NCLEX PN Fundamentals

PASS

Pull, Aim, Squeeze, and Sweep

The nurse has received a prescription from the health care provider to administer 80 mg of methylprednisolone IV piggyback. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.

The volume of medication to be administered is 1.28 mL, which should be rounded to the first decimal place for administration. Therefore, the nurse should draw the medication to the 1.3-mL mark on the syringe. Using dimensional analysis, use the following steps to calculate the administration volume of methylprednisolone in milliliters: Educational objective:The nurse should fill the syringe appropriately based on dosage calculation. To calculate the dose in milliliters of methylprednisolone, the nurse should first identify the prescribed dose (eg, 80 mg/dose) and available dose (eg, 125 mg/2 mL), then convert to milliliters per dose (eg, 1.3 mL).

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next?

Correct Answer: A. Collect gastric pH measurement. Before administering intermittent (bolus) enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement. Ensuring that the tip of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration. Incorrect Answers: [Answer B. Delay feeding for at least 1 hour.] Gastric residual volume (GRV) is one indicator of how well the client is tolerating enteral feedings. High GRV (eg, >500 mL) may indicate delayed gastric emptying and poor intestinal motility (ie, feeding intolerance), which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the health care provider (HCP) to determine if feedings should be delayed for high GRV or other symptoms of intolerance (eg, gastric distension, nausea/vomiting). GRVs are traditionally checked every 4 hours with continuous feeding or before each intermittent feeding. However, some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk. [Answer C. Discard the gastric residual.] Repeatedly discarding gastric contents can cause hypokalemia and metabolic alkalosis. If GRV is excessively high, contents may be discarded to relieve abdominal distension (per facility policy or HCP prescription). However, GRV of 80 mL is not excessive and should be returned to the stomach. [Answer D. Return residual and administer feeding.] Tube placement must be verified before enteral feedings. Educational Objective: Before administering enteral feedings, the nurse must verify tube placement (eg, gastric pH measurement). Administration of enteral feeding through a misplaced feeding tube may result in life-threatening aspiration.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? A. Compressing the chest to a depth of at least 2 in (5 cm). B. Pausing after each set of 15 compressions to allow for 2 rescue breaths. C. Placing the heel of the hand on the upper half of the client's sternum. D. Providing compressions at a rate of at least 80-100/min.

Correct Answer: A. Compressing the chest to a depth of at least 2 in (5 cm). The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury. The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. Incorrect Answers: [Answer B. Pausing after each set of 15 compressions to allow for 2 rescue breaths.] Interruption of compressions should be minimized; at least 60% (preferably more) of the total resuscitation time should be made up of compressions. For adults (and in single-rescuer CPR for any age), a cycle of 30 compressions followed by 2 rescue breaths provides the best outcome. If the client has an advanced airway, continuous compressions and 10 breaths/min should be provided. [Answer C. Placing the heel of the hand on the upper half of the client's sternum.] Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone). Hand placement on the upper half of the sternum does not provide adequate perfusion. [Answer D. Providing compressions at a rate of at least 80-100/min.] Studies have shown better client outcomes due to improved perfusion with a compression rate of 100-120/min. Educational Objective: For a high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths.)

Which situations would require the nurse to obtain a prescription for physical restraints? Select all that apply. A. Belt restraint used for a confused client who keeps trying to get out of bed but is on bed rest. B. Elbow restraints used temporarily for a toddler while drawing blood. C. Full padded side rails in the raised position for a client during a seizure. D. Long leg immobilizer used for a client with a fractured tibia. E. Soft ankle restraint to prevent bleeding at the femoral site following cardiac catheterization.

Correct Answer: A and E. A physical restraint is a device or method used to immobilize, limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint. Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a health care provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so. The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-release knot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily. Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently. Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity. Incorrect Answers [Answer B. Elbow restraints used temporarily for a toddler while drawing blood.] Elbow restraints used as a protective device to temporarily immobilize a child (less than 30 minutes) to perform a medical, diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint. [Answer C. Full padded side rails in the raised position for a client during a seizure.] The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint. [Answer D. Long leg immobilizer used for a client with a fractured tibia.] An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint. Educational Objective: Common physical restraint devices include limb (eg, ankle, wrist) and belt restraints. The client situation, rather than the device, determines whether it is classified as a restraint.

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse finds the client wide awake. The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be most appropriate? A. "Please try no to worry, you have an excellent surgeon." B. "Tell me about how you feel about your surgery." C. "Why are you considering refusing the surgery." D. "You have the right to make your own decisions and can refuse the surgery."

Correct Answer: B. "Tell me about how you feel about your surgery." "Tell me about how you feel about your surgery," is the most appropriate statement to encourage the client to express the source of anxiety. Using an open-ended question enables the client to take control of the conversation and direct it to concerns about the surgery. The nurse can then address the specific concerns identified and provide individualized explanations and support. Incorrect Answers: [Answer A. "Please try no to worry, you have an excellent surgeon."] This statement is nontherapeutic as giving false reassurance minimizes the client's concerns and diminishes trust between the nurse and client. [Answer C. "Why are you considering refusing the surgery."] This statement is nontherapeutic and intimidating. Asking "why" and "how" is an ineffective method of gathering information. [Answer D. "You have the right to make your own decisions and can refuse the surgery."] A client may share a decision with the nurse in an effort to discuss feelings. This statement is nontherapeutic because giving approval of the client's decision does not encourage the client to express concerns about the surgery. Educational Objective: Therapeutic conversation techniques (eg, active listening, using open-ended questions) encourage the client to express feelings and ideas and establish an open, trusting relationship with the nurse. Nontherapeutic communication techniques (eg, expressing approval or disapproval, giving advice, asking why) discourage expression of feelings and ideas and close down the conversation between the nurse and client.

A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? A. A private room with contact and droplet precautions B. A private room with negative airflow and contact and airborne precautions C. A private room with positive airflow and airborne precautions D. A semi-private 2-bed room with standard precautions.

B. A private room with negative airflow and contact and airborne precautions Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions. Incorrect Answers: [A. A private room with contact and droplet precautions] Negative airflow and airborne precautions are also required in addition to contact precautions. Droplet precautions are not necessary. [C. A private room with positive airflow and airborne precautions] Positive airflow would pull fresh air from outside into the hospital room, and then the air from the room would circulate throughout the rest of the hospital. It is not appropriate for this type of airborne infection. Instead, positive airflow would be used for protective isolation in a client who is severely immunocompromised. [D. A semi-private 2-bed room with standard precautions.] A semi-private room is not appropriate for this client with a communicable illness. Standard precautions are used for localized shingles in clients with intact immune systems and contained/covered lesions. Educational objective:The client with open lesions from a zoster virus infection, such as shingles or chicken pox, will require both contact and airborne precautions along with a private room with negative airflow.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply. A. Do not leave a tourniquet on more than 1 minute while looking for a vein B. Draw the specimen while the skin is still wet with the alcohol prep C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes D. Use a highly visible vein on the ventral side of the client's wrist E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution

Correct Answer: A and C A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. Incorrect Answer: [B. Draw the specimen while the skin is still wet with the alcohol prep] Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. [D. Use a highly visible vein on the ventral side of the client's wrist] The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. [E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution] The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Educational objective:When performing phlebotomy for a laboratory specimen, allow the cleansed area to air dry, do not use the veins on the ventral side of wrist, position the tourniquet for no more than 1 minute at a time, and invert the tube gently 5-10 times to mix the solution with blood. Insertion in an artery will cause pulsation; if this happens, immediately remove the needle and apply pressure for 5 minutes.

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine. The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once. The client weighs 3600 grams and naloxone 0.4 mg/mL is available. How many milliliters will the nurse administer? Record your answer using one decimal place.

Correct Answer: 0.9 mL Educational objective:To calculate the milliliters per dose of naloxone, the nurse should first identify the prescribed dose (eg, 0.1 mg/kg/dose) and available dose (eg, 0.4 mg/mL), then convert to milliliters per dose (eg, 0.9 mL/dose).

The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? Select all that apply. A. Gloves when contact with body fluids is anticipated B. Gloves when starting an intravenous line C. Gown, gloves, face shield, and goggles for every client encounter D. Hand hygiene before and after providing client care E. N95 respiratory mask and face shield

Correct Answer: A, B, and D Hand hygiene is performed before and after providing client care. HIV is a blood-borne virus, and standard precautions are sufficient protection against viral transmission. The nurse wears gloves when anticipating exposure to blood or body fluids. Isolation gowns are applied if the nurse anticipates splashing of body fluids on clothing. A face shield and goggles are applied if splashing in the eyes is a possibility. The nurse should always don gloves when starting an intravenous line. Incorrect Answers: [C. Gown, gloves, face shield, and goggles for every client encounter] This would be an acceptable level of protective equipment if the client undergoes a non-sterile procedure with significant splash risk, such as vaginal delivery. [E. N95 respiratory mask and face shield] Face shields are used when splashing on the face or in the eyes is anticipated. A N95 respirator mask is used when caring for a client with airborne isolation precautions. Educational objective:The Centers for Disease Control and Prevention recommend the use of standard precautions for preventing transmission of HIV.

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. A. Open a sterile container of 4x4's using the outermost corner to peel back the cover. B. Pull glove off over the soiled dressing to encase it before disposal. C. Save unused sterile 4x4's by taping original package shut for the next dressing change. D. Wash hands prior to putting on gloves and after removing them. E. Wrap soiled dressing in paper towels before disposing of it in the trash can.

Correct Answer: A, B, and D. The nurse is responsible for observing the home health aide periodically during delegated tasks. The aide should wash the hands prior to gloving and after glove removal. Sterile dressing supplies should be opened prior to the dressing change; this should be done by carefully peeling from the outermost corner of the package to expose the contents without contaminating the sterile product. A contaminated used dressing should be placed in impervious plastic or a paper bag before disposal in the household trash. Incorrect Answers: [Answer C. Save unused sterile 4x4's by taping original package shut for the next dressing change.] Unused sterile supplies should not be saved as it is not possible to ensure their sterility. [Answer E. Wrap soiled dressing in paper towels before disposing of it in the trash can.] Paper towels are not impervious and infectious waste from the dressing can seep through and into other items in the trash can. Educational Objective: In the home care setting, infection control procedures for changing a dressing include washing the hands before and after gloving, opening sterile supplies carefully to avoid contamination, and placing old dressings inside a glove or plastic bag before disposal in the household trash.

The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on emergency use of epinephrine injection, which statements by the parent indicate understanding of the instructions? Select all that apply. A. "I will give the injection if my child has trouble breathing after a bee sting." B. "I will give the injection in the upper arm." C. "I will keep an epinephrine injection close to my child at all times." D. "I will take my child to the emergency room after giving the injection." E. "The injection can be given through clothing."

Correct Answer: A, C, D, and E A critical part of self-care for a person with a history of anaphylaxis is to use an emergency epinephrine injection (EpiPen or EpiPen Jr) when an anaphylactic reaction occurs. The client and/or the client's caregiver should be taught the following principles: · Always have the EpiPen readily accessible for emergency use, and carry (eg, purse, pocket, backpack) or have it within reach at all times. · Administer EpiPen at the first notable sign of anaphylactic symptoms, such as tightening or swelling of the airway, difficulty breathing, wheezing, stridor, or shock. · Administer the injection in the mid-outer thigh; it can be given through clothing. · Call 911 or go to the emergency department (ED) to receive care as soon as possible; ED staff will monitor for further complications. Educational objective:Emergency self-injection of epinephrine (EpiPen) can be done through clothing into the mid-outer thigh when the client or the client's caregiver first notices any anaphylactic symptoms.

A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse? A. "How is your spouse's new job going?" B. "I've noticed that you seem frustrated lately." C. "It's normal to be angry when you can't work anymore." D. "We have a support group that can help you adjust to rehab."

Correct Answer: B. "I've noticed that you seem frustrated lately." A client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new role, and this stress can increase a client's vulnerability to ongoing health problems. This client has gone from being the main source of income to being unable to support the family and dependent on the spouse for financial stability. This causes a strain, and such a drastic role change can be particularly difficult for individuals who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not interviewed the client to determine the factors contributing to this change. The nurse should first communicate with the client in a therapeutic manner, using open-ended reflective statements and nonverbal communication to express acceptance and willingness to listen. Incorrect Answer: [A. "How is your spouse's new job going?"] This response ignores the client's feelings and closes off an opportunity to assess the client's emotional state regarding the role change brought on by illness and the spouse's new job. [C. "It's normal to be angry when you can't work anymore."] The nurse is assuming that the client is angry about the inability to work, but the client has not said this. Further communication is needed to understand the client's emotions and their source. [D. "We have a support group that can help you adjust to rehab."] The cause of the client's behavior change is not apparent at this point, so further communication is needed. It is premature to intervene by recommending a support group. Educational objective:Chronic illness can result in role changes that negatively influence a client's self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and listening to the client's feelings and perceptions on the issue.

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply. A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication. B. Breaks the ampule neck away from the nurse's body to prevent injury from glass. C. Disposes of the empty glass ampule in sharps container. D. Injects air into the glass ampule prior to withdrawing the medication. E. Rests and steadies the needle on the ampules outer rim to withdraw mediation.

Correct Answer: B and C A glass ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by: - Flicking the upper stem of the ampule with a fingernail several removal of medication from the ampule neck. - Using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards. - Setting the ampule on a flat surface or inverting to withdraw the medication. - Disposing of the ampule in a sharps container. [Incorrect Answer: A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication.] Glass shards may be present in the medication after an ampule is opened. To prevent the accidental administration of glass shards, the nurse must use a filter needle, rather than an injection needle, when withdrawing medication. [Incorrect Answer: D. Injects air into the glass ampule prior to withdrawing the medication.] Unlike when withdrawing medication from a vial, air should not be injected into a glass ampule; this causes the contents to spill from the container. [Incorrect Answer: E. Rests and steadies the needle on the ampule's outer rim to withdraw medication.] Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria. Education Objective: When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws the medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to the contaminated ampule edges, and avoids injecting air to prevent spillage.

The unlicensed assistive personnel (UAP) reports to the nurse tht during rounds a client has recently become pale. What is the nurses first action? A. Activate the facility's emergency response system. B. Ask the UAP to obtain a full set of vital signs. C. Check on the client to collect further data. D. Immediately notify the health care provider.

Correct Answer: C. Check on the client to collect further data. When there is an acute change in client status or new abnormal finding, the nurse should immediately check on the client and gather data to ensure safety and physiological integrity. Further clinical data on the client's respiratory status (eg, rate, depth), circulation (eg, blood pressure, pulse), and mentation (eg, alertness, orientation) should be obtained quickly. Following the steps of the nursing process, the nurse should first gather data (eg, vital signs, history), then collaborate in planning activities of care, implement these activities, and finally evaluate the client's response. [Option A. Activate the facility's emergency response system.] The nurse should obtain further data about the client's status before activating the emergency response system (eg, rapid response team). Data can help guide emergency intervention should it become necessary. [Option B. Ask the UAP to obtain a full set of vital signs.] A full set of vital signs should be obtained, but the nurse should directly observe the client to gauge the seriousness and validity of a potential emergency. [Option D. Immediately notify the health care provider.] The nurse should check the client and gather clinical data, as well as perform any necessary independent nursing actions, to ensure client safety before notifying the health care provider. Educational Objective: When a client experiences an acute change or possible emergency, the nurse should immediately obtain further clinical data about the client's status to ensure safety and physiological integrity. Additional clinical data on the client's respiratory status, circulation, and mentation should be obtained and appropriate actions taken.

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? A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive. B. Place one AED pad on the chest and the other on the back. C. Place one AED pad on the upper chest and the other on the lower left side. D. Place one AED pad on the upper right chest and dispose of the other.

Correct Answer: B. 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"). Incorrect Answers: [Answer A. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive.] 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. [Answer C. Place one AED pad on the upper chest and the other on the lower left side.] 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. [Answer D. Place one AED pad on the upper right chest and dispose of the other.] 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 nurse is assisting with the care of a newborn during circumcision. Which is an appropriate intervention? A. Apply a snug-fitting diaper following the procedure. B. Anticipate the use of clean technique during the circumcision. C. Offer oral fluids during the procedure. D. Wrap the newborns upper body in a blanket restraint for the circumcision.

Correct Answer: D. Wrap the newborn's upper body in a blanket restraint for the circumcision. Application of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive suckling are nonpharmacologic approaches to manage pain during circumcision. [Answer A. Apply a snug-fitting diaper following the procedure.] A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. [Answer B. Anticipate the use of clean technique during the incision.] Sterile technique is used during the surgical procedure of circumcision. [Answer C. Offer oral fluids during the procedure.] The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique. Educational Objective: During circumcision, the newborn is restrained in a wrapped blanket or placed on a special board to prevent injury. Non-nutritive sucking of a concentrated sucrose solution is offered for pain management.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. A. Don gown, gloves, and N95 respirator when entering the client's room. B. Ensure that pregnant staff members are not assigned to care for this client. C. Place single-use, disposable thermometer and stethoscope in the room. D. Place the client in a private room with negative air pressure. E. Request discontinuation of isolation precautions once all lesions are dry and crusted over.

Airborne Precautions: Indications: Tuberculosis — Varicella Zoster — Herpes Zoster — Rubeola Components: N95 respirator or powered air-purifying respirator — Negative-pressure isolation room with high-efficiency particulate air filter — As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield Only when uncrusted lesions are present; contact precautions also required. Only in disseminated disease or immunocompromised clients; contact precautions also required. Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued. Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway. Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities. Educational Objective: Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

Aortic Stenosis

Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur.

Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion. Educational objective:Aortic stenosis is a type of valvular heart disease causing narrowing of the valve between the left ventricle and aorta, impairing ejection of blood from the heart. Nurses attempting to auscultate heart murmurs associated with aortic stenosis should listen at the right sternal border, second intercostal space (ie, aortic area).

The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs? A. Descends with the cane on the step first, followed by the left leg, and then the right leg. B. Descends with the cane on the step first, followed by the right leg, and then the left leg. C. Descends with the left leg on the step first, followed by the cane, and then the right leg. D. Descends with the right leg on the step first, followed by the left leg, and then the cane.

Correct Answer A. Descends with the cane on the step first, followed by the left leg, and then the right leg. To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: 1. Lead with the cane. 2. Bring the weaker leg down next (in this client, it is the left leg.) 3. Finally, step down with the stronger leg. When ascending the stairs, the client should: 1. Step up with the stronger leg first. 2. Move the cane next, while bearing weight on the stronger leg. 3. Finally, move the weaker leg. To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. Incorrect Answers: [Answers B, C, and D] These options do not provide enough support to the weaker leg when descending. Educational Objective: To prevent falls when descending the stairs using a cane, the client should lead with the cane, follow with the weaker leg, and then step down with the stronger leg.

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important? A. Allowing the clients husband to be with her during clinical examinations. B. Assigning the client to a private room. C. Ensuring that female health care workers are available to provide care to the client. D. Obtaining the services of a local Muslim imam.

Correct Answer. C. Ensuring that female health care workers are available to provide care to the client. For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently. [Answer A. Allowing the clients husband to be with her during clinical examinations.] A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration. [Answer B. Assigning the client to a private room.] A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client's roommate could be problematic and cause distress. [Answer D. Obtaining the services of a local Muslim imam.] Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration. Educational Objective: In the care of female Muslim clients, modesty is highly valued and most body parts are covered. Female health care workers should be available to provide care and conduct examinations. If a male health care provider must be involved in care, female clinical staff should also be present whenever possible.

A client with ascites had 5400 mL of fluid removed during paracentesis. The health care provider prescribes 8 g of albumin IV per 1000 mL of fluid removed. If the albumin is supplied as 25 g in 100-mL bottles, how many mL will the nurse administer? Record your answer using one decimal place.

Correct Answer: 172.8 Albumin may be given after paracentesis to prevent volume depletion in a client with cirrhotic ascites. Using dimensional analysis, use the following steps to calculate the volume of albumin per dose in milliliters: Educational objective:Albumin may be given after paracentesis to prevent volume depletion. To calculate the volume per dose of albumin, the nurse should first identify the prescribed dose (eg, 8 g/L peritoneal fluid) and available medication (eg, 25 g/100 mL) and then convert to volume in milliliters per dose (eg, 172.8 mL).

A child with congenital heart disease weighing 44 lb is prescribed furosemide 1 mg/kg PO every 8 hours. It is available as an oral solution of 10 mg/mL. How many milliliters (mL) of furosemide should the nurse administer to the client each dose? Record your answer using a whole number.

Correct Answer: 2 mL Furosemide is a diuretic medication used to treat fluid overload in children with congenital heart disease. Using dimensional analysis, use the following steps to calculate the volume of furosemide in milliliters: Educational objective:To calculate the volume per dose of furosemide, the nurse should first identify the prescribed dose (eg, 1 mg/kg/dose) and available medication (eg, 10 mg/mL) and then convert to volume in milliliters per dose (eg, 2 mL).

The school nurse is assisting a student with type 1 diabetes mellitus to calculate the insulin dosage needed based on the student's lunch menu selections. Using the prescribed carbohydrate-to-insulin ratio, how much insulin should the student receive? Record your answer using a whole number.

Correct Answer: 3.75 Carbohydrate-based insulin dosing uses carbohydrate counting to calculate the insulin dosage required at meal times. Carbohydrate-based insulin dosing is a form of basal-bolus insulin therapy, which typically involves fixed, basal doses of a short- or intermediate-acting insulin (eg, regular insulin, insulin NPH) and variable, bolus doses of rapid-acting insulin (eg, insulin lispro) at specific intervals (eg, before meals). The client's individually prescribed carbohydrate-to-insulin ratio is used to calculate the insulin bolus dose. The following steps are performed to calculate the carbohydrate-based dosage of insulin lispro: Educational objective:Carbohydrate-based insulin dosing is a form of basal-bolus insulin therapy. To calculate the required dosage of insulin, the nurse should first identify the client's individually prescribed carbohydrate-to-insulin ratio (eg, 1 unit insulin/15 g carbohydrates), calculate the total carbohydrate content in the meal (eg, 75 g), and then convert to units per meal (eg, 5 units).

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? A. 12 hours. B. 24 hours. C. 36 hours. 4. 72 hours.

Correct Answer: 4. 72 hours. TST (Mantoux) is the standard method of conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: 1. Injection of purified protein derivative solution under the first layer of skin of the forearm. 2. Evaluation of the injection site 48 - 72 hours later. The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB. The QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours. Incorrect Answers: [Answer A. 12 hours.], [Answer B. 24 hours.], and [Answer C. 36 hours.] The 12-, 24-, and 36-hour time frames are incorrect. Educational Objective: The presence of an indurated area of the injection site 2-3 days after the tuberculin solution is administered indicates a positive TST.

The nurse is preparing to administer an antibiotic to a child with pneumonia. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, PO in liquid form. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many milliliters (mL) should the client receive for each dose? Record your answer using one decimal place.

Correct Answer: 5.3 mg/kg divided by 2.2 x (lbs) divided by dose per day x ( ml divided by mg) Educational objective:To calculate the volume per dose of antibiotic, the nurse should first identify the prescribed dose (eg, 7.5 mg/kg/day) and available medication (eg, 125 mg/5 mL) and then convert to volume in milliliters per dose (eg, 5.3 mL).

The nurse is caring for a client who is prescribed ampicillin 1.5 g in 100 mL of normal saline IV to be administered over 30 minutes every 6 hours. The nurse has IV tubing with a drip factor of 15 gtt/mL. At what rate in drips per minute (gtt/min) should the nurse administer the IV ampicillin? Record your answer using a whole number.

Correct Answer: 50 gtt/min Ampicillin is an antibiotic used to treat bacterial infections. Using dimensional analysis, use the following steps to calculate the drip rate of ampicillin per minute: Educational objective:To calculate the drip rate of ampicillin, the nurse should identify the prescribed dose (eg, 1.5 g/dose) and available medication (eg, 1.5 g/100 mL) and then convert to the rate in drips per minute (50 gtt/min).

The nurse is calculating IV fluid resuscitation for a client weighing 85 kg with visible partial-thickness burns covering 40% of the body. Using the Parkland formula, how many liters of IV fluid resuscitation are needed during the first 8 hours? Record your answer using one decimal place. Click the exhibit button for additional information.

Correct Answer: 6.8 Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. This intravascular loss often leads to hypovolemic shock in clients with extensive burns and requires emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after injury, when the greatest amount of intravascular volume loss occurs. The following steps should be used to calculate the volume needed for infusion during the first 8 hours. 1. Calculate the total volume needed for infusion for 24 hours 4 mL x weight (kg) x TBSA burned = total infusion volume 2. Calculate the volume needed for infusion during the first 8 hours. 24-hr infusion volume divided by 2 = 8 hour infusion volume 3. Convert milliliters to liters (8 hour infusion volume divided by 1) x (L divided by 1000 mL) Educational objective:The Parkland formula (4 mL × weight [kg] × body surface area burned [%]) is used to calculate the amount of IV fluid required for a burn victim during the initial 24 hours after injury. Half of the calculated volume is administered within the first 8 hours.

The nurse admits an adult client with partial-thickness burns to the anterior surface of the right leg and the anterior and posterior torso. The client weighs 198 lb. The total body surface area burned is calculated using the rule of nines. How many mL of IV fluid will the client require in the first 24 hours? Parkland Formula Protocol 24-hr fluid requirement calculation: 4 mL x body weight (kg) x total body surface area burned (%) First 8-hr gluid administration: 50% total fluid requirement Remaining 16-hr fluid administration: 50% total fluid requirement

Correct Answer: 9.72 mL Burn injuries are caused by direct tissue damage from exposure to caustic sources (eg, thermal, chemical, electric). This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses often lead to hypovolemic shock in clients with extensive burns and require emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after the injury, when many clients have the greatest amount of intravascular volume loss. Use the following steps to calculate the volume needed for infusion: Educational objective:The Parkland formula (4 mL × body weight [kg] × total body surface area burned [%]) is used to calculate the amount of IV fluid required for a client during the initial 24 hours after a burn injury. Half of the calculated volume is administered within the first 8 hours.

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters (mL) should the nurse document as the net urine output for the shift? Record your answer using a whole number.

Correct Answer: 900 mL A transurethral prostatectomy (TURP) is a surgical prostate-removal procedure commonly performed for male clients with prostate cancer. Following a TURP, clients typically receive continuous bladder irrigation (CBI) with a sterile, isotonic solution (eg, normal saline) via indwelling urinary catheter. CBI prevents bladder obstruction by large blood clots in the bladder or urethra. Monitoring urine output in clients receiving CBI can be challenging because there is continuous output from the irrigation. To calculate net urine output, the nurse should subtract the irrigation input from the total catheter output. Use the following steps to calculate the net urinary output: Educational objective:Continuous bladder irrigation is a therapy commonly used to prevent bladder obstruction by blood clots after a prostatectomy. To calculate the net urine output in a client with continuous bladder irrigation, the nurse should subtract the total amount of irrigating solution infused from the total amount of catheter output.

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. A. Epoetin alfa B. Fresh frozen plasma C. Homologous packed red blood cells D. Normal saline E. Platelet transfusion

Correct Answer: A and D Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products. Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels. Educational Objective Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringers, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply. A. Allow the client to refuse food if not feeling hungry. B. Ask if the client is experiencing any pain or nausea. C. Involve the client in meal planning and food selection. D. Plan for loved ones to share mealtimes with the client. E. Provide oral care before and after meals to alleviate dry mouth.

Correct Answer: A, B, C, D, and E. The goal of end-of-life care is comfort and quality of life. In many cases, clients may be more comfortable when they do not eat or drink. Anorexia is a common complication in clients who are dying and may be exacerbated by many factors (eg, medication, anxiety, underlying disease). The client should be allowed to refuse food and drink. However, the nurse can implement strategies to stimulate appetite or alleviate symptoms associated with anorexia, including: — Assessing the need for analgesia, antiemetic medications (eg, ondansetron), and appetite stimulants (eg, dexamethasone, megestrol acetate, dronabinol) to enhance client comfort and increase intake. — Involving the client in meal planning to encourage autonomy and helping the client select foods that are preferred and well tolerated, regardless of nutritional value, to increase appetite and oral intake. — Providing opportunities for meals with friends/family outside of the client's room, if possible, to promote stimulation and enjoyment. — Providing oral care frequently, especially after eating, and using topical treatments to minimize oral discomfort and dry mouth. Educational Objective: Managing anorexia during end-of-life care includes involving the client in meal planning/food selection; including friends/family at meals; offering preferred foods when the client is hungry; providing frequent oral care; administering antiemetics, analgesics, and appetite stimulants; and allowing the client to refuse food or drink.

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. A. Level of alertness B. Lung sounds C. Oxygen saturation D. Respiratory pattern E. Temperature F. Urine output

Correct Answer: A, B, C, and D Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain. A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. Incorrect Answers: [E. Temperature] Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. [F. Urine output] Urine output should not be affected by thoracentesis or the drugs administered for this procedure. Educational objective:Following thoracentesis, the nurse should monitor for signs of pneumothorax, including level of alertness, respiratory rate, respiratory effort, oxygen saturation, and lung sounds.

Which measures will help prevent falls in elderly clients of a long-term care facility. Select all that apply. A. Exercise programs. B. Good room lighting. C. Handrails in the stairwell. D. Smooth-soled shoes. E. Staff hourly rounds.

Correct Answer: A, B, C, and E. Falls are a leading predictor of mortality and morbidity in older adults. General exercise programs, especially those including gait, balance, and strength training, not only reduce the risk of falls but also prevent injuries from falls. Vision impairment can contribute to fall risks; most adults need additional light by age 50. The nurse should ensure that clients are wearing needed prescription glasses. Handrails, particularly in stairwells, hallways, and bathrooms, have been shown to reduce falls. Studies show that staff rounds at regular intervals (hourly or every other hour) decrease falls and call light use. The practice allows staff to intervene early in needs. Typically, staff checks on the "Ps": potty, position, pain, and placement/proximity of personal items (eg, bed height, call light, water, tissues, urinal.) A common reason clients get out of bed unassisted is to use the bathroom. Incorrect Answers [Answer D. Smooth-soled shoes.] Non-slip rubber-soled shoes are recommended to prevent falls. Educational Objective: Client falls can be prevented with exercise programs, good lighting, handrails, and hourly staff rounds.

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. A. Arrange for health care workers of the same se to provide care for the client. B. Coordinate with the registered dietician to provide halal meals. C. Reposition the immobile client to face the city of Mecca daily during prayer times. D. Restrict the number of visitors from the family to preserve the client's privacy. E. Upon death, provide the family with supplies for postmortem care.

Correct Answer: A, B, C, and E. Spiritually, 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. 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. 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. 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 the burial. Burial occurs quickly after death, sometimes the same day. Incorrect Answer [Answer D. Restrict the number of visitors from the family to preserve the client's privacy.] 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.

A nurse is preparing client medications in the medication room at the nurse's station. The nurse should perform which actions to be consistent with client safety practices related to medication administration? Select all that apply. A. Check laboratory values before administering anticoagulants. B. Compare medication, dosage, and route to prescriptions prior to administration. C. Discard any unlabeled medications. D. Open unit dose packages and place medications in a dispensing cup to take to the bedside. E. Wear gloves to handle unopened individual unit dose medication packages.

Correct Answer: A, B, and C. The nurse must follow the 6 rights of medication administration. 1. The right client. 2. The right medication. 3. The right dose 4. The right time. 5. The right route. 6. The right documentation. In addition, one of the 2015 National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as these are prepared, discarding all unlabeled medications, and being extra careful with clients taking anticoagulant drugs (eg, assessing laboratory values prior to administration.) Incorrect Answers [Answer D. Open unit dose packages and place medications in a dispensing cup to take to the bedside.] Individual dose packages should be opened at the client's bedside and placed in a medication cup only immediately before administration. [Answer E. Wear gloves to handle unopened individual unit dose medication packages.] Gloves are generally not required during medication preparation/handling of unopened packages or vials. However, hand hygiene should be performed both prior to preparation/handling and before administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or body fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers.) Educational Objective: The nurse should follow the 6 rights of medication administration when preparing and administering drugs to a client. In addition, the National Patient Safety Goals for improving the safety of medication use should be followed. These include labeling all medications, discarding unlabeled medications, and being extra careful with clients taking anticoagulants.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply. A. Avoid the arm on the affected side after a mastectomy. B. Do not make further attempts to draw blood if unsuccessful on the first 2 attempts. C. If necessary to use an arm with IV infusing, draw proximal to infusion point. D. Insert the needle bevel up at a 15-degree angle to the skin. E. Obtain a finger capillary specimen from the middle of the finger pad.

Correct Answer: A, B, and D When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degrees.) Some recommended bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. Incorrect Answers [Answer C. If necessary to use an arm with IV infusing, draw proximal to the infusion point.] An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal) the point of IV infusion, with the tourniquet placed in between. [Answer E. Obtain a finger capillary specimen from the middle of the finger pad.] The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A hell stick collection on an infant should be done on the plantar surface. Educational Objective: When obtaining blood from a client, insert the needle at a 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion.

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply. A. Apply patch to upper arm of chest. B. Fold used patches in half with sticky sides together before discarding. C. Remove patch if dizziness occurs when getting up. D. Rotate sites each time a new patch is applied. E. Shave hair before applying patch.

Correct Answer: A, B, and D. Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the Clonidine (transdermal) patch: w Apply the patch to a dry, hairless area on the upper outer arm or chest once every 7 days. w Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars. w Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. w Remove the patch from the package. Do not touch the sticky side. w Rotate sites of patch application with each new patch. Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP.) w When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested. w Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur. Educational Objective The nurse should teach a client receiving a clonidine patch to: w Apply patch to a dry, hairless area on the upper arm or chest. w Wash hands before and after application. w Rotate sites with each new patch application. w Discard patch away from children or pets with sticky sides folded together. w Never wear more than 1 patch at a time. w Never stop using the patch abruptly.

The nurse is caring for an older client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the rest room. Which nursing interventions are appropriate when caring for this client? Select all that apply. A. Ensuring bed alarm remains activated. B. Initiating an hourly rotating schedule. C. Inserting an indwelling urinary catheter. D. Moving client to a room to the nurses' station. E. Raising all side rails of the client's bed.

Correct Answer: A, B, and D. Fall Risk Precautions Standard: — Orientation to room & call light. — Call light within reach — Bed in lowest position. — Uncluttered room — Nonslip socks or shoes — Well-lit room — Belongings within reach High Fall Risk — Bed alarm — High fall risk signs — Room close to the nurses' station — Color-coded socks & wristbands. Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: — Hourly rounding (eg, assessing pain, offering toileting and nutrition) — Moving the client to a room close to the nurses' station. — Activating bed alarms to alert staff if the client gets out of bed unassisted — Asking family members or visitors to stay at the bedside with the client [Answer C. Inserting an indwelling urinary catheter.] Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) to client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care.) The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. [Answer E. Raising all side rails of the client's bed.] Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails. Educational Objective: Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated.

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply. A. Acting as a witness that the client signed the consent form voluntarily. B. Documenting in the medical record the date and time the signature was obtained. C. Educating the client if there is a misunderstanding about the procedure. D. Explaining to the client the right to refuse surgery. E. Verifying that the client is competent to provide informed consent.

Correct Answer: A, B, and E. Written consent is required for invasive procedures and surgery. Clients must be informed of and competent to understand information about the procedure, alternate treatments, and risks. They must also be informed that they have the right to refuse the procedure or surgery. The nurse's role in informed consent is to witness that the client signed the consent voluntarily and was competent at the time of signing. The nurse should ensure that the client received necessary information and has no remaining questions about the procedure. After obtaining the signature, the nurse should document in the client's medical record that the informed consent was given and the date/time of the signature. Incorrect Answers: [Answer C. Educating the client if there is a misunderstanding about the procedure.] & [Answer D. Explaining to the client the right to refuse surgery.] The health care provider is responsible for explaining all aspects of the procedure, ensuring that the client has a correct understanding of the procedure and its potential risks, providing the names/qualifications of those who will be involved, describing available alternate treatments, and reinforcing that the client has the right to refuse the procedure. The health care provider should be contacted if the client does not have a correct understanding of the procedure. The nurse should not try to explain procedures as he/she could be held liable for giving incorrect/incomplete information. Educational Objective: The nurse's role in informed consent is to witness a client's signature and ascertain that the client signed voluntarily, was competent to provide consent at the time of signature, received the necessary information, and has no further questions.

Which interventions does the nurse perform for promoting normal rest and sleep patterns for a critically ill client? Select all that apply. A. Dimming the lights at night. B. Leaving the television on for diversion at night. C. Opening the window blinds/shades in the morning. D. Scheduling interventions and activities during the day when possible. E. Turning off equipment alarms in the client's room at night.

Correct Answer: A, C, D It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. Incorrect Answers [Option B. Leaving the television on for diversion at night.] Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. [Option E. Turning off equipment alarms in the client's room at night.] Turning the alarms off in the client's room would pose a risk to safety as the nurse may not be alerted to a change in condition or equipment failure. if possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational Objective: To prevent disorientation and delirium in the intensive care unit, it is important to provide care that maintains the client's normal circadian rhythm (dimming lights at night, allowing uninterrupted sleep when possible, scheduling interventions and activities during the day, frequent reorientation, and opening window shades in the morning.)

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. A. Guide the client to the floor and gently cradle the head. B. Insert a tongue blade to prevent client from swallowing the tongue. C. Move objects that may cause injury away from the client. D. Physically restrain the client to prevent injury. E. Place the client in left lateral position. F. Remain with the client, observe, and record the seizure activity.

Correct Answer: A, C, E, and F Protecting the ambulating client from injury is the immediate priority. The nurse assists the client to the floor, cradles the head, and places the client in the left lateral position. Left lateral position is preferred to avoid the risk of aspiration. Hard or sharp objects should be removed from the client's environment to prevent injury. The nurse remains with the client until the seizure is over to assess seizure activity and postictal symptoms and to minimize injury. Incorrect Answers: [Answer B. Insert a tongue blade to prevent client from swallowing the tongue.] No objects should be placed in a client's mouth during a seizure. Following the seizure, the client may require assessment and maintenance of the airway, suctioning, and oxygen administration. [Answer D. Physically restrain the client to prevent injury.] Attempting to restrain a client during a seizure may cause injury to the client. Educational Objective: Safety measures implemented during a seizure include positioning the client to protect from injury, maintaining a patent airway, and observing the seizure activity. During the seizure, the nurse does not restrain the client or place objects in the client's mouth.

A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply. A. Cardiac pacemaker B. Colostomy C. Retained metal foreign body in eye. D. Total hip replacement E. Transdermal testosterone patch.

Correct Answer: A, C, and D. Clients must be screened for contraindications before exposure to the magnetic field of MRI as it can damage implanted devices (including metallic objects). Absolute contraindications can preclude testing, and relative contraindications can pose a hazard to the client's devices or implants, affect the quality of the images, or cause discomfort. Therefore, the imaging health care provider should determine the client's eligibility for MRI. Absolute contraindications include the following: — Cardiac pacemaker — Implantable cardioverter defibrillator. — Cochlear implant — Retained metallic foreign body, especially in organs such as the eye. Relative contraindications include the following: — Prosthetic heart valve — Metal plate, pins, brain aneurysm clip, or joint prosthesis — Select devices; those composed of nonferrous MRI-safe materials should be verified first. — Implanted device (eg, insulin pump, medication port.) Other factors that can affect the client's eligibility include inability to remain supine for 30-60 minutes and claustrophobia; sedation can be prescribed or an open MRI machine can be used in such cases. Incorrect Answers: [Answer B. Colostomy] Colostomy is not contraindication for MRI. [Answer E. Transdermal testosterone patch.] Transdermal metal-containing medication patches (clonidine, nicotine, scopolamine, testosterone, and fentanyl) are not a contraindication for MRI. However, these must be removed before and replaced after testing. Educational Objective: Absolute contraindications for MRI include metallic implants (eg, pacemaker, implantable cardioverter defibrillator, plates, pins, brain aneurysm clips), implanted devices (eg, insulin pumps, medication ports), and prostheses (eg, joints, heart valves). Some of these devices are manufactured with MRI-safe materials that should be verified prior to testing.

The nurse is reinforcing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply. A. Conducting teaching sessions while a family member is present. B. Discourage the client from using the internet to look up health information. C. Have client watch a DVD about heart failure management. D. Print out pictures of a food label and review where to look for sodium content. E. Speak slowly and loudly so the client can understand you.

Correct Answer: A, C, and D. The nurse needs to consider several factors when selecting teaching strategies; these include client characteristics (eg, age, educational background, language skills, culture), subject matter, and available resources. Learning can be improved as follows: — Using pictures and simplified text is beneficial to the older adult with low literacy. — Including a family member in the teaching process will assist the client in reinforcement of the material at a later date. — Professionally produced programs are beneficial as they contain high quality visual content as well as a delivery of auditory content in lay person's language. Incorrect Answers: [Option B. Discourage the client from using the internet to look up health information.] Older adults are using the internet in increasing numbers as are clients with low literacy. Several organizations are developing and promoting user-friendly websites. Society in general relies heavily on web-based health information. It is important for the nurse to teach the client and possibly supply a list of reputable sites for the client to view. [Option E. Speak slowly and loudly so the client can understand you.] Unless the client is hard of hearing, speaking slowly and loudly is unnecessary and demeaning. Educational Objective: For a client with low literacy, the nurse should use multiple teaching strategies including professionally produced educational programs, pictures with simplified text, and inclusion of a family member during teaching sessions.

Which of these are correct nursing actions related to client positioning? Select all that apply? A. Position client in high Fowler's for a paracentesis related to end-stage cirrhosis. B. Position client on left side after liver biopsy. C. Position client on side with head, back, and knees flexed after lumbar puncture. D. Position client Trendelenburg on left side if air embolism is suspected. E. Position client with arm raised above head for chest tube placement.

Correct Answer: A, D, E [Correct Answer: A. Position the client in high Fowler's for a paracentesis related to end-stage cirrhosis.] Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture. [Correct Answer D. Position the client in Trendelenburg on left side if air embolism is suspected.] In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The registered nurse and health care provider should be notified immediately with the practical nurse remains with the client. [Correct Answer: E. Position the client with arm raised above head for chest tube placement.] Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm. [Incorrect Answer: B. Position client on left side after liver biopsy.] After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk. [Incorrect Answer: C. Position client on side with head, back, and knees flexed after lumbar puncture.] During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine) or with the head of the bed elevated 30 degrees. Educational Objective: For medical procedures, the nurse should ensure that the client: — Has an empty bladder and is in the high Fowler's or sitting position for paracentesis. — Is Trendelenburg on the left side for suspected air embolism. — Has the arm raised above the head on the affected side for chest tube insertion. — Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy. — Is side-lying with the head, back, and knees flexed for a lumbar puncture.

The clinic nurse is reinforcing client teaching about the tiotropium that has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? A. "A capsule holds the powdered medication that I put in a special inhaler." B. "I do not need to rinse my mouth out with water after taking tiotropium." C. "I have been taking tiotropium every time I have difficulty breathing." D. "Tiotropium helps control my COPD by reducing inflammation in my airway."

Correct Answer: A. "A capsule holds the powdered medication that I put in a special inhaler." Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic inhaled medication used to control chronic obstructive pulmonary disease (COPD) and is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client how to administer the medication prior to the first dose, emphasizing that the capsules should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. Incorrect Answer: [B. "I do not need to rinse my mouth out with water after taking tiotropium."] Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. [C. "I have been taking tiotropium every time I have difficulty breathing."] Tiotropium is a controller medication for COPD, and the peak effect takes about a week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. [D. "Tiotropium helps control my COPD by reducing inflammation in my airway."] Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help to dry up airway secretions. Educational objective:Tiotropium and umeclidinium are long-acting, 24-hour, anticholinergic medications. Ipratropium is a short-acting anticholinergic used as a rescue medication for chronic obstructive pulmonary disease and asthma. Tiotropium is typically administered as a powder via a special inhaler.

The nurse is reinforcing teaching on self-administering ophthalmic lubricating ointment medication to a client with newly diagnosed Sjögren's syndrome. Which client statement indicates the need for further teaching? A. "After applying the ointment, I'll close my eyes tightly and rub the lid for 2-3 minutes." B. "I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge." C. "I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment." D. "I'll use my ointment at bedtime and my eyedrops during the day."

Correct Answer: A. "After applying the ointment, I'll close my eyes tightly and rub the lid for 2-3 minutes." Ophthalmic lubricants (drops, ointment, gel) replace tears and add moisture to the eyes. They are prescribed to treat dry eyes, a common symptom in clients with Sjögren's syndrome, an autoimmune disorder. Administering an ophthalmic ointment by tightly closing the eyes and rubbing the lid for 2-3 minutes can squeeze the ointment out of the eye and cause injury. The client is taught to gently close the eyes for 2-3 minutes to distribute the medication after applying the ointment Incorrect Answers: [Answer B. "I'll squeeze a thin strip of ointment on my lower eyelid, from the inner to the outer edge."] This statement indicates the client's understanding that when administering the medication, the client should squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge, without letting the tube touch the eye to prevent contamination. [Answer C. "I'll tilt my head back, pull my lower lid down, and look upward when administering the ointment."] This statement indicates the client's understanding that when administering the medication, the client tilts the head back, pulls the lower lid down, and looks toward the ceiling to help decrease blink reflex. [Answer D. "I'll use my ointment at bedtime and my eyedrops during the day."] Some clients use the ophthalmic ointment at bedtime and the eyedrops during the day due to blurred vision that ointments and gels can cause. Educational Objective: Clients are taught the following steps for self-administration of ophthalmic ointments: 1. Wash hands. 2. Tilt the head back, pull the lower lid down, and look upward. 3. Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge. 4. Close the eyes gently for 2 - 3 minutes after applying the ointment.

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client who practices traditional Islamic customs. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity to this client? A. "Ask the client's wife if she would like to give the bed bath." B. "Do not make eye contact with the client during the bath." C. "The client may prefer for you not to talk to him during the bath." D. "Touching the head is a sign of disrespect; let the client wash his own face."

Correct Answer: A. "Ask the client's wife if she would like to give the bed bath." To provide culturally competent care, it is important for the nurse to realize that in many Arab cultures, a man is not allowed to be alone with a woman other than his wife. It may also be inappropriate for a female health care worker to physically care for him; however, in some instances, direct physical care from the opposite sex is allowed if a third party is present. Incorrect Answers: [B. "Do not make eye contact with the client during the bath."] Eye contact varies greatly among cultural groups. Some cultures (eg, Arab, Asian, Native American) view eye contact as a sign of disrespect or aggressiveness. This could be a concern with this client, but it is not as high a priority as respecting the client's cultural beliefs of not being alone in the same room with a member of the opposite sex. [C. "The client may prefer for you not to talk to him during the bath."] Some cultures (eg, Native American, Asian) are comfortable with silence and see it as a sign of respect, privacy, or respect for elders. [D. "Touching the head is a sign of disrespect; let the client wash his own face."] In some Asian and Hispanic cultures, the head is thought to be the basis of one's strength or soul, and touching a person's head is considered disrespectful. Educational objective:The nurse should be aware that in many Arab cultures a man is not allowed to be alone with a woman other than his wife. In addition, cultural customs may not allow physical care by a member of the opposite sex. The nurse needs to plan accordingly to provide culturally sensitive care.

A 2-year-old who swallowed an overdose of adult cough syrup is being discharged from the emergency department. The parent says to the nurse, "From now on, I'm going to store all medicines in my top dresser drawer." Which is the best response by the nurse? A. "Can you lock your dresser drawer?" B. "Make sure all of your medicines have childproof caps." C. "That sounds like a safe plan." D. "You need to keep an eye on your child at all times."

Correct Answer: A. "Can you lock your dresser drawer?" Children are naturally curious and attracted to medicine, especially if it is sweet and syrupy like many over-the-counter cold products. They usually find medicines when exploring their environment and "getting into everything" when no one is watching. Children may find medicine in a parent's coat pocket or purse, under a counter cabinet, or on a nightstand. Even if a drug is stored in a place that seems out of reach, children can climb on a chair or stool to reach it. Medications are the leading cause of child poisoning. The best preventive measures include placing all medications out of sight, placing them in a drawer or cabinet with a childproof lock, and putting them away after each use. Incorrect Answers: [Answer B. "Make sure all of your medicines have childproof caps."] Advising a parent/caregiver to ensure that medicine containers have childproof caps is an appropriate instruction; however, it is not the priority response in this situation. [Answer C. "That sounds like a safe plan."] Storing medicines in a dresser drawer is not a safe plan unless the drawer can be locked. [Answer D. "You need to keep an eye on your child at all times."] Although it is impossible for a parent or caregiver to watch a child every minute of the day, toddlers need adult supervision when active and exploring their environment. Educational Objective: The most important strategy to prevent accidental drug overdoses in children is teaching parents and caregivers to keep medicines out of sight, in a locked drawer or cabinet. Parents/caregivers should also be advised to put drugs away after each use.

The practical nurse is collaborating with the registered nurse to admit a client who will receive general anesthesia in the same-day surgery unit. The client has never had surgery before. Which question is most critical for the nurse to ask the client during preoperative assessment and health history taking? A. "Has any family member ever had a bad reaction to general anesthesia?" B. "Have you ever experienced low back pain?" C. "Have you ever had an anaphylactic reaction to a bee sting?" D. "Have you ever received opioid pain medications?"

Correct Answer: A. "Has any family member ever had a bad reaction to general anesthesia?" Malignant hyperthermia (MH) is a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic agents and succinylcholine (Anectine), a depolarizing muscle relaxant used to induce general anesthesia. In MH-susceptible clients, the triggering agent leads to excessive release of calcium from the muscles, causing sustained muscle contraction and rigidity (usually the jaw and upper body [early sign]), increased oxygen demand and metabolism, and a dangerously high temperature (later sign). Because MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and health history can help minimize the client's risk. Incorrect Answers: [B. "Have you ever experienced low back pain?"] Cervical spine problems should be assessed before intubation. A history of low back pain is not a deterrent for general anesthesia. [C. "Have you ever had an anaphylactic reaction to a bee sting?"] It would be appropriate to ask about allergies (eg, drugs, latex). However, asking about an anaphylactic reaction to a bee sting is not the most critical question. [D. "Have you ever received opioid pain medications?"] Querying the client about prior opioid intake may be helpful, but the most important action is to ask about anesthesia side effects and allergies. Educational objective:Malignant hyperthermia (MH) is a rare, life-threatening inherited muscular abnormality that is triggered by specific drugs used to induce general anesthesia. Therefore, it is critical for the perioperative nurse to screen for MH susceptibility by asking if any of the client's blood relatives have ever experienced an adverse reaction to general anesthesia, including unexplained death.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? A. "He is critically ill and we are caring for his needs." B. "His heart has stopped and we are attempting to revive him." C. "I don't know how he is doing but you need to come." D. "I will have the health care provider talk to you once you arrive."

Correct Answer: A. "He is critically ill and we are caring for his needs." Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times. Stating that the client is critically ill and is being cared for meets the ethical principle of veracity (telling the truth) but also avoids overwhelming the family before they travel to the hospital. The nurse does not want the family to be too distressed to process the situation and arrive safely. Incorrect Answers: [Answer B. "His heart has stopped and we are attempting to revive him."] This is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely. [Answer C. "I don't know how he is doing but you need to come."] This is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child. [Answer D. "I will have the health care provider talk to you once you arrive."] Although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis. Educational Objective: The ethical principle of beneficence means doing good. It can involve not saying all known information immediately but delaying notification until appropriate support is in place.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? A. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" B. "We will do everything possible to prevent that from happening." C. "Well, we're all going to die sometime." D. "You should concentrate on getting better rather than thinking about death."

Correct Answer: A. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" Incorrect Answer: [B. "We will do everything possible to prevent that from happening."] This response attempts to give reassurance but does not address the client's thoughts and concerns. [C. "Well, we're all going to die sometime."] This is a very trite response and will close down any opportunity for further discussion. [D. "You should concentrate on getting better rather than thinking about death."] This response gives advice to the client and is non-therapeutic; it does not acknowledge the client's current concerns. Educational objective:Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations.

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse. A. "I can see that you are very upset. Let's talk about what happened." B. "I'll report the technician to the head of the radiology department." C. "The technician never should have said that to you." D. "Your health care provider will discuss treatment options with you."

Correct Answer: A. "I can see that you are very upset. Let's talk about what happened." Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening.) This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. [Option B: "I'll report the technician to the head of the radiology department."} This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. [Option C: "The technician never should have said that to you."] This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears. [Option D: "Your health care provider will discuss treatment options with you."] This response does not address the client's feelings or what happened during the mammogram. Educational Objective: Therapeutic communication techniques such as acknowledgment of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, and caring.

The nurse is caring for a client who weighs 450 lb (204.1 kg) 2 days after bariatric surgery. The client is pleasant, cooperative, and able to fully bear weight. What would be the most appropriate method for transferring this client safely? A. 1-person safety standby with walker B. 2-person full-body sling lift C. 2-person standing-assist lift D. 4-person full-body sling lift

Correct Answer: A. 1-person safety standby with walker When determining the most appropriate method to transfer a client safely, the nurse should assess: 1. Whether the client can bear weight 2. Whether the client is cooperative This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear full weight, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff. When working with bariatric clients, equipment that has the capacity to bear the client's full weight and accommodate their size should be used while maintaining the client's dignity throughout the process. Incorrect Answers: [B. 2-person full-body sling lift] These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. [C. 2-person standing-assist lift] These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. [D. 4-person full-body sling lift] A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer. Educational objective:A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety. If there is any concern for caregiver or client safety during the transfer of a bariatric client, the type of equipment should be reconsidered and the number of caregivers should be increased.

A client is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safely transfer this client? A. 1-person stand and pivots with gait belt and walker. B. 1-person standby assist with walker. C. 2-person motorized stand-assist lift. D. 2-person stand and pivot with gait belt and walker.

Correct Answer: A. 1-person stand and pivots with gait belt and walker. To determine the most appropriate method to safely transfer a client, the nurse should assess: 1. Whether the client can bear weight. 2. Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift. If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance. Incorrect Answers: [Answer C. 2-person motorized stand-assist lift.] This method would be appropriate for a client who has no weight-bearing ability but can follow instructions and has enough upper body strength to use a motorized stand-assist lift. [Answer D. 2-person stand and pivot with gait belt and walker.] If the nurse determines that the client cannot be safely transferred with assistance from 1 caregiver, a 2-person stand and pivot transfer may be performed. However, the nurse should first encourage the client to use as much own strength as possible. Educational Objective: If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial reaction? A. Abdominal thrusts. B. Back blows and chest thrusts. C. Blind sweep of the child's mouth. D. Call 911 for an ambulance.

Correct Answer: A. Abdominal thrusts. Foreign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it. If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention. Incorrect Answers: [Answer B. Back blows and chest thrusts.] Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway. [Answer C. Blind sweep of the child's mouth.] Blind sweeping a child's mouth can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway, requiring surgical removal. [Answer D. Call 911 for an ambulance.] This child is experiencing a blocked airway, which is a medical emergency that requires intervention at the skill level of a nurse. The nurse can ask a bystander to contact 911 while attempting to clear the airway. This differs from a situation such as anaphylaxis, in which the nurse would require epinephrine and would call 911 for immediate assistance. Educational Objective: The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.

The nurse walks into the client's inpatient room and sees a fire in the wastebasket. The nurse should take which action first? A. Activate the fire alarm B. Close the door C. Pour water on the fire D. Use a fire extinguisher

Correct Answer: A. Activate the fire alarm RACE is the acronym used to remember how to deal with fires in inpatient settings. RACE represents the following actions: 1. Rescue (remove clients from immediate danger) 2. Alarm (activate the fire alarm, call "code red," alert nearby appropriate personnel) 3. Confine (close the doors and windows) 4. Extinguish the fire or evacuate clients—first horizontally, then vertically In the provided options, the client rescue has been done or is not needed (ie, no one is in the room). The next priority is to pull the fire alarm to get assistance to help rescue other clients or contain the fire. Incorrect Answers: [B. Close the door] Closing the doors (this room, all client rooms, and the fire doors between the units) is part of containment and should be done immediately after activating the alarm. [C. Pour water on the fire] Extinguishing the fire is performed after rescue, alarm, and containment. As a rule, water is not used on a fire in a hospital. It is used on Class A fires (paper, wood, and cloth) only. Instead, the nurse should use a fire extinguisher, which is designated for the types of material seen in hospitals. [D. Use a fire extinguisher] PASS is the acronym representing how to use an extinguisher and is part of the fourth step of RACE. It stands for Pull the pin, Aim the nozzle, Squeeze the handle, and Sweep back and forth over the fire. Educational objective: RACE is the acronym that represents the steps to take when dealing with fires at inpatient settings. The order of actions is Rescue, Alarm, Confine, and Extinguish/Evacuate. PASS is the acronym representing how to use a fire extinguisher (Pull, Aim, Squeeze, and Sweep).

The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action? A. Administers the medication in small amounts at the back of the cheek using a syringe. B. Allows the client to sip the medication from a cup. C. Expels the medication from a dropper onto the back of the tongue. D. Mixes the medication in the infants bottle of formula.

Correct Answer: A. Administers the medication in small amounts at the back of the cheek using a syringe. The correct procedure for administering oral liquid medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk of choking and ensures that all the medication is consumed. Incorrect Answers: [Answer B. Allows the client to sip the medication from a cup.] Although cup feeding may be a method used for infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infants spitting or drooling. [Answer C. Expels the medication from a dropper onto the back of the tongue.] Infants have an extrusion reflex (outward extension of tongue when it is touched) and a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration. [Answer D. Mixes the medication in the infants bottle of formula.] It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle of formula as the infant may not consume the entire amount. Educational Objective: Using a syringe to measure medication for an infant is the most accurate technique to ensure that the proper amount is being administered. The extrusion reflex and a decreased gag reflex in infants age <4 months increase the risk of choking and aspiration. Using a syringe to instill the medication at the back of the cheek decreases the risk of choking and ensures the correct amount is consumed.

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route. The nurse intervenes when the student performs which action? A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin. B. Chooses a 1 mL tuberculin syringe with a 27-gauge ¼ inch needle; dons clean gloves C. Injects medication slowly while raising a small wheel (bleb) on the skin D. Inserts needle at a 10-degree angle almost parallel to skin with the bevel up.

Correct Answer: A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin. Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: 1. Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch 2. Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. 3. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. 4. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees 5. Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis 6. Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis 7. Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. 8. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction. Educational objective: For TB skin testing: 1. Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe 2. Administer injection on inner forearm at a 10-degree angle with bevel up 3. Make a wheal (bleb) Avoid rubbing site after injection

The nurse preceptor observes a graduate practical nurse collecting a urine sample for urinalysis and culture as pictured in the exhibit. What is the preceptor's best action? A. Advise the graduate nurse to discard the collected urine specimen and record the output. B. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection C. Explain to the graduate nurse that midstream clean catch or straight catheterization is required D. Remind the graduate nurse that the specimen should be kept cool until it is sent to the laboratory

Correct Answer: A. Advise the graduate nurse to discard the collected urine specimen and record the output. Urine specimens are collected aseptically from the port located on the tubing of an indwelling urinary catheter; therefore, the client's collected urine should be measured and discarded. Colonization and multiplication of bacteria within the stagnant urine in the collection bag may occur and cause incorrect results. Some urinary drainage bags are impregnated with an antimicrobial agent to help prevent catheter-associated urinary tract infections. However, the antimicrobial agents can also affect the results of urinalysis and culture. To collect the urine specimen: · Clean the collection port with an alcohol swab · Aspirate urine with a sterile syringe · Use aseptic technique to transfer the specimen to a sterile specimen cup Incorrect Answer: [B. Advise the graduate nurse to use a sterile specimen cup rather than a graduated container for collection] Using a sterile specimen cup to obtain urine from a collection bag is improper collection technique. Specimens should never be obtained from a collection bag. [C. Explain to the graduate nurse that midstream clean catch or straight catheterization is required] The urine sample can be taken from the port on the current catheter. Although midstream clean catch and straight catheterization can be used to obtain a urine sample, these techniques are not necessary with a catheter in place. [D. Remind the graduate nurse that the specimen should be kept cool until it is sent to the laboratory] Specimens should be kept cool until transported to the laboratory; however, this sample was collected incorrectly and should be discarded. Educational objective:A urine specimen is collected aseptically from the specimen port of an indwelling urinary catheter. Urine that has been collected from a bag does not yield accurate urinalysis and culture results.

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action? A. Apply a gauze wrap and elastic stockinette around the IV site. B. Apply a mitt on the right hand. C. Apply a soft wrist restraint on the right wrist. D. Apply an arm board to the left arm.

Correct Answer: A. Apply a gauze wrap and elastic stockinette around the IV site. A physical restraint that restricts body movement should be the last resort to keep a client from interfering with medical treatment. Restraints can cause bodily injury such as pressure ulcers, neurovascular and peripheral circulatory deficits, and psychological trauma. Therefore, less restrictive methods should always be tried first. Concealing the IV site and tubing by wrapping the forearm in gauze and an elastic stockinette can be effective in keeping a confused client from pulling at the IV line. [Answer B. B. Apply a mitt on the right hand.] & [Answer C. C. Apply a soft wrist restraint on the right wrist.] & [Answer D. D. Apply an arm board to the left arm.] Applying a hand mitt, soft wrist restraint, or arm board may be necessary if less restrictive techniques, such as concealing the IV site or encouraging family member or sitter involvement, are ineffective in keeping the client from pulling at the IV line. However, applying one of these restraints should not be the nurse's next action. Educational Objective: The least restrictive device or method to keep a client from interfering with medical treatment should always be tried first, before applying a physical restraint.

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time? A. Ask about the client's recent bowel and bladder habits. B. Assess the home for sources of excessive noise. C. Provide information about respite and daily adult care. D. Review behavior-management techniques with caregiver.

Correct Answer: A. Ask about the client's recent bowel and bladder habits. Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needs according to the Maslow hierarchy of needs. Incorrect Answers: [Answer B. Assess the home for sources of excessive noise.] Environmental stressors (eg, excessive noise, overstimulation) may cause behavioral changes such as agitation or restlessness in client with AD and should be addressed after intervening to meet the client's basic needs. [Answer C. Provide information about respite and daily adult care.] Caregiver support is essential to client care, especially in the home health environment. After addressing the clients needs, the nurse should provide information about community support groups, respite care, and adult day care to help reduce caregiver fatigue. [Answer D. Review behavior-management techniques with caregiver.] The nurse should use behavioral-management techniques (eg, reassurance, distraction, and redirection) to assist with de-escalation. However, the nurse must assess for and address sources of agitation first. Educational Objective: When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings? A. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+ B. Bilateral DP pulses palpable. Right DP 3+. Left DP 2+. C. Bilateral popliteal pulses palpable. Right > left foot. D. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT.

Correct Answer: A. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+ The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 0: Absent 1+ : Weak 2+: Normal 3+ : Increased, full, bounding. [Answer B. Bilateral DP pulses palpable. Right DP 3+. Left DP 2+.] DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. [Answer C. Bilateral popliteal pulses palpable. Right > left foot.] The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. [Answer D. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT.] Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational Objective: The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented should be documented in the client's record.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. The practical nurse reviews the client's vital signs and most current serum laboratory results at 8 AM. Which client finding is most important to report to the registered nurse? A. Blood pressure of 180/100 mm Hg. B. Creatinine of 2 mg/dL (177 µmol/L) C. Hemoglobin of 9.8 g/dL (98 g/L) D. Platelet count of 120,000/mm3

Correct Answer: A. Blood pressure of 180/100 mm Hg. Percutaneous kidney biopsy is an invasive diagnostic procedure; it involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well controlled (goal (140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy. Incorrect Answers: [Answer B. Creatinine of 2 mg/dL (177 µmol/L)] An elevated serum creatine of 2 mg/dL (normal: 0.6 - 1.3 mg/dL [53-115 µmol/L]) can be expected in a client with probable renal disease. This is not the most important finding to report to the registered nurse (RN.) [Answer C. Hemoglobin of 9.8 g/dL (98 g/L)] A decreased hemoglobin level of 9.8 g/dL (normal adult male: 13.2-17.3 g/dL [132-173 g/L0; normal adult female: 11.7 - 15.5 g/dL [117 - 155 g/L]) can be expected in a client with probably renal disease due to decreased erythropoietin production. The nurse should continue to monitor the client's hemoglobin post procedure as it can decrease further (within 6 hours) if bleeding occurs. [Answer D. Platelet count of 120,000/mm3] Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 10 9/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although a platelet count of 120,000/mm3 (120 x 109/L) is less than normal (150,000 - 400,000/mm3 [150-400 x 109/L]), it is not the most important finding to report to the RN. Educational Objective: The kidney is a highly vascular organ and bleeding is a major complication after a percutaneous biopsy. The client should have normal coagulation studies, an adequate platelet count, and well-controlled blood pressure prior to the procedure to reduce bleeding risk.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action? A. Check the urethral catheter and drainage tubing B. Irrigate the catheter with 30 mL sterile normal saline C. Notify the registered nurse D. Remove and reinsert the next larger size catheter

Correct Answer: A. Check the urethral catheter and drainage tubing Obstruction (eg, clots, mucus, thick sediment) and kinking/compression of a catheter or tubing, bladder spasms, and improper catheter or balloon size can cause leakage of urine from the insertion site of an indwelling urinary catheter (Foley). The nurse's first action should be to assess for a mechanical obstruction by inspecting the urethral catheter and drainage tubing. The nurse should try to alleviate the causes of the obstruction of urine from the bladder by relieving any kinks or compressions in the catheter or tubing. The registered nurse should be notified if the intervention is not successful in removing the obstruction. Incorrect Answer: [B. Irrigate the catheter with 30 mL sterile normal saline] Irrigation is usually avoided because pus or sediments that may be present can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to the flow of urine. If there is a discrepancy in expected urine output compared to fluid intake, a blockage of the urine flow is suspected and a bladder scan can be performed first to confirm the presence of urine in the bladder. Furthermore, the nurse would not irrigate the catheter without a prescription from the health care provider (HCP), and so this is not the first action. [C. Notify the registered nurse] The registered nurse should be notified if the intervention is not successful in removing the obstruction. [D. Remove and reinsert the next larger size catheter] The client has the recommended size catheter and balloon for an adult male. The HCP must provide a prescription for removal and reinsertion of a different size catheter, so this is not the first action. Educational objective:If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for common causes that can impede the flow of urine. These include obstruction (eg, clots, mucus, thick sediment), kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size.

The nurse is reinforcing proper insulin self-administration technique to a client of American Indian heritage. As the nurse describes the necessary steps in the injection process, the client avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? A. Continue instructing the client and verify understanding by return demonstration. B. Discuss how important it is for the client to pay attention during the teaching. C. Maintain eye contact during the instruction by following the client's movements. D. Provide written instructions and a private place for the client to learn independently.

Correct Answer: A. Continue instructing the client and verify understanding by return demonstration. Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles, including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If these clients avoid eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. Incorrect Answers: [Answer B. Discuss how important it is for the client to pay attention during the teaching.] Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. [Answer C. Maintain eye contact during the instruction by following the client's movements.] In the American Indian culture, maintaining eye contact during a conversation is viewed as disrespectful. Attempting to force eye contact would likely make the client uncomfortable or upset. [Answer D. Provide written instructions and a private place for the client to learn independently.] A client learning the process of insulin self-administration requires guidance and evaluation from the nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational Objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move their eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses' station. What is the most important intervention by the nurse? A. Facilitate immediate removal of people from the area. B. Inform the client that the client cannot act that way. C. Pull the fire alarm to get additional immediate help. D. State that the nurse can see the client is upset

Correct Answer: A. Facilitate immediate removal of people from the area. When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. Incorrect Answers: [B. Inform the client that the client cannot act that way.] The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. [C. Pull the fire alarm to get additional immediate help.] Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. [D. State that the nurse can see the client is upset] When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective:Safety is the priority when violence occurs. People should leave the area and call security immediately.

The intensive care nurse is monitoring the central venous catheters of 4 clients. Which central line should be removed the earliest to prevent infection? A. Femoral line inserted in emergency department post cardiac arrest 48 hours ago. B. Internal jugular line inserted 6 days ago in operating room. C. Peripherally inserted central catheter line with one lumen occluded placed 2 weeks ago. D. Subclavian line with slightly red anchor suture sights inserted in intensive care unit 72 hours ago.

Correct Answer: A. Femoral line inserted in emergency department post cardiac arrest 48 hours ago. In adult clients, the establishment of central venous access sites in the upper body (internal jugular or subclavian) is preferred to minimize infection risk. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site needs to be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and evidence of infection. Incorrect Answers: [Answer B. Internal jugular line inserted 6 days ago in operating room.] Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as there is a clinical need and no evidence of infection. [Answer C. Peripherally inserted central catheter line with one lumen occluded placed 2 weeks ago.] Peripherally inserted central catheter lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal. [Answer D. Subclavian line with slightly red anchor suture sites inserted in intensive care unit 72 hours ago.] The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture site, it is not present at the insertion site. The femoral line is still at a greater risk for infection. Educational Objective: Femoral central venous catheters may be placed in emergency situations but should be removed/replaced as soon as possible due to the high risk of contamination and infection.

The nurse is caring for a client who has subclavian central venous access. Which nursing intervention is most important to prevent the spread of infection to this client? A. Frequent hand hygiene B. No artificial nails C. Use of chlorhexidine bath wipes D. Wearing personal protective equipment

Correct Answer: A. Frequent hand hygiene Hand hygiene is the single most important factor in preventing the spread of infection and microorganisms. It includes hand washing with soap and water, alcohol-based hand rubs, and surgical hand antisepsis. Hand hygiene is indicated before client contact and donning gloves. It is also indicated after client contact, glove removal, or contact with bodily fluids. Alcohol-based hand rubs should cover the entire surface of the hands, which should then be allowed to dry. Proper hand washing procedure involves wetting the hands; applying soap; scrubbing all hand surfaces, wrists, and beneath the nails for at least 15-30 seconds; rinsing; drying hands with a paper towel; and then using the paper towel to turn off the faucet. Incorrect Answers: {Answer B. No artificial nails] Artificial nails or extenders have been found to harbor microorganisms before and after hand washing. They may lead to the spread of hospital-acquired infections and should not be worn, especially in high-risk areas (eg, intensive care unit, operating room). {Answer C. Use of chlorhexidine bath wipes] Use of chlorhexidine bathing wipes may be indicated the day before and the morning of a planned surgical procedure or for a client with methicillin-resistant Staphylococcus aureus. [Answer D. Wearing personal protective equipment] Personal protective equipment is appropriate, but it is not as important and does not replace hand hygiene to prevent the spread of infection. Educational Objective Hand hygiene is the single most important nursing intervention to prevent the spread of infection to clients.

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next? A. Further insert the catheter 1-2 in (2.5-5.1 cm) B. Have the client hold his breath C. Immediately inflate the 5 mL balloon D. Secure the tubing to the client's leg

Correct Answer: A. Further insert the catheter 1-2 in (2.5-5.1 cm) Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. Incorrect Answers: [B. Have the client hold his breath] The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. [C. Immediately inflate the 5 mL balloon] The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. [D. Secure the tubing to the client's leg] Securing the catheter to the leg occurs after the balloon is inflated and placement is assured. Educational objective:Insert the Foley urinary catheter further if drops appear in the tubing to ensure that the tip with the balloon is in the bladder. Inflating the balloon before advancing the catheter could result in urethral trauma.

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan. When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room. Which instruction should the nurse give the transporter? A. Have the client wear a mask. B. Have the client wear gloves. C. Wear a mask. D. Wear an isolation gown.

Correct Answer: A. Have the client wear a mask. Droplet precautions are used to prevent transmission of respiratory infection. These precautions include the use of a mask and a private room. When the client is in the room, staff should wear masks and follow standard precautions. The client on droplet precautions should wear a mask at all times when outside the hospital room. Incorrect Answers: [Answer B. Have the client wear gloves.] Gloves are not required as part of droplet precautions. Standard precautions should guide the use of gloves in clients on droplet precautions. [Answer C. Wear a mask.] The transporter does not need to wear a mask outside of the client's room as long as the client keeps a mask on to prevent transmission of infection. [Answer D. Wear an isolation gown.] An isolation gown is not required for droplet precautions. Educational objective:Droplet precautions require the use of regular masks to prevent the transmission of infection. A mask should be worn by the client when outside the hospital room and by staff when in the client's room.

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene? A. Hold a crutch in each hand for support when standing up from a chair. B. Move to the edge of the chair before standing and use the unaffected leg to rise. C. Touch the back of the unaffected leg to the chair before preparing to sit. D. Use an armrest or seat for assistance when lowering the body into a chair.

Correct Answer: A. Hold a crutch in each hand for support when standing up from a chair. Clients prescribed crutches after a musculoskeletal injury must understand appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. When educating a client to rise from sitting, the nurse instructs the client to hold the hand grips of both crutches in the hand on the affected side, move to the chair's edge, and hold the armrest with the hand on the unaffected side. The client then uses the crutches, armrest, and unaffected leg for support when rising. To sit, the client backs up to the chair and moves both crutches into the hand on the affected side. The client holds the armrest with the other hand and lowers the body. Incorrect Answers: [Answer B. Move to the edge of the chair before standing and use the unaffected leg to rise.] To rise from a chair, the client should move to the edge of the chair and flex the unaffected leg for support. [Answer C. Touch the back of the unaffected leg to the chair before preparing to sit.] Before sitting, the client should back up to the chair until the unaffected leg touches the chair seat. [Answer D. Use an armrest or seat for assistance when lowering the body into a chair.] When standing or sitting, clients should place the hand opposite the injury on the armrest or chair seat for support. Educational Objective: When standing or sitting in a chair, clients with crutches should hold both crutches in the hand on the affected side and hold the armrest with the other hand for support. They should touch the back of the unaffected leg to the chair before sitting and should move to the chair's edge and rise up with the unaffected leg to stand.

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? A. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags. B. Instruct the teacher of the child's classroom to use an insecticide spray. C. Send letters home to all of the children's parents informing them about the finding. D. Send the child home and prohibit school attendance until the infestation has been resolved.

Correct Answer: A. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags. Although full-blown bed bug infestations are uncommon in a school setting, a bed bug brought in on the clothing or possessions of one student could easily "hitch" a ride to another student's home and cause an outbreak there. The most important measure to prevent bed bugs from infesting other students' homes is to prevent the bugs from entering the school in the first place. Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation Incorrect Answers: [Answer B. Instruct the teacher of the child's classroom to use an insecticide spray.] A professional pest control company should be brought in to evaluate the classroom/school for bed bugs; treatment with an insecticide may or may not be necessary. [Answer C. Send letters home to all of the children's parents informing them about the finding.] Sending letters home to parents is premature at this point. After professional pest control personnel evaluate the classroom/school, letters can be sent to inform parents of the findings and any precautions that should be taken. [Answer D. Send the child home and prohibit school attendance until the infestation has been resolved.] Sending the child home is unnecessary and may be perceived as punitive and stigmatizing. Bed bugs do not inhabit humans; this child is not "infested" (seen in children with head lice). Educational Objective: The most important measures to prevent bed bugs from getting onto apparel is to launder clothes in hot water, dry them using the highest temperature setting on a dryer, and then store them in tightly sealed plastic bags. This will help to prevent additional bed bug infestation and transportation to other locations.

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? A. Leave the catheter in place and insert a new catheter higher up in the perineal area. B. Leave the catheter in place for 30 minutes and then recheck. C. Notify the prescribing health care provider that there is an obstruction. D. Remove the catheter and reinsert it at a position higher than the initial insertion.

Correct Answer: A. Leave the catheter in place and insert a new catheter higher up in the perineal area. Urine output would be expected as this client has not voided for 6 hours (obligatory amount is at least 30 mL x 6 = 180 mL). The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina. Incorrect Answers: [Answer B. Leave the catheter in place for 30 minutes and then recheck.] There sometimes can be a brief (15 second) delay from the water-based lubricant partially blocking the opening before quickly "melting." 30 minutes is too long a delay without an additional intervention. There is no reason to wait that long. [Answer C. Notify the prescribing health care provider that there is an obstruction.] There is no sign that there is an obstruction; the catheter was not adequately inserted. [Answer D. Remove the catheter and reinsert it at a position higher than the initial insertion.] A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening. Educational Objective: If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position.

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? A. The axillary pads are torn and show signs of wear. B. The client has a 30-degree bend at the elbow when walking. C. The crutches and injured foot are moved simultaneously in a 3-point gait. D. There is 3 finger-width space noted between the axilla and axillary pad.

Correct Answer: A. The axillary pads are torn and show signs of wear. The proper fit and use of crutches are important in preventing injury. They include : — Proper measurement and fit: There should be a 3-4 finger-width space between the axilla and axillary pad. Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow. — Proper gait: The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously. The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing-status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait.) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational Objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and the axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues.

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? A. The client has acute urinary retention. B. The client is confused and incontinent. C. The client is elderly and at risk for falls. D. The client is receiving intravenous diuretics.

Correct Answer: A. The client has acute urinary retention. Catheter-associated urinary tract infections are prevalent in hospital settings. Indwelling urinary catheters should only be used when appropriate. Appropriate uses include the following: — Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients — Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery — During prolonged immobilization when bedrest is essential — To improve end-of-life comfort — To facilitate healing of an open perineal or sacral wound in incontinent clients Inappropriate uses include the following: — Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently — For obtaining a urine culture when the client can follow instructions and void voluntarily — Postoperatively for prolonged periods when other appropriate indications are not present Educational Objective: The use of indwelling urinary catheters should be minimized during hospitalization. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care.

On arrival in the post-anesthesia care unit, the practical nurse assists the registered nurse in performing the initial assessment of a client who had surgery under general anesthesia. Which assessment finding is the most concerning? A. Difficult to rouse. B. Muscle stiffness. C. Pinpoint pupils. D. Temperature of 96 F

Correct Answer: B Muscle Stiffness Malignant hyperthermia is a rare, life-threatening inherited muscle abnormality triggered in susceptible clients by certain drugs used to induce general anesthesia. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit. (PACU.) The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (e.g, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1.8 F every 5 minutes and can exceed 105 F. The health care provider should be notified so the client can receive immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) [Options A and C] A client who just arrived in the PACU after general anesthesia would be expected to be difficult to rouse and have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. [Option D] A decreased body temperature is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed with appropriate nursing care (eg, warm blankets, forced air warmers). Hyperthermia and fever are also common due to blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational Objective Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. A. Advance past the external sphincter only. B. Guide suppository along the rectal wall. C. Hold buttocks together firmly after insertion. D. Position client supine with knees and feet raised. E. Use gloved fifth finger for insertion.

Correct Answer: B, C, D, and E Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce stress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following: 1. Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) 2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. 3. Inserts the suppository past the internal sphincter using the fifth finger if the child is under 3 years. Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. 4. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption. 5. Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion. 6. If a bowel movement occurs with 10-30 minutes, observe for the presence of the suppository. [Incorrect Answer: A. Advance past the external sphincter only.] The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect. Educational Objective: In children younger than age 3 years, suppositories are inserted with the fifth finger of the nurse's gloved hand. Age-appropriate explanations and/or distractions are implemented to reduce distress

The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply. A. Check gastric residual every 12 hours. B. Keep head of the bed at ≥30 degrees. C. Maintain endotracheal cuff pressure. D. Monitor for abdominal distension every 4 hours. E. Use caution when administering sedatives.

Correct Answer: B, C, D, and E. Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk in clients receiving enteral tube feedings include: — Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension and pain, bowel movements, and flatus. — Assess feeding tube placement at regular intervals. — Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal, to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated — Keep the endotracheal cuff inflated at appropriate pressure (about 25 cm H2O) for intubated clients as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents — Suction any secretions that may have collected above the endotracheal tube before deflating the cuff, if deflation is necessary. — Use caution when giving sedatives and frequently monitor for oversedation, which can slow gastric emptying and reduce gag reflex — Avoid bolus tube feedings for clients at high risk for aspiration. Incorrect Answers: [Answer A. Check gastric residual every 12 hours.] Gastric residual should be checked at least every 4 hours with continuous feedings. Educational Objective: Precautions to prevent aspiration in the client receiving continuous tube feedings include assessing for tube placement regularly and gastric intolerance (eg, residual, distension) every 4 hours, keeping the head of the bed at ≥30 degrees, and using sedation cautiously. If the client is intubated, the nurse should also keep the endotracheal tube cuff inflated and the area above the tube suctioned appropriately.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply. A. Ask the client to nod so the nurse can confirm the client understands the situation. B. Attempt to use a female interpreter to avoid gender sensitivity. C. Make good eye contact with the client (rather than the interpreter) when speaking. D. Preferably use a personal friend or relative to facilitate client privacy under HIPAA. E. Teach about one intervention at a time and in the order it will occur.

Correct Answer: B, C, and E. Clients from many cultures will be more responsive if the interpreter is the same gender, especially when the condition is highly personal or sensitive. The nurse should maintain good eye contact when communicating with the client. The interpreter should translate the client's words literally. Communication is with the client, not the interpreter. The nurse should use basic English rather than medical terms, speak slowly, and pause after 1-2 sentences to allow for translation. Providing simple instructions about upcoming actions in the order they will occur will be easier for the client to understand. For example, the nurse can indicate that there will be surgery and then a follow-up visit as opposed to, "You'll follow up with the health care provider after your procedure". Incorrect Answers: [Answer A. Ask the client to nod so the nurse can confirm the client understands the situation.] The nurse should obtain feedback to be certain that the client understands. This feedback should extend beyond nodding as some people nod to indicate that they are listening or nod in agreement to "save face" even though they do not understand. It is better to use a tactic such as having the client repeat back information (which is then translated into English). [Answer D. Preferably use a personal friend or relative to facilitate client privacy under HIPAA.] Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights. Educational Objective: Using a fee-based agency or language line is preferred if an appropriate bilingual employee is not available. The client may not want the friend/relative to know about this personal situation, or the person may not be able to adequately translate medical concepts and/or understand client rights.

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. A. Report any itching, tingling, or numbness around your incisions B. Report any redness, swelling, warmth, or drainage from your incisions C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion D. Wash incisions daily with soap and water in the shower and gently pat them dry E. Wear an elastic compression hose on your legs and elevate them while sitting

Correct Answer: B, D, and E Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions: · Wash incisions daily with soap and water in the shower. Gently pat dry. · Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves. · Avoid tub baths due to the risk of infection. · Do not apply powders or lotions on incisions as these trap bacteria at the incision site. · Report any redness, swelling, drainage increase, or if the incision has opened. · Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling. Educational objective:The nurse should instruct the client with chest and leg incisions from coronary artery bypass grafting to wash them daily with soap and water in the shower. In addition, the client must be instructed not to apply any powders or lotions to the incisions; to report any redness, swelling, or drainage increase; and to wear an elastic compression hose on the legs.

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply. A. Keeps hearing aids clean by rinsing them with water B. Lowers television volume when talking with nurse C. Places hearing aids on food tray when not in use D. Turns volume completely down prior to insertion of aid into the ear E. Verifies that battery compartment is closed before insertion

Correct Answer: B, D, and E Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with improved outcomes. Proper hearing aid use and care include: · Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness. · Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level. · To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increase length of wear time. · Do not wear the hearing aids when using hair dryers or heat lamps. · Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion. · Remove the battery (if possible) at night and when the aid is not in use to extend battery life. Incorrect Answers: [A. Keeps hearing aids clean by rinsing them with water] Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components. [C. Places hearing aids on food tray when not in use] Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged. Educational objective:The nurse should ensure that clients with hearing aids understand proper hearing aid use and care. Principles of hearing aid care include: turning volume off and ensuring the battery compartment is shut before insertion; minimizing background noise; cleaning the aids with a soft cloth; keeping the aids in a safe, dry place; and not immersing them in water.

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. Place the instructions for ascending the stairs in the correct order. 1. Advance the affected leg and crutches up the stair. 2. Assume the tripod position, then bear body weight on the crutches. 3. Place the unaffected leg onto the stair. 4. Transfer the body weight to the unaffected leg and raise the body onto the stair. A. 1, 2, 3, 4 B. 2, 4, 3, 1 C. 2, 3, 4, 1 D. 1, 4, 3, 2

Correct Answer: B. 2, 4, 3, 1 Clients prescribed crutches after a musculoskeletal injury must be educated on appropriate device use to facilitate independent ambulation, promote wound healing, and prevent reinjury. A common method used to climb stairs is the modified three-point gait ("leading with the good leg"), which is used to prevent weight-bearing on the injured leg. Nurses should instruct clients with crutches to use the following steps to ascend the stairs with the modified three-point gait: 1. Assume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move the unaffected leg. 2. Place the unaffected leg (ie, good leg) onto the step. 3. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to raise the body up onto the step. 4. Advance the affected leg and the crutches together up the step. 5. Realign the crutches with the unaffected leg on the step before repeating the process. Educational Objective: Using a modified three-point gait to ascend the stairs, the client should place body weight on the crutches and step up with the unaffected leg. Body weight should then be transferred from the crutches to the unaffected leg. The client should raise the body to align with the unaffected leg, followed by the affected leg and crutches together.

A client with advanced Alzheimer's dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely? A. 1-person stand and pivot with a gait belt and walker B. 2-person full-body sling lift C. 2-person motorized standing-assist lift D. 2-person stand a pivot with a gait belt and walker

Correct Answer: B. 2-person full-body sling lift To select the most appropriate method to transfer a client safely for the first time, the nurse should determine: 1. Whether the client can bear weight 2. Whether the client is cooperative Given this client's recent delirium and history of advanced Alzheimer's dementia, full participation and cooperation with instructions during the transfer is unlikely. As a result, a pivot transfer would be unsafe. A standing-assist lift may also be unsafe as this also requires that the client follow directions during the transfer. Therefore, a full-body sling lift should be used to transfer this client safely, particularly during the early phase of hospitalization. Incorrect Answer: [A. 1-person stand and pivot with a gait belt and walker] A pivot transfer requires client cooperation with instructions during the transfer. [C. 2-person motorized standing-assist lift] A standing-assist lift transfer also requires client cooperation with instructions to promote safety during the transfer. [D. 2-person stand a pivot with a gait belt and walker] A pivot transfer requires client cooperation with instructions during the transfer. Educational objective:A client who can bear weight partially but is unable to cooperate with instructions will require a full-body sling lift and 2 caregivers for safe transfer.

The nurse is reinforcing instructions to a client with obstructive lung disease in the correct use of a short-acting beta agonist metered-dose inhaler without the use of a spacer. Place the steps in the correct order. 1. Compress canister while inhaling slowly through the mouth for about 3-5 seconds. 2. Hold breath for 10 seconds, if possible, before exhaling 3. Place mouthpiece between teeth and wrap lips around mouthpiece 4. Shake canister well 3-5 seconds 5. Tilt head back slightly and exhale slowly for 3-5 seconds A. 4, 3, 1, 2, 5 B. 4, 5, 3, 1, 2 C. 5, 4, 3, 1, 2 D. 4, 5, 1, 3, 2

Correct Answer: B. 4, 5, 3, 1, 2 Inhalation devices include metered-dose inhalers (MDIs), dry powder inhalers, and nebulizers. The devices deliver a measured dose of medication with each actuation. They are used primarily to treat respiratory disorders but may also be used for some nonrespiratory conditions (eg, diabetes, analgesia). The inhaled route is preferred for beta agonist, anticholinergic, and steroid medications as it causes fewer side effects. Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows: 1. Shake canister well for about 3-5 seconds. 2. Tilt head back slightly and exhale slowly for 3-5 seconds. 3. Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of an open mouth prevents impaction of the particles into the tongue and sides of mouth. 4. Compress canister while inhaling slowly through the mouth for about 3-5 seconds. 5. Hold breath for 10 seconds, if possible, before exhaling. 6. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff. Educational objective:Correct use of the metered-dose inhaler is necessary to receive the full benefit of the inhaled medication. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in he wheelchair. What is the priority nursing action? A. Ask the client to explain the bruises on the torso. B. Assess the client's general hygiene and nutritional status. C. Report the bruises to the client's health care provider (HCP). D. Talk to the client's child about the injuries.

Correct Answer: B. Assess the client's general hygiene and nutritional status. The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain the bruising on the extremities but does not account for the bruises on the torso (trunk.) In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. [Answer A. Ask the client to explain the bruises on the torso.] Asking the client to explain the bruises on the torso is a "why" type question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. [Answer C. Report the bruises to the client's health care provider (HCP).] Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. [Answer D. Talk to the client's child about the injuries.] Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational Objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? A. Administer an inhaled bronchodilator. B. Check marked insertion depth of the tube. C. Request a prescription for a diuretic. D. Start the client on incentive spirometry.

Correct Answer: B. Check marked insertion depth of the tube. A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg., crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is the client's airway and must be removed immediately. [Answer A: Administer an inhaled bronchodilator] An inhaled bronchodilator may be prescribed to treat aspiration pneumonia, but the priority is to stop the feeding and check tube placement to prevent additional aspiration. [Answer C: Request a prescription for a diuretic.] Crackles may be heard with fluid overload, aspiration, or pneumonia. A diuretic would be appropriate if a client is experiencing pulmonary edema from fluid overload. If a client receiving enteral feedings develops signs of aspiration, the nurse should initially hold feedings and assess tube placement. [Answer D: Start the client on incentive spirometry.] Incentive spirometry promotes expansion of the lungs and resolves atelectasis; however, the priority for this client is assessing for and preventing aspiration. Educational Objective: Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if the client develops signs of aspiration.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours B. Client with a do-not-resuscitate prescription who has swelling at the IV site C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

Correct Answer: B. Client with a do-not-resuscitate prescription who has swelling at the IV site During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Interventions include: · Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity · Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) · Elevating the affected extremity to decrease swelling · Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop · Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs. Incorrect Answers: [A. Client scheduled for discharge who has had a peripheral IV in place for 84 hours] Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority. [C. Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago] It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority. [D. Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag] An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag. Educational objective:The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client? A. An appropriate form must be signed, verifying refusal. B. Complications, including death, could result. C. The client will be billed for the equipment regardless. D. The surgeon will be informed of the refusal.

Correct Answer: B. Complications, including death, could result. Just as there is informed consent, there is informed refusal. The client should be made aware of all the possible complications (including the possible worst-case scenario, which is usually death) when making a decision, and this should be documented. The nurse should try to work with the client to get at least partial compliance when it is in the client's best interest (eg, wear the SCDs for a limited time). Incorrect Answers: [Answer A. An appropriate form must be signed, verifying refusal.] This would occur, but it is more important to make the client aware of the potential implications of this refusal so that the client can make an informed refusal. [Answer C. The client will be billed for the equipment regardless.] Safe, quality care is the priority, not financial concerns. The nurse should avoid discussing financial implications when a client is making care decisions. [Answer D. The surgeon will be informed of the refusal.] Depending on the hospital policy, a refusal to wear the SCDs could result in an additional form being completed and the refusal documented in the medical record. Documentation should include the information given to the client and the client's understanding of that information. Even if the client refuses to sign the form, the nurse should obtain other witnesses and document the refusal in detail in the medical record. Educational Objective: The most important aspect of a client's refusal for treatment is to make sure that the client is informed of the potential results of the refusal.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? A. Ask the health care provider to prescribe a different calcium channel blocker B. Consult with the pharmacist to see if an alternate form of the drug is available C. Open the capsule and sprinkle the medication in a cup of applesauce D. Warn the client about the dangers of uncontrolled hypertension

Correct Answer: B. Consult with the pharmacist to see if an alternate form of the drug is available Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. Incorrect Answers: [A. Ask the health care provider to prescribe a different calcium channel blocker] It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable. [C. Open the capsule and sprinkle the medication in a cup of applesauce] Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects. [D. Warn the client about the dangers of uncontrolled hypertension] Although it is important to perform client teaching, the nurse should first assess the reason for this client's nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching. Educational objective:Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? A. Collect a urine specimen and send to the lab B. Deflate the balloon on the urinary catheter C. Remove the catheter by gently pulling from the urethra D. Use a sterile 4x4 pad to absorb the blood around the meatus

Correct Answer: B. Deflate the balloon on the urinary catheter Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: · Perform hand hygiene · Ensure privacy and explain the procedure to the client · Apply clean gloves · Place a waterproof pad underneath the client · Remove any adhesive tape or device anchoring the catheter · Follow specific manufacturer instructions for balloon deflation · Loosen the syringe plunger and connect the empty syringe hub into the inflation port · Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. · Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. · If any resistance is met, stop the removal procedure and consult with the urologist for removal · Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy · Remove gloves and perform hand hygiene Incorrect Answers: [A. Collect a urine specimen and send to the lab] A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. [D. Use a sterile 4x4 pad to absorb the blood around the meatus] The meatus should be cleaned after balloon deflation. Educational objective:When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.

A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning. B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning. C. Discard the urine and container, have client void, add urine to new container, and then restart the test. D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM.

Correct Answer: B. Discard urine and container, and restart the 24-hour urine collection tomorrow morning. Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding. [Option B] [Option A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning} Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. [Option C. Discard urine and container, have client void, add urine to the new container, and then restart the test.] To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container.) The 24-hour period starts at the time of the client's first voiding. [Option D. Relabel the same collection container, and change the start time from 6:00 AM to 10:00 AM.] Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate. Educational Objective: It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool.

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor? A. Discourages the client from rubbing the injection site. B. Ejects air bubble that is in the syringe prior to administration. C. Inserts needle and injects medication at a 90-degree angle. D. Selects an injection site on the left lateral side of the abdomen.

Correct Answer: B. Ejects air bubble that is in the syringe prior to administration. Enoxaparin comes in a prefilled syringe from the manufacturer. To ensure complete medication delivery, the air bubble should not be expelled prior to injection The injection site should be on the right or left side of the abdomen at least 2 inches from the umbilicus. The needle should be inserted at a 90-degree angle into a pinched-up area of tissue. To prevent excessive bruising, the nurse should discourage the client from rubbing the area around the injection site. Educational Objective: When injecting a prefilled enoxaparin syringe, a nurse should choose an injection site on the right or left side of abdomen, at least 2 inches from umbilicus; avoid expelling the air bubble in the syringe; insert the needle at a 90-degree angle into a pinched-up area of skin; and discourage the client from rubbing the site.

A client is receiving IV potassium. The IV pump displays an occlusion alarm. The tubing is free of occlusions, and the IV flushes easily without symptoms of infiltration. Which action should the nurse take next? A. Discard potassium and document administration of a partial dose B. Exchange the IV pump with a different one C. Insert a new IV catheter in a different location D. Remove the pump and administer medication by gravity drip

Correct Answer: B. Exchange the IV pump with a different one IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked IV tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency. In the absence of identifiable occlusion, an alarming IV pump should be exchanged for a different one. Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. Incorrect Answers: [A. Discard potassium and document administration of a partial dose] An IV pump alarm does not indicate that a medication is no longer needed. The nurse should replace a malfunctioning pump and restart the medication. [C. Insert a new IV catheter in a different location] An IV catheter that has no symptoms of occlusion (ie, resistance to flushing) or infiltration (eg, swelling, coolness, pain) does not need to be replaced. [D. Remove the pump and administer medication by gravity drip] IV pump infusion is more accurate than gravity drip. IV pumps are required when administering high-risk IV medications (eg, heparin, insulin, potassium). IV potassium should never be administered by gravity as it may cause lethal arrhythmias if administered too quickly. Educational objective:If an IV infusion pump displays an alarm without an identifiable problem, the nurse should replace the pump. Malfunctioning equipment may harm the client and should be removed from the care area. The equipment is labeled as out of service and sent for maintenance.

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? A. Explain to the family that this is a normal physiological response to dying. B. Explore the family's thoughts and concerns about the client's refusal of food. C. Recommend a feeding tube. D. Tell the family that "force feeding" the client could cause the client to choke on the food.

Correct Answer: B. Explore the family's thoughts and concerns about the client's refusal of food. When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. [Answer A. Explain to the family that this is a normal physiological response to dying.] Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. [Answer C: Recommend a feeing tube.] Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. [Answer D: Tell the family the "force feeding" the client could cause the client to choke on the food.] This is a true statement, but it is not the priority nursing action. Educational Objective: It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care.

The practical nurse observes a student nurse administering ear drops to an elderly client to help loosen cerumen. The nurse intervenes when the student performs which action? A. Instills ear drops at room temperature. B. Instills ear drops with dropper by occluding the ear canal. C. Places a cotton ball loosely in the outermost auditory canal after instillation. D. Pulls pinna up and back and instills drops.

Correct Answer: B. Instills ear drops with dropper by occluding the ear canal. Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum. The general procedure for instilling ear drops includes the following steps: 1. Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used to instill drops. 2. Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear. 3. Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes. 4. Pull the pinna up and back to straighten the ear canal in clients age >3 years. Pull the pinna down and back in clients age <3 years. 5. Support the hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper. 6. Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain; this facilitates the flow of medication into the ear canal. 7. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage. 8. Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as the cotton ball is a choking hazard. Educational Objective: To administer otic medications in an adult client, use the following steps: Perform hand hygiene; position the client side-lying with the affected ear up; pull pinna up and back; administer prescribed number of ear drops; instruct the client to remain side-lying for 2-3 minutes; and place a cotton ball loosely in the outer ear canal for 15 minutes (if needed.)

The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter? A. Ensure the client understands the procedure prior to implementation B. Maintain a sterile field and keep the urinary catheter sterile C. Place the catheter supply kit between the client's legs in the center of the bed D. Throw swabs used to clean the perineum directly into the biohazard bin

Correct Answer: B. Maintain a sterile field and keep the urinary catheter sterile. Maintaining sterility is key when inserting an indwelling urinary (Foley) catheter. Sterile technique (surgical asepsis) should be used to prevent catheter-associated urinary tract infections, the 2nd most common type of health care-associated infection. Proper placement of the kit and application of sterile gloves are important to maintaining sterility. The dominant hand should be kept sterile until the procedure is complete. Once the nondominant hand is placed on the client's genitalia (to spread the labia or grasp the penis) for cleansing, it should be kept in place until the catheter is inserted to prevent contamination. Incorrect Answer: [A. Ensure the client understands the procedure prior to implementation] The procedure should be explained to the client; however, this client is confused and likely will not understand. [C. Place the catheter supply kit between the client's legs in the center of the bed] The catheter kit may be placed between the client's legs if the client is cooperative. However, use of a clean bedside table is more effective in maintaining a sterile field when the client is confused and uncooperative. [D. Throw swabs used to clean the perineum directly into the biohazard bin] Swabs should be disposed of in the trashcan or biohazard bin in accordance with hospital policy; however, maintaining a sterile field is a higher priority. Educational objective:Maintenance of sterile technique is a key outcome for indwelling urinary catheterization. A sterile field should be maintained during the entire procedure through proper placement of the kit and application of sterile gloves. The nondominant hand should be used for cleansing and kept in place to prevent contamination. The sterile dominant hand should be used for insertion.

On arrival in the postanesthesia care unit, the practical nurse assists the registered nurse in performing the initial assessment of a client who had surgery under general anesthesia. Which assessment finding is the most concerning? A. Difficult to rouse B. Muscle stiffness C. Pinpoint pupils D. Temperature of 96 F

Correct Answer: B. Muscle stiffness Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality triggered in susceptible clients by certain drugs used to induce general anesthesia. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the postanesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1.8 F (1 C) every 5 minutes and can exceed 105 F (40.6 C). The health care provider should be notified so the client can receive immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation). Incorrect Answers: [Answer A. Difficult to rouse.] & [Answer C. Pinpoint pupils.] A client who just arrived in the PACU after general anesthesia would be expected to be difficult to rouse and have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. [Answer D. Temperature of 96 F] A decreased body temperature is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed with appropriate nursing care (eg, warm blankets, forced air warmers). Hyperthermia and fever are also common due to blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational Objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse? A. Have the child sit upright with the chin tilted down B. Pull the pinna upward and back C. Remove the medication from the refrigerator just before use D. Touch the dropper to the entrance of the ear canal

Correct Answer: B. Pull the pinna upward and back When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal. For an infant, the pinna is pulled downward and straight back. Incorrect Answers: [A. Have the child sit upright with the chin tilted down] The child should be placed in the prone or supine position with the head turned to the appropriate side. [C. Remove the medication from the refrigerator just before use] Otic medication should be warmed to room temperature if removed from a refrigerator prior to administration. Holding the bottle in the palm of the hand is an effective method of warming. Instilling cold drops into the ear can cause a vestibular reaction, resulting in dizziness and vomiting. [D. Touch the dropper to the entrance of the ear canal] The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication. Educational objective: When administering otic medication to children age 3 and older, the pinna is pulled upward and back to straighten the ear canal. The child is placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal.

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? A. High-Fowler's position with the affected side's arm resting on the bed. B. Semi-Fowler's position with the affected side's arm on several pillows. C. Supine with the affected side's arm on several pillows. D. Supine with the affected side's arm resting on the bed.

Correct Answer: B. Semi-Fowler's position with the affected side's arm on several pillows. Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy. Incorrect Answers [Answer A. High-Fowler's position with the affected side's arm resting on the bed.] Placing the client in high-Fowler's position immediately after anesthesia might cause a decrease in blood pressure and subsequent dizziness. Resting the affected side's arm on the bed would place the arm in a dependent position, which would lead to swelling due to decrease in lymphatic and venous drainage. [Answer C. Supine with the affected side's arm on several pillows.] & [Answer D. Supine with the affected side's arm resting on the bed.] Resting the head of the bed slightly would promote ease of breathing. Resting the arm on several pillows would promote drainage and prevent lymphatic pooling. Educational Objective: Immediately post mastectomy, the client is placed in semi-Fowler's position to promote ease of breathing. The affected side's arm should be elevated on several pillows to promote drainage and prevent lymphatic pooling.

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take? A. Have the client take slow, deep breaths B. Stop infusing the solution for 30 seconds, then resume at a slower rate C. Tell the client that the process will not take much longer D. Withdraw the tube approximately 2 cm and continue the infusion

Correct Answer: B. Stop infusing the solution for 30 seconds, then resume at a slower rate Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. Incorrect Answer: [A. Have the client take slow, deep breaths] Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first. [C. Tell the client that the process will not take much longer] This response disregards the client's cramping and pain and is not appropriate. [D. Withdraw the tube approximately 2 cm and continue the infusion] Withdrawing the tube will risk not instilling the fluid high enough into the rectum/colon to be effective. Educational objective:If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then resumed at a slower rate.

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider? A. The client ate a full breakfast that morning. B. The client has an implantable cardioverter defibrillator (ICD.) C. The client is allergic to povidone-iodine. D. The client took all prescribed cardiac medications before arriving.

Correct Answer: B. The client has an implantable cardioverter defibrillator (ICD.) Radio waves and a magnetic field are used to view soft tissue during MRI. This test is especially useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis. MRIs can have open or closed chambers. The client should be advised that the procedure is painless but the machine will make loud tapping noises that may cause claustrophobia in some clients inside a closed chamber. MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of the MRI can damage the ICD or interfere with its function. Incorrect Answers [A. The client ate a full breakfast that morning and D. The client took all prescribed cardiac medications before arriving] MRI is a noninvasive test that does not require anesthesia. The client is not required to have nothing by mouth and can take medications as normally indicated. [C. The client is allergic to povidone-iodine.] No povidone-iodine (Betadine) is used during an MRI; gadolinium contrast is used. Educational Objective: MRI is contraindicated in clients with aneurysm clips, metallic implants such as ICDs, pacemakers, electronic devices, hearing aids, and shrapnel. The large magnet of an MRI can damage implantable devices or interfere with their function.

The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse? A. A sitting position is assumed as the head is bowed slightly forward. B. The client points the spray tip towards the nasal septum during instillation. C. The nasal spray tip is inserted into the nostril as the other nostril is occluded. D. While administering the medication, the client inhales deeply through the nose.

Correct Answer: B. The client points the spray tip towards the nasal septum during instillation. The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer a nasal spray, the nurse teaches the client to: — Assume a high Fowler's position with the head slightly tilted forward. — Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger. — Point the nasal spray tip toward the side and away from the center of the nose. — Spray the medication into the nose while inhaling deeply. — Remove the nozzle from the nose and breathe through the mouth. — Repeat the above steps for the other nostril. — Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation. Educational Objective The correct administration of nasal medication includes pointing the nasal spray tip toward the side and away from the center of the nose.

The nurse is acting as a preceptor for a student nurse in the labor and delivery unit. Which action by the student would require correction by the nurse? A. Removing gloves prior to removing isolation gown B. Using a nail brush to scrub underneath artificial nails C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room D. Washing hands and not wearing gloves when preparing medications in the med room

Correct Answer: B. Using a nail brush to scrub underneath artificial nails Although this student nurse is scrubbing underneath the artificial nails, it is still not advisable to wear artificial nails, especially in high-risk areas (eg, labor and delivery unit, intensive care unit). Some evidence suggests that artificial nails can contribute to the transmission of health care-associated pathogens. Unlike health care workers with natural nails, those who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips, both before and after hand washing. Incorrect Answer: [A. Removing gloves prior to removing isolation gown] It is appropriate to remove soiled gloves before removing an isolation gown. The gown should be removed by grasping the inside and pulling it off inside out. [C. Using alcohol-based hand sanitizer instead of washing hands when entering and exiting client room] Nurses should wash their hands periodically throughout the day and when visibly dirty. It is appropriate to use alcohol-based hand sanitizer when entering and exiting a client's room. [D. Washing hands and not wearing gloves when preparing medications in the med room] Gloves are typically not required when preparing medications, but hand washing is appropriate. Educational objective:Nurses should not wear artificial nails in the clinical setting, especially in areas with high-risk clients.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. A. "I can mix the medication in a bowl of my child's favorite cereal." B. "I should give another dose if my child vomits after taking the medication." C. "I should measure liquid medications using an oral syringe." D. "I will encourage my child to help me as I prepare the medication." E. "I will place my child in time-out if the medication is refused."

Correct Answer: C and D For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses. Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control. Incorrect Answer: [A. "I can mix the medication in a bowl of my child's favorite cereal."] The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. [B. "I should give another dose if my child vomits after taking the medication."] Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. [E. "I will place my child in time-out if the medication is refused."] Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective:For pediatric clients, liquid medication should be measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply. A. Fold tube in half and mark at the halfway point. B. Extend tape measure from naris to stomach. C. Measure from the tip of the nose to earlobe to xiphoid process. D. Place a small piece of tape at the point of measurement. E. Use rubber clamp after measuring to mark the point of measurement.

Correct Answer: C and D. Because distance from the nares to the stomach varies with each client, it is important to measure and mark the NG tube prior to insertion to ensure its correct placement in the stomach. The Traditional Method is most commonly used for large-bore NG tube placement. Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed. Educational Objective: Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed.

The practical nurse collaborates with the registered nurse to perform an admission assessment on a client with Alzheimer disease. Which of the following techniques are appropriate when speaking with this client? Select all that apply. A. Ask open-ended questions. B. Move close to the client and speak in a loud voice. C. Remove background noise by turning off the television. D. Touch the client on shoulder prior to speaking. E. Use clear and simple sentences.

Correct Answer: C and E Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (eg, dementia) in clients >60. Conversation becomes progressively more difficult for clients with AD, who often experience problems with word-finding, understanding, focus, and frustration. To best communicate with this client, the nurse should provide a quiet, non-distracting environment (eg, remove background noises such as television and music) and use clear and simple explanations to facilitate better understanding and reduce frustration. [Answer A. Ask open-ended questions] Asking open-ended questions is often an appropriate technique for collecting information from clients, but this type of question may confuse clients with AD. [Answer B. Move close to the client and speak in a loud voice.] AD results in reduced cognitive function but is not associated with hearing loss. Speaking loudly may induce agitation, anxiety, stress, and confusion in a client with AD. [Answer D. Touch the client on the shoulder prior to speaking.] Touching the client before speaking is appropriate for a client with hearing loss but may upset or agitate a client with AD. Educational Objective: When speaking with a client with Alzheimer disease, the nurse should provide a quiet, nondistracting environment (eg, remove background noises such as television and music) and use clear and simple explanations to facilitate better understanding and reduce frustration.

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. A. Address the interpreter directly. B. Ask the client's adult child to translate. C. Hold a pre-conference with the interpreter. D. Identify any gender or age preferences. E. Speak in short sentences.

Correct Answer: C, D, and E. Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: — Address the client directly in the first person. — Speak in short sentences, pausing to allow the interpreter to speak. — Ask only one question at a time. — Avoid complex issues, idioms, jokes, and medical jargon. — Hold a pre-conference with the medical interpreter to review the goals of the interview. — Use a qualified professional interpreter whenever possible. The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences. Incorrect Answers: [Answer A. Address the interpreter directly.] The nurse should speak directly to the client, not the interpreter. [Answer B. Ask the client's adult child to translate.] A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology. Educational Objectives: When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences.

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? A. "I am busy right now but can stay for a few minutes." B. "I can call the clergy to come sit with you." C. "I can stay and sit with you if you would like." D. "I don't think I should interrupt your family time."

Correct Answer: C. "I can stay and sit with you if you would like." During the end-of-life process the client's family members may be frightened, sad, confused, or concerned, and may ask staff questions about belief systems or the death process. Sometimes clients or family members simply want the nurse to sit with them and provide reassurance that their loved ones are worthy of time and attention. The most therapeutic response by the nurse is to sit with the client and/or family for at least a few minutes. Incorrect Answers: [A. "I am busy right now but can stay for a few minutes."] Telling family members that a nurse is busy is not a helpful response. They may feel guilty about asking for the nurse's time and attention. If needed, the nurse can ask coworkers to help with other assigned clients. [B. "I can call the clergy to come sit with you."] Although calling clergy members may be appropriate, it may take several hours for them to arrive. This is not the most helpful response. [D. "I don't think I should interrupt your family time."] Family members who ask the nurse to stay for a few minutes may have questions or need emotional support. In such cases, it is not helpful for the nurse to decline. Educational objective:During the end-of-life process, the client and family members typically go through several emotional stages, each requiring therapeutic communication techniques by the nurse. The nurse can help the client and family by providing a few minutes of time and attention. The nurse should validate the family's needs by providing emotional support.

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching? A. "I will avoid naps later in the day." B. "I will keep the bedroom temperature cool." C. "I will read in bed before trying to go to sleep." D. "I will try to go to bed and wake up at the same time each day."

Correct Answer: C. "I will read in bed before trying to go to sleep." Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep-related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed. The nurse should encourage the following healthy sleep habits: — Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep. — Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep. — Avoid going to bed hungry or eating a heavy meal just before bed. — Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia. Incorrect Answers [Answer A. "I will avoid naps later in the day."] It is best to avoid naps during the day, especially later in the day. Any naps should be short (20-30 minutes.) [Answer B. "I will keep the bedroom temperature cool."] The client should keep the bedroom slightly cool, quiet, and dark for comfort. [Answer D. "I will try to go to bed and wake up at the same time each day."] As much as possible, the client should develop a consistent sleep-wake pattern (ie, same bedtime and wake time each day) to obtain 7-8 hours of sleep nightly. Educational Objective: The nurse should teach clients with insomnia good sleep hygiene such as using the bed for sleep only (no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day.)

A client who is diagnosed with breast cancer asks the nurse, "Am I going to die?" Which statement by the nurse promotes a therapeutic relationship? A. "Cancer is no longer a death sentence; you may live for many years." B. "I will ask the chaplain to talk to you sometime today." C. "People with cancer experience fear of dying; tell me about your concerns." D. "Tell me about your life and hopes for the future."

Correct Answer: C. "People with cancer experience fear of dying; tell me about your concerns." Many individuals diagnosed with cancer experience anxiety and fear related to death and desire to talk with someone about these feelings. To promote a therapeutic relationship, the nurse should initiate conversations by acknowledging clients' fears, use open-ended statements to invite them to talk about death, and actively listen as they verbalize their feelings. [Answer A. "Cancer is no longer a death sentence; you may live for many years."] The nurse offers false reassurance by making this statement. Providing false reassurance is not part of a therapeutic relationship or an effective communication strategy. [Answer B. "I will ask the chaplain to talk to you sometime today."] This statement does not acknowledge the client's concerns and blocks communication. The nurse should first assess the client's cultural and spiritual practices. If the client requests spiritual support, then the nurse may make a referral to the chaplain's office. [Answer D. "Tell me about your life and hopes for the future."] By changing the subject, the nurse is attempting to redirect the conversation away from the client's desire to talk about death; this does not promote a therapeutic relationship. Educational Objective: Fear of dying is a common concern for many clients with a terminal disease. The nurse should acknowledge these feelings and use open-ended statements and active listening to invite clients to talk about death.

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? A. "Have you shared your concerns with the health care provider (HCP)?" B. "If I were you, I would be more worried about whether the melanoma has spread." C. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." D. "There is a special make-up you can use to hide any facial scars left from the surgery."

Correct Answer: C. "Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. the best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: 1. The client is provided with factual information about facial surgery and the healing process. 2. The client is given assurance and support that something can be done to minimize the complication of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. [Answer A: "Have you shared your concerns with your health care provider (HCP)?"] This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. [Answer B: "If I were you, I would be more worried about whether the melanoma has spread."] This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnoses. [Answer D: "There is special make-up you can use to hide any facial scars left from the surgery."] This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns. Educational Objective: Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? A. "The Allen's test is done to determine if capillary refill is adequate." B. "The Allen's test is done to determine if the radial pulse is palpable." C. "The Allen's test is done to determine the patency of the ulnar artery." D. "The Allen's test is done to determine the presence of a neurological deficit."

Correct Answer: C. "The Allen's test is done to determine the patency of the ulnar artery." The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: — Instruct the client to make a tight fist (if possible) — Occlude the radial and ulnar arteries using firm pressure — Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded — Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. Incorrect Answers: [Answer A. "The Allen's test is done to determine if capillary refill is adequate."] Capillary refill is tested by applying pressure to the fingernail bed to cause blanching. If refill is adequate, the nail bed should become pink in less than 3 seconds after pressure is released. [Answer B. "The Allen's test is done to determine if the radial pulse is palpable."] The radial artery is palpated with the fingertips to determine the presence of the radial pulse. [Answer D. "The Allen's test is done to determine the presence of a neurological deficit."] A neurologic deficit is assessed by monitoring color, sensation, and movement of the hand. Educational Objective: The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond? A. "Don't worry. You'll feel better in a few weeks." B. "How well are you sleeping at night?" C. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." D. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant."

Correct Answer: C. "These symptoms can be common after major surgery. It will take 4-6 weeks to completely heal and start to feel normal again." Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder. Incorrect Answer: [A. "Don't worry. You'll feel better in a few weeks."] The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information. [B. "How well are you sleeping at night?"] This is good information for the nurse to have, but it does not directly relate to the client's issues of forgetfulness and becoming teary often. [D. "You may be experiencing depression. I'll call the health care provider and see if we can get a prescription for an antidepressant."] Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptoms. Educational objective:The nurse should teach the client that possible memory impairment and problems with concentration, language comprehension, social integration, and emotional lability are common following major surgery. Symptoms typically resolve after 4-6 weeks or when healing is complete. Persistent problems should be reported to the health care provider.

The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse? A. "Do you have any questions about the diagnoses?" B. "There are medications available to treat Alzheimer disease." C. "This new diagnoses must be frightening for you." D. "We can help you make decisions about your care."

Correct Answer: C. "This new diagnoses must be frightening for you." Reflecting is a therapeutic communication technique that reiterates the feeling, idea, or message conveyed by the client. Therapeutic communication encourages the client and family to express feelings and thoughts, increases the nurse's understanding, and conveys support. Emotional expression is an important part of the coping process for the client and family. The nurse provides support by expressing empathy, actively listening, and encouraging open communication. Nontherapeutic responses can block communication by shifting the receiver's focus away from the expression of feelings and thoughts. Incorrect Answer: [Answer A. "Do you have any questions about the diagnoses?"] Questions or statements that prevent the client from expressing feelings (eg, changing the subject) when a client and family are trying to cope with a new diagnosis are not therapeutic and can block communication. Once the nurse understands the client's thoughts and feelings, information can be provided. [Answer B. "There are medications available to treat Alzheimer disease."] Providing false reassurance is not therapeutic and can block communication. A client and family may not fully understand the progression of Alzheimer disease immediately after receiving the diagnosis. Stating that medications are available to treat the disease may lead to a false belief that it can be cured. [Answer D. "We can help you make decisions about your care."] A client diagnosed with Alzheimer disease may need assistance with care planning, but the nurse should first support the process of coping when the client receives the life-changing diagnosis. Educational Objective: When clients and families are faced with significant life changes, the nurse should support the process of coping by encouraging emotional expression. The nurse provides support by expressing empathy, actively listening, and encouraging therapeutic communication.

Place the nursing actions for performing a renal system physical assessment in the correct order. All options must be used. 1. Advise client to empty the bladder completely. 2. Auscultate the renal arteries in right and left upper quadrants. 3. Document the assessment of renal system function. 4. Observe skin and contour of abdomen and lower back. 5. Percuss and palpate both the right and left kidneys. A. 1, 2, 4, 5, 3 B. 1, 2, 4, 3, 5 C. 1, 4, 2, 5, 3 S. 1, 5, 2,4, 3

Correct Answer: C. 1, 4, 2, 5, 3 Examination of the urinary system requires an abdominal assessment. Therefore, assessment techniques must be reordered to optimize the examination. The steps for a renal system assessment are: 1. Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) 2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination 3. The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants 4. Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney 5. Document all renal assessment findings immediately after the examination Educational Objective: Physical assessment of the renal system includes the techniques of inspection, auscultation, percussion, and palpation, in that order. Allow the client to empty the bladder before beginning the assessment and auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Always document the findings.

The nurse prepares to insert an indwelling urinary catheter for a female client. The nurse assesses for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. 1. Apply sterile gloves and place sterile drape under the client's buttocks. 2. Perform hand hygiene and open a sterile urinary catheterization kit. 3. Use the dominant hand to cleanse the labial folds with antiseptic swabs. 4. Use the dominant hand to cleanse the urethral meatus with antiseptic swabs. 5. Use the dominant hand to insert the catheter until urine return is observed. 6. Use the dominant hand to gently spread the labial folds. A. 2, 1, 3, 6, 4, 5 B. 1, 2, 3, 6, 4, 5 C. 2, 1, 6, 3, 4, 5 D. 2, 1, 6, 4, 3, 5

Correct Answer: C. 2, 1, 6, 3, 4, 5 Steps for indwelling urinary catheter insertion for the female client include: — Position the client supine with knees flexed and hips slightly externally rotated. — Perform hand hygiene and open a sterile catheterization kit (Option 2). — Apply sterile gloves and place a sterile drape underneath the client's buttocks (Option 1). — Remove the protective covering from the catheter, lubricate the catheter tip, and pour antiseptic solution over cotton balls or swab sticks while maintaining sterility of gloves and sterile field. — Use the nondominant hand to gently spread the labia. The nondominant hand is now contaminated (Option 6). — Use the dominant (sterile) hand to cleanse the labia and urinary meatus with antiseptic-soaked cotton balls or swab sticks. Cleanse in an anteroposterior direction (from the clitoris toward the anus). Use a new swab for each swipe to avoid transferring bacteria between areas. Cleanse the labia majora first, then the labia minora, and lastly the urinary meatus (Options 3 and 4). — Use the dominant hand to insert the catheter until urine return is visualized in the tubing (usually 2-3 inch [5-7.6 cm]), and then advance it an additional 1-2 inch (2.5-5 cm) (Option 5). — Hold the catheter in place with the nondominant hand, and then use the dominant hand to inflate the balloon. Educational objective:To insert an indwelling urinary catheter in a female client: perform hand hygiene; apply sterile gloves and place a sterile drape under the client; arrange supplies on a sterile field; gently spread the labia with the nondominant hand; cleanse the labia majora, then the labia minora, and lastly the urinary meatus; insert the catheter until urine return is visualized; advance an additional 1-2 inch (2.5-5 cm); and inflate the balloon.

The nurse is preparing to administer a continuous enteral feeding for a client with a nasogastric tube. Place the steps in the correct order. All options must be used. 1. Administer the prescribed feeding solution. 2. Elevate the head of the bed 30-45 degrees. 3. Flush the tube with 30 mL of water. 4. Identify the client using 2 identifiers. 5. Validate tube placement. A. 4, 2, 3, 1, 5 B. 4, 2, 1, 3, 5 C. 4, 2, 5, 3, 1 D. 5, 4, 2, 3, 1

Correct Answer: C. 4, 2, 5, 3, 1 The steps for administering a continuous enteral feeding include: — Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. — Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration — Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation. — Check gastric residual volume. — Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration — Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump Educational objective:The general steps for administering a continuous enteral feeding include identifying the client, elevating the head of bed at least 30 degrees, validating tube placement, flushing the tube with 30 mL of water, and administering the prescribed enteral feeding solution.

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client? A. 2-point gait. B. 3-point gait. C. 4-point gait. D. 5-point gait.

Correct Answer: C. 4-point gait. The client who is rehabilitating from a lower-extremity injury usually progresses from no-touch-down non-weight bearing using the 3-point gait, to touch-down with partial-weight bearing using the 2-point gait, to full-weight bearing using the 4-point gait. The nurse reinforces prior teaching on how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot, 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot. Incorrect Answers: [Answer D. 5-point gait.] There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait. Educational Objective: The 4-point crutch gait is appropriate for a client with leg weakness who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times.

The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse? A. Client in a belt restraint in the semi-Fowler position. B. Client in mitten restraints in the side-lying position. C. Client in soft-wrist restraints in the supine position. D. Client in vest restraint in the high-Fowler position.

Correct Answer: C. Client in soft-wrist restraints in the supine position. Clients in any form of restraint should not be in the supine position as it may lead to aspiration, especially in clients with altered mental status. The supine position may also increase anxiety and agitation. Unless contraindicated, clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote airway patency and allow the client to safely swallow or expectorate secretions or emesis. Incorrect Answers: [Answer A. Client in a belt restraint in the semi-Fowler position.] Belt and vest restraints are secured around the client's waist. A client in a belt or vest restraint can be safely placed in the side-lying, semi-Fowler, or high-Fowler position. [Answer B. Client in mitten restraints in the side-lying position.] Mitten restraints cover the client's hands and contain the fingers to help prevent removal of lines, tubes, and drains. These restraints are made of soft padding and fabric that allow some movement of the hand and fingers within the mitten. The client in mitten restraints is able to reposition independently and can be placed safely in the side-lying, semi-Fowler, or high-Fowler position. [Answer D. Client in vest restraint in the high-Fowler position.] Belt and vest restraints are secured around the client's waist. A client in a belt or vest restraint can be safely placed in the side-lying, semi-Fowler, or high-Fowler position. Educational Objective: Restrained clients are at risk for aspiration in the supine position as they cannot safely swallow or expectorate secretions or emesis. Clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position.

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action? A. Assess the condition of the IV site. B. Check 2 client identifier before administering medications. C. Consult a medication guide for compatibility. D. Was hands prior to administering medications.

Correct Answer: C. Consult a medication guide for compatibility. The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and health care provider to determine the safest and most beneficial plan for the client. {Answer A. Assess the condition of the IV site.] Assessing the IV site for complications (eg, infiltration, phlebitis) should always be performed before giving any IV medication. This will be completed after determining drug compatibility [Answer B. Check 2 client identifiers before administering medications.] Verification using 2 client identifiers pertains to the "right client" in the "6 rights" of medication administration. Drug compatibility should be determined prior to entering the client's room and verifying identity. [Answer D. Wash hands prior to administering medications.] Hand hygiene is a standard precaution taken before any type of client interaction to prevent contamination and infection; hand washing will be completed after checking for drug compatibility. Educational Objective: Checking for drug compatibility is a priority before administering 2 IV medications concurrently at the same IV site. Incompatible drugs will deteriorate or form a precipitate that is visible as a color change, cloudiness, or particulates.

A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen? A. Inject into the upper arm where the sleeve can be pulled up. B. Inject info the most accessible vein. C. Inject through the clothing into thigh and hold in place for 10 seconds. D. Take the child inside, remove excess clothing, and inject into the thigh.

Correct Answer: C. Inject through the clothing into thigh and hold in place for 10 seconds. The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected. The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult. Incorrect Answers: [Answer A. Inject into the upper arm where the sleeve can be pulled up.] The EpiPen should be injected into the mid-outer thigh, not the upper arm. [Answer B. Inject info the most accessible vein.] IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation. Educational Objective: The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing.

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching? A. Faces forward when going up and down the stairs B. Holds the cane with the right hand C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs D. Places full weight on left leg when going down the stairs

Correct Answer: C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs. They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail. The nurse should instruct the client on the following: When ascending stairs: 1. Step up with the stronger leg first (in this client, the right leg) 2. Move the cane next while bearing weight on the stronger leg 3. Finally, move the weaker leg (in this client, the left leg) When descending the stairs 1. Lead with the cane 2. Bring the weaker leg down next 3. Finally, step down with the stronger leg The nurse may use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg Incorrect Answers: [D. Places full weight on left leg when going down the stairs] Clients are usually hospitalized for 3-4 days following a total knee replacement and can bear full weight by the time of discharge. Early ambulation and weight-bearing helps to hasten recovery and prevent complications (eg, thromboembolism). Educational objective:Clients who have had total knee replacement surgery can typically bear full weight by the time of discharge. To reduce the risk of falls, the client should hold the cane on the stronger side and face forward when going up and down the stairs. To ascend the stairs, the client should first step up with the stronger leg, next bear weight on that leg and move the cane, and finally step up with the weaker leg.

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? A. Adenosine IV. B. Dopamine IV. C. Magnesium IV. D. Metoprolol IV.

Correct Answer: C. Magnesium IV Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change the size and shape in a characteristic twisting pattern. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium. Treatment may also include defibrillation and discontinuation of any QT-prolonging medications. Incorrect Answers: [Answer A. Adenosine IV] Adenosine is an antiarrhythmic used to treat supraventricular tachycardia. [Answer B. Dopamine IV] Dopamine is a vasopressor used to treat symptomatic hypotension. [Answer D. Metoprolol IV] Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias. Educational Objective: Torsades de pointes is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. First-line treatment is magnesium IV. Treatment may also include defibrillation and discontinuation of QT-prolonging medications.

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia? A. Fully inflate the cuff before feeding. B. Have the client sit in an upright position with the neck hyperextended. C. Partially or fully deflate the cuff. D. Provide a modified diet of pureed foods.

Correct Answer: C. Partially or fully deflate the cuff. A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: — Having the client sit upright with the chin flexed slightly toward the chest — Monitoring for a wet or garbled-sounding voice — Monitoring for signs of fever Incorrect Answers: [Answer A. Fully inflate the cuff before feeding.] Inflating the cuff makes it difficult for a client who is awake to swallow and talk. In addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it, causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of aspiration. [Answer B. Have the client sit in an upright position with the neck hyperextended.] Having the client sit upright will help reduce the risk of aspiration. However, the chin should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration. [Answer D. Provide a modified diet of pureed foods.] There is no reason to give pureed foods just because the client has a tracheostomy. The client's diet should be determined by a swallowing evaluation. Educational Objective: The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick? A. Apply adhesive urine collection bag around the genital area and wait for the child to void. B. Intermittently catheterize the child every morning to avoid contaminating the specimen. C. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick. D. Place urine dipstick in the child's diaper overnight and check result in the morning.

Correct Answer: C. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick. Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect non-sterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. [Answers A. Apply adhesive urine collection bag around the genital area and wait for the child to voice] & [Answer D. Place urine dipstick in the child's diaper overnight and check result in the morning.] Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. [Answer B. Intermittently catheterize the child every morning to avoid contaminating the specimen.] Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization.) Educational Objective: Children with nephrotic syndrome often require daily urinalysis to monitor for proteinuria. Urine collection bags for dipsticks in the diaper risk breakdown of edematous skin. To collect a nonsterile urine specimen from a child in diapers, the nurse can place cotton balls in a dry diaper and later squeeze urine onto a dipstick.

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? A. Assist the client in ambulating to the bathroom. B. Dim the room lights. C. Place the bed in low position with all side rails up. D. Turn off the television.

Correct Answer: C. 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, 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. Incorrect Answers [Answer B. Dim the room lights.] & [Answer D. Turn off the television.] 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 nurse is reviewing the most recent laboratory results of a client on the telemetry floor. The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm. Which critical value is most likely due to laboratory error? A. Blood urea nitrogen of 60 mg/dL (21.4 mmol/L) B. Creatinine of 4.0 mg/dL C. Potassium of 7.0 mEq/L D. Sodium of 155 mEq/L

Correct Answer: C. Potassium of 7.0 mEq/L With the exception of clients with end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in a client who is walking and talking should raise suspicion for an erroneously elevated serum potassium (pseudohyperkalemia) level due to poor hematology technique. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) constitutes a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. Assessment focuses on evaluating cardiac symptoms and muscle strength and should be reported to the registered nurse (RN). It is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw through minimal use of a tourniquet and fist clenching and use of a larger gauge needle and heparin-impregnated hematology vials to prevent clotting. Incorrect Answers: [A. Blood urea nitrogen of 60 mg/dL (21.4 mmol/L)] This blood urea nitrogen (BUN) value is elevated (normal: 6-20 mg/dL [2.1-7.1 mmol/L]) and could be related to kidney damage or dehydration. Therefore, it is not the most likely erroneous result. [B. Creatinine of 4.0 mg/dL} Similar to the BUN value, this creatinine value is significantly elevated (normal: 0.6-1.3 mg/dL [53-115 µmol/L]). Further nursing assessment is indicated, with documentation and involvement of the RN and health care provider in evaluating the impact of the kidney damage on the client's health. [D. Sodium of 155 mEq/L] This sodium value is high (normal: 135-145 mEq/L [135-145 mmol/L]) and requires further exploration. The nursing assessment should be documented and reported to the RN. Educational objective:High serum potassium levels could be due to hemolysis or clotting during the blood draw. If clinical assessment does not correlate with laboratory values, repeat testing is needed

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? A. Lavage through a small-bore nasogastric tube. B. Place client in Trendelenburg position during lavage. C. Prepare intubation and suction supplies at the bedside. D. Wait for an hour after gastric decompression to initiate lavage.

Correct Answer: C. Prepare intubation and suction supplies at the bedside. Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress Incorrect Answers: [A. Lavage through a small-bore nasogastric tube.] GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. [B. Place client in Trendelenburg position during lavage.] During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. [D. Wait for an hour after gastric decompression to initiate lavage.] GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards. Educational Objective: Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside.

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? A. Consult with the wound care nurse specialist B. Insert a rectal tube to contain the feces C. Provide perianal skin care with barrier cream D. Use incontinence briefs to protect the skin

Correct Answer: C. Provide perianal skin care with barrier cream Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick layer of moisture barrier product to the skin. Clean, dry linens and clothing should be provided. Incorrect Answers: [A. Consult with the wound care nurse specialist] Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management plan; however, the highest priority is promotion of skin integrity. [B. Insert a rectal tube to contain the feces] Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of the anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices; however, if other measures fail, these devices may be used. [D. Use incontinence briefs to protect the skin] Absorptive incontinence products (eg, briefs) can be used after interventions to prevent incontinence and maintain perineal hygiene have failed. Incontinence products, such as adult briefs, may cause chemical irritation of the skin, further exacerbating skin breakdown. These products should wick moisture away from the client's skin. Educational objective:Interventions to prevent and handle fecal incontinence should be implemented from least to most invasive. Maintenance of skin integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, adult briefs, rectal tubes) should only be considered after less invasive hygiene practices fail.

A home health nurse is reinforcing teaching with the spouse of an elderly client who experienced a stroke regarding ways to reduce risk for falls in the home. Which suggestion by the spouse would be the most effective plan to prevent falls? A. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping B. Purchase a walker for the client to use when ambulating around the home C. Remove all area rugs and install grab bars in the bathroom D. Take the client for an annual eye exam and new glasses

Correct Answer: C. Remove all area rugs and install grab bars in the bathroom All of the choices are appropriate options to reduce falls in the home, but the one with the greatest impact is the removal of all area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial. Incorrect Answers: [A. Have a respite caregiver come once a week to stay with the client so the spouse can go shopping] Not leaving the client alone is preferable and could decrease the incidence of falls while the spouse is away. However, it is less effective than the removal of area rugs and installation of grab bars in the bathroom. [B. Purchase a walker for the client to use when ambulating around the home] A walker would be beneficial for this client but could get caught on an area rug. [D. Take the client for an annual eye exam and new glasses] Poor eyesight can contribute to falls, but the removal of rugs and installation of grab bars will have a greater impact. Educational objective:The nurse should educate the client and family about removing area rugs and installing grab bars in the bathroom to reduce the risk of falls in the home.

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? A. Document a description of the injury B. Question the mother about where the infant sleeps C. Report the injury per facility protocol D. Separate the mother from the infant

Correct Answer: C. Report the injury per facility protocol The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old infant, as the muscles required for rolling over do not develop until age 4-5 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory infants, are always of concern and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada. However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, Mongolian spots) mimicking maltreatment. After reporting suspected maltreatment, the nurse should: · Facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) · Document facts and observations objectively, using medical terms when possible. Include the history provided by the parent or caregiver and the time period from injury occurrence to evaluation. · Perform a review of child-care practices with the caregiver. A child and caregiver should only be separated when the child is in immediate physical danger or if authorities must interview a verbal child without the parent present. Educational objective:Injuries in a nonambulatory child, especially fractures, warrant suspicion. The nurse has a duty to report suspected child maltreatment to the appropriate authorities as required by law.

The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and incontinent of urine. The precepting nurse should intervene when the student performs which action? A. Attaches the drainage tubing to a lower leg collection bag. B. Leaves a 1-2 in (2.5 - 5 cm) space at the tip of the condom. C. Retracts the foreskin before applying the condom sheath. D. Uses elastic adhesive in a spiral fashion to secure the device.

Correct Answer: C. Retracts the foreskin before applying the condom sheath. Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when a health care worker accidentally leaves the foreskin in the retracted position for an extended period of time (eg, under a condom catheter sheath). It is critical for the precepting nurse to intervene when the student nurse retracts the foreskin before applying the condom catheter to avoid permanent damage to the glans resulting from impaired circulation Incorrect Answer: [Answer A. Attaches the drainage tubing to a lower leg collection bag.] The drainage tubing is attached to a leg collection bag in a mobile client to enable ambulation, prevent tube kinking, and facilitate gravity drainage. [Answer B. Leaves a 1-2 in (2.5 - 5 cm) space at the tip of the condom.] A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom. [Answer D. Uses elastic adhesive in a spiral fashion to secure the device.] If the condom catheter is not self-adhesive, elastic adhesive is used in a spiral fashion to secure the device to the penis. Adhesive tape may cause irritation and/or injury, and should not be used. Educational Objective: Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans.

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 minutes or more after eating. The client accuses the nurse of not providing food, saying, "I'm hungry. You didn't feed me." The nurse should take which action? A. Give the client gentle reminders that the client has already eaten? B. Say that the client can have a snack in a couple of hours. C. Serve the client half of the meal initially and offer the other half later. D. Take a picture of the client having a meal and show it when the client becomes upset.

Correct Answer: C. Serve the client half of the meal initially and offer the other half later. Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. [Answer A. Give the client gentle reminders that the client has already eaten.] Reality orientation has been recommended in the past as a way to deal with confusion (eg, dementia, Alzheimer disease), but research has shown that it may cause anxiety and distress. Validation therapy is a newer and more therapeutic approach that validates and accepts the clients reality. [Answer B. Say that the client can have a snack in a couple of hours.] Offering to provide a snack later does not address the client's stated need to eat now. Delay in giving food will only further increase the client's anger and frustration. [Answer D. Take a picture of the client having a meal and show it when the client becomes upset.] Showing a picture of the client having a meal is confrontational and will have no meaning to the client. Educational Objective: Clients with Alzheimer disease experience eating and nutritional problems throughout the course of the disease. During the earlier stages, it is common for them to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry.

The practical nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy would be most effective to reinforce prior teaching from the registered nurse? A. Leave diet pamphlets for the client to review at a later time B. Refer the client to the nurse case manager to follow up with diet instructions C. Sit with the client during meal selections and assist with identification of low sodium options D. Turn the television on in the client's room to the patient education channel to watch.

Correct Answer: C. Sit with the client during meal selections and assist with identification of low sodium options When teaching clients and caregivers, the nurse must keep in mind several principles of adult learning. These include the learner's: — Need to know — Readiness to learn — Prior experiences — Motivation to learn — Orientation to learning — Self-concept Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change in behavior has value, or perceives the learning activity as new and stimulating. The client's age and occupation may help to determine the vocabulary the nurse uses during teaching. Sitting down with the client to assist with the choice of items on the menu that are low in sodium actively involves the client and provides immediately applicable information. Incorrect Answers: [Answer A. Leave diet pamphlets for the client to review at a later time.] Pamphlets will be helpful to supplement the teaching that the nurse has already provided in the hospital with the client directly. [Answer B. Refer the client to the nurse case manager to follow up with diet instructions.] The registered nurse or the nurse case manager can refer the client to be seen by a dietician before leaving the hospital or to follow up with one when discharged. This will be helpful to the client, but the opportunity to teach when the information is immediately applicable is preferred. [Answer D. Turn the television on in the client's room to the patient education channel to watch.] The hospital's education channel is a good source of information for the client, but it does not actively involve the client in the teaching. Educational objective:The nurse should actively engage the client in teachings that the client is ready to receive and perceives as an immediate need.

A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor? A. Step behind the client with arms around waist, squat using the quadriceps, and lower client to the floor. B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently. C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor. D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor.

Correct Answer: C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor. To prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary. These actions include: — Step slightly behind the client and place the arms under the axillae or around the client's waist — Place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse — Place one foot behind the other and extend the front leg - allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight — Let the client slide down the extended leg to the floor - lowers the client gently to the floor while keeping the client's head protected from injury Incorrect Answers: [Answer A. Step behind the client with arms around waist, squat using the quadriceps, and lower client to the floor.] These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. [Answer B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently.] These actions are appropriate for helping a client rise from the bed or chair but not for assisting a falling client to the floor. [Answer D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor.] These actions do not provide close proximity to the client, a broad base of support, or a lower center of gravity to increase the nurse's stability and help prevent back injury. Educational objective:These nursing actions can help prevent injury if a client is falling while the nurse is assisting with ambulation: step slightly behind the client with feet wide apart and knees bent, place arms under the axillae or around the client's waist, place one leg behind the other and extend the front leg, and let the client slide down the extended leg to the floor.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention? A. UAP has attached a bed alarm to the client's gown and bed. B. UAP has been making hourly rounds on the client. C. UAP has lowered the bed and raised all 4 side rails. D. UAP has placed a fall risk ID bracelet on the client's wrist.

Correct Answer: C. UAP has lowered the bed and raised all 4 side rails. Placing the client's bed in the lowest position is appropriate, but raising all 4 side rails is considered a form of restraint. Having all 4 side rails up may actually increase clients' risk for falls as they may try to climb up and over the rails. Raising 2-3 side rails is appropriate. The nurse should lower at least one side rail and communicate to the UAP that having all 4 up is inappropriate. Incorrect Answers: [Answer A. UAP has attached a bed alarm to the client's gown and bed.] Placing a bed alarm would be an appropriate intervention for this client. [Answer B. UAP has been making hourly rounds on the client.] Making rounds at least hourly is appropriate for this client. The nurse should assess if more frequent rounds are warranted. [Answer D. UAP has placed a fall risk ID bracelet on the client's wrist.] Placing a fall risk ID band will help communicate to other members of the interdisciplinary team that the client is at risk for falls. Educational Objective: The nurse should ensure that multiple interventions are put in place for the client at high risk for falls. These include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client.

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take? A. Have the client remove the existing dressing while the nurse prepares sterile supplies B. Wear clean gloves for removal and application of a new dressing C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

Correct Answer: C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing The existing dressing is already contaminated so clean gloves can be worn to remove and discard it. Surgical wounds should be re-dressed using aseptic technique, which would require sterile gloves and sterile dressing supplies. The nurse should carefully remove the soiled dressing to avoid shedding any microorganisms into the air and expose the wound for minimal time to avoid additional contamination. Incorrect Answers: [A. Have the client remove the existing dressing while the nurse prepares sterile supplies] It would be better for the nurse to perform the dressing change as the wound is already infected. The client may be able to assist in the home setting. [B. Wear clean gloves for removal and application of a new dressing] Clean gloves can be used for removal but not for application of a new dressing. [D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing] Sterile gloves are not needed to remove the existing dressing. A gown and goggles may be required if splashing is possible. Educational objective:When changing the dressing of a surgical incision, the nurse may wear clean gloves to remove the existing dressing but should wear sterile gloves to apply a new one.

The nurse should consider which of the following client reports as an indication of an allergic reaction? A. "I can't eat broccoli or cabbage when I take my warfarin." B. "I get a headache when using my nitroglycerine patch." C. "My feet swell when I take felodipine." D. "My lips swell when I eat bananas or avocados."

Correct Answer: D. "My lips swell when I eat bananas or avocados." People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: 1 Allergic contact dermatitis (rash, itching, vesicles) developing 3-4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). 2 Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include: · Glove use · Procedures involving balloon-tipped catheters (eg, arterial catheterization) · Blowing up toy balloons · Use of bottle nipples, pacifiers · Use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. Incorrect Answer: [A. "I can't eat broccoli or cabbage when I take my warfarin."] Foods rich in vitamin K reduce the effects of warfarin (which works by inhibiting vitamin K-dependent clotting factors). Consumption of these foods decreases the effectiveness of warfarin; clients must be taught to eat the same amount of or avoid dark, green, leafy vegetables. [B. "I get a headache when using my nitroglycerine patch."] Nitroglycerine is a vasodilator and a headache from dilating cerebral vessels is an expected finding. The side effect is treated with acetaminophen (Tylenol). [C. "My feet swell when I take felodipine."] Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. This is an expected, frequent side effect and is not an allergic reaction. Clients are advised to elevate the legs when lying down and to use stockings. Educational objective:Latex allergy is suspected when there is a food allergy to banana, kiwis, or avocados. Peripheral edema is an expected side effect of peripherally acting calcium channel blockers. Headache is an expected side effect of nitroglycerine. Clients taking warfarin (Coumadin) should consume the same amounts of food high in vitamin K.

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? A. "A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns." B. "I will clean the injection site with an antiseptic swab before administration." C. "I will draw the medication into a 1-mL syringe." D. "The medication should be administered into the deltoid muscle."

Correct Answer: D. "The medication should be administered into the deltoid muscle." Intramuscular (IM) injections (eg, hepatitis B vaccine, vitamin K) are commonly administered to newborns shortly after birth or before discharge. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred site for IM injections in newborns (age <1 month) and infants (age 1-12 months). The deltoid muscle is an inappropriate injection site for newborns due to inadequate muscle mass. Incorrect Answers: [Answer A. "A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns."] For IM injections, the needle length should be ⅝ inch for newborns and ⅝ to 1 inch for infants; these lengths are adequate for reaching the muscle mass while avoiding underlying tissues (eg, nerves, bone). A 22- to 25-gauge needle is appropriate for clients age <12 months. [Answer B. "I will clean the injection site with an antiseptic swab before administration."] The medication should be administered using aseptic technique; cleaning the site with an antiseptic solution (eg, alcohol) is appropriate. [Answer C. "I will draw the medication into a 1-mL syringe."] A 1-mL syringe (eg, tuberculin) should be used to measure very small doses in 0.01-mL increments for newborns, infants, and small children. Pediatric medication dosages can be very small and should be measured to two decimal places. Educational Objective: The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A ⅝-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn.

The nurse cares for a child with bed bug bites. Which parent statement indicates that further teaching is required? A. "I need to have the entire house treated by pest control to ensure the bed bugs are gone." B. "I should concentrate on alleviating scratching as it can cause further complications." C. "My other family members and pets are at risk of bed bug bites." D. "This must have happened because I did not wash the bed sheets this week."

Correct Answer: D. "This must have happened because I did not wash the bed sheets this week." It is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. Incorrect Answers: [Answer A. "I need to have the entire house treated by pest control to ensure the bed bugs are gone."] It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. [Answer B. "I should concentrate on alleviating scratching as it can cause further complications."] Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. [Answer C. "My other family members and pets are at risk of bed bug bites."] Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted. Educational Objective: Bed bugs spread quickly and travel in bedding, clothing, and furniture. It is important to recognize bed bug bites and eliminate this pest from the home. Client treatment aims to minimize itching until the rash is gone.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? A. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." B. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." C. "The heel area should be warmed for 3-5 minutes prior to puncture." D. "Venipuncture should be reserved only for failed heel sticks because it is more painful."

Correct Answer: D. "Venipuncture should be reserved only for failed heel sticks because it is more painful." The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria.) Proper technique is essential for minimizing discomfort and preventing complications and includes: — Select a location on the medial or lateral of the outer aspect of the heel. Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. — Warm the heel for several minutes with a warm towel compress or approved single-use instant heel pack to promote vasodilation. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain. — Use an automatic lancet, which controls the depth of the puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternative method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed. Educational Objective: To perform a neonatal heel stick, select a location on the medial or lateral side of the outer aspect of the heel to avoid insult to the calcaneus bone. Provide comfort measures (eg, nonnutritive sucking), warm the selected puncture site to promote vasodilation, cleanse with alcohol, and puncture using an automatic lancet.

The client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? A. "Avoid excess stretching of your lower extremities." B. "Build strength by increasing the duration of daily exercise." C. "Let me speak with your health care provider about getting a wheelchair." D. "You should keep your feet apart and use a cane when walking."

Correct Answer: D. "You should keep your feet apart and use a cane when walking." Multiple sclerosis (MS) is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. Incorrect Answers: [Answer A. "Avoid excess stretching of your lower extremities."] Range-of-motion, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS. [Answer B. "Build strength by increasing the duration of daily exercise."] Fatigue is common symptom with MS. Rather than increasing the duration, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation. [Answer C. "Let me speak with your health care provider about getting a wheelchair."] Wheelchairs are advised only ifnexercise and gait training are not successful as clients should maintain mobility and independence as long as possible. Educational Objective: Clients with multiple sclerosis experience fatigue, incoordination, balance impairment, muscle weakness, and muscle spasticity from demyelination of nerve fibers. Gait training (eg, walking with the feet apart) and assistive devices can help prevent falls and injury and preserve independence as long as possible.

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)? A. 15-year-old student athlete in the emergency department with a fractured femur. B. 46-year-old with a large abdominal incision and 2 peripheral IV lines. C. 72-year-old who received a permanent pacemaker 24 hours ago. D. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator

Correct Answer: D. 80-year-old with chronic obstructive pulmonary disease (COPD) who is on a ventilator Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. Incorrect Answers: [Answer A. 15-year-old student athlete in the emergency department with a fractured femur.] A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. [Answer B. 46-year-old with a large abdominal incision and 2 peripheral IV lines.] This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. [Answer C. 72-year-old who received a permanent pacemaker 24 hours ago.] This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery. Educational Objective: Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients.

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take? A. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal B. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections C. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first D. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first

Correct Answer: D. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first Intermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe. Six units of regular insulin are needed to address the client's blood glucose reading (220 mg/dL [12.21 mmol/L]) along with the scheduled 20 units of NPH insulin. Prepare the mixed dose: 1. Inject the NPH insulin vial with 20 units of air without inverting the vial or passing the needle into the solution. 2. Inject 6 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble. 3. Draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total quantity. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. Incorrect Answer: [A. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal] The 2 insulins may be safely given together before the meal because regular insulin has a rapid onset of action, whereas NPH has a slower onset but longer duration. [B. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections] The insulins can be given as 2 separate injections; however, this increases client discomfort and infection risk. [C. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first.] Regular insulin should be drawn first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular comes before NPH). Educational objective: NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to decrease the risk of cross-contaminating multidose vials (mnemonic - RN: Regular comes before NPH).

The nurse responds to a client room where a resuscitation effort is in progress. The client's immediate family member refuses to leave the room. How should the nurse handle this situation? A. Call security to escort the family member to the waiting room. B. Have the family member stand or sit in an area that is not in the staff's way. C. Inform the family member that relatives are not allowed in rooms during emergency situations D. Let the family member stay and assign a staff person to explain what is happening.

Correct Answer: D. Let the family member stay and assign a staff person to explain what is happening. If family members are not causing a disruption in care of the client, they should be allowed to stay in the room with a staff member assigned to explain the interventions being implemented. The nurse should always try to be an advocate for the client and family. Witnessing the efforts of the resuscitation team can be reassuring even when the outcome is negative. The nurse should be prepared to escort family members from the room if they become disruptive. Incorrect Answers: [Answer A. Call security to escort the family member to the waiting room.] Calling security is appropriate only if the family member is disruptive to the staff. [Answer B. Have the family member stand or sit in an area that is not in the staff's way.] This could increase the family member's anxiety and result in a traumatizing experience if this person does not understand what is occurring during the resuscitation effort. [Answer C. Inform the family member that relatives are not allowed in rooms during emergency situations.] Many professional organizations support allowing a family member to stay during emergency situations, in accordance with specific hospital policy. Educational Objective: The nurse should support a family member who wants to be present during the resuscitation of a client. The family member should be allowed to sit or stand in an area that is out of the way of the resuscitation team. A staff member should be assigned to stay with the family member to explain the interventions taking place.

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? A. "I will hold the cane in my right hand." B. "I will move my left leg forward after moving the cane." C. "I will place the cane several inches in front of and to the side of my right foot." D. My cane should equal the distance from my waist to the floor."

Correct Answer: D. My cane should equal the distance from my waist to the floor." Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane measured from the waist would be too long to provide optimal support. Teaching points to assist a client in appropriate use of a cane include: 1. Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees). 2. Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance. 3. For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg. If minimal support is needed, the cane and weaker leg are advanced forward at the same time. 4. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg. 5. Always keep at least 2 points of support on the floor at all times. Educational objective:Clients should hold the cane on the stronger side to provide maximum stability. Cane length should equal the distance from the greater trochanter to the floor.

The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately? A. Elevated blood pressure. B. Heart rate irregularity. C. Low oxygen saturation. D. Noisy breathing

Correct Answer: D. Noisy breathing Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. [Option A. Elevated blood pressure.] Although elevated blood pressure is important to monitor, it is a less serious symptom than stridor. [Option B. Heart rate irregularity.] An irregular heart rate is a less serious symptom than stridor, and it may be a baseline finding in the client with hyperthyroidism. [Option C. Low oxygen saturation.] Although low oxygen saturation is a sign of impending airway compromise, it is also commonly seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing in the thyroidectomy client. Educational Objective: Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention.

The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, "That pill is too big. I won't be able to swallow it." What is the best action by the nurse? A. Contact the pharmacy and request the liquid form of the medication. B. Crush the medication and place it in a small amount of applesauce. C. Instruct the client to tuck chin to chest while swallowing the tablet. D. Obtain a new prescription for the liquid form of the medication.

Correct Answer: D. Obtain a new prescription for the liquid form of the medication. If a client is unable to swallow a large, extended-release tablet or capsule, the nurse should contact the health care provider (HCP) and request a new prescription (eg, liquid form of the medication). Incorrect Answers: [Answer A. Contact the pharmacy and request the liquid form of the medication.] The HCP's prescription is specifically for a tablet. The pharmacist cannot substitute the liquid form of the medication without HCP verification. [Answer B. Crush the medication and place it in a small amount of applesauce.] Crushing an extended-release (ER) medication and administering it with applesauce would be a wrong-dose medication error and can cause client harm, as the medication would be absorbed all at once instead of over an extended period. [Answer C. Instruct the client to tuck chin to chest while swallowing the tablet.] Instructing a client to tuck chin to chest while swallowing is the correct action for a client with impaired swallowing; however, this does not address a client's concern about swallowing a large tablet. Educational Objective: If a client is unable to swallow an extended-release (ER) tablet, the nurse should contact the health care provider to clarify the prescription (eg, request liquid medication). The nurse should not crush ER tablets.

The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, "That pill is too big. I won't be able to swallow it." What is the best action by the nurse? A. Contact the pharmacy and request the liquid form of the medication. B. Crush the medication and place it in a small amount of applesauce. C. Instruct the client to tuck chin to chest while swallowing the tablet. D. Obtain a new prescription for the liquid form of the medication.

Correct Answer: D. Obtain a new prescription for the liquid form of the medication. If the client is unable to swallow a large, extended-release tablet or capsule, the nurse should contact the health care provider (HCP) and request a new prescription (eg, liquid form of the medication). [Incorrect Answer: A. Contact the pharmacy and request the liquid form of the medication.] The HCP's prescription is specifically for a tablet. The pharmacist cannot substitute the liquid form of the medication without HCP verification. [Incorrect Answer: B. Crush the medication and place it in a small amount of applesauce.] Crushing an extended-release (ER) medication and administering it with applesauce would be a wrong-dose medication error and can cause client harm, as the medication would be absorbed all at once instead of over an extended period. [Incorrect Answer: C. Instruct the client to tuck chin to chest while swallowing the tablet.] Instructing a client to tuck chin to chest while swallowing is the correct action for a client with impaired swallowing; however, this does not address the clients concern about swallowing a large tablet. Educational Objective If a client is unable to swallow an extended-release (ER) tablet, the nurse should contact the health care provider to clarify the prescription (eg, request liquid medication.) The nurse should not crush ER tablets

The nurse is caring for an elderly client after hip replacement surgery. The client is distressed because he has not had a bowel movement in 3 days. Which action by the nurse would be most appropriate? A. Administer the prescribed as-needed milk of magnesia B. Ask dietary services to add more fruits and vegetables to the client's tray C. Notify the registered nurse D. Perform a focused abdominal assessment

Correct Answer: D. Perform a focused abdominal assessment Constipation may develop as a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client to determine the cause of this client's constipation. The nurse can administer the as-needed laxative once it has been determined to be safe. The registered nurse should be consulted if the focused abdominal assessment indicates a potential complication, such as postoperative ileus. Incorrect Answer: [A. Administer the prescribed as-needed milk of magnesia] The nurse's first priority is assessment. A laxative would not help if this client had intestinal obstruction (from adhesions). [B. Ask dietary services to add more fruits and vegetables to the client's tray] The client is taught to eat a high-fiber diet and increase fluid intake to promote normal bowel function. The nurse would not change the diet until further assessment of the client is accomplished and the health care provider has prescribed a new diet. [C. Notify the registered nurse] The nurse should complete a focused abdominal assessment before notifying the registered nurse. Educational objective:Constipation may be a side effect of anesthesia, pain medication, physiological stress, and/or immobility. The nurse's first priority is to assess the client and then use measures that promote normal bowel function (eg, as-needed laxatives, stool softeners, bulk agents, high-fiber diet, increased fluids).

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? A. Assess pupillary response. B. Auscultate lung sounds. C. Inform anesthesia professional D. Perform head tilt and chin lift.

Correct Answer: D. Perform head tilt and chin lift. Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. [Answer A. Assess pupillary response.] Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. [Answer B. Auscultate lung sounds.] Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95% - 100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. [Answer C. Inform anesthesia professional.] The anesthesia professional may need to be informed, but methods to restore oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent. Educational Objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway.

A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action. A. Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field. B. Opens the sterile gauze package with ungloved hands. C. Places the sterile gauze dressings within 2" (5 cm) from the edge of the sterile drape. D. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago.

Correct Answer: D. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago. The sterility of an opened bottle of sterile saline cannot be guaranteed. Some institutions' policies permit recapped bottles of solution to be reused within 24 hours of opening, and some require disposal of the remaining solution. Therefore, the nurse should intervene when the student uses sterile saline from a bottle that was opened over 24 hours prior. The general steps for prepping the sterile field for a wet-to-damp dressing change include: 1. Perform hand hygiene. 2. Open a sterile gauze package that has a partially sealed edge with ungloved hands by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze. 3. Hold the inverted opened gauze package 6" (15 cm) above the waterproof sterile field so it does not touch the field, and then drop the gauze dressing onto the sterile field. 4. Place the sterile dressings on the sterile field 2" (5 cm) from the edge; the 1" (2.5 cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces. 5. Use sterile NSS from a recapped bottle that was opened less then 24 hours prior (if policy permits.) Educational Objective The general steps for preparing a sterile field for a wet-to-damp dressing change include: 1. Perform hand hygiene. 2. Open a sterile gauze package with ungloved hands. 3. Hold the inverted opened gauze package 6" (15 cm) above the sterile field. 4. Place the sterile gauze dressing more than 1" (2.5 cm) from the edge of the sterile field. 5. Use sterile NSS from a recapped bottle that was opened less than 24 hours prior (if policy permits.)

The nurse is preparing to care for a client with acute myelogenous leukemia who has been going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Click on the exhibit button for additional information. A. Administer erythropoietin injection. B. Minimize venipunctures and avoid intramuscular injections. C. Place sequential compression devices on the legs. D. Provide a private room and neutropenic precautions.

Correct Answer: D. Provide a private room and neutropenic precautions. The client's laboratory results show severe neutropenia, with a reduced white blood cell count and lowered absolute neutrophil count (normal >1500/mm3 [1.5x109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: — A private room. — Strict handwashing — Avoid exposure to people who are sick — Avoid all fresh fruits, vegetables, and flowers — Ensure that all equipment used with the client has been disinfected Incorrect Answers: [Answer A. Administer erythropoietin injection.] The client's laboratory results show moderate anemia. Blood transfusion and/or erythropoietin injections are important but not a priority. Infections in immunocompromised clients are life-threatening. [Answer B. Minimize venipunctures and avoid intramuscular injections.] The client's platelet count of 78,000/mm3 (78x109/L) is decreased but not dangerously low; therefore, it is not the highest priority. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50x109/L), as these can cause prolonged bleeding. [Answer C. Place sequential compression devices on the legs.] This client would need sequential compression devices for prevention of deep vein thrombosis to the legs as anticoagulants may not be used due to the risk of bleeding from borderline low platelet count. However, this is not a priority over infection prevention. Educational Objective: Neutropenic precautions should be used to prevent infection in clients who have low white blood cell and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life-threatening.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first. A. Ask the client to take several small sips of water. B. Continue to slowly advance the tube until placement is reached. C. Gently remove the tube and reinsert in the other naris if possible D. Pull back on the tube slightly and then pause to give the client time to breathe.

Correct Answer: D. Pull back on the tube slightly and then pause to give the client time to breathe. During the NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible. Educational Objective Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? A. Insist the client sign the AMA form. B. Provide the client with a copy of hospital results. C. Reassure that the client can return later. D. Remove the intravenous catheter.

Correct Answer: D. Remove the intravenous catheter. A competent client can refuse medical treatment and leave against medical advice (AMA.) The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is the most important that the clients IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. {Answer A. Insist the client sign the AMA form.] The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign. [Answer B. Provide the client with a copy of hospital results.] Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not essential to provide the clients with results. Removing the catheter is the priority. [Answer C. Reassure that the client can return later.] Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a priority over removal of the catheter. Educational Objective: When a client leaves against medical advice (AMA), it should be an informed refusal. The nurse should inform the health care provider immediately. The most important action is for the nurse to remove the IV catheter prior to discharge. A client cannot be held against his/her will if the client refuses to sign an AMA form.

The nurse is caring for a client with bacterial meningitis who has been placed on droplet precautions. Which personal protection is mandatory for the nurse when administering medications? A. Face shield. B. Gown C. N95 respirator D. Surgical mask.

Correct Answer: D. Surgical mask Bacterial meningitis is transmitted through large droplets spread by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 ft away from the client. Droplet precautions during routine care (eg, assessment, medication administration) of a client with bacterial meningitis require a surgical mask. Droplet precautions can be discontinued after the client receives 24 hours of antibiotics. When caring for clients on droplet precautions, the nurse should also observe these measures: — Proper hand hygiene is the most vital infection-control measure in any client care setting. — All surfaces within 3 ft of the bed are considered contaminated — Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room. Incorrect Answers: [Answer A. Face shield.] & [Answer B. Gown] Wearing a face shield, gown, and gloves is required only if the nurse suspects possible splashing of body fluids from procedural client care (eg, suctioning, wound care), not for routine care such as assessment or medication administration. [Answer C. N95 respirator] For client care involving airborne precautions, a class N95 or higher respirator must be used instead of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated only for barrier protection from droplets and filtration of large respiratory particles. Educational Objective: For routine care of clients on droplet precautions, such as assessment or medication administration, handwashing and a surgical mask are needed. If there is risk of contact with body fluids during procedures (eg, suctioning), gloves, a gown, and eye protection are used.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room? A. Isolation gown, surgical mask, goggles, and gloves B. Isolation own and surgical mask. C. N95 respirator mask. D. Surgical mask

Correct Answer: D. Surgical mask Clients with airborne infections such as TB, measles, or chickenpox (varicella) are confined to a negative-pressure room except when traveling to various departments for essential diagnostic procedures or surgery. While being transported through the health care facility, the client on airborne transmission-based precautions wears a surgical mask to protect health care workers (HCWs) and other clients from respiratory secretions. Incorrect Answers: [Answer A. Isolation gown, surgical mask, goggles, and gloves] & [Answer B. Isolation own and surgical mask.] The client on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions. The other personal protective equipment is not necessary. [Answer C. N95 respirator mask.] The Centers for Disease Control and Prevention recommends that HCWs who transport clients wear N95 respirator masks as protection against exposure to airborne droplets. N95 respirator masks protect HCWs by removing particles from inhaled air. The client is already infectious and does not require protection from inhaled air. Educational Objective: While away from the negative-pressure isolation room, all clients on airborne transmission-based precautions must wear a surgical mask to contain exhaled respiratory secretions.

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? A. Ask the UAP to go back and ask the client what the current needs are. B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room. C. Tell the UAP to inform the client in the next room that the nurse will be there shortly. D. Tell the UAP to tell the charge nurse about the needs of the client in the next room.

Correct Answer: D. Tell the UAP to tell the charge nurse about the needs of the client in the next room. With procedural moderate sedation at the bedside, the nurse takes on the role of an anesthetist. The nurse's role is to monitor the client's condition while the health care provider focuses on performing the procedure. The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door. Incorrect Answers: {Answer A. Ask the UAP to go back and ask the client what the current needs are.] This action would place the UAP in the role of assessing and prioritizing, which is beyond the scope of the UAP's practice. In addition, the nurse must stay in the room and cannot meet the other client's need as a result. [Answer B. Ask the UAP to stay and take over while the nurse goes to check on the client in the next room.] Taking on the role of assessing/monitoring (related to anesthesia) and/or administering additional intravenous drugs during the procedure is beyond the scope of the UAP's practice. [Answer C. Tell the UAP to inform the client in the next room that the nurse will be there shortly.] The UAP has already communicated that the client's need is urgent. The client should not be kept waiting without further assessment to evaluate the situation. Educational Objective: The nurse takes on the role of anesthetist when assisting with bedside procedural moderate sedation and cannot leave the client during the procedure.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which assessment data as soon as possible before surgery? A. Hemoglobin 15 g/dL, hematocrit 45% B. International Normalized Ratio 1.3 C. Platelet count 295,000/mm3 D. Temperature 100.4 F (38 C) with cough

Correct Answer: D. Temperature 100.4 F (38 C) with cough Low-grade temperature and cough could indicate an infection. The practical nurse should report these findings to the registered nurse (RN) as soon as possible before surgery. Administration of anesthesia in a client with fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The RN should notify the health care provider (HCP) and obtain further instructions. Depending on the individual situation and type of surgery scheduled, the HCP may prescribe further testing, consult the anesthesia professional, or postpone or proceed with the surgery. Incorrect Answers: [A. Hemoglobin 15 g/dL, hematocrit 45%] Hemoglobin (13.2-17.3 g/dL), hematocrit (39%-50%), and platelet count (150,000- 400,000/mm3) levels are within normal ranges and do not indicate increased risk for bleeding. The normal range for the International Normalized Ratio is 0.75-1.25; a value of 1.3 represents only borderline elevation and would not increase the bleeding risk. [B. International Normalized Ratio 1.3] Hemoglobin (13.2-17.3 g/dL), hematocrit (39%-50%), and platelet count (150,000- 400,000/mm3) levels are within normal ranges and do not indicate increased risk for bleeding. The normal range for the International Normalized Ratio is 0.75-1.25; a value of 1.3 represents only borderline elevation and would not increase the bleeding risk. [C. Platelet count 295,000/mm3] Hemoglobin (13.2-17.3 g/dL), hematocrit (39%-50%), and platelet count (150,000- 400,000/mm3) levels are within normal ranges and do not indicate increased risk for bleeding. The normal range for the International Normalized Ratio is 0.75-1.25; a value of 1.3 represents only borderline elevation and would not increase the bleeding risk. Educational objective:The registered nurse should be notified as soon as possible if a client scheduled for surgery develops manifestations that could indicate infection. Anesthesia and the physiologic stress of surgery in a client with fever and cough can cause potential intraoperative and postoperative complications.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? A. The client has been admitted to the facility without the client's consent. B. The client is becoming delirious and should be assessed for infection. C. The client is concerned that someone might steal possessions. D. The client wants to take care of business before imminent death.

Correct Answer: D. The client wants to take care of business before imminent death. This client with advanced renal failure who decides not to start dialysis treatments may have only a few weeks to live. Toxins will build up in the body and soon lead to increased weakness and cognitive decline. This client knows there is a limited time left to live and wants to ensure that possessions will be taken care of appropriately after the client's death. Incorrect Answers: [Answer A. The client has been admitted to the facility without the client's consent.] The client has probably been admitted to the facility due to concerns about safe management at home. However, the statement does not indicate that the client has been admitted against the client's will. [Answer B. The client is becoming delirious and should be assessed for infection.] Clients with end-stage renal disease are at risk for delirium due to a buildup of toxins, which may manifest as agitation and statements about needing to go somewhere. However, the nurse should not automatically assume that the client is delirious. Instead, it is important to assess the client's concern with an open mind so that appropriate interventions can be planned. [Answer C. The client is concerned that someone might steal possessions.] The client's statement about having "so much to do" suggests that this is not the concern prompting the behavior. Educational Objective: The client with a limited life expectancy will have concerns about completing personal business, such as ensuring that possessions go to the appropriate people. The nurse should assess the client's needs and ensure that the plan of care will facilitate the client's life closure activities (eg, legacy building).

The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort? A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them B. Lying on the affected side with head of the bed elevated to 30-45 degrees C. Prone with head turned to the affected side and arms over the head, supported by a pillow D. Upright leaning forward over the bedside table, with arms supported on pillows

Correct Answer: D. Upright leaning forward over the bedside table, with arms supported on pillows During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. Incorrect Answers: [A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them.] The fetal position is appropriate for a client having a lumbar puncture, not a thoracentesis. [B. Lying on the affected side with head of the bed elevated to 30-45 degrees] If unable to sit, the client can be positioned lying on the unaffected, not affected, side [C. Prone with head turned to the affected side and arms over the head, supported by a pillow] Prone position is not used for this procedure, is uncomfortable, and would make it more difficult for a client with dyspnea to breathe. Educational objective:Before a thoracentesis, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort.

An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents' primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home? A. Demonstrate the procedure using simple English phrases B. Give the parents written instructions with picture illustrations C. Tell the parents to have a friend or relative come in to translate D. Use an interpreter via the telephone interpretation service

Correct Answer: D. Use an interpreter via the telephone interpretation service Effective teaching can be accomplished only with effective communication, which can be compromised by language barriers, cultural differences, and low health literacy. When an interpreter is necessary, using a translator who is skilled in medical terminology is the best approach to provide accurate information. Hearing instructions and information in one's primary language decreases the risk of adverse clinical consequences. If a professional medical translator is unavailable, language lines, telephone systems, and remote video interpreting services can be used. Translation by family members and friends should only be used as a last resort and only with the permission of the client, especially during situations in which sensitive information needs to be communicated. Children should not be used as translators except in an emergency when there are no other options. Incorrect Answers: [A. Demonstrate the procedure using simple English phrases] This client's parents have very limited English language proficiency; this approach will not be effective in providing instructions about the child's care at home. [B. Give the parents written instructions with picture illustrations] Providing written materials without verbal teaching does not give the client (or the client's caregiver) the chance to ask questions, nor does it give the nurse the opportunity to assess the client's (or the caregiver's) understanding of the given information. Educational objective:When language is a barrier to effective communication and teaching, the nurse should use a trained medical interpreter for translation purposes.

The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection? A. Assist the client to the shower and provide directions to use antibacterial soap. B. Delay the bath until the client has received antibiotic therapy for 24 hours. C. Use a bath basin with warm water and a new wash cloth for each body area. D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client.

Correct Answer: D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client. Current evidence supports the recommendation for clients with methicillin-resistant Staphylococcus aureus (MRSA) or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. Incorrect Answers: [Answer A. Assist the client to the shower and provide directions to use antibacterial soap.] This action may be appropriate for a client in the home setting. However, chlorhexidine is recommended in the hospital setting. [Answer B. Delay the bath until the client has received antibiotic therapy for 24 hours.] It is not appropriate to delay bathing as the client's skin and incision need to be cleaned. Delay should only occur if the client is unstable. [Answer C. Use a bath basin with warm water and a new wash cloth for each body area.] This option would be appropriate if the bath water contained a solution of chlorhexidine. Educational Objective: Pre-moistened cloths or warm water with a chlorhexidine solution should be used when bathing clients infected with methicillin-resistant Staphylococcus aureus or other drug-resistant organisms.

A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? A. Nasal cannula B. Non-rebreathing mask C. Oxymizer D. Venturi mask

Correct Answer: D. Venturi mask A Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume. The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased tidal volume, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with chronic obstructive pulmonary disease (COPD). Incorrect Answers: [A. Nasal cannula] A nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate tidal volume and normal vital signs. It is not the best choice in an unstable COPD client with varying tidal volumes because the inspired oxygen concentration is not guaranteed. [B. Non-rebreathing mask] A non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short-term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client. [C. Oxymizer] An Oxymizer is a nasal reservoir cannula device that conserves oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen to reach the same saturation (eg, 3 L/min nasal cannula is equivalent to 1 L/min Oxymizer). It is not the best choice in an unstable COPD client with varying tidal volumes as the inspired oxygen concentration is not guaranteed. Educational objective:Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable chronic obstructive pulmonary disease [COPD]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, COPD exacerbation).

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first? A. Ask another nurse to help. B. Delegate the task to unlicensed assistive personnel. C. Premedicate the client for pain. D. Verify the client's activity prescription.

Correct Answer: D. Verify the client's activity prescription. A client newly admitted from a surgical procedure may have activity restrictions or bed rest prescribed for a certain period. Before assisting the client to the chair, the nurse needs to verify the activity level prescribed by the health care provider. Getting the client out of bed too early could cause injury to the surgical site or result in a fall. Incorrect Answers: [Answer A. Ask another nurse to help.] A client who had knee surgery will likely be unable to bear any weight on the affected limb. Depending on the client's size, it may be prudent for the nurse to get additional help. This could be requested after the activity prescription has been verified. [Answer B. Delegate the task to unlicensed assistive personnel.] Assistance with ambulation is often delegated to unlicensed assistive personnel (UAP); however, the nurse should verify the prescription first. It would also be prudent to have the UAP assist the nurse as this is the client's first time up after surgery. [Answer C. Premedicate the client for pain.] The nurse should assess the client's pain level before providing pain medication. Educational Objective: The nurse should verify activity prescriptions before getting clients out of bed after surgery or a procedure. The nurse should be present when these clients begin ambulating and may need assistance from another nurse or unlicensed assistive personnel.

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? A. Crush and administer medications B. Dilute enteral formula as prescribed. C. Flush the tube with 30 mL of water. D. Verify tube placement with an x-ray.

Correct Answer: D. Verify tube placement with an x-ray. Enteral feedings are given to provide nutrition to clients who are unable to take in nutrients by mouth. Placement verification is imperative prior to initiating enteral feedings to prevent complications such as aspiration. Lung aspiration can lead to pneumonia, acute respiratory distress syndrome, and abscess formation. Methods to verify the tube placement include the following: 1. Imaging: visualization of tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings. 2. Gastric content pH testing: although testing the pH of aspirated contents is an evidence-based method, it is typically used to assess for displacement after initial x-ray verification. It can also be used to test the position of the tube prior to each feed as the frequent x-rays expose the client to radiation. Gastric pH is usually acidic (<5) because of acid secretion. pH ≥6 indicates bronchial secretions and incorrect placement. 3. Air auscultation: verification by auscultating air is not an evidence-based method for placement verification. After placement is verified, the nurse may flush the tube with water, administer prescribed medications, flush the tube again, and then prepare and deliver the enteral feeding. Educational Objective: Visualization of the NG tube placement by x-ray is the standard protocol to ensure proper placement prior to initiating enteral tube feedings. Verification by auscultating air is not an evidence-based method of placement verification.

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? A. Arrange for the client's service dog to come to the health care facility as soon as possible. B. Describe the environment in detail so the client can ambulate safely with a cane. C. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand. D. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow.

Correct Answer: D. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow. On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse used the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. Incorrect Answers [Answer A: Arrange for the client's service dog to come to the health care facility as soon as possible.] The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. [Answer B: Describe the environment in detail so the client can ambulate safely with a cane.] After the evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. [Answer C: Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand.] Instructing the unlicensed to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely. Educational Objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate? A. Obtain a smaller-gauge needle and reattempt at the same site. B. Partially withdraw and then reinsert the needle at a different angle. C. Provide reassurance and firmly stabilize the arm to complete the collection. D. Withdraw the needle and reattempt in a different site with new equipment.

Correct Answer: D. Withdraw the needle and reattempt in a different site with new equipment. The preferred site for venipuncture when collecting blood specimens is the antecubital fossa's median cubital vein. The basilic vein lies close to the brachial nerve and artery. When severe, shooting pain radiates down a client's arm during venipuncture, nerve injury may be occurring. The client may also report feelings of "pins and needles" or numbness at and/or near the venipuncture site. If this occurs, the nurse should promptly withdraw the needle, obtain new equipment, and choose a different site for specimen collection. Incorrect Answers: [Answer A A. Obtain a smaller-gauge needle and reattempt at the same site.] & [Answer B. Partially withdraw and then reinsert the needle at a different angle.] Because the pain and numbness during venipuncture indicate a nerve injury, the nurse should reattempt the specimen collection using a different site. Reattempting at the same site with a smaller-gauge needle or from a different angle could cause nerve damage. [Answer C. Provide reassurance and firmly stabilize the arm to complete the collection.] Reassurance may help calm an anxious client, and stabilization may help prevent injury if a client attempts to withdraw the arm during routine venipuncture. However, this client has nerve pain, which indicates that the attempt should be stopped immediately to prevent nerve damage. Educational Objective: The presence of pain and feelings of "pins and needles" during venipuncture may indicate nerve pain and require prompt cessation of the attempt. The nurse should withdraw the needle, obtain new equipment, and choose a different site for the specimen collection.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? A. Administer pain medication. B. Call the health care provider to meet with the family to obtain informed consent. C. Complete the preoperative checklist. D. Perform the morning assessment.

Correct Answer: Perform the morning assessment. The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. Incorrect Answers: [Answer: A. Administer pain medication.] Pain medicine is not due until 0830 and can be administered after the initial assessment if necessary. [Answer B. Call the health care provider to meet with the family to obtain informed consent.] The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. [Answer C. Complete the preoperative checklist.] The preoperative checklist can be completed after consent is obtained. Educational Objective: Before surgery, the nurse makes sure informed consent is obtained, performs a complete physical assessment to collect baseline data and determine the client's physiologic and psychologic status, and completes the preoperative checklist.

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply. A. Apply a water-based lubricant to the enema tube before insertion. B. Assist the client into left lateral position with the right knee flexed. C. Encourage the client to retain the enema for as long as possible. D. Keep the enema solution refrigerated until ready to administer. E. Slow administration rate if the client reports abdominal cramping.

Correct Answers: A, B, C, and E. Cleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: — Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon — Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. — Lubricate the enema tube and gently insert the tip 3-4 in (7.6-10 cm) into the rectum — Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation. — Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) — Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration Incorrect Answers: [D. Keep the enema solution refrigerated until ready to administer.] Enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water. Educational Objective When administering an enema, the nurse should place the client in the left lateral position with the right knee flexed, lubricate and insert the enema tube into the rectum with the tip directed toward the umbilicus, and slow the rate of administration if the client reports abdominal cramping. Enemas should be administered at room temperature or warmed.

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. A. "I should rinse my mouth with water before collecting the sputum." B. "I will be careful not to touch the inside of the specimen cup or lid." C. "I will inhale deeply a few times and then cough forcefully." D. "It is best to collect the sputum mid-day when my secretions are loose." E. "It is helpful if I am sitting upright when I collect the sputum."

Correct Answers: A, B, C, and E. Sputum culture and sensitivity testing is used to identify infectious organisms in the respiratory tract and determine which antimicrobials are most effective at treating the identified organism. Nurses assisting a client to collect sputum should instruct the client to: — Rinse the mouth with water before collecting the sputum sample to reduce bacteria in the mouth and prevent specimen contamination by oral flora — Avoid touching the inside of the sterile container or lid to avoid accidental specimen contamination by normal flora of the skin — Inhale deeply several times and then cough forcefully, which promotes expectoration of lower lung secretions and increases sample volume — Assume a sitting or upright position before specimen collection, if possible, to promote cough strength during collection Incorrect Answers: [Answer D. "It is best to collect the sputum mid-day when my secretions are loose."] Sputum specimens should be collected early in the morning after awakening, which improves the quality of the sample because secretions accumulate overnight due to cough inhibition. A nebulizer treatment may be prescribed to help mobilize thick secretions. Educational Objective: Collection of a sputum specimen by expectoration is a sterile procedure that requires the client to breathe deeply and cough effectively. The nurse should instruct the client to rinse the mouth with water, sit upright, inhale deeply several times, and cough prior to expectorating. The client should avoid touching the inside of the sterile container or lid. Sputum should be collected in the morning to improve sample quality.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. A. Ensure the client is given an analgesic 30-60 minutes before tube removal B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed C. Place the client in the Trendelenburg position D. Prepare a sterile airtight petroleum jelly gauze dressing E. Provide the health care provider with sterile suture removal equipment

Correct Answers: A, B, D, and E. A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: 1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal 2. Provide the health care provider (HCP) with sterile suture removal equipment 3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space 4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space 5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. Incorrect Answers: [Answer C. Place the client in the Trendelenburg position] The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective:Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.

A nurse is making a home visit when a fire starts in the client's kitchen trash can. The client has a fire extinguisher. The nurse should take which actions to properly operate the fire extinguisher? Select all that apply. A. Aim the nozzle at the base of the fire. B. Pull out the pin on the handle. C. Shake the canister prior to use. D. Squeeze the handle to spray. E. Sweep the spray from side to side.

Correct Answers: A, B, D, and E. A small fire can quickly become very dangerous. During an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation, especially when operation of unfamiliar equipment (eg, fire extinguisher) is involved. The mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher: P — Pull the pin on the handle to release the extinguisher's locking mechanism. A — Aim the spray at the base of fire S — Squeeze the handle to release the contents/extinguishing agent S — Sweep the spray from side to side until the fire is extinguished. [Answer C. Shake the canister prior to use.] The extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire. Educational Objective: PASS is the mnemonic to help people remember the steps used in operating a fire extinguisher. P - Pull the pin; A - Aim the spray at the base of the fire; S - Squeeze the handle; and S - Sweep the spray.

The community health nurse is preparing to reinforce teaching to a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. A. Cervical cancer B. Hypertension C. Ischemic stroke D. Osteoporosis E. Skin melanoma

Correct Answers: A, B, and C The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women. African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women. African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia. Incorrect Answers: [D. Osteoporosis] White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. [E. Skin melanoma] Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than in African Americans. Educational objective:African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding? Select all that apply. A. "I will apply the prescribed bacitracin ointment after collecting the wound culture." B. "I will cleanse the wound by gently flushing it with normal saline." C. "I will obtain a sample of the drainage accumulated since the last dressing change." D. "I will perform hand hygiene and apply new gloves before obtaining the wound culture." E. "I will swab the wound from the outermost margin toward the center."

Correct Answers: A, B, and D Wound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: 1. Perform hand hygiene, and apply clean gloves. Remove the old dressing. Remove and discard gloves. 2. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris. Remove and discard gloves. 3. Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin. Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. 4. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. 5. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification. Apply new dressing. 6. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. Pooled purulent exudate likely contains skin flora different from the pathogen(s) responsible for the infection. Microorganisms responsible for infection are most likely found in viable tissue. Educational objective:Wound cultures are used to identify microorganisms and select appropriate antibiotics. The nurse should assess and clean the wound, swab from the wound center toward the outer margin, and avoid contamination (eg, hand hygiene, not touching intact skin with swab) to prevent misidentification of microorganisms.

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply. A. Apply moisture barrier cream to dry skin B. Clean perineal area after incontinent episodes C. Massage bony prominences frequently D. Place foam-padded seat cushions on chairs E. Reposition clients in bed every 6 hours

Correct Answers: A, B, and D Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: — Use emollients and barrier creams to hydrate, protect, and strengthen the skin — Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences — Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin — Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. Incorrect Answers: [C. Massage bony prominences frequently] Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin. [E. Reposition clients in bed every 6 hours] Clients must be repositioned and turned every 2 hours. Turning clients every 6 hours is too infrequent and will not confer the same protection against pressure and associated tissue ischemia. Educational objective:Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure injuries. Massage over the bony prominences is not recommended for pressure injury prevention.

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply. A. Date of birth B. First and last name C. Health care provider D. Medical record number E. Room number

Correct Answers: A, B, and D. "The right client" is one of the "6 rights" of medication administration. Two identifiers are used to compare client statements and information on the identification band with the client's medication administration record. An identifier should be permanent and unique to the client. Acceptable identifiers include first and last name and date of birth. These two identifiers are commonly used together because there is a chance that more than one client may share a similar surname or date of birth, which increases the risk of administering a medication to the wrong client. Medical record numbers are also an acceptable form of identification and may help further differentiate client. Incorrect Answers: [Answer C. Health care provider] & [Answer E. Room number] The name of the health care provider and room number are not specific or unique to the client and are subject to change based on the client's plan of care or condition. Educational Objective: During medication administration, the nurse identifies "the right client" using information that is permanent and unique to the client. Acceptable identifiers are first and last name, date of birth, and medical record number.

A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply. A. Apply patch to the upper arm or chest. B. Fold used patches in half with sticky sides together before discarding. C. Remove patch if dizziness occurs when getting up. D. Rotate sites each time a new patch is applied. E. Shave hair before applying patch.

Correct Answers: A, B, and D. Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the clonidine (transdermal) patch: — Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days — Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars — Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. — Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. — Remove the patch from the package. Do not touch the sticky side. — Rotate sites of patch application with each new patch. Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP). — When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested. — Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur. Educational Objective: The nurse should teach a client receiving a clonidine patch to: — Apply patch to a dry hairless area on the upper arm or chest. — Wash hands before and after application. — Rotate sites with each new patch application. — Discard patch away from children or pets with sticky sides folded together. — Never wear more than 1 patch at a time. — Never stop using the patch abruptly.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. A. Ensuring the client wears an N95 respirator at all times. B. Keeping the door of the client's room closed at all times. C. Maintaining a log of everyone in and out of the client's rooms. D. Removing both pairs of gloves before removing gown and mask. E. Restricting visitors from entering the client's room

Correct Answers: A, B, and D. Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed. Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms. Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. Incorrect Answers: [Answer A. Ensuring the client wears an N95 respirator at all times.] In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). [Answer D. Removing both pairs of gloves before removing gown and mask.] The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last. Educational Objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply. A. 38-year-old with methicillin-resistant Staphylococcus aureus. B. 42-year-old with Clostridium difficile diarrhea. C. 69-year-old with pertussis infection. D. 72-year-old with vancomycin-resistant Enterococcus E. 80-year-old with influenza.

Correct Answers: A, B, and D. Infections caused by methicillin-resistant Staphylococcus aureus(MRSA), C difficile, vancomycin-resistant Enterococcus (VRE), and scabies require contact precautions to be used. Contact precautions include: — Placing client in private room (preferred) or cohorting clients with the same infection — Using dedicated equipment (must be disinfected when removing from room) — Wearing gloves when entering room — Perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) — Wearing gown with client contact and removing before leaving room — Place door notice for visitors — Having client leave room only for essential clinical reasons (ie, tests, procedures). If an x-ray is needed, try to arrange for a portable one. Incorrect Answers: [Answer C. 69-year-old with pertussis infection.] Clients with pertussis infection (whooping cough) need droplet precautions. [Answer E. 80-year-old with influenza.] Influenza requires droplet precautions. Educational Objective: Clients with multidrug-resistant organisms (MRSA, VRE), C difficile diarrhea, and scabies require nursing staff to implement contact precautions.

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client's newly diagnosed seizure disorder. The health care provider prescribes seizure precautions for the client. The nurse prepares to initiate which interventions? Select all that apply. A. Apply pads to the side rails. B. Have oxygen supplementation available. C. Prepare to insert a urinary catheter. D. Remove all linen from the bed. E. Set up bedside suction equipment.

Correct Answers: A, B, and E. Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: 1. Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure. 2. During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside. Some facilities also encourage the use of a continuous pulse oximeter. Incorrect Answers: [Answer C. Prepare to insert a urinary catheter.] Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. [Answer D. Remove all linen from the bed.] t is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions. Educational Objective: Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply. A. Keep dedicated equipment for a client. B. Perform hand hygiene before exiting the room. C. Place a "No visitors" sign on the client's door. D. Wear a face mask when in the room. E. Wear an isolation gown when providing direct care.

Correct Answers: A, B, and E. In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following: — Place client in a private room (preferred) or semi-private room with another client with the same infection — Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) — Wear gloves when entering the room — Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) — Wear gown with client contact and remove it before leaving the room — Place door notice for visitors — Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures) Incorrect Answers: [Answer C. Place a "No visitors" sign on the client's door.] The client with MRSA or VRE is allowed to have visitors. However, these individuals will need instructions from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions. [Answer D. Wear a face mask when in the room.] A face mask is required for droplet precautions. An N95 particulate respirator mask is required for certain airborne precautions (eg, tuberculosis). Educational Objective: The client with multidrug-resistant organism (MRSA or VRE) infections, C difficile diarrhea, or scabies will require institution of contact precautions such as good hand hygiene on entry and exit of the client's room, gloves on entry, and a gown for direct client care. The client's room should have dedicated equipment, and the door should have a sign informing visitors about these precautions.

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply. A. Administers 100% oxygen prior to suctioning the client. B. Applies suction while withdrawing the catheter from the airway. C. Instills sterile normal saline into the tracheostomy prior to suctioning. D. Limits suctioning to 20 seconds during each suction pass. E. Uses sterile gloves and technique throughout the procedure.

Correct Answers: A, B, and E. Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should: — Proxygenate with 100% oxygen and allow for reoxygenation periods between suction passes. — Suction only while withdrawing the catheter from the airway. — Use strict sterile technique throughout suctioning. — Limit suctioning to ≤10 seconds on each suction pass Incorrect Answers: [Answer C. Instills sterile normal saline into the tracheostomy prior to suctioning.] Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. [Answer D. Limits suctioning to 20 seconds during each suction pass.] Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%). Educational Objective: Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning, the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass to ≤10 seconds.

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply. A. Audible gurgling B. Heart rate 105/min C. Increased irritability D. Oxygen saturation 88% E. Respiratory rate 30/min

Correct Answers: A, C, D Artificial airways (eg, tracheostomies, endotracheal tubes) impair the cough mechanism and ciliary function, causing an increase in thick secretions that may occlude the airway. Focused respiratory assessments are critical to determine the need for suctioning and to maintain a patent airway. To decrease the risks associated with the procedure (eg, atelectasis, hypoxemia, trauma, infection), suctioning should be performed only when necessary. Assessment findings that indicate a need for suctioning include: — Decreased oxygen saturation — Altered mental status (eg, irritability, lethargy) — Increased heart rate (normal infant range: 90-160) — Increased respiratory rate (normal infant range: 30-60) — Increased work of breathing (eg, flared nostrils, use of accessory muscles) — Adventitious breath sounds (eg, crackles, wheezes, rhonchi) — Pallor, mottled, or cyanotic skin coloring Incorrect Answers: [B. Heart rate 105/min] Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning. [E. Respiratory rate 30/min] Respiratory rate of 30/min and heart rate of 105/min are within normal limits for an infant and would not indicate distress or a need for suctioning. Educational objective: Assessment findings that indicate the need to suction a client's tracheostomy or endotracheal tube include decreased oxygen saturation, altered mental status (eg, irritability), increased heart rate or respirations, increased work of breathing, and adventitious breath sounds.

The practical nurse is collaborating with the registered nurse to create a teaching plan for a client rehabilitating after a tibial fracture. Which instructions should be included to promote safety in the home when using crutches? Select all that apply. A. Keep a clear path to the bathroom. B. Look down at the feet when walking. C. Remove scatter rugs from floors. D. Use a small backpack/shoulder bag to hold personal items E. Wear rubber-soled shoes, preferably without laces.

Correct Answers: A, C, D, and E. Interventions to promote safety when using crutches in the home include the following: — Keep the environment free of clutter and remove scatter rugs to reduce fall risk — Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk — Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking — Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk — Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard. — Keep crutch rubber tips dry. Replace them if worn to prevent slipping. Educational Objective: Interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include looking forward when walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair.

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply. A. Palliative care focuses on quality of life and can be provided at any time B. Palliative care is only possible with a terminal diagnosis of ≤6 months C. Palliative care is provided by a multidisciplinary team D. Palliative care is another term for hospice care E. Palliative care provides relief from symptoms associated with chronic illnesses

Correct Answers: A, C, E Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. Incorrect Answers: [B. Palliative care is only possible with a terminal diagnosis of ≤6 months] Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). [D. Palliative care is another term for hospice care] The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment. Educational objective:Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families.

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply. A. 22-year-old man with a head injury sustained during a college football game. B. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty. C. 56-year-old man 2 weeks post myocardial infarction. D. 68-year-old woman recently diagnosed with pancreatic cancer. E. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis. F. 82-year-old woman 1 week post cataract surgery.

Correct Answers: A, C, E, and F. The Valsalva maneuver (straining during defecation) involves holding the breath while bearing down on the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery. Incorrect Answers: [Answer B. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty.] The otherwise healthy client recovering from reconstructive augmentation mammoplasty is not at risk for complications related to the Valsalva maneuver. [Answer D. 68-year-old woman recently diagnosed with pancreatic cancer.] The client recently diagnosed with pancreatic cancer is not at risk for complications related to the Valsalva maneuver. Educational Objective: The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply. A. Area around the insertion site feels cool to the touch. B. Client reports mild arm discomfort after the infusion has started. C. Edema is observed on the dependent side of the involved arm. D. Intraoperative peripheral IV catheter was placed in the left antecubital region. E. Serous fluid is leaking from the site despite secure connections.

Correct Answers: A, C, E. Peripheral IV (PIV) catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications (eg, phlebitis, infiltration) develop. Signs of phlebitis include erythema, edema, warmth, pain, and a palpable venous cord. Coolness to touch may indicate infiltration. The nurse should monitor for infiltration under the involved limb, particularly in the elderly. Infiltrated fluid may leak into loose skin and accumulate in dependent areas with no obvious signs of infiltration at the PIV site. If a PIV site leaks fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change. Incorrect Answers: [Answer B. Client reports mild arm discomfort after the infusion has started.] Potassium is a known irritant to veins. Discomfort is not a specific sign of infiltration, although the site should be regularly monitored for complications. [Answer D. Intraoperative peripheral IV catheter was placed in the left antecubital region.] Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location. Educational Objective: Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and area dependent from it (ie, edema).

Which of the following drug administrations should be reported as a practice error? Select all that apply. A. Cephalexin administered; client has history of anaphylaxis from penicillin. B. Hydromorphone 2 mg administered; client reports pruritus. C. Immunization for 3-month-old administered in ventrogluteal site. D. Oral niacin (nicotinic acid) administered; client has facial flushing. E. Warfarin administered; client at 12 weeks gestation.

Correct Answers: A, C, and E. Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% Incorrect Answers: [Answer B. Hydromorphone 2 mg administered; client reports pruritus.] Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. [Answer D. Oral niacin (nicotinic acid) administered; client has facial flushing.] Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues. Educational Objective: Do not administer warfarin if the client is pregnant. Intramuscular injections are given in the vastus lateralis to children age <7 months. Penicillins and cephalosporins can have a cross-sensitivity response. Narcotic-induced pruritus is not a true allergy.

Which of these are correct nursing actions related to client positioning? Select all the apply. A. Position the client in high Fowler's for a paracentesis related to end-stage cirrhosis. B. Position the client on the left side after liver biopsy. C. Position client on the side with head, back, and knees flexed after lumbar puncture. D. Position client in Trendelenburg on left side if air embolism is suspected. E. Position client with arm raised above head for chest tube placement.

Correct Answers: A, D, and E. Abdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture. In the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The registered nurse and health care provider should be notified immediately while the practical nurse remains with the client. Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm. Incorrect Answers: [Answer B. Position the client on the left side after liver biopsy.] After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk. [Answer C. Position client on the side with head, back, and knees flexed after lumbar puncture.] During a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine) or with head of the bed elevated 30 degrees). Educational Objective: For medical procedures, the nurse should ensure that the client: — Has an empty bladder and is in high Fowlers or a sitting position for paracentesis. — Is in Trendelenburg on the left side for suspected air embolism. — Has the arm raised above the head on the affected side for chest tube insertion. — Lies on the right side (for 2 hours) and then supine (12 - 14 hours) after liver biopsy. — Is side-lying with the head, back, and knees flexed for lumbar puncture.

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy. Which infection control measures are appropriate to implement? Select all that apply. A. Disinfect surfaces with diluted bleach solution. B. Hand hygiene with alcohol-based hand rub. C. Wear a face mask. D. Wear a protective gown. E. Wear nonsterile gloves.

Correct Answers: A, D, and E. C difficile poses a unique hazard in health care settings. This infection of the colon may develop/spread through contact with the organism or after prolonged antibiotic therapy alters normal bowel flora, allowing for C difficile overgrowth. Clients with C difficile infection should be placed on strict contact precautions in private rooms. These precautions require staff to wear protective gowns and gloves when entering the client's room. Hand hygiene using soap and water is the only effective method for removing C difficile spores. In addition, alcohol is not an effective agent for killing C difficile spores; therefore, a diluted bleach solution must be used to disinfect contaminated equipment and surfaces. Contact precautions require the caregiver to wear a gown and gloves. A face mask must be worn as personal protective equipment if an organism is spread via droplets. However, it is not required to prevent the spread of a contact-transmissible infection. The nurse should not wear a mask solely to avoid the unpleasant odor associated with C difficile diarrhea as this may be offensive and embarrassing to the client. Educational Objective: C difficile infection requires strict contact precautions, including wearing a gown and gloves at all times. Alcohol cannot kill C difficile spores, so caregivers must use soap and water in place of alcohol-based hand sanitizers. Contaminated surfaces and equipment should be disinfected using a diluted bleach solution.

A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action? A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room. B. Removes the urine specimen cup from the room in a sealed, leak-proof bag C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen D. Uses an alcohol-based hand antiseptic after removing gloves

Correct Answers: A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room. Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci, are placed in contact precautions to limit the transmission of microorganisms through direct or indirect contact. A designated stethoscope is usually kept in the client's isolation room. The health care practitioner should clean the stethoscope and earpieces with alcohol before use but should not remove them from the room. Incorrect Answers: [B. Removes the urine specimen cup from the room in a sealed, leak-proof bag] The urine specimen should be placed in a leak-proof container and then put in a sealed plastic bag before transport to the laboratory. [C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen] The nurse should scrub the surface of the collection port with alcohol or chlorhexidine solution for 15 seconds to help prevent the transmission of microorganisms before collecting a urine specimen from a Foley catheter [D. Uses an alcohol-based hand antiseptic after removing gloves] The nurse can perform hand hygiene with an alcohol-based antiseptic solution after removing gloves, except when caring for a client with Clostridium difficile. For this type of client, the nurse should perform hand hygiene with 5 mL of soap and running water to help rinse spores down the drain. Educational objective:To prevent the transmission of microorganisms when caring for a client in contact precautions, the nurse cleans and disinfects equipment (eg, medication scanner, glucose meter) appropriately, keeps dedicated equipment (eg, stethoscope, blood pressure cuff) inside the room, practices hand hygiene, and uses aseptic technique consistently.

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates client positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply. A. High Fowler position in preparation for a paracentesis B. Left side-lying position after percutaneous liver biopsy C. Semi-Fowler after cardiac catheterization via femoral entry D. Sims during soap-suds enema administration E. Supine position after a lumbar puncture

Correct Answers: B and C A paracentesis requires the client to be upright (semi- to high Fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it. Before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of a post-puncture headache from the loss of cerebrospinal fluid. Sims position (left side-lying with right hip and knee flexed) is best for enema administration. Incorrect Answer: [B. Left side-lying position after percutaneous liver biopsy] After a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding. [C. Semi-Fowler after cardiac catheterization via femoral entry] After cardiac catheterization via femoral entry, place clients flat or in low Fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma. Educational objective:Clients undergoing paracentesis should be upright. After liver biopsy, clients should be in a right side-lying position to prevent hemorrhage. After femoral cardiac catheterization, clients should remain flat. After lumbar puncture, clients should be flat in bed to minimize risk of headache.

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia. Which actions are appropriate? Select all that apply. A. Advance past the external sphincter only. B. Guide suppository along the rectal wall. C. Hold buttocks together firmly after insertion. D. Position client supine with knees and feet raised. E. Use gloved fifth finger for insertion.

Correct Answers: B, C, D, and E. Pediatric administration of rectal suppositories is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following. — Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) — Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. — Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years. Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. — Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption — Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion. — If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository Incorrect Answers: [Answer A. Advance past the external sphincter only.] The suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect. Educational Objective: In children younger than age 3 years, suppositories are inserted with the fifth finger of the nurse's gloved hand. Age-appropriate explanations and/or distractions are implemented to reduce distress.

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform? Select all that apply. A. Locate and remove any medication patches. B. Locate possible medical alert band or necklace. C. Remove rings and jewelry and lock in a secure location. D. Remove tampon and replace with menstrual pad. E. Take out contacts if no presence of eye trauma.

Correct Answers: B, C, D, and E. The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: — Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status. — Contact lenses: Remove to prevent corneal injury. — Medication patches: To prevent drug interactions and determine conditions currently being treated. — Tampons (in female clients): Remove to prevent toxic shock syndrome or infection. — Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops. Incorrect Answers: [Answer A. Locate and remove any medication patches.] Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client. Educational Objective: When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply. A. Combine all medications and administer together. B. Crush each medication separately before administration. C. Determine if the medications are available in liquid form. D. Flush the tube before and after medication administration. E. Mix medications with enteral feeding formula before administration.

Correct Answers: B, C, and D. Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube. Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption. In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency. Incorrect Answers: [Answer A. Combine all medications and administer together.] When using a feeding tube, each medication should be administered individually to prevent interactions between medications. [Answer E. Mix medications with enteral feeding formula before administration.] Medications mixed with enteral feedings may form a thick consistency and clog the tube. Educational Objective When using a feeding tube, medications should be crushed, dissolved, and administered separately to prevent interactions. Feeding tubes should be flushed before and after each medication is given. Liquid medications should be used if possible.

The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply. A. "I ate lunch about 4 or 5 hours ago." B. "I got a rash the last time I had IV contrast." C. "I had my last period 6 weeks ago." D. "I have a hearing aid implanted in my ear." E. "I smoked a cigarette about an hour ago."

Correct Answers: B, C, and D. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium. A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy. Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP. Incorrect Answers: [Answer A. "I ate lunch about 4 or 5 hours ago."] Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. [Answer E. "I smoked a cigarette about an hour ago."] Smoking does not affect MRI visualization and is not a contraindication. Educational Objective: Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks. Which of the following actions by the nurse are appropriate? Select all that apply. A. Discard aspirated gastric residual in a biohazard container. B. Flush the nasogastric tube before and after administering the feeding. C. Place the client in the semi-Fowler position. D. Start the feeding after obtaining a gastric residual volume of 75 mL. E. Start the feeding when the gastric residual has pH of 6.

Correct Answers: B, C, and D. When administering bolus enteral feedings, the nurse should elevate the head of the bed to 30-45 degrees (semi-Fowler position) and keep it elevated for 30-60 minutes afterwards to decrease aspiration risk. Many institutions require the nurse to hold feeding if the client must remain supine (eg, diagnostic tests). Feeding tubes should be flushed before and after feedings to keep the tube patent. Gastric residual volumes (GRVs) are traditionally checked every 4 hours with continuous feeding or before each bolus feeding. Per facility policy, enteral feedings may be held for high GRV (eg, >500 mL) to reduce aspiration risk. Low GRV indicates that the client is tolerating feedings well. Some facilities no longer routinely check GRVs because recent evidence shows that the procedure may not truly indicate aspiration risk and actually impairs calorie delivery. Regardless of GRV checks, the nurse should closely monitor clients for symptoms of intolerance (eg, abdominal distension, nausea/vomiting), which may indicate that feedings should be held or reduced in volume. Incorrect Answers: [Answer A. Discard aspirated gastric residual in a biohazard container.] Aspirated GRV should be returned to the stomach. If acidic gastric juices are repeatedly discarded, there is risk for hypokalemia and metabolic alkalosis. [Answer E. Start the feeding when the gastric residual has pH of 6.] Gastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. Newly inserted nasogastric tubes also require x-ray confirmation before feedings are initiated. Educational Objective: When administering bolus enteral feedings, the nurse should place the client in semi-Fowler position, check gastric residual volumes (GRVs) as prescribed, verify acidic pH ≤5, return aspirated GRV to the stomach, and flush the tube before and after feedings.

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. A. Ensuring the client wears an n95 respirator at all times. B. Keeping the door of the clients room closed at all times. C. Maintaining a log of everyone in and out of the clients room. D. Removing both pairs of gloves before removing gown and mask. E. Restricting visitors from entering the client's room.

Correct Answers: B, C, and E. Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed. Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms. Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. Incorrect Answers: [Answer A. Ensuring the client wears an n95 respirator at all times.] In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). [Answer D. Removing both pairs of gloves before removing gown and mask.] The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last. Educational Objective: Ebola is an extremely contagious viral disease with a high mortality rate. Infected clients require extensive infection precautions, including an airborne isolation room, strict personal protective equipment use, restriction of visitors, and a log of individuals who enter and exit the room.

A client in the medical-surgical unit has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply. A. Cleanse periurethral area with antiseptics every shift. B. Ensure each client has a separate container to empty collection bag. C. Keep catheter bag below the level of the bladder. D. Routinely irrigate the catheter with antimicrobial solution. E. Use sterile technique when collecting a urine specimen.

Correct Answers: B, C, and E. Health care catheter-associated urinary tract infections (UTIs) are prevalent among hospitalized clients with indwelling urinary catheters. Staff members should take the following steps to prevent infections in clients with these catheters: — Wash hands thoroughly and regularly. — Perform routine perineal hygiene with soap and water at each shift and after bowel movements. — Keep drainage system off the floor or contaminated surfaces. — Keep the catheter bag below the level of the bladder. — Ensure each client has a separate, clean container to empty collection bag and measure urine. — Use sterile technique when collecting a urine specimen. — Facilitate urine drainage from tube to bag to prevent pooling of urine in the tube or backflow into the bladder. — Avoid prolonged kinking, clamping, or obstruction of the catheter tubing. — Encourage oral fluid intake if not contraindicated. — Secure the catheter in accordance with hospital policy (tape or Velcro device). — Inspect the catheter and tubing for integrity, secure connections, and possible kinks. Incorrect Answers: [Answer A. Cleanse periurethral area with antiseptics every shift.] Perineal hygiene is performed using soap and water only at every shift and as needed. Routine use of antiseptic cleansers has not been shown to prevent infection and may lead to the development of drug-resistant bacteria. [Answer D. Routinely irrigate the catheter with antimicrobial solution.] Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention. Educational Objective: Routine catheter care to prevent health care catheter-associated urinary tract infections includes performing routine hand hygiene and cleansing of the perineal area with soap and water, keeping the catheter bag below the bladder and off the ground, keeping the catheter and tubing free of kinks, facilitating urine drainage into the bag, and using sterile technique when collecting urine specimens.

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. A. Ask a family member about the client's preferences for room arrangement. B. Offer the client an elbow to hold and walk a half-step ahead for guidance. C. Say "goodbye" when leaving the room to help orient the client. D. Speak slowly and slightly louder so the client can understand. E. Use a clock-face pattern to explain food arrangement on the client's meal tray.

Correct Answers: B, C, and E. The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: — Offer the client an elbow for guidance while walking slightly ahead and describing the environment — Announce room entry and exit to orient and avoid startling the client — Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily — Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. — Orient the client to the room and maintain this orientation for safety. Incorrect Answers: [Answer A. Ask a family member about the client's preferences for room arrangement.] Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement. [Answer D. Speak slowly and slightly louder so the client can understand.] The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit. Educational Objective: When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

A 7-year-old client is being treated for a scalp laceration with yellow drainage. The nurse prepares to irrigate the wound. Place the steps of wound irrigation in the correct sequence. All options must be used. 1. Confirm two client identifiers, confirm prescription, and assemble supplies. 2. Dry wound by patting gently with sterile gauze and apply dressing. 3.Fill a 30-mL syringe with irrigation solution and attach an irrigation tip. 4. Irrigate the wound with a steady, gentle stream from the innermost region outward. 5. Obtain wound cultures from the wound base using sterile culturette swabs. A. 1, 2, 3, 4, 5 B. 1, 3, 4, 5, 2 C. 1, 3, 4, 2, 5 D. 1, 4, 3, 5, 2

Correct Answers: B. 1, 3, 4, 5, 2 Before an open wound may be closed (eg, sutured), irrigation is performed to wash out debris and bacteria, which assists in healing and infection prevention. To perform wound irrigation, the nurse should: 1. Verify the client's identification, confirm the prescription, and assemble necessary supplies. 2. Don a gown, face mask with shield (to protect from splashing fluid), and sterile gloves (to maintain surgical asepsis and prevent infection.) 3. Fill a 30- or 60-mL syringe with nonirritating irrigation fluid (eg, sterile saline), and attach an 18- or 19-gauge irrigation tip or angiocatheter. 4. Irrigate 1 in (2.5 cm) above the area, using a steady, gentle stream from the innermost part of the wound to the outermost margin until the drainage becomes clear. 5. If required, obtain wound cultures after irrigation using sterile culturette swabs, swabbing from the center of the wound toward the outer margin. 6. Gently dry the skin with sterile gauze sponges to prevent microorganism growth and skin irritation from residual moisture, and apply a dressing. Educational Objective: Before wound irrigation, the nurse first verifies the client and prescription and assembles the needed supplies. A 30- or 60-mL syringe is filled with a nonirritating irrigation fluid, and an irrigation tip or angiocatheter is attached. The nurse irrigates the wound from the innermost region outward using a steady, gentle stream. If required, a culture may be obtained after irrigation, before drying the wound with sterile gauze and applying a dressing.

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply. A. History of angioedema with lisinopril B. History of epilepsy C. Known allergy to avocados and bananas D. Known allergy to shellfish E. Lip swelling when blowing up balloons

Correct Answers: C & E Latex allergy is an exaggerated immune-mediated reaction when one is exposed to products or dusts containing latex, a natural rubber used in many medical devices (eg, gloves, catheters, tape). Many people, particularly health care workers and individuals requiring chronic invasive procedures (eg, self-catheterization), develop latex allergy from repeated exposures. When assessing for potential latex allergies, the nurse should inquire about the client's reactions to common latex-containing objects and potentially cross-allergenic products. Balloons commonly contain latex, and reports of lip swelling, itching, or hives after contact indicate a high risk for anaphylactic reactions with continued exposure. Many food allergies (eg, avocado, banana, tomato) also increase the risk for latex allergy because the food proteins are similar to those found in latex. Incorrect Answers: [A. History of angioedema with lisinopril] There is no documented cross-sensitivity reaction between ACE inhibitors (eg, lisinopril) and latex. [B. History of epilepsy] Epilepsy is not associated with an increased risk for latex allergy. However, clients who have spina bifida or who have undergone multiple surgeries are at increased risk. [D. Known allergy to shellfish] Shellfish allergy was previously believed to be associated with allergy to iodine (CT contrast material), which has now been disproved. Shellfish allergy has no relationship to latex allergy. Educational objective:Latex allergy is an exaggerated immune reaction to exposure to latex-containing products (eg, gloves, catheters, tape). Risk factors include swelling, hives, or itching after exposure to common latex-containing products (eg, balloons); certain food allergies (eg, banana, avocado, tomato); and a history of multiple latex exposures (eg, self-catheterization, multiple surgeries).

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. A. Gown B. Goggles or face shield C. Hand washing D. N95 particulate respirator E. Surgical mask

Correct Answers: C and D. Airborne Precautions Indications: Tuberculosis — Varicella zoster (chickenpox) — Herpes Zoster (shingles) — Rubeola (measles) Components: N95 respirator or powered air-purifying — Negative-pressure isolation room with high-efficiency particulate air filter — As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. Incorrect Answers: [Answers A. Gown] & [Answers B. Goggles or face shield] Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). [Answer E. Surgical mask] For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational Objective: Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator.

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. A. Age of 50 B. Diagnosis of ovarian cancer C. Lying pulse of 80/min, standing pulse of 110/min D. Osteoarthritis of knees E. Takes carbidopa/levodopa F. Uses a cane to ambulate

Correct Answers: C, D, E, and F Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls. Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk. Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls. The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling. Incorrect Answers: [A. Age of 50] Fall risk does not increase until age >65-75. [B. Diagnosis of ovarian cancer] Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall. Educational objective:Fall risks include using assistive ambulatory devices, orthostasis, taking sedatives or antiparkinson medications, or being age >65-70.

A nurse is caring for a group of clients on a medical surgical unit. Which client is most at risk for contracting a nosocomial infection? A. 51-year-old client who received a permanent pacemaker 48 hours ago B. 60-year-old client who had a myocardial infarction 24 hours ago C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days D. 75-year-old client with dementia and dehydration who is on IV fluids

Correct Answers: C. 74-year-old client with stroke and an indwelling urinary catheter for 3 days A nosocomial infection occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections. The 74-year-old client is most at risk due to age and the presence of the urinary catheter. The nurse will need to be on high alert for this complication and should follow infection control procedures diligently. Incorrect Answers: [A. 51-year-old client who received a permanent pacemaker 48 hours ago] This client does have a surgical incision, which poses a risk for infection. However, this client is younger and does not have any underlying chronic condition to compromise the immune system. [B. 60-year-old client who had a myocardial infarction 24 hours ago] This client does not fall in the category of elderly and has no surgical incision or indwelling catheters other than a possible IV site. [D. 75-year-old client with dementia and dehydration who is on IV fluids] This client is at risk due to age and presence of an IV catheter. However, the risk is not as high as the client with the urinary catheter. Educational objective:The nurse should be aware of the risk for nosocomial infections in young children, elderly, and immunocompromised clients, especially those with long hospital stays, indwelling catheters, and surgical incisions.

The nurse reinforces teaching to a parent of a 2 month old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action. A. Administers the medication in small amounts at the back of the cheek using a syringe. B. Allows the client to sip the medication from a cup. C. Expels the medication from a dropper onto the back of the tongue. D Mixes the medication in the infants bottle of formula.

Correct answer: A. Administers the medication in small amounts at the back of the cheek using a syringe. The correct procedure for administering oral liquid medication to an infant is to place small amounts of the medication at the back of the cheek, allowing time for the infant to swallow each amount. This technique decreases the risk of choking and ensures that all the medication is consumed. [Incorrect answer B: Allows the client to sip the medication from a cup.] Although cup feeding may be a method used for infants in specific cases, medication administration requires a more accurate measurement. A syringe can provide an accurate measurement and decrease the risk of waste due to the infants spitting or drooling. [Incorrect answer C: Expels the medication from the dropper onto the back of the tongue.] Infants have an extrusion reflex (outward extension of tongue when it is touched) and a decreased gag reflex. Dispensing medication onto the back of the tongue would increase the risk for aspiration. [Incorrect answer D: Mixes the medication in the infants bottle of formula.] It is very important for the infant to receive the entire dose of the medication. Medication should never be mixed in a bottle or formula as the infant may not consume the entire amount. Educational Objective: Using a syringe to measure medication for an infant is the most accurate technique to ensure that the proper amount is being administered. The extrusion reflex and a decreased gag reflex in infants age <4 months increase the risk of choking and aspiration. Using a syringe to instill the medication at the back of the cheek decreases the risk of choking and ensures that the correct amount is consumed

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? A. Ask the mother's permission to touch the child's hand B. Interview the mother about the reason for bringing the child to the clinic C. Reassure the mother that there is no reason for distress D. Suggest postponing the examination until the mother calms down

Correct answer: A. Ask the mother's permission to touch the child's hand. In Latin American culture, an illness called "mal de ojo" (evil eye) is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child immediately afterward. Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If the child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. Incorrect Answers [Option B. Interview the mother about the reason for bringing the child to the clinic.] Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. [Option C. Reassure the mother that there is no reason for distress.] This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. [Option D. Suggest postponing the examination until the mother calms down.] Postponing the examination does not address the cause of the mother's distress. Educational Objective: Many Latin Americans beleive in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? A. Check the health care provider's prescription in the medical record. B. Explain that the health care provider has prescribed the medication. C. Look up the medication in the pharmacology reference. D. Teach the client about the purpose of the medication.

Correct answer: A. Check the health care provider's prescription in the medical record. Safe medication administration is conducted according to 6 rights. - Right client using 2 identifiers - Right medication - Right dose - Right route - Right time - Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration. If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. Incorrect Answers: [B: Explain that the health care provider has prescribed the medication.] The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. [C: Look up the medication in the pharmacology reference.] A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. [D: Teach the client about the purpose of the medication.] The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational Objective: When a competent client questions a new medication, the nurse should first try to verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? A. Check the health care provider's prescription in the medical record? B. Explain that the health care provider has prescribed the medication. C. Look up the medication in the pharmacology reference. D. Teach the client about the purpose of the medication.

Correct answer: A. Check the health care provider's prescription in the medical record? Safe medication administration is conducted according to 6 rights: — Right client using 2 identifiers — Right medication — Right dose — Right route — Right time — Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration. If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. Incorrect Answers: [Answer B. Explain that the health care provider has prescribed the medication.] The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. [Answer C. Look up the medication in the pharmacology reference.] A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. [Answer D. Teach the client about the purpose of the medication.] The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational Objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply. A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication. B. Breaks the ampule neck away from the nurse's body to prevent injury from the glass. C. Disposes of the empty glass ampule in a sharps container. D. Injects air into the glass ampule prior to withdrawing the medication. E. Rests and steadies the needle on the ampule's outer rim to withdraw medication.

Correct answers: B and C. A glass ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by: — Flicking the upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck. — Using sterile gauze to break the ampule neck away from the nurse's body t prevent injury from glass shards. — Setting the ampule on a flat surface or inverting it to withdraw the medication. — Disposing of the ampule in a sharps container. Incorrect Answers: [Answer A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication.] Glass shards may be present in the medication after an ampule is opened. To prevent the accidental administration of glass shards, the nurse must use a filter needle, rather than an injection needle, when withdrawing medication. [Answer D. Injects air into the glass ampule prior to withdrawing the medication.] Unlike when withdrawing medication from a vial, air should not be injected into a glass ampule; this causes the contents to spill from the container. [Answer E. Rests and steadies the needle on the ampule's outer rim to withdraw medication.] Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria. Educational Objective: When preparing medication from a glass ampule, the nurse breaks the ampule away from the body and discards it in the sharps container. The nurse withdraws medication using a filter needle to prevent the injection of glass shards, avoids touching the needle to contaminated ampule edges, and avoids injecting air to prevent spillage.

Which client is at the greatest risk for development of hospital-acquired pressure injuries? A. 25-year-old client with quadriplegia, urosepsis, temperature of 101° F (38.3° C), and white blood cell count of 18,000/mm3 (18.0 x 10^9/L) B. 50-year old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg C. 80-year old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) D. 87-year old client 2 days post open cholecystectomy.

Correct Answer: B 50-year old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. Incorrect Answers: [Answer A. 25-year-old client with quadriplegia, urosepsis, temperature of 101° F (38.3° C), and white blood cell count of 18,000/mm3 (18.0 x 10^9/L) ] This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. [Answer C. 80-year old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L)] This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. [Answer D. 87-year old client 2 days post open cholecystectomy.] This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injuries. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients. Educational Objective: Although pressure injuries can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

The nurse is preparing to give a heparin injection to a client who is malnourished and cachectic. Which method of injection would be appropriate for this client? A. 27 gauge; ¼ in (0.6 cm) long at 15 degrees B. 25 gauge; ½ in (1.3 cm) long at 45 degrees C. 25 gauge; ½ in (1.3 cm) long at 90 degrees D. 18 gauge; 1 ½ in (3.8 cm) long at 90 degrees.

Correct Answer: B. 25 gauge; ½ in (1.3 cm) long at 45 degrees When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation. The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 2). Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus. Incorrect Answers: [Answer A. 27 gauge; ¼ in (0.6 cm) long at 15 degrees] A 15-degree angle is used for intradermal injections and would not deliver medication into the subcutaneous tissue. [Answer C. 25 gauge; ½ in (1.3 cm) long at 90 degrees] A 90-degree injection angle is appropriate for clients with sufficient adipose tissue (ie, at least 2 in [5 cm] can be grasped). [Answer D. 18 gauge; 1 ½ in (3.8 cm) long at 90 degrees.] Needles longer than 5⁄8 in (1.6 cm) are used to administer intramuscular injections. Educational Objective: Anticoagulant injections should be administered in the abdominal subcutaneous tissue at a 45- to 90-degree angle. A 45-degree angle is used for clients with minimal adipose tissue to avoid accidental intramuscular injection, which would cause rapid absorption and result in hematoma and painful muscle irritation.

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer. The client says to the nurse, "I'm so worried that my future spouse is going to call off our engagement." What is the best response by the nurse? A. "Are you concerned about how the surgery will affect your sexuality?" B. "If you are concerned about infertility, you could always bank your sperm." C. "The cancer is at an early stage. You are going to be fine." D. "What have you and your future spouse discussed about your condition?"

Correct Answer: D. "What have you and your future spouse discussed about your condition?" A diagnosis of testicular cancer is very often a source of anxiety for a client and can cause concern about sexual performance and fertility. How a client's sexuality is affected by this diagnosis depends on how advanced the cancer is and the course of prescribed treatment. Decisions about sperm banking and/or whether the client wants to procreate in the future are best made prior to surgery, radiation, and/or chemotherapy. The client and significant others need to be given counseling and the opportunity to discuss the potential effects of treatment and the options for preserving sperm. In this scenario, the client's stated concern about the future with the partner may be the way of voicing concern about how the surgery will affect sexuality. In order to determine what counseling or information this client needs, it is most important for the nurse to first assess the client's knowledge of the condition and what the client and the future spouse have already discussed. In addition, by using the therapeutic communication techniques of presenting a general lead and exploration, the nurse can facilitate the conversation and the nurse-client relationship. Incorrect Answers: [Answer A. "Are you concerned about how the surgery will affect your sexuality?"] This is not the best response as it requires a short, single answer from the client and does not provide the opportunity for exploration or elaboration. "Yes" or "no" questions are useful and necessary in some client-nurse interactions. However, generally they are considered to be nontherapeutic as they are not conversation enhancers. [Answer B. "If you are concerned about infertility, you could always bank your sperm."] Banking sperm is an option for clients with testicular cancer. However, it is more important for the nurse to first explore the client's concerns and knowledge about the condition. [Answer C. "The cancer is at an early stage. You are going to be fine."] This statement by the nurse may be giving false reassurance to the client. In addition, it blocks further discussion or exploration of the client's knowledge about the condition and related concerns. Educational Objective: A diagnosis of cancer is a cause of anxiety for any client due to concerns about prognosis. A client with a diagnosis of testicular cancer will have additional concerns about sexual performance and fertility. Using therapeutic communication techniques, such as a broad opening and a general lead and exploration, will facilitate the nurse-client relationship and a meaningful discussion about the condition and concerns.

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse? A. "Do you have family members or friends who could take care of you?" B. "I'll make a referral to the local home care agency in your area." C. "It will be very difficult to manage your care at home." D. "Tell me how you think your life would be different if you moved from here."

Correct Answer: D. "Tell me how you think your life would be different if you moved from here." After 2 years of residence, this client has expressed a desire to leave the nursing home and return home. This client with advanced MS will need maximal assistance with basic activities of daily living (bathing, grooming, toileting, transfers, locomotion), meal preparation, laundry, shopping, and other housekeeping chores. Discharging this client to care at home will require much planning and present numerous challenges related to safety, finances, support and informal caregiver system, durable medical equipment, and layout of the home. Therefore, before any discussion or planning can take place, the nurse needs to determine why the client wants to go home at this point in time. The nurse should also ask the client if something happened in the nursing home. However, asking "why" or "yes/no" questions is non-therapeutic and will not facilitate a meaningful nurse-client interaction. By using the therapeutic communication technique of exploring, the nurse can encourage the client to discuss thoughts, feelings, and reasons for wanting to leave the current residence. Incorrect Answers: [Answer A. "Do you have family members or friends who could take care of you?"] This is important information to obtain when planning the discharge of a client who needs care at home; however, it is not the priority assessment. [Answer B. "I'll make a referral to the local home care agency in your area."] This would be an appropriate nursing action after the nurse has discussed and assessed the reasons why the client wants to return home. [Answer C. "It will be very difficult to manage your care at home."] This is an appropriate response as it presents the reality of the client's situation, but it is not the priority response. Educational Objective: Exploring is a therapeutic communication technique that will facilitate further assessment of a particular subject or experience. It is a technique that is especially helpful when a client makes a statement or presents a topic that alerts the nurse that there could be additional information beyond the surface of the initial communication.

A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours. B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy. C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmoI/L) D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure.

Correct Answer: A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours. The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the clients fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. [Option B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy.] Anaphylaxis causes increased capillary permeability, leaking intravascular fluids into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. [Option C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmoI/L)] Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. [Option D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure.] A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. Educational Objective: Isotonic IV solutions, which have the same osmolality as plasma, are administered to expand intravascular fluid volume and replace the fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury.

A postoperative client with obesity and diabetes myelitis has an abdominal wound and is at risk for poor wound healing. Which of the following interventions does the nurse anticipate to prevent wound dehiscence? Select all that apply. A. Administer docusate sodium orally every day. B. Assist in applying an abdominal binder. C. Implement caloric restriction to promote weight loss. D. Monitor blood glucose to maintain tight control. E. Reinforce teaching to hug a pillow while coughing.

Correct Answer: A, B, D, and E. Dehiscence occurs when the edges of a surgical wound fail to approximate (ie, partial or total separation of the skin and tissue layers.) Clients with conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection) are at a higher risk. Mechanical stress on the wound (eg, straining to cough, vomit, or defecate) also increases the potential for dehiscence. Interventions to prevent dehiscence include: — Administer stool softeners (docusate [Colace]) to prevent straining during defecation and alleviate constipation from postoperative immobility and opioid medications. — Administer antiemetics (ondansetron [Zofran]) as needed to prevent straining with vomiting. — Apply an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing/moving. — Monitor blood sugar to maintain tight glycemic control (fasting glucose <140 mg/dL, random glucose <180 mg/dL) to help prevent infection and promote wound healing. — Splint the abdomen by holding a pillow or folded blanket against the wound for support when coughing/moving. Incorrect Answers: [Answer C. Implement caloric restriction to promote weight loss.] Nutritional therapy is critical to the normal wound healing process, which depends on adequate intake of calories and protein. Although this client should be educated about weight loss measures prior to discharge, caloric restriction is unnecessary at this time and could further delay wound healing. Educational Objective: Interventions to prevent wound dehiscence include administering stool softeners and antiemetics, applying an abdominal binder, splinting the abdomen, and maintaining tight glycemic control.

The nurse precepts a practical nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication. Which student action indicates that further instruction is needed? A. Instructs the client to close eyelid and move eye around; applies pressure to the lacrimal duct for 30 - 60 seconds. B. Pulls lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac. C. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to the inner canthus. D. Rests hand on client's forehead and holds dropper 1 - 2 cm (1/2 - ¾ in) above the conjunctival sac.

Correct Answer: C. Removes dried secretions with moistened sterile gauze pads by wiping from the outer to the inner canthus. If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: 1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct. 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa. 3. Rest hand on the client's forehead and hold dropper 1-2 cm (1/2 - ¾ in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination. 4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac. 5. Instruct the client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation into the cornea. 6. Instruct the client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30 - 60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption. 7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination. 8. Wait 5 minutes before instilling a different medication into the same eye. Educational Objective: To administer ophthalmic medications, follow these steps: (1) Remove secretions from the eyelid by wiping from the inner to outer canthus; (2) pull lower eyelid downward, have client look upward, and instill drops into the conjunctival sac; and (3) apply pressure to the lacrimal duct if medication has systemic effects (eg, beta blocker, timolol maleate).