1st 75 PART I

The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing actions should be included in the client's plan of care? Select all that apply.

- Assign client to a private room - Don mask before entering room - Elevate head of bed 10-30 degrees - Maintain dimmed room lighting

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply.

- Obtain baseline v/s, abdominal circumference, and wt - Place client in high fowler positon or as upright as possible -request that the client empty the bladder Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins

The charge nurse observes a new staff nurse collecting a urine sample for urinalysis and culture as pictured. What is the charge nurse's best action? Click on the exhibit button for additional information.

Advise the staff nurse to discard the collected urine specimen and record the output A urine specimen is collected aseptically from the specimen port in an indwelling urinary catheter. Urine that has been collected from the collection bag does not yield accurate urinalysis and culture results.

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision. The client's spouse arrives and demands to be with the client. Which action should the nurse take

Allow the spouse in the room, out of the way of care providers and explain the events occurring w/ the client The presence of family members during invasive procedures supports the psychosocial needs of the client and family. The nurse should reinforce family presence at bedside and provide information to the client's support person about the care being provided.

The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take?

Ask the client if the "numbness and tingling" were present before surgery. Numbness and tingling in both lower extremities are classic examples of neuropathic pain. bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use

The nurse is preparing 7:00 AM medications for a client with a urinary tract infection and a history of heart failure and type 2 diabetes. Based on the information from the medical and medication records, which prescription should the nurse question before administering?

Furosemide The nurse should question the prescription for furosemide (Lasix), a potent loop diuretic, before administering the medication. The client has a significant decrease in systolic blood pressure (50 mm Hg), a negative fluid balance of 2000 mL for 24 hours, hypernatremia (normal sodium, 135-145 mg/dL [135-145 mmol/L]), and a potassium level that is trending downward. These parameters indicate hypotonic dehydration, which is often caused by diuretic use. If the diuretic were administered, the fluid volume deficit would increase further.

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted?

Heart rate 120 Dopamine enhances heart rate. Dopamine is a sympathomimetic inotropic agent that increases heart rate, blood pressure, cardiac output, and urine output. Vital signs should be monitored closely in these clients as a higher dose can result in dangerous tachycardia and tachyarrhythmias

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse?

Instruct the parent to launder the childs clothing and store it in tightly sealed plastic bags The most important measures to prevent bed bugs from getting onto apparel is to launder clothes in hot water, dry them using the highest temperature setting on a dryer, and then store them in tightly sealed plastic bags. This will help to prevent additional bed bug infestation and transportation to other locations

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most?

Seizure activity Theophylline plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity. Seizures (central nervous system stimulation) and cardiac arrhythmias are the most serious and lethal consequences

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning?

Temp of 102.2 w/ increasing abdominal pain Acute pancreatitis may cause severe midepigastric abdominal pain, elevated blood glucose levels, and steatorrhea. The nurse should watch closely for high fever, increasing abdominal pain, and leukocytosis as these findings may indicate infection of the necrosed pancreas or pancreatic abscess formation.

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse?

Walk slightly ahead of the client w/ the clients hand resting on the nurses elbow When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow

A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client?

"Take it w/ a full glass of water and stay sitting upright afterward" The nurse should teach the client to take potassium tablets with plenty of water (≥4 oz [120 mL]) and to sit upright after ingestion to prevent pill-induced esophagitis. Potassium should be taken during or immediately following meals to prevent gastric upset. Sustained-release tablets should not be crushed

The graduate nurse (GN) is reinforcing teaching for a client who is initiating contraception with the etonogestrel and ethinyl estradiol vaginal ring. Which statement by the GN would require the nurse preceptor to intervene?

"The vaginal ring is effective as soon as you insert it" The etonogestrel and ethinyl estradiol vaginal ring (NuvaRing) is a combined hormonal contraceptiv. The ring is not a barrier method and requires time for hormone absorption.

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago. The client reports being forgetful and becoming teary easily. How should the nurse respond?

"These symptoms can be common after major surgery. It will take 4-6wks to completely heal and start to feel normal again postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred.

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply.

- 24 yr-old whose sister had breast cancer at age 38 - 32 yr old w/ genetic mutation in the BRCA1 & BRCA2 genes - 56 yr old who is postmenopausal and has gained 50lb in the last 5 yrs - 65 yr old who took combined oral contraceptives for 15 yrs Breast cancer is the second leading cause of cancer deaths among women. Breast cancer non-modifiable risk factors include female sex, advanced age, first-degree relative with breast cancer, and BRCA1 or BRCA2 genetic mutations. Modifiable risk factors include behaviors such as smoking, alcohol consumption, sedentary lifestyle, dietary fat intake, and postmenopausal weight gain and hormone therapy

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply.

- A few yrs ago, I switched from smoking cigarettes to smoking cigars 1-2x a week - I am proud that I was able to lose 10lb but im still considered obese for my ht -I drink 3-4 beers nightly to relax, but I did switch to light beer recently - I have struggled w/ daily episosdes of acid reflux for yrs especially at nighttime

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply.

- Abdominal Pain - Blood in the stools - Change in bowel habits - Low hemoglobin level - Unexplained wt loss Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.

The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply.

- Admin PRN stool softner w/ daily medications - Tell the client to call for assistance before getting out of bed Opioid analgesics are effective for managing postoperative pain, which encourages participation in deep breathing exercises. Side effects of opioid analgesics include sedation, respiratory depression, hypotension, and constipation. The nurse should administer IV hydromorphone slowly over 2-3 minutes, monitor sedation level, instruct the client not to get out of bed unassisted, and administer PRN stool softeners.

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply

- Admin an anticholinesterase drug AC - Encourage semi solid food consumption - Teach the necessity for annual flu vaccination Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.

A client admitted 3 days ago with upper gastrointestinal bleeding underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? Select all that apply.

- Apple juice -chicken broth -unsweetend tea A postoperative diet begins with ice chips and progresses to clear liquids, full liquids, soft diet, and then regular diet. Clear liquids with red dyes should not be given to clients with recent gastrointestinal bleeding.

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply.

- Arrange for health care workers of the same sex to provide care for the client - Corrdinate w/ registered dietician to provide halal meals -Reposition the immoble client to face the city of Mecca during daily prayer times - Upon death, provide the family w/ supplies for postmortem care Important aspects of care for Muslim clients include accommodating the following client needs: Facing Kaaba in the holy city of Mecca for prayer, modesty considerations, adherence to dietary practices (halal or kosher meals and possibly fasting during Ramadan), and involvement of family.

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply.

- Assess for skin breakdown of the limb in traction - Ensure adequate pain relief - Keep the limb in a neutral position - Perform frequent neurovascular checks on the limb in traction Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired surgically. The nurse caring for a client in Buck traction should frequently assess the neurovascular status and skin integrity of the affected limb and maintain it in a straight, neutral position.

A nurse is caring for a 3-month-old client with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply

- Audible gurgling - Increased irritability - Oxygen saturation 88% Decreased oxygen saturation (Option 4) Altered mental status (eg, irritability, lethargy) (Option 3) Increased heart rate (normal infant range: 90-160) Increased respiratory rate (normal infant range: 30-60) Increased work of breathing (eg, flared nostrils, use of accessory muscles) Adventitious breath sounds (eg, crackles, wheezes, rhonchi) (Option 1) Pallor, mottled, or cyanotic skin coloring

The nurse is providing discharge teaching to several clients with new prescriptions. Which instructions by the nurse are correct in regard to medication administration? Select all that apply.

- Avoid salt substitutes when taking valsartan for hypertension - When taking ethambutol, notify the health care provider of any changes in vision The nurse should watch for vision changes with ethambutol. Potassium supplements or salt substitutes should not be given to a client taking an ACE inhibitor or angiotensin receptor blocker. Sucralfate must be given before meals to prevent irritation of the ulcer. Quinolone antibiotics should not be given with antacids or supplements that reduce drug efficacy. Rifampin commonly causes red-orange discoloration of body fluids.

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply.

- Cardiac and renal changes may put the client at risk for hypervolemia -Older adults may have more fragile veins, increasing, the risk of infiltration -Skin protectancts and nonporous tape are helpful in reducing skin tears on fragile skin Important age-related considerations for the older adult receiving IV therapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.

The nurse assesses a client receiving peritoneal dialysis. Which assessment findings are most important for the nurse to report to the health care provider? Select all that apply.

- Cloudy outflow - Low-grade fever - Tachycardia Cloudy outflow (effluent), tachycardia, and low-grade fever are signs of peritonitis, an infection of the peritoneal cavity and a major concern with PD. Bloody fluid can indicate intestinal perforation or that the client may be menstruating. Brown effluent can indicate fecal contamination from perforation. All these findings need to be reported to the health care provider.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply.

- Dyspnea - Pallor - Tachycardia A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.

- Elevate affected extremities after rewarming - Provide adequate analgesia -Provide continuous warm water soaks Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

- Ensuring bed alarm remains activated - Initiating an hourly rounding schedule - Moving client to a room to the nurses station Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated.

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply

- Inhaled albuterol nebulizer every 20 min -Inhaled ipratropium nebulizer every 20 min -Intravenous methylprednisolone Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply.

- Maintain the head of the bed at 30-45 degrees - Pause sedation daily to assess weaning readiness -Perform oral care w/ chlorhexidine solution -Place a manual resuscitation bad at the bedside When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate?

- Notify the HCP Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm. Which actions by the graduate nurse indicate that more education is needed? Select all that apply.

- Reinforcing a torn peripherally inserted central catheter line dressing w/ tape - Scrubbing the port w/ alcohol for 5 seconds before use Peripherally inserted central catheter lines provide central venous access for clients who require long-term medication administration or infusion of noxious substances. Maintaining the line integrity with aseptic technique and routine care (sterile dressing changes, flushing the line, blood pressures/venipunctures on unaffected arm) is important for continued use and prevention of central line-associated bloodstream infections.

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply.

- elevate the affected extremity about the level of the heart - Notify the health care provider and prepare phentolamine If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line.

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.

-Attempt to use a female interpreter to avoid gender sensitivity - Make good eye contact with the client rather than the interperter when speaking - Teach about one intervention at a time and in the order it will occur When an interpreter is needed, the nurse should attempt to use a trained, proficient, same-sex individual rather than a family member or personal friend. The nurse should speak slowly and directly to the client, not the interpreter; provide information in the sequence it will occur; and obtain feedback of comprehension beyond merely nodding.

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply

-Chest pain during inhalation -Dimished breath sounds - Dyspnea A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? Select all that apply.

-Elevating the head of the bed 30-45 degrees - Practicing strict hand hygiene - Providing frequent oral care w/ chlorhexidine - Scheduling daily sedation vacations Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia (VAP) due to sedation and use of an artificial airway. VAP prevention includes elevating the head of the bed 30-45 degrees, providing regular oral hygiene with chlorhexidine solution, practicing strict hand hygiene, and performing daily sedation vacations.

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply

-Family hist of skin cancer -High number of moles -Immunosuppressant medication use -Outdoor occupation Risk factors for skin cancer include family or personal history of skin cancer, Celtic ancestry traits (eg, light skin, blue eyes), aging, atypical or high number of moles, immunosuppression, and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

The nurse is teaching a postoperative client to use a volume-oriented incentive spirometer device. Place the teaching steps in the proper order. All options must be used.

1. Exhale normally and place the mouthpiece in the mouth 5. Seal lips tightly on mouthpiece 4. Inhale deeply, until piston is elevated to predetermined level 3. Hold breath for at least 2-3 seconds 2. Exhale slowly around the mouthpiece Incentive spirometry is recommended to prevent atelectasis in postoperative clients. Clients with incisional pain should receive adequate pain medication prior to the inhalations. The client is instructed to use the device while sitting upright, seal the lips tightly around the mouthpiece, inhale deeply, sustain the maximal inspiration for at least 2-3 seconds, exhale slowly before repeating the procedure, and cough at the end of the session.

The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used.

2. Clamp the catheter tubing 4. Place the client in Trendelenburg position on the left side 1. Administer oxygen as needed 3. Notify the health care provider (HCP) 5. Stay with the client and provide reassurance Any delay in treatment of an air embolism could prove fatal. There is no time to call the HCP. Seal off the source of the leak, and ensure stabilization of the air bubble via left lateral positioning.

A home health nurse visits a client with chronic obstructive pulmonary disease. The nurse teaches the client to use abdominal breathing to perform the "huff" cough technique to facilitate secretion removal. Place the steps in the correct order. All options must be used.

5. "Sit upright in a chair with feet spread shoulder-width apart and lean forward." 2. "Perform a slow, deep inhalation with your mouth using your diaphragm." 1. "Hold your breath for 2-3 seconds and then forcefully exhale quickly." 3. "Repeat the huff once or twice more, while refraining from performing a normal cough." 4. "Rest for 5-10 normal breaths and repeat as necessary until mucus is cleared."

The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation?

55-yr old client missing all the hair on the lower legs and failing the pinprick test Failure of pinprick testing indicates peripheral neuropathy. Loss of hair on the lower extremities indicates poor perfusion. The combination of these suggests peripheral neuropathy and peripheral arterial disease, likely from undiagnosed diabetes mellitus and atherosclerosis. Nearly a third of clients diagnosed with diabetes mellitus will already have complications from years of uncontrolled hyperglycemia. Diabetes mellitus dramatically accelerates the buildup of plaque on the arterial walls (atherosclerosis) when blood glucose levels are uncontrolled.

A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

Check the uretheral catheter and drainage tubing Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option 1). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the tubing. This involves squeezing and releasing the full length of the tubing, starting from a point close to the client and ending at the drainage bag.

A nurse on an orthopedic unit is caring for four clients with a casted extremity. Which client does the nurse prioritize to see first?

Client reporting a tingling sensation Expected symptoms of a casted extremity include mild to moderate edema, warmth or throbbing secondary to edema, pain on movement or pain that improves with analgesics, itching (pruritus), and dry skin under the cast. Severe pain unresponsive to analgesics and changes in limb sensations (tingling or numbness) may indicate compartment syndrome.

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation

Continue teaching the client and verify understanding by return demonstration People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration.

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer. The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home. What intervention does the nurse prioritize to promote proper self care?

Explore the clients abilities and motivation to perform care home Self care is a critical component of health. However, barriers to self care are multifactorial, and include: Knowledge (lack of experience, cognitive abilities) Skills/supplies (lack of dexterity, experience, financial barriers) Motivation (lack of assumed threat to health, denial, hopelessness) The nurse must assess for adequate knowledge and ability to perform self-care activities and the desire to complete such activities

The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?

History of DVT The transdermal contraceptive patch (ethinyl estradiol and norelgestromin) is a combined hormonal contraceptive (CHC). As with all CHCs, a client history of thromboembolic events should concern the nurse because it may increase the risk of thromboembolic events while using the patch.

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

I can leave right after the shot as i didnt have a reaction last time A client receiving an allergy shot is at risk for anaphylaxis immediately after the injection, so the client must remain at the facility and be monitored for 30 minutes after the injection.

A client suffering from bladder prolapse and subsequent stress urinary incontinence has discussed treatment options with the health care provider (HCP). The nurse evaluates that the client understands support pessary use when the client makes which statement?

I can remain sexually active while my pessary is in place A pessary is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office.

The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?

I can resart my paroxetine once I get back home Linezolid is an antibiotic with monoamine oxidase inhibitor-type properties that is prescribed to treat vancomycin- and methicillin-resistant bacterial infections. Selective serotonin reuptake inhibitors are contraindicated during therapy due to the increased risk of serotonin syndrome.

The nurse provides discharge teaching to a client who had a total knee replacement 4 days ago. Which client statement indicates the need for additional teaching?

I have to use a walker because I cant bear any wt on this knee yet A client with total knee arthroplasty needs assistive devices (eg, walker, crutches) and a knee immobilizer to help ambulation; the client should be fully weight bearing by discharge. Prophylactic anticoagulation and recognition of postoperative complications (eg, DVT, PE) are also important

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching?

I prop my legs up in the recliner and use a heating pad when my feet are cold The nurse should instruct the client with peripheral arterial disease to never apply direct heat to extremities due to the risk of a burn from decreased sensitivity.

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching?

I will remove and clean the cervical cap as soon as possible after intercourse The cervical cap is a barrier method of contraception used with spermicide. It can be inserted several hours before intercourse and should be left in place for at least 6 hours after. Its use during menses increases the risk of toxic shock syndrome

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction?

I will take vitamin A supplements Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication

A home health nurse is giving an infection control presentation on pulmonary tuberculosis (TB) disease to a group of home health aides. Which statement made by a home health aide indicates an understanding about the mode of transmission of pulmonary TB?

It is spread by small droplets that the client coughs or sneezes into the air Mycobacterium tuberculosis microorganisms from a client with active pulmonary TB disease are transmitted to another person via airborne droplets.

A client with long-term hypertension and hypercholesterolemia comes to the clinic for an annual checkup. The client takes nifedipine, simvastatin, and spironolactone and reports some occasional dizziness. Which statement by the client would warrant intervention by the nurse?

Ive been trying to eat more fruits and vegetables. I discovered that I really like grapefruit The nurse should tell the client not to eat grapefruit or drink grapefruit juice while taking calcium channel blockers due to the possible development of severe hypotension. The nurse should report this client's statement to the HCP.

A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action?

Obtain a 12-lead electrocardiogram Nurses must take presenting cardiac symptoms seriously until the cause is determined. Assess airway, breathing, and circulation, and obtain baseline pulse oximetry and vital signs. Then obtain electrocardiogram (ECG) results.

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

Partial thomboplastin time of 110 seconds Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on a partial thromboplastin time (PTT). The therapeutic PTT target is 1.5-2.0 times the normal reference range of 25-35 seconds. A PTT value >100 seconds would be considered critical and could result in life-threatening side effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestinal bleeds.

The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention?

Perform head tilt and chin lift Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis.

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity?

Postical Phase seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client?

Presence of SOB, coughing, or edema The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.

The nurse is caring for a client receiving IVPB azithromycin. Which client data obtained by the nurse should be reported to the health care provider (HCP) prior to administering any additional doses?

Prolonged QT interval Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin) can cause QT prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes). They can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an ECG and report significant results to the HCP.

The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nursing diagnosis should be addressed first?

Risk for falls The nursing diagnosis of risk for falls should be addressed first for a client who has multiple risk factors for falls. Advanced age, incontinence, certain medications, and limited mobility increase fall risk.

The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake. When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement?

The decision whether to provide artificial hydration should consider client preferences and goals The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration; however, client preferences should be respected - clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life.

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan?

Wear a wrist immobilization splint Most clients with CTS can conservatively manage symptoms with wrist immobilization splints (Option 4). Splinting and immobilization of the wrist (particularly during sleep) reduces pain by preventing flexion or extension and subsequent nerve compression. Clients with CTS may require surgery to permanently relieve symptoms.

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?

at the first sign of an asthma attack I will take this medication

A client at 32 weeks gestation has been diagnosed with syphilis. The client expresses her belief that antibiotic therapy is harmful and refuses treatment. What is the nurse's appropriate response?

ate the client about the consequence of nothing taking antibiotics for her and the fetus During pregnancy, the client retains the right to refuse care for herself and on behalf of her fetus. The nurse is responsible for ensuring that the client's refusal is an informed decision by educating the client on the consequences of refusing treatment.

A client has been on long-term therapy with esomeprazole. What is essential for the nurse to ask the client?

have you had a bone density test recently Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis.

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive?

output urine is light pink in color A 3-way Foley catheter with continuous bladder irrigation allows urine to drain after a transurethral resection of the prostate. During the first 24 hours, the urine color changes from reddish-pink to pink. Small clots may occur for up to 36 hours. However, the nurse adjusts the irrigation flow to keep the urine light pink without clots.