UWORLD question bank
The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
Educational objective:Only persons needing client health information to carry out their job duties should have access to or be advised of this data. Nurses, health care providers, and hospitals should take reasonable precautions at all times to safeguard client information.
The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse?
Educational objective:Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and white blood cell count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation
A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse reinforce with this client?
The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis).
The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply.
dolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: Hypersomnolence or insomnia; napping during daily activities (Option 3) Low self-esteem; withdrawal from previously enjoyable activities (Option 4) Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior (Option 1) Weight gain or loss; increased food intake or lack of interest in eating (Option 2) Depression is also a significant cause of suicide in adolescents. (Option 5) Adolescent clients begin to become more aware of body image and may express concern regarding their appearance. It is normal for clients in this age group to experience insecurity about their appearance (eg, acne, body hair). These insecurities do not correlate with the onset of a depressive disorder. Educational objective: Adolescent clients with depression frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. In addition, changes in sleep patterns; low-self esteem; withdrawal from previously enjoyable activities; outbursts of aggressive or delinquent behavior; and precipitous weight changes may indicate the onset of a depressive disorder.
An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
Codeine is an opioid drug prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10-20 mg orally every 4-6 hours) is lower than the analgesic dose, clients can still experience the common adverse effects (eg, constipation, nausea, vomiting, orthostatic hypotension, dizziness) associated with the drug. Codeine decreases gastric motility, resulting in constipation. Increasing fluid intake and fiber in the diet and taking stool softeners or laxatives are effective measures to prevent constipation (Option 2). Changing positions slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in older clients (Option 4). Taking the medication with food is effective in preventing the gastrointestinal irritation (eg, nausea, vomiting) associated with codeine (Option 5). (Options 1 and 3) Wearing sunscreen while outside and avoiding caffeine are not indicated to prevent adverse effects related to codeine use. Educational objective:The common adverse effects of codeine, an opioid drug, include constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent these include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly.
The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?
Educational objective:Gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose. It should be initiated within one hour of overdose. The nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). (Option 1) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option 2) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option 4) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards.
The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client's caregiver?
Extended-release oxycodone (Oxycontin) is a long-acting opioid agonist prescribed to manage severe chronic pain when nonopioids and immediate-release opioids (eg, immediate-release oxycodone, hydrocodone) are inadequate. The nurse should teach the client's caregiver to administer extended-release oxycodone as scheduled, even if the client does not report pain. Administration twice daily is necessary to maintain a therapeutic level and provide continuous relief as the duration of the analgesic effect is 12 hours Educational objective:Long-acting controlled-release opioid drugs for chronic pain require regularly scheduled dosing to maintain a therapeutic drug level. Immediate-release opioids may be required for breakthrough pain. Long-term opioid use leads to tolerance and physical dependence; higher doses are eventually required for therapeutic effect. Additional Information Pharmacological Therapies NCSBN Client Need.
A nurse is changing a sterile dressing for a client with an infected wound. While doing so, unlicensed assistive personnel report that a second client is requesting pain medication. What is the nurse's most appropriate action?
The nurse can prioritize care according to degree of urgency, extent of threat to the client's survival, and potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the second client that the nurse will be there soon and to complete the sterile dressing change Educational objective:A nurse can prioritize client needs and problems according to degree of threat to the client's survival and potential for complications. The nurse uses clinical judgment to decide which client situations require immediate attention and which can wait.
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
n Hirschsprung disease, or congenital aganglionic megacolon, a child is born with a lack of specialized nerve cells in some sections of the distal large intestine; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction (eg, distended abdomen, difficulty feeding, vomiting green bile) and do not pass meconium within the expected 24-48 hours. In less severe cases of the disease, the diagnosis may not be made until the child is older. Clinical manifestations include chronic constipation that is not psychogenic in nature and ribbon- or pellet-like stools Educational objective:Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. An infant with Hirschsprung disease will not pass meconium but will have a distended abdomen and bilious emesis.
A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs?
testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty. Educational objective:Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.
A client with terminal cancer becomes hypoxic and unresponsive. According to the client's paperwork, the client's sister is the legal medical power of attorney. Both the client's spouse and sister are present. Which action by the nurse is appropriate at this time? 1. Ask the spouse about the client's wishes [3%] 2. Get directions about care from the client's sister [79%] 3. Prepare for emergency intubation [7%] 4. Request that the sister provide a living will [9%]
Advance directives are legal documents that allow clients to make decisions about their future medical treatment in case the client later becomes medically incompetent (eg, end of life, dementia, brain injury). The most common forms are a living will and a medical power of attorney (POA) (ie, health care surrogate/proxy). A living will declares the client's wishes related to specific situations (eg, do not intubate). A medical POA allows the client to designate a specific decision-making individual who can advocate for the client as needed and can be flexible in changing circumstances (Option 2). Educational objective:Medical power of attorney (POA) is an advance directive that allows clients to designate a specific decision-making individual who will advocate on their behalf if they become medically incompetent. Clients have the right to declare any individual they trust as their agent with medical POA, and that individual becomes the final decision maker.
The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply.
At birth, a newborn has enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Iron supplements should be given on an empty stomach between meals for best absorption (Option 5). If gastric irritation occurs, iron may be given with meals; however, this decreases absorption. If the child is old enough, supplements with citrus fruit juice should be offered as an abundance of vitamin C increases absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration as these will decrease absorption (Option 3). (Options 1 and 2) Iron supplements may cause constipation and black or dark green, tarry stools; therefore, parents should be taught not to be alarmed if these expected findings occur. (Option 4) Liquid iron supplements can stain teeth; to reduce this risk, parents should use a medicine dropper to administer the dose at the back of the infant's cheek. The dose may also be diluted with water or juice to prevent staining and improve flavor.An older child should use a straw to take the supplement and drink water or juice after each dose. Educational objective: Liquid iron supplements are best absorbed on an empty stomach. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. Iron may be given with meals to reduce gastric irritation; however, this will decrease absorption.
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?
Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. (Option 1) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. (Option 2) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnosis. (Option 4) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns. Educational objective:Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.
The nurse in a clinic is obtaining a developmental history of an 18-month-old during a well-child visit. Which activities should the child be expected to perform?
Developmental milestones of toddlers Age Gross motor Fine motor Language Social/cognitive 12 months Walks first steps independently Crawls up stairs Uses 2-finger pincer grasp Hits 2 objects together Says 3-5 words Uses nonverbal gestures (eg, waving goodbye) May have separation anxiety Searches for hidden objects 18 months Walks up/down stairs with help Throws ball overhand Jumps in place Builds tower of 3-4 blocks When looking at books, turns 2-3 pages at a time Scribbles Uses cup & spoon Has vocabulary of 10+ words Identifies common objects Has temper tantrums Understands ownership ("mine") Imitates others 2 years Walks up/down stairs alone, 1 step at a time Runs without falling Kicks ball Builds tower of 6-7 blocks When looking at books, turns 1 page at a time Draws line Has vocabulary of 300+ words Can form phrases of 2-3 words States own name Begins parallel play Begins to gain independence from parents 3 years Walks up stairs with alternating feet Pedals tricycle Jumps forward Draws circle Feeds self without help Grips crayon with fingers instead of fist Can form sentences of 3-4 words Asks "why" questions States own age Begins associative play Is toilet trained, except wiping
The health care provider has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action?
Educational objective:The most common side effects experienced by clients taking tricyclic antidepressants include dizziness, drowsiness, dry mouth, constipation, photosensitivity, urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.
The practical nurse is assisting the registered nurse during a physical assessment of a 10-year-old with abdominal discomfort. Which actions does the practical nurse anticipate during the assessment? Select all that apply.
Factors to consider during the physical assessment of school-age children (age 6-12) include the following: Clients (even those as young as age 3) can tell and/or show the examiner where they hurt or how they feel in their own terms Clients are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in medical equipment and how it works. Clients develop modesty during this period and some do not want a parent, especially of the opposite sex, in the room with them during a physical examination. This request should be honored. A head-to-toe sequence is appropriate for this age group. Educational objective:When performing a physical examination on a child, it is imperative that the examiner proceed according to developmental age so that the child will be more comfortable and cooperative during the examination.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
Hydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 monthsHydroxychloroquine (Plaquenil) is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Educational objective:Hydroxychloroquine (Plaquenil) is used to treat the skin and arthritic manifestations of systemic lupus erythematosus. Taking the medication with food can help alleviate gastrointestinal upset. Serious adverse drug reactions include retinopathy and visual disturbances; therefore, regular ophthalmologic examination every 6-12 months is required.
The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses. Which of the following are appropriate for the nurse to include? Select all that apply.
Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: The abusive partner exhibits intense jealousy and possessiveness (Option 3). The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) (Option 4). The abuse begins or intensifies during pregnancy Educational objective:Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.
Educational objective:Otitis media, inflammation of the middle ear, commonly occurs in children under age 2. Key interventions for prevention include avoiding exposure to tobacco smoke, obtaining routine immunizations, and discontinuing use of a pacifier after age 6 months
Otitis media (OM) is the inflammation or infection of the middle ear resulting from dysfunction of the eustachian tube. OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. The eustachian tubes in infants and young children are short, straight, and fairly horizontal, which results in ineffective drainage and protection from respiratory secretions. Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory inflammation. OM risk is also higher with activities such as using a pacifier or drinking from a bottle when lying down as these allow fluid to pool in the mouth and then reach the eustachian tubes.
A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? Hemoglobin and hematocrit levels [35%] Human chorionic gonadotropin level [17%] Serum folate level [42%] White blood cell count [3%]
Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. (Option 2) Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to determine if a client is pregnant. It is not affected by iron deficiency anemia or pica. (Option 3) Increased folic acid consumption is necessary during pregnancy to reduce the risk for neural tube defects in the developing fetus. However, folate levels are not related to pica. (Option 4) A white blood cell count should be assessed when a client is suspected of having an infection. There is no indication that this client has an infection. Educational objective:Pica is the constant craving for and consumption of nonfood and/or nonnutritive food substances that may occur in pregnancy. It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful in these clients to screen for anemia.
The clinic nurse is reinforcing teaching to a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism. Which statement made by the client indicates that further teaching is needed?
Several medications impair the absorption of levothyroxine (Synthroid). Common offenders are antacids, calcium, and iron preparations. Some of these could be present in several over-the-counter multivitamin and mineral tablets. Therefore, clients with hypothyroidism should be instructed to take levothyroxine on an empty stomach, preferably in the morning, separately from other medications. The most common reason for inadequately treated hypothyroidism is deficient knowledge related to the medication regimen (eg, not taking daily, taking with other medications). Educational objective:Levothyroxine should be taken on an empty stomach, preferably in the morning, separately from other medications
During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?
Starting at approximately age 1 year, the very high metabolic demands of infancy slow down to keep pace with the moderate growth of toddlerhood. During this phase, toddlers are increasingly picky about their food choices and schedules. Although to the parents it may appear that the child is not consuming enough calories, intake over several days actually meets nutritional and energy needs. Parents should be educated concerning what constitutes a healthy diet for toddlers and which foods they are more likely to consume. Some effective strategies for dealing with a toddler during this stage of decreased appetite and pickiness include: Set and enforce a schedule for all meals and snacks. Offer the child 2 or 3 choices of food items. Do not force the child to eat. Keep food portions small (1-2 teaspoons per serving) and provide an additional serving after the first serving is consumed. Expose the child repeatedly to new foods on several separate occasions. Do not allow the child to watch TV and play games during meals or snacks. (Options 1 and 2) Parasitic infection can cause malnutrition (eg, failure to thrive). There is no indication that the child is suffering from any malnutrition. Therefore, an evaluation for parasites or referral to a nutritionist is not necessary. (Option 3) Evaluation of a toddler's nutritional status is a routine assessment and within the nurse's scope of practice. Educational objective:During toddlerhood, it is normal for a child to have a decreased appetite as the result of reduced metabolic needs. Parents should be taught to provide multiple food options, set a schedule for meals/snacks, and avoid watching TV or playing games during mealtime. Toddlers should not be forced to eat.
The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with a migraine headache. Which item in the client's history would cause the nurse to question the prescription?
Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care provider (Option 3). (Option 1) A blood urea nitrogen level of 12 mg/dL (4.28 mmol/L) is a normal value (normal range 6-20 mg/dL [2.1-7.1 mmol/L]). (Option 2) Sumatriptan is not contraindicated for underweight or overweight clients. (Option 4) Sumatriptan is not contraindicated with alprazolam therapy. However, because of its serotonergic effects, clients already taking selective serotonin reuptake inhibitors (eg, sertraline, paroxetine) or selective norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine) should be monitored for signs of serotonin syndrome. Educational objective:Sumatriptan relieves migraines by constricting dilated cranial blood vessels. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because the vasoconstrictive effects can cause hypertensive urgency, angina, decreased cardiac perfusion, and acute myocardial infarction.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation. Educational objective:The EpiPen is designed to be delivered through clothing in the mid-outer thigh area. The nurse should not delay anaphylaxis treatment by attempting to remove the client's clothing.
The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate?
The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used. Educational objective:The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.
The nurse is reinforcing teaching about trazodone to an elderly client with depression. Which statement by the client indicates that additional teaching is needed?
Trazodone (Oleptro), a serotonin modulator, is used to treat major depressive disorder. In addition to affecting serotonin levels, the drug blocks alpha and histamine (H1) receptors. Blockade of alpha receptors can cause orthostatic hypotension similar to that from other alpha blockers (eg, terazosin, tamsulosin) used to treat benign prostatic hyperplasia. Blockade of H1 receptors leads to sedation. Therefore, this drug is particularly effective in treating insomnia associated with depression. However, concurrent intake of other medications or substances that cause sedation can be detrimental; these include benzodiazepines (eg, alprazolam, lorazepam, diazepam), sedating antihistamines (eg, chlorpheniramine, hydroxyzine), and alcohol Educational objective:Trazodone modulates serotonin levels in the brain. It also blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. Priapism, although rare, is another serious side effect.
The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply.
With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy, eggs]) can be appropriate for clients in all age groups. Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies(eg, protein, calories, calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing nutritional deficiencies in vegan diets should include information about: Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified cereals and breads to decrease risk of iron-deficient anemia (Option 2) Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together (Option 4) Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and vitamin D for bone health Educational objective:Pediatric clients consuming a vegan diet are at risk for dietary deficiencies (eg, iron, protein, calories, vitamin B12, calcium, vitamin D). Parent education about supplementation and adequate food sources of these nutrients is necessary.
Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply.
A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal. Educational objective:Before chest tube removal, the client is given an analgesic and then asked to perform Valsalva during the procedure. The nurse should also bring sterile suture removal equipment and a sterile airtight occlusive dressing. Post-procedure chest x-ray is necessary within 2-24 hours.
An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply
A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula. (Option 1) Bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This backflow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose. (Option 4) Feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth. Educational objective:Children with cleft palates are at increased risk for inadequate intake as well as aspiration. Actions to promote intake and reduce aspiration risk include feeding in an upright position, pointing the nipple away from cleft, feeding over no more than 20-30 minutes, using special nipples or bottles, and feeding every 3-4 hours. The infant should be burped at regular intervals to reduce gastric distension.
The nurse is reinforcing education to a group of clients that are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy should concern the nurse? Select all that apply.
Alcohol consumption during pregnancy is concerning and is reported by 1 in 9 women according to research surveys. Nurses play a significant role in educating clients about the teratogenic risks of alcohol consumption, which include miscarriage, preterm birth, low birth weight, and fetal alcohol spectrum disorders (eg, fetal alcohol syndrome). Fetal alcohol spectrum disorders may not be diagnosed immediately, but a range of permanent neurodevelopmental abnormalities or dysmorphic facial features may occur (Option 3). During pregnancy, the nurse should screen for substance abuse to identify clients who consume alcohol. The nurse should educate clients that alcohol freely crosses the placenta into the fetal bloodstream, affecting the growth and development of the fetus at any gestational age. Therefore, no amount of alcohol intake during pregnancy is safe (Options 1 and 5). The nurse should also inform clients that discontinuing alcohol intake at any time during pregnancy can improve future outcomes for the child (Option 2). (Option 4) The nurse should encourage clients who are planning pregnancy to abstain from alcohol to avoid potential exposure of the embryo during a highly critical period of development. Educational objective: Alcohol consumption is concerning in pregnant clients. The nurse should inform clients that no amount of alcohol is safe during pregnancy and that consumption may lead to miscarriage, low birth weight, or fetal alcohol spectrum disorders. Pregnant clients or those planning pregnancy should abstain from alcohol to protect offspring from permanent abnormalities (eg, neurodevelopmental, facial).
A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time?
An automated external defibrillator (AED) should be used as soon as it is available. Pediatric AED pads or a pediatric dose attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart"). (Option 1) If an AED is available, it should be placed on the client as soon as possible. Research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest. (Option 3) Standard placement of adult AED pads on a 2-year-old would cause the pads to touch or overlap. Touching or overlapping of pads allows the shock to move directly from one pad to the other without traveling through the heart. (Option 4) Both AED pads are necessary for the defibrillator to work effectively. Educational objective:An automated external defibrillator (AED) should be used as soon as it is available. Adult AED pads can be used on a pediatric client if pediatric pads are unavailable. One pad is placed on the chest and the other is placed on the back ("sandwiching the heart").
Which of the following are examples of medical battery? Select all that apply.
Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results. Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be legally charged educational objective:Battery is touching that is legally defined as unacceptable or occurs without consent. Examples include performing a procedure despite a competent client's refusal or without obtaining proper consent from a competent client (or parent/legal guardian when the client is a child). Assault is the threat of battery.
The nurse in a clinic is caring for an 8-month-old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent?
Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. It typically begins with viral upper respiratory symptoms (eg, rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as tachypnea, cough, and wheezing. Bronchiolitis is a self-limited illness and supportive care is the mainstay of treatment. Most children can be managed in the home environment. Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting (Option 3). Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove secretions prior to feedings and at bedtime Educational objective:Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. The focus of home care is on monitoring respiratory status and periodic nasal suctioning using saline nose drops to ease breathing. Additional fluids should be offered
Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?
Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. (Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. (Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. (Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery. Educational objective:Clients at highest risk for developing hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, invasive tubes or lines, or in the ICU. Nurses should follow infection control procedures diligently with these clients.
The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?
Five rights of delegation Right task Within delegatee's scope of practice Routine, frequently recurring task; minimal potential risk Established sequence of steps; requires little to no modification for individual clients Predictable outcome Right circumstances Relatively stable client; noncomplex task Adequate staffing, resources & supervision available Right person Delegator should assess competency prior to delegating Delegatee must have the appropriate knowledge, skills & abilities Right direction/communication Delegator needs to provide clear instructions; must include specific client concerns & observations to be reported back or recorded Delegatee should verbalize understanding & have the opportunity to ask questions Right supervision/evaluation Monitor, evaluate & intervene as needed Delegator retains ultimate accountability for task When assigning client care, the nurse must consider the five rights of delegation. Right direction/communication involves clear and precise instructions about assigned tasks, including any specific information necessary for completion. Necessary information includes the specific tasks (eg, take vital signs), the time frame (eg, in 10 minutes), and when to report back to the nurse (eg, if systolic blood pressure is <100)
A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.
In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following: Place client in a private room (preferred) or semi-private room with another client with the same infection Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) (Option 1) Wear gloves when entering the room Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) (Option 2) Wear gown with client contact and remove it before leaving the room (Option 5) Place door notice for visitors Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures) Educational objective:The client with multidrug-resistant organism (MRSA or VRE) infections, C difficile diarrhea, or scabies will require institution of contact precautions such as good hand hygiene on entry and exit of the client's room, gloves on entry, and a gown for direct client care. The client's room should have dedicated equipment, and the door should have a sign informing visitors about these precautions.
The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply.
Nursing interventions for a newborn immediately after delivery include: Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact aids in thermoregulation. Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed (Option 3). Educational objective:Nursing management of a newborn includes using standard precautions when in contact with blood or body fluids (eg, bathing), maintaining the infant's airway (suction the pharynx before the nose), thermoregulation, and administering vitamin K and prophylactic ophthalmic ointment.
The nurse reinforces teaching about methotrexate to a 28-year-old client with rheumatoid arthritis. Which client statement indicates the need for further instruction regarding this drug?
The client's statement about getting an eye checkup every 6 months indicates that further teaching is necessary. Eye examinations every 6 months are not indicated for clients on methotrexate (Option 3), whereas they are recommended for those who are prescribed hydroxychloroquine (Plaquenil), a nonbiological antimalarial DMARD that can cause retinal damage. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection and should avoid crowded places and contact with individuals who have known infections. Clients on methotrexate should receive the recommended killed (inactivated) vaccines (eg, influenza, pneumococcal), but live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Methotrexate is teratogenic and can cause congenital abnormalities and fetal death; therefore, clients should not become pregnant while taking this drug and wait at least 3 months after it is discontinued to conceive. (Option 4) Methotrexate is hepatotoxic; clients on this medication should avoid drinking alcohol as alcohol use increases the risk for hepatotoxicity. Educational objective:Methotrexate is a disease-modifying antirheumatic drug used to treat rheumatoid arthritis. The major adverse effects associated with methotrexate include bone marrow suppression, hepatotoxicity, congenital abnormalities, and fetal death.
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?
The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible (Option 1). (Option 2) Giving the child something warm to drink is an appropriate intervention; however, re-warming the child's feet in warm water is the priority action. (Option 3) Massaging a body part that has sustained a cold injury is contraindicated due to the risk of tissue injury. Educational objective:The most important treatment for suspected chilblains/pernio or frostbite is re-warming of the affected area by immersion in warm (104 F [40 C]) water. The individual can also be given a warm liquid to drink and should be seen by an HCP as soon as possible.
The nurse is caring for a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the nurse expect to find?
The core symptoms of attention-deficit hyperactivity disorder ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults Educational objective:The diagnosis of attention-deficit hyperactivity disorder includes the presence of hyperactivity, impulsiveness, and inattention. The negative consequences of the core manifestations include impaired social skills, poor self-esteem, academic or work failure, increased risk for depression and anxiety, and increased risk for substance abuse.
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?
The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions. (Option 1) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored." (Option 2) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given. (Option 4) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present. Educational objective:Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement. Additional Information Coordinated Care NCSBN Client Need
A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply.
The practices, needs, and experiences of grief vary greatly among individuals. Nurses caring for grieving clients must skillfully use therapeutic communication techniques to strengthen the nurse-client relationship and support clients in exploring emotions and experiences. Reflection (eg, acknowledging client statements) and using open-ended questions or statements assist the client in exploring emotions and allow for expression of needs (Option 4). Nurses may also suggest strategies and share resources (eg, support group) to facilitate the client's grieving process (Option 5). Educational objective:Nurses should use therapeutic communication techniques (eg, reflecting, asking open-ended questions, suggesting strategies or resources) to support clients' psychosocial needs and build the nurse-client relationship. Minimization, automatic responses, and leaving clients who are sharing strong emotions are nontherapeutic actions.
The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) [50%] 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths [18%] 3. Placing the heel of the hand on the upper half of the client's sternum [18%] 4. Providing compressions at a rate of at least 80-100/min [12%]
The primary goal of cardiopulmonary resuscitation (CPR) is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in (5 cm) deep to adequately pump blood but no more than 2.4 in (6 cm) deep to prevent unnecessary client injury (Option 1). The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion. Educational objective:For high-quality adult cardiopulmonary resuscitation, compressions should be in the center of the chest; at a rate of 100-120/min; and at least 2 in (5 cm) but no more than 2.4 in (6 cm) deep for adequate perfusion without unnecessary client injury. Compression interruption should be minimized (eg, 30 compressions to 2 rescue breaths).
A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse?
This client's spouse has experienced a traumatic or crisis event (also referred to as "a critical incident"). When faced with a traumatic situation, clients are often overwhelmed and respond with a wide range of emotions and thoughts, including shock, denial, anger, helplessness, numbness, disbelief, and confusion. Clients may also experience physical symptoms, such as hyperventilation, abdominal pain, and dizziness. Priority nursing actions need to be directed at the here and now, providing therapeutic interventions aimed at alleviating the immediate emotional impact of this disruptive crisis event. Acknowledging the severity of the event validates and normalizes the spouse's reaction. Assisting the spouse in identifying feelings and giving the spouse opportunity to ventilate will help reduce immediate emotional stress. Educational objective:Initial reactions to a crisis event may include shock, disbelief, denial, helplessness, and confusion. Nursing actions are directed at providing support to the client. Acknowledging the impact of the event and encouraging the client to ventilate are therapeutic interventions.
