Fundamentals

Which situations would require the nurse to obtain a prescription for physical restraints?

A physical restraint is a device or method used to immobilize or limit physical mobility or body movement to prevent falls, injury to self or others, or removal of medical devices. The client situation, rather than the device, determines whether it is classified as a restraint. Prescribed orthopedic immobilizers and protective devices used temporarily during routine procedures or examinations are not considered physical restraints and do not require authorization for use from a health care provider. Restraints should be used only after less invasive methods have failed and must be discontinued at the earliest time possible once it is safe to do so. The belt restraint is applied at the waist and tied to the bed frame under the mattress with straps using a quick-releaseknot. It is used to protect a confused or disoriented client who is on bed rest. Although the client can turn, it is considered a restraint because it restricts physical mobility and confines the client to the bed involuntarily (Option 1). Soft limb restraints (eg, wrist, ankle) immobilize one or more extremities and are used for the prevention of falls or attempted removal of devices. Following a procedure requiring sedation, clients may require restraints to protect them from disrupting a surgical site or medical device until they are alert enough to follow instructions independently (Option 5). Limb restraints should be applied loosely enough that 2 fingers can be inserted underneath the secured restraint. The nurse should closely monitor the peripheral neurovascular status and skin integrity of a client's restrained extremity. (Option 2) Elbow restraints used as a protective device to temporarily immobilize a child (<30 minutes) to perform a medical, diagnostic (eg, drawing blood), or surgical procedure are not considered a physical restraint. (Option 3) The use of full padded side rails in the raised position for clients during a seizure protects them from immediate injury; these are not considered a restraint. (Option 4) An orthopedic leg immobilizer used to restrict movement and maintain a client's extremity in proper alignment is prescribed for therapeutic purposes and is not considered a restraint.

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)?

Health care catheter-associated UTIs are prevalent among hospitalized clients with indwelling urinary catheters. Steps to prevent infections in clients with urinary catheters include the following: Wash hands thoroughly and regularly Perform routine perineal hygiene with soap and water each shift and after bowel movements Keep drainage system off the floor or contaminated surfaces Keep the catheter bag below the level of the bladder Ensure each client has a separate, clean container to empty collection bag and measure urine Use sterile technique when collecting a urine specimen Facilitate drainage of urine from tube to bag to prevent pooling of urine in the tube or backflow into the bladder Avoid prolonged kinking, clamping, or obstruction of the catheter tubing Encourage oral fluid intake in clients who are awake and if not contraindicated Secure the catheter in accordance with hospital policy (tape or Velcro device) Inspect the catheter and tubing for integrity, secure connections, and possible kinks (Option 1) Perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to the development of drug-resistant bacteria. (Option 4) Routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention.

Clean catch urine specimen

A clean catch urine specimen is commonly performed in clients requiring urinalysis. The correct collection method for a female client is as follows: 1. Perform hand hygiene and open the specimen container, leaving the sterile side of the collection lid positioned upward to prevent contamination. 2. Spread the labia using the index finger and the thumb of the nondominant hand so that the specimen cup can be held with the dominant hand. 3. Cleanse the vulva in a front-to-back motion with provided antiseptic wipes, using a new towelette with each wipe to prevent contamination. 4. Initiate the urinary stream to flush any remaining microorganisms from the urethral meatus before passing the container into the stream for the collection of 30-60 mL of urine. 5. Remove the specimen container from the stream before the urinary flow ends and the labia are released to prevent contamination. Replace the sterile cap without contaminating it and repeat hand hygiene.

The charge nurse must assign rooms to 4 clients who are scheduled for admission. Which client has the highest priorityfor a private room assignment?

A client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others. If signs of infection are absent, treatment is not required. Colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required. The Centers for Disease Control and Prevention (CDC) recommends placing a colonized client on contact precautions and in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. Therefore, the client with pneumonia should be placed in the private room. (Options 1 and 3) The CDC recommends standard precautions for clients with hepatitis C and those who are HIV positive. A private room is not necessary for a client who has osteomyelitis or diabetic ketoacidosis. (Option 2) A client with a latent tuberculosis infection (LTBI) has a positive tuberculin skin test, has no symptoms of infection, and is not contagious. Immunosuppressant drugs, chemotherapy, and debilitating disease can convert a LTBI to active disease. At this time, the client requires only standard precautions.

A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building?

A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter. (Option 1) The goal is for the client to always have an informed refusal and to sign the legal form to indicate understanding of that information. However, if the client refuses to sign, the client is still allowed to leave (failure to do so constitutes false imprisonment). The nurse should have witnesses to the events and clearly document in the chart what happened and that the client refused to sign. (Option 2) Discharge instructions, results, and prescriptions can be given despite the client leaving AMA. However, it is not essential to provide the clients with results. Removing the catheter is the priority. (Option 3) Reassuring that a client can return is ethical as the desire is for the client to receive needed care. However, it is not a priority over removal of the catheter.

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions?

A tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma. (Option 2) Skin preparation involves cleaning using an antiseptic solution and friction and allowing the skin to air dry. Remaining solution may hemolyze and/or dilute the blood sample. Traditionally, alcohol (alone or with povidone iodine) is applied in a circular motion, from insertion site outward (clean to dirty). Current research suggests that the most effective method is applying chlorhexidine (2%) in a back and forth motion, followed by adequate drying time. (Option 4) The veins on the ventral aspect of the wrist are located near nerves, resulting in painful venipuncture and a higher risk of nerve injury. There is also an increased risk of arterial access on the ventral aspect of the wrist, and so this site should be avoided. (Option 5) The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results.

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia?

A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: Having the client sit upright with the chin flexed slightly toward the chest Monitoring for a wet or garbled-sounding voice Monitoring for signs of fever (Option 1) Inflating the cuff makes it difficult for a client who is awake to swallow and talk. In addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it, causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of aspiration. (Option 2) Having the client sit upright will help reduce the risk of aspiration. However, the chin should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration. (Option 4) There is no reason to give pureed foods just because the client has a tracheostomy. The client's diet should be determined by a swallowing evaluation.

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next?

Before administering intermittent (bolus) enteral feedings, the nurse must verify tube placement, such as with x-ray confirmation or gastric pH measurement (<=5). Ensuring that the tip of the feeding tube is correctly placed in the stomach or small intestine is essential because administration of enteral feeding through a misplaced tube may result in life-threatening aspiration (Option 1). (Option 2) Gastric residual volume (GRV) is one indicator of how well the client is tolerating enteral feedings. High GRV (eg, >500 mL) may indicate delayed gastric emptying and poor intestinal motility (ie, feeding intolerance), which is traditionally considered a risk factor for aspiration. The nurse should follow facility policy or contact the health care provider (HCP) to determine if feedings should be delayed for high GRV or other symptoms of intolerance (eg, gastric distension, nausea/vomiting). GRVs are traditionally checked every 4 hours with continuous feeding or before each intermittent feeding. However, some facilities no longer routinely check GRVs because recent evidence shows that this practice impairs calorie delivery and may be ineffective for predicting aspiration risk. (Option 3) Repeatedly discarding gastric contents can cause hypokalemia and metabolic alkalosis. If GRV is excessively high, contents may be discarded to relieve abdominal distension (per facility policy or HCP prescription). However, GRV of 80 mL is not excessive and should be returned to the stomach. (Option 4) Tube placement must be verified before enteral feedings.

A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate?

Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: 1. Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option 1). 2. Ensure that blood type and Rh type are compatible (Option 3). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. 3. Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option 5). 4. Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). 5. Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option 2) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option 4) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product.

The nurse admits an adult client with partial-thickness burns to the anterior surface of the right leg and the anterior and posterior torso. The client weighs 198 lb. The total body surface area burned is calculated using the rule of nines. How many mL of IV fluid will the client require in the first 24 hours? Record your answer using a whole number. Gave the Parkland formula in the exhibit.

Burn injuries are caused by direct tissue damage from exposure to caustic sources (eg, thermal, chemical, electric). This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses often lead to hypovolemic shock in clients with extensive burns and require emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after the injury, when many clients have the greatest amount of intravascular volume loss. Use the following steps to calculate the volume needed for infusion: Calculate the total body surface area (TBSA) burned using the rule of nines (anterior torso)+(posterior torso)+(anterior leg)=TBSA burnedanterior torso+posterior torso+anterior leg=TBSA burned OR 18%+18%+9%=45% TBSA burned18%+18%+9%=45% TBSA burned Convert pounds to kilograms to determine body weight (1 kg2.2 lb)(198 lb )=90 kg1 kg2.2 lb198 lb =90 kg Calculate the volume needed for infusion 4 mL × body weight (kg)×TBSA burned (%)=infusion volume (mL)4 mL × body weight kg×TBSA burned %=infusion volume mL OR 4 mL × 90 kg × 45% TBSA = 16200 mL4 mL × 90 kg × 45% TBSA = 16200 mL

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

Client and staff safety is an ongoing concern when working with clients who are confused and agitated. The least restrictive restraint should be used. One-on-one supervision provided by a trained staff member who stays with the client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and the client's situation) can lessen disruptive behaviors. Placing a large clock and calendar within the client's visibility would also help. (Option 1) Ideally, the client will be placed in a room near the nursing station. However, the client with delirium and agitation will also require ongoing supervision to minimize harm to self or others. (Option 2) Four-point leather restraints are one of the most restrictive restraint options. These are not appropriate as a first-line option for promoting safety. (Option 3) Reducing environmental stimuli is important for an agitated client, but these alone are not most helpful.

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?

Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. The 80-year-old client with COPD in the ICU on the ventilator has several of these risk factors. COPD is a chronic illness that can affect the immune system, and clients experience exacerbations that may require frequent antibiotic and corticosteroid use. This client is elderly and also has an invasive tube from the ventilator. (Option 1) A student athlete could be colonized with MRSA from time spent in locker rooms and around athletic equipment. MRSA more often appears as skin infections in this age group. Unless this client has an open fracture, there is no break in skin integrity. (Option 2) This client does have an incision (portal of entry) and invasive lines but is younger and has no evidence of suppressed immunity. (Option 3) This client is older and does have a small surgical incision but is not as high risk as the client with COPD. All clients undergoing pacemaker placement will receive a prophylactic antibiotic to prevent surgical site infection just before surgery.

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia. The client needs a peripheral IV line for fluid administration. Which IV site should the nurse select to reduce the risk for infection?

Clients most at risk for catheter-related bloodstream infections are those with compromised immune systems; therefore, this client is at high risk. The IV site chosen for catheter insertion can influence the infection risk. The risk is higher using the lower extremities compared to the upper extremities and using the wrist or upper arm compared to the hand. Unless the client is very old or very young, the hand is a good site as it is most distal, allowing future sites to be selected higher on the arm if needed. (Option 1) The antecubital fossa is commonly selected in emergency situations due to its size and ease of cannulation but is problem prone for longer-term needs as it is in the bend of the elbow. Bending of the arm can move the catheter, causing irritation at the insertion site and increasing infection risk. (Option 3) The foot is not typically accessed in adults without a specific health care provider prescription. It is occasionally used in emergency situations; however, veins in the legs and feet may have decreased venous return, and complications can lead to thrombophlebitis or deep vein thrombosis. (Option 4) The radial vein is present on the lateral side of the wrist but is in close proximity to several nerves, which could cause severe pain or nerve damage.

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

Clients who have undergone surgery (eg, coronary artery bypass graft) may experience some postoperative cognitive dysfunction (POCD). This may include memory impairment and problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. POCD can occur days to weeks following surgery. Most symptoms typically resolve after complete healing has occurred. In some cases, this condition can become a permanent disorder (Option 3). (Option 1) The client will most likely feel better in a few weeks, but this statement is not therapeutic and does not really provide any useful information. (Option 2) This is good information for the nurse to have, but it does not directly relate to the client's issues of forgetfulness and becoming teary often. (Option 4) Two weeks postoperative is most likely too early for a diagnosis of depression. Depression can occur after a major illness or surgery, but antidepressants would be considered only for persistent symptoms.

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus(MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action?

Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact precautions to prevent transmission of microorganisms. Contact precautions include standard precaution measures in addition to use of a gown and gloves and single-client-use equipment (eg, stethoscopes, blood pressure cuffs, thermometers). Disposable or single-client-use equipment must not be shared between clients or transferred to other care areas. Dedicated equipment should be kept in the room for client care, and then disinfected or discarded when no longer needed (Option 1). (Option 2) The urine specimen should be placed in a leak-proof specimen cup and then sealed in a biohazard bag before transport to the laboratory. (Option 3) To prevent specimen contamination and the introduction of bacteria into the client's urinary tract, the nurse should scrub the Foley collection port with alcohol or chlorhexidine for 15 seconds before withdrawing a specimen. (Option 4) Hand hygiene with an alcohol-based hand rub is recommended, unless there is visible soiling of the hands with body fluids, or after contact with Clostridium difficile. In both situations, hand hygiene must be performed with soap and water to thoroughly remove contaminants left behind by alcohol-based rubs.

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA). Which instructions would be most effective for reducing infection?

Current evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. (Option 1) This action may be appropriate for a client in the home setting. However, most clients in the ICU are unable to go to the shower or have monitoring equipment and/or invasive lines that would make bathing difficult. Chlorhexidine is recommended in the hospital setting. (Option 2) It is not appropriate to delay bathing as the client's skin and incision need to be cleaned. Delay should only occur if the client is unstable. (Option 3) This option would be appropriate if the bath water contained a solution of chlorhexidine.

dehiscence

Dehiscence is a complication of poor wound healing that occurs when the edges of a surgical wound fail to approximate and separate (ie, partial or total separation of the skin and/or tissue layers). Dehiscence is associated with factors that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use) and with mechanical stress on the wound (eg, straining to cough, vomit, or defecate). Interventions to prevent abdominal wound dehiscence include: Administering stool softeners (eg, docusate) to prevent straining and constipation from postoperative immobility and opioid pain medications (Option 1) Administering antiemetics (eg, ondansetron) as needed for nausea to prevent straining that can occur with vomiting (Option 2) Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving (Option 3) Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL [7.8 mmol/L] fasting glucose; <180 mg/dL [10 mmol/L] random glucose) to decrease infection risk and promote wound healing (Option 5) Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving

A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client?

Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement?

Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube (Option 3). Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption (Option 2). In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency (Option 4). (Option 1) When using a feeding tube, each medication should be administered individually to prevent interactions between medications. (Option 5) Medications mixed with enteral feedings may form a thick consistency and clog the tube.

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?

Flushing the lumen of a central venous access device (central venous catheter [CVC]) with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC (Option 3). The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC. (Options 1 and 2) A smaller syringe (eg, 1 mL, 3 mL) creates more pressure, which increases the risk for damage to the CVC. (Option 4) A 30-mL syringe is unnecessarily large to flush a CVC.

The home health nurse visits a client who is rehabilitating after a tibial fracture. Which interventions are appropriate to include in the client's teaching plan to promote safety in the home when using crutches?

Interventions to promote safety when using crutches in the home include the following: Keep the environment free of clutter and remove scatter rugs to reduce fall risk (Options 1 and 3) Look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk (Option 2) Use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking (Option 4) Wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk (Option 5) Rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard Keep crutch rubber tips dry. Replace them if worn to prevent slipping.

Intradermal injections

Intradermal dermal injections deliver a small amount of medication (0.1 mL) into the dermal layer of the skin, just under the epidermis. This parenteral route is used to perform allergy testing and tuberculosis (TB) screening. The correct procedure for administering a TB intradermal injection is as follows: 1. Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch (Option 2). 2. Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. 3. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. 4. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees (Option 4). 5. Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis (Option 1). 6. Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis (Option 3). 7. Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. 8. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction.

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy?

Latex allergy is an exaggerated immune-mediated reaction when one is exposed to products or dusts containing latex, a natural rubber used in many medical devices (eg, gloves, catheters, tape). Many people, particularly health care workers and individuals requiring chronic invasive procedures (eg, self-catheterization), develop latex allergy from repeated exposures. When assessing for potential latex allergies, the nurse should inquire about the client's reactions to common latex-containing objects and potentially cross-allergenic products. Balloons commonly contain latex, and reports of lip swelling, itching, or hives after contact indicate a high risk for anaphylactic reactions with continued exposure (Option 5). Many food allergies (eg, avocado, banana, tomato) also increase the risk for latex allergy because the food proteins are similar to those found in latex (Option 3). (Option 1) There is no documented cross-sensitivity reaction between ACE inhibitors (eg, lisinopril) and latex. (Option 2) Epilepsy is not associated with an increased risk for latex allergy. However, clients who have spina bifida or who have undergone multiple surgeries are at increased risk. (Option 4) Shellfish allergy was previously believed to be associated with allergy to iodine (CT contrast material), which has now been disproved. Shellfish allergy has no relationship to latex allergy.

A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?

Low-grade temperature and cough could indicate the presence of an infection, and the nurse should report these findings to the HCP as soon as possible before surgery. The administration of anesthesia in a client with a fever and cough can exacerbate an unknown viral or bacterial condition, increase the risk for postoperative pneumonia, and interfere with the postoperative healing process. The HCP may prescribe further testing, consult the anesthesia professional, postpone the elective surgery, or proceed with the surgery depending on the individual situation and type of surgery scheduled. (Options 1, 2, and 3) Hemoglobin (13.2-17.3 g/dL [132-173 g/L]), hematocrit (39%-50% [0.39-0.50]), and platelet count (150,000- 400,000/mm3 [150-400 × 109/L]) levels are within normal ranges and do not indicate increased risk for a bleeding problem. Normal INR is 0.75-1.25; 1.3 is only borderline elevation and would not increase the bleeding risk.

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

Most CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3 mL containing 10 units/mL-100 units/mL are the standard of care for flushing a CVC. Doses of 1000-10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error and should be clarified by the nurse. The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error). (Option 1) TPN should be administered through a CVC. Because of its viscosity and high glucose, lipids, electrolytes, vitamins and minerals, it is safest when administered through a CVC or peripherally inserted central catheter. (Option 2) According to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. (Option 4) The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart.

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick?

Nephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edemamost evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result. (Options 1 and 4) Children with nephrotic syndrome often have significant edema of the scrotum or labia. Placing a urine dipstick in the child's diaper or applying a standard adhesive urine collection bag around the genital area would cause further irritation and increased risk for skin breakdown. (Option 2) Children with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization).

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene?

Oropharyngeal airways (OPAs) are temporary artificial airway devices used to prevent tongue displacement and tracheal obstruction in clients who are sedated or unconscious. As consciousness and the ability to protect the airway return, the client often coughs or gags, indicating a need to remove the OPA; clients may also independently remove or expel it. Nurses caring for a client with an OPA must ensure that the device is easily removable from the client's mouth because an obstructed (eg, taped) OPA may cause choking and aspiration (Option 4). (Option 1) Appropriate OPA size should be measured prior to insertion because an inappropriate size could push the tongue back and cause airway obstruction. The OPA should be measured with the flange next to the client's cheek. With correct sizing, the OPA curve reaches the jaw angle. (Options 2 and 3) When inserting an OPA, the nurse should initially suction the upper airway to remove secretions. The OPA is then inserted with the distal end pointing upward toward the roof of the mouth to prevent tongue displacement and tracheal obstruction. Once the OPA reaches the soft palate, the nurse rotates the OPA tip downward toward the esophagus, which pushes the tongue forward and maintains airway patency.

Oxygen safety

Oxygen is a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. Vaseline is an oil-based, flammable product and should be avoided. A water-soluble lubricant may be used instead. Oxygen canisters should be kept at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. (Option 4) The client understands that nail polish remover and nail polish contain acetone, which is highly combustible. (Option 5) Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics.

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence.

PPE for the health care worker protects the mucous membranes, airways, skin, and clothing from contact with potentially infectious agents. The category of transmission-based precautions (eg, contact, droplet, airborne) required determines the type of PPE that the health care worker will wear. The exact procedure for donning and removing PPE varies with the level of precautions required. Guidelines are provided by the Centers for Disease Control and Prevention (CDC) and by institution policy and procedure. The sequence for donning PPE includes: 1. Hand hygiene 2. Gown - fully cover torso from neck to knees, arms to end of wrists, and wrap around back; fasten in back of neck and waist 3. Mask or respirator - secure ties or elastic bands at middle of head and neck; fit flexible band to nose bridge; fit snugly to face and below chin; fit-check respirator 4. Goggles or face shield - place over face and eyes and adjust fit; may be combined with mask (visor) 5. Gloves - don and extend to cover wrist of isolation gown

The nurse is changing the dressing, injection caps, and IV tubing of a client who is receiving total parenteral nutrition through a right peripherally inserted central venous catheter. The nurse should implement what actions to prevent complications during this procedure?

Peripherally inserted central venous catheters (PICC) are commonly used for long-term antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral nutrition (TPN). Complications related to the PICC are occlusion of the catheter, phlebitis, air embolism, and infection due to bacterial contamination. Prior to a central line dressing change, the nurse performs hand hygiene (Option 3). The central line dressing change is performed using sterile technique with the nurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions (Option 5). During injection cap and tubing changes, the client is instructed to hold the breath (or perform the Valsalva maneuver) to prevent air from entering the line, traveling to the heart, and forming an air embolism (Option 1). (Option 2) When performing the dressing change, the client should be instructed to turn the head away from the PICC site to prevent potential contamination of the insertion site by microorganisms from the client's respiratory tract. (Option 4) During dressing, injection caps, and tubing changes, the client is placed in the supine position. If an air embolism is suspected, the client should be placed in the Trendelenburg position (head down) on the left side, causing any existing air to rise and become trapped in the right atrium.

The nurse recognizes that which factors place a client at increased risk for falls?

Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope and falls (Option 3). Osteoarthritis of the knees limits joint mobility, increasing the risk for falls. Presence of IV therapy, wet floors, rooms congested with furniture, and improper toilet seat or bed height are factors that increase this risk (Option 4). Carbidopa/levodopa (Sinemet) is an antiparkinson medication. Parkinson disease increases the risk of falls due to gait abnormality (eg, shuffling gait). Carbidopa/levodopa (Sinemet) may also cause dizziness, involuntary movements, and orthostatic hypotension, further increasing the risk for falls (Option 5). The use of an ambulatory aid such as a cane, walker, or crutches indicates a balance/gait problem and places the client at higher risk of falling (Option 6). (Option 1) Fall risk does not increase until age >65-75. (Option 2) Ovarian cancer does not inherently affect cognition and neurologic or muscular function and is therefore not a risk for falling. Advanced disease with weakness, perhaps from the treatment, could constitute a risk for a fall.

Postmortem care

Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible (Option 1). To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes (Option 3). Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in (Option 5). A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 4). Place a pillow under the head to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client's belongings to a family member or send with the body.

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids?

Proper use and care of hearing aids is essential to the success of hearing aid therapy and is associated with improved outcomes. Proper hearing aid use and care include: Minimize distracting sounds (eg, television, radio) during conversation to enhance effectiveness (Option 2). Turn the volume off prior to insertion, then gradually turn up the volume to a comfortable level (Option 4). To adjust to the new hearing aids, initially wear them for a short time (eg, 20 minutes) and gradually increaselength of wear time. Do not wear the hearing aids when using hair dryers or heat lamps. Regularly check that the battery compartment is clean, the batteries are inserted correctly, and the compartment is shut before insertion (Option 5). Remove the battery (if possible) at night and when the aid is not in use to extend battery life. (Option 1) Each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components. (Option 3) Store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged.

The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions?

The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1). (Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. (Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy. The client's laboratory results are shown in the exhibit. Which intervention would be a priority for this client? Laboratory results White blood cells1,100/mm3 (1.1 x 109/L) Absolute neutrophil count400/mm3 (0.4 x 109/L) Hemoglobin8.2 g/dL (82 g/L) Platelets78,000/mm3 (78 x 109/L)

The client's laboratory results show severe neutropenia, with a reduced white blood cell count (normal 4,000-11,000/mm3[4.0-11.0×109/L]) and reduced absolute neutrophil count (normal 2200-7700/mm3 [2.2-7.7 ×109/L]). Protection against infection is the most important goal for this client. The following neutropenic precautions are indicated: A private room Strict handwashing Avoiding exposure to people who are sick Avoiding all fresh fruits, vegetables, and flowers Ensuring that all equipment used with the client has been disinfected (Option 1) The client's laboratory results show moderate anemia. Blood transfusion and/or erythropoietin injections are important but not a priority. Infections in immunocompromised clients are life threatening. (Option 2) The client's platelet count of 78,000/mm3 (78 ×109/L) is decreased but not dangerously low; therefore, it is not the highest priority intervention. Avoiding intramuscular injections and minimizing venipunctures is most important when the platelet count is below 50,000/mm3 (50 ×109/L), as these can cause prolonged bleeding. (Option 3) This client would need SCDs for prevention of deep vein thrombosis to the legs as anticoagulants may not be used due to the risk of bleeding from low borderline platelet count. However, this is not a priority over infection prevention. Educational objective:Neutropenic precautions should be used to prevent infection in clients who have low white blood cell and absolute neutrophil counts and are receiving chemotherapy. Infections in these clients are life threatening.

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first?

The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained.

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client. The usual recommended dose is 0.2-1 mg every 2-3 hours prn. What action should the nurse initially take?

The nurse needs to have appropriate knowledge about a medication prior to administering it. Hydromorphone (Dilaudid) is a potent narcotic that has 5-10 times the strength of morphine. This client was prescribed a hydromorphone dose that is too high given that the typical maximum dose is 2 mg. As the drug prescription is outside a safe range, it must be questioned and cannot be administered automatically. (Option 1) A prescription that greatly exceeds the safety range should not be given without questioning/clarification. However, anytime the outer limit of drug dosing of a potent narcotic is administered, the client should be monitored frequently for adverse effects. This includes the sedation scale and arousability as sedation precedes respiratory depression for narcotics. (Option 2) When there is a medication dosing question, authoritative resources (eg, the pharmacist, current drug literature) should be consulted rather than relying on a nursing colleague who could be mistaken. (Option 3) Even if the client is opiate-tolerant, the dosage is significantly outside the safety range and the prescription should be questioned or clarified.

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections?

The nurse should select an IV catheter site on an upper extremity, preferably the hand or forearm. To reduce the incidence of catheter-related infections, the selected site should be cleaned with antiseptic solution using friction (preferably chlorhexidine, using a back-and-forth motion) and then allowed to air-dry completely (Option 3). Chlorhexidine is preferred as it achieves an antimicrobial effect within 30 seconds, whereas povidone-iodine takes ≥2 minutes. After insertion, the catheter hub should be secured with a narrow strip of sterile tape to prevent accidental removal or excessive back-and-forth motion, which can introduce microorganisms into the vein. In addition, a sterile, transparent, semipermeable dressing (eg, Tegaderm) should be used to secure the catheter hub to reduce infection risk and allow visualization of the site (Option 1). When the catheter is accessed, the needleless port should be cleansed with an alcohol swab to kill externally colonized microorganisms (Option 2). (Option 4) Excessive hair may be clipped but never shaved as shaving may cause microabrasions and potential portals of entry for microorganisms. (Option 5) Peripheral IV cat

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D5W at 1300 units/hr. After 6 hours of the heparin infusion, the client's PTT is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit). According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump?

The original heparin dose is 1300 units/hr. This client's PTT is 44 seconds, which is below the therapeutic range of 55-70 seconds (as shown in the exhibit), indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the heparin drip protocol (protocols vary per institution), the rate should be increased by 100 units/hr, or to an infusion rate of 1400 units/hr, which converts to 28 mL/hr. Using dimensional analysis, use the following steps to calculate the rate in milliliters per hour at which the IV infusion pump should be set to deliver 1400 units/hr (original dose of 1300 units/hr increased by 100 units/hr per protocol): Identify the prescribed, available, and required medication information Prescribed: 1400 units heparinhr Available: 25,000 units heparin500 mL Required: mLhrPrescribed: 1400 units heparinhr Available: 25,000 units heparin500 mL Required: mLhr Convert prescription to infusion rate needed for administration Prescription×available medication=mL/hrPrescription×available medication=mL/hr OR (Units heparinhr)(mL units heparin)=mL heparinhrUnits heparinhrmL units heparin=mL heparinhr OR ⎛⎝⎜⎜1400 units heparinhr⎞⎠⎟⎟⎛⎝⎜⎜500 mL25,000 units heparin⎞⎠⎟⎟=28 mL heparinhr 1400 units heparinhr500 mL25,000 units heparin=28 mL heparinhr

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action?

The recommended rates for an intermittent IV infusion of potassium chloride (KCl) are no greater than 10 mEq (10 mmol) over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr (40 mmol/hr) when infused through a central line (follow facility guidelines and policy). If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr (10 mmol/hr) (ie, 10 mEq [10 mmol] over 30 minutes = 20 mEq/hr [20 mmol/hr]). A too rapid infusion can lead to pain and irritation of the vein and postinfusion phlebitis. Contacting the health care provider to verify this prescription is the priority action. (Option 1) The nurse would assess the IV site for swelling, tenderness, and redness just before initiating the KCl infusion and every 30 minutes during administration. However, this is not the priority action. (Option 2) The nurse would check the most current serum potassium level just before administering the KCl and may obtain another level following the infusion, if prescribed. This is not the priority action. (Option 4) An electronic IV pump should always be used to administer KCl. To administer the infusion at the recommended rate of 10 mEq/hr (10 mmol/hr), the nurse would set the pump at 100 mL/hr, but this is not the priority action.

A female client is admitted to the emergency department after a motor vehicle collision. The client is unresponsive and on a mechanical ventilator. Which actions should the nurse perform?

The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: -Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option 2) -Contact lenses: Remove to prevent corneal injury (Option 5) -Medication patches: To prevent drug interactions and determine conditions currently being treated -Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option 4) -Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option 3) (Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client.

A nurse is caring for a client who has a chest tube drainage system in place. Where would the nurse observe to assess for tidaling?

The water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuousbubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output.

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours. The preoperative protocol ECG is done in the inpatient unit, and results indicate a "possibly acute" ST segment elevation. What action is most important for the nurse to take?

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

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse?

Treatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump. (Option 1) Hydromorphone is indicated for moderate to severe pain. A pain rating of 7 would warrant its administration. (Option 2) Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia. (Option 3) With the complete removal of the lung in a pneumonectomy, the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung.

Which of the following drug administrations should be reported as a practice error?

Warfarin (Coumadin) is generally contraindicated in pregnancy. Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy). It crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage, can occur. As a result, a client on warfarin is taught to use effective contraception (Option 5). For children age <7 months, the site for immunizations is the anterolateral thigh (vastus lateralis). The gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. The muscles are not developed enough at this age to be used as an acceptable site (Option 3). History of penicillin hypersensitivity should be determined prior to administration. Clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam antibiotics. The incidence of cross-reactivity is 1%-4% (Option 1). (Option 2) Pruritus (itching) is a known side effect of narcotic administration, particularly if the client is opioid naïve. It does not represent true allergy and is often treated with an antihistamine. Nausea is also quite common when opioid therapy is initiated, but clients quickly develop tolerance. (Option 4) Niacin (nicotinic acid or B3) is used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless. It may last for several hours. Effects usually subside as therapy continues.

The nurse plans to start an IV line to infuse 2 units of packed red blood cells for a stable 42-year-old client with a gastrointestinal bleed. Which IV catheter size is best?

When selecting catheter size, the need for rapid fluid administration and the type of fluid administered versus client discomfort should be assessed. A lower IV catheter gauge number corresponds to a larger bore IV catheter. 1. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock (Option 1). In somewhat stable adult clients who require large amounts of fluids or blood, an 2. 18-gauge catheter is preferred. (Options 3 and 4) A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration. A 24-gauge catheter is recommended for children and some older adults with small, fragile veins.

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers?

"The right client" is one of the "6 rights" of medication administration. Two identifiers are used to compare client statements and information on the identification band with the client's medication administration record. An identifier should be permanent and unique to the client. Acceptable identifiers include first and last name and date of birth (Options 1 and 2). These two identifiers are commonly used together because there is a chance that more than one client may share a similar surname or date of birth, which increases the risk of administering a medication to the wrong client. Medical record numbers are also an acceptable form of identification and may help further differentiate clients (Option 4). (Options 3 and 5) The name of the health care provider and room number are not specific or unique to the client and are subject to change based on the client's plan of care or condition.

Parkland formula

Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. This initial tissue injury, combined with the systemic inflammatory response, causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. This intravascular loss often leads to hypovolemic shock in clients with extensive burns and requires emergency fluid resuscitation for client survival. The Parkland formula is an IV fluid resuscitation protocol used to calculate the fluid replacement needed in the first 24 hours after a burn injury. Half of the calculated fluid volume is administered during the first 8 hours after injury, when the greatest amount of intravascular volume loss occurs. The following steps should be used to calculate the volume needed for infusion during the first 8 hours. Calculate the total volume needed for infusion for 24 hours 4 mL×weight (kg)×TBSA burned=total infusion volume4 mL×weight kg×TBSA burned=total infusion volume OR 4 mL×85 kg×40% TBSA=13,600 mL4 mL×85 kg×40% TBSA=13,600 mL Calculate the volume needed for infusion during the first 8 hours 24-hr infusion volume2 =8 hour infusion volume24-hr infusion volume2 =8 hour infusion volume OR 13,600 mL2=6800 mL13,600 mL2=6800 mL Convert milliliters to liters (6800 mL1)(L1000 mL)=6.8 L6800 mL1L1000 mL=6.8 L

The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first?

Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: 1. Perform hand hygiene 2. Ensure privacy and explain the procedure to the client 3. Apply clean gloves 4. Place a waterproof pad underneath the client 5. Remove any adhesive tape or device anchoring the catheter 6. Follow specific manufacturer instructions for balloon deflation 7. Loosen the syringe plunger and connect the empty syringe hub into the inflation port 8. Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. 9. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client.

The nurse performs nasogastric (NG) tube insertion using a large-bore NG tube on a hospitalized client with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the client begins to cough and gag. Which action should the nurse take first?

Coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx. When this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube.

Muslim Women

For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently. (Option 1) A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration. (Option 2) A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client's roommate could be problematic and cause distress. (Option 4) Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration.

Mastectomy positioning

Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy.

The nurse on the IV therapy team is making rounds in the intensive care unit on clients with central venous catheters. Which central line should be removed earliest to prevent infection?

In adult clients, central venous access sites in the upper body (internal jugular or subclavian) are preferred to minimize the risk of infection. Access sites in the inguinal area (femoral) are easily contaminated by urine or feces, and it is difficult to place an occlusive dressing over these sites. A central venous catheter (CVC) should be placed where aseptic technique can be applied. The site should be assessed daily for signs/symptoms of infection (eg, redness, swelling, drainage). The duration of CVC placement should be based on clinical need and judgment that there is no evidence of infection. (Option 2) Although this site has been in use for 6 days, it is a preferred site; the CVC was inserted in the operating room, where surgical asepsis was easily accomplished. The site can be used as long as there is a clinical need and no evidence of infection. (Option 3) Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter. (Option 4) The subclavian vein is a preferred site for a CVC. Although slight redness is present at the suture sites, it is not located at the insertion site. The femoral line is still at higher risk for infection.

CABG incision instructions

Incisions may take 4-6 weeks to heal. The nurse should instruct clients on how to care for their incisions; these instructions are as follows: Wash incisions daily with soap and water in the shower. Gently pat dry (Option 4). Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves (Option 1). Tub baths should be avoided due to risk of introducing infection (Option 3). Do not apply powders or lotions on incisions as these trap the bacteria at the incision (Option 3). Report any redness, swelling, and increase in drainage or if the incision has opened (Option 2). Wear a supportive elastic hose on the legs. Elevate legs when sitting to decrease swelling (Option 5).

Transfusion reaction steps

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option 4). Using new tubing, infuse normal saline to keep the vein open (Option 5). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option 1). Collect a urine specimen to be assessed for a hemolytic reaction (Option 2). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option 3).

Low-flow vs. High-flow delivery devices

Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type II respiratory failure [hypercarbic]).

National Pressure Ulcer Advisory Panel Pressure ulcer prevention Guidelines

National Pressure Ulcer Advisory Panelpressure ulcer prevention guidelines Skin care Barriers for incontinence Hydration Moisturizer Repositioning Pad bony prominences Pad medical devices Lift, do not pull Limit chair time Minimize shearing & frictional forces Turn every 2-4 hr Nutrition Calorie counting (30-35 kcal/kg/day) Enteral nutrition High-protein nutritional supplements (1.25-1.5 g/kg/day) Deficiency assessment Support surfaces Alternating pressure Avoid donut-type devices & synthetic sheepskins Heel protection Mattress Overlay

The nurse is obtaining orthostatic vital signs on a client admitted for dehydration. The nurse measures the client's blood pressure and pulse using the left brachial site with the client lying supine and then sitting. Which action by the nurse is appropriate?

Nurses measuring orthostatic vital signs should discontinue further measurements if the client experiences decreased systolic blood pressure ≥20 mm Hg, decreased diastolic blood pressure ≥10 mm Hg, and/or increased pulse ≥20/min in any position. Return the client to a recumbent position and notify the health care provider.

sleep hygiene

Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep-related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed (Option 3). The nurse should encourage the following healthy sleep habits: Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep Avoid going to bed hungry or eating a heavy meal just before bed Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia (Option 1) It is best to avoid naps during the day, especially later in the day. Any naps taken should be short (20-30 min). (Option 2) The client should keep the bedroom slightly cool, quiet, and dark for comfort. (Option 4) As much as possible, the client should develop a consistent sleep-wake pattern (ie, same bedtime and wake time each day) to obtain 7-8 hours of sleep nightly.

procedural sedation

When new-onset restlessness occurs during procedural sedation, oxygenation should be considered first before administering additional medications. If the client is snoring, opening the airway should be considered.

24-hour urine collection

A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: 1. Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity (Options 1 and 5). 2. Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded (Options 3 and 4). 3. Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservation (Option 2).

Steps for a lumbar puncture

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: 1. Verify informed consent 2. Gather the lumbar puncture tray and needed supplies 3. Explain the procedure to older child and adult 4. Have client empty the bladder 5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) 6. Assist the client in maintaining the proper position (hold the client if necessary) 7. Provide a distraction and reassure the client throughout the procedure 8. Label specimen containers as they are collected 9. Apply a bandage to the insertion site 10. Deliver specimens to the laboratory

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

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol (Option 1). Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity (Option 5). All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels (Option 2). (Option 3) Dressings that no longer occlude the insertion site must be changed immediately. Loose corners may be temporarily reinforced with tape.

Positioning for liver biopsy

After a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.

Alzheimer Disease- persistently restless and agitated

Alzheimer disease (AD) is a form of dementia that causes a progressive decline of cognitive and physical abilities. Behavioral changes (eg, agitation, aggression, resistance to care) often result from the client's inability to identify a stressor. Stressors may include pain or problems with elimination (eg, constipation) or eating (eg, inability to feed oneself). The nurse's priority must be identifying and solving problems related to the client's basic physiological needsaccording to the Maslow hierarchy of needs (Option 1). (Option 2) Environmental stressors (eg, excessive noise, overstimulation) may cause behavioral changes such as agitation or restlessness in clients with AD and should be addressed after intervening to meet the client's basic needs. (Option 3) Caregiver support is essential to client care, especially in the home health environment. After addressing the client's needs, the nurse should provide information about community support groups, respite care, and adult day care to help reduce caregiver fatigue. (Option 4) The nurse should use behavioral-management techniques (eg, reassurance, distraction, redirection) to assist with deescalation. However, the nurse must assess for and address sources of agitation first. Educational objective:When caring for a client with Alzheimer disease who has increasing or persistent behavioral changes, the nurse should first assess for possible physical stressors such as pain or problems with elimination or eating.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report?

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

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent transmission of infection while performing this procedure.

Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (eg, biohazard bag) (Option 4). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: -Meticulous hand hygiene (Option 3) -Use of disposable gloves during collection and handling of specimen -Cleaning the specimen bag with a disinfecting wipe -Proper and immediate transport of specimen to the lab -Avoiding placing specimen in clean areas (eg, nursing station) -An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (Option 5). (Option 1) When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. (Option 2) Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission.

A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering?

Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option 1). (Option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort.

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client?

Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: 1. Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) 2. Assess feeding tube placement at regular intervals 3. Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) 4. Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) 5. Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary 6. Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) 7. Avoid bolus tube feedings for clients at high risk for aspiration (Option 2) Gastric residual should be checked no less than every 4 hours in intubated clients.

Extravasation of Norepinephrine

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

Koser Diet

Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack (Option 3). This choice also provides a combination of carbohydrates and protein, which would help in regulating blood glucose.

The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade. (Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac. (Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure.

Postmortem care delays

Postmortem care typically is performed immediately following the pronouncement of death to allow visitation of the deceased by the family. There are several circumstances in which postmortem care may be delayed or not performed. Certain cultural or religious beliefs require that care be performed by the family or clergy (Option 3). The family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way (Option 5). Postmortem care can also be delayed, altered, or not performed in accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity (Option 4).

EpiPen use

The EpiPen is designed to be administered through clothing with a swing and firm push against the mid-outer thigh until the injector clicks. The position should be held for 10 seconds to allow the entire contents to be injected (Option 3). The site should be massaged for an additional 10 seconds. Timing is essential in the delivery of epinephrine during an anaphylactic reaction. The nurse should administer the medication immediately on the playground without removing the child's clothing. Any delays can cause client deterioration and make maintenance of a patent airway difficult (Option 4). (Option 1) The EpiPen should be injected into the mid-outer thigh, not the upper arm. (Option 2) IV epinephrine is not administered outside the hospital setting. It requires cardiac monitoring and is indicated in clients with profound hypotension (shock) or those who do not respond to intramuscular epinephrine and fluid resuscitation.

African American women teaching prevention

The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option 1). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option 2). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option 3). (Option 4) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option 5) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans.

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education?

The neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: Select a location on the medial or lateral side of the outer aspect of the heel (Option 1). Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. 2. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation (Option 3). Cleanse the intended puncture site with alcohol. 3. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain (Option 2). 4. Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed (Option 4).

Proper fit of sling

To ensure proper shoulder sling fit, the nurse should assess for the following: -Elbow is flexed at 90 degrees -Hand is held slightly above the level of the elbow -Bottom of the sling ends in the middle of the palm with the fingers visible -Sling supports the wrist joint

wound irrigation

To perform wound irrigation: 1. Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). 2. Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. 3. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. 4. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. 5. Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). 6. Dry the surrounding wound area to prevent skin breakdown and irritation.

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome. Which personal protective equipment will the nurse use when providing care to the client?

Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS. (Options 1, 2, and 3) These options do not provide enough protection as each is missing a vital element that is recommended when caring for a client with MERS.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action?

The Heimlich maneuver (ie, upward abdominal thrusts under the rib cage) is the primary rescue intervention for children over age 1 with a foreign body airway obstruction causing respiratory distress. Back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Blind sweeping of a child's mouth should not be attempted.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test?

When performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. (Option 3) An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. (Option 5) The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface.

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care?

Airborne precautions Indications Tuberculosis Varicella zoster* (chickenpox) Herpes zoster** (shingles) Rubeola (measles) Components N95 respirator or powered air-purifying respirator Negative-pressure isolation room with high-efficiency particulate air filter As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield *Only when uncrusted lesions are present; contact precautions also required.**Only in disseminated disease or immunocompromised clients; contact precautions also required. Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation.

A graduate nurse (GN) is caring for a client with right lower leg cellulitis that is seeping clear fluid. Which action by the GN requires intervention by the supervising nurse?

Cellulitis is inflammation of the subcutaneous tissues that is typically caused by bacterial infection (eg, Staphylococcus aureus, group A Streptococcus) resulting from an insect bite, cut, abrasion, or open wound. Cellulitis is characterized by redness, edema, pain, and fever. Nurses caring for clients with cellulitis should ensure that the affected extremity is elevated when the client is sitting or lying down to promote lymphatic drainage. Flat or dependent positioning may worsen edema, which delays recovery and contributes to pain (Option 2). In addition, clients with weeping or draining wounds must be protected from prolonged exposure to moist or soiled linens as this exposure promotes tissue injury and infection. (Option 1) Applying warm compresses promotes circulation to the area of infection, alleviates discomfort, and helps reduce edema. (Option 3) Daily marking and dating of reddened areas assist with monitoring improvement or worsening of the infection. Redness that progresses past the marked areas indicates ineffective antibiotic therapy and should be reported to the health care provider. (Option 4) Although standard precautions are typically sufficient for cellulitis, a gown and gloves are worn when contact with body fluids (eg, urine, stool) or potentially infectious drainage is expected, such as during bathing.

steps to suctioning Endotracheal tubes

Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before ETT suctioning to prevent introduction of oral bacteria into the lungs. The steps for suctioning an ETT include: Perform hand hygiene and don clean gloves (Option 5). Suction the oropharynx and perform oral care (Option 6). Ensure that the system is connected to appropriate wall suction (<120 mm Hg). Hyperoxygenate the lungs (100% FiO2) (Option 4). Advance the catheter into the trachea just until resistance is met (level of the carina) (Option 1). Do not suctionwhile advancing the catheter. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds (Option 3). Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the procedure when complete (Option 2). Resume oxygenation and ventilation settings as prescribed.

Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube?

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: 1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). 2. Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). 3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). 4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). 5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame. (Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to promote comfort and facilitate access for tube removal.

The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what?

Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. (Option 5) Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. (Option 6) Urine output should not be affected by thoracentesis or the drugs administered for this procedure.

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate?

Open endotracheal (ET) suctioning is a skill performed to remove pulmonary secretions and maintain airway patency in clients who are unable to clear secretions independently. ET suctioning is important to promote gas exchange and prevent alveolar collapse, but inappropriate technique increases the client's risk for complications (eg, pneumonia, hypoxemia) or tracheal injury (eg, trauma, bleeding). To reduce the risk of complications and injury during ET suctioning, the nurse should: 1. Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes (Option 1) 2. Suction only while withdrawing the catheter from the airway (Option 2) 3. Use strict sterile technique throughout suctioning (Option 5) 4. Limit suctioning to ≤10 seconds on each suction pass

Use of cane on stairs

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: 1. Lead with the cane 2. Bring the weaker leg down next (in this client, it is the left leg) 3. Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: 1. Step up with the stronger leg first 2. Move the cane next, while bearing weight on the stronger leg 3. Finally, move the weaker leg

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next?

Urine could be in the urethra and evident in the tubing even though the tip with the balloon is not in the bladder. It is necessary to further insert the catheter before inflating the balloon to make sure the tip is in the bladder and not the urethra (causing urethral trauma). In the male client, it is recommended that the catheter be inserted 7-9 in (17-22.5 cm) or until urine flows out, due to the longer urethra. The catheter should then be inserted at least an additional 1 in (2.5 cm) or to catheter bifurcation. (Option 2) The client should be told to take slow, deep breaths to help relax the external sphincter and provide a distraction. (Option 3) The catheter needs to be inserted further before inflating the balloon to prevent urethral trauma. (Option 4) Securing the catheter to the leg occurs after the balloon is inflated and placement is assured.

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care?

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) (Options 1 and 3). Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued (Option 5). Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway (Option 4). Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities (Option 2).