Study set 14 for RN NCLEX (Kaplan)

The nurse does rounds on clients midway through the evening shift. Which situation requires a priority intervention by the nurse? 1. A client diagnosed with emphysema is watching television with a visitor who is wearing a mask and gloves. 2. A client diagnosed with gastroesophageal reflux disease (GERD) is sitting in a chair sipping a can of ginger ale. 3. A client diagnosed with peripheral arterial disease (PAD) is sitting on the side of the bed with legs crossed at the knee. 4. A client diagnosed with dementia is being assisted with dinner by the nursing assistant, who is cutting the food into small pieces.

1) INCORRECT - This situation does require the nurse to intervene, as emphysema is not infectious and does not require particular infection control precautions such as a mask, gloves, or gown. However, this situation poses no physical risk for the client. Another answer choice is a higher priority. 2) INCORRECT - This situation does require the nurse to intervene, as clients diagnosed with GERD should not drink carbonated beverages because they cause increased pressure in the stomach. However, this situation poses minimal physical risk to the client. Another answer choice is a higher priority. 3) CORRECT — The client with peripheral vascular disease (PVD), either venous or arterial, should sit with feet flat on the floor or comparable surface and avoid crossing the legs or wearing constrictive clothing. Crossing the legs at the knee interferes with blood flow, diminishing arterial flow to the feet and reducing venous return to the heart. This situation poses a circulatory risk to the client and is the highest priority. 4) INCORRECT - This situation requires no intervention. Clients diagnosed with dementia may require assistance with feeding. Food should be cut into small bites and the client is encouraged to eat slowly. *Think Like A Nurse: Clinical Decision Making* The nurse is often required to prioritize care based on clinical data. Of the clients presented here, the client with peripheral arterial disease (PAD) is at the greatest risk for complications. Crossing the legs at the knees constricts venous return, increasing the risk for lower extremity edema, unnecessary pain, and discomfort due to the pooling of blood, which hinders systemic circulation. The nurse needs to be alert to actions and behaviors that can exacerbate manifestations or cause complications. *Content Refresher* Clinical manifestations of peripheral vascular disease (PVD) include pain during walking or activity, numbness, burning, non-healing wounds, skin color changes that can include pallor, redness or cyanosis, and hair loss to extremities. The nurse should assess the strength of distal pulses and the color and temperature of extremities. Assess for any non-healing wounds. Ask client about symptoms occurring with walking or activities and instruct the client about positions that impede and those that improve blood flow.

The nurse manager is planning an in-service to address confidentiality issues. Which measure is appropriate for the nurse manager to include as a way to prevent confidentiality violations? 1. Keep ambulatory clients and visitors away from the nursing station as much as possible. 2. Call clients and one another by first names only. 3. Answer the telephone by saying the type of unit, but not the floor number. 4. Accompany the health care providers doing walking rounds at the bedside.

1) CORRECT — The nursing station is a center of activity in terms of in-person and telephone conversations, paperwork, and computer screens, all of which may include confidential information. Ambulatory clients, or visitors waiting for their needs to be addressed, can easily be exposed to confidential information. 2) INCORRECT— This does not prevent confidentiality violations and may be disrespectful. Some clients may prefer to be addressed by their surname. 3) INCORRECT— This is more likely to violate confidentiality by conveying the client's diagnosis to the caller (for example, if a phone is answered with "Oncology," the caller can assume the client has cancer) than if the phone were answered simply with the floor number, which is the usual procedure. 4) INCORRECT— This action is very useful in terms of interdisciplinary collaboration and, if done correctly, in terms of involving the client. However, in terms of confidentiality, it can be a problem if there is more than one client in a room and also if discussions are held outside client rooms in hallways. *Think Like A Nurse: Clinical Decision Making* A shared client environment, including client care areas with curtain dividers, presents challenges to privacy and confidentiality. Staff members should speak in low voices or hold conversations away from the hearing distance of all individuals who are not members of the client's care team. Signage reminding staff to adhere to regulations related to privacy and confidentiality also may be helpful. *Content Refresher* Confidentiality refers to protecting and safeguarding a client's personal, identifiable health information and data. In 2003, the federal statute known as the Health Insurance Portability and Accountability Act (HIPAA) mandated the protection of client data. Unless officially authorized to do so by the client, nurses do not discuss or share the client's personal information, including health care data, with family, friends, coworkers, other members of the health care team, insurance providers, or financial aid organizations. The nurse should hold self and colleagues accountable when it comes to respecting client confidentiality and privacy.

The nurse assesses a newborn and notes that the neonate is hypothermic. Which interventions are appropriate for the nurse to include in the newborn 's plan of care? (Select all that apply.) 1. Warm the newborn slowly to avoid potential apnea episodes. 2. Wrap the newborn in a warm blanket. 3. Place a hat on the newborn 's head. 4. Bathe the newborn quickly and then place under a radiant warmer. 5. Provide the newborn with skin-to-skin contact with the mother.

1) CORRECT - A hypothermic newborn should be warmed gradually because rapid warming can cause apneic spells and acidosis. 2) CORRECT - The nurse should wrap the newborn in warmed blankets immediately after birth. 3) CORRECT - The nurse should keep the head well covered to avoid heat loss. 4) INCORRECT - The initial bath is postponed until the newborn 's skin temperature is stable and can adjust to heat loss from a bath. 5) CORRECT - The ideal method for promoting warmth and maintaining neonatal body temperature is early skin-to-skin contact with the mother. The naked newborn is placed prone directly on the mother 's chest and both mother and newborn are then covered with a warm blanket. *Think Like a Nurse: Clinical Decision-Making* Newborns have trouble regulating their temperature, especially during the first few hours after birth. The nurse anticipates use of a radiant heater to prevent newborn heat loss. The nurse makes sure that the newborn is not exposed to cold surfaces. For the first 2 hours, the baby 's temperature may be taken every 30 minutes until it is stabilized. To maintain body temperature, the nurse should dry the newborn immediately after birth, avoid placing the newborn near air vents, delay the initial bath until the baby 's temperature has stabilized, and place the newborn skin to skin with the mother or under a temperature-controlled radiant warmer. *Content Refresher* Because of the risk for hypothermia, it is important for the infant to be quickly dried, placed skin to skin with the mother, and covered with a blanket after delivery and after bathing. Multiple factors affect thermoregulation in the infant. The newborn has a large surface area relative to the newborn 's weight, facilitating heat loss to the environment. The second contributing factor is the newborn 's thin layer of subcutaneous fat. The third factor is the newborn 's inability to produce heat through shivering. Instead, the newborn produces heat through nonshivering thermogenesis, which is produced by stimulating cellular respiration and thus increases the need for oxygen and glucose.

The nurse teaches an adult female client with a family history of hypertension. Which recommendation does the nurse include in client education? (Select all that apply.) 1. Limit sodium intake to 2 grams or less daily. 2. Exercise at least twice weekly. 3. Avoid use of tobacco products. 4. Limit alcohol consumption to one serving per day. 5. Limit coffee consumption to two servings daily.

1) CORRECT - Excessive sodium intake (greater than 2 grams daily) increases the risk for hypertension. 2) INCORRECT - A sedentary lifestyle increases the risk for hypertension. The American Heart Association recommends moderate activity for at least 30 minutes daily, 5 days per week. 3) CORRECT - Smoking or the use of other tobacco products increases the risk for hypertension. 4) CORRECT - Excessive alcohol intake is linked to hypertension. For adult females, no more than one serving of alcohol per day is recommended. 5) INCORRECT - Although caffeine may cause a spike (not a sustained increase) in the blood pressure of some people, coffee use is not a recognized risk factor for hypertension. *Think Like a Nurse: Clinical Decision-Making* Risk factors for the development of hypertension include excessive sodium intake, a sedentary lifestyle, use of tobacco products, and excessive alcohol intake. Sodium increases the amount of body fluid, which can cause a subsequent increase in blood pressure. A sedentary lifestyle encourages hemo-stagnation in the extremities, which weakens blood vessels. Tobacco and nicotine directly effect the blood vessels, causing constriction. Alcohol alters fluid balance, which affects all body systems. *Content Refresher* Risk factors for hypertension include smoking, obesity, heavy alcohol consumption, sedentary lifestyle, increased cholesterol and triglycerides, stress, family history of hypertension, increased dietary sodium intake, and decreased dietary intake of potassium, magnesium, or calcium. In general, blood pressure typically increases with aging. However, hypertension is more common among men than women until 55 years of age; after age 55, this disorder is more common among women. Black men and women are more likely to develop hypertension than are individuals of other racial backgrounds.

The nurse discusses health care with a client diagnosed with polycystic ovary syndrome (PCOS). Which information is important for the nurse to include? 1. Maintain a normal weight. 2. Increase calcium and phosphorus intake. 3. Avoid exposure to the sun. 4. Eliminate alcohol from the diet.

1) CORRECT - It is important to teach the client the importance of weight management and exercise to decrease insulin resistance. Obesity exacerbates the problems related to PCOS. Losing weight may help to lower blood glucose levels, improve the way the body uses insulin, and help hormones reach normal levels. A 10% loss in body weight (for example, a 150-pound woman losing 15 pounds) can help make the menstrual cycle more regular and improve chances of getting pregnant. 2) INCORRECT- Increasing calcium and phosphorus intake has no relationship to PCOS. 3) INCORRECT- Avoiding exposure to the sun has no relationship to PCOS. 4) INCORRECT- Eliminating all alcohol from the diet has no relationship to PCOS. *Think Like a Nurse: Clinical Decision-Making* Polycystic ovary syndrome (PCOS) often occurs just after puberty, which can create emotional complications during a period that is already emotionally challenging. Polycystic ovary syndrome causes acne, mood changes, stubborn weight gain, and hair growth on the face and other areas of the body. Occasionally, PCOS causes the formation of a brown skin ring on the back of the neck. Hormone alterations responsible for these changes include increased androgens (male hormones), insulin resistance, and too little progesterone. As an adult, the continued insulin resistance and reduced fertility become the central concerns. Symptoms can be managed at any age through a combination of healthy lifestyle and medications. *Content Refresher* Polycystic ovary syndrome (PCOS) is characterized by ovulatory dysfunction, polycystic ovaries, and hyperandrogenism. It most commonly occurs in women under 30 years old and may cause infertility. The etiology is unknown. With PCOS, ovulation fails and multiple fluid-filled cysts develop from mature ovarian follicles. Signs and symptoms of PCOS include irregular menstrual periods, amenorrhea, hirsutism, and obesity (80% of women). Metformin may be prescribed to reduce hyperinsulinemia, improve hyperandrogenism, and restore ovulation. Cardiovascular disease and abnormal insulin resistance with type 2 diabetes mellitus may develop if PCOS is not treated.

The nurse provides care for a client receiving ibuprofen 400 mg PO 4 times daily. The nurse instructs the client about the medication. Which statement from the client indicates to the nurse the need to provide further teaching? 1. "I will take this medication on an empty stomach." 2. "I will tell my dentist that I am taking this medication." 3. "I should report any ringing in my ears to the health care provider." 4. "I should call if my stools become dark black in color."

1) CORRECT - Non-steroidal anti-inflammatory drugs (NSAIDs) cause gastrointestinal (GI) distress and should be taken with meals. Failure to do so can lead to GI ulcers and bleeding. 2) INCORRECT - Non-steroidal anti-inflammatory drugs (NSAIDs) reduce platelet adhesiveness, predisposing client to bleeding. The dentist should know the client takes this medication. 3) INCORRECT - Ear ringing is an adverse reaction to NSAIDs, and the medication should probably be stopped. 4) INCORRECT - Tarry stools indicate bleeding from the GI tract, a known adverse reaction to NSAID therapy. The medication should be stopped immediately, and the health care provider is notified. *Think Like A Nurse: Clinical Decision Making* Ibuprofen is an NSAID that can cause gastric irritation. This medication should be taken with food to reduce the potentially adverse gastrointestinal effects. A dentist should be aware of the client taking this medication since it can cause bleeding. The medication should be discontinued if tinnitus occurs. Tarry stools indicate gastrointestinal bleeding, which should be reported to the health care provider. *Content Refresher* Medication administration is the process by which medications are safely taken by a client. The nurse needs to inform the client about the medication, how to take the medication, the reason for its administration, how and when effectiveness will be determined, and possible adverse effects.

The nurse observes the parent of an adult client crying in the waiting area. The parent says to the nurse, "My father died of meningitis and it was awful. Now my child may die of the same thing." Which is the best initial response by the nurse? 1. "The outlook for meningitis is better now than it was then." 2. "I can have the chaplain come speak with you if you like." 3. "This must be bringing back a lot of memories." 4. "Not necessarily. You can't make that assumption."

1) CORRECT - This response directly responds to the parent's expressed concerns and offers factual information (family teaching) of which the parent may not have been aware. This may help alleviate some distress. 2) INCORRECT - The nurse should respond to the parent first and then assess if the chaplain is required or desired. 3) INCORRECT - This is an empathetic statement that reflects the obvious and provides opening for further discussion. However, the nurse can first allay some of the parent's fears about what is occurring. 4) INCORRECT - While factual, this statement blocks further communication by not encouraging the parent to express thoughts and feelings. *Think Like A Nurse: Clinical Decision Making* Providing information is an example of therapeutic communication. Providing relevant information tells clients what they need to know or want to know so they are able to make decisions, experience less anxiety, and feel reassured. The nurse should exercise active listening and be "in the moment." Other forms of therapeutic communication techniques that the nurse can use are clarifying, focusing, and asking relevant questions. *Content Refresher* Failure to establish a therapeutic relationship could result in stress, poor communication, and inability to achieve positive client outcomes. Be mindful of the range of human experiences and respond to health and illness within the client's physical and social environments. Review pertinent assessment data and knowledge, considering potential areas of concern. Clarify misconceptions. Be respectful, genuine, concrete, and specific. Consider family relationships and values.

The client undergoes diagnostic testing for lung cancer and requests information about associated risk factors. Which risk factor does the nurse include? (Select all that apply.) 1. African-American ethnicity. 2. BRCA1 genetic mutation. 3. History of smoking. 4. Repeated respiratory infections. 5. Facial and neck edema.

1) CORRECT — African-American men have the highest incidence of lung cancer. 2) INCORRECT— BRCA genes are not related to lung cancer. They are risk factors for breast cancer. 3) CORRECT — Smoking is a known risk factor for lung cancer. 4) INCORRECT— Repeated respiratory infections are a symptom of lung cancer, not a risk factor. 5) INCORRECT— Facial and neck edema are symptoms of a complication of lung cancer, not a risk factor. *Think Like a Nurse: Clinical Decision-Making* Risk factors for the development of lung cancer include smoking and African-American race. Respiratory infections may occur with lung cancer; however, they are not considered a risk factor. Facial and neck edema are symptoms of superior vena cava syndrome, a complication of lung cancer. However, they are not risk factors for the development of the disease. *Content Refresher* Smoking is the greatest risk for lung cancer. There may be a genetic susceptibility as well. Occupational exposure to carcinogens (radon, asbestos, soot, tar, arsenic, chromium, nickel) and air pollution have been implicated as risks for lung cancer. Aging is an additional risk. People who quit smoking lower their risk of lung cancer, but their risk is higher than the risk for people who have never smoked. Smoke from other people 's cigarettes, pipes, or cigars (second-hand smoke) also increases the risk for lung cancer.

A client is admitted to the postanesthesia recovery unit (PACU) after an open cholecystectomy. Which action is a priority of the nurse? 1. Assess the client for signs of pain. 2. Check the client's T-tube site for signs infection. 3. Remind the client to do coughing exercises. 4. Teach the client to avoid fatty foods.

1) CORRECT — An open cholecystectomy requires a large incision. In the PACU, a priority is to assess the client for pain. The nurse would also maintain the airway, check the dressing for bleeding, and monitor vital signs and T-tube drainage. 2) INCORRECT - Signs of surgical wound infection are not apparent immediately after surgery; therefore, this action is not the priority nursing action. 3) INCORRECT - This action is more appropriate once the client is transferred to the medical unit. The client can better perform the coughing exercises if pain is under control. 4) INCORRECT - Diet modification teaching is not a priority while the client is still in the PACU. *Think Like A Nurse: Clinical Decision Making* A diseased gall bladder can be removed by one of two ways - percutaneous removal or through an incision directly into the upper right abdomen. The nurse is aware an open cholecystectomy means that an incision was made into the abdomen to remove the organ. Any surgical wound will cause pain that should be assessed using a pain scale. In this scenario, the nurse recognizes during the immediate postoperative period, the client will experience severe pain. According to Maslow, pain is a psychosocial element, and should not take priority in post-operative care. However, the nurse recognizes the importance of pain control, which will make it possible for other postoperative interventions to be completed. Addressing ABCs with coughing will be more likely performed after pain management. *Content Refresher* Management of postoperative pain is a priority when caring for a client who had a cholecystectomy. Assess the client's pain, vital signs, dressing and/or incision site(s), fluid status, nutritional status, and emotional well being. Monitor the client for complications, such as infection and assess the drainage of the T tube, if present. Medicate the client for pain and nausea as prescribed. Encourage coughing and deep breathing, and ambulation. Advance diet as tolerated. Monitor incision(s) for redness. Place the client in the Sims position to alleviate pain from the carbon dioxide that was used to inflate the abdominal cavity during surgery.

The nurse teaches a group of pregnant clients about the risks of drinking alcohol during pregnancy. Which potential long-term effects of fetal alcohol syndrome does the nurse include in the teaching? (Select all that apply.) 1. Slowed physical growth. 2. Facial abnormalities. 3. Respiratory depression. 4. Learning disabilities. 5. Hypertension.

1) CORRECT — Slowed physical growth and developmental delays are potential effects of fetal alcohol syndrome. 2) CORRECT — Facial deformities are potential effects of fetal alcohol syndrome. 3) INCORRECT - Respiratory depression is not associated with fetal alcohol syndrome. 4) CORRECT — Learning disabilities are a potential effect of fetal alcohol syndrome. 5) INCORRECT - Hypertension is not associated with fetal alcohol syndrome. *Think Like a Nurse: Clinical Decision-Making* Fetal alcohol syndrome (FAS) or fetal alcohol spectrum disorders (FASDs) are due to alcohol abuse during pregnancy. Clinical assessment of FAS includes microcephaly, small palpebral (eyelids) fissures, abnormally small eyes, maxillary hypoplasia, epicanthal folds (fold of skin of the upper eyelid over the eye), thin upper lip, short upturned nose, altered palmar crease pattern, short birth length, low birth weight, narrow forehead, mental retardation, and cardiac defects. The nurse should perform a comprehensive assessment and be vigilant in monitoring the newborn for neonatal abstinence syndrome. *Content Refresher* Fetal alcohol syndrome (FAS) is a group of birth defects that occur when a pregnant woman drinks moderate amounts of alcohol. Assess the infant or child for unusual facial features (e.g., a smooth philtrum, thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, small palpebral fissures, small head circumference), lower-than-average height or weight, problems with attention and hyperactivity, and poor coordination. Identify health and community resources to assist with cognitive and developmental delays. Refer the mother to an alcohol treatment program.

The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply.) 1. Remove the newborn's eye patches during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. 3. Reposition the newborn every 4 hours. 4. Cover the newborn with light cotton clothing. 5. Cluster activities when caring for the newborn.

1) CORRECT — The nurse should place eye patches over the newborn's eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings. 2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin. 3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown. 4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights. 5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights. *Think Like a Nurse: Clinical Decision-Making* Phototherapy requires the newborn to be exposed to a special fluorescent light. Increased skin area exposed increases the therapy's effectiveness. The light is absorbed through the skin and blood, and then breaks down the bilirubin in the newborn's body so that it can be flushed out of the body in stool and urine. When administered appropriately, phototherapy is not harmful to the newborn's skin. However, eye protection is applied to prevent injury to the newborn's eyes. Exposure to UV filtered sunlight at home may be prescribed for treatment of clients with mild cases of jaundice, but caution is required to avoid sunburn. *Content Refresher* Phototherapy is used to promote bilirubin excretion. Closely monitor the infant's temperature because phototherapy can increase the body temperature. Monitor the infant's skin for burns. Monitor for side effects of phototherapy, including loose, greenish stools; hyperthermia or hypothermia; increased metabolic rate; priapism; dehydration; and electrolyte imbalances, such as hypocalcemia (uncommon, but possible). The full-term and late-preterm infant may require additional fluid volume or feedings to compensate for insensible and intestinal fluid loss.

A preschool-age client is recovering from a tonsillectomy and adenoidectomy. The client is discharged home with the parents. Which instructions will the nurse give to the parents? (Select all that apply.) 1. Monitor the child for continuous swallowing. 2. Encourage the child to deep breathe and cough every 2 hours. 3. Administer pain medication such as acetaminophen, as needed. 4. Administer codeine elixir routinely for pain. 5. Monitor the child for restlessness and difficulty breathing.

1) CORRECT- Frequent swallowing is a sign of bleeding. 2) INCORRECT - Deep breathing and coughing could precipitate bleeding. 3) CORRECT- The throat is sore after surgery and pain medication is needed regularly for the first few days. 4) INCORRECT - Codeine should not be routinely administered. 5) CORRECT- Restlessness or difficulty breathing is a sign of bleeding or airway obstruction. *Think Like a Nurse: Clinical Decision-Making* Post-tonsillectomy, the nursing interventions are focused on assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding. Discharge teaching may include reinforcing adherence with antibiotics, when to notify the health care provider (e.g., signs of difficulty breathing), and improving fluid and food intake. Water, apple juice, and grape juice, are well tolerated post-operatively. Soft foods such as applesauce, pudding, ice cream, sherbet, and yogurt are easy to swallow and will provide the client with nutrients. The nurse should instruct the client to avoid crunchy, hard foods and hot or spicy foods. The client may take pain medicine an hour before meals to reduce pain while eating. *Content Refresher* The tonsils are part of the lymphatic system and function to provide some immunity against pathogens entering the pharynx. When tonsils become infected repeatedly (tonsillitis), the tissues can become hypertrophied and enlarged. Tonsils can be so enlarged that airway obstruction occurs and breathing is affected. After a tonsillectomy, monitor for bleeding or airway obstruction due to edema and swelling. Monitor the back of the throat frequently in the post-operative period for bleeding. Monitor vital signs. Once the gag reflex has returned post-operatively, offer cool fluids and ice chips. Assess and treat pain as prescribed. Corticosteroids may be administered to reduce edema.

An adolescent client tells the nurse about being hungry and thirsty constantly, and that eating and drinking do not seem to help. It is most important for the nurse to ask which question? 1. "Have you had any weight changes in the past few months? " 2. "Are you taking any over -the -counter diet medication? " 3. "Are you allergic to any medication, food, or other substances? " 4. "Have you noticed any vaginal infections or non-healing sores? "

1) CORRECT- Polydipsia and polyphasia, as well as polyuria, suggest type 1 diabetes mellitus (DM). It is important for the nurse to assess for weight loss, which is also an indicator of the condition. In children, the nurse may see fatigue and bedwetting. 2) INCORRECT- Diet pills cause weight loss, but they usually suppress hunger. Diet pills do not usually cause insatiable thirst. 3) INCORRECT- Asking about allergies is always important for the nurse to do, but it is not the most important question in this scenario. 4) INCORRECT- Recurrent vaginal infections and UTIs are an early sign of type 2 DM in adolescents. This would be a valuable follow-up question after asking about weight loss. Weight loss usually precedes the occurrence of infections. *Think Like A Nurse: Clinical Decision Making* Ongoing hunger and unrelenting thirst are manifestations of diabetes. Weight loss in diabetes occurs because the body is unable to utilize available glucose in the blood for energy. Over-the-counter diet medication may alter appetite, but should have no effect on fluid balance or thirst. Recurrent infections are associated with type 2 diabetes mellitus and should be assessed after determining if the client is experiencing other symptoms of the disorder such as polyuria. *Content Refresher* Diabetes mellitus (DM) is a disease that is characterized by hyperglycemia. Type 1 DM is due to an absolute deficiency of insulin. The classic symptoms of diabetes mellitus include polydipsia, polyphagia, and polyuria. Other symptoms may include malaise, fatigue, and weight loss.

The nurse provides care for an older adult client 12 hours after a right total hip replacement. The client appears disoriented to person, place, and time. Which action does the nurse perform first? 1. Place an abductor pillow between the client's legs. 2. Frequently orient the client to person, place, and time. 3. Limit the client's fluid intake. 4. Encourage the client to use the incentive spirometer every 4 hours.

1) CORRECT— Abduction prevents dislocation of the hip while turning and is the priority intervention. The pillow is important to use because the client is confused and may not follow directions. Assess for pain, rotation, and/or extremity shortening. 2) INCORRECT— Orienting the client is appropriate because the client is confused, which is not unusual. Older adult clients may become confused by surgery and hospitalization. Preventing dislocation of the replaced joint is the priority. 3) INCORRECT— Nurse would encourage fluids to prevent dehydration, deep vein thrombosis, and further confusion. Instruct the client to wear elastic stockings and to perform leg exercises. Assess for redness, swelling, or pain of the calf. 4) INCORRECT— Encourage a client to cough and deep breath or to use the incentive spirometer every 2 hours to prevent atelectasis and pneumonia. *Think Like A Nurse: Clinical Decision Making* Because the client is disoriented, the surgical site and new joint prosthesis must be protected. Placing and keeping a pillow between the legs keeps the new hip joint in proper anatomical alignment and prevents accidental dislocation of the prosthesis. *Content Refresher* Following a hip replacement, the nurse will teach the client about preventing hip dislocation, which is a possible complication following the procedure. This complication is a result of hip flexion over 90 degrees or adduction during healing. The affected leg should be abducted to maintain proper alignment of the prosthesis. Post-operatively, abduction is achieved and maintained with the use of an abductor pillow. The pillow is a firm wedge-shaped cushion that is placed between the client's upper thighs (narrow angle placed upward) to hold the legs in an abducted position.

The nurse counsels the parent of a school-age client diagnosed with asthma. The health care provider prescribes albuterol and beclomethasone via metered dose inhaler. Which statement by the parent indicates that teaching is effective? 1. "Albuterol should be taken as needed when my child is short of breath. The beclomethasone should be taken every day to prevent asthma attacks." 2. "Both of the medications should be taken on a regular basis, at the same time each day." 3. "The beclomethasone is to be used only when my child is wheezing and is short of breath." 4. "Both inhalers should be used immediately before my child participates in physical exercise."

1) CORRECT— Albuterol is a rapid-acting bronchodilator used to treat acute asthma attacks. Beclomethasone is an anti-inflammatory agent used chronically to prevent asthma attacks by reducing inflammation in the airways. 2) INCORRECT - The beclomethasome is scheduled regularly. The albuterol is a rescue inhaler. 3) INCORRECT - The albuterol, not the beclomethasone, is the rescue inhaler. 4) INCORRECT - If prescribed by the health care provider, the albuterol should be taken 5 minutes before exercise. *Think Like A Nurse: Clinical Decision Making* A new diagnosis of asthma will require medication teaching. The nurse will provide education related to the prescribed medications. In this instance, education is provided for two types of medications one that is used for acute exacerbation (albuterol) and one that is used for maintenance and taken daily (beclomethasone). Once the teaching session is completed, the nurse evaluates the client's understanding of the information presented. Additional teaching may be required if the client is unable to state when each medication should be administered. *Content Refresher* Asthma is a chronic, lung disease that presents with intermittent airway obstruction due to bronchial constriction and inflammation. Treatment includes control of environmental factors that have been identified to trigger an attack such as smoke, pet dander, and aerosol sprays. Anti-inflammatory medications, bronchodilators, and anticholinergics are groups of medications that are prescribed for "rescue" or relief of an attack and to maintain long-term control of the disease.

The nurse makes client care assignments for the day. Which client does the nurse assign to the LPN/LVN? (Select all that apply.) 1. Client taking ferrous sulfate who reports black stools. 2. Client with jugular vein distention and muffled heart sounds. 3. Client with bronchitis who requires a sputum sample collection. 4. Client with new onset hemianopsia and aphasia. 5. Client receiving oral nitrofurantoin for cystitis. 6. Client with a new onset left bundle branch block.

1) CORRECT— Black stools are expected while taking ferrous sulfate. This is a stable client and an appropriate client to assign to the LPN/LVN. 2) INCORRECT— Jugular vein distention and muffled heart sounds are indicative of cardiac tamponade. This client is unstable and should not be assigned to the LPN/LVN. 3) CORRECT— This is a stable client. There is no indication the client is in respiratory distress. An LPN/LVN can collect a sputum sample. 4) INCORRECT— New onset hemianopsia and aphasia indicate possible stroke. This client is unstable and should not be assigned to the LPN/LVN. 5) CORRECT— This is a stable client. An LPN/LVN can administer the antibiotic (nitrofurantoin). Cystitis does not typically result in an unstable condition. 6) INCORRECT— A new onset left bundle branch block indicates possible myocardial infarction. This client is potentially unstable and should not be assigned to the LPN/LVN. *Think Like a Nurse: Clinical Decision-Making* LPNs/LVNs are supervised by an RN. What the LPN does depends on local state "scope of practice " laws. LPNs/LVNs can administer oral and intravenous medications; collect specimens such as blood, urine, sputum, etc.; take the client 's vital signs; and change wound dressings, among other tasks. As a general guide for staffing, the LPNs/LVNs are assigned stable clients. It is always best for the RN to determine the LPN/LVN's experience and expertise with a specific client population and to keep open communication between the RN and LPN/LVN. *Content Refresher* Delegation is the process of transferring client care to the LPN/LVN in a stable situation with a predictable outcome. In deciding whether or not to delegate client care, the nurse needs to assess the following factors: the client 's present health status, safety of the situation, and the intended client outcome.

A school-age client is prescribed phenobarbital 15 mg every 12 hours by mouth and phenytoin 30 mg/5 mL twice a day by mouth. Which information is most important for the nurse to instruct the parents? 1. Phenytoin comes as a suspension and should be shaken. 2. Phenytoin can cause a change in the growth of gums. 3. Phenobarbital can cause a discoloration of the urine. 4. Phenobarbital can affect vitamin D metabolism.

1) CORRECT— Teaching the importance of shaking the phenytoin is necessary for client safety. The medication needs to be provided accurately. 2) INCORRECT - Gingival hyperplasia is a side effect of phenytoin that occurs over a long period. This adverse effect is minimized with frequent dental care. 3) INCORRECT - Phenobarbital does not change the color of urine, but it may cause nausea, constipation, and epigastric pain. Phenytoin may turn the urine pink, red, or red-brown. 4) INCORRECT - Phenobarbital increases vitamin D metabolism, which can lead to sub-therapeutic levels with prolonged therapy. However, this is not the most important information to teach the parents. *Think Like A Nurse: Clinical Decision Making* For a client with a newly prescribed medication, focus instructions on the medication 's administration procedures, therapeutic effects, and adverse effects. Include instructions to shake the medication to ensure delivery of the prescribed dose needed to treat the client 's condition. Discuss such adverse effects as gastrointestinal problems and changes in urine color to prevent alarm should they occur. If the medications will be used long term, discuss the risk for gum hyperplasia and the need for vitamin D supplementation. Closely monitor serum drug levels. *Content Refresher* Phenobarbital and phenytoin are both anticonvulsant medications. Instruct parents not to stop the medications abruptly because this action may lead to seizures. Teach parents the importance of regular drug level monitoring for phenobarbital and phenytoin. Teach that the adverse effects of anticonvulsant medications involve the central nervous system and include diplopia, drowsiness, ataxia, and mental slowness. Stress the importance of good oral hygiene (brushing and flossing) and regular dental examinations.

The nurse cares for a Japanese American client. The nurse discusses preoperative procedures with the client. The client continually smiles and nods while the nurse is talking. How does the nurse interpret this behavior? 1. It reflects the cultural value of interpersonal harmony. 2. It indicates acceptance of the treatment plan. 3. It indicates agreement with what the nurse is saying. 4. It reflects the client's understanding of the procedure.

1) CORRECT— The client's behavior only indicates the client's attempt to be agreeable. 2) INCORRECT — This is not an accurate interpretation of the cultural gesture. 3) INCORRECT — This is not an accurate interpretation of the cultural gesture. 4) INCORRECT — This is not an accurate interpretation of the cultural gesture. *Think Like A Nurse: Clinical Decision Making* Adequate and thorough communication must take into consideration the messenger, the message, and the receiver. When delivering a message, the nurse needs to validate that the correct message was received. There are reasons why a message may be misinterpreted or believed to be accurately received when in fact it was not. One reason would be the cultural background of the receiver. In some cultures, health care providers are highly regarded and whatever is said, the receiver will agree verbally or nonverbally. For this type of situation, the nurse needs to validate that the message was received utilizing the teach-back method. *Content Refresher* Cultural diversity includes groups of individuals (religious, racial, ethnic, and/or social groups) with different values, beliefs, traditions, customs, behaviors, and/or language. When admitting a client, the nurse needs to complete a cultural assessment. This includes an ethnohistory (cultural orientation and background), family structure, education, communication patterns (e.g. eye contact), nutritional practices, and spiritual and religious beliefs. In addition, assess the client's perception and beliefs about illness and treatment methods along with values related to health. Finally, determine issues and/or concerns impacting current health.

The nurse prepares to administer newly prescribed clonazepam and meloxicam to the client. Upon assessment, the client reports hives and difficulty breathing after taking midazolam and oxycodone years ago. Which actions will the nurse implement? (Select all that apply.) 1. Holds the clonazepam. 2. Holds the meloxicam. 3. Administers half the prescribed dose of clonazepam. 4. Notifies the health care provider. 5. Administers half the prescribed dose of meloxicam.

1) CORRECT— The nurse should hold the clonazepam because of the client's previous allergic reaction. A client could develop an allergic reaction to midazolam if clonazepam is administered, as both medications are benzodiazepine medications. A client could also develop an allergic reaction if clonazepam is administered. 2) INCORRECT — There is no reason to hold the meloxicam, a nonsteroidal anti-inflammatory drug. No cross-reaction to midazolam or oxycodone exists. 3) INCORRECT — It is not within the nurse's scope of practice to change the dosage. The nurse should hold the clonazepam because of the client's previous allergic response, as the client could develop an allergic reaction if clonazepam is administered. The health care provider must be notified. 4) CORRECT— The health care provider should be notified of the client's previous medication allergy to midazolam for a change in the prescription. 5) INCORRECT — It is not within nurse's scope of practice to change the dosage without consulting with the health care provider. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes that both midazolam and clonazepam are benzodiazepines. Because the client had an allergic reaction to a benzodiazepine medication in the past, the clonazepam should be withheld since it is also a benzodiazepine. The health care provider should be notified, to remind of the allergy to benzodiazepines, and to receive a replacement prescription for the clonazepam. *Content Refresher* Medication administration is the process by which prescribed medications are safely dispensed to a client. The nurse must be knowledgeable about the medication, reason for its administration, how and when effectiveness will be determined, and possible adverse effects. Before administering the medication, the nurse needs to identify drug allergies, possible drug and/or food interactions, and recognize when a medication is contraindicated.

The nurse manager is informed that a client on the unit has developed a central line-associated bloodstream infection (CLABSI). The nurse manager collaborates with the risk manager during an investigation of the incident. Which actions are appropriate for the nurse to take in this situation? (Select all that apply.) 1. Determine if lack of supplies was a contributing factor. 2. Review nursing documentation prior to the CLABSI. 3. Determine the method by which nurses access central lines. 4. Reassure the client and family that the CLABSI was unavoidable. 5. Instruct the nurses who cared for the client to obtain legal counsel.

1) CORRECT— Those individuals participating in the investigation will determine whether appropriate supplies, such as chlorhexidine/silver sulfadiazine-impregnated catheters and occlusive dressings, were available. 2) CORRECT— Nursing documentation is reviewed to determine the frequency of dressing changes and how frequently catheter insertion sites were changed. 3) CORRECT— Those individuals participating in the investigation will determine the exact technique that nursing staff uses when accessing central lines to determine whether faulty nursing actions increase the risk of CLABSI. 4) INCORRECT - The investigation is ongoing, so this statement cannot be made. However, CLABSIs are largely preventable. 5) INCORRECT - The purpose of an investigation is quality improvement, not to assign blame. *Think Like A Nurse: Clinical Decision Making* When an unplanned event occurs on a care area, the nurse manager is responsible for conducting a root cause analysis. This is a process whereby every step is studied in order to determine the reason for the client outcome. Since this client developed an infection caused by care, the analysis should focus on the steps performed when providing the care. In this situation, the technique for changing the dressing and the supplies used must be reviewed. The quality and content of documentation should be analyzed for any indications that might have been clues or reasons for the infection to develop. *Content Refresher* Risk management entails the systematic application of management policies, procedures and practices for the purpose of communicating, consulting, identifying, analyzing, evaluating, treating, monitoring, and reviewing risk. Central to a risk management plan is client safety. Risk management entails analyzing, classifying, and prioritizing risks. Develop a plan to avoid risks. Gather data that indicates success at avoiding or minimizing risk. Evaluate and modify risk reduction program as necessary. Determine that client is receiving adequate care. Communicate changes in client's health. Document accurately and completely. Report suspected safety violations. If unsure about a safety situation, consult the risk manager. Neglecting to have comprehensive risk management plans in place can compromise client care, increase liability risks, and result in financial losses.

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best? 1. "The vaccine cannot cause polio because it contains killed virus particles." 2. "The vaccine contains weakened toxins that produce an immune response, not polio." 3. "Do not worry, your child will not get polio from the vaccine." 4. "The vaccine contains live virus, but it is weakened so it will not give your child polio."

1) CORRECT—The polio vaccine administered by the intramuscular route contains inactivated (or killed) polio virus. The organism causes an immune response, but is incapable of reproducing and causing infection. 2) INCORRECT - Toxoid vaccines, such as tetanus, contain weakened toxins that retain the ability to produce an immune response, but they cannot cause polio. 3) INCORRECT - The nurse should educate the parent about the vaccine, not dismiss the parent's concerns by telling the parent not to worry. 4) INCORRECT - The oral polio vaccine, not the polio vaccine administered by intramuscular injection, contains live attenuated vaccine. Live attenuated vaccines contains weakened organisms that produce an immune response, but not illness. However, people who receive the live attenuated vaccine can shed virus and spread the disease to individuals who are immunosuppressed. *Think Like A Nurse: Clinical Decision Making* Health promotion and disease prevention activities include monitoring and providing required vaccinations at the appropriate times. The use of vaccinations may cause anxiety for some parents because of a lack of knowledge of how the vaccine works and what the vaccination is intended to do. The parent who is concerned that a vaccination will cause a disease needs information about the contents of the vaccine and the expected response once the vaccine is administered. The person receiving the vaccination may also be concerned and the nurse should provide teaching prior to administering the vaccination. The nurse should maintain knowledge about the mechanism of immunity associated with various vaccines. *Content Refresher* Polio is a viral disease that can cause severe disability and risk of death. The United States has eliminated the disease through childhood immunization programs, but polio is still present in other countries. The polio vaccine currently provided to children in the United States is an inactivated version known as IPV. Children should receive a total of four doses before 6 years of age. Written information about vaccines are provided to the parent/client prior to administration. The nurse can reinforce the information provided and answer any questions.

The nurse provides care for clients in the intensive care unit (ICU). A client diagnosed with a head trauma needs to be admitted. There are no empty beds. Which client does the nurse anticipate as being the most stable for a transfer to the step-down neurological unit? 1. A client diagnosed with bacterial meningitis and Glasgow Coma Scale of 7. 2. A client 1 day postoperative after a transsphenoidal craniotomy with a possible cerebrospinal leak. 3. A client diagnosed with a stroke 4 days ago who is exhibiting confusion. 4. A client with a head injury who is having seizures.

1) INCORRECT - A Glasgow Coma Scale of 7 indicates a comatose state. The client is unstable and cannot be transferred. 2) INCORRECT - The client is at risk of increased intracranial pressure (ICP) and is unstable. 3) CORRECT - After 4 days, the risk for this client having a second stroke is significantly reduced. Therefore, the focus of care is rehabilitation. This client can be transferred. 4) INCORRECT - A client with a head injury who is experiencing seizures is unstable and should not be transferred. *Think Like a Nurse: Clinical Decision-Making* When an intensive care unit reaches maximum capacity and a critically ill client requires admission to the unit, the nurse must think, "Which client on the unit is most clinically stable and can be safely transferred to a lesser level of care?" A client with known or suspected Neisseria meningitidis requires close monitoring in the intensive care unit. A client who develops a cerebrospinal fluid leak 1 day after transsphenoidal resection necessitates close monitoring for signs of bacterial meningitis and diabetes insipidus. A client with head injury and active seizure activity requires immediate intervention by specialized nursing staff to prevent further neurologic compromise. Four days after experiencing a stroke, a client with no further neurologic changes can safely be cared for in a lesser level of care. *Content Refresher* The client who had a stroke can be transferred. Client recovery from stroke is a lengthy process that involves multidisciplinary, coordinated treatment. During the initial recovery, the focus is on restoring tissue perfusion to the injured area and reducing swelling. If the client's intracranial pressure is stable and no seizure activity is present, then the client can begin the lengthy rehabilitation process. The nurse should teach the client/family about the condition, treatment, risk factors, and prevention of further strokes.

The nurse provides care to a client diagnosed with acute streptococcal glomerulonephritis (ASGN). The client is receiving captopril 25 mg PO and expresses concern about side effects. Which response by the nurse is best? 1. "Where did you get this information? " 2. "What are your concerns? " 3. "You need to continue with the medication. " 4. "This is the best medication for you. "

1) INCORRECT - Although it is important to determine if a client is making decisions based on valid information, this response is not therapeutic. 2) CORRECT— The response allows a client to verbalize concerns so that the nurse can give a client appropriate information to make an informed decision. 3) INCORRECT - A client has the right to refuse treatment, but should be given appropriate information. Merely instructing the client to continue with the medication is not a therapeutic response. 4) INCORRECT - This response is not therapeutic as it does not encourage the client to verbalize concerns. It is important for the client to verbalize concerns so that the nurse can give the client appropriate information to make an informed decision. *Think Like A Nurse: Clinical Decision Making* Assessment is the first step of the nursing process and should be performed to gather information. When the nurse is evaluating the client's feelings/concerns, the assessment process requires the use of therapeutic communication principles. Before listing potential side effects of the medication, the nurse should first assess which specific concerns the client may have. This provides an opportunity to plan a response that will be meaningful and helpful to address the client's concerns. *Content Refresher* Streptococcal infection is the most common cause of acute glomerulonephritis. Depending upon the underlying cause, medications are prescribed to eliminate infection and reduce inflammation, suppress the immune system, and control hypertension. Dietary restriction of sodium and protein may reduce edema. The nurse should ask about client concerns and provide information about the cause and treatment of glomerulonephritis. All communication with the client should be done using therapeutic communication principles.

The nurse in the emergency department assesses an older adult client. The client's family member states that the client has glaucoma, is hard of hearing, and has been experiencing abdominal pain for the past 24 hours. Which action by the nurse is the most appropriate? 1. Assess the intensity of the client's pain using a numeric rating scale. 2. Ask if the client wears hearing aids. 3. Administer the prescribed pain medication to the client. 4. Determine when the client last saw a health care provider.

1) INCORRECT - Although this is an appropriate action, it is a priority to ensure that the client is able to understand what the nurse is asking. 2) CORRECT— Tools used for rating pain are ineffective if a client cannot hear what is being asked or see the pain rating scale. First ask if the client wears hearing aids and determine if they are in place. 3) INCORRECT - It is most important to assess the client before determining if medication for pain is appropriate. 4) INCORRECT - The priority is to ensure that the nurse can effectively communicate with the client prior to beginning the assessment process. *Think Like A Nurse: Clinical Decision Making* Assessment is the first step of the nursing process and is important for gathering client data. The client is the most important source of information during assessment because subjective information is more meaningful to the nurse when it is presented in the client's own words. However, the nurse needs to ensure that the client's sensory status is intact before beginning an assessment. Since the client is hard of hearing, asking if a hearing aide is used and worn helps ensure that the assessment will be valid. *Content Refresher* When caring for a client with hearing loss, assess client's ability to hear varied speech tones; determine if hearing loss is uni- or bilateral. Review health history and determine occupational exposures to loud noise, use of ototoxic medications, and chronic illnesses that contribute to hearing loss. Refer to audiologist for pure-tone air conduction hearing test, if indicated. Teach client and family about presbycusis-related hearing loss and treatment options such as training in lip reading, hearing aids, cochlear implants, and assistive listening devices. Refer to community support services, if indicated.

The home health nurse is providing care for several pediatric clients. Which client does the nurse identify as being at the greatest risk for injury? 1. An infant who is in a car seat placed on the coffee table. 2. A toddler who is playing alone in the living room. 3. A preschool-age client with a tracheostomy who is eating raisins. 4. A school-age client who stays home alone for half an hour after school.

1) INCORRECT - An infant should not be left unattended on a raised surface. However, the situation does not state the infant is alone. 2) INCORRECT - The doors and screens should be locked, and gates placed at the top and bottom of any stairs for the safety of a toddler. This child could be at risk but is not at the highest risk. 3) CORRECT—This child is at risk putting the raisins, which are foreign objects, into the tracheostomy. This child is at the highest risk for injury. 4) INCORRECT - This is not potentially a risk for injury situation. Teach the child to lock the door. Keep a list of emergency numbers by the phone. *Think Like A Nurse: Clinical Decision Making* To identify the client at highest risk, the nurse evaluates the potential safety risk present in each situation. The nurse prioritizes safety risks that pose an immediate threat to life. Keeping the ABC's (airway, breathing, circulation) in mind, the nurse identifies that the preschool age child with a tracheostomy who is eating raisins is at risk for an airway obstruction. One of the raisins can accidentally fall into the tracheostomy, affecting the child's airway and ventilation. *Content Refresher* Preschool is the term used for children 2 to 5 years of age, prior to beginning school. Significant physical, social, and emotional growth and developmental changes characterize this stage of life. Education for caregivers/parents on how to modify the environment to prevent injury or promote safety is an important goal for health care providers. Children need constant supervision to maintain a safe environment. A preschooler with a tracheostomy needs additional supervision, especially during meals.

The nurse counsels the spouse of a client diagnosed with generalized anxiety disorder about how to cope with the client's anxiety. Which statement, made by the spouse, indicates that teaching is successful? 1. "Anxiety is a conscious means of resolving conflict." 2. "Anxiety represents an unconscious conflict of needs." 3. "I should confront my spouse when I notice signs of anxiety." 4. "Defense mechanisms increase anxiety."

1) INCORRECT - Anxiety is a normal response to a threat, but generalized anxiety disorder is manifested by excessive anxiety or worry about many things. Unconscious conflict may cause anxiety. 2) CORRECT— The root of anxiety for generalized anxiety disorder is the conflict between expressing unacceptable impulses and the need to hold onto social approval. 3) INCORRECT - The spouse should not confront the client. The spouse should be patient and accepting and avoid placing undue emphasis on the anxiety. 4) INCORRECT - Defense mechanisms are a way for the client to cope with anxiety, rather than a cause of anxiety. *Think Like A Nurse: Clinical Decision Making* Generalized anxiety disorder (GAD) differs from the typical sense of anxiety that each person occasionally experiences. Physical symptoms associated with GAD may include fatigue, diarrhea, diaphoresis, and insomnia. This disorder routinely interferes with daily activities and the anxiety does not always have an identifiable cause. Without proper treatment, GAD may lead to or exacerbate conditions such as depression and substance abuse. The spouse and other family members must be taught how to be supportive, understanding, kind, and non-confrontational to help the client cope effectively with this mental disorder. *Content Refresher* Anxiety is a common, subjective response to a perceived or actual threat. It may range from vague discomfort to total panic leading to loss of control. Assess for agitation, restlessness, tachycardia, hypertension, and tachypnea. Teach the client relaxation techniques (e.g., deep breathing, listening to music, or progressive head to toe relaxation). Listen to the client and communicate clearly regarding concerns that the client expresses. Encourage the client to use coping strategies that were successful with anxiety in the past. Educate about pharmacologic treatments to decrease anxiety (e.g., benzodiazepines, anti-anxiety agents, antihistamines, and antidepressants).

The nurse prepares to perform the initial assessment on a school-age client. The client has an open wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which precaution will the nurse take? 1. Wear gloves only. 2. Wear gown and gloves. 3. Wear gown, gloves, and mask. 4. No precautions are necessary.

1) INCORRECT - Clients with MRSA should be placed in contact precautions. Contact precautions require the use of gloves and gown for any contact with the client or equipment. 2) CORRECT— The nurse should wear clean, nonsterile gloves and gown when entering the client's room, if the nurse is going to have any contact with the client or with surfaces that the client touches. 3) INCORRECT - Masks, eye protection, and face shield are only required if client care activity is likely to generate splashes or sprays (such as suctioning). 4) INCORRECT - Contact precautions are required with clients who are diagnosed with MRSA. *Think Like A Nurse: Clinical Decision Making* Contact precautions are designed to prevent skin and clothing contact with the infectious organism methicillin-resistant Staphylococcus aureus (MRSA) because the organism can travel with that vector (the nurse) to another host (a client). MRSA is spread through contact with the infection source and through contact with surfaces in the room, such as bedside tables, bed controls, and linen stored in the room. Keeping this in mind, the nurse should remember that the personal protective equipment needed includes equipment that prevents hand and clothing contamination. *Content Refresher* Transmission-based precautions are infection control practices used in health care, and are applied when clients are known or suspected to be infected or colonized with infectious agents. They are used in addition to standard precautions. There are three types of transmission-based precautions: contact precautions, droplet precautions, and airborne precautions. In addition to standard precautions, the nurse should wear a gown and gloves upon room entry and use disposable single-use or client-dedicated equipment with a client on contact precautions. Transmission-based precautions will prevent the spread of disease and infections.

The nurse provides care for a preschool-age client diagnosed with epiglottitis. Which action is appropriate for the nurse to implement? 1. Ask the nursing assistive personnel (NAP) to take the child to radiology. 2. Use a padded tongue blade to assess the child 's gag reflex. 3. Obtain a blood culture and ABGs as prescribed by the health care provider. 4. Apply a pulse oximeter and start an IV infusion.

1) INCORRECT - Epiglottitis is an inflammation of the epiglottis and can be life threatening. A licensed provider should be with the child at all times. 2) INCORRECT - Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis. The gag reflex can cause complete obstruction of the airway. 3) INCORRECT - These tests are usually not necessary for a client with suspected epiglottitis. Crying should be minimized as it can cause obstruction of the airway. 4) CORRECT— Treatment for epiglottitis includes moist air and IV antibiotics to decrease epiglottal swelling. A pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen. *Think Like A Nurse: Clinical Decision Making* The nurse needs to review the manifestations and risks associated with the client's diagnosis. The nurse will plan care with the understanding that epiglottis is an acute inflammation and swelling of the upper region of the throat. Because of the location of the swelling, the client is prone to developing an occluded airway. The nurse will apply the principles of airway-breathing-circulation (ABCs) in formulating a plan of care. The client's oxygen saturation level should be monitored to evaluate effectiveness of respirations. Additional treatment includes fluid replacement and medication to address the infection which is causing the health problem. *Content Refresher* When caring for a preschool-age client diagnosed with epiglottitis, the nurse will initially and continually assess the client for signs of respiratory distress including dyspnea, chest tightness, decreased pulse oximeter readings, wheezing, and diminished air movement. The nurse will review the client 's history of asthma and prior/current treatment plans, and assess level of anxiety. Supplemental oxygen may be needed, and the parameters of oxygen therapy will be maintained. Assessment will not include visual examination of the client's throat to avoid laryngeal spasms, which can cause airway occlusion. Emergency equipment, such as a tracheotomy set, will be kept as the bedside.

A client has a prescription for hydrochlorothiazide. Which client statement indicates to the nurse that teaching is successful? 1. "I should not operate heavy machinery. " 2. "I should drink five glasses of liquid per day. " 3. "This medication will cause orange urine. " 4. "I should eat dried apricots each day. "

1) INCORRECT - Hydrochlorothiazide does not cause drowsiness. 2) INCORRECT - There are no specific restrictions on fluid. 3) INCORRECT - Hydrochlorothiazide does not alter urine color. 4) CORRECT— Continued use of this diuretic may cause a loss of potassium. Dietary intake of foods such as bananas or dried apricots, which are high in potassium, is encouraged. *Think Like A Nurse: Clinical Decision Making* Use of loop and thiazide diuretics may lead to clinically significant hypokalemia. Therefore, the nurse must provide information to the client on foods that are potassium-rich to decrease the likelihood of this from occurring. Once the information is presented, the nurse evaluates for understanding. There may be a need for more teaching if the client is unable to restate which foods (e.g., dried apricots) are potassium-rich. *Content Refresher* Hydrochlorothiazide is a potassium-wasting thiazide diuretic prescribed to treat edema or hypertension. Assess for symptoms of hypokalemia, such as muscle weakness, muscle cramps, paresthesias, palpitations, and anorexia. Assess for ECG changes suggestive of hypokalemia (e.g., prominent U wave, ST-segment depression, or peaked P wave). Normal potassium level is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Educate the client about increasing intake of potassium-rich foods, such as green leafy vegetables, raisins, bananas, oranges, lentils, and potatoes. Administer oral or IV supplements, as prescribed.

The nurse instructs parents on ways to decrease the incidence of sudden infant death syndrome (SIDS). Which statements require the nurse to intervene? (Select all that apply.) 1. "I position my baby on the back for sleep. " 2. "My baby takes naps in the car seat. " 3. "My baby sleeps covered with one blanket from chest to feet. " 4. "My baby sleeps with one pillow under the head. " 5. "My baby sleeps best on the sofa. "

1) INCORRECT - Infants should always be placed on back for sleep. Prone and side-lying sleeping positions increase the risk for SIDS. 2) CORRECT—This statement requires immediate intervention. Infants should not routinely take naps in car seats, strollers, or swings. They may slump enough to obstruct the airway. 3) CORRECT—This statement requires immediate intervention. Infants should ideally be dressed warmly in pajamas, sleepers, or sleep sack instead of using blankets. If a blanket is used, it should be placed no higher than infant 's waist. The edges of the blanket should be tucked under the mattress to prevent blankets from covering the infant 's face. 4) CORRECT—This statement requires immediate intervention. Use of a pillow increases the risk for suffocation. 5) CORRECT—This statement requires immediate intervention. Infants should not sleep on soft surfaces like a sofa, armchair, soft mattress, or waterbed. *Think Like a Nurse: Clinical Decision-Making* The exact cause of sudden infant death syndrome (SIDS) is unknown, although many factors are associated with its occurrence. The nurse can provide education to the parents and caregivers of the newborn. The nurse should use the teach-back method in all educational encounters. It is also useful to have the parents or caregiver do a return demonstration of placing the infant on the back. Reading materials on SIDS should be provided. Client education materials should not be higher than a sixth- to eighth-grade reading level. The learners should be encouraged to ask questions. *Content Refresher* Sudden infant death syndrome (SIDS) is the occurrence of a sudden death of an infant that cannot be explained after investigation and performance of an autopsy. Risk factors for SIDS include: male gender; preterm or low birth weight; Native American or African American descent; prone or side-lying position for sleep; soft bedding, pillows, blankets, and stuffed animals in the crib; overheating; bed sharing; mother who smoked prenatally and/or continues to smoke; exposure to environmental tobacco smoke; maternal use of alcohol or illegal substances prenatally; and infants who experienced an apparent life-threatening event that presented with cyanosis, pallor, flaccid muscle tone, choking, or gagging. Assess parents ' child care practices and family and cultural practices, especially related to infant sleep.

The nurse provides care to an older adult client diagnosed with right-sided paralysis caused by a cerebrovascular accident (CVA). Which sign is most important for the nurse to post in the client's room? 1. "Keep floor dry and free of debris." 2. "Do not use the right arm for lifting." 3. "Client is hard of hearing." 4. "Client is paralyzed on the right side."

1) INCORRECT - Keeping the floor dry and free of debris is appropriate for every client and not just the client with right-sided paralysis. 2) CORRECT - Because the paralyzed muscles cannot offer resistance, the shoulder can be easily dislocated if the arm is used for lifting. This is a common injury in clients with paralysis, and the sign will help prevent it from occurring. 3) INCORRECT - Posting a sign about a sensory deficit is appropriate, but it is not as significant as the risk for a dislocated shoulder. 4) INCORRECT - Informing about the client's mobility status may help personnel address the client's specific needs, but it does not directly provide specific directions for client management and how to prevent a shoulder injury. *Think Like A Nurse: Clinical Decision Making* The nurse needs to consider the client's health problem prior to planning interventions. Because of the pathophysiological process of a cerebrovascular accident, the client will demonstrate paralysis of one side of the body. For this client, the right side of the body is affected. Because sensory and motor function is absent, the affected side of the body must be protected from harm and accidental injury. The nurse needs to communicate that the right side of the body should not be used when repositioning the client. *Content Refresher* A cerebrovascular accident (CVA) is an interruption of blood flow in the brain as a result of hemorrhage or thrombus. Depending on the location, paralysis, and/or weakness on one side of the body may be present. Facial paralysis may also cause dysphagia and mouth droop. Additional manifestations may include changes in level of consciousness, a change in behavior or affect, hypertension, dizziness, gait changes, and visual difficulties. The phrase "time is brain" has been used to demonstrate the importance of stroke recognition and seeking medical treatment quickly. Within 3 to 10 minutes of stroke, brain damage can occur due to ischemia and infarction. Risk factors for stroke include diabetes mellitus, hypertension, family history, cardiovascular disease, atrial fibrillation, increasing age, hyperlipidemia, obesity, smoking, previous CVA, and substance abuse.

The nurse provides care for a client with a peptic ulcer. Which initial assessment finding indicates to the nurse that the client has a perforated ulcer? 1. Nausea and vomiting. 2. Bradycardia. 3. Rigid, boardlike abdomen. 4. Swelling in the legs.

1) INCORRECT - Nausea and vomiting may occur due to the bleeding and pain after the ulcer perforates. This is not an initial assessment finding but may occur. 2) INCORRECT - Tachycardia, not decreased heart rate, may occur as shock develops. 3) CORRECT - A rigid, boardlike abdomen is the typical sign of the surgical emergency that occurs when a gastric ulcer perforates. Sharp, sudden, intolerable pain begins and spreads over the abdomen. 4) INCORRECT - Swelling in the legs is not a finding associated with a perforated ulcer. *Think Like A Nurse: Clinical Decision Making* When assessing the client in this scenario, the nurse will apply knowledge of the physiology of the gastrointestinal tract. The stomach is the organ where food begins the digestive process. At times, an excess amount of hydrochloric acid in the stomach injures the tissue wall. If left untreated, the injury enlarges, erodes through the tissue, and can progress to a perforation. The body's immediate response to tissue injury is bleeding, swelling, and pain. Bleeding will be present within the stomach, but also throughout the abdominal cavity. Bleeding into this area will cause the abdominal tissues, organs, and muscles to cramp. The abdomen becomes hard and extremely painful. *Content Refresher* Peptic ulcer disease (PUD) is caused by the erosion of the mucosa of the gastrointestinal (GI) tract by hydrochloric acid (HCL) and pepsin. Peptic ulcers can develop in any segment of the GI tract exposed to HCL and pepsin. The most common areas are stomach, lower esophagus, and duodenum. They are categorized as acute or chronic. Erosion of the mucosa may be deeper with prolonged, chronic PUD. When erosion of the mucosa occurs, the client is at risk for hemorrhage (blood in stool, dizziness, and hypovolemic shock), perforation that leads to peritonitis (severe abdominal pain that radiates, rigid abdomen, and fever), and gastric outlet obstruction (epigastric fullness, nausea, and vomiting). They are all emergent situations requiring rapid assessment and treatment.

The nurse provides care for a client who had a lower gastrointestinal (GI) series. The client reports weakness. Which nursing concern is priority in planning the client's care? 1. Insufficient nutritional intake. 2. Alteration in sensation-perception, gustatory. 3. Potential for hypovolemia. 4. Constipation.

1) INCORRECT - Nutrition is not a higher priority issue for the client than the problem of dehydration. 2) INCORRECT - This issue is related to the sense of taste, which should not be an issue for this client. 3) CORRECT - The preparation for the test is a clear liquid or low-residue diet for 2 days, nothing by mouth after midnight before the test, enemas and laxatives to prepare for the test. These preparations can result in dehydration. In addition, the laxatives posttest to remove the barium further increase the risk of dehydration. 4) INCORRECT - Constipation immediately after a lower GI series is unlikely. *Think Like a Nurse: Clinical Decision-Making* The client is experiencing weakness after having a lower gastrointestinal series. Before providing any interventions, the nurse should mentally ask, "What about this diagnostic test would cause the client to have weakness now?" The preparation for the diagnostic testing can be quite extensive. The client's diet is changed to clear liquids and the client is subjected to laxatives and enemas to clear the large intestines. The absence of regular nutrition and loss of fluids and electrolytes through the bowel when preparing for the test can cause both fluid and electrolyte imbalances. The nurse should plan interventions to address a potential fluid imbalance, including monitoring blood pressure, heart rate, and urine output. *Content Refresher* When caring for a client who had a lower gastrointestinal (GI) series, the nurse should prepare the client/family with information about what to expect, including the time period and complexity of the prescribed preparation. The nurse should include information about the need to increase fluid intake post-procedure to eliminate the barium used for the test and to reduce the possibility of dehydration. After the procedure, the nurse should monitor fluid intake and output, assess for signs of dehydration, and provide increased fluids.

The nurse prepares to insert an indwelling urinary catheter into a client. Which action is important for the nurse to take? 1. Place all supplies close to the edge of the table. 2. Keep the field holding the supplies in front of the nurse. 3. Set up the field below the nurse 's waist level. 4. Add only clean supplies to the field.

1) INCORRECT - Placing sterile materials close to the edge of the table would break sterile technique. 2) CORRECT— Having the supplies in front of the nurse represents the best technique for a sterile field. 3) INCORRECT - The sterile field is always above the waist of the nurse. Being below would break sterile technique. 4) INCORRECT - All supplies to be used for the insertion of a urinary catheter must be sterile to prevent the transmission of infection. The exception is for a client who self-catheterizes at home. *Think Like A Nurse: Clinical Decision Making* Nurses will develop a "sterile conscious" when performing sterile procedures, which means that the nurse can mentally envision conditions that are considered sterile or not sterile. The nurse needs to recall that inserting an indwelling catheter is considered sterile, and all equipment should be placed on a sterile field. When establishing a sterile field the nurse should use a surface that is waist-high and remember that approximately 1-inch from the surface edge is considered non-sterile. After establishing the field, the nurse should keep the field within sight to avoid accidental contamination of the items to be used for the catheterization. *Content Refresher* Aseptic technique refers to the process of providing care while keeping an area, object, or person free from disease-causing microorganisms. The use of aseptic technique reduces the chance the client will contract an infection during a procedure. To ensure invasive procedures are carried out using aseptic technique, obtain sterile supplies and check for expiration date and intact packaging. Use sterile drapes or linens to delineate and maintain the sterile field. Open packaging without breaking the sterile field. Carry out the procedure, maintaining the sterile field at all times. If the client, nurse, or equipment is accidentally contaminated, begin the procedure again using new equipment.

The nurse provides care to a client receiving sulfamethoxazole-trimethoprim (SMZ-TMP). Which observation indicates that the client is experiencing a common side effect of this medication? 1. Hypotonia. 2. Loss of hearing. 3. Hypotension. 4. Urticaria.

1) INCORRECT - SMZ-TMP does not cause muscle relaxation. 2) INCORRECT - Aminoglycosides are ototoxic. SMZ-TMP is not an aminoglycoside. 3) INCORRECT - Anti-hypertensives cause hypotension. SMZ-TMP is not an anti-hypertensive medication. 4) CORRECT— A mild to moderate rash is the most common side effect of SMZ-TMP, which is a urinary tract anti-infective. *Think Like A Nurse: Clinical Decision Making* The nurse is responsible for monitoring clients who are prescribed medications for both side effects and adverse reactions. While side effects are bothersome and may affect adherence, adverse reactions can be life-threatening. Adherence is particularly important for the client who is prescribed antibiotics such a sulfamethoxazole and trimethoprim (SMZ-TMP) as not completing the complete prescribed course can lead to drug resistance. The most common side effect for SMZ-TMP is a mild to moderate rash. The client should be educated regarding this information and provided with instruction on how to treat the rash if it occurs and when to notify the health care provider. *Content Refresher* Sulfamethoxazole-trimethoprim (SMZ-TMP) is a sulfa antibiotic that may be prescribed to treat infections of the urinary tract. Inform the client about the medication, the reason for its administration, and how and when effectiveness will be determined. Instruct the client to take the medication as prescribed and finish the full course of antibiotic therapy, even after the client starts to feel better. Adverse reactions associated with SMZ-TMP include Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis, allergic myocarditis, erythema multiforme, and exfoliative dermatitis. Instruct the client to drink plenty of fluids to prevent crystalluria and kidney stone formation. Also instruct the client to avoid prolonged sun exposure, wear protective clothing, and use sunscreen. Evaluate the effectiveness of the teaching/learning session.

The nurse provides care for an infant immediately after a surgical procedure. Which nursing action is the most important? 1. Minimize stimuli for the infant. 2. Restrain all extremities. 3. Encourage the parents to stroke the infant. 4. Explain to the parent how to assist with the infant's care.

1) INCORRECT - Sensory deprivation can cause failure to thrive in an infant. While excessive stimuli should be avoided, the parents and nurse should provide as normal a routine as possible. 2) INCORRECT - Restraints should be avoided, as these pose a risk for harm. 3) CORRECT— Tactile stimulation is imperative for an infant's emotional development and provides essential comfort. 4) INCORRECT - This is important for the parents' psychosocial comfort, but the nurse should first encourage the parents to stroke the infant to achieve a positive outcome for the infant. *Think Like A Nurse: Clinical Decision Making* Parents often experience anxiety when a child requires a surgical procedure. The nurse should prepare the parents regarding what to expect when seeing their child after surgery. In order to meet the psychosocial needs of this family, the nurse should encourage the parents to touch and stroke their infant. This not only provides comfort to the infant, but also meets the emotional and psychological needs of the parents as well. *Content Refresher* When providing care for an infant who is hospitalized for surgery, the nurse should recognize and promote comforting behaviors that will fill the needs of both the client and the parents. The nurse should allow parent(s) to be present and assist with meeting the infant's needs throughout the hospitalization, especially during procedures. Parent(s) should be encouraged to provide comfort to the infant during and after painful procedures.

The nurse discovers the IV infusion tubing disconnected from a peripherally inserted central catheter, and the client has tachycardia, chest pain, and shortness of breath. In which position will the nurse place the client? 1. Supine with the head of bed elevated 30 to 45 degrees. 2. Left side-lying Trendelenburg. 3. Right lateral decubitus. 4. Reverse Trendelenburg.

1) INCORRECT - Since the client exhibits signs and symptoms of an air embolism, the goal is to position the client to trap the air in the lower portion of the right ventricle, which can be achieved by positioning the client on the left side in the Trendelenburg position or in the left lateral decubitus position. A supine position with the head of bed elevated 30 to 45 degrees reduces the risk for hospital-acquired pneumonia. 2) CORRECT- The client exhibits signs and symptoms of an air embolism. Therefore, the nurse should position the client on the left side in the Trendelenburg position to trap the air in the lower portion of the right ventricle. 3) INCORRECT - Since the client exhibits signs and symptoms of an air embolism, the goal is to position the client to trap the air in the lower portion of the right ventricle, which can be achieved by positioning the client on the left side in the Trendelenburg position or in the left lateral decubitus position, not a right lateral decubitus position. 4) INCORRECT - The client shows signs and symptoms of an air embolism. Therefore, the client should be positioned on the left side in the Trendelenburg position, not the reverse Trendelenburg position. *Think Like A Nurse: Clinical Decision Making* Before considering the best action to take, the nurse needs to recall the anatomical location of the peripherally inserted central catheter. The treatment of this access site should be the same as if the catheter was placed in a central location. And, because of the type of device, the client's symptoms indicate an air embolism. Treatment of these symptoms should begin with positioning the client on the left side. This forces the air embolism to move to the right side of the heart. The Trendelenburg position helps contain the embolism to the right ventricle. The goal of this nursing intervention is to prevent the air embolism from entering the lungs or brain, which can cause life-threatening complications. *Content Refresher* An air embolism is an occlusion in the pulmonary arteries following the insertion of a central venous catheter, which puts the client at risk for developing an air embolism. While not as common, air embolis can also occur with peripheral intravenous access that become detached. Clinical manifestations include dyspnea, chest wall pain, cough, hypoxemia, tachypnea, tachycardia, confusion, hemoptysis, crackles, and wheezing. Treatment consists of supplemental oxygen to correct hypoxia symptoms and managing the client's physical position in an effort to prevent the embolis from moving to the lungs or brain. The air embolis is resolved when the air is absorbed by the body.

The nurse provides care to a client who is experiencing dyspnea. Which symptom does the nurse expect to observe in the client? 1. Tachycardia. 2. Shortness of breath. 3. Hemoptysis. 4. High blood pressure.

1) INCORRECT - Tachycardia refers to a heart rate of greater than 100 beats per minute. Tachycardia may or may not accompany dyspnea. 2) CORRECT- Dyspnea refers to a persistent feeling of inadequate ventilation, or "air hunger," and is often accompanied by difficult and labored breathing. Shortness of breath is commonly associated with dyspnea. 3) INCORRECT - Hemoptysis refers to coughing up bloody secretions that originated in the lungs or bronchial tubes. Hemoptysis is associated with conditions that cause dyspnea. However, the presence of dyspnea does not typically mean that hemoptysis will be present. 4) INCORRECT - High blood pressure does not necessarily occur in association with dyspnea. *Think Like a Nurse: Clinical Decision-Making* The nurse needs to have a solid understanding of medical terminology. Any unknown term should be validated using a reliable resource. Sometimes, the nurse can break down the term to aid in interpretation ("dys" means difficult; "pnea" means breathing). The nurse must then mentally clarify what is expected when assessing a client with dyspnea. Individuals who experience dyspnea will state that they feel "short of breath" or are unable to "catch their breath." The nurse should expect the client with dyspnea to have rapid respirations. Depending upon the degree of dyspnea, the client may display anxiety. The nurse will also need to assess for signs of hypoxia. *Content Refresher* When ventilatory effort is diminished (due to pain or muscle weakness), adequate oxygen is not taken into the lungs, thus limiting the amount that is available for gas exchange at the alveolar level. Also, if the size of the airway is reduced (due to constriction or presence of mucus), an inadequate amount of oxygen is taken in and less is available for alveolar gas exchange. These factors create the condition for hypoxemia and resulting hypoxia. Clients experiencing hypoxia may present with dyspnea, tachycardia, tachypnea, shallow inhalations, anxiety, restlessness, dizziness, change in mental status, and confusion. The treatment for hypoxia depends on the cause.

The nurse provides care to an infant client who is 4 months of age with meningitis. Which assessment finding indicates increased intracranial pressure (ICP)? 1. Positive Babinski reflex. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.

1) INCORRECT - The Babinski reflex is positive during the first 6 months of life. Dorsiflexion of the great toe when the sole of the foot is stroked is the expected response. 2) CORRECT - One of the first signs of increased intracranial pressure in an infant is a high-pitched cry. Other signs include irritability, poor feeding, and increased frontal occipital circumference. 3) INCORRECT - The posterior fontanelle closes at 2 months of age. 4) INCORRECT - Pupils respond slowly to light at 4 months of age. *Think Like a Nurse: Clinical Decision-Making* Meningitis places the infant at an increased risk for increased intracranial pressure (ICP). The infant with increased ICP may have a high-pitched cry due to the discomfort associated with this process. The nurse may also see bulging, tense fontanel, wide sutures and increased head circumference, and dilated scalp veins in the infant with increased intracranial pressure. It is important for the nurse to differentiate early signs (e.g., projectile vomiting, increased blood pressure or widening pulse pressure, sunset eyes) from late signs (e.g., bradycardia, decreased motor and sensory responses, Cheyne-Stokes respirations). *Content Refresher* The nurse will assess the client with meningitisfor changes in level of consciousness, presence of headache, fever, sensitivity to light, nausea and vomiting, nuchal rigidity, Kernig sign, and Brudzinski sign. Antibiotic therapy is a major component of the treatment of meningitis. If the etiology is determined to be viral in nature, the antibiotic medications will be cancelled. Medication will also be prescribed to manage the head and neck pain and to reduce fever. Respiratory isolation may be initiated depending upon the cause of the infection. Continuous assessment for seizure activity and for signs of increased intracranial pressure are essential components of treatment.

The community health nurse provides care to a newborn client who is prescribed enteral feedings through a gastrostomy tube. Which statement by the client's mother indicates a need for immediate follow up by the nurse? 1. "It takes about 25 minutes to give one feeding." 2. "I use a bottle warmer to warm the formula." 3. "I wash the syringe with soap after each time I use it." 4. "It is easy to give liquid medicine through the feeding tube."

1) INCORRECT - The enteral feeding should be administered over a period of 20-30 minutes to prevent complications, including dumping syndrome. A 25-minute feeding is within the appropriate window of time. 2) INCORRECT - Bolus enteral feedings may be warmed using an approved bottle warmer. Alternatively, both bolus and continuous enteral feedings may be removed from the refrigerator up to 15-20 minutes prior to administration and allowed to reach room temperature. Unlike bolus feedings, continuous enteral feedings should not be actively warmed prior to administration. 3) INCORRECT - To prevent bacterial contamination, the syringe should be washed with mild soap and warm water after every use. The syringe should then be stored in a clean area until the next use. 4) CORRECT— Liquid medication may contain sorbitol, which can cause diarrhea. Follow up is required, as additional information is needed to determine whether or not the client's medication contains sorbitol. *Think Like A Nurse: Clinical Decision Making* The nurse provides careful and frequent teaching for the parents of a newborn using a feeding tube. The parents may not know what to expect and may not know how feeding tube use differs from the oral route for feedings and medications. The nurse wants to find out if the medications are being given in a liquid form or a crushed form and what alternates might be available if the newborn client is experiencing diarrhea. *Content Refresher* When caring for a client receiving enteral feedings, the nurse should assess baseline laboratory values to determine nutritional deficits. Assess daily weights. Assess patency and gastric residual, including pH level as ordered by the provider. Verify that a chest x-ray confirmed accurate placement of tube. Flush the tube with water and initiate the feeding after verifying the volume, frequency, and rate of feeding. Maintain head of bed at 30 to 45 degrees during administration. Observe and document client tolerance, stools, gastric aspirate, and pH. Only standard enteral feeding formulas that include all the macro- and micronutrients, including fiber, should be delivered. For unstable clients, predigested formulas may be used.

The nurse learns that a new admission was responsible for the death of a neighbor during a robbery. The nurse says to the head nurse, "I don't think that I can care for that client." Which is the best response by the head nurse? 1. "I will talk with the supervisor about your situation." 2. "I can see about transferring you to another unit." 3. "Please share with me your concerns." 4. "You are a professional and will care for the client."

1) INCORRECT - The head nurse can resolve this situations and not pass it on. 2) INCORRECT - This is nontherapeutic. Transferring the nurse does not resolve the situation. 3) CORRECT— This is therapeutic, as it allows the nurse to express concerns and resolve the situation. 4) INCORRECT - This is an authoritarian response, and not therapeutic. The head nurse does have the authority to assign the nurse to clients, but should find out more information before making a decision. *Think Like A Nurse: Clinical Decision Making* The nurse is a professional who should be able to care for any individual, regardless of the circumstances; however, the nurse is also a human with thoughts, feelings, and experiences. The head nurse asks the nurse for his or her concerns, carefully listening for true conflicts in providing care. If the nurse was friendly with this neighbor, that likely is a true conflict, and the nurse should not be assigned to the client. *Content Refresher* The head nurse should use the following therapeutic communication skills: 1) being silent, 2) showing acceptance, 3) providing recognition, 4) offering self, 5) using broad openings, 6) providing leads and encouragement, 7) timing events, 8) focusing, 9) asking about thoughts/feelings, 10) encouraging comparisons, 11) restating and reframing, 12) reflecting, 13) presenting reality, 14) sharing observations, 15) clarifying meaning, 16) expressing doubt, 17) interpreting feelings, and 18) formulating a plan for care.

The nurse notes that after a laboratory technician draws a blood specimen from a client that there are drops of blood on the floor and the wall next to the needle container. Which action does the nurse take first? 1. Contact the laboratory supervisor to report the incident. 2. Contact the nurse manager to report the incident. 3. Call housekeeping to clean and disinfect the area. 4. Counsel the laboratory technician about appropriate technique.

1) INCORRECT - The immediate action is to ensure the area is cleaned and disinfected to prevent risk of contamination to other clients or personnel. When reporting, the nurse stays within the chain of command and notifies the nurse's supervisor, not the laboratory supervisor. 2) INCORRECT - The nurse's responsibility is to first ensure the area is properly cleaned and disinfected before communicating the incident to the nurse manager. 3) CORRECT— The priority for the nurse is cleaning up the contaminated area in the client's room by contacting housekeeping to clean and disinfect the area. 4) INCORRECT - Counseling the laboratory technician is the responsibility of the laboratory supervisor. The nurse's first action is to call housekeeping to ensure the contaminated area is cleaned appropriately. *Think Like A Nurse: Clinical Decision Making* The nurse identifies two concerns in this situation: a biohazard spill that poses a risk of contamination and an inappropriate action on the part of the lab technician that led to a spill. The nurse needs to address the immediate physical risk of contamination first. A blood spill needs to be immediately cleaned by the person or department with the appropriate cleansing materials. Contacting the housekeeping/environmental department to clean the spill is the best approach for the nurse to take. *Content Refresher* There are many different organisms and infections inside and outside of the health care setting. To prevent organisms from infecting more people, the chain of infection must be broken through transmission based precautions. There are six points at which the chain can be broken to stop the organism from infecting another person. The six links include: the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. Infection occurs when viruses, bacteria, or other microbes enter the body and begin to multiply. Disease occurs when the cells in the body are damaged as a result of infection, and signs and symptoms of an illness appear. If proper precautions are not taken, both clients and health care workers can develop infections

A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first? 1. "Why did you take the medication?" 2. "Can you share what is bothering you?" 3. "How much medication did you take?" 4. "Were you trying to kill yourself?"

1) INCORRECT - The nurse should avoid asking "why" questions as this can make the client defensive. While the nurse will want to assess whether this was an accidental overdose or an attempt at self-harm/suicide, the nurse should first focus on stabilizing the client physically. 2) INCORRECT - While this is an appropriate question, the client's physical condition takes priority. The nurse should first focus on stabilizing the client physically and then explore the client's emotional state. 3) CORRECT— This assessment provides the nurse with key information to determine what emergency interventions should be implemented. 4) INCORRECT - This is an appropriate question that can be asked after the client is physically stabilized. The nurse should first ensure the client's physical needs are met. *Think Like a Nurse: Clinical Decision-Making* Once the client is able to answer questions, the client should be asked about the kind and quantity of medication taken. The nurse may anticipate giving specific antidotes for the medications taken. A working IV line should be kept in place. The client may be placed on one-on-one observation, depending on the hospital policy. The key priorities in drug overdose are airway, breathing, and circulation. *Content Refresher* Overdose is defined as the overuse of a substance, resulting in potentially toxic effects to the brain, cardiovascular system, and/or respiratory system. Coma and death can occur. When providing care to a client who has attempted suicide, sssess the client's level of consciousness. Assess vital signs, including height and weight, and ask client about pregnancy status if applicable. Determine the amount of substance ingested, and the method and time of ingestion. Administer oxygen if indicated. Institute safety precautions. Provide supportive comfort care and unconditional positive regard.

The nurse interacts with a client verbalizing a cocaine craving. The nurse acknowledges the client's discomfort. Which is the best activity for the nurse to suggest to the client? 1. Rest quietly alone in the client's room. 2. Do a crossword puzzle. 3. Say prayers for strength. 4. Walk laps around the activity area with another client.

1) INCORRECT - The nurse should encourage the client to engage in activities that dissipate anxiety and increase self-esteem. Being alone does not increase self-esteem and does little to dissipate anxiety. 2) INCORRECT - Doing a crossword puzzle is mentally engaging and may distract the client, but there is another option that is even better for the nurse to recommend. 3) INCORRECT - While some clients may find religious engagement to be comforting and may reduce anxiety, this does not increase self-esteem and may not be relevant for all clients. 4) CORRECT - Low-impact physical activity will dissipate anxiety, helps to avoid weight gain that may occur with recovery, and stimulates the release of endorphins, which aid in boosting self-esteem. This is the best activity for the nurse to recommend. *Think Like A Nurse: Clinical Decision Making* The client can work on puzzles, rest, or use spirituality or religion as coping mechanisms, but cravings produce powerful desires that sometimes consume all thoughts until the craving is satisfied. The nurse has empathy for this feeling and helps the client occupy their mind and body by joining another client in walking and talking. Medications are sometimes offered to reduce craving sensations, as well. *Content Refresher* Cocaine is a short acting, highly addictive stimulant that produces an intense and rapid euphoric feeling. Common adverse effects include weight loss, risk for injury due to impaired judgment, fatigue, disturbed sleep cycle and patterns, irritability, and restlessness. Treatment may address symptoms caused by its use and withdrawal, such as hypertension, nausea and vomiting, dysphoria, agitation, and suicidal ideation. Involvement in physical activity and social activities may reduce the withdrawal symptoms and associated cravings.

The nurse at the daycare center observes children playing on the playground. Which observation requires immediate intervention by the nurse? 1. Two children fighting over a ball. 2. One child trying to pull another child off a swing. 3. A toddler who is crying, tugging at the ear, and hugging a stuffed animal. 4. A preschooler who is leaning forward with mouth open, tongue protruding, and drooling.

1) INCORRECT - The two children fighting over a ball could lead to an injury. However, this does not require immediate intervention. 2) INCORRECT - Pulling someone off of a swing could lead to an injury. However, this does not require immediate intervention. 3) INCORRECT - Crying and tugging at the ear could indicate otitis media. However, this does not require immediate intervention. 4) CORRECT - The client who is leaning forward with the mouth open, tongue protruding, and drooling is exhibiting manifestations of acute epiglottitis. The client sits upright to breathe better. Tongue protrusion increases pharyngeal movement. Drooling is caused by difficulty swallowing because of pain and excessive secretions. This requires immediate intervention by the nurse, as airway occlusion is likely to occur. *Think Like A Nurse: Clinical Decision Making* There are two children demonstrating acute health problems, and the nurse mentally asks, "Which child is the least stable or at risk for the greatest harm?" The first is a child tugging at the ear, which is most likely an indication of an ear infection. The condition is painful. However, the child is not an immediate risk. The child who is leaning forward, with the mouth open, tongue protruding, and drooling is demonstrating the manifestations of airway compromise. The nurse needs to support the client's body position, which is increasing body oxygenation. The nurse should recognize that the client's condition requires emergency interventions. *Content Refresher* Epiglottitis is a medical emergency. This condition occurs as a result of a bacterial invasion that causes the epiglottis to swell resulting in an obstruction of air flow into the lungs. This condition typically occurs between the ages of 2 and 8 years and can progress rapidly with complete obstruction of the airway occurring within hours of initial symptoms. This condition is diagnosed based on clinical manifestations along with lateral neck radiography. For any pediatric client manifesting symptoms indicative of epiglottis, it is essential to avoid visual inspection of the mouth and throat as this can cause laryngospasm and airway obstruction.

The adult child of a client with Alzheimer disease asks if the prescribed medication will improve dementia. Which response by the nurse is appropriate? 1. "It will help the client live independently once more." 2. "It is used to stop the progression of Alzheimer disease, but will not cure it." 3. "It will help provide a steady improvement in memory, but not in problem solving." 4. "It will not improve dementia, but can help control symptoms."

1) INCORRECT - There is no guarantee that medication for Alzheimer disease will help the client live independently. 2) INCORRECT - Medication for Alzheimer disease does not stop the progression of the disease. Evidence shows medication has little effect in slowing down the progress of the disease. 3) INCORRECT - Medication for Alzheimer disease does not lead to improvements in memory or other cognitive function. 4) CORRECT- Medication for Alzheimer disease is used to control emotional outbursts and other behavioral responses. *Think Like A Nurse: Clinical Decision Making* Caring for a client with Alzheimer disease can be challenging for the nurse and home caregiver. The disease process begins with cognitive changes that progress to affect physical status and abilities. Because the disease has no known cure, medications available are used to help control some of the manifestations. Family caregivers should be aware of the purpose and limitations of the prescribed medications. The nurse should encourage the use of medications even though the client and family may consider the intervention as ineffective for the illness. The nurse has a responsibility to assess the client's care giver for signs or stress or ineffective coping. *Content Refresher* Alzheimer disease is a progressive neurological disorder that results in functional and cognitive declines. The nurse should plan care to ensure safety, reduce anxiety, and facilitate orientation to person, place, time, and situation. Anticipate medicating with cholinesterase inhibitors and/or memantine. Provide client/family with information about medication use, potential effects, and side effects. Inform them that medication cannot stop progression of the disease, but should temporarily improve symptoms. Refer client/family/caregiver to social and support programs.

The nurse provides care for clients at risk for colorectal cancer. Which client does the nurse identify as being at highest risk for the development of colorectal cancer? 1. Caucasian client with a family history of adenomatous polyposis, consumes 2 servings of red meat per week, avoids alcohol, and is physically active. 2. African American client with a history of gastrectomy, consumes diet high in fruits and vegetables, avoids red meats, and is physically active. 3. African American client with a history of inflammatory bowel disease, smokes cigarettes, consumes 12 alcoholic beverages per week, and avoids red meats. 4. Caucasian client with a body mass index of 32, avoids alcohol, smokes cigarettes, and has a first-degree relative with a diagnosis of colorectal cancer.

1) INCORRECT - This client has one risk factor, which is the family history of adenomatous polyposis. The consumption of >7 servings of red meat per week is considered a risk factor. 2) INCORRECT - This client has two risk factors, which include being African American and having a history of gastrectomy. A diet high in fruits and vegetables helps prevent colorectal cancer. 3) CORRECT- This client has four risk factors, which include being African American, having a history of inflammatory bowel disease, smoking, and having an alcohol intake of >4 drinks per week. This client is at highest risk for developing colorectal cancer. 4) INCORRECT - This client has three risk factors, which include obesity with BMI >30, smoking, and having a first-degree relative with colorectal cancer diagnosis. *Think Like A Nurse: Clinical Decision Making* Colorectal cancer has been identified as a pathologic condition that can be avoided if caught early through screening and symptom identification. The nurse should recall the etiology of this health problem, specifically modifiable and non-modifiable risk factors. Non-modifiable risk factors cannot be changed and include age, gender race, and family history. Modifiable risk factors are those that can be changed and include lifestyle, alcohol intake, smoking history, dietary intake, and body weight. Of the clients being assessed, the nurse should identify the client with the most risk factors as having the highest risk for developing the disorder. *Content Refresher* Nurses play an active role in helping clients decrease modifiable risk factors for cancers, such as colorectal cancer, through health teaching. Topics include protected and moderate sun exposure, elimination of use of tobacco products, moderation of alcohol consumption, weight management, consumption of plant-based low fat diet, avoidance of environmental and occupational carcinogens, and participation in cancer screening tests. Non-modifiable risk factors include age and genetic predisposition. People at greatest risk for colon cancer are older adults, people who are obese or overweight, smokers, those with a history of bowel irritability, those who are physically inactive, and those who eat more red meat than recommended.

The nurse prepares to obtain vital signs on a client. The client's previous blood pressure reading was 138/76 mm Hg and the client's pulse rate was 68 beats/minute. How long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading? 1. 45 to 60 seconds. 2. 30 to 45 seconds. 3. 10 to 20 seconds. 4. 15 to 20 seconds.

1) INCORRECT - This is a longer period of time than is necessary for the client's blood pressure reading and not an appropriate related to the client's previous reading. 2) CORRECT - To ensure that the diastolic has been determined, the cuff shouldbe released slowly until the mid-60s mmHg for someone with the client'sprevious reading. Since the cuff should be deflated at a rate of 2 to 3 mm persecond, a range of 90 mmHg will require 30 to 45 seconds. 3) INCORRECT - This period of time is not enough to get an accurate reading for this client. 4) INCORRECT - This is not an adequate period of time to get an accurate reading for this client. *Think Like A Nurse: Clinical Decision Making* The American Heart Association states that the cuff should be deflated at a rate of about 2 to 3 mm Hg per second to obtain an accurate blood pressure measurement. The systolic pressure is the blood's force against the artery walls in order to pump blood to peripheral organs. The first sound the nurse hears means the systolic pressure is now greater than the pressure exerted on the artery by the inflated blood pressure cuff. The diastolic pressure is reflective of the pressure on the artery walls as the heart relaxes between forceful beats. Blood pressure readings are altered by cardiac output and arterial stiffness. *Content Refresher* Ensure the client avoids consumption of caffeinated products, smoking, or exercise for at least 30 minutes prior to obtaining blood pressure (BP) measurement. Position the client seated with feet flat on the floor and arm supported comfortably at the level of the heart. Avoid obtaining a BP in the same arm in which there is an arteriovenous fistula, where lymphedema exists, or after lymph node dissection for treatment of breast cancer. The BP cuff is placed above the elbow, with the stethoscope placed lightly over the brachial artery. The cuff is inflated to a pressure of 30 mm Hg above the level at which the radial pulse is no longer palpable. Slowly deflate the cuff, listen for the Korotkoff phase, watch the sphygmomanometer, and listen until the sounds disappear completely.

The nurse provides care for an adolescent admitted for burns to 50% of the body. What action is the highest priority for the nurse? 1. Counsel the client regarding body image changes. 2. Maintain airborne precautions. 3. Maintain sterile technique during procedures. 4. Encourage the client's friends to visit regularly.

1) INCORRECT - This is a relevant intervention, but the nurse should prioritize physical safety over psychosocial concerns. 2) INCORRECT - A cap, gown, mask, and gloves will be worn by the nurse to protect the client. However, the client does not need to be in airborne precautions. 3) CORRECT— The client is at high risk for infection. The nurse should use careful sterile technique when performing wound care. This ensures the client physical safety and is the highest priority. 4) INCORRECT - This is an important intervention for an adolescent, but the nurse should prioritize physical safety over psychosocial concerns. *Think Like A Nurse: Clinical Decision Making* The nurse needs to draw on integrated knowledge related to anatomy and physiology in making clinical judgments about this client's needs. Knowing the skin is the body's first line of defense against microorganisms will assist the nurse in making the best and safest care decisions. Since the client has lost 50% of the total body skin surface, the risk for infection is high. The nurse should ensure that all procedures and skin care are provided using sterile technique to reduce the client's risk for infection, which is the nurse's highest priority. *Content Refresher* Burnsresult in damage to the skin from heat, radiation, chemical, or electrical sources. Wound care for burns may include cleansing, debridement, and escharotomy using sterile technique. Complications associated with burn wounds include infection, hypothermia, and fluid and electrolyte imbalances. For the acute phase, fluid resuscitation is essential in managing hypovolemic shock. Maintaining airway is important. Medications to decrease gastric acid secretion, prevent infections, and for pain may be prescribed. Reducing risk of infection by using aseptic technique is a priority during the early stage of recovery.

The nurse provides care for a client in the emergency department (ED). The nurse reviews the health care provider (HCP) prescription and notes that digoxin 1.25 mg PO has been prescribed to be given now. Which action by the nurse is appropriate? 1. Administer the medication as prescribed. 2. Validate the prescription with the HCP. 3. Ask the client if this is the usual daily dosage. 4. Ask another nurse if the dosage is appropriate.

1) INCORRECT - This is an inappropriate prescription. Digoxin is a cardiac glycoside and the oral loading dose is 0.75 mg to 1.25 mg, administered in three divided doses over 24 hours. 2) CORRECT— Verify the rights of medication administration. The nurse needs to clarify the prescription with the HCP. If this is a digitalizing dose, it is to be given in three divided doses over a 24-hour time frame. If it is a maintenance dose, it would usually be between 0.1 to 0.375 mg per day. 3) INCORRECT - The nurse administering the medication should clarify the prescription with the HCP, not the client. The client may not know the actual dose of the prescribed drug, even if taking the medication at home. 4) INCORRECT - The nurse should clarify the prescription with the HCP, not another nurse. *Think Like A Nurse: Clinical Decision Making* The nurse is responsible for questioning any prescription that appears to be unusual or inappropriate for the client. The nurse recognizes the prescribed dose of digoxin is unusually high and should be questioned before administering to this client. If the nurse is not certain about the prescribed medication, the medications should be looked up in an up-to-date resource. The nurse should adhere to the rights of medication administration and question any medication dose that is beyond the expected and documented safe amount. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Assess the rights of medication administration which minimally include medication, dose, route, time, and client. Check allergies and identify the client following institutional policy. Inform the client about the medication, reason for its administration, and how and when effectiveness will be determined. Provide information about medications including anticipated side effects and management of the side effects, as well as adverse effects to report. Assess for expected outcomes for the administered medication.

The nurse in a day-care center is notified that a tornado is approaching. The nurse evacuates the children to a safe room with a freestanding gas heater. Which action does the nurse take first? 1. Comfort the frightened children. 2. Offer the children fruit juice. 3. Provide diversional activities. 4. Turn off the gas heater.

1) INCORRECT - This is appropriate, as it meets a relevant psychosocial need. However, the nurse should attend to the safety needs of the children first. 2) INCORRECT - This may be appropriate, and meets a physical need, but there is no indication that the children are hungry or nutritionally deprived. There is another action that addresses a greater physical need. 3) INCORRECT - This is appropriate, as it meets a relevant psychosocial need. However, the nurse should attend to the safety needs of the children first. 4) CORRECT— In confined areas, heaters can increase carbon monoxide levels and pose a safety risk to the children. The nurse should first turn off the heater to ensure safety. *Think Like A Nurse: Clinical Decision Making* After receiving a warning about an approaching tornado, the nurse evacuates children attending a daycare to another room. As soon as they arrive in the room the nurse should think, "Is there anything in this room that poses a safety risk for the children?" Contact with a space heater could cause burns. Additionally, the cord to the space heater could be a trip hazard. The safety needs of the children should take priority over their psychosocial needs. *Content Refresher* Tornadoes are most common in the central states of the United States, but can occur anywhere. A tornado watch indicates there is the possibility of a tornado, and a tornado warning indicates a tornado is approaching the area. Families and employers are encouraged to identify a safe place to gather, such as a basement or storm cellar, an interior room with no windows, or a central hallway. Emergency kits should be available, and adults should maintain a radio signal for any further alerts. All electrical appliances and equipment should be unplugged and, if possible, the room should be cleared. Children need constant supervision to assess their behaviors and the environment for potential dangers. Ensuring a safe environment is the priority nursing action.

The nurse provides care for a client diagnosed with a conversion reaction. Which assessment finding does the nurse expect to observe? 1. The client is experiencing delusions of messianic grandeur. 2. The client believes that the world is ending on a specific date. 3. The client is experiencing persistent pain after the resolution of herpes zoster. 4. The client is experiencing blindness without an identified physical cause.

1) INCORRECT - This is not an expected finding in conversion disorder and is more likely to be seen in a client with schizophrenia. 2) INCORRECT - This is not an expected finding in conversion disorder. 3) INCORRECT - This describes post-herpetic neuralgia and is common in clients after the acute outbreak of herpes zoster (shingles) has been resolved. 4) CORRECT - Conversion disorder is diagnosed when the client presents with neurologic symptoms such as blindness, deafness, or paralysis that cannot be explained by medical evaluation. *Think Like a Nurse: Clinical Decision-Making* The nurse understands that a conversion reaction is the development of a neurologic symptom without an identifiable reason. The client demonstrating blindness as a conversion reaction will have intact optic cranial nerve function, but will be blind. Additionally, a client diagnosed with a conversion reaction may report muscle paralysis, again, without an identifiable cause. *Content Refresher* When caring for a client diagnosed with a conversion disorder, the nurse needs to complete a comprehensive assessment to identify precipitating factors, frequency, and in which situations the undesirable behavior occurs. Determine if the behavior is life-threatening. Assess if the behavior influences family/friends, social interactions, and/or has an economic impact. Determine intrapsychic factors that may influence the undesirable behavior, along with feelings/thoughts (anxiety, depression) that may be occurring.

The nurse instructs a client diagnosed with genital herpes about acyclovir. Which client statement indicates that teaching has been effective? 1. "If I miss a dose of medication, I can double up the next dose." 2. "I should avoid sexual contact while I have lesions." 3. "I'm glad this medication will cure me." 4. "I must take this medication with food."

1) INCORRECT - This statement indicates that further instruction is needed. If a dose of acyclovir is missed, the client should take the dose as soon as possible. The dose should not be taken immediately before the next dose. The client should not double up on the next dose if a dose is missed. 2) CORRECT - This statement indicates correct understanding of the information presented. Acyclovir is an antiviral medication that is used to treat recurrent genital herpes and localized cutaneous herpes zoster. The client is considered contagious and should refrain from sexual contact while the lesions are present. 3) INCORRECT - This statement indicates that further instruction is needed. Acyclovir is not a cure for genital herpes or localized cutaneous herpes zoster. 4) INCORRECT - This statement indicates that further instruction is needed. Acyclovir can be taken with food or on an empty stomach with a full glass of water. *Think Like A Nurse: Clinical Decision Making* Prior to administering a newly prescribed medication, the nurse instructs the client on the mechanism of action, expected effects, any precautions, and possible adverse effects. Acyclovir (Zovirax) is an antiviral, used to treat the genital herpes virus, and does not cure the virus, but helps reduce the symptoms and promotes the healing of lesions. The nurse should emphasize the importance of refraining from sexual contact while the lesions are present to prevent the transmission of the virus to the client's sexual partner. The nurse uses the art of listening to determine if the client has a correct understanding about the prescribed medication and treatment regimen. *Content Refresher* Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus type 2 (HSV-2). Herpes simplex virus type 2 is spread by vaginal, anal, or oral-genital contact. Within a week of exposure, blisters containing the virus form. When the blisters break, the virus spreads. Eventually, the virus becomes latent, withdrawing into the nerve fibers that lead from the infected area to the lower spine. The virus can become reactivated. Signs and symptoms of HSV-2 include painful, itchy papules or blisters around the genitalia, presence of headache, malaise, fever, dysuria, urinary retention, and vaginal or urethral discharge. Antiviral medications, such as acyclovir or famciclovir, are used to treat genital herpes.

The nurse assesses an older adult client who has been on bed rest for 2 weeks. Which information provided by the client indicates a complication caused by immobility? 1. Decreased appetite. 2. Stiffness in left ankle joint. 3. Short term memory loss. 4. Dryness of skin.

1) INCORRECT- Decrease appetite is not likely to be related to immobility. 2) CORRECT-Joint stiffness may indicate the beginning of a contracture, early muscle atrophy, or both. 3) INCORRECT- Short term memory loss is not likely to be related to immobility. 4) INCORRECT- Dryness of skin is not likely to be related to immobility. *Think Like A Nurse: Clinical Decision Making* The nurse recognizes that reconditioning is a complex process of physiological change following a period of inactivity, bed rest, or sedentary lifestyle. It results in functional losses in such areas as mental status, degree of continence, and ability to accomplish activities of daily living. The nurse in this scenario should be acutely aware it is frequently associated with hospitalization of the older adult client. The nurse should advocate for early mobility for all clients, unless contraindicated. Turning and performing passive and active range-of-motion exercises are helpful. Clients should be assisted to get out of bed as appropriate. Deconditioning can diminish muscle mass and decrease muscle strength by 2 to 5 percent per day of immobility. *Content Refresher* Immobility influences the cardiovascular (venous status, orthostatic hypotension), musculoskeletal (osteoporosis, contractures, atrophy of muscles), respiratory (atelectasis), urinary (infection, retention, calculi), metabolic (metabolic rate decreases), gastrointestinal (constipation), and integumentary (breakdown) systems. Immobility also influences the client's psychological well-being. Consult physical therapy, if needed. Provide education regarding the importance of mobility. Encourage mobility, assisting as needed. Perform range-of-motion exercises. Determine if assistive devices are needed for ambulation, such as cane or walker.

The nurse provides discharge teaching to a client recently diagnosed with asthma. Which prescribed medication should the nurse instruct the client to use during an acute asthma episode? 1. Fluticasone. 2. Guaifenesin. 3. Theophylline. 4. Albuterol.

1) INCORRECT- Fluticasone, an inhaled corticosteroid, is a long-term maintenance medication used in the management of asthma. Fluticasone decreases inflammation, but does not provide the immediate bronchodilation that is needed in an acute asthma episode. 2) INCORRECT- Guaifenesin is used to thin and liquefy secretions. This medication does not promote bronchodilation, which is needed for treatment of an acute episode of asthma. 3) INCORRECT- Theophylline is a methylxanthine drug and nonselective phosphodiesterase enzyme inhibitor. Theophylline promotes bronchodilation. However, because this maintenance medication is not fast-acting, it is not indicated for treatment of an acute asthma episode. 4) CORRECT- Albuterol is a fast-acting bronchodilator used for treatment of acute asthma episodes. Albuterol may be administered using a metered-dose inhaler or a nebulizer. *Think Like A Nurse: Clinical Decision Making* Discharge teaching for a client with asthma includes a thorough explanation on how to use rescue (e.g., albuterol) and maintenance (e.g., ipratropium) medications. The nurse informs the client of potential side effects of albuterol, such as tachycardia, palpitation, or chest pain. The client is also taught how to use and to interpret findings from use of the peak flow meter. When the client is in the "red zone" based on the peak flow meter reading, the client should call 911 or report to the emergency department. The nurse should encourage the client to ask questions and should use the teach-back method in teaching. *Content Refresher* Asthma is a chronic lung disease that presents with intermittent airway obstruction due to bronchial constriction and inflammation. A client with asthma may present with dyspnea, wheezing, tachypnea, coughing, an increase in sputum production, and chest tightness. Treatment includes control of environmental factors that have been identified to trigger an attack, such as smoke, pet dander, and aerosol sprays. Monitor the client's peak flow and intervene depending on the severity of symptoms. Bronchodilators, corticosteroids, anticholinergics, and anti-inflammatories are groups of medications that are prescribed for "rescue" or relief of an attack and to maintain long-term control of the disease.

The nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial infection. The client's medications include furosemide 40 mg PO daily and aspirin 81 mg PO daily. Which new prescriptions cause the nurse to seek clarification from the health care provider? (Select all that apply.) 1. Potassium chloride (KCl) 40 mEq PO daily. 2. Enalapril 20 mg PO daily. 3. Vancomycin 3 g IV piggyback every 12 hours. 4. Digoxin 0.25 mg PO daily. 5. Clopidogrel 75 mg PO daily.

1) INCORRECT- KCl is indicated for the client who takes furosemide, which is a potassium-wasting loop diuretic. KCl is not contraindicated for the client who takes aspirin. 2) INCORRECT- Enalapril is not contraindicated for the client who takes furosemide. Enalapril is also not contraindicated for the client who takes low-dose aspirin. 3) CORRECT - The combination of vancomycin with furosemide, which is a loop diuretic, increases the client's risk for ototoxicity. 4) CORRECT - The combination of digoxin and with furosemide, which is a loop diuretic, increases the client's risk for digoxin toxicity. 5) INCORRECT- Clopidogrel is not contraindicated for the client who takes furosemide. Clopedigrel is also not contraindicated for the client who takes low-dose aspirin. *Think Like A Nurse: Clinical Decision Making* Heart failure is characterized by fluid within the pulmonary vasculature and peripheral body structures. Treatment typically includes diuretics and aspirin. Vancomycin can cause ototoxicity, which is enhanced if given with furosemide. The client is at risk for digoxin toxicity if digoxin is taken with furosemide. Potassium chloride is used to replace the loss of potassium, which can occur when taking furosemide. Enalapril and clopidogrel do not adversely interact with furosemide or aspirin and can be safely taken. *Content Refresher* Medication administration is the process by which prescribed medications are knowledgeably and safely dispensed to a client. Before administering medications, the nurse must check for medication incompatibilities and interactions along with following the rights of medication administration which minimally include the right client, the right medication, the right time, the right dose, the right site, and the right documentation.

The nurse provides discharge teaching to a client with multiple sclerosis. Which instruction is most important for the nurse to include? 1. Ambulate as tolerated every day. 2. Avoid overexposure to heat or cold. 3. Perform stretching and strengthening exercises. 4. Participate in social activities.

1) INCORRECT— Although the client should be encouraged to ambulate as tolerated, this is not the most important instruction. 2) CORRECTnbsp— Overexposure to heat or cold may cause damage related to the changes in sensation. Extremes in temperature can also exacerbate multiple sclerosis symptoms. 3) INCORRECT— The client should be encouraged to participate in an exercise program that includes range-of-motion (ROM), stretching, and strengthening exercises, but this is not the most important instruction. 4) INCORRECT— The client should be encouraged to continue usual activities as much as possible, including social activities. However, this is not the most important instruction. *Think Like A Nurse: Clinical Decision Making* Extremes in temperature can cause an exacerbation of symptoms in the client with multiple sclerosis. This is the most important area for the nurse to focus. Ambulation, exercise, and social activities are important; however, they do not help reduce the severity or exacerbation of symptoms. *Content Refresher* When working with a client with multiple sclerosis (MS), the nurse should: Determine history of symptom onset and disease progression. Assess mood, speech, visual acuity, gait, muscle strength, reflexes, sensation, and use of assistive devices. Conduct medication reconciliation to identify potential drug interactions and those that affect mobility. Plan an exercise program to reduce sedentary risk for weight gain and to maintain/increase muscle strength with physical therapy. Teach about strategies to prevent disease exacerbation.

The nurse admits a client to the surgical unit for a mastoidectomy due to chronic otitis media. Which question should the nurse first ask the client? 1. "When did you begin having problems with your ears? " 2. "Do you have problems with vertigo? " 3. "Do you have any questions about the procedure? " 4. "What are your concerns about the post-operative period? "

1) INCORRECT— The nurse will obtain a health history, including questions about infection, hearing loss, and vertigo. Because vertigo is a common occurrence with ear problems, the nurse needs to assess for vertigo to maintain client 's safety. 2) CORRECT— The nurse needs to anticipate that the client may be experiencing vertigo. This is the question that the nurse needs to ask first to ensure client safety. 3) INCORRECT— The nurse should reinforce information presented by the surgeon. However, the nurse should first assess for vertigo to evaluate the client's safety. 4) INCORRECT— The nurse will need to determine if the client has concerns regarding the post-operative period. However, in order to keep the client safe, the nurse needs to determine if the client is experiencing vertigo. *Think Like A Nurse: Clinical Decision Making* Chronic tympanic membrane perforation will not heal with conservative treatment, and surgery is necessary. A mastoidectomy is often performed with a tympanoplasty to remove the infected portion of the mastoid bone. Post-operative discharge teaching includes informing the client to avoid sudden head movements; change position slowly; report fever, uncontrolled pain, wound drainage, and hearing loss; and, if the client needs to cough or sneeze, the client should keep the mouth open to help reduce pressure. *Content Refresher* Otitis media is an inflammatory disease of the middle ear. With otitis media, older children and adults may report ear pain, vertigo, nausea, difficulty hearing, ringing and fullness in the ear, and/or headache. Small children are more susceptible due to having shorter eustachian tubes. Because of this, young children should not be allowed to sleep with a bottle, and infants should not be fed from a propped bottle.

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention? 1. Ensure that there will be several quiet rooms near the main gathering area. 2. Collect blood pressure cuffs of varied sizes. 3. Arrange low-cholesterol snacks for participants. 4. Procure booklets that explain hypertension in simple language.

1) INCORRECT— This may be useful to enhance the examiner's ability to hear the Korotkoff sounds and also to engage in discussion with participants. However, there is another answer that is a higher priority. 2) CORRECT — Having blood pressure cuffs of varied sizes is essential to ensure accurate blood pressure readings. People attending the fair almost certainly will vary in arm size. A cuff that is too small will produce a falsely high reading, while a cuff that is too large will produce a falsely low reading. The nurse will ensure the ability to obtain accurate readings. 3) INCORRECT— This may help attract people to have their blood pressure taken, but another action is a higher priority. 4) INCORRECT— Having written materials for later review is appreciated by many people, but another action is a higher priority. *Think Like A Nurse: Clinical Decision Making* Since the blood pressure screening is being held for a variety of people, the nurse should prepare to have different blood pressure cuff sizes so that the measurements will be accurate. Some people may enjoy having written material about blood pressure. However, this will not ensure that the measurements are accurate. *Content Refresher* Blood pressure readings may vary dependent upon the equipment used and the client's internal and external environment. The client may exhibit decreases in blood pressure while sleeping or resting or with dehydration or during vasodilation. They may exhibit increases in blood pressure when active or excited or anxious. The nurse should use a blood pressure cuff that is appropriately sized to fit the client's arm circumference. A blood pressure cuff that is too large will result in a falsely low reading, while a cuff that is too small will result in a falsely high reading.

The nurse admits a preschool-age client diagnosed with dehydration. The client has a small retractable tape measure and continually extends and withdraws the tape. The nurse notes the client does not make eye contact and does not respond to questions, but does step on the scale when asked to do so. Which interventions will the nurse include in the client's plan of care? (Select all that apply.) 1. Assign the same nurse to the client's care each day. 2. Replace the client's tape measure with a stuffed toy for safety. 3. Use the client's name and speak directly to the client. 4. Encourage the parent to hold the client in a bear hug during procedures. 5. Reward the client for positive behaviors, such as drinking acceptable fluids. 6. Use developmentally-appropriate language to explain procedures to the client.

1) CORRECT - Continuity of caregivers is especially helpful in establishing trust with children. This client is showing characteristics of autism spectrum disorder, in which continuity of care is even more important. 2) INCORRECT - It is not necessary to take away the client's toy. Allowing the client to keep familiar items will help the child feel comfortable. 3) CORRECT - Using the client's name and speaking to the client establishes trust and gains the child's cooperation. 4) INCORRECT - Parents should not be asked to restrain their child. They may give comfort and support to the child, but staff should perform any restraint. 5) CORRECT - A choice of rewards often soothes young pediatric clients. 6) CORRECT - With any pediatric client, the nurse explains procedures in appropriate words for the child to understand and be able to anticipate what is occurring. *Think Like a Nurse: Clinical Decision-Making* The child's fixation on the movement of the tape measure and lack of eye contact could indicate a cognitive disorder consistent with autism spectrum disorder. The nurse should support the child's developmental level by establishing trust, talking directly to the child, rewarding acceptable behavior, and using words that the child understands. The nurse recognizes a deviation from expected behavior, and is able to draw conclusions about the client. The nurse can validate the client's condition through the medical record, the family, and/or the health care provider. The ability to recognize the client's developmental deficits allows the nurse to make appropriate plans for the client's care. *Content Refresher* Autism is also known as autism spectrum disorder and is considered to be a neurodevelopmental disorder. It is diagnosed based on delayed communication development and poor social interactions along with repetitive behaviors. When caring for a client diagnosed with autism spectrum disorder , the nurse should establish a trusting nurse-client relationship. Additionally, the nurse should provide a safe environment, maintain the client's routines (such as nap time and bedtime), and implement behavioral interventions and modifications that promote positive behaviors.

The client receives continuous patient controlled analgesia (PCA) with demand dosing of morphine. As the nurse takes vital signs, the client startles awake and says, "Whoops, I keep forgetting to push this," and pushes the PCA pump button. Which response by the nurse is best? 1. "Using the morphine doses at even intervals is important." 2. "Show me on this pain chart the level of pain you are feeling." 3. "You seem very comfortable using the pump." 4. "Surgery and medication temporarily affect memory."

1) INCORRECT - Continuous infusion of morphine should maintain an even level without the client's participation. A PCA pump manages breakthrough pain, too, when the client pushes the button. The client does not need to worry about using it within specific periods, only about using the button when needed. 2) CORRECT- Assessment of pain status is needed to clarify the apparent discrepancy between patient's having appeared comfortable and suddenly "remembering" pain. The patient's response to nurse's question may lead to needed teaching. 3) INCORRECT - The client may seem comfortable about what to do mechanically, but may have a faulty understanding of the pump. The pump will not deliver more than is programmed. However, if the client self-delivers doses when not experiencing pain, this can lead to respiratory depression. 4) INCORRECT - It is true that surgery and narcotics do affect memory, but it does not address the patient's possibly dangerous misunderstanding of how to use the pump. *Think Like A Nurse: Clinical Decision Making* Following the nursing process, the nurse first assesses whether the client is experiencing pain. "Forgetting" to use the button attached to the patient-controlled analgesia (PCA) pump can indicate multiple things, including that the client's pain is controlled or use of the pain medication is not needed. Rather than making assumptions about the client's forgetfulness by discussing how pain medication affects memory or teaching the importance of regular dosing, teaching and encouragement occurs after the nurse finds out what the client means by "forgetting." *Content Refresher* For teaching and learning, ensure a comfortable environment with adequate lighting. Prepare for the teaching activity. Question learners regarding their expectations. Determine a learner's knowledge level and previous experiences. Allow time for discussion and questions. Stop for a break when the learner indicates that one is needed. Minimize distractions and use clear, brief instructions. Clearly communicate the objectives and expectations. Determine which factors help or hinder the learning process. Evaluate the effectiveness of the teaching and learning session.

The nurse instructs a client diagnosed with gout regarding the prevention of recurrent attacks. Which teaching is most important for the nurse to include for the client? 1. "Increase your intake of dried peas, beans, and lentils. " 2. "Drink at least 2000 -3000 mL of fluid every day. " 3. "Decrease your intake of milk, cheese, and yogurt. " 4. "Follow a low carbohydrate diet. "

1) INCORRECT - Gout is characterized by the overproduction or underexcretion of uric acid. High purine foods increase the incidence of gout. These foods include organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, and wild game. 2) CORRECT— Drinking at least 2000 -3000 mL of fluid a day increases urinary uric acid excretion. Eliminate or restrict alcohol intake. Drug therapy includes colchicine, allopurinol, and NSAIDs. 3) INCORRECT - Foods high in calcium can provide moderate protein and are appropriate for the client's diet; however, this is not the most important information to include when providing education to a client diagnosed with gout. 4) INCORRECT - A low carbohydrate diet can cause the formation of ketones that inhibit uric acid excretion, which is likely to exacerbate the client's diagnosis of gout. A high carbohydrate diet increases uric acid excretion. *Think Like A Nurse: Clinical Decision Making* Prior to teaching the client about actions to prevent the recurrence of a health problem, the nurse should recall the pathophysiologic process of the disorder. The nurse recalls that gout is caused by a build up of uric acid in the body, which settles in the joints and tissues. The result is inflamed painful joints caused by the deposit of uric acid crystals. The nurse will focus client teaching on how to prevent the buildup of uric acid in the future by altering the diet, taking medication to treat the disorder as prescribed, and ingesting sufficient fluids to flush the excess uric acid from the body. *Content Refresher* Gout is a disease in which elevated serum uric acid levels result in crystal deposits in joints and surrounding tissue causing inflammation and pain. Clinical symptoms include swollen, painful joint(s)(frequently the great toe) beginning at night and resolving within 2 to 10 days with or without treatment. Presence of tophic (urate crystal deposits) and possible joint deformity may be noted in severe, chronic cases. In the acute stage, an NSAID for pain and an agent such as colchicine, which reduces uric acid crystal build-up in joints, may be prescribed. Glucocorticoids may be prescribed to reduce inflammation and pain. Medications may be continued during asymptomatic periods as maintenance therapy. Use of allopurinol, a uric acid lowering agent, may be prescribed for chronic gout. However, acute gout is not treated with allopurinol since a rapid change in uric acid levels may precipitate, or increase, the severity of an attack. During acute gout, assist with pain management by repositioning, local application of heat and cold compresses, and administration of prescribed medications. To prevent gout attacks, educate the client about changes in diet to decrease foods high in purine, and the need to increase fluid intake.

An older adult client who appears alert, oriented, and well-groomed shares with the nurse, "Lately, I am seeing things that are not there. It is always people. I am awake and sitting down and I know they are not there, but I see them." Which response by the nurse is appropriate? 1. "Has anyone in your family ever been diagnosed with schizophrenia?" 2. "What medications have you been taking recently?" 3. "Don't worry. You may actually have been asleep and dreaming." 4. "The Alzheimer organization offers some tests you may want to take."

1) INCORRECT - This response is a closed-ended question, requiring only a yes or no answer. It also implies that the hallucination is a symptom of schizophrenia. The client does not have other indications of schizophrenia. There is a better answer choice. 2) CORRECT - This response is an open-ended question. Some medications can cause confusion and hallucinations. Older adult clients are more prone to experiencing these manifestations as the renal function declines with age, decreasing the rate at which medications are eliminated from the body. 3) INCORRECT - This is not an appropriate response. It dismisses the client's concerns and blocks further communication. The nurse should assess the client for medication toxicity. 4) INCORRECT - This is not an appropriate response. It implies that the client is experiencing symptoms of Alzheimer disease, when the client does not have symptoms consistent with that disease. *Think Like A Nurse: Clinical Decision Making* The nurse should mentally ask, "What factor can be assessed first that will provide important information without a jump to conclusions or disregard of client's concerns?" Older adult clients are at risk for medication toxicity due to a variety of age-related physiologic changes, including decreased renal clearance. Adverse drug reactions among older adult clients may manifest as altered mental status, delirium, orthostatic hypotension, incontinence, and gastrointestinal manifestations such as anorexia and nausea. Depending on the prescribed medication, monitoring the client's serum medication level may be indicated. *Content Refresher* Hallucinations are disturbances of perception in which the client perceives a sensory experience that has little or no basis in reality. Appropriate interventions include: Ensure a safe client environment. Establish a trusting relationship with the client. Reduce external stimulation. Monitor the client's verbalized thought patterns and perceptions, as well as associated behavior. Tactfully ask the client about current and past experiences with hallucinations. Monitor for increased negativity of content, anxiety, and agitation, or for social withdrawal. Gently challenge the client's perceptions. Report increased anxiety or increasing risk for violence. Conduct urinalysis for toxicology as indicated if hallucinations are suspected to be related to substance abuse.

Which nursing action would likely be considered negligence? 1. The nurse does not aspirate before injecting a client's subcutaneous heparin. 2. The nurse removes a client's wrist restraints hourly to conduct a skin assessment. 3. The nurse assesses pedal pulses every 4 hours for a client who just returned from having a cardiac catheterization. 4. The nurse administers a preoperative client's prescribed sedative medication without removing the client's dentures.

1) INCORRECT - Omitting aspiration prior to injection of a subcutaneous medication does not constitute negligence, as this is an appropriate action. In general, aspiration prior to subcutaneous injection of medication is unnecessary. With heparin, aspiration may increase the risk for damage to subcutaneous blood vessels and subsequent bleeding. 2) INCORRECT - Hourly removal of wrist restraints to conduct a skin assessment does not constitute negligence. While institutional guidelines should be followed, in general, removal of wrist restraints every 2 hours is required to perform skin assessment and maintain range of motion. Hourly removal of wrist restraints would exceed the minimum requirements. 3) CORRECT— For the client who undergoes cardiac catheterization, the nurse should follow organizational policy with regard to frequency of assessment. However, general guidelines include assessment of the client's pedal pulses immediately after the procedure, then every 15 minutes for 1 hour. Pedal pulses are then assessed every 30 minutes for 2 hours or until the client's vital signs are stable. Failure to assess the client's pedal pulses until 4 hours following cardiac catheterization likely constitutes negligence, as a nurse in similar circumstances would reasonably assess the client's pedal pulses much sooner and more frequently than 4 hours following the procedure. 4) INCORRECT - Administration of preoperative sedation without removal of the client's dentures is an acceptable practice and does not constitute negligence. One guideline for determining negligence is comparison of the nurse's actions to current standards of care, which include actions that other nurses would reasonably implement when faced with the same or similar circumstances. *Think Like A Nurse: Clinical Decision Making* Negligence occurs when a nurse fails to follow the standard of care and client harm could result. Aspiration before subcutaneous injection of heparin is not necessary, and the process may even increase client discomfort. Restraints should be released regularly to assess the client's skin under the restraints and to allow the client to participate in care and perform range-of-motion exercises. It is acceptable to administer preoperative sedation with the client's dentures in place. After cardiac catheterization, the nurse should frequently assess the client's neurovascular status distal to the catheter insertion site to promptly recognize signs of neurovascular compromise that may result from the procedure. *Content Refresher* Negligence/malpractice is the failure to provide the correct care to the client, which results in physical or psychological harm to the client. Bruising, bleeding, damage to artery or cardiac tissue, and allergy to dye are the most common complications of a cardiac catheterization. Serious complications include sepsis, cerebrovascular accident, and myocardial infarction. Post-procedure, the nurse should monitor vital signs, maintain pressure at cardiac catheter insertion site along with frequent observation of site, assess client's response to procedure, and provide foods, fluids, and medications.

The nurse assesses a client with a colostomy. Which stomal appearance indicates a prolapse has occurred? 1. Protruding. 2. Narrowed and flattened. 3. Sunken and inverted. 4. Dark, bluish colored.

1) CORRECT - A prolapsed stoma is protruding and indicates that the bowel is protruding through the stoma. 2) INCORRECT - A stenosed stoma appears narrow and flat. 3) INCORRECT - A retracted stoma appears sunken and inverted. 4) INCORRECT - A stoma that is dark and bluish in color indicates ischemia. *Think Like A Nurse: Clinical Decision Making* When preparing to care for a client with a colostomy, the nurse should mentally ask, "What characteristics are expected when assessing the stoma?" A normal stoma is nearly flush with the abdominal skin and is pink to beefy red in color. The skin around the site should be intact. The nurse identifies evidence of a problem if a portion of the colon can be seen protruding through the stoma. This is called a prolapse and must be immediately reported to the health care provider for evaluation and intervention. *Content Refresher* A colostomy is the creation of a temporary or permanent surgically created opening between the colon and the wall of the abdomen so that fecal material can drain into an external colostomy bag. Postoperatively, the nurse needs to assess the stoma for viability, appearance, bleeding, and functionality. Monitor intake and output, including fecal material as output. Provide impeccable skin care. Ensure that there is a skin barrier between the stoma and pouch, thereby protecting the skin from exposure to drainage. Stoma complications include circulatory compromise, prolapse, or retraction. Additional complications are related to the loss of fluid and electrolyte reabsorption.

The nurse presents information to staff regarding anatomic changes that occur shortly after birth to facilitate a newborn's adaptation to extrauterine life. Which anatomic changes are included by the nurse in the teaching session? (Select all that apply.) 1. Decrease in pulmonary vascular resistance. 2. Closure of the foramen ovale. 3. Closure of the ductus arteriosus. 4. Decrease pressure in the left atrium. 5. Closure of the ductus venosus.

1) CORRECT - As blood flows through the lungs and fetal shunts close, increased blood flow dilates pulmonary vessels. This change occurs to maintain blood pressure. 2) CORRECT - This circulatory system change occurs at or soon after birth, as the result of pressure changes in the lungs, heart, and major vessels. 3) CORRECT - This circulatory system change occurs by the fourth day as the result of pressure changes in the lungs, heart, and major vessels. 4) INCORRECT - There is an increase, not a decrease, in pressure in the left atrium. 5) CORRECT - This circulatory system change occurs as the result of pressure changes in the lungs, heart, and major vessels. *Think Like a Nurse: Clinical Decision-Making* At birth, the newborn shifts from a parasitic-type role (i.e., obtaining all needed nutrients, temperature regulation, gas exchange, and waste removal from the umbilical cord, placenta, and mother) to a much more physiologically self-sufficient role. With the newborn's first breath, a series of physiologic changes occur, including drainage or reabsorption of amniotic fluid from the lungs. Fetal circulation ends for the newborn as the ductus arteriosus and foramen ovale close. *Content Refresher* Immediately after delivery, the infant's respiratory system attempts to adapt to extrauterine life. Low oxygen, high carbon dioxide, and low pH are chemical factors in the blood that stimulate the respiratory center in the medulla. The temperature change from the warm intrauterine environment to the atmosphere excites sensory impulses in the skin, which are transmitted to the respiratory center. Tactile stimulation may also assist in initiating respiration and is achieved through normal newborn handling; gently rubbing the newborn's back, trunk, and extremities; and slapping or flicking the soles of the feet. In regards to the circulatory system, increased blood oxygen concentration is the most important factor controlling ductal closure.

After reviewing the history obtained from a client, the nurse recognizes that which risk factors are associated with degenerative joint disease? (Select all that apply.) 1. Diabetes mellitus (DM). 2. Carpet installer. 3. 78 years old. 4. Minimal physical activity. 5. Myocardial infarction (MI). 6. Ulcerative colitis.

1) INCORRECT — A diagnosis of DM is not a risk factor associated with degenerative joint disease. 2) CORRECT— An occupation that causes increased mechanical stress to joints along with repetitive joint use is a risk factor associated with degenerative joint disease. 3) CORRECT— Increasing age is the primary risk factor for degenerative joint disease. 4) CORRECT— Inactivity increases the risk of degenerative joint disease. 5) INCORRECT — An MI is not a risk factor associated with degenerative joint disease. 6) INCORRECT — Ulcerative colitis is not a risk factor associated with degenerative joint disease. *Think Like A Nurse: Clinical Decision Making* Degenerative joint disease, or osteoarthritis, can occur in those who engage in actions where a specific joint or joints are used repetitively. A carpenter would be at risk for the development of degenerative joint disease in the knees and hips, and possibly the fingers and wrists. Additional risk factors for the development of this disorder include increasing age and physical inactivity. Joint immobility causes stiffness, muscle shortening, and the development of contractures. *Content Refresher* Osteoarthritis (OA) is an idiopathic primary condition or a secondary one, associated with known risk factors including age, repetitive joint movement, obesity, and inactivity. Determine the current level of movement and ability. Assist the client to plan for regular exercise, a balanced diet to improve strength and decrease the risk for impaired mobility, and regular rest periods. Refer to physical and/or occupational therapy to offer exercise support and assistive devices, as needed. Educate the client about medications prescribed for pain management. Joint replacement surgery can be recommended.

The nurse is teaching a group of clients about vasectomies and tubal ligations. Which information does the nurse include in the teaching? 1. A tubal ligation is medically less complicated than a vasectomy. 2. Menstruation ceases after a tubal ligation. 3. Birth control measures are required after a vasectomyuntil the client has a negative sperm count. 4. A vasectomy is performed as a laparoscopic surgery.

1) INCORRECT- Vasectomy is considered the easiest and most commonly used operation for male sterilization, and is less complicated than a tubal ligation. 2) INCORRECT- The menstrual period will be about the same as it was before the sterilization. The tubal ligation impacts the ability of an egg to migrate to the uterus. It does not impact the lining of the uterus or hormonal regulation of the uterine lining. 3) CORRECT- It may take approximately 3 months for the client to achieve a negative sperm count in seminal fluid analysis after a vasectomy. Alternative methods of birth control should be used during this period. 4) INCORRECT- Two methods are used for scrotal entry. Those include conventional and non-scalpel vasectomy. Neither are considered a laparoscopic procedure. *Think Like A Nurse: Clinical Decision Making* Sterilization is a personal decision, and both vasectomy and tubal ligation are generally considered irreversible pregnancy prevention options. Vasectomy is accomplished via a 30-minute procedure in the health care provider's office, complications are low, and it is 99% effective after about 3 months. Vasectomy reversal is not guaranteed and is costly and complex. Tubal ligation, which is performed at a surgery center, requires anesthesia (general, spinal, or local) and also takes around 30 minutes to complete. Compared to vasectomy, tubal ligation has a higher risk of complications and is about 99% effective. Reversal of tubal ligation requires surgery. *Content Refresher* After a vasectomy, sperm cells continue to be produced by the testes but are stored in the epididymis and reabsorbed by the body rather than being passed through the ductus deferens. Vasectomy does not affect hormone production, ability to ejaculate, or physiologic mechanisms related to erection or orgasm. During a tubal ligation, the fallopian tubes are tied or cauterized through an abdominal incision, laparoscopy, or minilaparotomy. Success of reversal by reconstruction of the fallopian tubes is 40% to 75%. Instruct the client that intercourse may be resumed after bleeding ceases.

The nurse in the prenatal clinic assesses a client at 38 weeks' gestation. The client reports that she is unable to get comfortable. Which statement by the nurse is appropriate? 1. Encourage the client to exercise vigorously to stimulate labor. 2. Tell the client to lie on her back on a hard surface with her feet elevated. 3. Suggest the client drink 12 ounces of water per hour while awake. 4. Inform the client that low-heeled shoes might help back discomfort.

1) INCORRECT- Vigorous exercise may create cardiac overload and increase blood pressure. 2) INCORRECT- This position compresses the vena cava and decreases blood supply to the fetus. 3) INCORRECT- If the client drinks 12 ounces of fluid every hour, the client will consume approximately 5000 mL of fluid each day. This is not necessary. 4) CORRECT- Because the client is at 38 weeks' gestation, there are changes in the curvature of the sacrum. Low-heeled shoes (or orthopedic shoes) may relieve back discomfort. *Think Like A Nurse: Clinical Decision Making* Musculoskeletal pain is common during pregnancy. This is due to weight gain, posture changes, hormonal changes, muscle separation, and stress. Simple activities the client can do to relieve and prevent back pain include using legs to squat rather than bend over when picking up something from the ground, wearing low-heeled shoes, and wearing support hose. When sitting, the client is advised to use foot support and a pillow behind the back. The nurse should also explore and rule out other causes of back pain such as uterine contractions, urinary tract infection, and musculoskeletal disorders. *Content Refresher* During pregnancy, a mother will experience physiological changes in all systems of the body. Most result from hormonal shifts and some result in the increasing growth of the uterus and fetus. Physiological changes during pregnancy include palpable fetal and uterine growth in a predictable pattern and rate, vascular congestion and softening of the cervix, development of a cervical mucus plug, enlarged and tender breasts, and an increase in respiratory rate, tidal volume, and nasal congestion. Other signs include proportionate weight gain, increase in heart rate with stable blood pressure, increase in erythrocyte production, physiological anemia due to hemodilution, leukocytosis, nausea with or without vomiting, gastroesophageal reflux, constipation, hemorrhoid development, and urinary incontinence. The nurse should determine the presence of physiological changes and question the client about noted observations, while explaining the purpose of these changes.