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The emergency department nurse is caring for a client who has been recently prescribed methadone for chronic severe back pain. The client ingested extra tablets tonight because the pain returned. Which assessment findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply. 1. Falls asleep when the nurse is talking 2. Frequently scratches due to pruritus 3. Has third emesis since taking medication 4. Monitor shows occasional premature ventricular contractions 5. Pulse oximetry reading is 92%

1 3 5 Methadone is a potent and unique narcotic with a long half-life (up to 50+ hours) due to its lipophilic properties. There is a risk of overdose as the analgesic effect only lasts 6-8 hours. As a result, a client can inadvertently take too many tablets for additional pain relief even though fat cells continue to release a high amount of the drug in the circulation. Early signs of toxicity are nausea/vomiting and lethargy. A client who falls asleep with stimulation is described as obtunded and requires additional observation/monitoring. Sedation precedes respiratory depression, which is a life-threatening complication of severe toxicity (Options 1 and 3). A normal, healthy nonsmoking adult should have a pulse oximetry reading of 97%-100%. A value of 95%-100% is considered acceptable, but a reading of 92% is low and indicates inadequate depth or rate of respiration (Option 5). (Option 2) Itching sensation (pruritus) is an expected finding with narcotic use, especially in opiate naïve clients. It can be managed with an antihistamine. (Option 4) Occasional premature ventricular contractions are a common, non-significant finding in most adults. The client should have cardiac monitoring in the setting of methadone use as there is a risk of QT interval prolongation (normal 0.34-0.43 sec or less than half the RR interval). However, it is safe to discharge the client if this prolongation is absent.

The nurse is caring for a client who is dying from pancreatic cancer. The client is now unresponsive. Which of the following would the nurse expect to find on assessment in a client who is nearing death? Select all that apply. 1. Cool, dusky arms and legs 2. Light-colored urine 3. Low blood sugar 4. Mouth hanging open 5. Uneven breathing pattern with periods of apnea

1 4 5 Nursing assessment of the client in the last hours to days of life should include the physical changes that indicate where the client is in the dying process. Some signs that the client is nearing death include the following: Coolness and paleness or mottling of the extremities A slack, relaxed jaw and open mouth from loss of fascial muscle tone Difficulty in maintaining body posture or positions Eyelids half-open Cheyne-Stokes or uneven respirations with periods of apnea (Option 2) Urine output usually decreases and darkens (concentrated) from dehydration as the client nears death. (Option 3) Low blood sugar is not a typical finding in the client who is nearing death.

A client with abdominal pain and vomiting is feeling dizzy and "out of it." The blood pressure is 153/83 mm Hg and pulse is 70/min supine; blood pressure is 119/81 mm Hg and pulse is 90/min sitting. What should the nurse do next? 1. Anticipate administering normal saline intravenous fluids 2. Complete the orthostatic vital signs by having the client stand 3. Document that orthostatic vital signs are "within normal limits" 4. Perform further neurological assessment with tandem walking

1. Anticipate administering normal saline intravenous fluids In healthy, well-hydrated people, blood pressure and pulse do not significantly alter with a change in position. In the normal mechanism, vasoconstriction prevents large amounts of blood from pooling in the extremities when standing up. When a person is significantly dehydrated, vasoconstriction has already occurred: a loss of about 25% of blood volume is necessary for hypotension to occur. Therefore, there is no compensation capacity available in a dehydrated client with position change, and dropping blood pressure and rising pulse result. Orthostatic vital signs should first be done supine, then sitting, then standing, with 2 minutes between each position change. Positive orthostatic vital signs are present when systolic blood pressure drops by at least 20 mm Hg or diastolic blood pressure drops by at least 10 mm Hg. The pulse usually rises at least 20 beats/min. Associated symptoms (related to decreased cerebral perfusion) include dizziness, weakness, blurred vision, and syncope. These clients are expected to receive fluid replacement with isotonic solutions (eg, normal saline, lactated Ringer's). (Option 2) A client with postural hypotension is at risk for falling. If a client is significantly symptomatic or has findings already at sitting, the client should be assisted back to bed rather than completing the entire orthostatic measurements. The orthostatic vital signs are "positive." (Option 3) With a falling systolic blood pressure and rising pulse, the client does not have normal results. The client would be described as having "positive orthostatic vital signs." (Option 4) Additional assessments involving ambulation should not be done at this time due to the risk of falling from the dizziness and positive orthostatic vital signs. Other neurological assessments can be performed. The cerebellum (which heel-toe tandem walking assesses) can be evaluated by other tests.

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. The nurse observes blanching along the vein pathway. Which interventions are appropriate for the nurse to perform? Select all that apply. 1. Administer morphine IV PRN for pain after flushing line with saline 2. Elevate the extremity above the level of the heart 3. Establish new IV access proximal to the affected site 4. Notify the health care provider 5. Prepare to administer the drug phentolamine 6. Stop the infusion and disconnect IV tubing

2 4 5 6 Extravasation is the infiltration of a drug into the tissue surrounding the vein. The vasoconstrictor norepinephrine (Levophed) is a vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching along the vein pathway, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line whenever possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect IV tubing. Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema. Notify the health care provider. Obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of norepinephrine. (Options 1 and 3) The nurse should not flush the infiltrated IV site or use it for drug administration. Although new IV access must be obtained for morphine administration and to resume norepinephrine infusion, access should be established ideally through a central line, or on the unaffected extremity.

A parent has brought her 6-month-old to the clinic for routine immunizations. The nurse administers which of the following to the client? Select all that apply. 1. Hepatitis B (Hep B) 2. Inactivated poliovirus (IPV) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate vaccine (PCV) 5. Varicella zoster virus (VZV)

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Which of the following findings reflect concerning vital signs that require further nursing assessment and intervention? Select all that apply. 1. After albuterol administration, 5-year-old client reports tremor and has pulse 120/min 2. After hydromorphone 1 mg intravenous push (IVP), BP decreases from 130/80 mm Hg to 110/70 mm Hg 3. Client receiving blood transfusion; pre-infusion: BP 120/80 mm Hg and pulse 80/min; now: 90/70 mm Hg and 100/min 4. Fetal heart rate monitored during labor changes from 140/min to 100/min with decelerations 5. Nurse preparing to administer prescribed nifedipine; blood pressure is 90/60 mm Hg

3 4 5 Acute hemolytic reaction during a blood transfusion usually develops within the first 15 minutes. Signs/symptoms include chills, fever, lower back pain (from damaged cells in the kidneys), tachycardia, tachypnea, and hypotension. Acute hemolytic reaction is an emergency that requires the nurse to stop the transfusion and treat shock. Normal fetal heart tones are 110-160/min. Decrease in heart rate with decelerations could indicate uteroplacental insufficiency and must be assessed. Nifedipine (Procardia) is a potent calcium channel blocker antihypertensive. It should not be administered when the client's BP is on the lower end of the acceptable range, as this may result in hypotension. (Option 1) Albuterol (Ventolin) is a bronchodilator beta-adrenergic agonist. Expected side effects include tremor, tachycardia, and palpitation. Normal pulse rate in a 5-year-old can be 70-120/min and averages 100/min. This is the upper limit of expected findings. (Option 2) This is the upper normal dosing limit for initial IVP administration of hydromorphone (Dilaudid), a potent narcotic. Hypotension and bradycardia are expected adverse effects. Orthostatic hypotension occurs most often with ambulation or positioning in the semi-Fowler's position. Clients are not ordinarily allowed to be ambulatory for 20-30 minutes after IVP administration of narcotics. This one-time reading is not significant enough to require emergency intervention.

he clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2. A 7-year-old has had a high fever, cough, and sore throat for the past 2 days 3. A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches 4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain

4. A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. (Option 1) Skin peeling is expected in the subacute stage of Kawasaki disease; the new skin might be tender. This client it is not the priority. (Option 2) Fever, cough, and a sore throat in a 7-year-old must be evaluated. However, the client's condition is not immediately life-threatening; this client should be treated after the client with infectious mononucleosis. (Option 3) Corticosteroid inhalers can cause oral thrush. Clients must perform proper oral care (rinsing after use) and may use a nystatin oral suspension (swish throughout the mouth as long as possible before swallowing). This client is not the priority.

The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up? 1. Flat bluish discolored area on the buttocks 2. Localized soft tissue edema of the scalp 3. Small amount whitish substance in axilla 4. Tuft of hair at the base of the spine

4. Tuft of hair at the base of the spine The neural tube develops into the brain and spinal cord. Spina bifida is a defect in which the spinal cord contents can protrude through the vertebrae that did not close. The mildest form is spina bifida occulta, most often at the fifth lumbar or first sacral vertebrae. A tuft of hair or a hemangioma may be seen over the site. This is distinguished from lanugo, which is fine downy hair on the back that gradually falls out; a term infant will have minimal lanugo. There has been less incidence of spina bifida as there is awareness of the role of folic acid during pregnancy. The defect needs surgical repair. Depending on the location of the defect, the child can have bowel and bladder incontinence, hydrocephalus, and sensory loss. (Option 1) Congenital dermal melanocytosis (Mongolian spots) are flat, bluish discolored areas on the lower back and/or buttock. It is most common in African American, Asian, Hispanic, and Native American infants. Although the nurse would document the size and location, it is benign and usually resolves on its own by school age. (Option 2) Caput succedaneum is a localized soft tissue edema of the scalp from the prolonged pressure of the head against the mother's cervix during labor. It feels "spongy" and crosses the suture line (caput succedaneum = crosses suture); cephalhematoma does not cross the suture lines. Caput succedaneum resolves within the first week of life. (Option 3) Vernix caseosa is a protective substance secreted by the sebaceous glands that covers the fetus during pregnancy. Described as white and cheesy, it is most likely to be seen in the axillary or genital area. Full-term infants typically have very little present.

The nurse is triaging clients from the waiting room. The care of which client is a priority? 1. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic 2. 4-year-old who started crying and suddenly won't use the left arm after being swung by the arms 3. Child with cerebral palsy and a baclofen pump who has increased muscular spasms 4. Child with osteogenesis imperfecta who walks in reporting being hit on the front of the head with a baseball

1. 2-year-old who ingested a button battery approximately 30 minutes ago and is asymptomatic Foreign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur. (Option 2) This client likely has nursemaid's elbow due to the mechanism (swinging by the arms) by which the injury occurred. This condition is common in children and characterized by a subluxation of the radial head. It can seem like an urgent condition due to the suddenness of the child's inability to use the arm. A simple reduction of the arm by a health care provider should reposition the radial head. (Option 3) Clients with cerebral palsy commonly have an implanted baclofen pump to help control muscle spasms. Increased spasms indicate a possible problem with the pump, such as infection or displacement. Baclofen should not be stopped abruptly. This client needs prompt evaluation, but the condition is not immediately life-threatening. (Option 4) Osteogenesis imperfecta (imperfect bones) is a condition in which bones are brittle and fracture easily. Head trauma indicates a possible skull fracture and alerts the need to assess for intracranial hemorrhage. This child is walking, and so bleeding is unlikely. However, the child should be examined for fracture.

The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1. Drinks 6 cans of beers on the weekend 2. Gets up 4 times during the night to void 3. Smokes 1 pack of cigarettes daily 4. Uses sildenafil occasionally

4. Uses sildenafil occasionally Sildenafil (Viagra) is a phosphodiesterase inhibitor used to treat erectile dysfunction. The use of sildenafil is most important for the nurse to report to the HCP. This must be communicated immediately as concurrent use of nitrate drugs (commonly prescribed to treat unstable angina) is contraindicated as it can cause life-threatening hypotension. Before any nitrate drugs can be administered, further action is necessary to determine when sildenafil was taken last (ie, half-life is about 4 hours). (Option 1) Clients do not always report the amount of alcohol they consume accurately. The nurse should monitor all clients for alcohol withdrawal syndrome as it is quite common in hospitalized clients. (Option 2) Getting up 4 times during the night to void can be associated with medication, an enlarged prostate gland, or drinking fluids at bedtime. Further action may be needed to determine the cause of the nocturia, but this is not the most significant information to report to the HCP. (Option 3) Smoking 1 pack of cigarettes daily needs to be addressed as tobacco causes vasoconstriction and decreased oxygen supply to the body tissues. Further action is needed regarding smoking cessation education. However, the client's tobacco history is not the most important information to report to the HCP.

A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m2 (>95th percentile). Which is the most important assessment for the nurse to make before initiating a weight loss plan? 1. Child's pattern of daily physical activity 2. Family's eating habits 3. Family's financial resources for purchasing healthy foods 4. Family's readiness for change

Family's readiness for change Before initiating a treatment plan for weight loss, it is most important to make certain that the child and family are ready for change. Attempting to engage the family and child in weight loss strategies and dietary changes before they are ready could easily result in frustration, treatment failure, and reluctance to try new approaches in the future. The nurse needs to explore the reasons and desire for weight loss by assessing: Motivation and confidence Willingness to change behaviors and food choices Perceived importance of a weight loss treatment plan Confidence in ability to take on healthier eating habits (Option 1) Physical activity is an important component of a weight loss treatment plan, but it is not the priority nursing assessment. (Option 2) The family's eating habits will have a strong influence on the child's ability to make changes and need to be assessed. However, it is more important to assess the family's readiness for change. (Option 3) Assessing the family's financial resources is important in planning education about healthy food choices, but it is not the priority nursing action.

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply. 1. Desensitization to a specific stimulus or situation 2. Discussing the interpersonal difficulties that have led to the client's psychological problems 3. Helping the client develop insight into the psychological causes of the disorder 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking

1 4 5 6 Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity Physical control strategies - deep breathing and muscle relaxation exercises Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events (Option 2) This describes interpersonal psychotherapy. (Option 3) This describes psychodynamic or psychoanalytic therapy.

The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1. Fasting blood glucose 99 mg/dL (5.5 mmol/L) 2. Serum creatinine 2 mg/dL (177 µmol/L) 3. Serum potassium 3.9 mEq/L (3.9 mmol/L) 4. Serum sodium 140 mEq/L (140 mmol/L)

2. Serum creatinine 2 mg/dL (177 µmol/L) The normal serum creatinine for an adult is 0.6 -1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy. (Option 1) Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L). (Option 3) Normal serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L). (Option 4) Normal serum sodium is 135-145 mEq/L (135-145 mmol/L).

A client is admitted with an exacerbation of asthma following a respiratory viral illness. Which clinical manifestations characteristic of a severe asthma attack does the nurse expect to assess? Select all that apply. 1. Accessory muscle use 2. Chest tightness 3. Diminished breath sounds bilaterally 4. High-pitched wheezing on expiration 5. Prolonged inspiratory phase 6. Tachypnea

1 2 3 4 6 Asthma is a disease characterized by airway hyper-reactivity and chronic inflammation, resulting in bronchial muscle spasm, mucosal edema, and hypersecretion of mucus. The airways narrow, resulting in increased airway resistance, air trapping, and lung hyperinflation. Characteristic clinical manifestations include the following: Accessory muscle use related to increased work of breathing and diaphragm fatigue Chest tightness related to air trapping Diminished breath sounds related to hyperinflation High-pitched, sibilant wheezing on expiration caused by increased airway resistance; as the condition worsens, wheezing may be heard on both inspiration and expiration Tachypnea, which typically causes respiratory alkalosis initially Cough from inflamed airways and hypersecretion of mucus (Option 5) During an asthma attack, the expiratory phase is prolonged due to air trapping.

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? 1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells 2. Client with an ulcerative colitis flare-up has temperature 101 F (38.3 C) and abdominal cramping 3. Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 4. Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L)

1. Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells The nurse should check on the assigned clients in the following order: Client with the gastrointestinal bleed receiving packed red blood cells (PRBCs) - the nurse should: Check the infusion device; flow rate; and IV site, tubing, and filter Collect baseline physical assessment data against which to compare subsequent assessments Assess for complications associated with the administration of PRBCs, which include fluid overload and an acute transfusion reaction; these can occur at any time during the transfusion (Option 1) Client with chronic kidney disease scheduled for dialysis in 30 minutes - the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level (eg, normal 0.6-1.3 mg/dL [53-115 µmol/L]) is an expected finding. (Option 4) Client with ulcerative colitis (UC) with elevated temperature and abdominal pain - UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed. (Option 2) Client with history of atrial fibrillation, prescribed warfarin (Coumadin) - the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose. (Option 3)

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from sepsis 2. Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 3. Client refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 5. Provider was not notified of client's positive blood culture results

2 4 5 An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) Treatment (error in performance of procedure, treatment, dose; avoidable delay) Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship.

What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of Chinese checkers in the activity room 3. Playing video games 4. Watching a favorite movie

4. Watching a favorite movie A child in vaso-occlusive sickle cell crisis will be experiencing a high level of pain due to the occlusion of small blood vessels from increased red blood cell sickling. Supportive and symptomatic treatment includes round-the-clock pain management with opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and oxygen demand. Age-specific nonpharmacologic strategies should also be implemented to manage pain and help limit the amount of needed narcotic analgesia. For a school-aged child, such activities include distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm soaks, positioning, and gentle massage. (Option 1) Finger painting is messy and best done in the activity room; it is not appropriate for a child confined to bed. (Option 2) A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a game in the activity room does not maintain bed rest and would be too stimulating for the child. (Option 3) Playing video games may be too exciting and stimulating for the child; an environment low in stimuli will promote rest.

The neurological unit staff is composed of an experienced registered nurse (RN), a new graduate RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which are appropriate assignments for the charge nurse to give to the new graduate RN? Select all that apply. 1. Client with multiple sclerosis who has ataxia and is awaiting discharge placement 2. Discharge a client who had a stroke to the rehabilitation unit 3. New admission with Guillain-Barré syndrome with paralysis to the thigh 4. New admission with head injury and Glasgow Coma Scale (GCS) score of 8 5. Provide initial teaching for a client beginning prednisone therapy

1 2 5 The new graduate RN should be given RN-level responsibilities caring for stable clients who do not require specialized knowledge and performing skills taught in nursing school. Multiple sclerosis is a chronic relapsing and remitting nerve disorder caused by patchy demyelination of nerve fibers in the brain and spinal cord. Ataxia is an expected finding. The client is relatively stable and appropriate for management by a new graduate (Option 1). A client being discharged after an acute stroke is presumably stable. This task (eg, calling report) is an RN-level responsibility (Option 2). Initial teaching must be done by the RN, not an LPN. Providing client teaching for common medications is within the skill and knowledge set of a new graduate RN (Option 5). (Choice 3) Guillain-Barré syndrome results in bilateral, ascending paralysis. The ascent can be rapid and it is unknown at what level of the client's body the ascension will stop. This client is unstable. A key concern is the paralysis ascending to the diaphragm and causing respiratory failure. (Choice 4) The GCS score provides objective monitoring of acute head injury. This is an unstable client near the stage of a coma, which is a GCS score of <8. Urgent intubation is anticipated due to the risk of rapid loss of airway. The acuity and uncertainty of the nursing interventions in this situation require an experienced RN.

The nurse administers IV vancomycin to a client with a methicillin-resistant Staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply. 1. Assess client for lethargy and decreased deep tendon reflexes 2. Assess skin for flushing and red rash on face and torso 3. Infuse medication over at least 60 minutes 4. Monitor blood pressure during infusion 5. Observe IV site every 30 minutes for pain, redness, and swelling

2 3 4 5 When administering IV vancomycin, the nurse should assess for and work to prevent possible complications by performing the following: Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 10-20 mg/L (6.9-13.8 µmol/L) for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications (Option 3). Monitor blood pressure during the infusion. Hypotension is a possible adverse effect (Option 4) Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities (Option 2). Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy (Option 5). (Option 1) Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes.

Which discharge teaching instructions should the nurse provide to the parents of a 2-year-old with group A streptococcal pharyngitis? Select all that apply. 1. Complete all the antibiotics even if your child is feeling better 2. Cool liquids and soft diet are recommended 3. Keep your child home from daycare for at least a week 4. Replace your child's toothbrush 24 hours after starting antibiotics 5. Throat lozenges may soothe your child's sore throat

1 2 4 Pharyngitis caused by group A β-hemolytic Streptococcus is a contagious bacterial throat infection that can lead to renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated. Children may refuse to eat due to pain. A soft diet and cool liquids (ice chips) should be offered rather than solid foods (Option 2). It is important to complete the full course of antibiotics to prevent reinfection and complications (Option 1). Toothbrushes should be replaced 24 hours after starting antibiotics; the bristles can harbor the bacteria and reinfection may occur (Option 4). Young children may have minor cold symptoms and still be infected. The health care provider should test siblings age <3. (Option 3) Children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of antibiotics and are afebrile. (Option 5) Throat lozenges can be given to older children but are a choking hazard in younger children. Acetaminophen or ibuprofen (liquid preparations) should be given for pain.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gases (ABGs) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzymes (CK-MB) 4. Chest x-ray

2. B-type natriuretic peptide (BNP) BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. (Option 1) ABGs will be helpful in determining the client's oxygenation status and acid-base balance but will not determine whether the cause of the dyspnea is cardiac or respiratory. (Option 3) CK-MB is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure. (Option 4) A chest x-ray can show heart enlargement in the case of heart failure and may show infiltrations in the lungs. Pneumonia can also exacerbate COPD and can be confused with heart failure infiltrates. Chest x-ray is not as specific to heart failure as the BNP lab test.

The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. 1. Apply suction for no longer than 5-10 seconds 2. Insert catheter with low, intermittent suction applied 3. Set suction higher than 130 mm Hg for thick, copious secretions 4. Wait at least 1 minute between suction passes 5. Withdraw catheter immediately if client begins coughing

1 4 The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. (Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. (Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. (Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.

A nursing home client with major depressive disorder reports difficulty going to sleep until late at night. The client gets up, paces the hallway, wrings the hands, and appears teary. What interventions should be included in the client's nursing care plan? Select all that apply. 1. Allow the client to receive at least 20 minutes of natural sunlight each day 2. Encourage the client to take naps during the day to make up for lost sleep 3. Have the client engage in strenuous physical exercise just before bedtime 4. Spend time with the client in a quiet environment just before bedtime 5. Suggest that the client take a warm bath before going to bed

1 4 5 Sleep disturbances are part of the diagnostic criteria for major depressive disorder. Clients may experience insomnia (early in the night, in the middle of the night, or in the early morning hours) or hypersomnia. Long-term treatment with medication alone is not necessarily the best approach to treat insomnia. Nonpharmacological strategies for improving sleep hygiene include: Avoiding naps throughout the day Engaging in physical activity or exercise, preferably at least 5 hours before bedtime Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns Avoiding caffeinated beverages after noon Avoiding alcohol and/or smoking at bedtime Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet Avoiding heavy meals or large amounts of fluids at bedtime Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness (Option 2) Napping during the day interferes with normal sleep patterns. (Option 3) Exercising right before going to bed increases brain metabolic activity and wakefulness.

The nurse is assessing a client diagnosed with tuberculosis who started taking rifapentine a week ago. Which statement by the client warrants further assessment and intervention by the nurse? 1. "I do not want to get pregnant, so I restarted my oral contraceptive last month." 2. "I have been taking my medications with breakfast every morning." 3. "I should alert my health care provider if I notice yellowing of my skin." 4. "Since I started this medicine, my saliva has become a red-orange color."

1. "I do not want to get pregnant, so I restarted my oral contraceptive last month." Rifapentine (Priftin), a derivative of rifampin, is an antitubercular agent used with other drugs (eg, isoniazid) as a combination therapy in active and latent tuberculosis infections. Both rifampin and rifapentine reduce the efficacy of oral contraceptives by increasing their metabolism; therefore, this client will need an alternate birth control plan (non-hormonal) to prevent pregnancy during treatment (Option 1). (Option 2) Rifapentine should be taken with meals for best absorption and to prevent stomach upset. (Option 3) Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. (Option 4) Rifapentine may cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained.

An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client 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. 1. "I'll be sure to apply sunscreen if I go outside." 2. "I'll drink at least 8 glasses of water a day." 3. "I'll drink decaffeinated coffee so I can sleep at night." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food."

2 4 5 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 laxatives are effective measures to prevent constipation (Option 2). Changing position slowly is effective in preventing the orthostatic hypotension associated with codeine, especially in the elderly (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) These statements are inaccurate as photosensitivity, insomnia, palpitations, and anxiety are not adverse effects associated with codeine.

While delegating to the unlicensed assistive personnel (UAP), the registered nurse (RN) should utilize the 5 rights of delegation. The "right direction and communication" related to the task is one of those rights. Which statement best meets that standard? 1. "I need for you to take vital signs on all clients in rooms 1-10 this morning." 2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." 3. "Mrs. Jones fell out of bed during the night. Be sure you keep a close eye on her this shift." 4. "Would you please make sure Mr. Garcia in bed 8 ambulates several times?"

2. "Mr. Wu's blood pressure has been low. Please take his vital signs first and let me know if his systolic blood pressure is <100." In the Joint Statement on Delegation (2007), the American Nurses Association and the National Council of State Boards of Nursing outline the 5 Rights of Delegation as seen in the table above. The RN needs to direct the UAP's actions and communicate clearly about the assigned tasks including any specific information necessary for completion (eg, methods for collection, time frame, when to report back to the RN). Option 2 gives the UAP directions with prioritization and specific instructions for reporting back findings. (Option 1) The time frame in this option should be more specific. In addition, there is no communication about what the RN expects as follow-up. (Option 3) The instruction to "keep a close eye" on the client leaves the UAP too much room for interpretation. The expectation from the RN is not clear and the UAP needs more direction. (Option 4) The instructions are too broad and don't give a specific time frame. This delegation also needs to communicate the method needed to accomplish the task.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1. "Elevate your scrotum and apply an ice bag to reduce swelling." 2. "Practice coughing to clear secretions and prevent pneumonia." 3. "Stand up to use the urinal if you have difficulty voiding." 4. "Turn in bed and perform deep breathing every 2 hours."

2. "Practice coughing to clear secretions and prevent pneumonia." An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure (eg, heavy lifting). Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, nausea, and vomiting. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure (eg, coughing, heavy lifting) for 6-8 weeks (Option 2). If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing. (Option 1) Scrotal support garments and ice packs help decrease postoperative pain and scrotal swelling. The scrotum should be elevated with a pillow while the client is in bed. (Option 3) The nurse monitors urine output to assess for difficulty voiding after inguinal hernia repair. Male clients are encouraged to stand when voiding to improve bladder emptying. (Option 4) To prevent postoperative complications (eg, pneumonia, constipation) following inguinal hernia repair, the client should reposition frequently, ambulate as soon as possible, and practice deep breathing every 2 hours.

The nurse evaluates 4 clients in the primary care clinic. Which client should the nurse be most concerned about developing hypertension? 1. 30-year-old Hispanic female with controlled diabetes mellitus type 2 2. 38-year-old African American male who is starting his own company 3. 40-year-old female of white ethnicity who consumes a lot of salty snacks 4. 45-year-old Japanese male who smokes 20 cigarettes a day

2. 38-year-old African American male who is starting his own company Hypertension is referred to as the "silent killer" as most clients are asymptomatic. Chronic high blood pressure can result in coronary artery disease, stroke, heart failure, and kidney disease, so appropriate screening (at least annually), based on client risk factors, is key to prevent complications. The highest incidence of hypertension is seen in African American males, often earlier in life. The 38-year-old African American client is at the highest risk for developing high blood pressure as he has 2 risk factors (ie, African American ethnicity, stressful job) (Option 2). Appropriate teaching should be provided to help clients manage their high blood pressure and control their modifiable risk factors (eg, weight loss, Dietary Approaches to Stop Hypertension [DASH] diet, sodium reduction, alcohol limitation, increased physical activity, smoking cessation). (Option 1) This client has 1 risk factor - diabetes mellitus type 2. (Option 3) This client has 1 risk factor - excessive sodium intake. (Option 4) This client has 1 risk factor - cigarette smoking.

The pediatric nurse receives report on 4 clients. Which client should the nurse see first? 1. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside 2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside 3. A 7-year-old just returned from a noncontrast abdominal CT scan; no parents are at the bedside 4. An 11-year-old scheduled for ear surgery today; no parents are at the bedside

2. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside A bronchoscopy is an invasive procedure that allows visualization of the internal air passages via a flexible tube (bronchoscope) passed through either the nose or mouth to the internal airways. Following the procedure, the client will need to be monitored for complications such as bleeding, bronchial perforation, pneumothorax, and bronchial spasm. Potential for airway compromise requires that this client be seen first. (Option 1) A child with a potential hip dislocation will need to be evaluated, but this is not a priority. (Option 3) A CT scan can be done with or without the use of contrast (dye). Use of contrast would require monitoring for an allergic reaction to the dye. This client is young and has no parents present; the nurse will need to ascertain that basic needs are being met. (Option 4) This client is awaiting surgery. The nurse will need to assess that consent is signed and check for preoperative prescriptions. Although important, it is not a priority over the 6-year-old client's airway.

A client is admitted to the intensive care unit with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? 1. pH 7.26, PaCO2 56 mm Hg (7.5 kPa), HCO3 23 mEq/L (23 mmol/L) 2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) 3. pH 7.40, PaCO2 40 mm Hg (5.3 kPa), HCO3 24 mEq/L (24 mmol/L) 4. pH 7.58, PaCO2 48 mm Hg (6.4 kPa), HCO3 44 mEq/L (44 mmol/L)

2. pH 7.30, PaCO2 30 mm Hg (4.0 kPa), HCO3 15 mEq/L (15 mmol/L) The arterial blood gas (ABG) result most consistent with the diagnosis of diabetic ketoacidosis (DKA) is metabolic acidosis or partially compensated metabolic acidosis (pH 7.30, PaCO2 30 mm Hg [4.0 kPa], HCO3 15 mEq/L [15 mmol/L]). DKA is a life-threatening complication of type 1 diabetes characterized by hyperglycemia (>250 mg/dL [13.9 mmol/L]) resulting in ketosis, a metabolic acidosis. Glucose cannot be taken out of the bloodstream and used for energy without insulin, which individuals with type 1 diabetes cannot produce. Similar to a state of starvation, the body begins to break down fat stores into ketones, causing a metabolic acidosis (low pH and low HCO3). As a compensatory mechanism, this client has deep and rapid respirations with fruity/acetone smell (Kussmaul respirations) in an attempt to reduce carbon dioxide levels by inducing a respiratory alkalosis to partially compensate for the ketoacidosis, which has nearly normalized the pH. (Option 1) This is an example of respiratory acidosis (low pH and increased CO2 levels). It is commonly seen in conditions that cause CO2 retention (eg, chronic obstructive pulmonary disease, obesity hypoventilation syndrome, respiratory depression due to narcotics). (Option 3) This is an example of normal ABG results. (Option 4) This is an example of metabolic alkalosis (high pH and elevated HCO3), which typically presents with prolonged vomiting and aggressive diuresis.

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? 1. "I can keep a few pills in a plastic bag in my pocket in case I need them while I'm out." 2. "I can still take this with my vardenafil prescription." 3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." 4. "I should stop taking the pills if I experience a headache."

3. "I can take up to 3 pills in a 15-minute period if I am experiencing chest pain." Current evidence shows that up to 50% of clients lack knowledge about NTG administration procedures, storage, and side effects. Proper teaching can prevent many hospital visits for chest pain due to stable angina. Instructions for proper NTG administration include: Tablets are heat and light sensitive: They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months (Option 1). Take up to 3 pills in a 15-minute period: Take 1 pill every 5 minutes (up to 3 doses). Emergency medical services (EMS) should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Previously, clients were taught to call after the third dose was taken, but newer studies suggest this causes a significant delay in treatment (Option 3). Avoid fatal drug interactions: Concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension (Option 2). Headache may occur: Headache and flushing are common side effects of NTG due to systemic vasodilation and do not warrant medication discontinuation (Option 4).

A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response? 1. "Basic structures of major organs are not yet formed." 2. "External genitalia are not usually visualized until 21-24 weeks." 3. "If the baby is in the right position, the genitalia may be visualized." 4. "Sex cannot be determined until fetal movement is felt."

3. "If the baby is in the right position, the genitalia may be visualized." By the end of 12 weeks gestation, fetal sex can often be determined by the appearance of the external genitalia on ultrasound, depending on the quality of the image. (Option 1) By the end of 8 weeks gestation, all major organ systems are in place, and many are functioning in a simple way. By 7 weeks gestation, fetal heart tones can be detected. (Options 2 and 4) Clients typically begin feeling fetal movements in the second trimester at around 16-20 weeks gestation. Parous (have been pregnant before) clients can notice this earlier than the nulliparous (first pregnancy). Fetal sex can be determined as early as the end of 12 weeks gestation.

The nurse is discussing feeding and eating practices with the mother of a 1-year-old. Which statement made by the mother indicates a need for further instruction? 1. "I give my child chopped fruit rather than juice." 2. "I make sure my child drinks plenty of water between meals." 3. "My child is fussy at bedtime so I put him to sleep with a bottle of milk." 4. "When I give my child a new food, I wait a week before trying a second new food."

3. "My child is fussy at bedtime so I put him to sleep with a bottle of milk." Putting a child to bed with a bottle of milk or other beverage containing sugar leads to extensive and rapid dental caries in the developing teeth, a condition known as baby bottle tooth decay. The carbohydrate-rich fluid pools around the teeth and nourishes decay, producing bacteria (Streptococcus mutans). Sucking on a bottle for extended periods can also push the jawline out of shape. Bottles containing milk or sugary beverages should not be used as bedtime pacifiers. (Option 1) Whole fruit chopped in small pieces is a better choice than juice. Fruit juice is higher in sugar, has no fiber, promotes tooth decay, and can affect the child's appetite for other non-sugary foods. (Option 2) Providing water to a child between meals has several benefits: It accustoms the child to the taste of water, and the child will be more likely drink water than a sugary beverage when thirsty It helps reduce the risk of constipation and urinary tract infections It helps the child maintain a healthy weight (Option 4) Spacing the introduction of new foods by several days to a week allows for detection of a food intolerance or allergic reaction.

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse? 1. "It may take time to overcome those thoughts and feelings." 2. "Those kinds of thoughts are self-destructive. You should stop thinking about it." 3. "You could not have anticipated the rape. You did not deserve or ask for it." 4. "You have to stop blaming yourself so you can move on with your life."

3. "You could not have anticipated the rape. You did not deserve or ask for it." One of the common features of PTSD is a persistent distorted perception about the cause of the traumatic event that leads the affected individuals to blame themselves or others. Clients may be in a persistent, negative emotional state of guilt and/or shame and also believe that they are responsible for what happened. This is particularly true in cases of rape. A pervasive culture of "blaming the rape victim" also contributes to clients' perception that the rape was somehow their own fault. Providing a realistic perspective of the rape may help clients develop a more objective view of their perceived role in the traumatic event and may reduce feelings of self-blame and guilt. The nurse needs to reinforce repeatedly that rape is never the victim's fault (Option 3). (Option 1) This is a nontherapeutic response as it reinforces the client's feelings of self-blame and guilt. The best therapeutic response should reinforce that the client is not to blame for the rape. (Option 2) This is a nontherapeutic response; it does not assist in changing the client's perception of the traumatic event and implies that the client should not cope with the experience at all. (Option 4) This is a nontherapeutic response. Clients cannot simply make negative feelings disappear; these need to be resolved through therapy.

The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event? 1. Administered flumazenil to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L) 3. Administered warfarin to a client with International Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

3. Administered warfarin to a client with International Normalized Ratio of 6 A sentinel event is any unanticipated event in a health care setting that results in death or serious physical or psychological injury. Warfarin is an anticoagulant often used in clients with the following: Atrial fibrillation (to prevent clot formation and reduce the risk for stroke) Deep venous thrombosis and pulmonary embolism (to prevent additional clots) Mechanical heart valves (to prevent clot formation on valves) The International Normalized Ratio (INR) is a blood test used to monitor the effectiveness of warfarin therapy. The typical target INR is 2-3. In some instances (eg, mechanical heart valves), the therapeutic INR target is as high as 3.5. The higher the INR, the higher the bleeding risk. The nurse should not administer warfarin if the INR is over 4. (Option 1) Flumazenil is the appropriate antidote for a benzodiazepine overdose. (Option 2) Insulin quickly lowers serum potassium by pushing it intracellularly. Dextrose is given to prevent hypoglycemia. This is an appropriate action. (Option 4) Nitroprusside is a potent vasodilator often used for hypertensive urgencies.

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time? 1. Administer albuterol nebulizer 2. Assist the client in identifying the trigger and ways to avoid it 3. Coach the client through controlled breathing exercises 4. Continue to monitor oxygen saturation

3. Coach the client through controlled breathing exercises Anxiety is an emotional reaction to a perceived threat. For the client with COPD, the fear of having difficulty breathing can actually trigger difficulty breathing, which worsens as the client's anxiety increases. This client is stable, with no obvious cause of shortness of breath. The nurse should intervene by calmly coaching the client through breathing exercises, which will promote relaxation and help alleviate the anxiety that is causing the client to feel short of breath. (Option 1) The client's lung sounds are clear bilaterally and so albuterol, a bronchodilator used for wheezing, will not be helpful. Its action as an adrenergic agonist may cause tachycardia and tremulousness and actually worsen the client's anxiety. (Option 2) Trigger avoidance and problem solving are appropriate strategies for long-term control of anxiety and shortness of breath. However, these are not appropriate at this time as the client has acute symptoms that need to be controlled. (Option 4) This client has normal oxygen saturation. Constant monitoring is not likely to alleviate the symptoms unless the client is reassured by this knowledge. However, the client's anxiety may actually be worsened by worrying about the saturation results and the alarms that are likely to be triggered by monitoring.

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation? 1. Client appears to be sleeping. Eyes closed. 2. Client reports, "I'm in pain." Medication provided. 3. Inspiratory wheezes heard in bilateral lower lung fields 4. Voided x 1

3. Inspiratory wheezes heard in bilateral lower lung fields 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.

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for further instruction? 1. Faces forward when going up and down the stairs 2. Holds the cane with the right hand 3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs 4. Places full weight on left leg when going down the stairs

3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs To provide full support when climbing stairs, clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction of the stairs (Option 2). They should also keep 2 points of support on the floor at all times (eg, both feet, cane and foot) and face forward when going up or down the stairs, especially if there is no handrail (Option 1). The nurse should instruct the client on the following: When ascending stairs: Step up with the stronger leg first (in this client, the right leg) Move the cane next while bearing weight on the stronger leg Finally, move the weaker leg (in this client, the left leg) When descending stairs: Lead with the cane Bring the weaker leg down next Finally, step down with the stronger leg The nurse may use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg. (Option 4) Clients are usually hospitalized for 3-4 days following a total knee replacement and can bear full weight by the time of discharge. Early ambulation and weight-bearing helps to hasten recovery and prevent complications (eg, thromboembolism).

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? 1. Insert a Foley catheter into the existing tract and inflate the balloon 2. Insert a small-bore nasointestinal tube to administer feedings and medications 3. Notify the health care provider who inserted the PEG tube 4. Reinsert the PEG tube into the existing tract immediately

3. Notify the health care provider who inserted the PEG tube A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention.

he nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first? 1. Client with a history of thyroidectomy who needs a refill for levothyroxine 2. Client with Addison disease who is taking corticosteroids and reports new mood swings 3. Client with diabetes who reports blood sugars of 250-300 mg/dL (13.9-16.7 mmol/L) in the past week 4. Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C)

4. Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C) Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). (Option 1) The post-thyroidectomy client who needs a refill of the thyroid replacement medication should be contacted third. Without thyroid replacement therapy, this client would experience signs and symptoms of hypothyroidism (eg, extreme fatigue, bradycardia). (Option 2) Clients on corticosteroids may report moods swings and irritability; these are common side effects. (Option 3) The client with diabetes who is asymptomatic but has elevated blood sugars should be contacted second as prolonged hyperglycemia may lead to dehydration and acidosis.

An elderly client with hypothyroidism is brought to the emergency department for depressed mental status. The client lives alone but has not taken medications for several months or seen a health care provider. Which action should the nurse take first? Click on the exhibit button for additional information. 1. Administer IV levothyroxine 2. Check serum thyroid-stimulating hormone, T3 and T4 3. Place a warming blanket on the client 4. Prepare for endotracheal intubation

4. Prepare for endotracheal intubation Myxedema coma is a complication associated with progression of symptoms of hypothyroidism from lethargy and mental sluggishness to a coma state. This client has hypothermia, bradycardia, hypotension, and depressed mental status. Hypothyroidism can also cause hypoventilation due to central depression of respiratory drive, respiratory muscle fatigue, and mechanical obstruction by a large tongue. This client exhibits signs of acute respiratory distress (increased respirations, very low oxygen saturation). Therefore, life-saving measures to facilitate respiratory support, such as mechanical ventilation, must be implemented first. Other treatments include thyroid hormone replacement with levothyroxine (Synthroid) IV push (Option 1), heating warming the client with a warming blanket (Option 3), and frequent diagnostics of the thyroid, including a serum thyroid panel (Option 2).

A client comes to the emergency department following a bee sting. The client has a diffuse rash, hypotension, and throat tightness. One injection of IM epinephrine does not improve the client's condition. What action should the nurse take next? 1. Administer IV fluid bolus 2. Administer methylprednisolone 3. Prepare for emergency cricothyrotomy 4. Repeat IM epinephrine injection

4. Repeat IM epinephrine injection Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). Circulatory failure and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine), can lead to cardiac/respiratory arrest. The management of anaphylactic shock includes: Ensure patent airway, administer oxygen Remove insect stinger if present IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders or vasopressors Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. Blood urea nitrogen 15 mg/dL (5.4 mmol/L) 2. Serum albumin 3.7 g/dL (37 g/L) 3. Serum potassium 4.5 mEq/L (4.5 mmol/L) 4. Serum sodium 153 mEq/L (153 mmol/L)

4. Serum sodium 153 mEq/L (153 mmol/L) Nutritional deficiencies (eg, zinc, protein, vitamin C) and dehydration can impair wound healing. Dehydration (loss of free water) can increase serum sodium levels. The normal value for serum sodium is 135-145 mEq/L (135-145 mmol/L). The value listed, 153 mEq/L (153 mmol/L), is high. Increased serum sodium level (hypernatremia) has an osmotic action that causes water to be pulled from the interstitial spaces into the vascular system. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair. (Option 1) Normal blood urea nitrogen (BUN) values are 6-20 mg/dL (2.1-7.1 mmol/L). Elevated BUN may indicate dehydration and could impair wound healing. (Option 2) Malnutrition can impair wound healing. Serum albumin and prealbumin levels are obtained to assess nutritional status. The normal value for albumin is 3.5-5.0 g/dL (35-50 g/L). (Option 3) The normal value for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L).

A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to recommend to the parents in order to prevent recurrence? 1. Exclusive breastfeeding 2. Not sending the child to day care 3. Preventing water from entering the ear 4. Smoking cessation by the parents

4. Smoking cessation by the parents 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. Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6 months. (Option 1) Breast-fed infants have a decreased risk for OM, possibly due to the semivertical position used when breastfeeding, which reduces reflux to the eustachian tubes. Exclusive breastfeeding is recommended for the first 6 months. However, this client is age 1 and should be receiving a varied, healthy intake of solid food at this time. (Option 2) Day care attendance is a significant risk factor to the development of OM. However, the recommendation to avoid day care is usually not practical as many parents must work outside of the home. (Option 3) Excess water in the ears from bathing or swimming can alter the protective environment of the external ear and contribute to otitis externa, known as swimmer's ear; however, this does not contribute to OM.

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? 1. Consume a low-fat, low-salt diet 2. Do not smoke cigarettes 3. Exercise and lose weight 4. Take prescribed antihypertensive medications

4. Take prescribed antihypertensive medications Risk factors for stroke include diabetes, high cholesterol, hypertension, smoking, obesity (particularly in the abdomen), older age, and genetic susceptibility. The single most important modifiable risk factor is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of hypertension. Because clients often experience side effects from the antihypertensive medications and don't feel bad with untreated hypertension, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point. (Option 1) A low-fat, low-salt diet is beneficial to the client, but managing hypertension with medications is most important. (Option 2) Smoking is also a major risk factor for stroke, and smoking cessation should be emphasized. However, hypertension is the single most important risk factor. (Option 3) Normal BMI is 18.5-24.9 kg/m2. Obesity increases the risk of ischemic stroke, but hypertension control is most important. In addition, it is not indicated if the client is slightly overweight or morbidly obese to make this the highest risk factor.

A client at 39 weeks gestation is brought to the emergency department after a motor vehicle crash. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. What action should the nurse take first? 1. Administer normal saline fluid bolus 2. Assess cervix for presenting part 3. Obtain fetal heart rate 4. Turn client laterally

4. Turn client laterally Supine hypotensive syndrome results from compression of the maternal inferior vena cava by the large gravid uterus in mid to late pregnancy when the client is in the supine position. The venous return is reduced, causing maternal hypotension from reduced cardiac output. The client can also report feeling dizzy and faint. The first step is to rectify the cause by turning the client laterally while still strapped on the backboard. (Option 1) The etiology is not hypovolemia but perfusion. A fluid bolus of isotonic fluids (normal saline or lactated Ringer's) can be administered if the position change does not relieve the symptoms. Mean arterial pressure (MAP) should be >60 mm Hg for effective organ perfusion. Normal MAP is 70-105 mm Hg. (Option 2) The client does not have classic signs of a precipitous or impending delivery. Classic signs or symptoms of the second stage of labor/delivery of the baby include feeling the need to push, an intense urge to bear down, or a sensation of cervical pressure. A pelvic examination can be performed, but it is not the first priority. (Option 3) The etiology is related not to the fetus, but to the maternal circulation. Because the client does not have adequate cardiac output, circulation to the fetus could be compromised. The first priority is to rectify the client's perfusion issue and check the fetus. The best indicators of fetal health are heart rate and movement.

An obese client is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? 1. Coffee, tea, flavored club soda 2. Diet soft drinks, tea, water 3. Diet tea, low-fat milk, vegetable juice 4. Sports drinks, unsweetened juice, coffee

1. Coffee, tea, flavored club soda Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and the obesity epidemic. Individuals who are attempting to lose weight should consume beverages with few or no calories, including: Water Club soda (flavored or unflavored) Club soda or sparkling water with a splash of fruit juice Unsweetened tea and/or coffee Non-fat or low-fat milk (in limited amounts) A 12-oz (355-mL) serving in a typical can of regular cola-type beverage contains around 140 calories (kcal). For this client, the consumption of 5 cola beverages daily is contributing 255,500 kcal per year and accounts for 73 lb (33.2 kg) (3500 kcal/lb). This client could lose 73 lb (33.2 kg) in a year simply by substituting zero-calorie beverages for cola. (Option 2) Diet beverages are not recommended as studies now associate them with weight gain (particularly belly fat), increased cravings for sweet foods, and increased risk for developing metabolic syndrome. (Option 3) Diet drinks are not recommended; low-fat milk can be consumed in limited amounts; vegetable juice is very high in sodium and is not the healthiest choice. (Option 4) Fruit juices and many sports drinks contain relatively high amounts of sugar and calories (kcal); consumption of these beverages should be limited.

After giving birth to a full-term neonate, the client informs the nurse that she has been taking hydrocodone on a regular basis for several years. What should the nurse plan as part of the neonate's care? 1. Feed newborn while swaddled 2. Keep newborn close to the nurse's station 3. Position newborn supine after feeding 4. Stimulate newborn with light regularly

1. Feed newborn while swaddled A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high risk for neonatal abstinence syndrome, in which the newborn experiences opioid withdrawal typically within 24-48 hours after birth. Clinical manifestations of withdrawal in infants include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding. Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to minimize stimulation and promote nutritive sucking (Option 1). Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern. Excessive movement places the newborn at high risk for skin excoriation; the infant should be tightly swaddled with arms flexed to minimize irritation and prevent damage to the skin. Hand mittens and barrier skin protection to the knees, elbows, and heels may also be used. (Options 2 and 4) Stimulation should be avoided due to the newborn's hypersensitive state; the newborn should be placed in a quiet, dim-lit section of the nursery. The nurse should also organize tasks ("cluster care") to minimize stimulation. (Option 3) The newborn should be placed on the right side after feeding to promote gastric emptying and reduce the risk of vomiting.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take? 1. Document the test results on the preoperative checklist 2. Notify the health care provider about the test results 3. Place the printed ECG in the front of the chart 4. Report the results to the surgical nurse to tell the surgeon

2. Notify the health care provider about the test results This is a high-risk client (eg, older age, hypertension, diabetes), and the acute, new, significant finding needs further evaluation and possible intervention before undergoing the stress of surgery. In addition, clients with a long history of diabetes often have associated neuropathy and may not experience the chest pain typical of myocardial infarction (MI), known as silent MI. As a result, the nurse must ensure that the health care provider (HCP) is made aware of this client's new findings in a timely manner. (Options 1, 3, and 4) All of these actions should also be performed. However, the most important action is for the nurse to personally notify the client's HCP in a timely manner so that appropriate treatment can be provided.

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1. Ecchymosis of the scrotum 2. Increased abdominal girth 3. Increased urinary output 4. Report of groin pain 5. Report of increased thirst and appetite loss

1 2 4 Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output (Options 1, 2, and 4). (Option 3) Urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. (Option 5) Increased thirst and appetite loss are not signs of graft leakage.

Which principles of nursing care or resources are used to define the standards of professional nursing practice and to determine nursing negligence? Select all that apply. 1. Care given in good faith to the best of one's ability 2. Clinical practice statements of professional organizations 3. Nursing medical-surgical textbooks 4. The nurse's usual custom and practice 5. The state's Nurse Practice Act

2 3 5 Standards of nursing practice and care are criteria used to determine if appropriate, professional care has been delivered. The definition of this minimum acceptable level of care is reflected as what reasonable, prudent, and careful nurses would do in specific circumstances. The state boards of nursing help to regulate these standards. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, the Nurse Practice Act, and statutes from regulatory organizations (eg, Joint Commission, Board of Health). (Option 1) The standard of care includes objective criteria and does not consider intention. It is assumed that nurses always intend to give good care to the best of their ability. Deliberately giving inferior care would be unethical and possibly illegal, depending on the action. (Option 4) Standard of care is determined by objective, third-party authoritative/reasonably reliable sources. Nurses who are suspected of negligence, yet cannot provide documentation of the event in question, can testify about their interpretation of usual custom and practice as it relates to the incident. However, an individual's typical actions are not authoritative in determining the universal standard of nursing care and cannot replace the use of objective, authoritative, and predetermined standards of care.

The emergency department nurse is assigned to triage. Which of the following clients does the nurse triage first? 1. A client who smokes with 2 months of intermittent leg cramping pain that gets worse with walking and eases with rest 2. A client with leg swelling and calf pain who flew from Australia to New York 2 days ago 3. A diabetic client with a temperature of 100.7 F (38.2 C) 4. A healthy, afebrile client with edema and redness in the leg following a dog bite 1 hour ago

2. A client with leg swelling and calf pain who flew from Australia to New York 2 days ago Emergency department triage requires the nurse to quickly assess clients' needs and identify which are most urgent to prioritize care. Airway, breathing, and circulation problems take precedence and have the highest priority and level of risk. Mental status changes, unresolved medical issues, acute pain, and abnormal laboratory values have the second highest priority and degree of risk; these are followed by longer-term issues, which have the lowest level of risk. A common risk factor for deep venous thrombosis (DVT) is traveling/sitting with prolonged periods (>4 hours) of inactivity. Common symptoms of a lower-extremity DVT include unilateral edema and calf pain. Diagnosis and treatment of DVT (circulation problem) is a high priority because a piece of the clot can break off, travel though the systemic and/or pulmonary circulation, and cause a life-threatening complication (eg, pulmonary embolus). (Option 1) The client who smokes probably has intermittent claudication, and further diagnostic testing and client teaching will be necessary. This longer-term condition does not present an immediate threat to survival at this time. (Option 3) The diabetic client has a preexisting medical condition, and physiologic stress related to elevated temperature and possible infection would most likely increase serum glucose level. Although infection in a diabetic client can present a risk to survival, it is not immediate at this time. (Option 4) The healthy afebrile client will need antibiotic therapy and counseling about rabies vaccination. This condition does not present an immediate threat to survival at this time.

A client comes to the clinic for a follow up visit following a Billroth II surgery (gastrojejunostomy). The client reports occasionally experiencing sweating, palpitations, and dizziness 30 minutes after eating. What action should the nurse take? 1. Check serum blood glucose 2. Encourage dry foods with a low carbohydrate content 3. Take vital signs lying and standing 4. Teach the client to sit up after eating

2. Encourage dry foods with a low carbohydrate content The Billroth II surgery (gastrojejunostomy) removes the distal two-thirds of the stomach. Dumping syndrome is a complication of the surgically reduced gastric capacity. Dumping syndrome is the rapid emptying of hypertonic gastric contents into the duodenum and small intestine. This process leads to fluid shift from the intravascular space to the small intestine, leading to hypotension and activation of the sympathetic nervous system. Symptoms include abdominal pain, diarrhea, nausea and vomiting, dizziness, generalized sweating, and palpitations (tachycardia). The symptoms usually diminish over time, and dietary changes are helpful in controlling the symptoms. Dietary recommendations to promote delayed gastric emptying: Small, frequent meals - reduces the amount of food in the stomach at any one time Foods high in protein and fat - these take longer to digest and will remain in the stomach longer than carbohydrates Drink fluids between meals (at least 30-45 min before or after meals) - fluids with meals would promote passage of stomach contents into the jejunum easily and worsen symptoms Avoid meals high in carbohydrates - may trigger dumping syndrome as the carbohydrates are broken down into simple sugars (Option 2) Diets high in fiber - delay the emptying of the stomach and prevent rapid absorption of simple sugars Eat slowly in a relaxed environment Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after meals would slow down gastric emptying and is preferred (Option 4). (Option 1) Sweating, palpitations, and dizziness can result from hypoglycemia, which are not likely to occur 30 minutes after a meal and are not the cause of this client's symptoms. (Option 3) Checking vital signs lying and standing assess for orthostatic hypotension, which occurs with dehydration. There is no indication that the client is presently dehydrated, and this assessment would not be helpful.

The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia? 1. Decreased right hip adduction 2. Presence of extra gluteal folds on right side 3. Right leg longer than the left leg 4. Right pelvic tilt with lordosis

2. Presence of extra gluteal folds on right side Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head. Because it is much easier to treat during infancy, DDH screening is a standard assessment for newborns and infants. Manifestations in infants age <2-3 months include: The presence of extra inguinal or thigh folds Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers. However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is not treated, these signs disappear after age 2-3 months due to the development of muscle contractures. (Option 1) Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months. (Option 3) In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also apparent after age 3 months. (Option 4) If DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs include a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis.

The nurse is working on a busy medical-surgical unit and is responding to the client call lights. Which statement would be the priority to assess first? 1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." 2. A client's child says, "My parent has been here for 2 days without anything to eat or drink." 3. A paraplegic client with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." 4. A postoperative client says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

1. A 65-year-old female client recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting quite a bit." Celecoxib (Celebrex), a COX-2 inhibitor, has a black box warning for increased risk of cardiovascular complications. Myocardial infarction symptoms, which can be vague in female clients, include nausea and upper back and shoulder pain. These symptoms would be the priority to assess first, and immediate testing (ie, ECG, cardiac enzymes) would be warranted. (Option 2) This client's nutritional status is concerning and needs to be addressed but would not be a priority over a client experiencing a possible acute myocardial infarction. (Option 3) This client needs cleaning as soon as possible to prevent fecal matter from entering into wounds. Cleaning the client can be delegated to a licensed practical nurse or unlicensed assistive personnel and would not be a priority over a client experiencing a possible acute myocardial infarction. The registered nurse can assess the wounds and dressings later. (Option 4) This client's nausea and pain medication need to be addressed; they would not be a priority over a client experiencing a possible acute myocardial infarction.

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client

2 3 5 When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option 1) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option 2) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated. (Option 4) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space.

A client with obesity is diagnosed with pulmonary embolism (PE). Which assessment data would the nurse expect to find? Select all that apply. 1. Bradycardia 2. Chest pain 3. Chills and fever 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2 4 5 A pulmonary embolus is a blood clot that usually originates from the deep veins of the legs (>90%), travels to the pulmonary circulation, and obstructs a pulmonary artery or one of its branches, resulting in decreased perfusion in relation to ventilation and impaired gas exchange (hypoxemia). Clients are at risk for formation of venous thromboembolism (VTE) when the conditions detailed in Virchow's Triad are present. Clients at risk for PE include those with prolonged immobilization (eg, during hospitalization if not ambulatory), obesity, recent surgery, varicose veins, smoking, heart failure, advanced age, or history of VTE. The assessment data most characteristic of PE include: Dyspnea (85%) Pleuritic chest pain (60%) Tachycardia Tachypnea Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar ventilation, shunting) Apprehension and anxiety A more atypical presentation can be associated with a larger sized PE, and may include manifestations of cardiopulmonary compromise and hemodynamic instability (eg, right ventricular dysfunction, pulmonary hypertension, systemic hypotension, syncope, loss of consciousness, distended neck veins). (Option 1) A classic manifestation of PE is tachycardia to compensate for hypoxemia (not bradycardia). (Option 3) Chills and fever can indicate the presence of an infection and are not characteristic of PE. However, a low-grade fever without chills can occur 1-2 weeks after PE due to inflammation. (Option 6) Tracheal deviation is a symptom of tension pneumothorax. The trachea deviates from midline toward the unaffected side, away from the collapsed lung.

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

2. "I can begin driving again after I have been on this medication for a few weeks." Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure disorders. As with other antiseizure medications, levetiracetam has a depressing effect on the central nervous system (CNS), which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks (Option 1). However, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications. New or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation (Option 3). Like other anticonvulsants, levetiracetam can trigger Stevens-Johnson syndrome, a rare but life-threatening blistering reaction of the skin. Rash, blistering, muscle/joint pain, or conjunctivitis should be reported and assessed immediately (Option 4). (Option 2) Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their health care provider and have met the requirements of their department of transportation. Typically, the client must be free from seizures for an allotted time period.

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)? 1. "I haven't had anything to eat or drink since 8 PM yesterday." 2. "I took my prasugrel this morning with just a tiny sip of water." 3. "I'm really nervous about this surgery." 4. "It always takes several attempts to start my IV."

2. "I took my prasugrel this morning with just a tiny sip of water." Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week. (Option 1) Nothing by mouth for at least 6-8 hours prior to surgery is typical. (Option 3) The nurse can assist the client in discussing reasons for the anxiety. Anxiety is common prior to surgery; unless the client refuses to go through with the surgery or requests to speak with the HCP, the nurse can usually deal with this issue. (Option 4) Difficult IV sticks can be handled by the nurse.

The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. "If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing, and having more trouble breathing, I will not make any changes in my medications." 2. "If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medications." 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." 4. "If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes before calling an ambulance."

3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care." An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4).

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? 1. Need for discharge to a skilled nursing facility 2. Nutritional consult with instructions on a high-calorie diet 3. Option of palliative care 4. Physical therapy prescription to promote activity

3. Option of palliative care This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments (Option 3). Palliative care may eventually include hospice care, after it is determined that the client has a life expectancy of less than 6 months. The nurse should advocate for the client and collaborate with members of the health care team to explore care options based on the client's wishes. (Option 1) This client has not clearly demonstrated a need for skilled nursing; additional assessment is needed to determine the most appropriate discharge setting. (Option 2) A high-calorie diet is appropriate for a client with weight loss, but many clients may have difficulty maintaining weight due to factors such as advanced disease and poor appetite. It is not the highest priority in this client, who is nearing the end of life and has expressed an interest in avoiding further testing and hospitalization. (Option 4) Physical therapy may be appropriate to help this client maintain current abilities. However, a client with disease this advanced is not likely to tolerate more activity or gain much additional functional capacity. Therefore, physical therapy is not the highest priority at this point.

The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding 2. Demonstrates to the mother how to use an electric breast pump 3. Provides supplemental formula feedings until improved breastfeeding occurs 4. Shows the mother how to hand express breast milk

3. Provides supplemental formula feedings until improved breastfeeding occurs Ineffective breastfeeding can be attributed to many factors, including prematurity; breast anomaly or previous breast surgery; poor infant latch or sucking reflux; or the use of formula feeding. The use of supplemental formula feedings and artificial nipples should be avoided, as research demonstrates it interferes with the mother's ability to exclusively breastfeed (Option 3). Supplemental formula feeds are only provided for medical indications (eg, newborn hypoglycemia, dehydration, excessive weight loss) and if alternate breastfeeding techniques are unsuccessful. A mother having difficulty with breastfeeding may be able to pump or hand express small amounts of colostrum that can be fed to the newborn by syringe, cup, or spoon. Hand expression may be preferable before the mature milk supply is established and is also useful when a breast pump is not available. If ineffective breastfeeding occurs, the nurse should: Assess the baby's sucking reflex and physical condition Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) (Option 1) Teach how to express milk by hand and use an electric pump to enhance milk production (Options 2 and 4) Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours

A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? 1. "I need to drink 1-2 liters of fluid daily." 2. "I need to have my blood levels checked periodically." 3. "I should not limit my sodium intake." 4. "I should use ibuprofen for pain relief."

4. "I should use ibuprofen for pain relief." Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L (0.6-1.2 mmol/L). Levels >1.5 mEq/L (1.5 mmol/L) are considered toxic. Lithium toxicity usually occurs with the following: Dehydration Decreased renal function (eg, elderly clients) Diet low in sodium Drug-drug interactions (nonsteroidal anti-inflammatory drugs [NSAIDs] and thiazide diuretics) Lithium is cleared renally. Even a mild change in kidney function (as seen in elderly clients) can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow (eg, NSAIDs) should be avoided. Acetaminophen would be a better choice for pain relief (Option 4). (Options 1 and 3) Sodium, water, and lithium are normally filtered by the kidneys. Restriction of dietary sodium/water or dehydration signals renal sodium and water reabsorption which will also increase lithium absorption, resulting in toxicity. Therefore, clients should never restrict their sodium or water intake while taking lithium; instead, they should maintain a consistent sodium intake. (Option 2) Blood should be drawn frequently to monitor for therapeutic lithium levels and toxicity.

he nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching? 1. "I will call 911 if my chest pain isn't relieved by NTG." 2. "If I have chest pain, I can take up to 3 pills 5 minutes apart." 3. "I'll call my doctor if I start having chest pain at night." 4. "I'll keep one bottle in the house and one in the car."

4. "I'll keep one bottle in the house and one in the car." NTG is a vasodilator used to treat stable angina. It is a sublingual tablet or spray that is placed under the client's tongue. It usually relieves pain in about 3 minutes and lasts 30-40 minutes. The recommended dose is 1 tablet or 1 spray taken sublingually for angina every 5 minutes for a maximum of 3 doses (Option 2). If symptoms are unchanged or worse 5 minutes after the first dose, emergency medical services (EMS) should be contacted (Option 1). Previously, clients were taught to call EMS after the third dose was taken, but newer studies suggest that this leads to a significant delay in treatment. The NTG should be easily accessible at all times. Tablets are packaged in a light-resistant bottle with a metal cap. They should be stored away from light and heat sources, including body heat, to protect from degradation. Clients should be instructed to keep the tablets in the original container. Once opened, the tablets lose potency and should be replaced every 6 months. The car is not a good place to store NTG due to heat (Option 4). (Option 3) Waking up at night with chest pain can signify that angina is occurring at rest and is no longer considered stable angina. This should be reported to the health care provider.

Dobutamine hydrochloride (Dobutrex) is a positive inotropic drug that increases cardiac muscle contractility. The dosage is weight-based and is prescribed in micrograms per kilogram per minute (mcg/kg/min) and administered with an IV pump. Because IV pumps are set by milliliters per hour (mL/hr), the nurse must be able to calculate the drug dose and the infusion rate in mL/hr.

Dobutamine hydrochloride (Dobutrex) is a positive inotropic drug that increases cardiac muscle contractility. The dosage is weight-based and is prescribed in micrograms per kilogram per minute (mcg/kg/min) and administered with an IV pump. Because IV pumps are set by milliliters per hour (mL/hr), the nurse must be able to calculate the drug dose and the infusion rate in mL/hr. Dobutrex can be diluted in dextrose or normal saline, and concentrations usually range from 500-2,000 micrograms per milliliter (mcg/mL) depending on client status. This medication may be administered in acute or long-term facilities or in the home. It is most often administered in the emergency department, intensive care unit, and step-down units. The nurse must always follow institution policy and procedure in relation to its dilution, dosage, administration, and titration.

Which is a management concern for a male teenage client with cystic fibrosis (CF)? Select all that apply. 1. Diabetes insipidus 2. Frequent respiratory infections 3. Infertility 4. Obesity 5. Vitamin A deficiency

2 3 5 CF is an autosomal recessive disorder. There is a mutation of a gene that impairs chloride transport and sodium absorption, resulting in thickened secretions. Other manifestations include: Recurrent sinus and pulmonary infections - the thickened mucus inhibits normal ciliary action and cough clearance. The resulting airway obstruction can lead to frequent infections and eventual bronchiectasis. Respiratory failure is the leading cause of mortality. Frequent sinus infections are also common. Pancreatic insufficiency - mucus plugs in the pancreas obstruct the release of pancreatic enzymes, leading to malabsorption of fat-soluble vitamins (A, D, E, K). Because of malabsorption and an increased metabolic rate associated with frequent infection, children with CF have difficulty maintaining adequate weight and growth (Option 4). Infertility - Cystic fibrosis causes congenital absence of vas deferens in male clients, resulting in low sperm levels and infertility. Female clients have thick cervical secretions that can obstruct sperm entry. (Option 1) Diabetes insipidus is a disorder of the posterior pituitary gland and is an inability of the kidneys to concentrate urine. It is not related to the pathophysiology of CF. Pancreatic damage in CF will cause some clients to develop diabetes mellitus but not insipidus.

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythropoietin and iron sucrose. An assessment of laboratory work shows hemoglobin of 9.7 g/dL (97 g/L) and hematocrit of 29% (0.29). What is the best nursing action? 1. Administer the erythropoietin in the client's abdominal area 2. Check the client's blood pressure prior to administering the erythropoietin 3. Hold the client's next scheduled iron sucrose dose 4. Hold the erythropoietin dose and inform the health care provider

2. Check the client's blood pressure prior to administering the erythropoietin Anemia associated with chronic kidney disease is treated with recombinant human erythropoietin (Epogen/Procrit, epoetin). Therapy is initiated to achieve a target hemoglobin of 10-11.5 g/dL (100-115 g/L) and to alleviate the symptoms of anemia (eg, fatigue) and the need for blood transfusions. However, higher hemoglobin concentrations, especially >13 g/dL (130 g/L), are associated with venous thromboembolism and adverse cardiovascular outcomes. Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administration of erythropoietin. (Option 1) Erythropoietin is administered intravenously or in any subcutaneous area. However, checking the client's blood pressure must be done prior to administering. (Option 3) Iron in the form of iron sucrose (Venofer) or ferric gluconate (Ferrlecit) may be prescribed to promote an adequate response to erythropoietin. Adequate stores of iron, vitamin B-12, and folic acid are required for the erythropoietin to work. There is no reason to hold iron therapy at this time. (Option 4) The dose is held if the client has higher target hemoglobin or uncontrolled hypertension.

The nurse has just received shift report. Which client should be seen first? 1. Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants 2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale 3. Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time 4. Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands

2. Client 2 days post-op below-the-knee amputation (BKA) who reports same-leg foot pain rated as 7 on the pain scale The client with a BKA is experiencing phantom limb pain, pain/tingling felt in a missing portion of a limb. It is real pain that many amputees experience immediately following surgery and that sometimes becomes chronic. This client is rating the pain at a high level on the scale (7 of 10). The nurse should prioritize this client and administer prescribed opiates or other analgesics. (Option 1) Because the bowels have been manipulated in AAA surgery, hypoactive sounds are common for several days afterward. (Option 3) Bed rest is no longer required for a client with DVT unless the client is having severe edema or leg pain. Early ambulation does not increase the short-term risk of pulmonary embolism, and it can reduce edema and leg pain. The nurse should see this client second to assess the affected limb. (Option 4) Raynaud's phenomenon is usually triggered by cold exposure. During a typical episode, digital arteries (most often in the fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel numb and cold. As blood flow returns to the affected digits, the skin turns red and a throbbing or tingling sensation is often felt. This is an expected finding; episodes usually resolve in 15-20 minutes once the trigger has been removed (eg, rewarming of the fingers).

A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? 1. Elevates the head of the bed 2. Increases the oxygen flow 3. Opens both flutter valves (ports) on the mask 4. Tightens the face mask straps

2. Increases the oxygen flow A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option 1) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option 3) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option 4) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag.

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? 1. Administer docusate and teach the client to avoid straining during defecation 2. Give pain medications and instructions related to pain control 3. Remove the rectal dressing and check the client for bleeding 4. Teach the client how to self-administer a sitz bath 2-3 times daily

2. Give pain medications and instructions related to pain control Hemorrhoids (distended, inflamed veins located in the anus or lower rectum) are caused by increased anorectal pressure (straining to defecate, constipation). Clients may experience symptoms such as rectal bleeding, pain, pruritus, and prolapse. Although removal of hemorrhoids (hemorrhoidectomy) is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe. Nursing management for the post-hemorrhoidectomy client includes the following: Pain relief: Initially, pain is managed with pain medications, including nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and/or acetaminophen; opioids can be prescribed initially but may worsen constipation. Beginning 1-2 days postoperatively, warm sitz baths are used as a means to relieve pain. Clients often dread their first bowel movement due to severe pain with defecation. Therefore, pain must be appropriately controlled to prevent further constipation (Option 2). Preventing constipation: Encourage a high-fiber diet and adequate fluid intake (at least 1500 mL/day). Administer a stool softener such as docusate (Colace) as prescribed. An oil-retention enema may be used if constipation persists for 2-3 days (Option 1). (Option 3) Postoperatively, the health care provider may pack the rectum and apply a T-binder to hold the packing in place. The dressing is usually removed 1-2 days postoperatively unless excess soaking is noted before. (Option 4) Warm sitz baths are used beginning 1-2 days postoperatively, 2-3 times daily (15-20 minutes each) for 7-10 days to provide pain relief, decrease swelling, and cleanse the rectal area.

The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? 1. Ask the client when a spiritual leader or clergy member is coming to visit 2. Document the response and notify the health care provider and perioperative team 3. Follow up with the client regarding the nature of the spiritual needs or religious practices 4. Notify the hospital chaplain and tell the client that the chaplain will come by to assist

3. Follow up with the client regarding the nature of the spiritual needs or religious practices Spirituality and religious beliefs are often integral parts of a client's life and can be therapeutic in the management of illness. Some studies have found that clients who engage in regular spiritual or religious practices have shorter recovery times, better coping mechanisms, and improved health outcomes. Spiritual, cultural, or religious needs should be accommodated within the plan of care. During the nursing process, the nurse should first assess the client's needs to best address them. By following up with the client regarding the questionnaire and asking about the specific nature of spiritual needs or religious practices, the nurse can effectively assist the client and create an appropriate plan of care (Option 3). (Option 1) Asking a client if a spiritual leader or clergy member is coming to visit may alarm the client or raise suspicion about the surgery. It also assumes that the client's religious or spiritual practices involve a spiritual leader or clergy person. (Option 2) The nurse should attempt to gather more information before notifying the perioperative team. Simply documenting the questionnaire response does not address the client's spiritual needs. (Option 4) The chaplain should not be called until the nurse has assessed the client's specific needs. The client may not wish to see a chaplain.

There has been a major disaster with the collapse of a large building. Hundreds of victims are expected. The emergency department nurse is sent to triage victims. Which client should the nurse tag "red" and send to the hospital first? 1. Client at 8 weeks gestation with spotting; pulse of 90/min 2. Client with bone piercing skin on leg with oozing laceration; pulse of 88/min 3. Client with fixed and dilated pupils and no spontaneous respirations 4. Client with see-saw chest movement with respirations

4. Client with see-saw chest movement with respirations Triage in a mass casualty incident, also known as disaster triage, focuses on saving the greatest number of people with the limited resources available. The two most commonly taught methodologies to assess trauma in a disaster are Simple Triage and Rapid Transport (START) and Sort, Assess, Lifesaving interventions, Treatment/Transport (SALT). Both systems rapidly assess circulation, respiration, and mental status to categorize trauma cases in under a minute. Trauma status is then ranked using the following system: Red has the highest priority, indicating a life-threatening injury that a client will survive if treated in the next hour, usually with significant impairment to airway, breathing, or circulation. Yellow could likely wait 1-2 hours without loss of life or limb. Green is considered walking wounded and clients may wait hours for treatment. Black indicates that the victim is unlikely to survive transport to definitive clinical care due to either the severity of trauma, insufficient transportation resources, level of available care, etc. Option 4 describes a flail chest, a scenario where multiple ribs sustain multiple fractures and become independent of the chest wall, floating on top of the lung and pleura. The fractured segment moves paradoxically in relationship to the intact chest wall, pushing outward with expiration and inward with inspiration. In addition to being extremely painful, impaired respiration can occur and rib fragments may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Supplemental oxygen is often necessary, and a chest tube and intubation may be necessary to stabilize the client. (Option 1) This client has stable airway, breathing, and circulation and can lie flat. There is a chance that the client may have a spontaneous abortion and that the fetus is not viable. In disaster/MCI triage, the sickest go first, not women and children. (Option 2) Extremity injuries can wait hours for the necessary surgery. In the meantime, the nurse can cover the injury with a sterile dressing, immobilize, and provide pain relief (if available). This client has no signs of signs of shock/internal bleeding. (Option 3) In normal circumstances, cardiopulmonary resuscitation could be attempted, but success is unlikely, as <4% of clients suffering cardiac arrest outside of a hospital will survive to discharge. In mass casualty events time, personnel, and resources are extremely limited.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? 1. Atropine sublingual drops 2. Lorazepam sublingual tablet 3. Morphine sublingual liquid 4. Ondansetron sublingual tablet

1. Atropine sublingual drops The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle."

A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse? 1. Cancel the procedure until a valid consent form is signed 2. Determine if the client meets legal requirements to sign the consent form 3. Locate the client's parent or guardian to sign the consent form 4. Verify that the consent is properly witnessed and send the client to surgery

2. Determine if the client meets legal requirements to sign the consent form A client must meet the legal requirements of the age of majority, which is 18 in most states, in order to sign informed consent. A client may be considered an emancipated minor when under the age of majority and deemed legally capable of making decisions because of marriage, military service, or living independently of parents or a guardian. A nurse should verify that a client meets this requirement before sending the client for a surgical procedure. (Options 1 and 3) The nurse should determine if legal consent has been obtained. If the consent is invalid, then the surgery is cancelled until a parent or guardian is located and a legal consent form is signed. (Option 4) Verifying that a consent form has been witnessed and sending the client to surgery is not the first action by the nurse. A legal consent that is properly witnessed must be available before surgery can take place.

A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client? 1. 12 cm above the umbilicus 2. At the level of the umbilicus 3. Halfway between the symphysis pubis and the umbilicus 4. Just above the symphysis pubis

4. Just above the symphysis pubis The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation (Option 4). At 16 weeks gestation, the fundus is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the xiphoid process around 36 weeks gestation. At 38-40 weeks, the fetus engages into the maternal pelvis and the fundal height drops. After 20 weeks gestation, the fundal height, measured in centimeters from the symphysis pubis to the top of the fundus, correlates closely to the weeks of gestation. (Options 1, 2, and 3) At 12 weeks gestation, the uterine fundus should be just above the symphysis pubis.