Practice
A client with advanced kidney disease has serum potassium of 7.1 mEq/L and creatinine of 4.5 mg/dL. What is the priority prescribed intervention? 1. Administer IV 50% dextrose and regular insulin 2. Administer IV furosemide 3. Administer oral sodium polystyrene sulfonate 4. Prepare the client for hemodialysis catheter placement
1 IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body. If the client has ECG changes (tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose
A client who has been on long term omeprazole therapy for GERD is admitted to the hospital for a UTI. The nurse recognizes that this client is at highest risk for which complication due to omeprazole use? 1. C. diff infection 2. Gait disturbance 3. Jaw necrosis 4. Tremor
1 Long-term use of proton pump inhibitors is common as these medications are available OTC. PPIs impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases the possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the upper GI tract. This leads to increased risk of pneumonias PPI use may also increase the risk for C. diff. Currently the cause is unclear. This client would be receiving antibiotics for a UTI, further increasing the risk for C diff infection Option 2: Gait disturbance (ataxia) is commonly seen with phenytoin toxicity Option 3: Jaw necrosis is associated with long term bisphosphonate therapy Option 4: Tremor is seen with lithium toxicity and albuterol
The daughter of an 80 year old client recently diagnosed with Alzheimer disease says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? 1. "Engaging in regular exercise decreases the risk of AD." 2. "Having a family history of AD is not a risk factor." 3. "Try not to worry about this now as you can't do anything to prevent AD." 4. "You should avoid aluminum cans and cookware to prevent AD."
1 The development of Alzheimer disease is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age >65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease For late-onset AD, the strongest known risk factor is ADVANCING AGE. Having a first-degree relative with late-onset AD also increases the risk of developing AD. Trauma to the brain has been associated with the development of AD in the future. Research suggests that healthy lifestyle choices reduces the risk for develop AD
A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the UAP would require immediate action by the nurse? 1. "I changed the client's perineal pad 3 times in the last 2 hours." 2. "I have been encouraging the client to exercise the legs while in bed." 3. "I thought you should know the client voided 500 mL of straw-colored urine." 4. "I just took the client's vital signs, which are blood pressure 108/60 mmHg, pulse 58, and respirations 12."
1 The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates MORE THAN ONE PAD IN AN HOUR. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the HCP Option 3: The client's voiding of 500 mL of straw-colored urine is a normal finding
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 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 3. Instills sterile normal saline into the tracheostomy prior to suctioning 4. Limits suctioning to 20 seconds during each suction pass 5. Uses sterile gloves and techniques throughout the procedure
1, 2, 5 Open endotracheal 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 (pneumonia, hypoxemia) or tracheal injury (trauma, bleeding). To reduce the risk of complications, the nurse should: -Preoxygenate 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 Option 3: Instilling sterile NS solution or sterile water in the client's airway greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways
The nurse is preparing to teach the perinatal staff about caring for newborns with either omphalocele or gastroschisis. Which of the following statements are appropriate for the nurse to include? Select all that apply 1. "An omphalocele with an intact peritoneal sac should be covered with a sterile, nonadherent dressing immediately after birth." 2. "If immediate surgical repair of the defect is planned, the newborn should be fed via a NG tube instead of breastfed." 3. "Newborns with omphalocele or gastroschisis require IV access for fluid and electrolyte replacement." 4. "Newborns with omphalocele or gastroschisis should be monitored closely for temperature instability and infection." 5. "Petroleum jelly should be applied to the exposure bowel of newborns with gastroschisis before it is covered with plastic."
1, 3, 4 Omphalocele and gastroschisis are congenital defects of the abdominal wall. An omphalocele occurs when bowel, usually covered with a peritoneal sac, herniates through the abdominal wall via the umbilical opening. Gastroschisis occurs when bowel herniates through the abdominal wall without a protective peritoneal sac Immediately after birth, the nurse should cover the herniated bowel to prevent injury; a nonadherent dressing (plastic bowel bag; sterile, saline soaked gauze covered by loose plastic) is necessary to prevent fluid loss and protect the bowel from drying. The nurse should monitor for temperature instability, infection, and fluid loss and initiate IV access to facilitate antibiotic administration and fluid and electrolyte replacement Option 2: If immediate surgical repair is planned, the nurse should keep the newborn NPO in preparation for surgery
A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination
1, 4, 5 Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetycholine is depleted Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered BEFORE MEALS so that the client's ability to swallow is strongest during meal Semi-solid foods (easily-chewed foods) are preferred over solid foods to avoid stressing muscles involved in chewing or swallowing All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted Option 3: The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis
The nurse is caring for 4 clients requiring IV fluid therapy. For which client should the nurse anticipate the need for isotonic crystalloid administration? 1. 25 year old with closed-head injury and signs of increasing intracranial pressure 2. 45 year old with acute gastroenteritis and dehydration 3. 60 year old with seizures and serum sodium of 112 mEq/L 4. 68 year old with chronic renal failure and hypertensive crisis
2 Acute gastroenteritis is associated with nausea, vomiting, and diarrhea, placing the client at risk for dehydration and sodium loss. Isotonic crystalloid fluids (0.9% sodium chloride, LR) are the treatment of choice due to the similarity in concentration with plasma and ability to increase extracellular fluid without moving into the intracellular space. In addition, isotonic fluids may increase sodium levels in clients experiencing excess sodium loss Option 1: Hypertonic solutions (3% sodium chloride) are administered to clients with increased ICP to raise the osmolality of ECF, which decreases cellular swelling by drawing water from the cells. Isotonic fluids are avoided because an increase in circulating isotonic fluid promotes additional fluid shifting into the cells, which further increases ICP Option 3: The client with a serum sodium of 112 mEq/L is dangerously hyponatremic and at risk for further neurological decline. A hypertonic solution (3% sodium chloride) is the most appropriate choice to rapidly correct sodium deficits
The nurse is assessing a 3 month old infant who was admitted to the floor 18 hours ago after undergoing surgical repair of a cleft lip. Which assessment finding would cause the nurse to be concerned? 1. The area around the incision appears swollen 2. The client is prone while playing with the parent 3. The client is wearing bilateral elbow restraints 4. There are adhesive strips over the incision
2 Cleft lip and cleft palate are common congenital defects that occur separately or together. Cleft lip is an opening (notch) in the upper lip, and cleft palate is a malformation of the roof of the mouth due to incomplete fusion of the palatine bones and maxilla during fetal development. Surgery to repair a cleft lip and/or palate is usually performed between age 2 months to 12 months Postoperative care includes protecting the surgical site from trauma to facilitate proper healing. The nurse should ensure the infant is positioned to facilitate secretion drainage and prevent airway obstruction (upright, supine). The nurse should avoid placing the infant PRONE OR ON THE SIDE OF THE INCISION because of the risk for damage to the surgical site due to bumping or rubbing the face against the mattress or floor
The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? 1. Compensation 2. Displacement 3. Projection 4. Reaction formation
2 Displacement occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses Option 3: Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. Example: a husband with thoughts of infidelity who then accuses his wife of being unfaithful Option 4: Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. Example: a client with cancer who fears dying but behaves in an overly optimistic and fearless manner about his treatment and prognosis
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? 1. Blood cultures 2. Creatinine levels 3. Magnesium levels 4. WBC count
2 Vancomycin can cause NEPHROTOXICITY, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with HCP and/or pharmacist before administering the dose
The nurse is caring for a client receiving IVPB azithromycin. Which client data obtained by the nurse should be reported to the HCP prior to administering any additional doses? 1. Currently nauseated and vomited once 2. Decreased white blood cell count 3. Prolonged QT interval 4. Temperature of 101.4
3 All macrolide antibiotics (azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an ECG should be monitored. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic meds such as tylenol, phenothiazines, and sulfonamides.
A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first? 1. Administer IV ondansetron 2. Apply oxygen via face mask 3. Obtain blood pressure 4. Perform vaginal examination
3 An epidural block can provide effective pain relief during labor, however, it also inhibits the sympathetic nervous system. SNS inhibition causes peripheral vasodilation, which may produce significant hypotension. If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava
The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Driving is not recommended until I stop taking this medication." 2. "If I experience a panic attack I should take an extra dose of medication." 3. "It will be 2-4 weeks before I feel the full effect of this medication." 4. "Withdrawal symptoms will occur if I abruptly stop taking this medication."
3 Buspirone (Buspar) is an anxiolytic medication that differs from other medications used to manage anxiety disorders (benzodiazepines) because it typically lacks central nervous system depressant effects and has a low abuse potential. Therefore, buspirone has a favorable side effect profile because it usually does not produce withdrawal symptoms, dependence, or psychomotor slowing However, unlike other anxiolytic medications, buspirone does not work immediately. Onset of symptom relief occurs AFTER 1 WEEK of therapy, with FULL EFFECTS OCCURRING BETWEEN 2 AND 4 WEEKS
The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn? 1. Choose an infant carrier with a narrow seat 2. Place 2 diapers on the infant at all times 3. Swaddle the infant with hips flexed and abducted 4. Use an infant swing that keeps both legs straight
3 Developmental dysplasia of the hip is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include: -Proper swaddling technique- infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement -Choosing infant carriers or car seats with wide bases- infant seats should allow for proper hip positioning in an abducted manner -Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight together Option 1: Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments
The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding? 1. Bilateral rales found on lung auscultation 2. Dullness over bladder found on percussion 3. Ptosis of right eyelid found on facial inspection 4. Single testicle found on genital palpation
3 Eyelids should sit above the pupils symmetrically with irises showing. Ptosis (drooping of the eyelids below the level of the pupil) could indicate paralysis of the oculomotor nerve. Option 1: Crackles (rales) indicate fluid in the lungs and are expected immediately after birth. Rales will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or presence of crackles after the first few hours of birth are abnormal and should be reported Option 2: Percussing dullness in the hypogastric area is a normal finding when the bladder is full. The neonate should void spontaneously within a few hours after birth Option 4: An undescended testicle (cryptorchidism) at birth is not concerning. Most undescended testes descend spontaneously by age 6 months
The nurse is caring for a dying child on a palliative unit. Which statement by the nurse is most important to make to the parents immediately following the death of their child? 1. "Finding support with other local grieving parents can be helpful." 2. "Self care is important at this time. Take a break while the staff completes care." 3. "Some parents like to cuddle and speak to the child. Take the time you need." 4. "This must be a very difficult time. How have you dealt with loss in the past?"
3 Parents should be allowed as much time as they need with the child's body and should not be rushed while they say goodbye The nurse should be present to provide emotional support and identify if parents wish to help participate in some or all care activities, such as bathing and dressing the child
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect? 1. Constipation 2. Sedation 3. Sexual dysfunction 4. Weight loss
3 SSRIs are commonly used to treat major depression and anxiety disorders. SSRIs (fluoxetine, paroxetine, citalopram, escitalopram, sertraline) are gentally well tolerated except for SEXUAL DYSFUNCTION. The side effect may decrease or cease after 2 to 4 week waiting period for the therapeutic effect, or the client may be able to switch to a different antidepressant (bupropion)
The clinic nurse assesses an 8 year old client who reports a sore throat and has a bright red, pruritic rash on the chest that feels like fine bumps and looks like a sunburn. Which diagnostic tool does the nurse anticipate the HCP will prescribe? 1. Allergy skin testing 2. CBC 3. Rapid streptococcal antigen test 4. Skin biopsy
3 Scarlet fever, a complication of group A streptococcal infection, is common in early childhood and is characterized by a distinctive RED RASH. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper.
The nurse is working in the ED. Which client should the nurse see first? 1. 12 year old with severe neck muscle spasms who is taking haloperidol for Tourettes syndrome 2. 80 year old with irritability and agitation who has taken alprazolam for 2 weeks 3. Client taking clozapine who has sudden onset of high fever, diaphoresis, and change in mental status 4. Client taking olanzapine who has dry mouth, blurry vision, and constipation
3 The client taking clozapine is exhibiting classic signs of neuroleptic malignant syndrome, and uncommon but life-threatening adverse reaction to anti-psychotic meds. NMS is characterized by high fever, muscular rigidity, altered mental status, and autonomic dysfunction. Treatment includes supportive care (rehydration, cooling body temperature) and immediate discontinuation of the medication. Option 1: Severe neck spasms in an individual taking haloperidol (and other psychotropic meds) indicate a dystonic reaction. This client is in no immediate danger but needs treatment with IV benztropine (Cogentin) as soon as possible. The client should be seen second Option 2: Benzodiazepines can cause paradoxical worsening of agitation in elderly clients. This client needs a change in medication but does not need to be seen immediately
The charge nurse on a telemetry unit is training a new RN. The charge nurse assists the new RN in prioritizing assessments of multiple clients. Which client should be assessed first? 1. A client in atrial fibrillation with an INR of 4.0 who has a warfarin dose due 2. A client who had coronary artery bypass surgery 2 days ago, has a temperature of 99.0 F, and has a dose of vancomycin due 3. A client who is 48 hours post MI, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been discontinued after 8 hours and who is anxious to drink fluids
3 Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of an MI indicate VENTRICULAR IRRITABILITY and increase the risk for a more serious dysrhythmia (v-tach, v-fib). Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. After assessing the client's vitals, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify HCP Option 1: The client with A-fib should be seen after the MI client. Vital signs are stable, but the INR should be lower (2.0-3.0 for A-fib). The nurse should assess for signs of bleeding and notify the HCP, the scheduled dose of warfarin should likely be held
The nurse is caring for a client with C. diff colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in the client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care
3, 5 C. diff is a highly infectious bacteria causing severe colitis in infected clients. When caring for a client with C. diff, it is critical that the nurse implement CONTACT ISOLATION PRECAUTIONS to prevent transmission of microorganisms between clients Option 2: Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact precautions if performing activities with the possibility of body fluid splashing (suctioning, wound care)
What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of Chinese checkers in the activity room 3. Playing video games 4. Watching a favorite movie
4 A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, IV for hydration, and bed rest to decrease energy expenditure and oxygen demand Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage Option 1: Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed Option 2: A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not maintain bed rest and would be too stimulating for the child Option 3: Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest
A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block
4 A pudendal nerve block infiltrates local anesthesia (lidocaine) into the areas surround the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the HCP. It does not relieve contraction pain but does relieve perineal pressure
The nurse is assessing a client with HTN and essential tremor 2 hours after receiving a first dose of propranolol. Which assessment is most concerning to the nurse? 1. Client reports a headache 2. Current blood pressure is 160/88 mmHg 3. Heart rate has dropped from 70 to 60 4. Slight wheezes auscultated during inspiration
4 Propanolol is a beta blocker. It is used for many indications (essential tremor) in addition to blood pressure control. Blood pressure decreases secondary to a decrease in heart rate. BRONCHOCONSTRICTION may occur due to the effect on the beta 2 receptors. The presence of WHEEZING in a client taking propanolol may indicate that bronchoconstriction or bronchospasm is occuring. The nurse should assess for any history of asthma or respiratory problems and notify HCP
The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions? 1. "Having sex will make the infection worse." 2. "I enjoy iced tea, so I will drink more to stay hydrated." 3. "I should take ciprofloxacin until I feel better." 4. "I should take docusate to prevent straining."
4 Prostatitis is inflammation of the prostate gland, usually caused by a bacterial infection. Symptoms include rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management includes antimicrobial and anti-inflammatory medications (ibuprofen). Alpha-adrenergic blockers (tamsulosin, alfuzosin) help relax the bladder and prostate. Option 1: Engage in sex or masturbation to reduce discomfort related to retained prostatic fluid
