client has decision-making capacity. This can be done by completing a competency assessment. If the client is deemed to be competent, the nurse should honor the client's wishes and proceed with the offered treatment. Choice B is appropriate if assessment reveals that the client does not have decision-making capacity. However, the client's competence should be assessed first. Choice C is an inappropriate response, as this statement is patronizing and based on assumptions rather than facts. A more appropriate approach would be to explore the client's wish for, and expectation of, treatment (which may or may not be realistic) and ensure awareness of risks and benefits. Choice D may be necessary if the client is deemed incompetent and no decision can be reached, but is premature at this time.

The nurse is caring for a client who is admitted following a left-sided ischemic cerebral vascular accident (CVA). Which actions by the nurse warrant intervention? (Select all that apply). A. After 2 hours on right side, nurse repositions client to left side. B. Places bedside commode on client's right side. C. Uses short closed questions to communicate with the client. D. Keeps the head of the bed at a 30-degree angle. E. Performs range of motion exercises every 4 hours.

ANS: A, B Clients with a left-sided stroke experience symptoms on the right side of the body. The observations that require intervention are option A and B. Choice A requires intervention because even though the nurse is correct in repositioning the client every 2 hours, the client should not have been placed on the affected (right) side for more than 30 minutes. Because the client's sensation is impaired on the right side, the risk for tissue injury and pressure overload is increased on this side. Skin breakdown can occur after only 30 minutes. Choice B requires intervention because a bedside commode should be placed on the unaffected (left side) for safety. Note that the client should not be allowed to use the commode independently until the nurse has confirmed that the client can leave the bed without assistance. Options C, D, and E are all appropriate interventions for a client in the acute recovery phase of a left-sided stroke. The use of short questions that can be answered with "yes" and "no" will make it easier for the client to indicate his needs. Clients with a left-sided stroke often experience language problems (Choice C). Keeping the head of the bed at a 30-degree angle reduces the risk of aspiration (Choice D). Range of motion exercises should be started in the acute recovery phase to maintain joint mobility (Choice E).

A client is prescribed a non-selective beta blocker. What adverse effects should the nurse include when teaching about this medication? (Select all that apply.) A. Seizures. B. Hypoglycemia. C. Hypotension. D. Bleeding abnormalities. E. Migraine.

ANS: A, B, C Non-selective beta-blockers activate both beta-1 and beta-2 receptors. They work on the heart and vasculature to decrease the heart rate, cardiac contractility, blood pressure, and myocardial oxygen demand. Adverse effects include bradycardia and heart block, neurological dysfunction resulting in delirium or seizures (Choice A), hypoglycemia (Choice B) and hypotension (Choice C). Note that the effect of non-selective beta-blockers on blood glucose levels can be twofold. By blocking beta-2 receptors in muscle and liver, non-selective beta-blockers can suppress glycogenolysis, thereby preventing the release of glucose into the bloodstream and causing hypoglycemia. This effect will not be seen with selective beta-blockers, as these only block beta-1 receptors. Controversely, in clients with diabetes, non-selective beta-blockers can increase insulin resistance and hence induce hyperglycemia. Both selective and non-selective beta-blockers should be used with caution in clients with diabetes as they inhibit beta-1 receptor-mediated tachycardia and other SNS effects, which normally serve as early warning signals that blood glucose levels are falling low. Beta-blockers do not cause bleeding abnormalities (Choice D) or migraine (Choice E). Propranolol (a non-selective beta-blocker) is used for the treatment of migraine.

The nurse is caring for a client with a small bowel obstruction who is being treated with a nasogastric tube on low intermittent suction and an intravenous normal saline infusion. On assessment, the client reports muscle cramping. Based on the client's presentation and laboratory results, what interventions should the nurse implement? (Select all that apply.) A. Obtain electrocardiogram (ECG). B. Change infusion to Dextrose 5% and water (D5W) with potassium. C. Increase suction to high intermittent setting. D. Increase normal saline infusion rate. E. Start sodium bicarbonate infusion.

ANS: A, D The client is experiencing a hypochloremic, hypokalemic metabolic alkalosis as a result of a bowel obstruction (decreased uptake of potassium, chloride) and gastric suctioning (loss of potassium, chlorine, acid). Choices A and D are appropriate interventions for this client. An ECG should be obtained to monitor for changes in cardiac excitability related to hypokalemia (Choice A). Increasing the normal saline infusion rate will dilute the client's high bicarbonate level and helps normalize the acid base abnormality (Choice D). Note that potassium should be added to the infusion to correct the low serum potassium levels; However, Choice B is incorrect because potassium replacement should be given in a saline solution and not in D5W. D5W can increase insulin secretion, which in turn promotes uptake of potassium from the bloodstream into the cells. This may worsen the client's hypokalemia. Choice C is incorrect because increasing the suction will promote further loss of potassium, chloride and acid, and worsen the client's metabolic alkalosis. Choice E is incorrect because a sodium bicarbonate infusion is indicated for clients with metabolic acidosis. In a client with metabolic alkalosis it will further worsen the acid-base disturbance.

A clear liquid diet is ordered for a client scheduled for a colonoscopy. Which food selection indicates that teaching has been effective? (Select all that apply) A. Gelatin B. Orange juice with pulp C. Cappuccino D. Tea with honey E. Broth

ANS: A, D, E Clients on clear liquid diet can- as the name implies- only consume clear liquids. No solids are included in this diet. Option A (gelatin), D (tea with honey), and E (broth) are proper choices for a client on a clear liquid diet. Choice B is incorrect because pulp cannot be consumed while on a liquid diet. The client is permitted to drink clear juices such as apple juice or grape juice without pulp. Choice C is incorrect because a cappuccino contains milk, which is not permitted on a clear liquid diet. The client is permitted to drink a cup of dark coffee without milk

A client with diabetes mellitus and a capillary blood glucose level of 120 mg/dl is complaining of blurred vision that started several weeks ago. What action should the nurse take? A. Provide 4 ounces of orange juice B. Notify the physician for an ophthalmology consultation C. Assess the client's urine for ketones D. Apply a cool compress to the client's forehead

ANS: B A client with diabetes mellitus who is complaining of blurred vision could be experiencing vision changes associated with diabetic retinopathy. Diabetic retinopathy develops when consistently elevated blood glucose levels cause glycosylation of vascular proteins. The retinal vessels in the eye and the small blood vessels in the kidney are particularly sensitive to glycosylation. Retinal small vessel disease leads to diabetic retinopathy, which manifests with blurred vision. On fundoscopy, retinal exudates and micro-hemorrhages can be seen. The nurse should notify the physician for an ophthalmology consultation. Choices A and C are incorrect because the client's blood glucose level is within normal limits. Although blurred vision can occur as a sign of diabetic ketoacidosis, this is unlikely to be the cause of this client's symptoms because the client's vision changes have been present for several weeks and the client's capillary blood glucose is within normal limits. Choice D is incorrect because a cool compress to the forehead will not help the client's blurred vision.

A perioperative nurse is preparing to obtain consents from a group of clients that are scheduled for outpatient surgery today. Which client requires informed consent from next of kin? A. A 54 year old client with a hand tremor B. A 16 year old client with acetaminophen allergy C. A 32 year old client who is legally blind D. A 72 year old client whose primary language is Russian

ANS: B All clients have the legal right to be fullly informed about their medical condition as well as any purposed treatments. Informed consent is defined as the client's choice to undergo a treatment or procedure based on their full understanding of the risks and benefits as well as any potential alternatives. In order to provide informed consent, the client must be an adult with the mental ability to make decisions. For this reason, Option B, a 16-year-old client with an acetaminophen allergy, is correct because this client is a minor and would require informed consent from a legal guardian such as a parent. For most states, a client must be 17 years of age or older in order to provide informed consent for treatment or a procedure. There are certain exceptions to this such as treatment for a sexually transmitted disease or if they are legally married. Option A, a 54-year-old client with a hand tremor is incorrect because the client is of legal age and is competent to consent to care. Although their signature may be shaky, the nurse is verifying their understanding of the procedure and not their ability to write legibly. Option C, a 32-year-old client who is legally blind, is incorrect because this client is still competent to provide consent despite their injury. If a client is unable to see or to read the consent, the nurse can read the information to them or provide an alternative text, such as large print or braille Their ability to understand is not affected by their inability to see the text on the consent form. Option D, a 72-year-old client whose primary language is Russian, is incorrect because this client's ability to understand the procedure is not affected because his primary language is Russian. It is a client's right to receive written oral medical information in their primary language. Many computer programs will offer translations of consent forms or the nurse may use a trained translator. The nurse should use a trained medical translator, rather than available family members, to ensure that the information is communicated correctly and that confidential medical information is kept private.

A client with community-acquired pneumonia is admitted and started on IV vancomycin. Upon assessment, the client reports itching and the nurse observes skin changes as seen in the image. After stopping the infusion, which action should the nurse implement first? A. Check an oral temperature. B. Obtain a blood pressure. C. Give 50mg IV diphenhydramine. D. Start a 1000cc bolus of 0.9% normal saline.

ANS: B Community-acquired pneumonia is a lung infection most often caused by streptococcus pneumonia or Haemophilus influenzae. Vancomycin is a powerful antibiotic commonly used to treat community-acquired pneumonia. The client's symptoms of flushing and itching are characteristics of red man syndrome, a known side effect of vancomycin that can occur vancomycin being infused too quickly. The signs of red man syndrome include itching and the development of a red maculopapular skin eruption involving the neck, face, and upper torso, These changes are the result of excessive histamine release in response to the antibiotic. After the medication is stopped, the nurse should assess the client for other systemic symptoms that occur with red man syndrome. Option B, obtain a blood pressure, is correct because the client is at high risk for developing hypotension due the histamine release. The nursing process should be utilized in this situation and the nurse should gather information before implementing any interventions. Using the ABC framework, the nurse should ensure the client has an open airway and is free of breathing concerns followed by assessing circulatory concerns including blood pressure, heart rate and level of consciousness. Option A, check an oral temperature, is incorrect as this is not the first assessment data that the nurse should gather. A temperature may be obtained as part of a full set of vital signs however the nurse should focus on gathering data related to the ABCs before checking a temperature. Option C, give 50mg IV diphenhydramine, is incorrect because the nurse should complete a full assessment before working toward any interventions. Checking a blood pressure would be a higher priority than implementing this order. Diphenhydramine is an H1 receptor blocker used to treat the immune response symptoms such as rash and itching. Option D, start a 1000cc bolus of 0.9% normal saline, is incorrect because this is an action step in the nursing process and the nurse should first gather prioritized assessment data before moving to interventions. If the client does develop hypotension related to the anaphylactic red man syndrome, then the nurse should administer a fluid bolus. However, the nurse should gather assessment data using the ABC framework first before initiating any interventions.

When providing care to a newly admitted elderly client, the nurse explains that someone will stop by the clients room every hour. This intervention is likely to provoke what effect in the client? A. Orientation to time B. Reassurance that she will be checked on every hour C. Worry that she is ill enough to need hourly care D. Irritation that her rest will be interrupted

ANS: B Elderly clients might be lonely or afraid that someone will not be there to address their needs. By explaining to the client that someone will come to the clients room every hour, the client can be reassured that they are not alone and will be helped if needed. Choice A is incorrect because this intervention does not orient the client to time. A visible clock and daylight are appropriate interventions to improve time awareness. Choices C and D may occur but are less likely than B. Very ill clients will be admitted to the ICU and monitored continuously (Choice C). The person checking in on the client does not have to engage the client in conversation or complete a physical exam if the client is resting. Simply opening the door and "laying eyes" on the client is enough to ensure that the client feels safe yet is able to rest (Choice D).

A new graduate nurse tells the nurse that due to the presence of nail polish on the fingernails a client's pulse oximeter was applied to a toe as seen in the picture. How should the nurse respond? A. "The toe is not a reliable location for pulse oximetry." B. "Placing the probe on the toe is a good solution." C. "The probe is too small to provide a reliable reading." D. "You should keep the client's feet covered to prevent vasoconstriction."

ANS: C The exhibit shows that a finger probe is placed on the large toe. The probe is incorrectly positioned because the toe is too big for the probe, which compromises circulation in the toe and interferes with the probe's light detection. The result is an unreliable oximetry reading. In addition, the current positioning may result in damage to the probe. The nurse should instruct the graduate nurse to place the probe on a smaller toe. Other locations that can be used if the fingers are not available include the ear, palm, sole, and forehead. Choice A is incorrect because the toe is a reliable location for pulse oximetry as long as the probe is properly positioned. Choice B is incorrect because the reading will be compromised unless the probe is repositioned. Choice D is incorrect because this comment does not address the fact that the probe needs repositioning. Keeping the feet warm will increase the reliability of the reading once the probe is properly positioned.

A client is recovering from a hip replacement and has not voided 6 hours post-surgery. Which intervention should the nurse implement first? A. Calculate the client's net intake and output. B. Use bedside ultrasound to measure urine volume in the bladder. C. Initiate a 1-liter fluid bolus of 0.9% normal saline at 200cc/hr. D. Use an intermittent catheter and drain the bladder of urine.

ANS: B In a post-surgical client, the nurse should be continually monitoring urine output as part of the ABC (airway, breathing, circulation) framework. Assessment of urine output falls into the circulation category as it provides information related to the perfusion of the kidneys. There are two potential complications for a client who has no urine output following surgery. The first, and most serious, is poor kidney perfusion. This can be caused by low blood pressure or fluid volume deficit causing the kidneys to produce less than the optimal 30ml/hr of urine. The second, less serious complication, is that the kidneys are making urine but there is urinary retention due to anesthesia or obstruction. The nurse should use the nursing process, beginning with assessment, to determine which of these complications is occurring. Option B, use a bedside ultrasound to measure urine volume in the bladder, is correct because this assessment gives the nurse information about whether the client is experiencing decreased kidney perfusion versus urinary retention. The data the nurse collects will allow them to determine the next course of action. Option A, calculate the client's net intake and output, is incorrect as this is not the best first action for the nurse. Calculating net intake and output will give the nurse information about whether the client is in fluid volume deficit or excess and urine output should be considered in this calculation. If the client has urine in their bladder, it should be emptied before this calculation is completed. Option C, initiate a 1-liter fluid bolus of 0.9% normal saline at 200cc/hr, is incorrect as this action is an intervention that could be completed after the nurse has gathered sufficient assessment data. If the nurse determines that the lack of urine output is due to poor perfusion, this intervention would be appropriate. Option D, use an intermittent catheter to drain the bladder of urine, is incorrect because this action should not be taken until the nurse has determined that the client is experiencing urinary retention. If the nurse uses the bedside ultrasound, finds the bladder volume to be greater than 300ml and attempts reasonable interventions to encourage the client to void independently, then an intermittent catheter may be used to empty the bladder. This action step should only be taken after the nurse has completed an assessment and attempted less invasive methods of bladder emptying.

A client with schizophrenia tells the nurse that his roommate is trying to steal his clothes from his closet. What should nurse document in the client's medical record? A. The client is demonstrating confusion. B. The client is experiencing paranoid thoughts. C. The client is experiencing visual hallucinations. D. The client is exhibiting manic behavior.

ANS: B Schizophrenia is a severe mental health disorder characterized by psychosis, delusions, and hallucinations. Symptoms have to be present for at least 6 months and must be associated with the inability to function properly in everyday life. Clients often experience a combination of positive symptoms (hallucinations, delusions, disorganized speech/behavior), negative symptoms (flat affect, poverty of speech, catatonia), neurocognitive symptoms (memory problems, decreased attention span, problems with planning and organizing) and mood symptoms (typically depression). Paranoid delusions are a common feature and revolve around the belief that certain people are trying to harm the client. The statement that the roommate is trying to steal the client's clothes is an example of a paranoid delusion (Choice B). Choice A is incorrect because confusion suggest lack of orientation to time, place or person. The client's statement does not indicate confusion. Choice C is incorrect because visual hallucinations involve seeing things (objects, people, lights, patterns) that are not there. While the client could theoretically have a visual hallucination of the roommate stealing his clothes, visual hallucinations are typically bizarre and different in character. Visual hallucinations are less common than auditory hallucinations in clients with schizophrenia. Choice D is incorrect because mania is characterized by a sense of euphoria, delusions of grandeur, and state of hyperactivity. Reporting that the roommate is trying to steal clothing is not characteristic of mania.

The nurse is planning care for a client with multi-organ dysfunction syndrome (MODS). Which interventions to reduce oxygen demand should the nurse include in the client's care plan? (Select all that apply.) A. Cluster care activities to be completed in the morning. B. Provide a peaceful and quiet environment. C. Reduce anxiety. D. Ensure that pain management is adequate. E. Frequently turn and reposition the client.

ANS: B, C, D Clients with multi-organ dysfunction syndrome (MODS) have inadequate tissue perfusion and increased oxygen demands. Nursing interventions that reduce oxygen consumption include providing a peaceful and quiet environment (Choice B), reducing anxiety (Choice C) and ensuring that pain management is adequate (Choice D). Anxiety, pain, and stress all activate the body's stress response, leading to vasoconstriction, hypertension, and tachycardia. This increase in cardiac workload will in turn increase the client's metabolic rate and oxygen consumption. Choices A and E are inappropriate because nursing care activities and repositioning lead to an increase in oxygen consumption, which lasts for up to 30 minutes after the activities are completed. Nursing care should be spaced out instead of clustered to not overwhelm the client's oxygen needs. Repositioning should be done only as needed.

The nurse is visiting a senior client to complete a fall assessment. Which observations indicate that the client would benefit from instructions regarding balance and positioning? (Select all that apply.) A. Wide stance. B. Knees are locked. C. Weight is focused on balls of the feet. D. Weight is focused on heels of the feet. E. Chest is slightly further back than abdomen.

ANS: B, C, D, E Proper positioning and balance is essential in preventing falls among older clients. Observations B (knees are locked), C (weight is focused on balls of the feet), D (weight is focused on heels of the feet) and E (chest is slightly further back than abdomen) indicate that the client will benefit from balance instructions. The nurse should instruct the client to assume a wide stance with the center of gravity positioned in the midline of the body. The knees should be slightly flexed. The body weight should be equally divided between the two feet, with even pressure on the balls of the foot, little toe and heels (which together form the tripod of the foot). The chest and abdomen should be in one line to keep the center of gravity positioned at midline.

A client recently diagnosed with breast cancer is scheduled for a sentinel node biopsy prior to a mastectomy. What explanation should the nurse provide? A. "A sentinel node biopsy will determine if part of the chest muscle will need to be removed in addition to the breast tissue." B. "A sentinel node biopsy will allow you to have reconstructive surgery within 6 to 12 months of surgery." C. "A sentinel node biopsy determines if the surgeon will need to remove lymph nodes in addition to the breast tissue." D. "A sentinel node biopsy is a standard precaution and it is unlikely that cancer will be found in the lymph nodes."

ANS: C A sentinel node biopsy is a test to determine if cancer has spread beyond the primary tumor site of the breast and into the lymphatic system. The sentinel nodes are those lymph nodes closest to the tumor site and are most likely to have developed cancerous cells. A biopsy is the aspiration or surgical removal of lymph node tissue which can then be evaluated for cancerous cells. Option C, "A sentinel node biopsy determines if the surgeon will need to remove lymph nodes in addition to the breast tissue," is correct because this type of biopsy allows the surgeon to evaluate if the cancer has spread to the lymph system. If the biopsy is positive, the surgeon will need to complete an axillary lymph node dissection and more systemic treatment, such as chemotherapy or radiation following surgery. If the biopsy is negative, lymph node dissection is not needed. Option A, "A sentinel node biopsy will determine if part of the chest muscle will need to be removed in addition to the breast tissue," is incorrect because the biopsy is a diagnostic tool used to determine if cancerous cells have spread to the lymph system. It does not determine if part of the pectoral muscle will need to be removed. Some surgeons will elect to remove the lining over the pectoralis major muscle depending on the severity or proximity of the tumor. This decision is made based on the location of the tumor, not the results of the SLN biopsy. Option B, "A sentinel node biopsy will allow you to have reconstructive surgery within 6 to 12 months of surgery," is incorrect because a sentinel node biopsy does not affect the client's ability to have reconstructive surgery. It is recommended that clients finish radiation and chemotherapy treatment before undergoing reconstructive surgery. This is typically about 6 to 12 months following a mastectomy. Option D, "A sentinel node biopsy is a standard precaution and it is unlikely that cancer will be found in the lymph nodes," is incorrect because the nurse does not know whether the lymph nodes are involved. A biopsy will determine their involvement as well as the next treatment steps following a mastectomy. Because of the close proximity of the axillary lymph nodes to the breast tissue, lymph node involvement is common in breast cancer.

Which intervention should the nurse delegate to a licensed practical nurse (LPN) when caring for a client who just arrived to the emergency department with an acute ischemic stroke? A. Complete the National Institute of Health Stroke Scale (NIHSS). B. Provide teaching related to CT scanning procedures. C. Administer 325mg aspirin orally. D. Assess the client's gag reflex.

ANS: C A stroke is an abrupt disruption to the blood flow of the brain. Ischemic strokes are both common and deadly, accounting for 80% of strokes and are the 3rd leading cause of death in the United States. The client who is experiencing an acute stroke needs rapid assessment and intervention by the healthcare team and the nurse is responsible for coordinating the care across multiple disciplines. Option C, administer 325mg aspirin orally, is a correct intervention to delegate to the LPN. It is within the scope of practice of the LPN to administer oral medications and this would be appropriate in the critical setting for the nurse to delegate this task. Option A, complete the National Institute of Health Stroke Scale (NIHSS), is incorrect as it is the responsibility of the nurse to complete assessment. The NIHSS is a specialized neurological exam that provides the nurse with baseline data and helps the team determine the need for thrombolytics or other supportive measures. A nurse should receive special training in utilizing the NIH stroke scale to ensure consistency across care areas. Option B, provide teaching related to CT scanning procedures, is incorrect as teaching and evaluating understanding are tasks that are unique to the scope of practice of the registered nurse. A helpful pneumonic is nurses cannot delegate what they can EAT (evaluate, assess, and teach). These tasks are specific to the registered nurse role. Option D, assess the client's gag reflex, is incorrect as the RN is responsible for the initial assessment of clients. It is within the scope of practice for the LPN to obtain basic assessment data such as vital signs and blood sugar but this data should be reported to the RN immediately to interpret. Complex assessments, such as in-depth neurological assessments, are the responsibility of the RN.

A client develops urticaria over the torso while receiving intravenous penicillin. After discontinuing the medication and assessing the client, what action should the nurse take? A. Provide a drug-antidote. B. Contact pharmacy about error in drug preparation. C. Complete an adverse-event report. D. Draw blood to test for anti-penicillin antibodies.

ANS: C Adverse reactions to penicillin are the most reported drug side effect. If a rash occurs, the nurse should immediately stop the infusion, assess the client, document the occurrence and the type of reaction, and report the event to the physician. Afterwards, an adverse-event report needs to be completed. The Adverse Event Reporting System (AERS) is used by the FDA to monitor the safety and incidence of adverse effects of all approved drugs. Choice A is incorrect because there is no such thing as a drug-antidote for penicillin. Antihistamines and steroids can provide symptomatic relief. If anaphylaxis occurs, treatment with epinephrine is indicated. Choice B is incorrect because penicillin allergy is caused by an abnormal reaction of the immune system to the drug, not by an error in the preparation of the drug. Choice D is incorrect because the client should undergo penicillin skin testing to determine the presence of a true allergy (versus an adverse reaction).

A client with a history of Parkinson's disease is admitted with muscle weakness, rigidity, and left foot contracture. Which assessment should the nurse implement first? A. Nutritional intake B. Frequency of following daily exercise program C. Ability to swallow D. Feelings of depression

ANS: C Parkinson disease is a progressive neurological condition characterized by the loss of dopaminergic nerve cells in the brain. The loss of these nerve cells causes a decrease in dopamine levels which leads to the development of the progressive symptoms of Parkinson's disease, including resting tremors, muscle rigidity, bradykinesia, postural instability, and other motor and non-motor symptoms. Treatment of Parkinson's disease is focussed on symptom control. However, the disease is progressive, and no cure is available. The client's condition is deteriorating, as evidenced by increased muscle weakness, rigidity and contracture development. An extensive assessment is required at this time to ensure that the client's physiological and safety needs are identified and addressed. As muscle weakness can affect the muscles of the pharynx and larynx, the nurse should assess the client's ability to swallow first (Choice C). Options A, B, and D are appropriate actions but - using the ABCs and Maslow's hierarchy of needs - do not get priority over choice C. Nutritional status is often suboptimal in client's with Parkinson's disease due to trouble preparing food and swallowing, and decreased appetite secondary to medication use. The nurse should carefully assess the client's nutritional status and plan interventions as required. Note that the ability to swallow should always be assessed prior to providing the client with something to eat/drink to prevent aspiration (Choice A). Daily exercise is important for client's with Parkinson disease as it helps maintain muscle straight and delays the onset of rigidity. The nurse should investigate if the client developed the current symptoms because of lack of adherence to the exercise program, or if the current symptoms developed despite daily exercise. A new exercise program should be developed based on the client's current physical capacity (Choice B). Feelings of depression are common in clients with Parkinson's disease and should be addressed. Using Maslow's hierarchy of needs, the nurse would assess and/or address the client's physical needs first (Choice D).

A client who follows a vegan diet is demonstrating signs of poor wound healing after surgery. What instruction should the nurse provide to improve the healing of the surgical wound? A. Ingest several servings of cheese and yogurt each day B. Increase the intake of red meat C. Add additional servings of tofu and beans each day D. Incorporate extra virgin olive oil into the diet each day

ANS: C Poor wound healing can be seen in clients with decrease protein intake. Vegan clients are at risk for protein deficiencies as many traditional sources of protein (meat, eggs, dairy) are avoided. The nurse should make recommendations for foods rich in vegetable-based protein to improve wound healing, such as tofu and beans (Choice C). Choices A and B are incorrect as cheese, yogurt, or red meat are not part of a vegan diet. Choice D is incorrect because extra virgin olive oil does not aid with wound healing.

The nurse is assessing a client who is retaining carbon dioxide. The client opens the eyes to verbal commands, responds with inappropriate single words, and withdraws the arm when pain is applied. What score on the Glasgow Coma Scale (GCS) should the nurse document in the client's record? A. 15 B. 12 C. 10 D. 3

ANS: C The Glasgow Coma Scale (GCS) is a widely used scale to objectively monitor neurological status. The scale runs from 3-15. The higher the score, the better the client's neurological status and prognosis. The Glasgow coma scale (GCS) rates verbal, motor, and eye responses to painful and verbal stimuli. The scoring system for each category is as follows. Eyes: opens spontaneously (4 points); opens eyes in response to voice (3 points); opens eyes in response to pain (2 points); does not open eyes (1 point). Verbal: is oriented and participates in spontaneous conversation (5 points); speaks, but is confused and disoriented (4 points); speaks single words only (3 points); makes sounds (2 points); makes no sounds (1 point). Motor: obeys commands (6 points); localizes to pain (5 points); withdraws in response to pain (4 points); abnormal flexion in response to pain (3 points); abnormal extension in response to pain (2 points); no response to pain (1 point). This client opens the eyes in response to voice (3 points), uses inappropriate single words (3 points), and withdraws the arm in response to pain (4 points), which makes the client's total score 10 (Choice C). The other choices are incorrect.

A client with a 40 pack year history of smoking is scheduled for a pulmonary function test. What should the nurse explain regarding this diagnostic test? A. "This test is used to assess your risk for lung cancer" B. "This test is used to determine the percentage of oxygen that is in your lungs with every breath" C. "This test shows if you would benefit from medication to improve your breathing" D. "This test identifies the best interventions to help you quit smoking"

ANS: C Pulmonary function tests (PFTs) consist of a series of tests to measure how well the lungs are functioning. Typically, spirometer, diffusion studies, and plethysmography are performed to measure lung volume, capacity, rates of flow, and gas exchange. Client should be instructed to breath through a mouthpiece connected to a measuring device. Choice C is the correct answer as the PFTs provide quantification of the damage that is sustained through smoking and provide information on the need for additional therapies to improve pulmonary function, such as bronchodilators. Choice A is incorrect because PFTs are not used for the detection of lung cancer. An X-ray or CT scan should be ordered if lung cancer is suspected. Choice B is incorrect because the percentage of oxygen in the lungs is dependent on the mixture of air that is inhaled regardless of the capacity or condition of the lungs. Choice D is incorrect because PFTs do not identify interventions to aid the client with smoking cessation.

The nurse is instruction a new graduate on the use of a pleur evac drainage system for a client with a pleural effusion. In what location should the nurse instruct the new graduate to look if an air leak is suspected? A. Location A B. Location B C. Location C D. Location D

ANS: C The nurse should instruct the graduate nurse to assess location C to see if an air leak is present. Location C is the air leak meter; bubbling in this location indicates an air leak. In contrast, fluctuation of the fluid in the air leak chamber and water seal (tube connecting B and C) is normal as a result of pressure changes during respiration. Choice A is incorrect because location A is the collection chamber. In this chamber, the drainage from the chest is collected. It has calibration marks and make it easier to read and document the amount of drainage. There will be no bubbling in this chamber. Choice B is incorrect because location B is the high negativity float valve and high negativity relief chamber. The negativity float valve and negativity relief chamber are safety measures that maintain the water seal in the event of high negative pressures (which can be caused by coughing, crying, and stripping of the chest tubes or decreased suctioning). Choice D is incorrect because location D is the suction control chamber. The amount of suction is regulated by the height of the column of water in the suction control chamber A suction pressure of -20 cm H2O is typically used. Gentle continuous bubbling in this chamber is normal and does not indicate an air leak

A pregnant woman with hyperemesis gravidarum has been vomiting excessively and lab results reveal hypokalemia (serum potassium 3.0 mEq/L). What other abnormalities should the nurse expect to find? A. Peaked T waves and QRS prolongation on EKG B. Decreased PCO2 C. Increased serum bicarbonate D. Decreased serum chloride E. Increased urinary potassium

ANS: C, D Excessive vomiting results in the loss of potassium, chloride, and (stomach) acid. This results in the development of hypokalemic, hypochloremic metabolic alkalosis. Therefore, lab results will show a rise in bicarbonate levels (Choice C) and low chloride levels (Choice D). Choice A is incorrect because the nurse would expect to see U wave and ST depression on the EKG due to hypokalemia. Peaked T waves and QRS prolongation are signs of hyperkalemia. Choice B is incorrect because the PCO2 will be increased (i.e. the client will be hypoventilating) to compensate for the rise in bicarbonate. Choice E is incorrect because this client is hypokalemic as a result of excess vomiting and not as a result of renal potassium loss. the kidneys will minimize potassium excretion in an attempt to raise serum potassium levels.

The nurse is planning the care of a 7-year-old child with acute glomerulonephritis. Which intervention should the nurse include in the client's plan of care? A. Keep pitcher of lemonade on bed stand to promote fluid intake. B. Instruct visitors not to bring fresh flowers or fruits into the room. C. Arrange for time at the playground with other children each day. D. Measure blood pressure every 4 hours.

ANS: D Acute glomerulonephritis (GN) is a condition characterized by hematuria, proteinuria, and red blood cell casts in the urine that develops when the renal glomeruli are not working properly (due to injury, inflammation, or infection). Edema, hypertension, and fluid retention are associated findings. In children, the most common cause of acute glomerulonephritis is a recent streptococcal throat infection (post-streptococcal glomerulonephritis (PSGN)). A child with acute glomerulonephritis is at risk of developing acute hypertension. Blood pressure levels can rise rapidly and should be monitored every 4 hours to ensure that antihypertensive therapy can be started rapidly if needed, to avoid the occurrence of hypertensive encephalopathy (Choice D). Choice A is incorrect because children with acute glomerulonephritis should limit fluid intake as the kidneys are unable to excrete fluid properly, increasing the risk for volume overload and hypertension. Choice B is incorrect because these measures are appropriate for children that are severely immunocompromised or have low white blood cell counts. Fresh fruits or flowers may carry micro-organisms that can be harmful to those with a severely suppressed immune system. While children with glomerulonephritis may experience mild immune suppression, these measures are not necessary. Choice C is incorrect because children with acute glomerulonephritis are typically placed on bedrest to decrease metabolic demand and reduce the workload of the kidneys. Playing with other children on the playground would be too strenuous.

A school-age client with celiac disease reports frequent abdominal cramping after meals. What instruction should the nurse provide? A. Use whole wheat crackers or spelt bread instead of white bread B. Sushi with soy sauce and Cassava chips are healthy snack options C. Use barley instead of beans in soups D. Increase intake of eggs, lean dairy, and rice

ANS: D Celiac disease is a gastrointestinal disorder caused by an intolerance to gluten, a protein found in most grains, including wheat, barley, rye, and oats. When clients with celiac disease ingest gluten, an immune reaction is initiated, leading to the release of antibodies and cytokines in the intestine. This response damages the villi of the small intestine, which are responsible for nutrient absorption. Shortly after ingesting gluten, the client may experience abdominal pain, nausea, vomiting, or diarrhea. Long-term effects of this disease are often related to poor nutritional absorption and include weight loss, anemia, osteoporosis, and failure to thrive. A well-balanced diet rich in lean protein (unprocessed meats and/or fish), fresh fruits and vegetables is recommended to maintain GI health and to prevent nutritional deficiencies. Choice D, "increase the intake of eggs, lean dairy, and rice" is an appropriate instruction as these foods are gluten-free and provide essential nutrients for a school-age client. Choice A is incorrect because whole wheat and spelt are grains that are rich in gluten and should be avoided, just like white bread. Choice B is incorrect because soy sauce contains gluten. Sushi (if appropriately prepared in a gluten-free environment) and cassava are gluten-free and can be incorporated into the client's diet. Choice C is incorrect because barley is a grain rich in gluten. Beans, however, are a good source of protein for clients with celiac disease.

A licensed practical nurse (LPN) asks why a client with extensive burns over the arms and torso is receiving the histamine-2 (H2) blocker cimetidine. What should the nurse respond? A. "This drug decreases the risk of anaphylactic shock." B. "This drug helps fluids shift from the interstitial space into the circulation." C. "This drug decreases the risk of airway swelling." D. "This drug decreases hydrochloric acid production by the gastric mucosa."

ANS: D Clients with extensive burns have a high risk of developing stress ulcers (Curling ulcers) in the stomach and duodenum due to reduced blood flow to the gastrointestinal tract, which causes local ischemia and a reduction in protective mucus production. An H2 blocker (such as cimetidine) decreases stomach acid production and is given prophylactically to prevent ulcer development. Choice A is incorrect because Histamine-1(H1) blockers (diphenhydramine), and not H2 blockers, can be used for symptomatic relief in clients with anaphylactic shock. Clients with extensive burn injuries are at risk for hypovolemic and septic shock, not anaphylactic shock. Choice B is incorrect because diuretics help shift fluids from the interstitium to the circulation. H2 blockers have no effect on fluid movement. Choice C is incorrect because H1 blockers, and not H2 blockers, can reduce tissue swelling and itching. However, they are not used for airway management.

A client recovering from pituitary tumor removal has a urine output of 3500 ml over 12 hours with a urine specific gravity of 1.002. What action should the nurse implement? A. Collect urine sample for culture and sensitivity. B. Assess for presence of the Cushing reflex. C. Review labs for elevated creatinine and blood urea nitrogen. D .Assess for lethargy, confusion, and weakness.

ANS: D Diabetes insipidus (DI) is a condition in which a (relative) shortage of AntiDiutretic Hormone (ADH) results in the production of large volumes (>3L/day) of dilute urine (< 300mOsm/kg, urine specific gravity < 1.005). DI is subclassified as central (loss of production of ADH by the pituitary) or nephrogenic (normal levels of ADH but resistance to AHD action in the kidney). Clients with DI present with polydipsia (increased thirst), polyuria, and nocturia. In addition, signs of hypernatremia may develop (lethargy, confusion, weakness (Choice D)), as the serum sodium levels continue to rise due to intravascular dehydration. Due to the concentration of serum electrolytes, the plasma osmolality is typically > 290mOsm/kg. Management includes fluid repletion to correct electrolyzing abnormalities and administration of Desmopressin (which takes over the function of ADH). Note that this client's DI is very likely to be central in origin given the recent pituitary surgery. Distinction between central and nephrogenic DI can be made using a water deprivation test. Choice A is incorrect because a urine collection for culture and sensitivity is appropriate when a urinary tract infection is suspected. The combination of increased urinary output with low urine specific gravity the setting of recent pituitary surgery is more suggestive of DI. Choice B is incorrect because the Cushing reflex is used to assess for increased intracranial pressure (ICP). The Cushing reflex consists of increased blood pressure, bradycardia, and irregular breathing. While all clients recovering from brain surgery should be monitored for ICP, this is not a priority action based on the nurse's assessment findings. Choice C is incorrect because an elevated serum creatinine and BUN are seen in clients with acute renal failure. The serum creatinine in clients with DI is typically low because of the large volume of dilute urine that is being produced. Important labs to obtain in addition to the BUN and creatinine include the urine and plasma osmolality, serum and urine electrolytes, serum glucose and serum ADH levels as these are essential to establish the diagnosis of DI.

A client with a history of well-controlled type 2 diabetes mellitus and a myocardial infarction 2 years ago is admitted for pneumonia. Assessment of the client reveals increased yellow sputum production, decreased breath sounds over the right upper lobe, mild confusion, and polyuria. What action should the nurse take? A. Reduce the intravenous infusion rate. B. Obtain a sample for urinalysis and culture. C. Raise the head of the bed and provide extra pillows. D. Measure capillary blood glucose.

ANS: D Mental status changes and polyuria are a sign of dysregulation of the client's blood glucose levels. Clients with type 2 diabetes who develop an infection (such as pneumonia) are at risk of developing hyperglycemia, which may progress into hyperglycemic hyperosmolar nonketotic syndrome (HSS). The nurse should measure the capillary blood glucose and report abnormal values to the health care provider. Even if the hyperglycemia is mild, careful observation is required. Choices A and C are appropriate interventions for clients with fluid volume overload, which is not consistent with this client's symptoms. Symptoms associated with fluid volume overload include peripheral edema, orthopnea, and cough with pink sputum. Clients with hyperglycemia and/or HSS are severely dehydrated and require ongoing fluid replacement. Note that the decreased breath sounds in the right upper lobe are expected findings in the setting of pneumonia, whereas decreased breath sounds in the setting of volume overload would occur at the bilateral lung bases. Choice B is incorrect because the client's polyuria is caused by osmotic diuresis due to increased blood glucose levels, and not by a urinary tract infection.

A 2-month-old infant had surgery to correct pyloric stenosis two days ago. After reviewing the infant's intake and output record, which intervention should the nurse implement? A. Use the bladder scanner to assess for post-void residual. B. Increase rate of 0.9% saline infusion. C. Instruct the mother to include electrolyte replacement in feedings. D. Document the results in the chart.

ANS: D Pyloric stenosis is the narrowing of the pyloric orifice, which forms the junction between the stomach and the duodenum. Children with this condition will develop projectile vomiting and are at risk for developing fluid volume deficit, weight loss and malnutrition. Surgery to widen the pylorus muscle is often curative and infants are typically discharged from the hospital after 1-2 days once vomiting has decreased, fluid balance is maintained and the infant begins to gain weight. In this infant's record, the child has gained weight, intake and output are balanced, and there has been minimal to no vomiting. Option D, document the results in the chart, is correct because the nurse should continue to monitor fluid balance by calculating intake and output and assessing daily weight. No further action is needed at this time. Option A, use the bladder scanner to assess for post-void residual, is incorrect as there is no indication that the child is retaining urine. A bladder scan is an ultrasound tool that estimates the volume of urine left in the bladder. The nurse can complete a bladder scan after a client voids if there is concern for urinary retention. Normal urine output for a 2-month-old child is 2-3ml/kg/hr and this child is voiding an adequate amount using this formula. Option B, increase rate of 0.9% saline infusion, is incorrect as this action is not needed because the infant has adequate intake. As the infant has transitioned from oral gastric feeding to oral intake from the bottle, the nurse may request that the IV fluid is discontinued. Option C, instruct the mother to include electrolyte replacement in feedings, is incorrect as this action is not necessary following surgery for pyloric stenosis. Infants who are actively vomiting prior to surgery often develop hypokalemia and hyponatremia. Once the condition has been corrected and vomiting has stopped, breast milk or formula will provide adequate nutrition and electrolytes.

The nurse documents the nursing diagnosis "Disturbed sensory perception" for a client with schizophrenia. What did the nurse observe? A. Yelled that the nurse is working for the FBI and is out to "get him." B. Tried to hit another client with a chair but missed. C. Withdrawn and does not respond to speech or touch. D. Standing in the corner, mumbling and gesticulating.

ANS: D Schizophrenia is a severe mental health disorder characterized by psychosis, delusions, and hallucinations. Symptoms have to be present for at least 6 months and must be associated with the inability to function properly in everyday life. Clients often experience a combination of positive symptoms (hallucinations, delusions, disorganized speech/behavior), negative symptoms (flat affect, poverty of speech, catatonia), neurocognitive symptoms (memory problems, decreased attention span, problems with planning and organizing) and mood symptoms (typically depression). The nursing diagnosis "Disturbed sensory perception" is appropriate for the client standing in the corner while mumbling and gesticulating. This behavior is a sign that the client is experiencing auditory hallucinations ("hearing voices"), which is an example of altered sensory perception. Choices A, B and C are incorrect because these clients do not display signs of disturbed sensory perceptions. Choice A is incorrect because this client is experiencing paranoid delusions. The nursing diagnosis "Disturbed thought processes" or "Impaired environmental perception" is more appropriate for this client. Choice B is incorrect because this client is violent. The nursing diagnosis "Risk for violence" or "Disturbed thought processes" is more appropriate for this client. Choice C is incorrect because this client is experiencing negative symptoms of schizophrenia and appears to be catatonic. The nursing diagnosis "Self-care deficit" or "Impaired verbal communication" is more appropriate for this client

A client discharged on oral warfarin (Coumadin) following a deep vein thrombosis (DVT) in the right popliteal vein is seen in the outpatient clinic. Which finding indicates that treatment is effective? A. INR 2.5 B. Negative Homans' sign. C. Reduction in right leg swelling and pain D. Lack of other thromboembolic events

ANS: D The goal of anticoagulation therapy in clients with deep vein thrombosis (DVT) is to reduce clotting ability of the blood to reduce the incidence of new DVTs or pulmonary emboli. Commonly used anticoagulants include IV heparin (used as initial treatment while hospitalized) followed by oral warfarin (overlapped with heparin for several days until at therapeutic INR). Heparin and warfarin have no thrombolytic abilities and do not affect the size of the original blood clot that caused the DVT. Treatment efficacy is determined by the lack of recurrent thrombosis-embolic events (Choice D). Choice A is incorrect because a therapeutic INR does not indicate that treatment is effective. Some clients develop recurrent DVTs while on therapeutic doses of Warfarin and require to be switched to alternate forms of DVT prevention such as Apixaban. Warfarin works by decreasing hepatic production of Vitamin K, which in turn decreases the production of multiple clotting factors down the line. Prothrombin time (PT) and international normalized ratio (INR) are the laboratory values affected by warfarin and should be monitored closely. Choice B is incorrect because Homans' sign (calf pain at dorsiflexion of the foot) is no longer considered a valid indicator for the presence or absence of a deep vein thrombosis. Choice C is incorrect because warfarin is unable to dissolve blood clots that have already formed. Reduction in leg swelling following a DVT is due to the body's natural fibrinolytic mechanisms, which take 1-2 weeks to fully disintegrate a blood clot.

The community health nurse is preparing an initiative to offer the annual influenza vaccination at the community health clinic. What should the nurse identify as the primary purpose of this intervention? A. Relieve physician offices of flu vaccination burden. B. Reduce the cost of the vaccination. C. Decrease the number of emergency department visits for influenza. D. Provide easy access to the vaccine to improve vaccination rates.

ANS: D The influenza vaccine or "flu shot" is a vaccine that protects against the influenza virus subtypes that are predicted to be the most common during the upcoming flu season. The flu shot is known to reduce the number of influenza cases and to decrease disease severity as well as the risk of flu-related death. Yearly vaccination is recommended as the flu virus is constantly changing. The CDC currently recommends yearly vaccination for everyone 6 months and older unless contraindications exist. High vaccination rates in a community are beneficial to prevent the spread of the virus. The flu shot is typically offered in a variety of places (physician offices, clinics, health departments, pharmacies, hospitals, community health centers) to provide easy accessibility, which in turn will improve vaccination rates (Choice D). While Choices A and C may be additional benefits of this intervention, they are not the primary goals of offering the vaccine through the community clinic. While physician offices provide the vaccine, most people obtain their yearly flu shot at other locations such as health centers, local pharmacies, and at work (Choice A). A higher immunization rate (primary goal) is likely to reduce the number of people getting sick with the flu and will thereby lessen the burden on the health care system in general, including ED visits (Choice C). Choice B is incorrect because the goal of offering the vaccine at the community health clinic is not to reduce costs. Many locations offer the vaccine free of charge to improve public participation.

A client has developed thrombocytopenia following chemotherapy. Which information should the nurse include in the client's discharge teaching plan? A. Use a non-steroidal anti-inflammatory agent for pain such as aspirin or ibuprofen. B. Increase dietary intake of foods high in vitamin B12 and iron. C. Return to the clinic 24-48 hours after chemotherapy to receive a dose of filgrastim. D. Practice good oral hygiene but avoid the use of dental floss

ANS: D Thrombocytopenia occurs when a client's platelet count falls to less than 150,000. Injuries that may cause minimal bleeding in the general population can cause life-threatening bleeding in a client with thrombocytopenia. Precautions should be taken to protect the client from injury. For this reason, Option D, practice good oral hygiene but avoid the use of dental floss, is correct because dental floss can cause injury to the gums that can lead to bleeding. Thrombocytopenic clients should be instructed to maintain good oral hygiene with a soft bristle toothbrush and to avoid toothpicks as well as dental floss until their platelet count returns to normal. Other precautions for thrombocytopenic clients include wearing shoes at all times, wearing gloves when working outside, avoiding alcohol, and using an electric razor. Option A, use a non-steroidal anti-inflammatory agents (NSAIDs) for pain such as aspirin or ibuprofen, is incorrect because this class of medications should be avoided in a client with thrombocytopenia. NSAIDs prolong bleeding time and can worsen bleeding in the presence of thrombocytopenia. Option B, increase dietary intake of foods high in vitamin B12 and iron, is incorrect as this instruction is useful for a client with anemia. Vitamin B12 and iron are useful in raising hemoglobin levels in the treatment of anemia related to blood loss, bone marrow suppression, pernicious anemia or dietary insufficiency. Option C, return to the clinic 24-48 hours after chemotherapy to receive a dose of filgrastim, is incorrect as this intervention is appropriate for a client with neutropenia. Filgrastim is a colony-stimulating factor that stimulates white blood cells to mature and differentiate. It is especially useful in preventing the development of life-threatening infections following chemotherapy.

A client recovering from thoracic surgery has a chest tube. What amount of drainage would the nurse document in the client's chart?

ANS:580 The drainage chamber of a chest drainage system consists of several calibrated columns. Drainage enters the drainage chamber from left to right. If most right column is filled, fluid drains into the next column on the left. Because the surface tension of the drainage fluid into the next column when the fluid is nearing the top, sometimes a column is only partially filled. In this image, there is 180 mL of drainage present in column 1 (utmost right) and another 200 mL in the middle column. Together this makes 380 mL of drainage. (Note that the 400 mL mark includes the 200mL of the column on the right and does not mean that 400 mL is present in just the middle column)

A 10-month-old child is admitted with pneumonia and a rectal temperature of 39.2C (102.5F). The healthcare provider has ordered a dose of IV antibiotic. Following the administration of oral ibuprofen, which action should the nurse implement? A. Hold antibiotic administration until fever resolves B. Undress the child and provide a warm bath C. Allow the child to breastfeed before administering the antibiotic D. Reassess the infant's temperature 20 minutes following ibuprofen administration

Fever is defined as a body temperature greater than 38.5C (100.4F) rectally or via other central body temperature measurements. A fever is the body's attempt to defend itself against infection by initiating an inflammatory response. Discomfort or irritability related to fever is best managed in children by administering acetaminophen or ibuprofen. Dosing should be weight based and parents often need education on safe medication administration in infants. Education for parents should also include fluid management as fever can cause substantial fluid loss, especially in the very young. For this reason, Option C, allow the child to breastfeed before administering the antibiotic, is the correct response. Insensible fluid loss during a fever episode occurs through rapid breathing or sweating and the nurse should encourage adequate fluid intake with either formula or breastmilk. The administration of the oral ibuprofen or the IV antibiotic has no effect on the infant's ability to breastfeed. Option A, hold antibiotic administration until fever resolves, is incorrect because the presence of a fever does not have an effect on the scheduled administration of an antibiotics. Antibiotics should be dosed according to weight and given on a timed schedule to keep blood levels in a therapeutic range in order to effectively treat the infection. The nurse should work to keep the antibiotics on the correct dosing schedule and minimize interruptions to administration. Option B, undress the child and provide a warm bath, is incorrect as this intervention has not been shown to be effective in the management of a fever in children. A child with a fever may find being undressed and bathed uncomfortable and upsetting. Instead, children with a fever should be dressed in light, breathable clothing, even if they are chilled or shivering. A popular folk remedy, bathing a child in rubbing alcohol, should never be used as it is extremely drying to the skin and can induce toxic effects. Option D, reassess the infant's temperature 20 minutes following ibuprofen administration, is incorrect as this will not give the nurse useful data about the effectiveness of the medication. The peak response for ibuprofen administration is 90 minutes and the nurse may recheck a temperature at that time to evaluate the effectiveness of the intervention.

A client who is 12 weeks' pregnant is admitted for hyperemesis gravidarum. What nursing intervention is appropriate at this time? (Select all that apply) A. Place on nothing-by-mouth status B. Initiate IV fluids and electrolytes C. Start small frequent meals with non-fatty, bland foods D. Involve client in selection of foods E. Provide vitamin B6 supplement

Hyperemesis gravidarum is a severe type of morning sickness with persistent nausea and vomiting that is associated with dehydration, electrolyte abnormalities, ketosis and weight loss (> 5% of the pre- pregnancy weight). Initial treatment consists of placing the client on nothing-by-mouth status until all vomiting has stopped for at least 48 hours (Choice A) and intravenous fluids and electrolyte replacement (Choice B). Clients can also be prescribed vitamin B6 (pyridoxine, Choice E) and antiemetic drugs to suppress the nausea and vomiting. Choices C and D are not appropriate in the initial management of a client with hyperemesis gravidarum as they are likely to result in increased nausea and vomiting. After vomiting has been subsided for at least 48 hours, the client can slowly be introduced to non-fatty bland foods. At this time, a nutritionist should work together with the client to develop a nutritional plan

Respiratory syncytial virus (RSV) is a common respiratory virus that affects people of all ages. It causes inflammation of the smaller airways, hypersecretion of mucous and edema. It is most dangerous for children and infants, especially those infants that were born prematurely, as their smaller airways are more easily obstructed. Other assessment findings may include rapid breathing, fever, runny nose and barking cough. Infants may have trouble nursing or bottle feeding due to nasal congestion and can easily become dehydrated. When caring for a child with RSV, the nurse should prioritize respiratory assessments including rate, rhythm, depth and lung sounds. Substernal chest retractions are an abnormal breathing pattern that is indicative of severe respiratory distress. Retractions are caused when the pressure created on inspiration is obstructed and becomes strong enough to pull in the soft tissues surround the chest. Retractions can be supraclavicular (above the clavicle), suprasternal (above the sternum), intracoastal (between the ribs) or subcoastal (in abdomen). The nurse should monitor for substernal chest retractions in the marked location, which is the collapse of the soft tissue below the sternum.

The nurse notes substernal chest retractions on inspiration while assessing an 18-month-old client diagnosed with respiratory syncytial virus (RSV). Use the image to indicate where the nurse made this observation. (Click on the correct location. To change, click on a new location.)

The nurse is caring for a client who is placed on telemetry for cardiac monitoring. Where would the nurse place the 5 electrodes?

The picture that correctly displays the electrode lead placement is A. The nurse should place the white electrode in the 2nd intercostal space (ICS) right midclavicular line; the green lead on the right lower ribcage (8th ICS right midclavicular line); the brown lead in the 4th ICS on the right sternal border; the black lead in the 2nd ICS left midclavicular line; and the red lead on the lower left ribcage (8th ICS left midclavicular line). The other configurations are incorrect. Note that choice B is the proper configuration for ECG electrode placement.