419 delegation quiz

The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client's spouse. The client says, "I don't see why I need any teaching. I don't think I need to change anything right now." Which response is *most* appropriate? •"Do you think your family may want you to make some lifestyle changes?" •"Can you tell me why you don't feel that you need to make any changes?" •"You are still in the stage of denial, but you will want this information later on." •"Even though you don't want to change, it's important that you have this teaching."

•"Can you tell me why you don't feel that you need to make any changes?" •For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client's statement and asks for further clarification. This will give the nurse more information about the client's feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle.

A parent calls the emergency department, saying, "I think my toddler might have swallowed a little toy. He is breathing okay, but I don't know what to do." What is the *most* essential question to ask the caller? •"Has he vomited?" •"Have you been checking his stools?" •"What do you think he swallowed?" •"Has he been coughing?"

•"Has he been coughing?" •Even though the caller reports that the child is "breathing okay," additional questions about possible airway obstruction are the priority (e.g., coughing, gagging, choking, drooling, refusing to eat or drink). Gastrointestinal symptoms should be assessed but are less urgent. The type of foreign body, in the absence of symptoms, may dictate a wait-and-see approach, in which case the parent would be directed to check the stools for passage of the foreign body.

A teenager arrives in the triage area alert and ambulatory, but his clothes are covered with blood. His friends are yelling, "We were goofing around, and he got poked in the abdomen with a stick!" Which comment would be of *most* concern? •"There was a lot of blood, and we used three bandages." •"He pulled the stick out, just now, because it was hurting him." •"The stick was really dirty and covered with mud." •"He has diabetes, so he needs attention right away."

•"He pulled the stick out, just now, because it was hurting him." •An impaled object may be providing a tamponade effect, and removal can precipitate sudden hemodynamic decompensation. Additional history, including a more definitive description of the blood loss, depth of penetration, and medical history, should be obtained. Other information, such as the dirt on the stick or history of diabetes, is important in the overall treatment plan but can be addressed later.

The nurse is caring for a 5-year-old whose mother asks why he still wets the bed. What is the *best* response? •"He is old enough that he should no longer be wetting the bed." •"Most children outgrow bed-wetting by the time they start school." •"His bed-wetting may be due to an immature bladder or deep sleep pattern." •"He will probably stop once he realizes how embarrassing it is to wet the bed."

•"His bed-wetting may be due to an immature bladder or deep sleep pattern." •Theories about bed-wetting relate it to immature bladder and deep sleep patterns. Although it is true that most children stop bed-wetting by the time they start school, this does not answer the mother's question. Many boys wet the bed until after the age of 5 years. The fourth response is not accurate because often bed-wetting is not within the control of a 5-year-old child.

The nurse caring for a 3-year-old child plans to assess the child's pain using the Wong-Baker FACES® Pain Rating Scale. Which accompanying assessment question would be the *most* useful? •"If number 0 (smiling face) were no pain and number 10 (crying face) were a big pain, what number would your pain be?" •"Can you point to the face picture with one finger and tell me what that pain feels like inside of you?" •"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •"If you look at these faces and I give you a paper and pencil, can you draw for me the face that looks most like your pain?"

•"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •Pain rating scales using faces (depicting smiling, neutral, frowning, crying, and so on) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other questions require abstract reasoning abilities to make analogies and the use of advanced vocabulary.

Parents of a 13-year-old adolescent girl expressed concern because she spends "quite a bit of time in her room alone in front of the mirror." The girl's height and weight are in the 50th percentile. In the exam room, the girl is quiet but does answer questions appropriately. What advice should the nurse provide to the parents? •"Further evaluation by a psychologist is needed because your daughter spends a lot of time alone in her room." •"Limit the amount of time that your daughter is allowed to spend alone in her room." •"This behavior is normal. Your daughter is adjusting to the physical changes she is experiencing." •"This behavior may be associated with depression, and further evaluation by a counselor is advised."

•"This behavior is normal. Your daughter is adjusting to the physical changes she is experiencing." •This is normal behavior in early adolescence. During this time period, adolescents are conscious of their rapid physical changes. As a result, they spend more time in front of the mirror inspecting their bodies. Consider that the height and weight are normal; therefore, an eating disorder is not likely. Also, the girl does answer questions appropriately, so mental health issues are not likely.

The nurse is preparing to insert a peripherally inserted central catheter (PICC) in a client's left forearm. Which solution will be *best* for cleaning the skin prior to the PICC insertion? •70% isopropyl alcohol •Povidone-iodine solution •0.5% chlorhexidine in alcohol •Betadine followed by 70% isopropyl alcohol

•0.5% chlorhexidine in alcohol •Current Institute for Healthcare Improvement guidelines indicate that chlorhexidine is more effective than the other options at reducing the risk for central line-associated bloodstream infections. The other solutions provide some decrease in the number of microorganisms on the skin but are not as effective as chlorhexidine.

The nurse has just received a change-of-shift report about these pediatric patients. Which patient will the nurse assess *first*? •A 1-year-old patient with hemophilia B who was admitted because of decreased responsiveness •A 3-year-old patient with von Willebrand disease who has a dose of desmopressin (DDAVP) scheduled •A 7-year-old patient with acute lymphocytic leukemia who has chemotherapy-induced thrombocytopenia •A 16-year-old patient with sickle cell disease who reports acute right lower quadrant abdominal pain

•A 1-year-old patient with hemophilia B who was admitted because of decreased responsiveness •Because decreased responsiveness in a 1-year-old patient with a clotting disorder may indicate intracerebral bleeding, this patient should be assessed immediately. The other patients also require assessments or interventions but are not at immediate risk for life-threatening or disabling complications.

The pediatric unit charge nurse is working with a newly graduated RN who has been on orientation in the unit for 2 months. Which patient should the charge nurse assign to the new RN? •A 2-year-old patient with a ventricular septal defect for whom digoxin 90 mcg by mouth has been prescribed •A 4-year-old patient who had a pulmonary artery banding and has just been transferred in from the intensive care unit •A 9-year-old patient with mitral valve endocarditis whose parents need teaching about IV antibiotic administration •A 16-year-old patient with a heart transplant who was admitted with a low-grade fever and tachycardia

•A 2-year-old patient with a ventricular septal defect for whom digoxin 90 mcg by mouth has been prescribed •This patient requires the least complex assessments and interventions of the four patients. Safe administration of oral medications such as digoxin would have been included in the orientation of the new RN graduate. The conditions of the other patients are more complex, and they require assessments or interventions (e.g., teaching) that should be carried out by an RN with more experience.

The pediatric unit charge nurse is making patient assignments for the evening shift. Which patient is *most* appropriate to assign to an experienced LPN/LVN? •A 1-year-old patient with severe combined immunodeficiency disease who is scheduled to receive chemotherapy in preparation for a stem cell transplant •A 2-year-old patient with Wiskott-Aldrich syndrome who has orders for a platelet transfusion •A 3-year-old patient who has chronic graft-versus-host disease and is incontinent of loose stools •A 6-year-old patient who received chemotherapy 1 week ago and is admitted with increasing lethargy and a temperature of 101°F (38.3°C)

•A 3-year-old patient who has chronic graft-versus-host disease and is incontinent of loose stools •LPN/LVN scope of practice includes care of patients with chronic and stable health problems, such as the patient with chronic graft-versus-host disease. Chemotherapy medications are considered high-alert medications and should be given by RNs who have received additional education in chemotherapy administration. Platelets and other blood products should be given by RNs. The 6-year-old patient has a history and clinical manifestations consistent with neutropenia and sepsis and should be assessed by an RN as quickly as possible.

While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which client will be *best* to assign to the new graduate? •A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today •A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV •A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care •A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

•A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV •The new RN's education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses.

The nurse is observing a preschool classroom of children between the ages of 3 to 4 years of age. When planning actions to ensure that each child meets normal developmental goals, which child will require the *most* immediate intervention? •A 3-year-old boy who needs help dressing •A 4-year-old girl who has an imaginary friend •A 4-year-old girl who engages only in parallel play •A 3-year-old boy who draws stick figures

•A 4-year-old girl who engages only in parallel play •At 4 years of age, children engage in pretend play. Parallel play is seen in younger children between the ages of 2 and 3 years when they play side by side with limited interaction. The other behaviors are developmentally appropriate. The nurse will plan interventions to ensure that all the children meet developmental goals, but the 4-year-old child engaging only in parallel play will require the most immediate intervention.

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess *first*? •A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today •A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change •A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure •A 77-year-old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

•A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change •The client's symptoms indicate acute hypoxia, so immediate further assessments (e.g., assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client.

Four clients arrive simultaneously at the emergency department. Which client requires the *most* rapid action by the triage nurse to protect other clients from infection? •A 3-year-old client who has paroxysmal coughing and whose sibling has pertussis •A 5-year-old client who has a new pruritic rash and a possible chickenpox infection •A 62-year-old client who has an ongoing methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection •A 74-year-old client who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight

•A 5-year-old client who has a new pruritic rash and a possible chickenpox infection •Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the emergency department. The child with the rash should be quickly isolated from the other clients through placement in a negative-pressure room. Droplet or contact precautions (or both) should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB.

After receiving the change-of-shift report, which patient should the nurse assess *first*? •An 18-month-old patient with coarctation of the aorta who has decreased pedal pulses •A 3-year-old patient with rheumatic fever who reports severe knee pain •A 5-year-old patient with endocarditis who has crackles audible throughout both lungs •An 8-year-old patient with Kawasaki disease who has a temperature of 102.2°F (38.9°C)

•A 5-year-old patient with endocarditis who has crackles audible throughout both lungs •Crackles throughout both lungs indicate that the child has severe left ventricular failure as a complication of endocarditis. Hypoxemia is likely, so the child needs rapid assessment of oxygen saturation, initiation of supplemental oxygen delivery, and administration of medications such as diuretics. The other children should also be assessed as quickly as possible, but they are not experiencing life-threatening complications of their medical diagnoses.

Which pediatric pain patient should be assigned to a newly graduated RN? •An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose •A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •A child who is receiving palliative end-of-life care; the child is receiving opioids around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness •A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful

•A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management, the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management.

Parents of a 6-month-old girl bring the infant to the emergency department because "she has not held anything down for the entire day." The nurse obtains a fingerstick blood glucose of 94 (5.22 mmol/L). The infant's rectal temperature is 101°F (38.3°C), heart rate is 198 beats/min, respiratory rate is 40 breaths/min, and blood pressure 60/38 mm Hg in the left arm. Which nursing action is a *priority*? •Administer an antiemetic rectally •Administer a bolus of D10W •Administer a bolus of normal saline •Administer an antipyretic rectally

•Administer a bolus of normal saline •This infant is experiencing severe dehydration, which is evidenced by tachycardia and hypotension. The child is at risk for hypovolemic shock, which is a life-threatening event. A bolus of normal saline or lactated Ringer's solution of 20 mL/kg is the standard of care to establish hemodynamic stability. The blood glucose is normal. The safety profile for antiemetics have not been established with infants, and the priority for this patient is to establish hemodynamic stability. Fever can cause increased fluid loss; however, the priority in this life-threatening situation is to establish hemodynamic stability.

The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take *first*? •Insert an IV catheter •Auscultate heart sounds •Administer sublingual nitroglycerin •Draw blood for troponin I measurement

•Administer sublingual nitroglycerin •The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority.

While working in the pediatric clinic, the nurse receives a telephone call from the parent of a 13-year-old child who is receiving chemotherapy for leukemia. The patient's sibling has chickenpox (varicella). Which action will the nurse anticipate taking *next*? •Administer varicella-zoster immune globulin to the patient •Teach the parent about the correct use of acyclovir •Educate the parent about contact and airborne precautions •Prepare to admit the patient to a private room in the hospital

•Administer varicella-zoster immune globulin to the patient •The administration of varicella-zoster immune globulin can prevent the development of varicella in immunosuppressed patients and will typically be prescribed. Acyclovir therapy and hospitalization may be required if the child develops a varicella-zoster virus infection. Contact and airborne precautions will be implemented to prevent the spread of infection to other children if the child is hospitalized with varicella.

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is *best* assigned to the LPN/LVN? •Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities •Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation •Teaching the client energy conservation techniques to decrease myocardial oxygen demand •Explaining the rationale for alternating rest periods with exercise to the client and family

•Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities •Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice.

A client who has frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN/LVN? •Performing ongoing assessments to determine the client's hydration status •Explaining the purpose of ordered stool cultures to the client and family •Administering the prescribed metronidazole 500 mg PO to the client •Reviewing the client's medical history for any risk factors for diarrhea

•Administering the prescribed metronidazole 500 mg PO to the client •LPN/LVN scope of practice and education include administration of medications. Assessment of hydration status, client and family education, and assessment of client risk factors for diarrhea should be done by the RN.

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of *most* concern? •Blood pressure is 154/78 mm Hg •Pedal pulses are palpable at + 1 •Left groin has a 3-cm bruised area •Apical pulse is 122 beats/min and regular

•Apical pulse is 122 beats/min and regular •The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern.

When the community health nurse is counseling a client who has an acute Zika virus infection, which information is *most* important to include? •Drink fluids to prevent dehydration •Use acetaminophen to reduce pain and fever •Apply insect repellant frequently to prevent mosquito bites •Symptoms of Zika infection include fever, red eyes, rash, and joint pain

•Apply insect repellant frequently to prevent mosquito bites •Prevention of Zika transmission is the priority because Zika infection usually causes a relatively mild and short-duration illness. Because mosquitos spread Zika infection from infected individuals to others, it is essential that the client use insect repellant consistently during the active infection. The other information is correct but will not assist in decreasing the risk to the community.

Which information about a client who has meningococcal meningitis is the *best* indicator that the nurse can discontinue droplet precautions? •Pupils are equal and reactive to light •Appropriate antibiotics have been given for 24 hours •Cough is productive of clear, nonpurulent mucus •Temperature is lower than 100°F (37.8°C)

•Appropriate antibiotics have been given for 24 hours •Current Centers for Disease Control and Prevention evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy (with drugs that are effective against Neisseria meningitidis) for 24 hours. The other information may indicate that the client's condition is improving but does not indicate that droplet precautions should be discontinued.

A pregnant client in the first trimester tells the nurse that she was recently exposed to the Zika virus while traveling in Southeast Asia. Which action by the nurse is most important? •Arrange for testing for Zika virus infection •Discuss need for multiple fetal ultrasounds during pregnancy •Describe potential impact of Zika infection on fetal development •Assess for symptoms such as rash, joint pain, conjunctivitis, and fever

•Arrange for testing for Zika virus infection •Current guidelines recommend that pregnant women who are exposed to Zika virus be tested for infection. Fetal ultrasonography is recommended for any pregnant woman who has had possible Zika virus exposure, but multiple ultrasound studies will not be needed unless test results are positive. Education about the effects of Zika infection on fetal development may be needed, but this is not the highest priority at this time. The nurse will assess for Zika symptoms, but testing for the virus will be done even if the client is asymptomatic.

During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the *most* immediate implications for the client's care? •Arterial line indicates a blood pressure of 190/112 mm Hg •Cardiac monitor shows frequent premature atrial contractions •There is no response to verbal stimulation •Urine output is 40 mL of amber urine

•Arterial line indicates a blood pressure of 190/112 mm Hg •Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client's hemodynamic stability.

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, "My blood pressure at home is always fine!" What action should the nurse take *next*? •Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems •Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day •Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week •Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects

•Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week •The American Heart Association recommends home blood pressure monitoring for clients with hypertension or hypertension risk factors because home blood pressure monitoring provides more accurate data about usual blood pressure than periodic monitoring. The other actions may be necessary, but further assessment of the client's usual blood pressure is needed before decisions about therapy can be made.

The nurse is supervising an LPN/LVN who says, "I gave the client with myasthenia gravis 90 mg of neostigmine instead of the ordered 45 mg!" In which order should the nurse perform the following actions? •Assess the client's heart rate •Complete a medication error report •Ask the LPN/LVN to explain how the error occurred •Notify the healthcare provider (HCP) of the incorrect medication dose

•Assess the client's heart rate •Notify the healthcare provider (HCP) of the incorrect medication dose •Ask the LPN/LVN to explain how the error occurred •Complete a medication error report •The first action after a medication error should be to assess the client for adverse outcomes. The nurse should evaluate this client for symptoms such as bradycardia and excessive salivation, which indicate cholinergic crisis, a possible effect of excessive doses of anticholinesterase medications such as neostigmine. The health care provider should be rapidly notified so that treatment with atropine can be ordered to counteract the effects of the neostigmine, if necessary. Determining the circumstances that led to the error will help decrease the risk for future errors and will be needed to complete the medication error report.

The health care provider has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which task will the nurse delegate to the unlicensed assistive personnel (UAP)? •Providing explanations of nursing actions to the family •Assisting the child to remove the outer clothing •Advising the parent to use acetaminophen instead of aspirin •Monitoring the child's level of consciousness and orientation level

•Assisting the child to remove the outer clothing •The UAP can help with the removal of outer clothing, which allows the heat to dissipate from the child's skin. Assessments, advising, and explaining require RN-level education and scope of practice.

A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident's care is *best* for the nurse to delegate to the unlicensed assistive personnel (UAP)? •Teaching family members the signs of infection •Monitoring capillary perfusion once every 8 hours •Evaluating foot sensation and movement each shift •Assisting the client in cleaning around the Unna boot

•Assisting the client in cleaning around the Unna boot •Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members.

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? *Select all that apply.* •Attaching cardiac monitor leads •Giving heparin 5000 units IV push •Administering morphine sulfate 4 mg IV •Obtaining a 12-lead electrocardiogram (ECG) •Asking the client about pertinent medical history •Having the client chew and swallow aspirin 162 mg

•Attaching cardiac monitor leads •Obtaining a 12-lead electrocardiogram (ECG) •Having the client chew and swallow aspirin 162 mg •Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice.

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be *most* useful to monitor? •Serum potassium •B-type natriuretic peptide •Blood urea nitrogen •Hematocrit

•B-type natriuretic peptide •Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the client has heart failure.

When the nurse is monitoring a 53-year-old client who is undergoing a treadmill stress test, which finding will require the *most* immediate action? •Blood pressure of 152/88 mm Hg •Heart rate of 134 beats/min •Oxygen saturation of 91% •Chest pain level of 3 (on a scale of 0 to 10)

•Chest pain level of 3 (on a scale of 0 to 10) •Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing.

A 16-year-old female adolescent arrives at the health center. She tells the nurse that she's been sexually active for 6 months "but only with my boyfriend." Her immunizations are up to date. Screening for which sexually transmitted disease (STD) will be *most* important for this patient? •Syphilis •Genital herpes simplex •Human papillomavirus •Chlamydia

•Chlamydia •Recommendations by the Centers for Disease Control and Prevention recommend annual screening for chlamydia (and gonorrhea) for all sexually active women younger than the age of 25 years. Chlamydia is the most prevalent STD in the United States. Screening for syphilis and genital herpes simplex is recommended only if other risk factors or evidence of disease are present. The patient is fully immunized, which would include the human papillomavirus vaccine.

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is *most* important to report to the health care provider? •Client reports frequent urination •Client's blood pressure is 138/86 mm Hg •Client complains about a frequent dry cough •Client says, "I get dizzy sometimes if I stand up fast."

•Client complains about a frequent dry cough •A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy.

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit? •Client requiring discharge teaching about coronary artery stenting before going home today •Client receiving IV furosemide to treat acute left ventricular failure •Client who just transferred in from the radiology department after a coronary angioplasty •Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

•Client receiving IV furosemide to treat acute left ventricular failure •An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have acute coronary syndrome and with collaborative treatments such as coronary angioplasty and coronary artery stenting.

A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is *most* important for the nurse to discuss with the health care provider? •Heart rate is 52 beats/min •Client is also taking carvedilol for angina •Client reports having chronic constipation •Blood pressure is 106/56 mm Hg

•Client reports having chronic constipation •Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the client plan of care.

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is *most* important for the nurse to communicate to the health care provider (HCP) before the procedure? •Blood glucose level is 144 mg/dL (8 mmol/L) •Cardiac monitor shows sinus bradycardia, rate 56 beats/min •Client reports chest pain that occurred yesterday •Client took metformin 500 mg this morning

•Client took metformin 500 mg this morning •Because use of metformin may lead to acute lactic acidosis when clients undergo procedures that use iodine-based contrast dye, metformin should be held for 24 hours before and 48 hours after coronary arteriogram. The arteriogram will need to be rescheduled. The other information will also be reported to the HCP but would not be unusual in clients with coronary artery disease.

The nurse is caring for four clients who are receiving IV infusions of normal saline. Which client is at *highest* risk for bloodstream infection? •Client with an implanted port in the right subclavian vein •Client who has a midline IV catheter in the left antecubital fossa •Client who has a nontunneled central line in the left internal jugular vein •Client with a peripherally inserted central catheter (PICC) line in the right upper arm

•Client who has a nontunneled central line in the left internal jugular vein •According to Centers for Disease Control and Prevention guidelines, several factors increase the risk for infection for this client: central lines are associated with a higher infection risk, jugular vein lines are more prone to infection, and the line is nontunneled. Peripherally inserted IV lines such as PICC lines and midline catheters are associated with a lower incidence of infection. Implanted ports are placed under the skin and are the least likely central line to be associated with catheter infection.

The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need *immediate* intervention? •Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest •Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min •Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions •Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

•Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions •Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of myocardial infarction.

The nurse at the infectious disease clinic has four clients waiting to be seen. Which client should the nurse see *first*? •Client who has a 16-mm induration after a tuberculosis (TB) skin test •Client who has human immunodeficiency virus and a low CD4 count •Client who has swine influenza (H1N1) and reports increased dyspnea •Client who has been exposed to Zika virus and has a rash and joint pain

•Client who has swine influenza (H1N1) and reports increased dyspnea •The client with increased dyspnea should be seen first because rapid actions such as oxygen administration and IV fluids may be needed. The other clients will require further assessment, counseling, or treatment, but they do not have potentially life-threatening symptoms or diagnoses.

The nurse admits four clients with infections to the medical unit, but only one private room is available. Which client is *most* appropriate to assign to the private room? •Client with diarrhea caused by C. difficile •Client with vancomycin-resistant enterococcus (VRE) infection •Client with a cough who may have active tuberculosis (TB) •Client with toxic shock syndrome and fever

•Client with a cough who may have active tuberculosis (TB) •Clients with infections that require airborne precautions (e.g., TB) need to be in private rooms. Clients with infections that require contact precautions (e.g., those with C. difficile VRE infections) should ideally be placed in private rooms; however, they can be placed in rooms with other clients with the same diagnosis. Standard precautions are required for the client with toxic shock syndrome.

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen *most* urgently? •Client with peripheral arterial disease who complains of leg cramps when walking •Client with atrial fibrillation who reports episodes of lightheadedness and syncope •Client with a new permanent pacemaker who has severe itchiness at the wound site •Client with angina who took nitroglycerin twice in the last week while exercising

•Client with atrial fibrillation who reports episodes of lightheadedness and syncope •Lightheadedness and syncope may indicate that the client's heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other clients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled.

An excited mother calls the nurse for advice. "My child got cleaning solution in her eyes, and I rinsed her eyes with water for a few minutes. What should I do? She is still screaming!" What does the nurse instruct the caller to do *first*? •Comfort the child and check her vision •Continue to irrigate the eyes with water •Call the Poison Control Center •Call 911 to request an ambulance

•Continue to irrigate the eyes with water •Even though the child is screaming, the mother must continue to irrigate the eyes for at least 20 minutes. Another adult, if present, should call the Poison Control Center and 911.

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm (Ventricular Fibrillation). Which action will the nurse take *first*? •Defibrillate at 200 joules •Start cardiopulmonary resuscitation (CPR) •Administer epinephrine 1 mg IV •Intubate and manually ventilate

•Defibrillate at 200 joules •Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client's rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available.

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members? •Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs •Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake •Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes •Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

•Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes •Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN.

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? •Screening clients for upper respiratory tract symptoms •Asking clients about the use of immunosuppressant medications •Demonstrating correct hand washing to the clients' visitors •Disinfecting blood pressure cuffs after clients are discharged

•Disinfecting blood pressure cuffs after clients are discharged •The UAP can follow agency policy to disinfect items that come in contact with intact skin (e.g., blood pressure cuffs) by cleaning with chemicals such as alcohol. Teaching and assessment for upper respiratory tract symptoms or use of immunosuppressants require more education and a broader scope of practice, and these tasks should be performed by licensed nurses.

The school nurse is performing developmental screenings for children who will be entering preschool. A 4-year-old girl excitedly tells the nurse about her recent birthday party. As she relates the details of the event, she frequently stutters. Which action by the nurse is *most* appropriate at this time? •Refer the child to an audiologist •Obtain a detailed birth history from the parents •Document the findings on the child's school record •Refer the child to a speech pathologist

•Document the findings on the child's school record •Stuttering during the preschool years is a normal variation, particularly when excited or upset. The cause is attributed to preschool children's increased cognitive abilities and imagination such that their speech cannot keep up with their thoughts. Documenting this on the child's record is important for continued observation to determine if it extends beyond the preschool years.

A 2-year-old child arrives at the health center for a routine well-child visit. A complete blood count and lead level are obtained. The lead level is less than 10 mcg/dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/L). The hematocrit is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is 65 μm3 (65 fL). What questions should the nurse ask the parent to obtain a more thorough history? *Select all that apply.* •Does your child eat nonfood substances? •Is your child more prone to infections? •Has your child experienced hair loss? •Does your child frequently have nosebleeds? •How much milk does your child drink?

•Does your child eat nonfood substances? •How much milk does your child drink? •Iron deficiency anemia is a microcytic anemia. Laboratory findings consistent with iron deficiency anemia include low hemoglobin, hematocrit, and MCV. Additionally, the patient may have thrombocytosis, which is an increase in the number of platelets; so the child will not be more likely to have nosebleeds. The white blood cell count (WBC) and WBC differential are not affected by anemia; therefore, the child will not be more prone to infections. Children with iron deficiency anemia experience pica, which is a consumption of nonfood items. Excessive cow's milk intake has been found to cause anemia by irritating the intestine and resulting in microscopic blood loss from the gastrointestinal tract.

A newborn infant is diagnosed with tracheoesophageal fistula. Which nursing interventions should be implemented in the preoperative period? *Select all that apply.* •Provide small frequent feedings •Elevate the head of the bed •Prepare a tracheostomy tray •Set up suctioning •Administer IV antibiotics

•Elevate the head of the bed •Set up suctioning •Administer IV antibiotics •A tracheoesophageal fistula is a congenital malformation in which the esophagus ends in a blind pouch and there is a fistula (opening) between the esophagus and the trachea. The infant is a high risk for aspiration of esophageal contents into the trachea; hence, the infant is NPO in the preoperative period. IV fluids are administered to maintain hydration. A tracheostomy is not indicated for tracheoesophageal fistula. Surgical intervention for tracheoesophageal fistula include ligation of the fistula and reanastomosis of the esophagus. Suction should be on hand to remove secretions from the blind pouch. IV antibiotics are initiated in the preoperative period.

Which action by the infection control nurse in an acute care hospital will be *most* effective in reducing the incidence of health care-associated infections? •Require nursing staff to don gowns to change wound dressings for all clients •Ensure that dispensers for alcohol-based hand rubs are available in all client care areas •Screen all newly admitted clients for colonization or infection with methicillin-resistant Staphylococcus aureus (MRSA) •Develop policies that automatically start antibiotic therapy for clients colonized by multidrug-resistant organisms

•Ensure that dispensers for alcohol-based hand rubs are available in all client care areas •Because the hands of health care workers are the most common means of transmission of infection from one client to another, the most effective method of preventing the spread of infection is to make supplies for hand hygiene readily available for staff to use. Wearing a gown to care for clients who are not on contact precautions is not necessary. Although some hospitals have started screening newly admitted clients for MRSA, this is not considered a priority action according to current national guidelines. Because administration of antibiotics to individuals who are colonized by bacteria may promote development of antibiotic resistance, antibiotic use should be restricted to clients who have clinical manifestations of infection.

Which action will the public health nurse take to have the *most* impact on the incidence of infectious diseases in the school? •Make soap and water readily available in the classrooms •Ensure that students are immunized according to national recommendations •Provide written information about infection control to all parents •Teach students how to cover their mouths when they cough or sneeze

•Ensure that students are immunized according to national recommendations •The incidence of once-common infectious diseases such as measles, chickenpox, and mumps has been most effectively reduced by the immunization of all school-age children. The other actions are also helpful but will not have as great an impact as immunization.

The nurse notes white powder on the arms and chest of a client who arrives at the emergency department and reports possible anthrax contamination. Which action included in the hospital protocol for possible anthrax exposure will the nurse take *first*? •Notify hospital security personnel about the client •Escort the client to a decontamination room •Give ciprofloxacin 500 mg PO •Assess the client for signs of infection

•Escort the client to a decontamination room •To prevent contamination of staff or other clients by anthrax, decontamination of the client by removal and disposal of clothing and showering are the initial actions in possible anthrax exposure. Assessment of the client for signs of infection should be performed after decontamination. Notification of security personnel (and local and regional law enforcement agencies) is necessary in the case of possible bioterrorism, but this should occur after decontaminating and caring for the client. According to the Centers for Disease Control and Prevention guidelines, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax.

An unimmunized 7-year-old child who attends a local elementary school contracts rubeola (measles). The child has two siblings, ages 9 and 11 years, who also attend the elementary school. Which action by the school nurse is a *priority*? •Exclude the child and siblings from attending school for 21 days •Notify all parents of children attending the school of the exposure •Recommend that siblings receive the measles vaccine •Recommend that siblings receive measles immunoglobulin

•Exclude the child and siblings from attending school for 21 days •Rubeola is a highly contagious infectious disease with severe consequences that include death. The Centers for Disease Control and Prevention reports that 9 of 10 susceptible persons with close contact to a person with measles will contract the disease. The incubation period is 7 to 21 days. Excluding the infected and exposed children during this period of time is a priority to prevent exposure of healthy children enrolled in the elementary school. Although it is important to notify the parents of the other children in the school of the exposure, limiting exposure of other children is the priority. Mumps, measles, and rubella vaccine administered within 72 hours of initial measles exposure and immunoglobulin administered within 6 days of exposure may provide some protection or modify the clinical course of the disease in unimmunized children; however, the priority is to prevent an epidemic by limiting exposure.

An 80-year-old client on the coronary step-down unit tells the nurse "I do not need to take that docusate. I never get constipated!" Which action by the nurse is *most* appropriate? •Document the medication on the client's chart as "refused." •Mix the medication with food and administer it to the client •Explain that his decreased activity level may cause constipation •Reinforce that the docusate has been prescribed for a good reason

•Explain that his decreased activity level may cause constipation •The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as "refused" or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it unless someone else has health care power of attorney and has authorized use of the medication.

A 6-year-old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse's *best* response to this behavior? •Remind the child that foods tasted good today and will help her or his body to get strong •Allow the mother and child time alone to review and control the behavior •Ask the mother to leave until the child can finish eating and then invite her back •Explain to the mother that the behavior could be a normal expression of anger

•Explain to the mother that the behavior could be a normal expression of anger •Help the mother to understand that the child may be angry about being left in the hospital or about her inability to prevent the illness and protect the child. Reminding the child about the food and the purpose of the food does not address the strong emotions underlying the outburst. Allowing the mother and child time alone is a possibility, but the assumption would be that the mother understands the child's behavior and is prepared to deal with the behavior in a constructive manner. Asking the mother to leave the child suggests that the mother is a source of stress.

An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)? •Reporting evidence of severe mucosal ulceration •Assisting the child in swishing and spitting mouthwash •Assessing the child's ability and willingness to drink through a straw •Feeding the child a bland, moist, soft diet

•Feeding the child a bland, moist, soft diet •Helping the child to eat is within the scope of responsibilities for a UAP. Assessing ability and willingness to drink and checking for extent of mucosal ulceration is the responsibility of an RN. An 18-month-old child is not able to swish and spit, which could result in swallowing the mouthwash. Mouthwash is not intended for swallowing because it can contain alcohol and other ingredients not safe for ingestion.

The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated laboratory result would cause the nurse the greatest concern? •Nausea and vomiting with a potassium level of 3.3 mEq/L (3.3 mmol/L) •Epistaxis with a platelet count of 100,000/mm3 (100 × 109/L) •Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •Fatigue with a hemoglobin level of 8 g/dL (80 g/L)

•Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L (3.3 mmol/L) is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3 (20 × 109/L). Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue.

The nurse has obtained this assessment information about a 3-year-old patient who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the *most* immediate follow-up? •Frequent swallowing •Hypotonic bowel sounds •Reports of a sore throat •Heart rate of 112 beats/min

•Frequent swallowing •Frequent swallowing after tonsillectomy may indicate bleeding. The nurse should inspect the back of the throat for evidence of bleeding. The other assessment results are expected in a 3-year-old child after surgery.

Liquid supplemental iron is prescribed for a 10-month-old child with iron deficiency anemia. The parents tell the nurse that their child hates the taste of medicine. Which of the following instructions should the nurse provide to the parents? *Select all that apply.* •Give the iron orally with a syringe •Mix the iron in a little bit of chocolate syrup •Give the iron with food or milk •Let the child drink the iron through a straw •Give the iron with orange juice

•Give the iron orally with a syringe •Give the iron with orange juice •Iron supplementation can stain the teeth and has an unpleasant taste. By administering the iron with a syringe to the back of the throat, it will mask the taste and prevent staining of the teeth. The vitamin C in orange juice increases iron absorption and may mask the unpleasant taste. Chocolate contains caffeine, which interferes with the absorption of iron. Milk and food also interfere with the absorption of iron. Although allowing a child to drink the iron through a straw is feasible for an older child, a 10-month-old child cannot developmentally perform this task.

The nurse is preparing to change the linens on the bed of a client who has a sacral wound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? *Select all that apply.* •Gown •Gloves •Goggles •Surgical mask •N95 respirator

•Gown •Gloves •A gown and gloves should be used when coming in contact with linens that may be contaminated by the client's wound secretions. The other PPE items are not necessary because transmission by splashes, droplets, or airborne means will not occur when the bed is changed.

The nurse is teaching a group of day-care workers about how to avoid transmission of hepatitis A in day-care settings. What is the single *most* effective measure to emphasize? •Hand hygiene should be performed often to prevent and control the spread of infection •Children in whom hepatitis has been diagnosed should not share toys with others •Children with episodes of fecal incontinence should be isolated from others •Immunizations are recommended before children are admitted into day-care settings

•Hand hygiene should be performed often to prevent and control the spread of infection •Hand washing is the most important aspect to emphasize. Addressing fecal incontinence and sharing of personal items may be recommended when the disease is in an infectious stage. Immunizations are recommended, but this would be emphasized to parents rather than day-care workers.

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions? •Call the client's healthcare provider •Have the client sit down •Check the client's blood pressure •Administer as needed (PRN) oxygen by nasal cannula

•Have the client sit down •Administer as needed (PRN) oxygen by nasal cannula •Check the client's blood pressure •Call the client's healthcare provider •Because the increased heart rate may be associated with a drop in blood pressure and with lightheadedness, the nurse's first action should be to decrease risk for a fall by having the client sit down. Cardiac ischemia may be causing the client's tachycardia, and administration of supplemental oxygen should be the next action. Assessment of blood pressure should be done next. Finally, the health care provider should be notified about the client's response to activity because changes in therapy may be indicated.

The emergency department receives multiple individuals, mostly children, who were injured when the roof of a day-care center collapsed because of a heavy snowfall. Based on physiologic differences in children compared with adults, for which injuries and complications will the nurse assess *first*? *Select all that apply.* •Head injuries •Bradycardia or junctional arrhythmias •Hypoxemia •Liver and spleen contusions •Hypothermia •Fractures of the long bones •Lumbar spines injuries

•Head injuries •Hypoxemia •Liver and spleen contusions •Hypothermia •Children have proportionately larger heads that predispose them to head injuries. Hypoxemia is more likely because of their higher oxygen demand. Liver and spleen injuries are more likely because the thoracic cages of children offer less protection. Hypothermia is more likely because of children's thinner skin and proportionately larger body surface area. They have strong hearts; therefore, pulse rate will increase to compensate, but other arrhythmias are less likely to occur. Children have relatively flexible bones compared with those of adults. The most likely spinal injury in children is injury to the cervical area.

The nurse is reviewing a complete blood count for a 3-year-old patient with idiopathic thrombocytopenic purpura (ITP). Which information should the nurse report *immediately* to the health care provider (HCP)? •Prothrombin time (PT) of 12 seconds •Hemoglobin level of 6.1 g/dL (61 g/L) •Platelet count of 40,000/mm3 (40 × 109/L) •Leukocyte count of 5600/mm3 (5.6 × 109/L)

•Hemoglobin level of 6.1 g/dL (61 g/L) •The low hemoglobin count may signify bleeding; therefore, alerting the HCP is recommended. ITP is an autoimmune disorder by which circulating platelets are destroyed by autoantibodies. Platelet production from the bone marrow, however, is not affected. Laboratory findings characteristic of ITP include a low platelet count generally less than 20,000/mm3 (20 × 109/L). However, all other indices of the complete blood count are normal. Additionally, the PT and partial thromboplastin time are normal with ITP. In this 3-year-old child, the leukocytes and PT are normal. The platelet count is low but consistent with this disease.

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? *Select all that apply.* •How to monitor and record daily weight •Importance of stopping exercise if heart rate increases •Symptoms of worsening heart failure •Purpose of chronic antibiotic therapy •How to read food labels for sodium content •Date and time for follow-up appointments

•How to monitor and record daily weight •Symptoms of worsening heart failure •How to read food labels for sodium content •Date and time for follow-up appointments •To avoid rehospitalization, topics that should be included when discharging a client with heart failure include low-sodium diet, purpose and common side effects of medications such as angiotensin-converting enzyme inhibitors and beta-blockers, what to do if symptoms of worsening heart failure occur, and follow-up appointments. The nurse will teach the client that a moderate increase in heart rate and respiratory effort is normal with exercise. Antibiotics are not included in the treatment regimen for heart failure, which is not an infectious process.

The nurse is checking medication prescriptions that were received by telephone for a client with hypertensive crisis and tachycardia. Which medication is *most* important to clarify with the healthcare provider (HCP)? •Carvedilol 12.5 mg PO BID daily •Hydrochlorothiazide 25 mg PO daily •Labetalol 20 mg IV over a 2-min time period now •Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg

•Hydroxyzine 50 mg PO as needed (PRN) systolic blood pressure greater than 160 mm Hg •Hydroxyzine is a first-generation antihistamine that is used to treat patients with anxiety and pruritus. It is likely that the correct medication is hydralazine, a vasodilator that is used to treat hypertension. Hydroxyzine and hydralazine are "look-alike, sound-alike" drugs that have been identified by the Institute for Safe Medication Practices (ISMP) as being at high risk for involvement in medication errors. All treatment prescriptions that are communicated by telephone should be reconfirmed with the health care provider; however, the most important order to clarify is the hydroxyzine, which is likely an error.

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is *most* important to clarify further with the health care provider? •Clopidogrel 75 mg/day •Ibuprofen 200 mg every 4 hours as needed •Metoprolol succinate 50 mg/day •Nitroglycerin patch 0.4 mg/hr

•Ibuprofen 200 mg every 4 hours as needed •Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for clients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the client but should be verified because the orders were received by telephone.

A client with a vancomycin-resistant enterococcus (VRE) infection is admitted to the medical unit. Which action can be delegated to the unlicensed assistive personnel (UAP) who is assisting with the client's care? •Teaching the client and family members about means to prevent transmission of VRE •Communicating with other departments when the client is transported for ordered tests •Implementing contact precautions when providing care for the client •Monitoring the results of ordered laboratory culture and sensitivity tests

•Implementing contact precautions when providing care for the client •All hospital personnel who care for the client are responsible for correct implementation of contact precautions. The other actions should be carried out by licensed nurses, whose education covers monitoring of laboratory results, client teaching, and communication with other departments about essential client data.

A 10-year-old girl has completed a course of amoxicillin for a urinary tract infection (UTI). This is the second UTI the child has had this year. The child is in the 95th percentile for weight and has a history of constipation. Her parents ask the nurse for preventive strategies for UTIs. Which of the following preventive strategies is *best* for the nurse to recommend? •Increase fiber in the diet •Drink cranberry juice •Increased vitamin C in a diet •Limit fluids at bedtime

•Increase fiber in the diet •Based on the history, this child's constipation is the most likely etiology of the UTI, and increasing dietary fiber is the best intervention. Urinary stasis from constipation is the primary cause of UTIs in children. Stool in the intestine prevents complete emptying of the bladder. There is no conclusive evidence to support that cranberry juice and vitamin C prevent UTIs. Limiting fluids at bedtime has not been shown to decrease UTI. Increasing fluids however, helps to flush bacteria out of the bladder.

A 3-month-old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud sound. Which response by the nurse is *best*? •Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •Tell the parents that if the behavior does not change by 6 months, the infant will need further evaluation •Remind the parents that this is a normal response that indicates the infant's hearing is intact •Reassure the parents that the behavior is normal and not an indicator of any problem such as cerebral palsy

•Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •The infant's behavior is consistent with the Moro and startle reflexes. The Moro reflex usually disappears by 6 months of age. The startle reflex usually disappears by 4 months of age. A hearing test is not based on response to loud sounds alone. Although it is true that further evaluation may be needed if the reflexes do not disappear, there is no need for the nurse to discuss this with the parents at this time. The infant's behavior is not consistent with cerebral palsy.

A client who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and complains of headache, nausea, and severe lightheadedness. Which action included in the treatment protocol should the nurse take *first*? •Give acetaminophen 650 mg PO •Administer ondansetron 4 mg IV •Infuse normal saline at 500 mL/hr •Increase oxygen flow rate to 6 L/min

•Infuse normal saline at 500 mL/hr •Because hypovolemia is a major concern with Ebola infection and IV fluid infusion has been demonstrated to improve outcomes, the nurse's first action will be to infuse normal saline. Treatment of nausea and headache are appropriate and should be implemented next. There is no indication that this client is hypoxemic, although clients with Ebola may develop multiorgan failure and require respiratory support.

The nurse is caring for a child with a foreign body in the ear canal who has not been evaluated by the health care provider. Which actions should the nurse implement? *Select all that apply.* •Inspect the pinna for trauma •Irrigate the auditory canal with warm water •Obtain a history for the type of object •Attempt to remove the object with forceps •Use an otoscope to check for perforation

•Inspect the pinna for trauma •Obtain a history for the type of object •The nurse should assess the pinna for trauma and obtain history for the type of object as a component of a complete assessment which could determine the course of action by the health care provider. Some foreign bodies may swell when water is used for irrigation, further lodging the object in the auditory canal. Removing the object with forceps could traumatize the tympanic membrane and auditory canal further. Placing an otoscope in the auditory canal could wedge the object further into the canal.

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is *most* indicative of a need for a change in therapy? •Blood pressure is 106/54 mm Hg •International normalized ratio (INR) is 1.2 •Bruises are noted at sites where blood has been drawn •Client reports eating a green salad for lunch every day

•International normalized ratio (INR) is 1.2 •An INR of 1.2 is not within the expected therapeutic range of 2 to 3 and indicates a need for an increase in warfarin dose. The blood pressure is in the low-normal range. Although the client will be encouraged to avoid injury, increased bruising is common when clients are taking anticoagulants and not a reason to discontinue the medication. Although foods that are high in vitamin K will have an impact on INR, this is not a concern when these foods are eaten consistently because the warfarin dose will be adjusted accordingly.

The nurse is caring for a client who is intubated and receiving mechanical ventilation. Which nursing actions are most essential in reducing the client's risk for ventilator-associated pneumonia (VAP)? *Select all that apply.* •Keep the head of the client's bed elevated to at least 30 degrees •Assess the client's readiness for extubation at least daily •Ensure that the pneumococcal vaccine is administered •Use a kinetic bed to continuously change the client's position •Provide oral care with chlorhexidine solution at least daily

•Keep the head of the client's bed elevated to at least 30 degrees •Assess the client's readiness for extubation at least daily •Provide oral care with chlorhexidine solution at least daily •The ventilator bundle developed by the Institute for Healthcare Improvement includes recommendations for continuous elevation of the head of the bed, daily assessment for extubation readiness, and daily oral care with chlorhexidine solution. Pneumococcal immunization will prevent pneumococcal pneumonia, but it is not designed to prevent VAP. The use of a kinetic bed may also be of benefit to the client, but it is not considered essential.

Which policy implemented by the infection control nurse will *most* effectively reduce the incidence of catheter-associated urinary tract infections (CAUTIs)? •Limit the use of indwelling urinary catheters in all hospitalized clients •Ensure that clients with catheters have at least a 1500-mL fluid intake daily •Use urine dipstick testing to screen catheterized clients for asymptomatic bacteriuria •Require the use of antimicrobial/antiseptic-impregnated catheters for catheterization

•Limit the use of indwelling urinary catheters in all hospitalized clients •According to the Centers for Disease Control and Prevention (CDC), CAUTIs are the most common health care-acquired infection in the United States. Recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible. Although a high fluid intake will also help to reduce the risk for CAUTIs, 1500 mL may be excessive for some clients. The CDC recommends against routine screening for asymptomatic bacteriuria. Antimicrobial catheters are a secondary recommendation and may be appropriate if other measures are not effective in reducing the incidence of CAUTIs.

The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is *most* appropriate to assign to an LPN/LVN team member? •Weighing all residents with heart failure each morning •Listening to lung sounds and checking for edema each week •Reviewing all heart failure medications with residents every month •Updating activity plans for residents with heart failure every quarter

•Listening to lung sounds and checking for edema each week •LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice.

These medications have been prescribed for a 9-year-old patient with deep partial- and full-thickness burns. Which medication is *most* important to double-check with another licensed nurse before administration? •Silver sulfadiazine ointment •Famotidine 20 mg IV •Lorazepam 0.5 mg PO •Multivitamin 1 tablet PO

•Lorazepam 0.5 mg PO •Oral sedation agents such as the benzodiazepines are considered high-alert medications when ordered for children, and extra precautions should be taken before administration. Many facilities require that all medications administered to pediatric patients be double-checked before administration, but the lorazepam is the most important to double-check with another nurse.

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is *most* important to discuss with the health care provider? •Serum potassium is 3.4 mEq/L (3.4 mmol/L) •Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L) •Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L) •Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L)

•Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L) •The client's low-density lipoprotein level continues to be elevated and indicates a need for further assessment (e.g., the client may not be taking the atorvastatin), a change in medication, or both. Although statin medications may cause rhabdomyolysis, which could increase BUN and potassium, the client's BUN and potassium are not elevated. Although ongoing monitoring of liver function is recommended when statins are used, this client's AST is normal.

Based on this information in a client's medical record, (health history: denies any chronic health problems, takes no medications currently; physical exam: height - 5 feet and 6 inches, weight - 115 lb or 52.2 kg, BMI of 18.6; social and diet history: work as an accountant, 1 glass of wine once or twice weekly, eats "fast food" frequently) which topic is the highest priority for the nurse to include in the initial teaching plan for a 26-year-old client who has blood pressures ranging from 150/84 to 162/90 mm Hg? •Symptoms of acute stroke and myocardial infarction •Adverse effects of alcohol on blood pressure •Methods for decreasing dietary caloric intake •Low-sodium food choices when eating out

•Low-sodium food choices when eating out •Current guidelines recommend low sodium intake for lifestyle management of hypertension, and the nurse should teach the client about the high sodium content in many fast foods and how to make low-sodium choices. A 26-year-old with this level of hypertension is not likely to have a stroke or myocardial infarction. Weight loss or changes in alcohol intake are not necessary. The client's weight and BMI are normal. Alcohol intake of less than 1 or 2 glasses of wine daily is recommended to prevent hypertension.

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is *most* appropriate to delegate to experienced unlicensed assistive personnel (UAP)? •Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated •Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing •Obtaining information about allergies from a client who is scheduled for left leg contrast venography •Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

•Measuring ankle and brachial pressures in a client for whom the ankle-brachial index is to be calculated •Measurement of ankle and brachial blood pressures for calculation is within the UAP's scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN.

A 4-year-old patient with acute lymphocytic leukemia has these medications ordered. Which one is *most* important to double-check with another licensed nurse? •Prednisone 1 mg PO •Amoxicillin 250 mg PO •Methotrexate 10 mg PO •Filgrastim 5 mcg subcutaneously

•Methotrexate 10 mg PO •Methotrexate is a high-alert drug, and extra precautions, such as double checking with another nurse, should be taken when administering this medication. Although many pediatric units have a policy requiring that all medication administration to children be double-checked, the other medications listed are not on the high-alert list published by the Institute for Safe Medication Practices.

A client has been diagnosed with disseminated herpes zoster. Which personal protective equipment (PPE) will the nurse need to put on when preparing to assess the client? *Select all that apply.* •Surgical face mask •N95 respirator •Gown •Gloves •Goggles •Shoe covers

•N95 respirator •Gown •Gloves •Because herpes zoster (shingles) is spread through airborne means and by direct contact with the lesions, the nurse should wear an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves. Surgical face masks filter only large particles and do not provide protection from herpes zoster. Goggles and shoe covers are not needed for airborne or contact precautions.

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take *next*? •Lower the client's left foot below heart level •Administer oxygen at 4 L/min to the client •Notify the health care provider about the change in status •Reassure the client that embolization is common in endocarditis

•Notify the health care provider about the change in status •The client's history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the health care provider should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain.

The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant Staphylococcus aureus (VRSA). Which nursing action can be assigned to an LPN/LVN? •Planning ways to improve the client's oral protein intake •Teaching the client about home care of the leg ulcer •Obtaining wound cultures during dressing changes •Assessing the risk for further skin breakdown

•Obtaining wound cultures during dressing changes •LPN/LVN education and scope of practice include performing dressing changes and obtaining specimens for wound culture. Teaching, assessment, and planning of care are complex actions that should be carried out by the RN.

The nurse notices that the health care provider omits hand hygiene after leaving a client's hospital room. Which action by the nurse is *best* at this time? •Report the health care provider to the infection control department •Offer the health care provider an alcohol based hand sanitizing fluid •Provide the health care provider with a list of upcoming inservices on hand hygiene •Remind the health care provider about the importance of minimizing infection spread

•Offer the health care provider an alcohol based hand sanitizing fluid •Because the most immediate need is to ensure that hand hygiene is accomplished, the nurse should offer an alcohol-based cleaner to the health care provider. The other actions may also be needed, especially if there is a pattern of nonadherence to hand hygiene, but further assessment is necessary before these actions are taken.

A 4-month-old infant boy is brought to the emergency department by his parents. He has been vomiting and fussy for the past 24 hours. On exam, there are circular bruises on his back. What *priority* assessment does the nurse anticipate? •Chest x-ray examination •Ultrasonography of the head •Electroencephalography •Ophthalmologic examination

•Ophthalmologic examination •The history and physical examination suggests shaken baby syndrome. An ophthalmologic examination is indicated to determine if the infant has retinal hemorrhages characteristic of shaken baby syndrome. Electroencephalography may be indicated if there is evidence of seizures. Magnetic resonance imaging or computed tomography of the head (not ultrasonography) can detect subdural hematomas. There is no evidence that would support the need for a chest x-ray examination.

A 88-year-old client who has not yet had the influenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is *most* important for the nurse to administer at this time? •Oseltamivir 75 mg PO •Guaifenesin 600 mg PO •Acetaminophen 650 mg PO •Influenza vaccine 180 mcg IM

•Oseltamivir 75 mg PO •Because antivirals are most effective when used early in influenza infection, the nurse should administer the oseltamivir as soon as possible to decrease the severity of the infection and risk of transmission to others. Guaifenesin and acetaminophen will help with the symptoms of cough and muscle aching but will not shorten the course of the client's illness or decrease risk of transmission. The influenza vaccine may still help in preventing future influenza caused by another virus.

An adolescent who was hospitalized for anorexia nervosa is following the prescribed treatment plan. Her self-esteem and weight have gradually improved, but she continues to refer to herself as "fatty." She is able to verbalize an appropriate diet and exercise plan. At this point, what is the *priority* concern? •Patient needs to continue to gain weight •Patient has an unrealistic body image •Patient needs more information about nutrition •Patient lacks motivation to adhere to therapy

•Patient has an unrealistic body image •The patient continues to refer to herself as "fatty" and still has a disturbed body image; however, she has appropriate knowledge, and her self-esteem has improved. The patient has demonstrated ability to follow the therapeutic plan while in the hospital. Interventions should be designed to help her to continue after discharge.

In which order will the nurse take these actions before doing wound irrigation and a dressing change for a client who has a wound infected with methicillin-resistant Staphylococcus aureus (MRSA)? •Don gloves •Put on gown •Perform hand hygiene •Place google over eyes •Put on mask to cover nose and mouth

•Perform hand hygiene •Put on gown •Put on mask to cover nose and mouth •Place google over eyes •Don gloves •Centers for Disease Control and Prevention guidelines recommend initially hand hygiene and then donning of gown, mask, goggles, and finally gloves to protect staff members and limit the spread of contamination. Goggles and a mask (or use of a face shield) will be needed with this dressing change because of the possibility of splashing during wound irrigation.

The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client's response 5 minutes after giving the medication, which finding indicates a need for *immediate* further action? •Blood pressure decrease from 114/65 to 106/58 mm Hg •Respiratory rate drop from 18 to 12 breaths/min •Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min •Persisting chest pain at a level of 1 (on a scale of 0 to 10)

•Persisting chest pain at a level of 1 (on a scale of 0 to 10) •The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time.

A client who has had recent exposure to Ebola while traveling in Africa arrives in the emergency department with fever, headache, vomiting, and multiple ecchymoses. Which action should the nurse take *first*? •Place the client in a private room •Obtain heart rate and blood pressure •Notify the hospital infection control nurse •Ask the client to describe type of Ebola exposure

•Place the client in a private room •Centers for Disease Control and Prevention guidelines recommend that the initial action be to place the client in a private room and implement standard, contact, and droplet precautions. Further assessment of the type of possible Ebola exposure, obtaining vital signs, and notification of the infection control nurse will also be needed but should be done after measures to minimize transmission of Ebola are implemented.

A client who has been diagnosed with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take *first*? •Place the client in an airborne isolation room •Initiate infusion of 500 mL of normal saline bolus •Ask the client about any recent travel to Asia •Obtain sputum specimen and nasal cultures

•Place the client in an airborne isolation room •The initial action should be to prevent transmission of avian influenza to other clients, visitors, or health care personnel through the use of airborne, contact, and standard isolation precautions. Initiating IV fluids, determining whether the client has been exposed to avian influenza through travel, and obtaining cultures are also appropriate, but the highest priority is to prevent spread of infection.

A hospitalized 88-year-old client who has been receiving antibiotics for 10 days tells the nurse about having frequent watery stools. Which action will the nurse take *first*? •Notify the health care provider about the stools •Obtain stool specimens for culture •Instruct the client about correct hand washing •Place the client on contact precautions

•Place the client on contact precautions •The client's age, history of antibiotic therapy, and watery stools suggest that he may have C. difficile infection. The initial action should be to place him on contact precautions to prevent the spread of C. difficile to other clients. The other actions are also needed and should be taken after placing the client on contact precautions.

A 16-year-old patient arrived at the cystic fibrosis (CF) clinic for a routine 3-month visit. The most recent respiratory culture results are negative. Which action is *best* for the nurse to take? •Place the patient in an exam room immediately upon arrival to the clinic •Allow the patient to wait in the reception area until the provider is available to see the patient •Allow the patient to wait in the reception area with a mask until the provider is available to see the patient •Place the patient in a waiting area with other patients who also have negative respiratory cultures

•Place the patient in an exam room immediately upon arrival to the clinic •This is a CF clinic, so this patient may be exposed to others with CF if he or she remains in the reception area. The CF Foundation recommends all individuals with CF, regardless of respiratory culture results, be separated from others with CF to reduce risk of droplet transmission of CF pathogens. National guidelines indicate that the best solution is that patients with CF not wait in common areas but be placed in a private exam room. However, when patients are in common waiting areas, a minimum distance of 3 feet (1 meter) between patients should be maintained if patients have CF.

A toddler is brought to the health center for a fever of 102°F (39°C) and a sore throat. As the nurse places a toddler and his parents in the exam room, the child experiences a tonic-clonic seizure. Which nursing action is a *priority*? •Assess the child's level of consciousness •Obtain an oxygen saturation •Loosen the child's clothing •Position the child in side-lying position

•Position the child in side-lying position •To ensure safety and prevent aspiration the first action by the nurse should be to position the child in side-lying position. Other assessment and actions will follow this initial step.

The RN is working with an LPN/LVN to provide care for a 10-year-old patient with severe abdominal, hip, and knee pain caused by a sickle cell crisis. Which action taken by the LPN/LVN requires the RN to intervene *immediately*? •Administering oral pain medication as needed •Positioning cold packs on the child's knees •Encouraging increased fluid intake •Monitoring vital signs every 2 hours

•Positioning cold packs on the child's knees •Sickle cell crisis may include vaso-occlusive crisis, splenic sequestration, and aplastic crisis. The symptoms experienced by this child are indicative of both vaso-occlusive crisis and splenic sequestration. Placing cold packs on the knees of a child with vaso-occlusive crisis results in vasoconstriction, placing the child at risk for thrombosis formation. Encouraging increased fluid intake is advised to prevent thrombosis formation. Monitoring vital signs is a method to assess for life-threatening complications associated with both vaso-occlusive crisis and splenic sequestration. Vaso-occlusive crisis is associated with severe pain and pain medication is recommended.

The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be *most* important to monitor? •Sodium level •Blood glucose level •Potassium level •Alkaline phosphatase level

•Potassium level •Hyperkalemia is a common adverse effect of both angiotensin-converting enzyme inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening.

At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take *first*? •Put the client on "nothing by mouth" (NPO) status •Teach the client about the procedure •Insert an IV catheter in the client's forearm •Attach the client to a cardiac monitor

•Put the client on "nothing by mouth" (NPO) status •Because transesophageal echocardiography is performed after the throat is numbed using a topical anesthetic and with the use of IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the echocardiogram but do not need to be implemented immediately.

A 16-year-old boy comes into the office of the school nurse complaining of left hip pain that began when playing basketball in gym class. The boy is in the 85th percentile for height and weight. He complains of increased pain with weight bearing. The nurse observes out-toeing of the left leg with ambulation. Which nursing action is a *priority*? •Administer ibuprofen and instruct the boy to rest •Apply heat to the hip and elevate the left leg •Refer the boy to the emergency department •Apply ice to the hip and immobilize it with a splint

•Refer the boy to the emergency department •This boy is presenting with classic symptoms of slipped capital femoral epiphysis (SCFE), which is a slippage of the femoral head at the proximal epiphyseal plate. SCFE is an emergency. A delay in treatment can result in necrosis and death of the femoral head. Although the exact cause of SCFE is unknown, there is an increased incidence in boys. Additionally, obesity is a risk factor for SCFE.

While reviewing a hospitalized client's medical record, the nurse obtains this information about cardiovascular risk factors (health history: hypertension for 10 years, takes hydrochlorothiazide 25 mg daily, blood pressure range 110/60 to 132/72 mmHg; family history: client's mother and 2 siblings have had myocardial infarctions; social history: 20 pack-year history of cigarette use, walks 2 to 3 miles daily). Which interventions will be important to include in the discharge plan for this client? *Select all that apply.* •Referral to community programs that assist in smoking cessation •Teaching about the impact of family history on cardiovascular risk •Education about the need for a change in antihypertensive therapy •Assistance in reducing emotional stress •Discussion of the risks associated with having a sedentary lifestyle

•Referral to community programs that assist in smoking cessation •Teaching about the impact of family history on cardiovascular risk •The client's major modifiable risk factor is ongoing smoking. The family history is significant, and the client should be aware that this increases cardiovascular risk. The blood pressure is well controlled on the current medication, and no change is needed. There is no indication that stress is a risk factor for this client, and the client's activity level meets the American Heart Association recommendation for at least 150 minutes of moderate activity weekly.

Which intervention for a 5-year-old child who still wets the bed would be *best* assigned to the unlicensed assistive personnel (UAP)? •Reminding the child to use the bathroom before going to bed •Teaching the mother about moisture alarm devices •Administering the prescribed dose of imipramine •Discussing research related to the use of hypnosis with the mother

•Reminding the child to use the bathroom before going to bed •Reminding the child about something that has already been taught is within the scope of practice for a UAP. An LPN/LVN could administer the oral medication. Teaching and discussion of other strategies for dealing with bed-wetting require additional education and are more appropriate to the scope of practice of the professional RN.

The nurse is preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will the nurse perform the following actions? •Remove N95 respirator •Take goggles •Remove gloves •Take off gown •Perform hand hygiene

•Remove gloves •Take goggles •Take off gown •Remove N95 respirator •Perform hand hygiene •This sequence will prevent contact of the contaminated gloves and gown with areas (e.g., the hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to the nurse and to other clients. If the nurse is wearing a disposable gown, the gown and gloves can be removed simultaneously by grasping the front of the gown and breaking the ties and then peeling the gloves off while removing the gown. The correct method for donning and removal of PPE has been standardized by agencies such as the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration.

An adolescent with cystic fibrosis (CF) is admitted to the pediatric unit with increased shortness of breath and pneumonia. Which nursing activity is *most* important to include in the patient's care? •Allowing the adolescent to decide if aerosolized medications are needed •Scheduling postural drainage and chest physiotherapy every 4 hours •Placing the adolescent in a room with another adolescent with CF •Encouraging oral fluid intake of 2400 mL/day

•Scheduling postural drainage and chest physiotherapy every 4 hours •National guidelines indicate that airway clearance techniques are critical for patients with CF; hence, postural drainage and chest physiotherapy are a priority. National guidelines also indicate that children and adolescents with CF who are hospitalized with respiratory illnesses should be placed on contact precautions. Furthermore, people with CF should be separated from others with CF to reduce droplet transmission of CF pathogens. There is no evidence that increased fluid intake adequately thins respiratory secretions, and chest physiotherapy is the priority.

Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of *most* concern? •Reports of increased fatigue and activity intolerance •Weight increase of 0.5 kg over a 1-week period •Sinus bradycardia at a rate of 48 beats/min •Traces of edema noted over both ankles

•Sinus bradycardia at a rate of 48 beats/min •Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, a heart rate of 48 beats/min indicates a need to decrease the carvedilol dose.

While administering vancomycin 500 mg IV to a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection, the nurse notices that the client's neck and face are becoming flushed. Which action should the nurse take *next*? •Discontinue the vancomycin infusion •Slow the rate of the vancomycin infusion •Obtain an order for an antihistamine •Check the client's temperature

•Slow the rate of the vancomycin infusion •"Red man" syndrome occurs when vancomycin is infused too quickly. Because the client needs the medication to treat the infection, vancomycin should not be discontinued. Antihistamines may help decrease the flushing, but vancomycin should be administered over at least 60 minutes to avoid vasodilation. Although the client's temperature will be monitored, a temperature elevation is not the most likely cause of the client's flushing.

The nurse is caring for a newly admitted client with increasing dyspnea, hypoxia, and dehydration who has possible avian influenza ("bird flu"). Which of these prescribed actions will the nurse implement *first*? •Start oxygen using a nonrebreather mask •Infuse 5% dextrose in water at 100 mL/hr •Administer the first dose of oral oseltamivir •Obtain blood and sputum specimens for testing

•Start oxygen using a nonrebreather mask •Because the respiratory manifestations associated with avian influenza are potentially life threatening, the nurse's initial action should be to start oxygen therapy. The other interventions should be implemented after addressing the client's respiratory problems.

The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take *next*? •Prepare to defibrillate the client •Offer to take over chest compressions •State: "Epinephrine 1 mg IV has been given." •Continue to monitor the client's responsiveness.

•State: "Epinephrine 1 mg IV has been given." •The American Heart Association recommends "closed loop" communication between team members who are involved in resuscitation of a client. The other actions may also be needed, but the initial action after administering a medication is to assure that the team leader knows that the prescribed medication has been administered.

A child with Hirschsprung disease arrives on the pediatric unit from the operating room with a temporary colostomy. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? •Assess the frequency and consistency of stool •Instruct the parents on skin care •Stock the room with ostomy supplies •Assess the patient for pain

•Stock the room with ostomy supplies •Assessment and patient teaching is the responsibility of the RN. The UAP may stock the room with ostomy supplies but the nurse would give instructions or validate the UAP's knowledge of supplies.

The nurse is preparing to care for a 6-year-old child who has just undergone allogenic stem cell transplantation. Which nursing tasks should the nurse delegate to the unlicensed assistive personnel (UAP)? *Select all that apply.* •Stocking the child's room with standard personal protective equipment items •Teaching the child to perform thorough hand washing after using the bathroom •Reminding the child to wear a face mask outside of the hospital room •Assessing the child's oral cavity for signs and symptoms of infection •Talking to the family members about the methods to reduce risk of infection

•Stocking the child's room with standard personal protective equipment items •Reminding the child to wear a face mask outside of the hospital room •Because all patient care staff members should be familiar with standard personal protective equipment, a UAP will be able to stock the room. Reminding the child to wear a face mask is also a task that can be done by a UAP, although the RN is responsible for the initial teaching. Initially teaching the child hand-washing technique, nursing assessments, and family education is within the scope of the registered nurse and not a UAP.

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is *most* important to report to the health care provider? •Stools have been black in color •Bruising is present at the right groin •Home blood pressure today was 104/52 mm Hg •Home radial pulse rate has been 55 to 60 beats/min

•Stools have been black in color •Dark or tarry stools may indicate gastrointestinal bleeding, which is a possible adverse effect of both aspirin and clopidogrel. The client will need to continue on the medications but may need treatment with proton pump inhibitors or histamine2 blockers to decrease risk for gastrointestinal bleeding. The other findings will also be reported to the health care provider but will not require a change in the therapeutic plan for the client.

A 7-month-old infant arrives at the health center for a scheduled well-child visit. When the nurse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the *best* explanation for the infant's behavior? •Separation anxiety •Disassociation disorder •Stranger anxiety •Autism spectrum

•Stranger anxiety •This infant is displaying stranger anxiety; the child becomes anxious when exposed to unfamiliar people (strangers). Separation anxiety occurs when the child is separated from the primary caregiver; anxiety and crying are also common behaviors. Stranger anxiety and separation anxiety are concurrent and generally begin at 7 to 8 months of age. Disassociation disorder is characterized by disconnected thoughts and is not a disorder of infancy. Autism spectrum is characterized by poor social interaction. The age of the child is significant because autism is not usually detected at 7 months of age.

The nurse is assisting with the delivery of a 31-week gestational age premature newborn who requires intubation for respiratory distress syndrome (RDS). Which medication does the nurse anticipate will be needed first for this infant? •Theophylline •Surfactant •Dexamethasone •Albuterol

•Surfactant •Research indicates that the administration of synthetic surfactant improves respiratory status and decreases the incidence of pneumothorax in premature infants with RDS. The other medications may be used if respiratory distress persists, but the first medication administered will be the surfactant.

The nurse is caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of *most* concern? •Bulging of the sac when the infant cries •Oozing of stool from the anal sphincter •Flaccid paralysis of both legs •Temperature of 101.8°F (38.8°C)

•Temperature of 101.8°F (38.8°C) •The elevated temperature indicates possible infection and should be reported immediately to the surgeon so that treatment can be started. The other data are typical in an infant with myelomeningocele.

Which finding in a client with aortic stenosis will be *most* important for the nurse to report to the health care provider? •Temperature of 102.1°F (38.9°C) •Loud systolic murmur over sternum •Blood pressure of 110/88 mm Hg •Weak radial and pedal pulses to palpation

•Temperature of 102.1°F (38.9°C) •Because endocarditis is a concern with valvular disease, an elevated temperature indicates a need for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systolic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic stenosis and do not indicate an immediate need for further evaluation or treatment.

A healthy 65-year-old client who cares for a newborn term-33grandchild has a clinic appointment in May. The client needs several immunizations but tells the nurse, "I hate shots! I will only take one today." Which immunization is *most* important to give? •Influenza •Herpes zoster •Pneumococcal •Tetanus, diphtheria, pertussis

•Tetanus, diphtheria, pertussis •Individuals who have contact with infants should be immunized against pertussis to avoid infection and to prevent transmission to the infant. The influenza and pneumococcal vaccines can be administered later in the year, before the influenza season. The herpes zoster vaccine is important to prevent shingles in the client but does not need to be administered today.

The nurse is obtaining the history and physical information for a child who is recovering from Kawasaki disease and receives aspirin therapy. Which information concerns the nurse the *most*? •The child attends a day-care center 5 days a week •The child's fingers have areas of peeling skin •The child is very irritable and cries frequently •The child has not received any immunizations

•The child has not received any immunizations •Children who receive aspirin therapy are at risk for the development of Reye syndrome if they contract viral illnesses such as varicella or influenza, so the lack of immunization is the greatest concern for this child. Peeling skin on the fingers and toes and irritability are consistent with Kawasaki disease but do not require any change in therapy. Because Kawasaki disease is not a communicable disease, there is no risk for transmission to other children in the day care (although assuring that immunizations are up to date before returning to day care is important).

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril-valsartan. Which client information is *most* important to discuss with the health care provider before administration of the medication? •The client's oxygen saturation is 92% •The client receives lisinopril 10 mg/day •The client's blood pressure is 150/90 mm Hg •The client's potassium is 3.3 mEq/L (3.3 mmol/L)

•The client receives lisinopril 10 mg/day •Because combination angiotensin receptor blocker-neprilysin blockers markedly increase the risk for angioedema in clients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril-valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension is increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril-valsartan.

At 9:00 pm, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is *most* important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client? •The client was treated with alteplase about 8 months ago •The client takes famotidine for gastroesophageal reflux disease •The client has ST-segment elevations on the electrocardiogram (ECG) •The client reports having continuous chest pain since 8:00 am

•The client reports having continuous chest pain since 8:00 am •Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are usually not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use.

A tearful parent brings a child to the emergency department after the child takes an unknown amount of children's chewable vitamins at an unknown time. The child is currently alert and asymptomatic. What information should be *immediately* reported to the health care provider? •The ingested children's chewable vitamins contain iron •The child has been treated previously for ingestion of toxic substances •The child has been treated several times before for accidental injuries •The child was nauseated and vomited once at home

•The ingested children's chewable vitamins contain iron •Iron is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure. Deferoxamine is an antidote that can be used for severe cases of iron poisoning. The other information needs additional investigation but will not change the immediate diagnostic testing or treatment plan.

The nurse obtains this information when assessing a 3-year-old patient with uncorrected tetralogy of Fallot who is crying. Which finding requires *immediate* action? •The apical pulse rate is 118 beats/min •A loud systolic murmur is heard in the pulmonic area •There is marked clubbing of the child's nail beds •The lips and oral mucosa are dusky in color

•The lips and oral mucosa are dusky in color •Circumoral cyanosis indicates a drop in the partial pressure of oxygen that may precipitate seizures and loss of consciousness. The nurse should rapidly place the child in a knee-chest position, administer oxygen, and take steps to calm the child. The other assessment data are expected in a child with congenital heart defects such as tetralogy of Fallot.

The nurse has received a needlestick injury after giving a client an intramuscular injection, but has no information about whether the client has human immunodeficiency virus (HIV) infection. What is the *most* appropriate method of obtaining this information about the client? •The nurse should personally ask the client to authorize HIV testing •The charge nurse should tell the client about the need for HIV testing •The occupational health nurse should discuss HIV status with the client •HIV testing should be performed the next time blood is drawn for other tests

•The occupational health nurse should discuss HIV status with the client •The staff member who is most knowledgeable about the regulations regarding HIV prophylaxis and about how to obtain a client's HIV status and/or order HIV testing is the occupational health nurse. It is unethical for the nurse to personally ask the client to consent to HIV testing or to perform unauthorized HIV testing. The charge nurse is not responsible for obtaining this information (unless the charge nurse is also in charge of occupational health).

The nurse is preparing a child for IV moderate (conscious) sedation before repair of a facial laceration. What information should the nurse *immediately* report to the health care provider? •The parent is unsure about the child's tetanus immunization status •The child is upset and pulls out the IV •The parent declines the IV moderate (conscious) sedation •The parent wants information about the IV moderate (conscious) sedation

•The parent declines the IV moderate (conscious) sedation •Parental refusal is an absolute contraindication; therefore, the provider must be notified. Tetanus status can be addressed later. The RN can reestablish the IV access and provide information about moderate (conscious) sedation; if the parent is still not satisfied, the provider can give more information.

The nurse is providing nursing care for a newborn infant with respiratory distress syndrome (RDS) who is receiving nasal continuous positive airway pressure ventilation. Which assessment finding is *most* important to report to the health care provider? •Apical pulse rate of 156 beats/min •Crackles audible in both lungs •Tracheal deviation to the right •Oxygen saturation of 93%

•Tracheal deviation to the right •Tracheal deviation suggests tension pneumothorax, a possible complication of positive-pressure ventilation. The nurse will need to communicate rapidly with the health care provider and assist with actions such as chest tube insertion. The heart rate, crackles, and oxygen saturation will be reported to the health care provider but are expected in RDS and do not require immediate intervention.

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be *most* useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol? •Creatine kinase MB level •Troponin I level •Myoglobin level •C-reactive protein level

•Troponin I level •Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarction (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglobin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myoglobin is nonspecific. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction.

Which medication order for a client with a pulmonary embolism is *most* important to clarify with the prescribing health care provider before administration? •Warfarin 1.0 mg PO •Morphine 2 to 4 mg IV •Cephalexin 250 mg PO •Heparin infusion at 900 units/hr

•Warfarin 1.0 mg PO •The Institute for Safe Medication Practices guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate based on the client's diagnosis.

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is *most* important to double-check with another licensed nurse? •Famotidine 20 mg IV •Furosemide 40 mg IV •Digoxin 0.25 mg PO •Warfarin 2.5 mg PO

•Warfarin 2.5 mg PO •Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed.

A 6-year-old girl arrives in the emergency department with her parents. She hit her head when she fell from the jungle gym in the school playground. Which questions are appropriate for the nurse to ask to assess the child's neurologic status? *Select all that apply.* •What is your home address? •What time does your family eat dinner? •What grade are you in? •What is your teacher's name? •What time did you fall? •What is the name of your school?

•What is your home address? •What grade are you in? •What is your teacher's name? •What is the name of your school? •This child is in Piaget's stage of concrete operations. Children in this stage can organize experiences and understand some complex information. However, children in this age group have difficulty conceptualizing time; therefore, asking questions about the time that incidents occur will not be helpful in determining the child's orientation.

When the nurse is educating a group of women of childbearing age about the Zika virus, which information will be included? *Select all that apply.* •Women who are pregnant will be asked about possible Zika exposure at each prenatal visit •Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika •There is a high risk for maternal death when women are infected with the Zika virus during pregnancy •Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission •Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure

•Women who are pregnant will be asked about possible Zika exposure at each prenatal visit •Testing for recent infection with the Zika virus is available for women who may have been exposed to Zika •Women who are trying to get pregnant should avoid travel to geographic areas with active Zika virus transmission •Barrier methods such as condoms should be used during intercourse if the sex partner has possible Zika exposure •National guidelines recommend that all pregnant women be assessed for Zika exposure at each prenatal visit, that women who may have been exposed be tested, that women who are anticipating pregnancy should avoid travel to areas where they might be exposed to Zika, and that barrier methods be used if the sex partner has been exposed to Zika infection. Congenital defects to the fetus occur if there is Zika infection during pregnancy, but the maternal infection is usually mild and nonfatal.

A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hour. Based on the heparin concentration on the label (40 usp/mL), the nurse will set the infusion pump to deliver __________ mL/hr.

• 17.5 mL/hr •Each mL of the solution contains heparin 40 units; 700 units/hour equals 17.5 mL/hr.

A 70-kg client who has had unprotected sexual intercourse with a partner who has hepatitis B is to receive 0.06 mL/kg of hepatitis B immune globulin. The immune globulin is available in a 5-mL vial. The nurse will plan to administer __________ mL.

• 4.2 mL •0.06 mL × 70 kg = 4.2 mL

The pediatric unit charge nurse is working with a new RN. Which action by the new RN requires the *most* immediate action on the part of the pediatric unit charge nurse? •Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy •Placing a newly admitted child with respiratory syncytial virus (RSV) infection in a room with another child who has RSV •Wearing a N95 respirator mask when caring for a child with tuberculosis •Performing hand hygiene with soap and water after caring for a child with diarrhea caused by Clostridium difficile

•Wearing gloves, gowns, and a mask for a neutropenic child who is receiving chemotherapy •Protective isolation (wearing gloves, gowns, and mask) revealed no significant differences in infection rates for children who are neutropenic. General standard precautions are advised with routine patient care. Although private rooms are preferred for patients who need droplet precautions, such as patients with RSV infection, they can be placed in rooms with other patients with exactly the same microorganism. An N95 respirator is recommended for tuberculosis. Washing hands with soap and water after caring for a patient with C. difficile is also recommended.

A 6-year-old child arrives in the emergency department with active seizures. Which assessment is a priority for the nurse to obtain? •Heart rate •Body mass index (BMI) •Blood pressure •Weight

•Weight •The child will need medication to control the seizures. Medications for children are based on weight in kilograms. Although heart rate and blood pressure may be obtained, the priority is to stop the seizures with medication. There is no clinical indication for BMI for a child with active seizures.

The nurse is caring for a confused and agitated client who has wrist restraints in place on both arms. Which action included in the client plan of care can be assigned to an LPN/LVN? •Determining whether the client's mental status justifies the continued use of restraints •Undoing and retying the restraints to improve client comfort •Reporting the client's status and continued need for restraints to the health care provider •Explaining the purpose of the restraints to the client's family members

•Undoing and retying the restraints to improve client comfort •Hospital staff who have been trained in the appropriate application of restraints may reposition the restraints. Evaluation of the continued need for restraints, communication with the provider about the client's status, and teaching of the family require RN-level education and scope of practice.

During a home visit to an 88-year-old client who is taking digoxin 0.25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is *most* important to communicate to the health care provider? •Apical pulse 68 beats/min and irregular •Digoxin taken with meals •Vision that is becoming "fuzzy" •Lung crackles that clear after coughing

•Vision that is becoming "fuzzy" •The client's visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure.

The nurse is caring for a 3-year-old patient who has returned to the pediatric intensive care unit after insertion of a ventriculoperitoneal shunt to correct hydrocephalus. Which assessment finding is *most* important to communicate to the surgeon? •The child is crying and says, "It hurts!" •The right pupil is 1 mm larger than the left pupil •The cardiac monitor shows a heart rate of 130 beats/min •The head dressing has a 2-cm area of bloody drainage

•The right pupil is 1 mm larger than the left pupil •Pupil dilation may indicate increased intracranial pressure and should be reported immediately to the surgeon. The other data are not unusual in a 3-year-old patient after surgery, although they indicate the need for ongoing assessments or interventions.

A client with atrial fibrillation is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, "I feel really dizzy." Which action should the nurse take *first*? •Help the client to sit down •Check the client's apical pulse •Take the client's blood pressure •Have the client breathe deeply

•Help the client to sit down •The first priority for an ambulating client who is dizzy is to prevent falls, which could lead to serious injury. The other actions are also appropriate but are not as high a priority.

A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed. Which finding should be reported *immediately* before surgery proceeds? •Palpable sausage-shaped abdominal mass •Passage of normal brown stool •Passage of currant jelly-like stools •Frequent nausea and vomiting

•Passage of normal brown stool •Passage of brown stool indicates resolution of the intussusception, so surgery may not be necessary. The other findings are part of the clinical presentation of this disorder.