SELF-TEST 1 REVIEW UWorld

The nurse caring for a male client prepares to insert an indwelling urinary catheter. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Place in order the steps the nurse should take when inserting the urinary catheter. All options must be used. - Place fenestrated drape with shiny side down. - Perform hand hygiene and apply sterile gloves. - Use nondominant hand to grasp penis below glans. - Use dominant hand to cleanse meatus with cotton balls or swab sticks. - Advance catheter to tubing bifurcation and inflate balloon. - Use dominant hand to insert catheter until urine return is observed.

- Perform hand hygiene and apply sterile gloves. - Place fenestrated drape with shiny side down. - Use nondominant hand to grasp penis below glans. - Use dominant hand to cleanse meatus with cotton balls or swab sticks. - Use dominant hand to insert catheter until urine return is observed. - Advance catheter to tubing bifurcation and inflate balloon. Steps for indwelling urinary catheter insertion for the male client include: Perform hand hygiene, open sterile catheterization kit, and apply sterile gloves from kit (Option 2). Maintaining sterility of gloves, place sterile fenestrated drape with opening centered over penis (Option 3). Arrange remaining kit supplies on sterile field. Remove protective covering from catheter, lubricate catheter tip, and pour antiseptic solution over cotton balls or swab sticks. Firmly grasp penis with nondominant hand, retracting foreskin if present (Option 6). Nondominant hand is now considered contaminated and remains in this position for duration of procedure. Use dominant (sterile) hand to cleanse meatus with antiseptic solution using cotton balls or swab sticks (Option 4). Use new cotton ball or swab stick with each swipe. Use dominant hand to pick up catheter and insert it until urine return is visualized in catheter tubing (Option 5). Advance to bifurcation of catheter tubing. Hold in place and inflate balloon (Option 1). Urine return in catheter tubing may be from urethra and does not indicate that balloon tip is fully inside bladder. Because male urethra varies in length, balloon should not be inflated until catheter is fully advanced.

A 2-month-old infant is admitted with respiratory syncytial virus and bronchiolitis. Which interventions would the nurse anticipate? Select all that apply. 1. Administer antipyretics 2. Initiate IV fluids 3. Keep the head of the bed flat 4. Maintain isolation precautions 5. Suction as needed

1, 2, 4, 5. Respiratory syncytial virus (RSV) is a common cause of respiratory tract infection and bronchiolitis in infants and children, occurring primarily during the winter. It affects the ciliated cells of the respiratory tract, causing bronchiolar swelling and excessive mucus production. RSV in infants causes rhinorrhea, fever, cough, lethargy, irritability, and poor feeding. Severe RSV infection also causes tachypnea, dyspnea, and poor air exchange. Interventions are supportive, including: Providing supplemental oxygen and suctioning to support oxygen exchange and clear the airway (Option 5) Elevating the head of the bed to improve diaphragmatic expansion and promote secretion clearance (Option 3) Administering antipyretics to reduce fever and provide comfort (Option 1) Initiating IV fluids to correct dehydration due to fever, tachypnea, or poor oral intake (Option 2) RSV is transmitted via direct contact with respiratory secretions. Contact isolation is required, and droplet precautions are added if within 3 ft (0.91 m) of the client, depending on facility policy (Option 4). Palivizumab (Synagis), a monoclonal antibody, is administered intramuscularly once monthly during the winter and spring to prevent RSV in children at high risk for contracting the infection (eg, prematurity, chronic lung disease).

A nurse is teaching an inservice regarding prevention of venous thromboembolism. Which nursing interventions should be included in the teaching? Select all that apply. 1. Administer scheduled anticoagulants 2. Apply sequential compression devices 3. Elevate the legs with pillows behind the knees 4. Have clients ambulate regularly as tolerated 5. Instruct clients to point and flex the feet in bed

1, 2, 4, 5. Venous thromboembolism (VTE) occurs when a thrombus (eg, deep vein thrombosis) forms and embolizes into the bloodstream (eg, pulmonary embolism). Hospitalized clients tend to have multiple risk factors for VTE, including venous stasis from prolonged immobility and endothelial damage from surgeries or IV catheter placement. VTE prophylaxis should be implemented in all hospitalized clients. Measures include: Administration of anticoagulants (eg, enoxaparin), usually prescribed in clients with a moderate or high risk of VTE (eg, postsurgical) unless contraindicated (eg, active bleeding) (Option 1) Application of compression devices or antiembolism stockings to limit venous stasis (Option 2) Frequent ambulation, 4-6 times daily as tolerated, to improve circulation and promote venous return (Option 4) Foot and leg exercises (eg, extend and flex the feet and knees) to promote venous return by activating calf muscles (Option 5) (Option 3) Elevating the legs while in bed promotes venous return by gravity. However, the nurse should ensure that any pillows used to elevate the legs do not place pressure directly behind the knees, as pressure on the posterior knees compresses leg veins. Clients should also avoid crossing the legs to prevent pressure on the back of the knees.

After addressing a group of young adults about sexual health and hygiene, the nurse recognizes that teaching regarding genital warts and the human papillomavirus (HPV) has been effective when hearing which client statements? Select all that apply. 1. "Genital warts that have been treated are at risk of recurrence." 2. "I should begin Pap testing as soon as I am sexually active." 3. "I should receive the HPV vaccine series even if I am already sexually active." 4. "Infection with HPV increases my risk of cervical cancer." 5. "Using condoms during sex will eliminate the risk of spreading the virus."

1, 3, 4. Human papillomavirus (HPV) is a common sexually transmitted infection (STI) that is often asymptomatic and may resolve spontaneously in young, healthy people. However, certain HPV strains can persist, resulting in genital warts. Genital warts can be treated (eg, topical podophyllin, cryotherapy, laser surgery) but may recur at any time (Option 1). High-risk HPV strains (types 16 and 18) increase risk of cervical, oral, and genital cancers (Option 4). The HPV vaccine helps prevent HPV infection and is most effective if taken before becoming sexually active. However, current guidelines suggest that even teens and young adults (age ≤26) who have already become sexually active may benefit from HPV vaccination (Option 3). (Option 2) The majority of clinical organizations recommend that cervical cancer screening (Pap testing) be initiated at age 21, regardless of sexual history. In women age <21, HPV infection rarely progresses to malignancy. Overdiagnosis and treatment of potentially benign HPV infections can lead to negative reproductive outcomes in the future (eg, pregnancy loss, preterm birth). (Option 5) Barrier methods (eg, condoms) can reduce the risk of HPV transmission. However, abstinence is the only definitive way to eliminate the risk of contracting STIs.

The nurse is caring for an older adult client with dementia and a history of falls. Which interventions are appropriate to promote client safety? Select all that apply. 1. Activate the bed alarm before leaving the room 2. Keep the lights dim to create a calm environment 3. Place a bedside commode next to the bed 4. Place the client in a room close to the nurses' station 5. Request a prescription for a vest or belt restraint

1, 3, 4. The nurse promotes client safety by implementing fall risk precautions. Standard fall risk precautions (eg, bed in lowest position, call light within reach) are appropriate for all clients. A client with multiple fall risk factors (eg, altered mental status, advanced age) has an increased risk for falls and requires additional precautions. The nurse should activate the bed alarm, place the client in a room close to the nurses' station, and place a bedside commode next to the bed. (Option 2) Keeping the lights dim increases the risk for falls, particularly when the client is in an unfamiliar environment. A well-lit room promotes orientation and helps the client avoid obstacles during ambulation. (Option 5) Restraints increase agitation and are associated with serious complications (eg, impaired perfusion and skin integrity). Restraints are indicated only if less restrictive measures fail to keep the client safe. The nurse should first consider alternatives such as family involvement or supervision by a trained staff sitter.

A nurse is reading a client's tuberculin skin test 48 hours after placement and notes an 11-mm area of induration. The client is a recent immigrant from Nigeria and reports no symptoms. Which actions would be appropriate by the nurse? Select all that apply. 1. Ask the client about a history of bacille Calmette-Guérin vaccine 2. Document the negative response in the client's medical record 3. Have the client return in a week to receive a second injection 4. Obtain a prescription for a chest x-ray from the health care provider 5. Place the client in droplet precautions and wear a surgical mask during care

1, 4. Tuberculin purified protein derivative (PPD) skin tests (ie, Mantoux test) screen individuals for tuberculosis (TB) exposure. The skin is assessed at the bleb administration site 48-72 hours after placement. Positive results include an induration of ≥15 mm in healthy individuals, ≥5 mm in high-risk populations and ≥10 mm in clients with potential risk or mild immunosuppression. Redness without induration is a negative reaction. This immigrant client has a positive purified protein derivative test (>10-mm induration). The bacille Calmette-Guérin vaccine improves TB resistance in high-risk countries but produces false-positive tuberculin skin test results. Knowing this information and documenting it is important (Options 1 and 2). Positive results warrant further testing. Chest x-ray helps identify clients who do not have symptoms but still have active disease. Sputum cultures can be used for diagnosis if the client is symptomatic (Option 4). (Options 3 and 5) Clients with active TB are placed under airborne isolation precautions in single-occupancy, negative-pressure rooms. Staff/visitors must wear N95 particulate respirators when in the room. Surgical masks are not protective against TB. Regardless, this client has no symptoms, and unless chest x-ray or sputum culture is positive, the client has only latent TB (exposure).

A client with bipolar disorder experiencing an episode of acute mania has recently been admitted to the psychiatric unit. Which nursing diagnosis is the priority at this time? 1. Imbalanced nutrition [39%] 2. Impaired social interaction [6%] 3. Risk-prone health behavior [46%] 4. Self-neglect [7%]

1. Bipolar disorder is characterized by alternating episodes of depression and mania. Manic clients demonstrate hyperactivity and distractibility and may refuse to sit still long enough to drink or eat, placing them at risk for imbalanced nutrition: less than body requirements (Option 1). This is a physiological need that takes priority over psychological or self-fulfillment needs. The nurse can address imbalanced nutrition in a manic client by providing high-calorie snacks and finger foods that can be carried and eaten without having to sit down. (Options 2 and 3) Manic clients lack impulse control and may demonstrate sexual promiscuity, uninhibited social interaction, and excessive spending. They may have rapid, incoherent speech and may attempt to manipulate others. However, this client is in a controlled environment in the inpatient psychiatric unit, where risk-prone and manipulative behaviors can be monitored and limited. (Option 4) Clients with mania are highly distractible and may fail to maintain self-hygiene or adhere to health activities. This client may require encouragement to engage in self-care and health activities (eg, medication compliance). However, this does not take priority over physiological needs.

The nurse is caring for an African American client with disseminated intravascular coagulation. Which locations are best to assess for the presence of petechiae? 1. Buccal mucosae and conjunctivae of the eyes [46%] 2. Nail beds of the fingers and toes [6%] 3. Palms of the hands and soles of the feet [37%] 4. Skin over the sacrum and behind the heels [9%]

1. Petechiae are reddish or purple pinpoints on the skin that occur due to bleeding from capillaries. Petechiae usually occur due to blood vessel injury or bleeding disorders (eg, thrombocytopenia, disseminated intravascular coagulation). Petechiae and similar skin conditions are often challenging to detect in dark-skinned clients as dark pigmentation makes it difficult to assess skin color changes. In dark-skinned clients, petechiae can best be assessed in the conjunctivae of the eyes and the buccal mucosae. (Option 2) The nail bed of the finger is the best location to assess dark-skinned clients for cyanosis, a blue discoloration that may occur with hypoxemia (ie, decreased blood oxygen). Petechiae generally do not occur in the nail bed. (Option 3) The palms of the hands and soles of the feet are ideal locations for assessing other skin color changes that may occur in dark-skinned clients, such as jaundice (ie, yellowing of the skin due to increased bilirubin in the blood). However, these are not ideal locations to assess for petechiae in a dark-skinned client. (Option 4) Over the sacrum and behind the heels are common locations for pressure injury formation; skin here typically appears dark, especially in dark-skinned clients.

The health care provider has explained the risks and benefits of a planned surgical procedure and asks the nurse to witness the client's signature on the consent form. Which situation would affect the legitimacy of the signature? 1. Client asks whether a blood transfusion will be required during surgery [35%] 2. Client expresses a fear of postoperative pain [3%] 3. Client received a dose of hydrocodone for pain 12 hours ago [39%] 4. Client wishes to wait to sign the consent until the spouse is present [20%]

1. To provide informed consent, a client must be a mentally competent adult; understand the explained procedure, risks, benefits, and alternatives; and sign voluntarily without coercion. Before witnessing a client's signature, the nurse should ensure that the client meets these criteria. A client question regarding the need for a blood transfusion during surgery indicates an incomplete understanding of risk and would invalidate the signature (Option 1). (Option 2) Fears about the recovery process do not indicate confusion about the procedure itself. Fear about postoperative pain is an opportunity for the nurse to provide teaching and emotional support. (Option 3) Narcotics and other medications (eg, some antiemetics) can cause sedation and impairment. The client can provide informed consent only after the effects of sedating medications have worn off. The duration of action for hydrocodone is 4-6 hours; a client who received a dose 12 hours ago would no longer be impaired from the medication. (Option 4) Many clients wish to have family members present during the preoperative period to offer emotional support. The need for family presence does not invalidate an informed consent signature unless clients are mentally incompetent and require a legal next of kin to make medical decisions on their behalf.

The nurse in the public health clinic is caring for a client with pubic lice. Which statements should the nurse include in the education? Select all that apply. 1. "Pubic lice are only passed through sexual contact." 2. "Remove nits from pubic hair with a fine-toothed nit comb." 3. "Sexual partners should also receive treatment." 4. "Wash clothes and linens with hot water." 5. "Wash pubic hair with lice treatment shampoo."

2, 3, 4, 5 Pediculosis pubis (ie, "crabs") is an infestation of pubic lice. Pubic lice are most often passed via sexual contact and feed on human blood for nourishment. Clients with pubic lice have intense itching in the affected area. The nits (ie, lice eggs) are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair (eg, chest, axilla). Clients with pubic lice should be given the following instructions: Use lice treatment shampoo (1% permethrin) or rinse on pubic and body hair to kill lice (Option 5) After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers (Option 2) Wash and dry clothes, towels, and bedding with hot water and highest-heat dryer setting (Option 4) Sexual partners should also receive pubic lice treatment (Option 3) (Option 1) Pubic lice may be passed through close contact and sharing of linens. All household members are at risk for developing a pubic lice infestation and should be screened.

A nurse is caring for a client who had a transurethral resection of the prostate and is receiving continuous bladder irrigation by gravity. Which tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Calculating the difference between irrigant intake and total drainage output 2. Cleaning around the catheter insertion site daily 3. Immediately notifying the nurse if the client reports pain 4. Increasing the irrigation rate when the urine becomes more red than pink 5. Measuring the total volume of output in the drainage collection bag

2, 3, 5. Continuous bladder irrigation is prescribed following surgical transurethral resection of the prostate and prevents obstruction of urine outflow by removing clotted blood from the bladder. A 3-way catheter is used to continuously infuse solution into the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a collection bag. The registered nurse (RN) should consider the five rights of delegation when delegating to unlicensed assistive personnel (UAP): Catheter care is a routine, noncomplex task that may be safely delegated to UAP (Option 2). Any client reports of pain or bladder spasms to UAP should be immediately conveyed to the RN as these symptoms may indicate obstruction (Option 3). Measuring output is routine data measurement. UAP should report the volume to the RN, who will determine the adequacy of drainage (Option 5). (Option 1) Clots or kinks may obstruct drainage and cause a smaller volume of outflow than inflow. The nurse should calculate this difference to determine the need to reestablish patency using manual irrigation. (Option 4) The irrigation rate should be titrated to maintain light pink outflow drainage with few clots. UAP do not have the knowledge and skills necessary to titrate the inflow rate or to monitor drainage quality.

The charge nurse is making client assignments for the oncoming shift. Which client assignment is most appropriate for a nurse who is 10 weeks pregnant? 1. Client receiving brachytherapy for endometrial cancer [28%] 2. Client with an infected surgical wound positive for methicillin-resistant Staphylococcus aureus [44%] 3. Client with a herpes zoster rash on the face and scalp [18%] 4. Client with pneumonia who recently traveled to a region with the Zika virus [7%]

2. A pregnant nurse does not have a high risk for contracting methicillin-resistant Staphylococcus aureus (MRSA) if appropriate infection precautions are used (Option 2). The nurse should carefully follow contact precautions, including wearing gloves and gown and performing strict hand hygiene. Even if the pregnant nurse were to contract MRSA, there are few known harmful effects to the fetus. TORCH infections (Toxoplasmosis, Other [parvovirus B19/varicella-zoster virus], Rubella, Cytomegalovirus, Herpes simplex virus) can cause fetal abnormalities, and clients with these infections should not be assigned to pregnant health care workers. (Option 1) Clients receiving brachytherapy have radioactive implants placed in a body cavity. To safely care for these clients, nurses limit/cluster client time and keep a distance of at least 6 ft (1.8 m) unless wearing lead shielding for direct care. Pregnant health care workers should not care for these clients if possible as fetal radiation exposure is teratogenic. (Option 3) Herpes zoster (ie, shingles, varicella-zoster virus infection) is a TORCH infection, and pregnant health care workers should avoid caring for these clients. (Option 4) Zika virus may be transmitted through mosquito bites, infected body fluids, and sexual contact. Using standard precautions should provide protection; however, because Zika is known to cause birth defects, pregnant health care workers should not care for a client exposed to it if at all possible.

The nurse is reviewing client phone messages. Which client should the nurse call back first? 1. Client asking whether to take the morning dose of phenytoin before surgery the next day [29%] 2. Client taking dabigatran who reports heavier bleeding with her menstrual cycle [33%] 3. Client taking metronidazole who reports abdominal cramping and diarrhea [19%] 4. Client who has taken the last dose of insulin glargine and needs a refill [17%]

2. Dabigatran (Pradaxa) is a thrombin inhibitor anticoagulant often prescribed to prevent thrombotic events in clients with atrial fibrillation, pulmonary embolism, and deep vein thrombosis. Clients taking dabigatran are at increased risk for bleeding and hemorrhage. Clients with signs of abnormal bleeding (eg, bruising; blood in the urine, sputum, vomitus, or stool; epistaxis; heavy menstrual bleeding [menorrhagia]) should be prioritized as prompt intervention and treatment may be required. (Option 1) Missing a dose of phenytoin (Dilantin), an antiseizure medication, could precipitate seizure activity. The client should be instructed to take the medication as prescribed with a small sip of water; however, this client does not take priority over one with active bleeding. (Option 3) Gastrointestinal upset is a common side effect of many antibiotics, including metronidazole (Flagyl). Abdominal discomfort may be relieved by taking the medication with food or a glass of milk. (Option 4) This client requires a refill of insulin to prevent hyperglycemic episodes but is not a priority over a client with active bleeding. Glargine is long-acting insulin that works for 24 hours.

The nurse is caring for a client who has been pronounced brain dead. The client is a registered organ donor. The client's family is voicing concerns about the possibility of disfigurement because they want to have an open casket funeral. How should the nurse respond? 1. "If the family is not in complete agreement about organ donation, we won't be able to proceed." [9%] 2. "Once the body is dressed, there is no evidence of organ removal. An open casket will be fine." [69%] 3. "Some organ procurement leaves evidence on the body. You may want to consider a closed casket." [9%] 4. "Your family member consented to be an organ donor. You should really honor this wish." [12%]

2. Friends and family of deceased clients often have questions about, and may even be suspicious of, the organ donation process, especially during their time of loss and grieving. Organ procurement does not leave obvious evidence on the client's body when the body is dressed. Special precautions and techniques are used by the surgical team and funeral home personnel (eg, morticians) to maintain the integrity and outward appearance of the body (Option 2). Funeral arrangements are not delayed by organ donation and the family will not incur any costs related to procurement. An organ transplant coordinator should be consulted by the nurse to address the family's specific questions related to donation. (Option 1) Consent is not needed from the family if the client is already registered to be an organ donor. (Option 3) Organ procurement does not leave obvious evidence once a body is clothed and prepared for viewing. A closed casket is not necessary. (Option 4) Family members should be advised of the donor's wishes and have their questions answered as to how procurement will proceed. However, the nurse should never try to invoke guilt when communicating with clients or families.

The nurse is caring for a pediatric client with osteomyelitis. Prior to the nurse administering IV antibiotics, the client's parent states, "We don't believe in antibiotics. Healing comes from within, and medications are toxic to that process." What is the nurse's priority response? 1. "Please tell me how medications are toxic to the healing process." [7%] 2. "Please tell me your understanding of your child's condition." [41%] 3. "What type of healing practices would you prefer for your child?" [36%] 4. "Without this medication, your child can get worse and could die." [14%]

2. IV antibiotics are necessary for treating osteomyelitis (infection of the bone), and without them, the client is at risk for potentially life-threatening complications (eg, sepsis). Parental refusal of necessary medication for a minor creates an ethical dilemma. The nurse's first response should be assessment of a parental knowledge deficit regarding the client's condition. The nurse should ask open-ended questions, allowing the parent to demonstrate knowledge. With education and proper understanding of the condition, the parent may consent to the necessary treatment (Option 2). (Option 1) Asking about beliefs regarding medications in general may help in developing a teaching plan. However, it is more important to educate the parent about this child's specific and immediate need for antibiotics. (Option 3) Preferred healing practices are an important aspect of spiritual assessment; however, the priorities are to obtain parental consent for and initiate necessary treatment. Spiritual and cultural elements may be appropriate to include after physical needs (eg, IV antibiotics) are met. (Option 4) Although true, this statement is inflammatory and would likely cause the situation to deteriorate, possibly leading to total refusal of care by the parent. It is most effective and important to respectfully assess parental knowledge and educate parents to obtain consent.

Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. EXHIBIT: Progress notes 1300 Shallow, open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx. Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry, and intact. No drainage noted. Enterostomal consult made.________________, RN 1. Stage 1 [10%] 2. Stage 2 [75%] 3. Stage 3 [12%] 4. Stage 4 [1%]

2. Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar

The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client is constantly requesting pain medicine. I had to administer normal saline instead of morphine because it is too early for another dose of morphine." Which action by the charge nurse is the priority at this time? 1. Document the incident in the nurse's employee file and review it with the unit manager [8%] 2. Follow institutional protocol for filing an incident or variance report [30%] 3. Instruct the nurse to notify the health care provider about the lack of pain relief [52%] 4. Report the incident to the hospital's ethics committee for evaluation [8%]

3. Administration of a placebo (a substance with no therapeutic effect) outside of a consented research trial is unethical and deceitful. Clients with a history of drug abuse and increased opioid tolerance often require a higher-dose analgesic or stronger opioid (eg, hydromorphone) to achieve pain relief. The most appropriate action by the charge nurse at this time is to instruct the staff nurse to contact the health care provider to discuss the client's frequent requests for morphine to alleviate uncontrolled pain (Option 3). (Options 1 and 2) Any documentation or reporting (eg, variance or incident report) should be completed after addressing the issue with the nurse, to ensure the client receives the appropriate medications for pain relief. (Option 4) A hospital ethics committee examines the overall plan of care for clients with complex, often life- or limb-threatening conditions. A scenario such as this client's should be resolved by unit management and not be escalated to the ethics committee unless it becomes a pervasive issue or a pattern of behavior among nursing staff.

The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? 1. Call for help to initiate cardiopulmonary resuscitation [10%] 2. Call the health care provider to confirm the DNR status [6%] 3.. Explain the client's wishes to the client's child [79%] 4.. Offer to call the hospital chaplain to provide support [4%]

3. Advance directives outline the client's choices for medical care (eg, cardiopulmonary resuscitation [CPR], mechanical ventilation) ahead of time. This allows the family and care team to follow the client's wishes at the end of life, when the client may be unable to make choices known. Clients can sign a do not resuscitate (DNR) directive instructing that CPR and other life-saving measures be withheld. With an advance directive in place, the client's wishes are followed, even if they conflict with the wishes of loved ones (Option 3). This is different from a medical power of attorney (health care proxy) in which the client designates a person to make decisions on their behalf. (Option 1) Initiating CPR on a client with a DNR status does not respect the wishes of the client to forgo life-saving measures and allow natural death. Nurses must advocate for clients' wishes, even if family members are in disagreement. (Option 2) The client has a terminal illness and in an advance directive expressed wishes that were verified prior to initiating DNR status; therefore, there is no need to clarify with a health care provider. (Option 4) The client's child should be offered support from the hospital chaplain after the client's wishes are explained.

The nurse cares for a client with an established ascending colostomy. Which statement made by the client indicates that further teaching is required? 1. "I always try to drink 3 liters of water each day." [14%] 2. "I avoid eating beans, onions, broccoli, and cauliflower." [9%] 3. "I change the appliance and bag every other day." [64%] 4. "I empty the bag when it is about one-third full." [11%]

3. Colostomies may be performed on any part of the colon (ascending, transverse, descending, sigmoid). Stool becomes more solid as it passes through the colon, so stool drainage characteristics vary with location of the ostomy. Ascending colostomies produce semiliquid stool. Stool is contained in an ostomy appliance bag secured to the skin. The appliance opening is cut to fit closely around the stoma. If the appliance does not fit well, liquid stool may leak onto the peristomal skin, and skin irritation occurs due to the digestive enzymes in stool. Peristomal skin irritation may also occur if the ostomy appliance is removed and changed too frequently. The appliance should be changed every 5-10 days (Option 3). (Option 1) The semiliquid consistency of stool from an ascending colostomy results in increased fluid loss. The client is encouraged to drink plenty of fluids to prevent dehydration. (Option 2) The client with a colostomy has few dietary restrictions, but the client may be encouraged to decrease intake of odorous and gas-forming foods (eg, beans, onions, broccoli). (Option 4) The ostomy bag is emptied when it becomes one-third full. Leaking and skin irritation may occur if the appliance becomes too heavy and pulls away from the skin.

There has been a major disaster involving a manufacturing plant explosion. The emergency department nurse is sent to triage victims. Which client should the nurse send to the hospital first? 1. Client who has partial-thickness burns on both hands [7%] 2. Client who is screaming and has a left lower arm laceration [3%] 3. Client with a broken bone protruding from a wound on the right lower leg [66%] 4. Client with a gaping head wound and Glasgow Coma Scale score of 3 [22%]

3. During mass casualty events, the goal is to do the greatest good for the greatest number of people. Clients are triaged using various systems (eg, Simple Triage and Rapid Transport/Treatment [START]; Sort, Assess, Life-saving interventions, Treatment/Transport [SALT]) and placed into 4 categories: Immediate (red tag): Life-threatening injuries with good prognoses once treated (eg, airway obstruction, open fractures, second- or third-degree burns covering 15%-40% body surface area) Delayed (yellow tag): Injuries requiring treatment within hours (eg, stable abdominal wounds, soft tissue injuries) Minimal (green tag): Injuries requiring treatment within a few days (eg, minor burns or fractures, small lacerations) Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment Immediate medical care of the client with an open fracture would likely result in a good prognosis (Option 3). (Option 1) Delayed treatment is appropriate for the client with partial-thickness burns to a small portion of the body (eg, hands). (Option 2) Depending on its size and depth, a laceration would require minimal or delayed treatment. (Option 4) A large, open head wound with a Glasgow Coma Scale score of 3 has a poor prognosis regardless of treatment; death is expected.

An older adult client takes multiple prescription medications plus several over-the-counter medications. Which intervention by the clinic nurse is most important in reducing the risk for drug interactions? 1. Assist client with making a list of all medications, doses, and times to be taken [34%] 2. Encourage client to obtain all prescription medications from the same pharmacy [14%] 3. Have client bring all medications taken regularly or occasionally to each appointment [39%] 4. Instruct client to use a pill organizer to separate pills by day and time [11%]

3. Polypharmacy and the physiologic changes associated with aging place older adults at an increased risk of adverse drug events. Decreased renal and hepatic function causes increased drug half-life and impaired drug clearance, potentially resulting in toxicity and adverse events. Clients may see different health care providers and receive multiple prescriptions for different health problems (polypharmacy). Clients should be encouraged to bring all medications (ie, prescription, over-the-counter [OTC], herbal supplements) they take regularly and occasionally to each appointment so that potential drug interactions can be evaluated (Option 3). (Option 1) Keeping a list of all medications and their dosages is a good idea to help organize the client's medications. However, the client may not remember all the medications and may not regularly update the list. (Option 2) Getting all medications from the same pharmacy is preferable. The pharmacist can monitor for possible interactions from prescription drugs, but many clients do not report the use of OTC medications or herbal supplements to the pharmacist. (Option 4) A pill organizer helps the client remember to take medications at the appropriate times. By ensuring drugs are taken at prescribed intervals, some interactions can be avoided. However, this may not take into account herbal supplements and OTC drugs taken as needed.

A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? 1. Dons a mask with eye shield before irrigating a draining wound for a client on standard precautions [7%] 2. Places a "soap and water only" sign on the door of a client with Clostridium difficile [12%] 3. Wears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV [55%] 4. Wears an N95 respirator before entering the room of a client with active varicella-zoster [23%]

3. The best way for health care workers to protect themselves against possible HIV infection is to consistently follow standard (universal) precautions with all clients, regardless of HIV status. HIV is spread when nonintact skin comes into contact with infected blood, breast milk, semen, and vaginal secretions. No extra precautions are needed for routine care of clients with HIV as the virus is not spread through casual contact, droplets, or aerosolized particles. Some experienced nurses hold to the common misconception that "double-gloving" reduces the risk of contracting HIV. Appropriate use of a single pair of clean gloves provides a barrier between the nurse's hands and the client's blood and body fluids (Option 3). (Option 1) In compliance with standard precautions, situations in which blood or body fluids may splash or be sprayed (eg, suctioning, irrigation) require additional personal protective equipment (eg, face shield, gown) as necessary. (Option 2) Washing hands with soap and water is required to remove Clostridium difficile spores; hand hygiene with foam or gel alone is ineffective. (Option 4) An N95 respirator is worn when the client has an illness that can be aerosolized and spread through the air (eg, tuberculosis, varicella-zoster).

The charge nurse is responsible for making room assignments for multiple clients. Which pair of client assignments to a shared room is appropriate? 1. Client with blood loss anemia and client with intractable diarrhea 2. Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting 3. Client who had a bowel resection 1 day ago and client with asthma exacerbation 4. Client who had a total hip arthroplasty 2 days ago and client with influenza

3. When making room assignments, it is important to remember that a client with an active or suspected infection should not be paired with a client who has a fresh surgical wound or is immunocompromised. A client having an asthma exacerbation does not have an infection and is not at risk for spreading infection to a client who had recent bowel resection surgery (Option 3). (Option 1) A client with uncontained or excessive excretions, drainage, or secretions (eg, profuse diarrhea, draining wounds) is more likely to spread infection, if present, and therefore should be assigned to a private room. (Option 2) The client who has chemotherapy-induced nausea and vomiting is likely immunocompromised secondary to the chemotherapy and is therefore vulnerable to infection from a client with gastroenteritis. (Option 4) A client who has a fresh surgical wound has an increased risk of infection and should not be paired with a client with an active influenza infection, which is transmitted through the droplet route.

The nurse is caring for a client with cellulitis of the leg. At 11:00 AM, the client reported itching and received a PRN dose of diphenhydramine. At 9:00 PM, the client reports trouble sleeping and requests another dose of diphenhydramine to help with sleep. Which action is most appropriate? Click on the exhibit button for additional information. EXHIBIT: Medication administration record Allergies: None Medications Time Vancomycin: 1 g IVPB every 12 hours 1000 and 2200 Piperacillin-tazobactam: 3.375 g IVPB every 8 hours 0600, 1400, and 2200 Diphenhydramine: 25 mg orally as needed for itching Every 8 hours PRN Lorazepam: 2 mg orally as needed for anxiety Every 8 hours PRN Oxycodone: 10 mg orally as needed for pain Every 4 hours PRN 1. Administer a dose of diphenhydramine as it is within the specified time interval [23%] 2. Administer a dose of lorazepam to encourage relaxation [30%] 3. Inform the client that no medications can be administered for sleep at this time [6%] 4. Request a prescription for a sleep aid from the health care provider [39%]

4. A PRN (ie, as needed) medication prescription must state the name, dose, route, and purpose of the medication (eg, pain, nausea, sleep) and the time interval between doses. The nurse should administer a PRN medication for its prescribed purpose only. If the client requires medication for a different purpose, the nurse should contact the health care provider (HCP) to either clarify the current prescription or request a new prescription. If a client requests a sleep aid and does not have a prescription for sleep medication, the nurse should contact the HCP to request a prescription (Option 4). (Option 1) If diphenhydramine (Benadryl) is prescribed every 8 hours PRN and the previous dose was at 11:00 AM, it would be appropriate to administer a dose at 9:00 PM; however, diphenhydramine that is prescribed for itching may be administered only for itching. (Option 2) Lorazepam that is prescribed for anxiety may be administered only for anxiety. (Option 3) Informing a client that there is no prescribed medication that can be administered for sleep does not resolve a client's request for help with sleep. The nurse should implement actions to address the client's difficulty sleeping.

The nurse in an ambulatory surgery center triages telephone messages from clients. Which client should the nurse call back first? 1. Client who had a colonoscopy with polypectomy who reports abdominal cramping and a small amount of rectal bleeding [9%] 2. Client who had a lumbar laminectomy with spinal fusion 3 days ago who reports straining to have a bowel movement [23%] 3. Client who underwent laparoscopic inguinal hernia repair yesterday who reports difficulty urinating [21%] 4. Client who underwent placement of an arteriovenous graft who reports a temperature of 100.9 F (38.3 C) [45%]

4. Arteriovenous (AV) graft placement involves surgical connection of an artery and a vein using a synthetic material to graft a hemodialysis access site. Postoperative infection of an AV graft may cause thrombosis, graft failure, or systemic infection. Fever in a postoperative client may indicate infection of the graft site, which warrants immediate notification of the health care provider (HCP); this client may require antibiotics and surgical removal of the graft (Option 4). (Option 1) A small amount of rectal bleeding and abdominal cramping is expected following a colonoscopy as the bowel contracts to expel the air inserted during the procedure. Following a colonoscopy, clients should notify the HCP of severe abdominal pain, distension, and excessive bleeding, which may indicate bowel perforation. (Option 2) Following surgery, constipation can occur due to decreased ambulation and narcotic pain medications. The client may require a stool softener to reduce straining. (Option 3) Anesthesia and opioid analgesics may cause postoperative urinary retention for up to 3 days following surgeries, especially abdominal or pelvic surgeries. This client should be instructed on measures to aid voiding (eg, standing) and may need to come to the clinic for bladder ultrasound or straight catheterization.

The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? 1. BMI of 29.5 kg/m 2 [10%] 2. Family history of osteoporosis [13%] 3. History of a daily glass of wine [0%] 4. Peripheral arterial disease [75%]

4. Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for healing (Option 4). (Option 1) A BMI of 25-29.9 kg/m2 indicates that the client is overweight. A sedentary lifestyle often leads to elevated BMI and also correlates with decreased bone density, which places the client at risk for fractures. However, neither sedentary lifestyle nor elevated BMI directly affects bone healing. (Option 2) Osteoporosis (low bone density) increases the risk of fractures and delays bone healing. Although a family history does increase the risk of osteoporosis, the family history itself would not directly hinder bone healing as this client has not been diagnosed with osteoporosis. (Option 3) Heavy alcohol use is associated with inadequate nutrition and can decrease osteoblastic activity (ie, bone formation). However, a single serving of alcohol (ie, 12 oz of beer, 5 oz of wine, 1.5 oz of liquor) per day is considered moderate usage and is not a risk factor for delayed healing.