July 17th

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? 1. Attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place 2. Fills irrigation container with 500-1000 of lukewarm tap water and flushes the irrigation tubing 3. Hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma 4. Slowly opens the roller clamp, allowing the irrigation to flow, but clamps the tubing when cramping occurs

1. ATTACHES AN ENEMA SET TO THE IRRIGATION BAG, LUBRICATES IT, GENTLY INSERTS INTO THE STOMA, AND HOLDS IT IN PLACE A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. The procedure for bowel irrigation is as follows: Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole (Option 2) Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma (Option 3) Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes Clamp the tubing if cramping occurs, until it subsides (Option 4) Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet (Option 1) A cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening. Educational objective: Colostomy irrigation allows the client to create a bowel regimen and to apply a dressing or smaller pouch device over the stoma. To properly irrigate the stoma, use 500-1000 mL of lukewarm water, hang the bag 18-24 inches above the stoma, use the cone-tipped irrigator to slowly infuse the solution, and allow stool to drain through the sleeve into the toilet.

The clinic nurse performs an admission assessment on a client diagnosed with systemic lupus erythematosus (SLE). Which characteristic cutaneous manifestation of SLE would the nurse most likely assess? 1. Butterfly shaped rash 2. Petechiae 3. Pruritis 4. Uticaria

1. BUTTERFLY SHAPE RASH SLE is an autoimmune disorder in which the body's immune system produces autoantibodies that attack the body's tissues and cells. It is characterized by alternating periods of exacerbation (flare) and remission. The skin is one of the target organs commonly affected by the disease. The characteristic cutaneous manifestation of SLE (> 50%) is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks. It is often related to sunlight exposure (ultraviolet light) and is more pronounced during a disease flare (Option 1). Recurrent oral ulcers are also very common. (Options 2, 3, and 4) Although petechiae, pruritus, and urticaria may be associated cutaneous manifestations, they are not characteristic specifically to SLE. Educational objective: The characteristic cutaneous manifestation of SLE is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. Drowsiness is a common side effect and will improve over time 2. I can begin driving after I have been on this medication for a few weeks 3. I need to immediately report and new or increased anxiety 4. I need to immediately report any new rash when on this medicine

2. I CAN BEGIN DRIVING AFTER I HAVE BEEN ON THIS MEDICATION FOR A FEW WEEKS Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted time period. Educational objective: Levetiracetam is an anticonvulsant prescribed for seizure disorders. It may have depressing effects on the central nervous system (eg, drowsiness) as the body adjusts to therapy. Serious adverse effects include suicidal ideation and Stevens-Johnson syndrome. Clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their health care provider prior to legally operating a motor vehicle.

The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next? 1. Have the UAP change the pt's peripad 2. Immediately assess the pt's fundus 3. Obtain a stat hgb and hct 4. Tell the UAP to increase the IV line to 150 ml/hr

2. IMMEDIATELY ASSESS THE PT'S FUNDUS Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition. The nurse should assess the client's fundus and, if it is boggy, massage it. The nurse should also assess the client's vital signs and should never leave the client alone. (Option 1) The nurse can delegate changing the peripad to the UAP; however, it is not the priority at this time. (Option 3) Determining the client's hemoglobin and hematocrit levels will help determine the amount of blood that has been lost, but it is not the priority for this client. (Option 4) The nurse cannot delegate changing IV fluid rates to the UAP as this is beyond the scope of practice. Educational objective: Postpartum hemorrhage is a potentially life-threatening condition that should be addressed immediately. The nurse should first assess the fundus and massage it if boggy.

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used.

-Advise client to empty the bladder completely -Observe skin and contour of abdomen and lower back -Auscultate the renal arteries in right and left upper quadrants -Percuss and palpate both the right and left kidneys -Document the assessment of renal system function

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply. 1. Ask if the pt knows what day it is 2. Ask the pt to extend the arms 3. Assess for telangiectasia (spider nevi) 4. Determine of the conjunctiva is jaundiced 5. Note anmylase and lipase serum levels

1 & 2 Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis. Educational objective: HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Pt on IV heparin and the platelet count is 50,000 2. Pt on newly prescribed lisinopril and is at 8 weeks gestation 3. Pt on nitro patch for heart failure and BP is 84/56 4. Pt on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Pt on warfarin and PT/INR is 1.5 times control time

1, 2, & 3 Heparin is a natural anticoagulant. Its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia. Normal platelet range is 150,000-400,000/mm3 (150-400 x 109/L). A mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration. The danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparin (Option 1). Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are teratogenic. Lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation. During the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction (Option 2). Nitroglycerine causes vasodilation and can lower blood pressure. Systolic blood pressure should be >90 mm Hg to ensure renal perfusion (Option 3). (Option 4) Gingival hyperplasia or hypertrophy is a known side effect of phenytoin (Dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy). (Option 5) Warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control (International Normalized Ratio [INR] of 2-3), but up to 3-4 times the control (INR of 2.5-3.5) in high-risk situations such as an artificial heart valve. Educational objective: Heparin should be held when there is significant thrombocytopenia. Angiotensin-converting enzyme inhibitors are not administered to pregnant women, and nitrates are not administered when a client is hypotensive. Prothrombin time/International Normalized Ratio is expected to be 1.5-2.5 (up to 4) times the control value when therapeutic effects are reached. Gingival hyperplasia is a side effect of phenytoin (Dilantin) administration and is not a reason to stop the drug.

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply. 1. Pt may be required to lie flat for several hours following the procedure 2. Pt may feel warm or flushed when contrast dye is injected during the procedure 3. Pt should be expected to stay in the hospital for 1-3 days following the procedure 4. Pt should not drink or eat anything for 6-12 hours before the procedure 5. Pt will receive general anesthesia and will not be awake during the procedure

1, 2, & 4 A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) The client may feel warm or flushed while the contrast dye is being injected (Option 2) Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1) (Option 3) If the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed. (Option 5) General anesthesia is not used during coronary angiography. Sedating medications are given during the procedure. Educational objective: Coronary arteriogram requires that the client have nothing by mouth for 6-12 hours prior to the procedure and have an IV line started for sedation medications. The client may feel warm and flushed while the dye is being injected. The client is required to lie flat for several hours following the procedure to achieve hemostasis at the access site (femoral access). The client typically goes home the same day unless other interventions have been performed.

A nurse on a pediatric unit is reviewing interventions for a toddler with a practical nurse who will be caring for this child. Which of the following are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply. 1. Integrate preferred snack foods in the day's routine 2. Plan quiet play prior to usual nap time 3. Point out body changes that may occur 4. Post a daily schedule by the child's bed 5. Provide 1 or 2 options when choosing toys

1, 2, & 5 Toddlers (age 1-3) display an egocentric approach as they strive for autonomy. They attempt to control their experiences through intense emotional displays, such as temper tantrums or forceful negative responses (eg, "no!"). Hospitalization results in loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The toddler may also be frequently separated from the parents, leading to separation anxiety. Nursing care activities should be similar to home routines, such as providing preferred snacks and anticipating nap time. The toddler should be given options rather than asked yes/no questions to limit the potential negative responses. It is also important to encourage participation and presence of the parents whenever possible. (Option 3) This is an appropriate activity when working with an adolescent. Adolescents are often very concerned with outward changes that may occur as a result of illness or surgery. (Option 4) This is an appropriate activity when working with school-age children after they have grasped the concept of time. Toddlers have not yet reached this level of cognition. Educational objective: Toddlers react to the experience of hospitalization with a display of intense emotions, regressive behaviors, and manifestations of separation anxiety. Nursing care centers on integrating home routines into planned activities.

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. 1. Pt has had school disciplinary issues due to absenteeism and angry outbursts 2. Pt has lost 8 lbs over the last 3 weeks without trying 3. Pt is often found sleeping during class or activities 4. Pt quit sports despite receiving prveious athletic awards and trophies 5. Pt voices concerns about appearance related to facial acne

1, 2, 3, & 4 Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: Hypersomnolence or insomnia; napping during daily activities (Option 3) Low self-esteem; withdrawal from previously enjoyable activities (Option 4) Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents. (Option 5) Adolescent clients begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective: Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.

Which interventions would the nurse expect to be included in the care plan for a client with acute diverticulitis who has acute pain rated 8/10, nausea and vomiting, blood pressure 126/64 mm Hg, apical pulse 102/min, respirations 20/min, and temperature 101.2 F (38.4 C)? Select all that apply. 1. Administration of morphine sulfate 2 mg via IVP 2. Instructions to avoid straining 3. Maintenance of NPO status 4. Placement of an IV line and infusion of NS at 75 ml/hr 5. Protection of the skin from diarrhea by insertion of a rectal tube

1, 2, 3, & 4 Diverticular disease of the colon is a condition in which sac-like protrusions in the large intestine are caused by chronic increased intraabdominal pressure (eg, straining, lifting, tight clothing) and/or chronic constipation. When diverticula become infected and inflamed, the individual has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes: NPO status - more acute cases require complete rest of the bowel. Less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3). IV fluids to prevent dehydration when NPO (Option 4) Pain relief via IV medications to maintain NPO status (Option 1) Preventing increased intraabdominal pressure to avoid perforation and rupture (Option 2) Preventing increased intestinal motility - avoid laxatives and enemas (Option 5) The most common area for diverticula to form is the sigmoid colon. Inserting a rectal tube/colonoscope/sigmoidoscope may cause further damage or perforation of the inflamed diverticula by increasing pressure and stimulating the rectum. Educational objective: Management of acute diverticulitis focuses on bowel rest (NPO status, bed rest) and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided.

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for HCP of the same sex to provide care for the pt 2. Coordinate with the registered dietitian to provide halal meals 3. Reposition the immobile pt to face the city of mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the pt's privacy 5. Upon death, provide the family with supplies for postmortem care

1, 2, 3, & 5 Spirituality, religious beliefs, and traditions are important to include in client care. Aspects of care for Muslim clients include: Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer (Option 3) - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. Modesty - Care providers should be the same sex as the client whenever possible (Option 1). The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable (Option 2). During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly. Postmortem care of the Muslim client involves ritual washing, usually performed by family members, in preparation for burial. Burial occurs quickly after death, sometimes the same day (Option 5). (Option 4) In Islam, the family is the most important unit, and family presence brings strength to the individual. Multiple visitors should be accommodated unless they interfere with care. Educational objective: Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply. 1. Difficulty concentrating 2. Feeling detached from others 3. Feeling lethargic and apathetic 4. Flashbacks of the traumatic event 5. Persistent angry, fearful mood

1, 2, 4, & 5 Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). There are 3 categories of PTSD symptoms: Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) (Option 4) Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event (Option 2) Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response (Options 1 and 5) (Option 3) Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep. Educational objective: A person suffering from post-traumatic stress disorder experiences 3 categories of symptoms: reexperiencing the traumatic event, avoiding reminders of the trauma, and hyperarousal.

A client with ulcerative colitis is prescribed the drug sulfasalazine. Which information should the nurse discuss with the client concerning this drug? Select all that apply. 1. Drinking 8 glasses of water daily 2. Stopping the medicine of blood is present in stool 3. Stopping the medicine if urine turns an orange-yellow color 4. Taking folic acid supplements 5. Wearing sunscreen when outdoors

1, 4, & 5 Sulfasalazine (Azulfidine) is a sulfonamide (salicylate and sulfa antibiotic) and nonbiologic disease-modifying antirheumatic drug (DMARD) used for mild to moderate chronic inflammatory rheumatoid arthritis (RA) and inflammatory bowel disease (eg, ulcerative colitis). It inhibits the production of prostaglandin, a mediator in the body's inflammatory response. Most "sulfa" medications (eg, trimethoprim, sulfamethoxazole) share common side effects, including: Crystalluria causing kidney injury - client should drink 8 glasses of water daily to maintain adequate urine output (eg, 1200-1500 mL/day) Photosensitivity and risk for sunburn - client should avoid sun exposure and apply sunscreen Folic acid deficiency (megaloblastic anemia and stomatitis) - client should eat folate-rich foods and take 1 mg/day folic acid supplement Rarely life-threatening agranulocytosis (leukopenia) - client should be monitored for complete blood count at the start of therapy and report fever or sore throat immediately Stevens-Johnson syndrome - client should stop the medicine if rash develops (Option 2) Ulcerative colitis is characterized by bloody diarrhea, and the medication is taken to reduce this effect. (Option 3) Urine and skin can turn an orange-yellow color but will return to normal when the drug is discontinued. This is an expected finding. Educational objective: Sulfasalazine (Azulfidine) is used for mild to moderate chronic inflammatory RA and inflammatory bowel disease. Important adverse effects include crystalluria with kidney injury, yellow-orange skin and urine discoloration, folic acid deficiency, and photosensitivity.

A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply. 1. Excess blinking of eyes 2. Dry mouth 3. Dull headache 4. Lip smacking 5. Puffing of cheeks

1, 4, & 5 Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis) (Options 2 and 3) Common side effects of metoclopramide such as sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea need not be reported to the health care provider. Educational objective: Both antipsychotic medication and metoclopramide use can be associated with significant extrapyramidal side effects (eg, tardive dyskinesia). The nurse should teach the client the importance of immediately communicating these to the health care provider.

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was delegated to the unlicensed assistive personnel (UAP) by the registered nurse (RN). At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first? 1. Ask the UAP about the situation 2. Inform the nurse manager 3. Perform the test 4. Review the fingerstick procedure with the UAP

1. ASK THE UAP ABOUT THE SITUATION The nurse should first verify the accuracy of the client's statement. The client could be mistaken. It is also important to make the UAP accountable for completing the action or reporting the inability to do so. (Option 2) Initially, the RN should solely attempt to handle this situation, which can probably be resolved without administrative involvement. If a pattern of neglect arises or if the UAP is belligerent and refuses the delegation, then management should be contacted. (Option 3) It is important for the nurse to make the extra effort to determine what has occurred, rather than to assume that the test was not done and then choose to perform it as the first action. In addition, performing the test might subject the client to an extra needlestick and does not make the UAP accountable to complete the tasks that were delegated. This is not an emergency situation requiring an immediate result. (Option 4) There is no evidence that the UAP does not know the procedure. Competency should be documented prior to the delegation. Therefore, the RN should first find out if the test was done. If not, the nurse should then find out why. The issue could be related to time management rather than lack of knowledge. If the UAP lacks knowledge, the procedure should be taught promptly. Educational objective: When the completion of a delegated task is questioned, the nurse should first confirm its completion with the designated personnel.

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? 1. Elevates the HIB to 45 2. Holds the weight while the pt is repositioned up in bed 3. Loosens the velcro straps when the pt reports that the boot is too high 4. Provides the pt with a fracture pan for elimination needs

1. ELEVATES THE HOB TO 45 Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option 1). Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option 3). Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option 4). Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option 2). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation. Educational objective: To maintain effective pull and avoid interrupting traction, weights should be free-hanging at all times. Proper body alignment should be maintained with the client supine or in semi-Fowler's position (maximum 30 degrees). The nurse should monitor the neurovascular status and skin integrity of the limb in traction.

The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3- hours 4. Runny, seedy, yellow stools

10% WEIGHT LOSS SINCE BIRTH During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and formula supplementation (eg, via spoon or syringe) may be indicated until exclusive breastfeeding is adequate (Option 1). (Option 2) Peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term (ie, >42 weeks gestation) newborns. (Option 3) Feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option 4) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools. Educational objective: During the first 3-4 days of life, a weight loss of approximately 5%-6% of birth weight is expected due to fluid excretion through urine, stool, and respirations. Weight loss >7% may indicate the need for breastfeeding support and formula supplementation and require evaluation.

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply. 1. Clarify the prescription of oselt with the HCP 2. Instruct the pt to cover the mouth and nose while coughing 3. Place a mask on the pt when transporting the pt through the halls 4. Plan discharge teaching about the importance of annual influenza vaccination 5. Use contact precautions when providing care for the pt

2, 3, & 4 Influenza (flu) is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are given to clients with symptom onset within the last 48-72 hours. These medications inhibit viral reproduction and can shorten the duration of the illness. Annual vaccination is recommended to prevent influenza (Option 4). To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while coughing or sneezing (Options 2 and 3). Hand hygiene should also be emphasized as the influenza virus can persist on unwashed hands and surfaces. (Option 1) Oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours ago. (Option 5) The influenza virus is spread via droplet transmission when infected persons cough or sneeze. Hospital personnel caring for clients with influenza should adhere to droplet precautions in addition to standard (universal) precautions. Educational objective: Clients hospitalized with influenza should be on droplet precautions, wear a mask during transport, be instructed to cover coughs and sneezes, and be assisted in performing hand hygiene frequently. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are most beneficial if given within 48-72 hours of symptom onset.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? Select all that apply. 1. Bananas 2. Broccoli with cheese 3. Multigrain bagel 4. Popcaorn 5. Spaghetti with sauce

2, 3, & 4 An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: High fiber: popcorn, coconut, brown rice, multigrain bread (Options 3 and 4) Stringy vegetables: celery, broccoli, asparagus (Option 2) Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit (Option 1) After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches, bananas, potatoes). (Option 5) Low-fiber carbohydrate options include white rice, refined grains, and pasta. Educational objective: The low-residue diet of a client with a new ileostomy helps prevent obstruction of the narrow lumen of the stoma. During the immediate postoperative period, the client should avoid foods that are high in fiber; stringy vegetables; and fruits and vegetables with pits, seeds, or edible peels.

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply. 1. Avoid discussing the adopotion details until after the birth 2. Encourage the birth mother to hold the newborn 3. Notify the staff who may interact with the pt of the adoption plan 4. Offer the birth mother a chance to say goodbye 5. Use phrases that illustrate adoption as a decision of love, not abondonment

2, 3, 4, & 5 Adoption, the decision to relinquish care of a child to another, is complex and involves a variety of emotional and psychosocial responses from clients. The nurse should encourage the birth mother to create memories with her newborn to facilitate the grieving process. This may include holding the newborn, taking pictures, and naming the newborn (Option 2). When the time comes, offering the client a chance to say goodbye to the newborn supports the birth mother in her emotional transition and acknowledges the importance of her relationship with the newborn (Option 4). The nurse protects the client by notifying relevant staff of the decision, which prevents unintended, potentially hurtful remarks (Option 3). Substituting phrases like "giving up" and "giving away" with "choosing adoption" reinforce adoption as a loving decision and not neglect or abandonment (Option 5). (Option 1) Avoiding discussion of adoption details until after the birth inhibits the nurse's ability to plan care that respects the birth mother's wishes for interaction with the newborn and/or involvement of the adoptive parents in the birth process. Acknowledging the adoption plan early in the plan of care encourages the client to express emotions and be involved in decision-making. Educational objective: Caring for a client who plans to relinquish a newborn to an adoptive family involves giving the client an opportunity to express emotions, be involved in decision-making, interact with the newborn, make memories, and feel reassured that the decision is one of love and not abandonment.

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess pt for lethargy and decreased DTR 2. Assess skin for flushing and red rash on face and torso 3. Infuse over 60 minutes 4. Monitor BP during infusion 5. Observe IV site every 30 minutes for pain, swelling, and redness

2, 3, 4, & 5 When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5). (Option 1) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes. Educational objective: Nursing care of clients receiving IV vancomycin includes drawing prescribed trough levels before drug administration, infusing the drug over at least 60 minutes, monitoring the client during administration (eg, blood pressure, respiratory status, signs of hypersensitivity/anaphylaxis), and assessing the IV site during and after administration.

The nurse in the emergency department is assessing a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply. 1. Palpable olive-shaped mass in epigastrum 2. Palpable sausage shaped mass in upper right quadrant 3. Projectile vomiting containing blood 4. Screaming and drawing the knees up to the chest 5. Stool mixed with blood and mucous

2, 4, & 5 Intussusception is a common obstructive disorder in infancy that occurs when one segment of the bowel telescopes into another. The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable "sausage-shaped" mass on the right side of the abdomen; and "currant jelly" stools. Other manifestations include inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may appear normal and comfortable between episodes. (Option 1) Infants with infantile hypertrophic pyloric stenosis often present with excessive hunger (frequent feeder), a palpable olive-shaped mass in the epigastrium to the right of the umbilicus, and projectile vomiting (can be up to 3 feet). (Option 3) Projectile vomiting (without blood) is seen with pyloric stenosis and elevated intracranial pressure. Bloody vomiting is seen with gastric ulcers and variceal bleed. Intussusception causes non-projectile vomiting that is usually non-bloody, but stools mixed with mucus and blood are seen. Educational objective: The classic clinical triad of intussusception is intermittent, severe, crampy abdominal pain; a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools.

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? 1. Ear pain 2. Frequent swallowing 3. Low grade fever 4. Objectionable mouth odor

2. FREQUENT SWALLOWING Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: Avoid coughing, clearing the throat, or blowing of the nose Limit physical activity Milk products are discouraged due to their coating effect, which can prompt clearing of the throat Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation (Options 1, 3, and 4) The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. Educational objective: Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing.

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client? 1. Diet high in iron 2. Good oral care and dental follow up 3. Shaving with a electric razor 4. Use of sunglasses for eye protection

2. GOOD ORAL CARE AND DENTAL FOLLOW UP The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). (Option 1) Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic acid and calcium should be recommended. (Option 3) Clients who use anticoagulants (eg, warfarin, rivaroxaban, apixaban) should avoid cuts and preferably use an electric razor for shaving. (Option 4) Exposure of the eyes to ultraviolet light and use of corticosteroids are risk factors for cataract development. Educational objective: The nurse should encourage the client taking phenytoin to perform good oral hygiene and visit the dentist regularly to prevent gingival hyperplasia. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis).

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse? 1. Have the pt keep a journal and write about feelings 2. Initiate one-on-one supervision of the pt during feedings 3. Remind the pt that gaining weight means being able to go home 4. Say the pt is not fat and ugly

2. INITIATE ONE-ON-ONE SUPERVISION OF THE PT DURING FEEDINGS Nutrition support (enteral tube feedings and total parenteral nutrition) is usually reserved for clients with anorexia nervosa who are severely ill and/or have not responded to oral nutritional therapy. Such clients are at high risk for medical complications from anorexia nervosa, including death. Criteria for nutrition support include: Severe weight loss that is life threatening Client's unwillingness to adhere to a treatment plan of oral feedings The priority nursing actions for this high-risk client include interventions to meet physiological and safety needs. Providing one-on-one supervision during the tube feeding will ensure that the client is actually receiving the feeding and prevent the client from stopping the feeding and/or pulling out the nasogastric tube. During the one-on-one contact with the client, the nurse can promote a therapeutic and trusting relationship with the client by: Being honest and accepting of the client Presenting the reality of the condition Acknowledging the client's feelings of loss of control and anger Encouraging the client to express feelings and fears (Option 1) This is an appropriate intervention for a client with anorexia nervosa. Feelings related to lack of control are an underlying problem for these clients, who use food as a way to deal with them. Keeping a diary or journal of feelings will help the client recognize and express them more clearly. However, this is not the priority nursing action. (Option 3) This may be a true statement; clients with anorexia nervosa are usually discharged to out-patient follow-up and treatment or to a residential treatment facility once an acceptable weight gain has been achieved and maintained. However, this is not the priority nursing action. (Option 4) Clients with anorexia nervosa have a distorted body image and a morbid fear of being overweight; they perceive themselves as "fat and ugly" even when they are emaciated. Saying that the client is not "fat and ugly" will not change this perception. Educational objective: The priority nursing care for a client with anorexia nervosa is nutritional rehabilitation and prevention of medical complications, including death. Clients who are severely ill and/or resistant to oral refeeding may require nutrition support with intense monitoring to achieve adequate caloric intake and weight gain.

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without the AED until EMT arrives 2. Place on pad on the chest and the other ont eh back 3. Place on AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other half

2. PLACE ONE AED PAD ON THE CHEST AND THE OTHER ON THE BACK An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective: An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Asl the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system

3. ASSESS THE INFANT'S PATTERN AND FREQUENCY OF CRYING During the first 3-4 months of life, it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment. The nurse needs to determine: What "all the time" means When the "all the time" crying started What makes the crying worse and what makes it better The quality of the crying (tone, pitch, loudness) Length and quality of periods of silence (Option 1) A pacifier would be appropriate to calm and soothe this infant. However, the nurse needs to first assess the pattern and quality of the crying along with the methods the parent is already using. (Option 2) Finding out what the parent is already doing to comfort the child is part of the nursing assessment. In this case, however, it is more important to determine if the crying is normal or abnormal. (Option 4) Exploring the parent's support system is an appropriate nursing action to determine if the parent has anyone to turn to when frustrated in caring for the infant. However, it is not the most important assessment. Educational objective: When a parent tells the nurse that an infant cries "all the time," the priority nursing action is to assess the pattern, quality, and frequency of the child's crying. This will help the nurse determine if the crying is normal infant behavior or a sign of a more serious condition that requires further evaluation and treatment.

A nurse in a pediatric clinic is performing a physical examination of a 30-month-old child. Which finding requires further evaluation? 1. Bladder and bowel control achieved 2. Chest circumference is greater than abdominal circumference 3. Current weight is 6 times greater than birth weight 4. Head circumference increased by 1 inch in the past year

3. CURRENT WEIGHT IS 6 TIMES GREATER THAN BIRTH WEIGHT Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed. (Option 1) A toddler achieves bowel and bladder sphincter control by age 24 months as bladder capacity increases. (Option 2) Chest circumference exceeds abdominal circumference after age 2, resulting in a taller and more slender appearance. (Option 4) Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth rate of 0.5 in (1.25 cm) per year until age 5. Educational objective: Weight gain slows during the toddler years. By age 30 months, a toddler's weight should be approximately 4 times greater than the birth weight.

The nurse is discharging a client hospitalized for a new diagnosis of heart failure. The discharge medications include lisinopril 10 mg and spironolactone 25 mg. The client has also been started on a 2000 mg low-sodium diet. Which statement by the client indicates teaching on discharge instructions has been effective? 1. I will be sure to take my medication before bedtime 2. I will eat more fresh fruits like bananas and oranges 3. I will limit my intake of cheeses, breads, and canned food 4. I will use a substitute to season my food

3. I WILL LIMIT MY INTAKE OF CHEESES, BREADS, AND CANNED FOODSPoor adherence to a low-sodium diet (Choice 3) and failure to take prescribed medications as directed (Choice 1) are the most common reasons for readmission of heart failure clients to the hospital setting. The edema associated with heart failure is often treated by dietary restriction of sodium. The nurse or dietician should assess the client's diet history, teach how to read food labels and plan for dining out, and develop an overall diet plan. Diet recommendations should be individualized and culturally sensitive for the client to make the needed changes successfully. The Dietary Approaches to Stop Hypertension (DASH) diet is widely used for clients with heart failure. All foods high in sodium (>400 mg/serving) should be avoided. General principles of a low-sodium diet are as follows: Do not add salt or seasonings containing sodium when preparing meals Do not use salt at the table Avoid high-sodium foods (eg, canned soups, processed meats, cheese, frozen meals) Limit milk products to 2 cups daily (Option 1) Medications such as spironolactone are diuretics. Taking them at bedtime would cause the client to have nocturia. Spironolactone should be taken in the morning. (Option 2) Hyperkalemia is a side effect of angiotensin-converting enzyme (ACE) inhibitors such as lisinopril. Spironolactone is a potassium-sparing diuretic. Although fresh fruit is a good option for a low-sodium diet, bananas and oranges are high in potassium, which could put this client at increased risk for hyperkalemia. (Option 4) Many salt substitutes are high in potassium. This client is already at risk for hyperkalemia due to the ACE inhibitor lisinopril and the potassium-sparing diuretic spironolactone. The nurse should encourage the client to substitute lemon juice or other spices for salt or a salt substitute. Educational objective: The client in heart failure on a low-sodium diet should be encouraged to limit the intake of such foods as processed meats, cheese, canned soups and vegetables, frozen meals, breads, and milk products.

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG 2. IV morphine 3. NS bolus 4. Urine sample

3. NS BOLUS Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue. (Option 1) With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem. (Option 2) Pain and symptom management should be a high priority but should not take precedence over preserving the client's kidney function. (Option 4) Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take priority over treatment to preserve kidney function. Educational objective: Rhabdomyolysis is a medical emergency caused by muscle injury that releases myoglobin into the bloodstream. The nurse's priority when treating the client is to preserve kidney function by administering large volumes of IV fluid.

The nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective? 1. Episodes of spasmodic coughing have decreased 2. No wheezes are audible on chest auscultation 3. Oxygen saturation has increased from 88% to 93% 4. Peak expiratory flow rate has dropped from 212 to 127

3. OXYGEN SATURATION HAS INCREASED FROM 88% TO 93% Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. (Option 1) Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. (Option 2) The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. (Option 4) Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected. Educational objective: Improvements in oxygen saturation and peak expiratory flow are the best indicators of treatment effectiveness during an acute asthma attack.

A mother brings a child to the emergency department with itching and the rash shown in the exhibit. The child continues to scratch the lesions. What action should the nurse take first? Click on the exhibit button for additional information. EXHIBIT: *gross shit on the forehead& 1. Administer antihistamine and closely crop the fingernails 2. Ask about the child's vaccination status 3. Place a mask on the child 4. Place the child in a positive airflow room

3. PLACE A MASK ON THE CHILD This child has chicken pox (varicella), given the vesicular lesions. Chicken pox is transmitted primarily by airborne spread of secretions from the nasopharyngeal secretions of an infected individual and through direct contact of open lesions. It is most contagious 1-2 days before the rash until shortly after onset of rash (until all lesions are crusted over). Supportive care is usually adequate, and most children recover fully. Children who are immunocompromised are at risk for complications. Contact and airborne precautions are used. A mask will help prevent the spread of infection until the child is placed in an isolation negative airflow room. (Option 1) Antihistamines help relieve itching and acetaminophen helps reduce fever. Fingernails should be cut short to prevent excoriation and secondary bacterial infection. However, these are not the first priority actions. (Option 2) Vaccination history is important but not the first priority. (Option 4) A positive air pressure room pushes air out of the room by increasing the rate of flow. It is used for immunosuppressed clients to prevent the organisms of a normal environment from entering the room. A negative air pressure room is a ventilation system that removes more exhaust air from the room than air allowed into the room. It prevents the infection from spreading out into the environment. A negative air pressure flow room would be required to prevent the airborne spread of the disease. Educational objective: The priority for a child with chicken pox is isolation (airborne, contact). Supportive care includes antihistamines for itching and acetaminophen (NOT aspirin) for fever. Fingernails should be cut short to prevent excoriation and secondary bacterial infection.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the pt when walking to the bathroom 2. Dim the room lights 3. Place the bed in low position with all siderails up 4. Turn off the televisioon

3. PLACE THE BED IN LOW POSITION WITH ALL SIDE RAILS UP Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective: Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

A client in the emergency department has an acute myocardial infarction (MI). The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1. Pt is currently menstruating 2. Pt rates chest pain at an 8 out of 10 3. Pt reports a history of cerebral aneurysm at age 20 4. Current BP is 170/96 and HR is 110

3. PT REPORTS A HISTORY OF CEREBRAL ANEURYSM AT AGE 20 Thrombolytic therapy is aimed at stopping the infarction process, dissolving the thrombus in the coronary artery, and reperfusion of the myocardium. This treatment is used in facilities without an interventional cardiac catheterization laboratory or when one is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot and may lyse other clots (eg, postoperative site). Minor or major bleeding can be a complication of therapy. Inclusion criteria for thrombolytic therapy are chest pain typical of acute MI 6 hours or less in duration, 12-lead electrocardiogram findings consistent with acute MI, and no absolute contraindications. (Option 1) Menstruating is not considered a contraindication. (Option 2) The presence of chest pain is part of the inclusion criteria for thrombolytic therapy. (Option 4) The client's blood pressure is high, but not >180/110 mm Hg, a relative contraindication. Educational objective: The client being considered for thrombolytic therapy should be screened for absolute and relative contraindications. The nurse should immediately notify the HCP if the client reports a history of cerebral aneurysm as it is an absolute contraindication to the use of thrombolytics.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? 1. Pt expereincing abdominal cramps 2 hours after colonoscopy 2. Pt reporting whote stools 8 hours after barium swallow study 3. Pt with epigastric pain after endoscopic retrograde cholangiopancreatography 4. Pt with a small bowel obstruction with copiuous, greenish brown drainage

3. Pt with epigastric pain after endoscopic retrograde cholangiopancreatography Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) (Option 3). (Option 1) Abdominal cramps can occur after a colonoscopy due to air inflation during the procedure. (Option 2) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. (Option 4) Copious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis. Educational objective: Acute pancreatitis, a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography. Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul smelling stools 3. Stools mixed with blood and mucus 4. Thin, ribbon like stools

3. STOOLS MIXED WITH BLOOD AND MUCUS Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. (Option 1) Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. (Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. (Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective: The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn? 1. Choose an infant carrier with a narrow seat 2. Place 2 diapers on the infant at all times 3. Swaddle the infant with hips flexed and abducted 4. Use an infant swing that keeps both legs straight

3. SWADDLE THE INFANT WITH HIPS FLEXED AND ABDUCTED Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include: Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement (Option 3) Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together (Option 1) Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments and possibly leading to DDH. (Option 2) Double/triple diapering is no longer recommended as a preventive measure for DDH. This practice can cause extension of the hip, leading to abnormal development. (Option 4) Infant swings, bouncers, wraps, and other similar items can cause the legs to be positioned straight and together, which can increase the risk for DDH. Educational objective: DDH is a range of hip abnormalities that may be present at birth or develop in early childhood. Preventive measures include proper swaddling with hips bent up and out, and avoiding seats or carriers that hold the legs straight and together.

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? 1. Continue avoiding foods with tyramine 2. Skip nightime dose of ipra and start the phenel the next morning 3. Taper down the ipra, then discontinue for 2 weeks before starting phenel 4. Taper down the pmipra whil egradually increasing the phenel

3. TAPER DOWN THE IMIPRAMINE, THEN DISCONTINUE FOR 2 WEEKS BEFORE STARTING PHENEZINE When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortriptyline) to a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine), a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This timing is based on the half-life value and allows for the first medication to leave the system. Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome. (Option 1) A tyramine-restricted diet is indicated for clients on an antidepressant regimen containing an MAOI to decrease the risk of hypertensive crisis. Because this client is starting an MAOI, the diet should be initiated 2 weeks prior to starting the medication. If the switch was from an MAOI inhibitor to another antidepressant, the client would need to continue to follow the dietary restrictions for 2 weeks after discontinuing the MAOI. (Option 2) An overnight washout period is inadequate to clear the imipramine from the client's system before starting the phenelzine. (Option 4) TCAs and MAOIs cannot be taken at the same time due to the risk of a hypertensive crisis. Educational objective: Caution must be taken when a client switches from a tricyclic antidepressant to a monoamine oxidase inhibitor to avoid adverse reactions (eg, hypertensive crisis, discontinuation syndrome). Usually, antidepressants are withdrawn gradually with a drug-free period before the new antidepressant is initiated.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Pt reports a headache 2. Current BP is 160/88 3. HR has dropped from 70 to 60 4. Slight wheezes auscultated during inspiration

4. SLIGHT WHEEZES AUSCULTATED DURING INSPIRATION Propranolol is a nonselective beta-blocker that inhibits beta1 (heart) and beta2 (bronchial) receptors. It is used for many indications (eg, essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring. The nurse should assess for any history of asthma or respiratory problems with this client and notify the health care provider (HCP). (Option 1) A headache is a common occurrence with hypertension. The nurse may administer an analgesic as needed. (Option 2) This is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading. (Option 3) A reduction in heart rate is expected with a beta-blocker. The nurse should continue to monitor it for further reduction. Educational objective: The nurse should be concerned about the presence of wheezing in a client taking a nonselective beta-blocker like propranolol. Wheezing may indicate bronchoconstriction or bronchospasm. The nurse should assess for any history of asthma or other respiratory problems and report to the HCP.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria 2. Increased thirst and dry mucous membranes 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes

4. TREMORS AND BRISK DEEP-TENDON REFLEXES Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option 2) Increased thirst with dry mucous membranes indicates hypernatremia. (Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias. Educational objective: Clients who abuse alcohol often have low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures.

A client at 39 weeks gestation is brought to the emergency department after a motor vehicle crash. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. What action should the nurse take first? 1. Administer NS bolus 2. Assess cervix for presenting part 3. Ontain fetal heart rate 4. Turn pt laterally

4. TURN PT LATERALLY Supine hypotensive syndrome results from compression of the maternal inferior vena cava by the large gravid uterus in mid to late pregnancy when the client is in the supine position. The venous return is reduced, causing maternal hypotension from reduced cardiac output. The client can also report feeling dizzy and faint. The first step is to rectify the cause by turning the client laterally while still strapped on the backboard. (Option 1) The etiology is not hypovolemia but perfusion. A fluid bolus of isotonic fluids (normal saline or lactated Ringer's) can be administered if the position change does not relieve the symptoms. Mean arterial pressure (MAP) should be >60 mm Hg for effective organ perfusion. Normal MAP is 70-105 mm Hg. (Option 2) The client does not have classic signs of a precipitous or impending delivery. Classic signs or symptoms of the second stage of labor/delivery of the baby include feeling the need to push, an intense urge to bear down, or a sensation of cervical pressure. A pelvic examination can be performed, but it is not the first priority. (Option 3) The etiology is related not to the fetus, but to the maternal circulation. Because the client does not have adequate cardiac output, circulation to the fetus could be compromised. The first priority is to rectify the client's perfusion issue and check the fetus. The best indicators of fetal health are heart rate and movement. Educational objective: Supine hypotensive syndrome results from compression of the maternal inferior vena cava by the large gravid uterus in mid to late pregnancy when the client is in the supine position. It can be corrected by first positioning the client laterally.

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

45% The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial (first-degree) burns are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg, TBSA is calculated as follows: TBSA = [back] + [anterior and posterior of right arm] + [anterior and posterior of right leg] TBSA = [18] + [4.5 + 4.5] + [9 + 9] TBSA = 18 + 9 + 18 = 45% Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (ie, Parkland formula [4 mL x kg of body weight x TBSA]). TBSA also determines the required level of care. In general, clients require transfer to a burn center for specialty care for: Full-thickness burns Partial-thickness burns >10% TBSA Electrical or chemical burns Inhalation injuries Educational objective: The rule of nines provides a quick estimate of the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. TBSA determines the volume of necessary fluid resuscitation and the required level of care. The rule of nines assigns 9% per arm, 18% per leg, 36% for the torso, 1% for the perineum, and 9% for the head and neck.