July 11th

The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? Select all that apply. 1. Implementing fall precautions for the pt with cerebellar stroke 2. Increase lighting got the pt with cranial nerve VII affected 3. Initiate swallow precautions for the pt with cranial nerve IX and X affected 4. Place spoon within field of vision for the pt with homonymous hemianopsia 5. Speak louder in front of the pt who has receptive aphasia

1, 3, & 4 Strokes cause different neurological deficits depending on the location of the affected area within the brain and the extent of injury. Cerebellar deficits affect balance and equilibrium; fall precautions are appropriate (Option 1). Cranial nerves IX (glossopharyngeal) and X (vagus) control the gag and swallowing mechanisms, making swallow precautions necessary (Option 3). Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists (eg, places utensil in unaffected visual field), but the client must learn to turn the head to scan the environment (Option 4). (Option 2) A stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one eyebrow. Increased light is unnecessary as vision is not affected. (Option 5) Clients experiencing receptive aphasia, impaired comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lobe. The nurse would not speak louder as this does not aid comprehension. The nurse should speak clearly, ask "yes" or "no" questions, and use gestures and pictures to increase understanding. Educational objective: Strokes cause different neurological deficits depending on the location and extent of injury. Cerebellar deficits affect balance and require fall precautions, cranial nerve IX and X injuries can impair swallowing, and a client with homonymous hemianopsia will not see objects on the affected side.

The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. The nurse should teach the parents to report which findings indicative of heart failure to the health care provider (HCP)? Select all that apply. 1. Cool extremities 2. Increase in appetite 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight loss

1, 3, & 4 Heart failure may develop after surgical repair of tetralogy of Fallot, and infants and children can quickly decompensate hemodynamically when it occurs. Clinical manifestations are grouped into 3 primary categories— impaired myocardial pumping, pulmonary congestion, and systemic venous congestion. (Option 2) The infant would have a decrease in appetite with heart failure symptoms. (Option 5) The infant would more likely have experienced weight gain due to fluid retention. Educational objective: The nurse should teach parents of an infant or child with a repaired congenital heart defect to recognize and report signs and symptoms of heart failure to the HCP. These may include rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance (especially during feeding in infants); pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the eyes.

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply. 1. I need to call the hCP if I have trouble reading 2. I need to check my BP before tkaing this medicine 3. I should call the HCP if I develop nausea and vomiting 4. I should check my heart rate prior to taking this medication 5. I will call the HCP if I feel dizzy and lightheaded

1, 3, 4, & 5 Digoxin (Lanoxin) is a cardiac glycoside used to treat heart failure and atrial fibrillation. Cardiac glycosides have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). However, drug toxicity is common due to digoxin having narrow therapeutic-range levels (0.5-2.0 ng/mL). Cardiac arrhythmias are the most dangerous symptoms. Digoxin toxicity can result in bradycardia and heart block, which can cause dizziness or lightheadedness (Option 5). Clients are instructed to check their pulse and if it is low (<60/min) or has skipped beats to hold the medication and notify the health care provider (Option 4). Other manifestations of digoxin toxicity that clients should report include: Visual symptoms (eg, alterations in color vision, scotomas, blindness) (Option 1) Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) - frequently the earliest symptoms (Option 3) Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) (Option 2) There is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check the pulse prior to administration. Educational objective: Cardiac glycosides (eg, digoxin) have positive inotropic effects (eg, increased cardiac output) and negative chronotropic effects (eg, decreased heart rate). Clients are instructed to check their pulse before administration and to report gastrointestinal (eg, anorexia, nausea), neurologic, and cardiac symptoms and visual changes.

A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply. 1. Dyspnea 2. Fever 3. Lightheadedness 4. Skin rash (hives) 5. Wheezing

1, 3, 4, & 5 The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention. (Option 2) Fever is not a symptom of an anaphylactic reaction that would be included in the rapid assessment. Educational objective: Anaphylaxis is a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? 1. Anal itching that is worse at night 2. Intestinal bleeding with anemia' 3. Poor appetite with weight loss 4. Red, scaly, blistered rings on skin

1. ANAL ITCHING THAT IS WORSE AT NIGHT The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with anti-parasitic medications. (Option 2) Hookworms (eg, Ancylostoma) are parasitic bloodsucking roundworms that are contracted from larvae in contaminated soil. They can infect the intestines, causing intestinal bleeding and anemia. (Option 3) Poor appetite, inadequate absorption of nutrients from food, and weight loss are symptoms associated with tapeworm infection (eg, Taenia solium). Tapeworm larvae are ingested when a person eats food that is contaminated with feces or undercooked meat from an infected animal. (Option 4) Ringworm is a skin infection caused by a fungus. It leads to red, scaly, blistered rings on the skin or scalp that grow outward as infection spreads. The fungus is easily spread by sharing hair care instruments and hats or via towels, linens, clothing, and sports equipment. Educational objective: The most common worm infection is pinworm, which is spread by inhaling or swallowing microscopic pinworm eggs, which travel to and hatch in the intestines. During the night, the female pinworm lays eggs in the skinfolds around the anus, resulting in anal itching and disturbed sleep.

A hospitalized client has been treated for the past 48 hours with a continuous heparin infusion for a deep vein thrombosis (DVT). When the nurse prepares to administer the evening dose of warfarin, the client's spouse says "Wait! My spouse can't have that! My spouse is already getting heparin for DVT." How should the nurse respond? 1. Both medications will be given for several days until the warfarin has time to take effect 2. I will be discontinuing the heparin infusion as soon as I give this dose of warfarin 3. The two medications work synergistically to help break down the clot in you spous's leg 4. We will hold the medication until I can call the HCP for clarification

1. BOTH MEDICATIONS WILL BE GIVEN FOR SEVERAL DAYS UNTIL THE WARFARIN HAS TIME TO TAKE EFFECT Warfarin begins to take effect in 48-72 hours and then takes several more days to achieve a maximum effect. Therefore, an overlap of a parenteral anticoagulant like heparin with warfarin is required. The typical overlap is 5 days or until the INR reaches the therapeutic level. The nurse will need to explain this overlap of the 2 medications to the client and the spouse. (Option 2) The nurse should not discontinue the heparin infusion until the INR is at the therapeutic level. (Option 3) Anticoagulants like heparin and warfarin will not break down or dissolve clots. However, they inhibit any further clot formation and keep the current clot from getting larger. Thrombolytics, such as tissue plasminogen activator, do break down clots. (Option 4) Clarification from the HCP is not needed. The warfarin should be administered to the client after explaining the reasons for its use to the client and the spouse. Educational objective: Warfarin requires an overlap of therapy with unfractionated heparin infusion or low-molecular-weight heparin (eg, enoxaparin, dalteparin) for several days until the INR is in the therapeutic range for the client's condition.

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the HCP's prescription and the medical record 2. Explain that the HCP has prescribed the medication 3. Look up the medicatino in the pharmacology reference 4. Teach the pt about the purpose of the medication

1. CHECK THE HCP PRESCRIPTION IN THE MEDICAL RECORD Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. I will alwahys travel with two trach tubes, one of the same size and one a size smaller 2. I will immediately change the trach tube if my child has difficulty breathing 3. I will provide deep suctioning frequently to prevent any airway obstruction 4. I will remove the humidifier if my child starts developing more secretions

1. I WILL ALWAYS TRAVEL WITH TWO TRACH TUBES, ONE OF THE SAME SIZE AND ONE A SIZE SMALLER In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. (Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. (Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. (Option 4) Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect. Educational objective: Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively.

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1. Immunosuppressive therapy as a lfielong commitment 2. Importance of accurate daily wight monitoring 3. Importance of periodic endomyocardial biopsies 4. Maintenance of meticulous surgivcal incision care

1. IMMUNOSUPPRESIVE THERAPY AS A LIFELONG COMMITMENT Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent acute transplanted organ rejection. (Option 2) Daily weight monitoring is important for identifying signs of heart failure; however, immunosuppressive therapy compliance is the priority. (Option 3) Endomyocardial biopsies are performed regularly, in addition to routine blood tests, to check for signs of rejection. This is important for the client to know; however, it is not the priority over strict immunosuppressive therapy compliance. (Option 4) Surgical incision care and signs of infection are important teaching topics; however, prior to transplantation, it is most important to ensure that the client understands and will comply with lifelong immunosuppressive therapy. Educational objective: Clients on the organ donation waiting list are educated regarding strict compliance with immunosuppressive therapy, which requires a lifelong commitment to prevent acute transplanted organ rejection.

A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply? 1. Nasal cannula 2. Non rebreather 3. Rebreather 4. Venturi

1. NASAL CANNULA The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and permits the client to eat and drink fluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication. The client is alert and oriented and able to follow directions. Because pain relief is effective according to the pain scale, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option 2) The non-rebreather mask is used in emergencies, delivers high concentrations of oxygen (up to 90%-95%), requires a tight face seal, and is restrictive and uncomfortable. (Option 3) The simple face mask delivers a higher concentration of oxygen (40%-60%), is more uncomfortable and restrictive, must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia does not resolve. (Option 4) The Venturi mask is a more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease. These clients cannot tolerate changes in oxygen concentration. Educational objective: The nasal cannula is an inexpensive, comfortable, low-flow oxygen delivery device capable of delivering oxygen concentrations of up to 44%. It can be used in the short term in responsive postoperative clients to treat hypoventilation and reverse hypoxemia effectively.

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is most important? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time

1. PASSED A NORMAL BROWN STOOL Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery. (Option 2) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. (Option 3) Pain in intussusception is typically intermittent. It occurs every 15-20 minutes, along with screaming and drawing up of the knees. Therefore, if a child stops crying, it may not be due to reduction of intussusception. (Option 4) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced. Educational objective: Reduction of intussusception is often performed with a saline or air enema. The HCP should be notified if there is passage of a normal stool as this indicates reduction of the intussusception. All plans for surgery should be stopped and the plan of care should be modified.

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. 1. Pt coughs and gasps when swallowing food and liquids 2. Pt is easily frustrated while attempting to speak 3. Pt is unable to understand speech and is completely nonverbal 4. Pt misunderstands and inappropriately responds to verbal instruction 5. Pt's speech os limited to short phrases that require effort

2 & 5 Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern. Educational objective: Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking.

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. 1. Pt admitted with WNC of 28,000 and dies from sepsis 2. Pt receiving 1 mg morphine instead of prescribed 0.5 mg 3. Pt refuses pneumonia vaccination and contracts pneumonia 4. Nurse did not report pt's new hgb result of 6 to onciming nurse 5. Provider was not notified of pt's positive blood culture results

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

The nurse initiates a norepinephrine infusion through a client's only IV access into a large peripheral vein. The client reports severe pain at the IV site shortly after the infusion is started, and blanching is visible along the vein pathway. Which nursing interventions are appropriate? Select all that apply. 1. Administer morphine IV PRN for pain after flushing the line 2. Elevate the affected extremity above the level of the heart 3. Establish a new iv access proximal to the affected site 4. Notify the HCP and prepare phentolamine 5. Stop the infusion immediately and disconnect the IV tubing

2, 4, & 5 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. Educational objective: If extravasation of IV norepinephrine occurs, the nurse should stop the infusion immediately, aspirate the drug, remove the IV catheter, elevate the extremity, and administer the antidote phentolamine into affected tissues as prescribed. IV access is reestablished on an unaffected extremity or through a central line.

Which findings in a newborn are considered abnormal and should be reported to the health care provider (HCP)? Select all that apply. 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate 150 4. Sacral dimple 5. Single artery in the umbilical cord

2, 4, & 5 Initial newborn assessments performed by the nurse are helpful in identifying anomalies that require further investigation by the HCP. Hypotonia, or decreased muscle tone, may be related to hypoxia, Down syndrome, or a muscular/neurologic disorder (Option 2). A sacral dimple may be a sign of spina bifida occulta, a defect where the bones that protect the meninges and spinal cord fail to close during gestation (Option 4). Although many clients with spina bifida occulta have no other disturbances or impairment, the HCP must assess for the extent of any neurologic involvement. A normal umbilical cord contains 2 arteries and 1 vein. The presence of a single umbilical artery is sometimes associated with congenital defects, particularly of the kidneys and heart (Option 5). (Option 1) Acrocyanosis is cyanosis of the hands and feet that results from poor peripheral blood perfusion as an initial mechanism to reduce heat loss and stabilize temperature. It is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold. (Option 3) The normal heart rate for a newborn ranges from 110/min to 160/min. Educational objective: Abnormal findings in a newborn assessment, such as decreased muscle tone, a sacral dimple, or a single artery in the umbilical cord, should be reported to the HCP for further evaluation.

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion." What assessment findings would be a classic indication of a potential malignant skin neoplasm? Select all that apply. 1. Blanches with manual pressure 2. Half of lesinon is raised and half is flat 3. History of purulent drainage 4. Lesion is the size of a nickel 5. Various color shades are present

2, 4, & 5 The examination for skin cancer follows the ABCDE rule: Asymmetry (eg, one half unlike the other) (Option 2) Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) (Option 5) Diameter of 6 mm or larger (about the size of a pencil eraser) (Option 4) Evolving (eg, appearance is changing in shape, size, color) (Option 1) Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is blood beneath the skin, as in petechiae and/or purpura. (Option 3) Pus or purulent drainage is usually indicative of an infectious process, not cancer. Educational objective: Examination of a skin lesion for malignancy should include ABCDE: Asymmetry, Border irregularity, Color change and variation, Diameter of 6 mm or more, and Evolving in appearance.

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? 1. Adolescent pt with coarcation of the aorta and diminished femoral pulses 2. Infant pt with ventricular septal defect with reorted grunting during feeding 3. Newborn pt with patent ductus arteriousus and a loud machinery-like systolic murmur 4. Preschool pt with tetralogy of fallot who has finger clubbing and irritability

2. INFANT PT WITH VENTRICULAR SEPTAL DEFECT WITH REPORTED GRUNTING DURING FEEDING Ventricular septal defect (VSD) is a congenital abnormality in which a septal opening between ventricles causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive heart failure (CHF) and pulmonary hypertension. Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs (eg, diaphoresis, tachypnea, dyspnea). The client is currently showing signs of increased respiratory exertion (eg, grunting) and requires further assessment for CHF (Option 2). (Option 1) Coarctation of the aorta (COA) is an abnormal aortic narrowing that results in decreased cardiac output. The client will exhibit elevated pulse pressure in the upper extremities and diminished pressures in the lower extremities. Further assessment is needed, but this client is not the current priority. (Option 3) A systolic murmur with a machine sound and poor feeding are expected, nonurgent findings in clients with patent ductus arteriosus (PDA). PDA commonly resolves within 48 hours and requires no intervention in full-term newborns. (Option 4) Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect commonly manifested by signs of irritability and clubbing of fingers due to oxygen saturation chronically remaining between 65-85% until the client can undergo surgical repair. Further evaluation of the client's oxygenation is necessary but not urgently required. Educational objective: Ventricular septal defect is a cardiac abnormality, with a septal opening between ventricles, that may progress to congestive heart failure (CHF). The client should be closely monitored for respiratory exertion and signs of CHF (eg, dyspnea, tachypnea).

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1. Difficult to arouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature 94

2. MUSCLE STIFFNESS Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2). (Options 1 and 3) A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse; and to have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. (Option 4) Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed by the nurse. Hyperthermia (fever) is also common due to the blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

A client had a levonorgestrel-releasing intrauterine device placed during a well-woman visit. Which teaching is appropriate for the nurse to include? 1. Avoid oil based lubricants, which can damage the device's silicone 2. Notify the HCP if the string feels longer or shorter after menses 3. Placement will need to be reassessed if you lose or gain significan twight 4. The device will rpovide protection from pregnancy for up to 10 years

2. NOTIFY THE HCP IF THE STRING FEELS LONGER OR SHORTER AFTER MENSES Priority teaching related to intrauterine devices (IUDs) for long-term contraception focuses on prevention of sexually transmitted infections, which increase the risk for pelvic inflammatory disease, and early recognition of a dislodged device, which places the client at risk for pregnancy. The nurse may use the acronym PAINS to discuss potential complications of IUDs. The client should assess the string position weekly for the first 4 weeks and then after each menses to ensure that the device remains in place. A longer, shorter, or missing string may indicate that the IUD is no longer in the uterus; the client should notify the health care provider and abstain from intercourse or use a barrier method (eg, condom) until placement is verified (Option 2). (Option 1) Clients using latex condoms should use water-based personal lubricants; oil-based lubricants (eg, baby oil) can weaken the condom and cause damage or breakage. IUD integrity is not affected by lubricants. (Option 3) Significant weight loss and childbirth are considerations for women using a diaphragm; these women may need to have the device refitted. IUD placement is not affected by significant weight changes. (Option 4) Copper IUDs (eg, ParaGard) provide 10 years of contraception. Levonorgestrel-releasing IUDs (eg, Mirena, Liletta) provide 3-5 years of contraception. Educational objective: Priority teaching related to intrauterine devices focuses on prevention of sexually transmitted infections and early recognition of a dislodged device. A longer, shorter, or missing string may indicate that the device is no longer in the uterus and should be reported to the health care provider.

The nurse on the mental health unit received report on 4 clients. Which client should the nurse see first? 1. Pt diagnosed with major depressive disorder who has consumed no food drom the last three meal trays 2. Pt diagnosed with PTSD who reports an anxiety level of 8/10 and is pacing the room 3. Pt newly admitted with bipolar mania who reports sleeping only 4 hours last night 4. Pt newly admitted with obssessive-compulsive disorcer who has spent the last hour counting socks

2. PT DIAGNOSED WITH PTSD WHO REPORTS AN ANXIETY LEVEL OF 8./10 AND IS PACING THE ROOM Post-traumatic stress disorder (PTSD) may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash). Symptoms of PTSD include re-experiencing the traumatic event via flashbacks, nightmares, and feelings of distress in reaction to reminders; avoiding reminders of the trauma (eg, places, activities, thoughts, other triggers); and increased anxiety and emotional arousal (eg, insomnia, hypervigilance, outbursts of rage, irritability). Clients with an anxiety level of 8/10 and pacing behavior are demonstrating distress and require immediate attention as they might harm themselves or others. (Option 1) Clients with major depressive disorder frequently demonstrate loss of appetite, weight loss, and insomnia (typical depression). Some with atypical depression will experience increased appetite, weight gain, and hypersomnia. This client's lack of appetite needs to be addressed but is not the priority at this time. (Option 3) Clients experiencing acute mania have a decreased need for sleep and boundless energy; they often do not sleep for days. This is an expected behavior in a client newly admitted with a manic episode. As the client's manic episode is resolved via medications and therapy, sleep patterns will improve. (Option 4) Clients with obsessive-compulsive disorder perform compulsive behaviors (rituals) to decrease their level of anxiety. When newly admitted, the client should be given time to perform the rituals to avoid causing panic anxiety. Treatment will focus on assisting the client to develop better coping behaviors and gradually reduce the time spent on the ritualistic behavior. Educational objective: Clients with post-traumatic stress disorder have periods of extreme anxiety and emotional arousal during which they can be a danger to themselves or others.

An adolescent client is brought to the emergency department by the parents after being found in the bathroom making cuts on an arm with a razor blade. There are a few minor cuts in various stages of healing on the client's forearms. Which of the following is the most appropriate statement to make to this client's parents? 1. Everything is going to be all right 2. The cuts on your arm are syperficial; there is no immediate danger 3. You did the right thing by bringing your child here to get help 4. You must be very upset after seeing this

2. THE CUTS ON YOUR CHILDS ARM ARE SUPERFICIAL; THERE IS NO IMMEDIATE DANGER The best therapeutic communication at this time is to inform the parents about the physical condition of their child and reassure them that this client is stable. These are the most immediate concerns of the family. Cutting in adolescence is usually a coping mechanism used when a client is emotionally overwhelmed. Although not technically a suicide attempt, it is a clear indication that this client is unable to process current stressors in life and needs formal assessment by a mental health care provider with experience in adolescent psychiatry. (Option 1) This is a nontherapeutic statement as it implies that there is no cause for concern and provides no specific information about this client's condition. (Option 3) This statement acknowledges that the parents took the appropriate action but provides no information about this client's condition. (Option 4) The nurse can explore the parents' reactions to finding their child cutting after the nurse provides them with information about the child's physical condition. Educational objective: Providing relevant information is a therapeutic communication technique. It helps clients make decisions and feel safer and less anxious.

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, the unlicensed assistive personnel (UAP) reports that another client is requesting medication for postoperative pain. What is the nurse's most appropriate action? 1. Ask the UAP to take the postoperative pt's vitals signs and report back immediately 2. Direct the UAP to ask the pt to rate the pain on a scale of 0-10 and report back immediately 3. Direct the UAP to tell the pt that you will be there shortly, and complete the sterile dressing change 4. Interrupt the dressing change to medicate the postoperative pt

3. DIRECT THE UAP TO TELL THE PT THAT YOU WILL BE THERE SHORTLY, AND COMPLETE THE STERILE DRESSING CHANGE The nurse can prioritize care according to the degree of urgency, the extent of threat to the client's survival, and the potential for complications. At this time, the other client's pain issue is of medium urgency and does not pose an immediate threat to survival. The most appropriate nursing action is to inform the postoperative client that you will be there shortly, and complete changing the sterile dressing (Option 3). Interrupting the sterile dressing change for a client with an infected wound puts the client at risk for injury, as microorganisms can invade the uncovered wound. However, if the dressing change were lengthy, the nurse could delegate the task of medicating the postoperative client to another nurse (Option 4). (Option 1) Although taking vital signs when a client reports pain is appropriate, evidence indicates that vital signs are unreliable physiologic indicators for pain. (Option 2) The UAP is instructed to ask the client if they are having pain and then report back to the nurse. However, the registered nurse is responsible for pain assessment and should not delegate this task to the UAP. Educational objective: A nurse can prioritize client needs and problems according to the degree of threat to the client's survival and the potential for complications. The nurse uses clinical judgment to decide which client situation requires immediate attention and which one can wait.

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia. The client currently has D5W infusing through a 20-gauge IV catheter. What action should the nurse take? 1. Attach the blood transfusion set to the port closest to the pt on the existing IV tubing 2. Discontinue the 20 gauge IV catheter and restart an 18 gauge IV catheter 3. Discontinue the D5W, flush the IV catheter with NS, and start the transfusion 4 .Run the blood transfusion as an IV piggy back through the infusion pump

3. DISCONTINUE THE D5W, FLUSH THE IV CATHETER WITH NS, AND START THE TRANSFUSION Normal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered. (Option 1) Packed red blood cells are not compatible with D5W. The nurse must discontinue the D5W and flush the catheter with NS before administering blood. (Option 2) Although an 18-gauge IV catheter is preferred for blood administration, a 20-gauge catheter is acceptable. The nurse can start a second IV catheter if required, but there is no need to discontinue the original one. (Option 4) Blood should not be run with any other fluid except NS. Blood can be infused with an IV pump if the fluid in the tubing is compatible. Educational objective: Blood transfusions cannot be run with any other IV fluid except normal saline (NS). Dextrose can lyse the red blood cells, and other fluids can cause precipitation. If another fluid has been infused through an IV catheter, the nurse should discontinue the infusion(s) and tubing and flush with NS before administering blood.

Four clients in labor are requesting pain medication from the nurse. Which client can safely receive an opioid agonist-antagonist analgesic intravenous (IV) push at this time? 1. Gravida 1, 2 cm dilated, 50% effaced, contractions 7-10 minutes apart, crying 2. Gravida 1, 6 cm dilated, 75% effaced, contractions 2-4 minutes apart, has history of heroin use 3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3-4 minutes apart, moaning and shaking 4. Gravida 4, 10 cm dilated, 100% effaced, contractions 2-3 minutes apart, wants to push

3. GRAVIDA 2, 5 CM DILATED, 100% EFFACED, CONTRACTIONS 3-4 MINUTES APART, MOANING AND SHAKING Systemic analgesia may be administered to the laboring client who is in the active phase of stage 1 labor. Systemic analgesia crosses the blood-brain barrier to provide a central analgesic effect. These medications also cross the placental barrier, with a resulting effect on the fetus depending on dose and time of administration prior to delivery. Parameters for safer administration include the following: Stable maternal vital signs Fetus with heart rate of 110-160 beats/min Well-established labor contractions Cervix dilated to at least 4-5 cm in primipara and 4 cm in multipara Opioid agonist-antagonist medications commonly used in labor are butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). IV push is the preferred route and is given over the peak of 2 contractions to decrease the bolus of medication to the fetus. During contractions, the uterine muscle is very tense and blood flow to the fetus is slowed. Therefore, medication reaches the fetus at a slower rate. This class of medications has a ceiling effect—after a certain dosage, subsequent or higher doses will not be effective or produce pain relief. Therefore, usually no more than 3 doses will be prescribed. The medications can precipitate withdrawal in opioid-dependent clients and should not be used. This gravida 2 client meets the criteria for medication administration. The client is in the active phase of stage 1 labor and contractions are well established. (Option 1) This client is in the early phase of stage 1 labor. Dilation is 2 cm, and the client is only 50% effaced. The contraction pattern is not well established at 7-10 minutes apart. This phase of labor can continue for up to 8 hours. The nurse can assist this client by using nonpharmacologic methods of pain relief until labor has progressed to the active phase of stage 1. (Option 2) This client has met the criteria for the active phase of stage 1 labor with a well-established contraction pattern and dilation. However, this client is a heroin user, and use of the opioid agonist-antagonist medication could cause withdrawal symptoms in both the client and fetus. This client will benefit from an epidural anesthetic for pain relief or use of nonpharmacologic pain relief methods. (Option 4) This client has now entered stage 2 of labor, which is not the appropriate time to administer IV or intramuscular pain relief methods. Being gravida 4, this client has a risk for delivery at about the time when an IV medication would peak in the fetus. Administering IV medication now will create a risk for respiratory distress at delivery and the need to administer naloxone (Narcan) to the neonate to reverse the effects of the medication. Educational objective: Opioid agonist-antagonist medications commonly used in labor are butorphanol tartrate and nalbuphine hydrochloride. These medications can precipitate withdrawal in opioid-dependent clients and should not be used. They are used in the active phase of stage 1 labor when labor contractions are well established and the cervix is dilated to at least 4 cm.

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit? 1. Attention span and activity level 2. Dental health and mouth dryness 3. Height/weight and BP 4. Progress with schoolwork and in making friends

3. HEIGHT/WEIGHT AND BP Methylphenidate (Ritalin, Concerta) is a central nervous system stimulant used to treat ADHD and narcolepsy. It affects neurotransmitters (dopamine and norepinephrine) in the brain that contribute to hyperactivity and lack of impulse control. A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development. It is very important to compare weight/height measures from one well-child checkup to the next. If weight loss becomes a serious problem, methylphenidate can be given after meals; however, before meals is preferable. Another side effect of methylphenidate is increased blood pressure and tachycardia. These should be monitored before and after starting treatment with stimulants. (Option 1) Therapeutic effects of methylphenidate include increased attention span and improvement in hyperactivity. These would be important components of a well-child assessment, but not the priority. (Option 2) Evaluating dental health is part of any well-child assessment. Dry mouth is not a common side effect of methylphenidate. (Option 4) Expected outcomes of methylphenidate therapy include improvement in schoolwork and social relationships. These would be important components of a well-child assessment, but not the priority. Educational objective: Side effects of methylphenidate therapy that require on-going monitoring are delayed growth and development and increased blood pressure. Children with ADHD should be weighed regularly at home or school; weight loss trends should be reported and discussed with the health care provider. Blood pressure and cardiac function also should be monitored on an on-going basis.

The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading? 1. Dehydration 2. Elevated temperature 3. Hypotension 4. Tachypnea

3. HYPOTENSION A pulse oximeter is a noninvasive device that estimates the arterial blood saturation (SaO2) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains both light-emitting and light-sensing components and measures the amount of light absorbed by hemoglobin in the arterial blood. Because the sensor estimates the value at a peripheral site, the oximeter reports the value as SpO2. The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning. (Option 1) Although dehydration can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. (Option 2) Elevated temperature is not a factor that could cause an inaccurately low pulse oximeter reading. (Option 4) Although tachypnea can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. Educational objective: Because the pulse oximeter sensor relies on adequate tissue perfusion, any condition associated with low blood flow or low perfusion states can decrease the reading. Pulse oximetry is also inaccurate in clients with carbon monoxide poisoning.

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question? 1. Administer pantoprazole IVPB every 12 hours 2. Initiate continuous ocreotide IV infusion 3. Insert and maintain an NGT 4. Maintain NPO status except for PO medications

3. INSERT AND MAINTAIN AN NGT Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive gastrointestinal bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure (eg, coughing, straining, vomiting) and from mechanical injury (eg, chest trauma, consuming sharp/hard foods). In UGIB, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage (Option 3). (Option 1) Pantoprazole is prescribed for clients with UGIB to reduce gastric acid secretion and help prevent ulceration of the gastric mucosa. (Option 2) Octreotide may be used to help control UGIB related to bleeding gastroesophageal varices, as it reduces portal venous pressure, which reduces bleeding. (Option 4) NPO status may be prescribed in cases of UGIB to prepare the client for invasive diagnostic or therapeutic procedures (eg, esophagogastroduodenoscopy, variceal ligation). Educational objective: Gastroesophageal varix rupture/hemorrhage is a potentially lethal complication of cirrhosis that may occur from increased portal venous pressure (eg, coughing) and mechanical injury (eg, nasogastric tube insertion). The nurse should question prescriptions for activities that increase the risk of such rupture.

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the pt's lungs 2. Check the pt's capillary refill 3. Measure the pt's BP 4. Review the pt's ECG

3. MEASURE THE PT'S BP Sodium nitroprusside is a highly potent vasodilator (both venous and arteriolar). Venous dilation reduces preload (volume of blood in ventricles at the end of diastole), and arterial dilation reduces afterload (resistance ventricle must overcome to eject blood during systole). Sodium nitroprusside is commonly used in hypertensive emergencies and for conditions in which blood pressure control is of utmost importance (eg, aortic dissection, acute hypertensive heart failure). Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity. (Option 1) Auscultation of lung sounds is a common assessment for the client in heart failure. However, in this client the signs and symptoms indicate hypotension and make checking the blood pressure a higher priority. (Option 2) Checking capillary refill can give the nurse information about perfusion status. Capillary refill may be prolonged and should be checked in this client, but after blood pressure is measured. (Option 4) The ECG of this client should be reviewed. The client is at risk for rhythm abnormalities, but because hypotension is the main adverse effect of nitroprusside, the blood pressure should take precedence. Educational objective: Sodium nitroprusside is given as an infusion for the short-term treatment of acute decompensated heart failure, especially in clients with markedly elevated blood pressure. It is a potent vasodilator and reduces preload and afterload. The main adverse effect is symptomatic hypotension, necessitating close monitoring of blood pressure.

A nurse is giving medications to a client who is being evaluated for a brain malignancy. The health care provider (HCP) has ordered a computed tomography (CT) scan with intravenous (IV) iodinated contrast for the next morning. Which medication should the nurse plan to withhold from this client? 1. Amlodipine 2. Gabapentin 3. Metformin 4. Phenytoin

3. METFORMIN IV iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury (contrast-induced nephropathy). The side effect of metformin (Glucophage) is lactic acidosis. If the client takes metformin and develops kidney injury from contrast, then the lactic acidosis will worsen. As a result, most HCPs discontinue metformin on the day of IV iodine contrast exposure (regardless of baseline creatinine) and restart the drug at least 48 hours later, after stable renal function has been documented. (Options 1, 2, and 4) Amlodipine (Norvasc) is a calcium channel blocker commonly used to treat hypertension. Gabapentin (Neurontin) is commonly used for neuropathic pain. Phenytoin (Dilantin) is an antiseizure medication. None of these medications interact with the iodinated contrast or worsen kidney injury. Therefore, these can be safely administered. Educational objective: Iodinated contrast used for CT scan or cardiac catheterization can cause kidney injury. Metformin (Glucophage) can worsen lactic acidosis in the presence of kidney injury. Metformin should be withheld prior to the contrast exposure and can be resumed when kidney function is within normal limits.

A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for Clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? 1. Ceftriaxone 2. Flucanazole 3. Metronidazole 4. Pantoprazole

3. METRONIDAZOLE C difficile is often associated with antibiotic therapy but can also be a nosocomial hospital-acquired infection. Antibiotics, especially broad-spectrum, reduce normal bacteria in the body. This allows other bacteria, such as C difficile, to take over and cause a superinfection. It grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. (Option 1) Ceftriaxone (Rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection. (Option 2) Fluconazole (Diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile. (Option 4) Pantoprazole (Protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection. Educational objective: Antibiotics reduce normal bacteria in the body, allowing other bacteria or fungi, such as C difficile, to take over. C difficile is a toxin-producing microorganism that grows in the intestinal tract and causes antibiotic-associated diarrhea. Metronidazole (Flagyl) and oral vancomycin are commonly used to treat this condition.

The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? 1. Check for history of bipolar disease 2. Determine if restraints can now be removed 3. Monitor for widened QT intervals and hypotension 4. Obtain blood for the current blood alcohol level

3. MONITOR FOR WIDENED QT INTERVALS AND HYPOTENSION Ziprasidone hydrochloride (Geodon) is an atypical antipsychotic drug that is used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol. (Option 1) Although knowing past psychiatric history will assist in determining the cause of this episode, this knowledge is not essential when caring for this client's current needs. Any physical reasons for the behavior should be ruled out before focusing on psychiatric history. Risk for suicide also needs to be assessed after the client is alert and sober. (Option 2) This should be reassessed after the drug is wearing off, not before the medication is peaking. The client could suddenly wake up and become violent again. Also, it is a priority to perform restraint monitoring per protocol, including checks on circulation and hydration/elimination needs. The client's physiological response is priority. (Option 4) It would be beneficial to know the current alcohol (ethanol) level in order to estimate the client's level of intoxication and when the client will be sober. The body normally clears alcohol at a rate of 25-50 mg/dL per hour. However, there is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological responses) from the drug than to quantify the current alcohol level. Educational objective: After ziprasidone hydrochloride administration, clients should be monitored for cardiac effects (including prolonged QT interval), hypotension, and/or seizure activity. Alcohol interacts with ziprasidone and increases the potential for an adverse effect from the drug.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? 1. I am trying to find makeup to cover my unattracive and ruddy facial complexion 2. I take a baby aspirin to reieve my occasional headaches 3. My leg has been sore. I suppose I need to elevate it more often when I am sitting 4. My skin itches so severely that no lotion or cream seems to help

3. MY LEG HAS BEEN SORE. I SUPPOSE I NEED TO ELEVATE IT MORE OFTEN WHEN I AM SITTING Polycythemia vera (PV) is a chronic disorder of the bone marrow in which excessive amounts of red blood cells, white blood cells, and platelets are produced. A secondary form of polycythemia can occur as a physiologic response to chronic hypoxemia. Clients with PV are at risk for developing blood clots due to the increased volume, viscosity, and stasis of their blood. Clients should be taught to monitor for warning signs of thrombus formation; these include redness, tenderness, and swelling in the legs or symptoms of stroke. In addition, they should be taught preventive measures such as using support stockings, elevating the legs when sitting, and hydrating properly (especially during hot weather and exercise). (Options 1 and 4) The venous stasis found in PV causes the skin on the face, hands, and feet to become a ruddy red color. Release of histamine from an increased number of basophils (subset of white blood cells) causes severe generalized itching, especially during a hot bath/shower. These are expected findings with PV. (Option 2) Clients with PV can develop headache or blurred vision due to venous stasis in the brain. Low-dose aspirin is often indicated in these clients to prevent blood clotting. Aspirin may also help alleviate the headache. Educational objective: Clients with polycythemia vera are at risk for developing thrombus due to the increased volume, viscosity, and stasis of their blood. Client reports of swelling, redness, or tenderness in the legs should be followed up immediately. Stroke is another potential complication.

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first? 1. Adminster IV ondansetron 2. Apply oxygen via favemask 3. Obtain BP 4. Perform vaginal exam

3. OBTAIN BP An epidural block (a form of regional anesthesia) can provide effective pain relief during labor; however, it also inhibits the sympathetic nervous system (SNS). SNS inhibition causes peripheral vasodilation, which may produce significant hypotension (ie, systolic blood pressure <100 mm Hg, ≥20% decrease from baseline). If a client exhibits hypotensive symptoms (eg, lightheadedness, nausea) while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening (Option 3). If hypotension is present, initial nursing interventions include administering an IV fluid bolus to increase blood volume and positioning the client in the left lateral position to alleviate pressure on the vena cava. (Option 1) IV ondansetron (Zofran) may help alleviate symptoms of nausea and vomiting, but evaluation and correction of potential hypotension should be completed first. (Option 2) If hypotension persists after initial interventions or fetal distress occurs, further measures include administering IV vasopressors (eg, phenylephrine, ephedrine) and applying 8-10 L/min oxygen via face mask to increase blood flow and oxygen delivery to the fetus. (Option 4) Nausea may occur independently of hypotension due to labor pain or as a sign of complete dilation. However, this client also has lightheadedness and is receiving epidural anesthesia; hypotension is extremely common with epidural anesthesia. Educational objective: Epidural blocks can inhibit the sympathetic nervous system, causing peripheral vasodilation leading to hypotension. Hypotensive symptoms include lightheadedness and nausea. The nurse should first assess blood pressure and then intervene (eg, IV fluids, left lateral positioning, oxygen) as appropriate.

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? 1. Fully inflate the cuff before feeding 2. Have the pt sit up in an upright position with the neck hyperextended 3. Partially or fully deflate cuff 4. Provide a modified diet of pureed foods

3. PARTIALLY OR FULLY DEFLATE THE CUFF 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. Educational objective: The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for a wet cough or voice quality, and monitoring vital signs.

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? 1. Pt with Guillian Barre syndrome yesterday is paralyzed to the knees 2. Pt admitted with MS exacerbation has scanning speech 3. Pt with epilepsy puts on call light and reports having an aura 4. Pt with fibromyalgia reports pain in the neck and shoulders

3. PT WITH EPILEPSY PUTS ON CALL LIGHT AND REPORTS HAVING AN AURA An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures (ie, seizure precautions) are in place. (Option 1) Guillain-Barré syndrome is an ascending symmetrical paralysis. It can move upward rapidly or relatively slowly (over days/weeks). Respiratory compromise is the worst complication. A client with paralysis at the level of the knee after 24 hours would not take priority over a client who will have a seizure in few minutes. (Option 2) Scanning speech is a dysarthria in which there are noticeable pauses between syllables and/or emphasis on unusual syllables. It is an expected finding with multiple sclerosis. (Option 4) Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Clients experience widespread pain with point tenderness at multiple sites, including the neck and shoulders. This client is not a priority. Educational objective: An aura is a sensory warning that a complex or generalized seizure will occur. It is a priority over stable or expected findings such as point tenderness in fibromyalgia, low-level location of paralysis in Guillain-Barré syndrome, or scanning speech in multiple sclerosis.

Which health history information would be most important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria? 1. Family risk factors 2. industrial chemical exposure 3. Tobacco use 4. Usual diet

3. TOBACCO USE The tell-tale symptom of bladder cancer, seen in >75% of cases, is painless hematuria; the client will report seeing blood in the urine with no associated pain. As with many other types of cancer, the primary cause of bladder cancer is cigarette smoking or other tobacco use (Option 3). Poorer outcomes are seen with increased length of time as a smoker and higher number of packs per day. (Option 1) Clients who have family members with bladder cancer have an increased risk of developing bladder cancer themselves; however, the primary risk factor is tobacco use. (Option 2) Occupational carcinogen exposure is the second most common risk factor. Occupational exposures include printing, iron and aluminum processing, industrial painting, metal work, machining, and mining. Clients are exposed to carcinogens through direct skin contact and inhalation (aerosols and vapors). (Option 4) Consuming a high-fat diet and using artificial sweeteners are risk factors for developing bladder cancer, but they are not the primary cause. Educational objective: Painless hematuria is the most common presenting symptom of bladder cancer. Cigarette smoking or other tobacco use is the primary risk factor.

The nurse develops a teaching plan for a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis (TB). Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include? 1. Notify the HCP if your urine is red 2. Take acetaminophen every 6 hours for drug associated joint pain while taking this medication 3. Wear eyeglasses instead of soft contact lenses while taking this medication 4. You can stop taking the medications as soon as one sputum culture comes back normal

3. WEAR EYEGLASSES INSTEAD OF SOFT CONTACT LENSES WHILE TAKING THIS MEDICATION Active TB is treated with combination drug therapy. Isoniazid causes hepatotoxicity and peripheral neuropathy. Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests should be obtained. Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg, jaundice, anorexia). Ethambutol causes ocular toxicity, and clients will need frequent eye examinations. A teaching plan for a client prescribed rifampin includes these additional instructions: Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives. (Option 1) Red urine is an expected finding with rifampin use; clients should not be concerned. (Option 2) Clients should be advised to not consume alcohol and drugs that can increase the risk for hepatotoxicity (eg, acetaminophen) during long-term use of this drug. (Option 4) The effectiveness of treatment for active TB is determined by 3 negative sputum cultures and chest x-ray. If the entire course of therapy (6-9 months) is not completed, reinfection, spread to others, and development of resistant strains of TB bacteria can result. Educational objective: Common potential side effects of rifampin include hepatotoxicity, red-orange discoloration of body fluids, and increased metabolism of some drugs (eg, oral contraceptives, hypoglycemics, warfarin).

The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate? 1. Administering a tocolytic 2. Initiating fundal pressure during a contraction 3. Obtaining the vacuum extractor 4. Pressing down on the symphisis pubis

4. PRESSING DOWN ON THE SYMPHISIS PUBIS Shoulder dystocia is an obstetrical emergency in which the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse may initially observe the fetal head retracting back toward the maternal perineum after birth of the head (ie, turtle sign). The condition is frequently associated with macrosomia (fetal weight >8 lb 13 oz [4000 g]) secondary to gestational diabetes mellitus. However, the occurrence of shoulder dystocia is unpredictable and may be related to maternal factors, such as suboptimal pelvic shape, obesity, or short stature, rather than fetal size. The nurse's primary responsibilities during shoulder dystocia include performing the McRoberts maneuver (ie, sharp flexion of maternal thighs toward abdomen to widen space between pubic bone and sacrum) and applying suprapubic pressure (ie, downward pressure applied to maternal pubic bone to dislodge fetal shoulder) (Option 4). (Option 1) Administering a tocolytic agent to stop contractions or relax the uterus is not recommended and does not resolve shoulder dystocia. (Option 2) Fundal pressure is contraindicated, as it may wedge the fetal shoulder further into the symphysis pubis or cause uterine rupture. (Option 3) Application of a vacuum extractor is contraindicated because it may further wedge the fetal shoulder into the symphysis pubis, increasing the risk for brachial plexus injury. Educational objective: Shoulder dystocia occurs when the fetal head emerges but the anterior shoulder remains wedged behind the maternal symphysis pubis. The nurse should be prepared to perform McRoberts maneuver and apply suprapubic pressure.

A client diagnosed with a ST-segment elevation myocardial infarction (STEMI) is receiving an intravenous thrombolytic infusion. In evaluating the client's response to treatment, which assessment finding by the nurse is the best indicator that reperfusion has occurred? 1. Increase in troponin level 2. Nonsustained ventricular tachycardia 3. Reduction of chest pain 4. Return of St segment to baseline

4. RETURN OF ST SEGMENT TO BASELINE Thrombolytic therapy is aimed at stopping the infarction process, dissolving the thrombus in the coronary artery, and reperfusing the myocardium. This treatment is used in facilities that do not have an interventional cardiac catheterization laboratory or when one is too far to transfer the client safely. Thrombolytics are administered within 12 hours of symptom onset. When the coronary artery that was blocked is reopened and blood flow is restored to the myocardium (reperfusion), several clinical indicators may be seen. The most reliable indicator is the return of the ST segment to the baseline on the electrocardiogram (ECG). Other markers include resolution of chest pain (Option 3) and a rapid rise of serum cardiac markers (Option 1). The levels increase as a result of necrotic myocardial cells releasing proteins into circulation when reperfusion is restored. The presence of a reperfusion arrhythmia (Option 2) is a less reliable indicator of reperfusion. The dysrhythmias are typically self-limiting and do not require aggressive treatment. Educational objective: Thrombolytic therapy can stop the infarction process in a STEMI and dissolve the clot, allowing for reperfusion of the myocardium. It is given within the first 12 hours of symptom onset. The most reliable clinical indicator of reperfusion is the return of the ST segment to the baseline on the ECG.

The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1. 25 year old with abdominal pain who smokes cigarettes and takes oral contraceptives 2. 55 year old ambulatory pt with exacerbation of chronic bronchitis and hematocrit of 56% 3. 72 year old pt with fever who is 2 days post coronary stent placement 4. 80 year old who is 4 days postoperative from repair of a fractured hip

4. 80 YEAR OLD WHO IS 4 DAYS POSTOPERATIVE FROM REPAIR OF A FRACTURED HIP Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk. Educational objective: DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply. 1 .Antibiotics can affect my INR value 2. I am going to eat more green leafy vegetables 3. I will shoot for my INR to be between 4 and 5 4. I will take warfarin at the same time daily 5. If I miss a dose, I can double it on the following day

1 & 4 A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 (Option 3). Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding (Option 1). Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically (Option 2). (Option 4) It is important to take warfarin at the same time daily to maintain a consistent therapeutic drug level. (Option 5) Clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated. Educational objective: Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by causing a vitamin K deficiency.

Which nursing interventions should be included in the plan of care for a newborn with suspected esophageal atresia (EA) and tracheoesophageal fistula (TEF)? Select all that apply. 1. Keep the infant NPO 2. Maintain the infant supine with the hOB elevated 30 degrees 3. Place suction equipment by the infant's bed 4. Prepare for urgent gastrostomy tube placement to start feedings 5. Refer family to palliative care team

1, 2, & 3 In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected surgically. Clinical manifestations include frothy saliva, choking, coughing, and drooling. Clients may also develop apnea and cyanosis when feeding. Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to maintain a clear airway and prevent aspiration. (Option 4) This client will likely require parenteral nutrition prior to surgery. A gastrostomy tube may be placed to allow for release of air and drainage of gastric contents to prevent aspiration; however, feedings or irrigations through the tube are contraindicated until after surgical correction of the TEF. (Option 5) Surgical correction is successful in most cases of EA/TEF. Infants diagnosed with extreme forms or with additional congenital anomalies may require referral to palliative care services if surgical correction fails. Educational objective: Priority nursing interventions to prevent aspiration in infants with EA/TEF include maintaining NPO status, positioning the child supine with the head elevated at least 30 degrees, and keeping suction equipment available by the bed.

The nurse is presenting an in-service educational session on child abuse and neglect to a class of certified home health aides. Which of the following statements should the nurse include when discussing the characteristics of the typical perpetrator of child abuse? Select all that apply. 1. Abusers often have a history of growing up in an environment of domestic violence 2. Abusers often have a historhy of substance abuse 3. Child abusers always rpesent as being agitated or out of control 4. Most child abusers have a low sense of self esteem 5. Teenage parents are particularly vulnerable to abusing their children

1, 2, 4, & 5 Typical characteristics of child abuse perpetrators include: Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation (Option 1) Low self-esteem—a sense of incompetence or unworthiness as a parent (Option 4) A history of substance abuse; use of alcohol or drugs at the time the abuse occurs (Option 2) Punitive treatment and/or abuse as a child Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age (Option 5) Resentment or rejection of the child Low tolerance for frustration and poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury (Option 3) Child abusers are not easily identified by appearance; they often appear calm and well in control but may have violent outbursts, typically in private. Educational objective: Child abusers often have a history of growing up in an environment of domestic violence and have a sense of low self-esteem. History of substance abuse is also a risk factor. Teenage parents are particularly vulnerable to abusing their children.

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply. 1. BP 82/64 2. Crackles on auscultation 3. Distended jugular veins 4. Pulse 120 5. Shoulder pain

1, 4, & 5 Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes. Risk factors include recurrent sexually transmitted infections, tubal damage or scarring, intrauterine devices, and previous tubal surgeries (eg, tubal ligation for sterilization). Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding, and missed or delayed menses. Signs of subsequent hypovolemic (hemorrhagic) shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs (eg, tenderness, rigidity, low-grade fever) may develop subsequently. (Options 2 and 3) Distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic (hemorrhagic) shock. Jugular veins would be flat in hypovolemic shock. Educational objective: The fallopian tubes are the most common site for an ectopic pregnancy. As the ectopic pregnancy grows and expands, rupture may occur, resulting in active bleeding that progresses to life-threatening hypovolemic (hemorrhagic) shock. Signs of ruptured ectopic pregnancy may include severe abdominal pain, dizziness, and referred shoulder pain.

The nurse is caring for the assigned clients on a pediatric inpatient unit. Which client is the priority? 1. 8 year old with sickle cell who has sudden onset unilateral arm weakness 2. 11 year old with viral meningitis requesting pain medication for headache 3. Male child scheduled for surgery for intusseception who has reddish mucoid stool 4. Male child with hemophilia who has hemathresis and is receiving desmopresin

1. 8 YEAR OLD WITH SICKLE CELL CRISIS WHO HAS SUDDEN ONSET UNILATERAL ARM WEAKNESS Children can have strokes. Ischemic strokes are more common in children with sickle cell disease. Other causes can include carotid abnormalities/dissection. The most common presentation of an ischemic stroke is the sudden onset of numbness or weakness of an arm and/or leg. These are handled with a similar emergent approach as for stroke in an adult. Children may require exchange blood transfusion to prevent the stroke from worsening. (Option 2) Viral meningitis can cause fever, headache, and meningeal signs (neck stiffness). Headache is expected and not a priority over a client with stroke. (Option 3) Intussusception occurs when one portion of the intestine prolapses and then telescopes into another. It is a frequent cause of intestinal obstruction during infancy. Onset is abrupt, initially with pain and brown stool. The condition then progresses to bilious emesis, palpable abdominal mass, and stools with a red, "currant jelly" appearance due to blood and mucus. This is an expected finding for this condition, and surgery is already scheduled to address it. (Option 4) Hemophilia is seen primarily in males and is due to a lack of clotting factors. Symptoms include spontaneous bleeding (hemarthrosis) into the joints, especially the knee, ankle, or elbow. Treatment includes replacing the missing clotting factor. Desmopressin (DDAVP) stimulates the release of factor VIII. The child is receiving treatment already and joint rest has been prescribed. The sudden neurological change in the child with sickle cell crisis is a priority. Educational objective: Children can have strokes. These usually are caused by clotting or vascular issues and require similar emergent care as adults. Desmopressin (DDAVP) is used to treat hemophilia.

The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1. Abrupt, tearing, moving back pain and epigastric pain 2. Severe lower back pain after lifting heavy boxes 3. Sharp calf pain with ambulation that improves with rest 4. Unilateral leg swelling with 2+ pitting edema after an airpllane trip

1. ABRUPT, TEARING, MOVING BACK PAIN AND EPIGASTRIC PAIN An aortic dissection occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever," "tearing," or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure. (Option 2) Severe lower back pain after lifting heavy boxes is likely due to disc herniation. Some clients may report radiculopathy pain radiating down the leg below the knee. While uncomfortable, this is not life-threatening. (Option 3) This is a description of intermittent claudication in the lower extremity due to peripheral artery disease. It is an ischemic muscle pain (due to the buildup of lactic acid from anaerobic metabolism) related to exercise that resolves with rest. (Option 4) This is a description of a deep venous thrombosis (DVT) resulting from immobility during a flight. The embolization of DVT can cause life-threatening pulmonary embolism; the client with aortic dissection already has a life-threatening condition. Educational objective: An aortic dissection, which classically includes moving, "ripping" back pain, is a medical emergency. Hypertension is the most important contributing factor.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? 1. Breast change that are not related to your cycle shoudl be reported to your provider 2. If your breasts become sore during the month, you may take ibuprofen as needed 3. Schedule yearly clinical breast exams with your HCP 4. These cysts are benign, and research shows that they do not increase the risk of cancer

1. BREAST CHANGES THAT ARE NOT RELATED TO YOUR CYCLE SHOULD BE REPORTED TO YOUR PROVIDER One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option 1). (Option 2) Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake; taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-inflammatory drugs (eg, ibuprofen). (Option 3) Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness. Emphasis is placed on the importance of reporting any suspicious breast changes. (Option 4) The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer; however, reporting noncyclic changes is a higher priority. Educational objective: Fibrocystic breast changes are cyclic changes that occur as a result of heightened responses to estrogen and progesterone. Clients should be taught the need to report noncyclic changes to the health care provider, as well as symptom management, breast self-awareness, and the importance of regular clinical breast examinations.

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene? 1. Elevating a pt's residual limb on a pillow 1 day after above the knee amputation 2. Placing an abductor pillow between a pt's legs after total hip replacement 3. Positioning a pt with Buck traction supine with the foot of the bed raised 4. Using pillows to raise a pt's extremity following a cast placement

1. ELEVATING A PT'S RESIDUAL LIMB ON A PILLOW 1 DAY AFTER ABOVE THE KNEE AMPUTATION To prevent hip flexion contractures in clients with above-the-knee amputation, the residual limb should not be elevated, especially after 24 hours. Instead, edema should be managed using a figure eight compression bandage. The bandage should be worn at all times until the residual limb is healed, and care should be taken not to wrap it too tightly. Hip flexion contractures can also be avoided by placing the client in prone position with hip in extension for 30 minutes 3 or 4 times a day. (Option 2) Following total hip replacement, hip dislocation is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or cross the legs or ankles. (Option 3) Buck traction immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into traction. The client is typically placed in supine position with the foot of the bed raised to maintain countertraction. (Option 4) After a new cast is placed, the nurse should elevate the client's limb above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if compartment syndrome develops. Educational objective: Care of the client with above-the-knee amputation includes placement in prone position for 30 minutes 3 or 4 times a day and using a figure eight compression bandage to decrease edema. The client's residual limb should not be elevated as this will promote flexion contractures.

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? 1. Give acetaminophen or ibuprofen every 6 hours to control fever 2. Give the infant frequent tepid sponge baths to control the fever 3. If the infant develops another seizure, wait 15 minutes to see of it subsides 4. Place ice bags under the arms and around the neck to reduce the fever

1. GIVE ACETAMINOPHEN OR IBUPROFEN EVERY 6 HOURS TO CONTROL THE FEVER Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable (Option 1). However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing. (Options 2 and 4) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. (Option 3) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures. Educational objective: Febrile seizures, although alarming, are generally benign. Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering.

A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1. 36 year old with endocarditis who has a temperature of 100.6, chills, malaise, and a heart murmur 2. 40 year old with pericardial effusion who has BP of 84/62 and JVD 3. 67 year old with pneumonia and new onset atril fib, who has a BP of 130/90 and a HR of 110 4. 70 year old with advanced heart failure who is receiving IV diuretics, has BP of 80/60, and is watching tv

2. 40 YEAR OLD WITH PERICARDIAL EFFUSION WHO HAS BLOOD PRESSURE OF 84/62 AND JVD The client with pericardial effusion should be seen first. This client is exhibiting signs and symptoms (narrowed pulse pressure, hypotension, and jugular venous distension) of developing cardiac tamponade, a life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid, and cardiac output can drop drastically. Emergency pericardiocentesis is needed. Other important manifestations of tamponade include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia. (Option 1) These are symptoms typically seen in the client with endocarditis. The nurse should further assess the murmur to see if it has worsened or changed, but this should be done after the client with pericardial effusion is seen. (Option 3) The new onset of atrial fibrillation should be reported to the health care provider, but the client's vital signs are stable; this client is not a priority over the client with possible tamponade. Atrial fibrillation is often a chronic arrhythmia and is managed with ventricular rate control and anticoagulation. (Option 4) Clients with advanced heart failure often have low cardiac output with resultant low blood pressure but remain asymptomatic. IV diuretics can worsen the hypotension. The client is watching TV, an indication that the client is stable. The nurse can delegate to the unlicensed assistive personnel directions for the client to stay in bed due to the hypotension until the nurse can perform further assessment. Educational objective: Clients with pericardial effusion should be monitored and assessed closely for the development of cardiac tamponade. Signs and symptoms of tamponade include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular venous distension, and pulsus paradoxus.

A client gives birth within an hour of arriving at the labor and delivery unit, and delivers the placenta 5 minutes later. During assessment, the nurse notes that the client's uterus is boggy and midline. Which action should the nurse take first?' 1. Administer IV oxytocin 2. Insert in and out catheter 3. Monitor amount of lochia 4. Perform fundal massage

4. PERFORM FUNDAL MASSAGE After delivery of the placenta, the uterus begins the process of involution. A boggy uterus indicates uterine atony, a state in which the uterus fails to contract adequately. The uterus should be firmly contracted, midline, and at or slightly below the umbilicus. Excessive blood loss may occur if vessels at the placental detachment site fail to constrict. The initial nursing action for uterine atony with a midline fundus is fundal massage, which stimulates contraction of the uterine smooth muscle (Option 4). If the uterus becomes firm with massage, the nurse should monitor uterine tone, position, and lochia at least every 15 minutes in the initial hour after birth. (Option 1) Uterotonics (eg, oxytocin, misoprostol, methylergonovine) stimulate the uterus to contract and encourage involution. If the uterus fails to become or remain contracted after massage, the next step is uterotonic administration. (Option 2) Bladder distension may interfere with uterine contractility and should be suspected if the fundus is elevated above the umbilicus and/or deviated to the right. The nurse should encourage the client to void soon after birth to prevent bladder distension. (Option 3) Lochia should be monitored frequently in the immediate postpartum period. However, in the presence of uterine atony, fundal massage should be performed even if lochia is minimal. Uncorrected uterine atony will eventually result in excessive blood loss. Educational objective: After placenta delivery, the fundus should be firm, midline, and at or slightly below the umbilicus. The initial nursing action to correct uterine atony with a midline, boggy uterus is fundal massage.

The nurse is preparing medications for a group of clients. Which prescription should the nurse clarify with the health care provider before administering? 1. Pt diagnosed with cirrhosis had 2 stools today; lactulose prescribed daily 2. Pt is prescribed lisinopril daily; serum potassium is 5.6 3. Pt is receiving vancomycin; mild facial flushing noted after 30 minutes 4. Pt with diabetes has insulin glargine prescribed; current blood glucose is 100

2. PT IS PRESCRIBED LISINOPRIL DAILY; SERUM POTASSIUM IS 5.6 ACE inhibitors ("-prils") and angiotensin II receptor blockers (ARBs) ("-sartans") may potentiate hyperkalemia. ACE inhibitors decrease the excretion of aldosterone. Aldosterone promotes sodium retention and causes potassium excretion. However, when the ACE inhibitor suppresses aldosterone, potassium rises, placing clients at risk for hyperkalemia, especially in the presence of impaired renal function. The nurse should question the administration of an ACE inhibitor in a client with hyperkalemia (Option 2). (Option 1) Lactulose is administered to clients with cirrhosis and hepatic encephalopathy to promote excretion of ammonia via fecal elimination and not solely for the treatment of constipation. The dose is adjusted to achieve 2-3 soft stools each day. (Option 3) Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect. (Option 4) Basal insulin glargine (Lantus) is used for glucose control in diabetic clients. Insulin glargine has no peak and should be administered even if the current blood glucose level is within normal limits. Educational objective: Clients receiving ACE inhibitors should be monitored for hyperkalemia, especially in the presence of renal insufficiency. The nurse should clarify a prescription for ACE inhibitor administration in a client with hyperkalemia.

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? 1. A 36 year old with postoperative venous thromboembolism who is to be started on the institution's heparin therapy protocol this morning 2. A 56 year old with newly diagnosed cancer, scheduled for surgery for a total laryngectomy this morning who is now refusing surgery 3. A 68 year old pt with MS, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning 4. An 80 year old pt, 3 days postoperative colectomy with peritnitis, who was mentally alert before and develops new onset confusion this morning

3. A 68 YEAR OLD WITH MS, 2 DAYS POSTOPERATIVE OPEN CHOLECYSTECTOMY WITH RECURRENT MUCOUS PLUGS, WHO IS SCHEDULED FOR A BRONCHOSCOPY THIS MORNING To prepare a client for a bronchoscopy, the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain nothing-by-mouth status; prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure. Because these are skills a graduate nurse possesses, this is an appropriate assignment. (Option 1) Initiating a heparin infusion according to institution protocol involves collecting baseline serum specimens (eg, partial thromboplastin time [aPTT], International Normalized Ratio [INR], prothrombin time, platelets, hemoglobin, hematocrit), calculating weight-based dosages, (eg, bolus dose, infusion rate in units/hr), and calculating intravenous infusion pump hourly rate. Serum aPTT and INR levels are monitored every 6 hours or according to protocol. Frequent changes in rate or dose based on these levels may be necessary to maintain a therapeutic level of heparin. For these reasons, this is not an appropriate assignment for a new graduate nurse. (Option 2) A client with newly diagnosed cancer who is refusing radical surgery that will result in the loss of speech and inability to communicate normally is demonstrating fear and anxiety. This client needs preoperative teaching about the surgical procedure, what to expect immediately after surgery, methods for speech restoration, and general preoperative teaching (eg, deep breathing, suctioning, pain management). Emotional support, education, and advanced therapeutic communication skills are necessary to help allay fear and anxiety. For these reasons, this is not an appropriate assignment for a new graduate nurse. (Option 4) The elderly client with new-onset confusion is at risk for developing hospital-induced delirium related to advanced age, surgery, hypoxia, fluid and electrolyte disturbances, immobility, pain, and/or drugs. The nurse must perform neurological assessments to determine the cause and intervene appropriately. For these reasons, it is not an appropriate assignment for a new graduate nurse. Educational objective: When assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member. The more experienced RN is assigned to the client with the more complex physiologic and psychologic needs, who requires a more advanced level of nursing skill. The new graduate nurse is assigned to the client with less complex needs, who requires basic nursing skills, such as measurement of vital signs and basic physical assessment.

The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next? 1. Advance the tube to the original exit mark, chech gastric aspirate pH, and resume feeding 2. Contact the HCP to request a prescription for hand mitts 3. Contact the HCP to request an x-ray to verify tube placement 4. Reinsert the guide wire and advance to the original exit mark

3. CONTACT THE HCP TO REQUEST AN XRAY TO VERIFY TUBE PLACEMENT A nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy (Option 3). (Option 1) Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement. (Option 2) A prescription for hand mitts to keep a confused client from disrupting enteral nutrition may be appropriate if other less restrictive interventions (eg, keeping tubing out of client's sight, one-on-one sitter) are ineffective or unavailable. However, this should not be the nurse's next action. (Option 4) The guide wire (stylet) is secured before tube insertion and remains in place until placement is verified by x-ray. Once removed, the guide wire should never be reinserted while the tube is in place as it can protrude and damage both the tube and the client's mucosa. Educational objective: A feeding tube is marked with indelible ink at the exit site (nare). If the external length of the tube changes, the nurse should contact the health care provider and request a prescription for a repeat x-ray to determine tube location before resuming administration of enteral feedings and medications.

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. 1. Calcium 7.4 2. Creatinine 4.o 3. Phosphorous 3.9 4. Potassium 4.9

4. POTASSIUM 4.9 The client with kidney disease is at risk for both hyperkalemia (normal potassium 3.5-5.0 mEq/L [3.5-5.0 mmol/L]) and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level. (Option 1) Serum calcium levels (normal 8.6-10.2 mg/dL [2.15-2.55 mmol/L]) may decrease with diminished renal function due to lower activation of vitamin D and subsequent impaired gut absorption of calcium. Calcium supplements are used to increase the serum calcium level. Sodium polystyrene sulfonate does not affect the serum calcium level. (Option 2) Sodium polystyrene sulfonate does not affect serum creatinine levels. Creatinine levels may decrease after dialysis. (Option 3) Phosphorus is also not filtered with kidney injury and the levels increase in serum (normal 2.4-4.4 mg/dL [0.78-1.42 mmol/L]). Phosphate binders (calcium acetate/carbonate) administered orally eliminate phosphorous through stool. Sodium polystyrene sulfonate does not bind phosphorous. Educational objective: Clients with kidney disease are at risk for hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level.

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to: 1. Fight the infection 2. Minimize rash 3. Prevent heart disease 4. Reduce spleen size

3. PREVENT HEART DISEASE Kawasaki disease (KD), also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. (Option 1) KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. (Option 2) Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. (Option 4) Lymphadenopathy (usually a single palpable anterior cervical node >1.5 cm) and splenomegaly are included in the clinical presentation of KD. IVIG therapy is not indicated to reduce incidence of these findings. Educational objective: IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.1 kg) but weighed 150 lb (68 kg) 3 months prior to admission. Which foods would be the best for this client? 1. Crackers and cheddar cheese 2. Hard boiled eggs and tomatoes 3. Steamed fish and potatoes 4. Tortilla chips with avocado dip

3. STEAMED FISH AND POTATOES Reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major depression (major depressive disorder). A 35-lb (15.9-kg) weight loss within 3 months is a 23% change in this client's usual body weight and is considered severe weight loss. The client needs a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier to chew and swallow may be better choices for promoting intake. Foods that are protein and/or calorie dense include: Whole milk and dairy products (eg, milkshakes), fruit smoothies Granola, muffins, biscuits Potatoes with sour cream and butter Meat, fish, eggs, dried beans, almond butter Pasta/rice dishes with cream sauce (Option 1) The client is taking phenelzine (Nardil), which is a monoamine oxidase inhibitor (MAOI). Foods high in tyramine (eg, aged cheese, yogurt, cured meats, fermented foods, broad beans, beer, red wine, chocolate, avocados) need to be restricted to reduce the risk of a hypertensive crisis. (Option 2) This choice is an excellent protein option but is low in calories. The client needs foods high in calories and protein. (Option 4) This choice provides calories but is low in protein and high in tyramine. The client needs to consume foods that are high in calories and protein but low in tyramine. Educational objective: Clients with unipolar major depression are likely to have reduced appetite and unintentional weight loss. Interventions to promote adequate nutritional intake include providing small frequent meals and snacks that are dense in protein and calories. In addition, drug-nutrient interactions need to be considered when choosing foods for a client on an MAOI.

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reports occasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? 1. Check serum glucose of hypoglycemia 2. Ensure that the pt comsumes fluids with meals 3. Take the pt's BP while lying and standing 4. Teach the pt to lie down after eating

4. TEACH THE PT TO LIE DOWN AFTER EATING Billroth II surgery (gastrojejunostomy) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. To reduce the occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying (Option 4). An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying. (Option 1) Hypoglycemia can cause symptoms similar to those of dumping syndrome (eg, sweating, dizziness) but is unlikely to occur 30 minutes after eating. (Option 2) Clients should avoid consuming fluids with meals, which causes stomach contents to pass faster into the jejunum and worsens symptoms. Fluid intake should occur at least 30 minutes before/after meals. (Option 3) Reports of dizziness after standing may indicate orthostatic hypotension and warrant assessment of blood pressure while lying and standing; dizziness after eating is indicative of dumping syndrome. Educational objective: Clients are at risk of dumping syndrome after a gastrectomy and may experience abdominal cramping, nausea, vomiting, and diarrhea. To delay gastric emptying, clients should avoid fluids with meals and lie down after eating.

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? 1. C reactive protein 2. PT 3. Serum LDL cholesterol 4. Tuberculin skin test

4. TUBERCULIN SKIN TEST TNF inhibitor drugs (eg, etanercept [Enbrel], infliximab [Remicade], adalimumab [Humira]) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Clients should have a baseline TST before initiating therapy and yearly skin tests thereafter. Those with latent tuberculosis (TB) must be treated with antitubercular agents before initiating treatment with these drugs. Otherwise, TB reactivation would occur (Option 4). (Option 1) CRP is a non-specific test used to detect acute or chronic inflammation in the body. CRP can be used to evaluate the effectiveness of medications that decrease inflammation. An elevation would be expected in clients with RA, especially during a flare, but it is not the most important test result to check before initiating therapy. (Options 2 and 3) LDL cholesterol and PT are unrelated to the administration of these medications. Educational objective: Major adverse effects of biologic disease-modifying TNF inhibitor drugs (eg, etanercept, infliximab, adalimumab) include severe infections and bone marrow suppression. TB reactivation is a major concern. Therefore, all clients must receive a TST to rule out latent TB.